TB

By Penelope A. Domogo, MD

“Fast forward to the present. Here in Mountain Province, we registered 396 new cases of TB in 2016, despite our aggressive case-finding and prompt treatment of cases. Cases are no longer within families.

TB, or tuberculosis, is an ancient disease so let us have a bit of its colorful history so we could understand it better.

“Evidence of tubercular decay found in the skulls and spines of Egyptian mummies, tell us that TB has been plaguing humans for at least 4,000 years.” (Nobelprize.org). Some accounts, however, say that TB has been with us for 9,000 years (Wikipedia). Whatever, it is ancient. In ancient times when there were no antibiotics yet, TB was called “consumption” or “phthisis” (Greek for consumption) probably because it seemingly “consumed” the sick person. The sick person becomes very thin and wasted. So when a person is emaciated, we say “kaneg ka na-TB” (“you look like you have TB.”)
TB is a chronic disease, “chronic” meaning the disease goes on and on for more than two weeks. Well, TB does not stay for two weeks only, the bacteria could stay in the body for years.
Because TB has been plaguing humankind for long, people have devised a variety of treatment modalities – like acupuncture, burning magic charms, travel to higher altitudes, fresh air, good diet, rest and the royal touch. It was believed then that the touch of a sovereign of England or France could cure diseases. Well, touch or what we term now as “laying of hands” must be the first healing modality, along with prayer. Touch is an automatic human response to someone in distress. I say prayer because when you touch someone who is sick, you also automatically say aloud or silently “may you be well.” That is prayer.
Brilliant ancient Chinese priest-doctors of the Song Dynasty (920-1279) already knew that TB was caused by a specific pathogen and was contagious but it was only in 1882 that Robert Koch, a brilliant German doctor and scientist, was able to see on the microscope the tubercle bacteria, Mycobacterium tuberculosis. For him to see this microscopic germ, he experimented with a lot of stains. He was able to prove by experimenting with laboratory rabbits that this bacteria was the cause of tuberculosis. For his breakthrough work, he was awarded the Noble Prize in 1905. TB is also termed “Koch’s disease”. In 1895, Wilhelm Roentgen discovered the x-ray which enabled physicians to diagnose TB and track its progression of the disease.
As stated above, TB was known early on to be contagious and in the 1800s, sanitariums (or sanatariums) purposely to house and confine TB sufferers were established. The first anti-tuberculosis sanatarium was established at Gorbersdorf, Germany in 1854 by Hermann Brehmer, a German physician. At that time when there were no antibiotics yet, 50% of patients who were isolated in sanatarias got well. In the sanatarias, they had enough rest, fresh air and good food. In the Philippines, Quezon Institute was established in 1938 in memory of President Manuel L. Quezon who died of TB in August 1944 at the age of 66.
In that year, 1944, streptomycin was discovered to be effective against the TB bacteria. Streptomcycin, just like many of the earlier antibiotics, is a chemical isolated from another kind of bacteria. Isn’t that interesting! Streptomycin is given by injection. In 1954, the first oral anti-TB drug, isoniazid (INH), was developed. In the 1970s, another drug, rifampicin, was developed, and this hastened the recovery from TB and controlled the spread of the disease. Naturally, if the patient is cured then he or she will no longer spread the disease. In the 1970s, treatment of tuberculosis lasted 12 months of continuous medication of two or more drugs. At present, the government’s protocol in the treatment of TB uses four drugs – rifampicin, isoniazid, pyrazinamide (PZA) and ethmabutol- for the first two months then rifampicin and isoniazid for next four months. Streptomycin is no longer used except in drug-resistant cases.
With the antibiotics, treatment of TB is now done at home but under direct observation by a treatment partner, usually a member of the family or barangay health worker. This means that the treatment partner should see the patient swallow his medicines everyday as prescribed. This is termed DOTS- directly-observed treatment strategy. This strategy is used because the theory is that drug resistance of the TB bacteria came about because the patients don’t continue their medicines up to 6 months or as prescribed, which could be 9 months (for extrapulmonary cases). What usually happens is that patients stop medications once they feel okay.
With these drugs, the world health authorities thought that TB can be eliminated. However, in the 1980s, this dream was dashed with the emergence of drug-resistant strains and the re-emergence of TB among people afflicted with HIV/AIDS. Just like any other disease, TB attacks those who have poor immune response like people with HIV/AIDS.
This brings us to what the British epidemiologist, Thomas McKeown, said about the decline of infectious diseases like TB. “McKeown explained the decline in mortality from infectious diseases by an improved standard of living, particularly by better nutrition, and by better hygiene, and less by medical intervention. McKeown, who is considered as the father of social medicine, has advocated for many years, that with drugs and vaccines we may win the battle but will lose the war against Diseases of Poverty.” (Wikipedia) He noted that even before streptomycin and BCG vaccination were widely available, there was already a 90 to 95% decline of deaths from TB in England and Wales. Thus he proposed that efforts and resources should be focused on improving the environmental conditions of the poor like providing clean water, sanitation, better housing, education and access to medical care.
This viewpoint of health as a social phenomenon brings us back to the Song Dynasty in which the masters wrote that, aside from being caused by an infectious parasite, TB is also caused “by overworking one’s mind and exhausting one’s energy…. “ Another big factor to be considered is diet. In the 17th century, Thomas Willis, an English doctor considered to be one of the greatest neuroanatomists of all time, tagged “sugar or acidity of the blood” as the culprit for TB (Wikipedia).
Fast forward to the present. Here in Mountain Province, we registered 396 new cases of TB in 2016, despite our aggressive case-finding and prompt treatment of cases. Cases are no longer within families. One here, another in a far away barangay, another in another municipality. The TB bacteria is everywhere but not everyone is afflicted. It is incumbent upon everyone, then, to take care of ourselves making sure we have a strong immune system. A healthy body-mind-spirit keeps the bacteria at bay.***
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“Devote yourselves to prayer, being watchful and thankful.” Colossians 4:2

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