Benel D. Lagua l November 10, 2022 l Manila Bulletin
In a previous column, this writer advocated for more attention by authorities to the threat of tuberculosis (TB). The country should aggressively address the potential cost of tuberculosis infection and mortality. The Department of Health (DOH) should allocate bigger funding to fighting TB and tap relevant institutions like the Philippine Coalition Against TB (PhilCAT) and Philippine Tuberculosis Society, Inc. (PTSI) to confront this problem.
Following is a recent update from The Economist. Before Covid-19, TB was the deadliest pathogen in the world, killing around 1.4 M people a year. After many years of slow but steady decline, the number of deaths from TB is rising again. According to figures published by the World Health Organization’s Global TB Program, the death toll from tuberculosis was 1.6M in 2021, a rise of 14% since 2019. That number will increase by 5% to 15% over the coming half decade. The WHO reckons that covid has set back progress against TB by many years. TB spikes up when there are wars and major catastrophes, like in times of financial crisis and the covid pandemic.
Tuberculosis is an ancient affliction. But it continues to be a pester. Around 1.8bn people worldwide are thought to be infected, with most infections remaining latent. Those who get sick are mostly people with weak immune systems, and the disease is more common in poorer countries, especially those who live in small badly ventilated homes.
Poverty and its associated ills, such as malnutrition and overcrowding, raise the risk of TB considerably. Just eight countries account for two thirds of the world’s symptomatic cases. And the Philippines ranks third, overtaken only by India and Indonesia. According to Dr. Camilo Roa of the PTSI, the Philippines had a mortality rate of 36 deaths per 100,000 population in 2000 and TB kills 27,000 yearly in the country. The country has high rates of affliction (morbidity) and deaths (mortality).
The Philippines is tagged as one of the TB high burden countries (HBC) based on the following criteria: a) the top countries in terms of their estimated absolute number of new (incident) cases; b) severe burden in terms of the incidence rate (new cases per 100,000 population); and c) meeting a minimum threshold of 10,000 cases per year for TB and 1000 new cases per year for HIV-associated TB and drug-resistant TB. There are three WHO global lists of HBCs — for TB, TB/HIV and multi drug resistant-TB. The Philippines is one of ten (10) countries in all the three global lists of HBCs.
Unlike in the past where TB patients had to be isolated and hospitalized, today the disease is preventable even as there is yet no vaccine available. About 85% of the afflicted can be successfully treated. The first step is to track and diagnose the carriers. Then the patients must complete treatment even if symptoms are not observed. Abandoning the treatment mid-way encourages the bacterium to evolve resistance to the antibiotics used for treatment.
The biggest challenge is tracking the potentially sick, especially among the poor. There must be consistent home checkups or clinic visits, including health workers watching to ensure patients swallows their pills. Existing treatments lasts from six and 30 months, although hopefully new research can develop faster treatments.
The most important player in this effort is, of course, the DOH with its National Tuberculosis Control Program (NTP). TB diagnostic and treatment services are part of the basic integrated health services which are provided by DOTS (directly observed treatment short course) facilities which could either be public health facilities or NTP-engaged private facilities. NTP collaborates with non-government organizations such as the PhilCAT, a consortium of 60 groups and the 112-year-old PTSI. PTSI provides actual case findings in the barangay, education and training and runs several facilities around the country like the Quezon Institute.
A study on the TB patients cost survey in the Philippines concluded that tuberculosis patients in the Philippines face a substantial financial burden due to the disease despite free TB services provided by the NTP. The cost of TB treatment includes non-medical costs and income loss. Households had to rely on dissaving, taking loans, or selling their assets to cope with the loss. Experts refer to this parameter as catastrophic cost.
Dr. Camilo Roa reveals that before the pandemic, it was estimated that about 100,000-150,000 people of the 535,000 annual estimated cases with TB suffer from catastrophic costs while seeking treatment in the public sector every year. Two or three out of five newly diagnosed TB cases or households become poor just because a family member developed active TB. This is despite the NTP that was developed to provide free testing and medicines.
Worldwide spending on TB, according to The Economist, was already less than half of the global target and it fell further, from $6bn in 2019 to $5.4bn in 2021. No less than the DOH acknowledged that investing to end TB is firstly financial. Hopefully, this recognition translates to better allocation of financial resources in the future, and a good dose of political will. To achieve zero catastrophic cost due to TB, we need to enhance the current social and welfare support through multisectoral collaboration.
*** (Benel Dela Paz Lagua was previously EVP and Chief Development Officer at the Development Bank of the Philippines. He is an active FINEX member and an advocate of risk-based lending for SMEs. Today, he is independent director in progressive banks and in some NGOs. The views expressed herein are his own and does not necessarily reflect the opinion of his office as well as FINEX.)