Tuesday, January 19, 2010

Why TB Persists

Every five years, the National Statistics Office conducts a National Demographic and Health Survey which mainly looks at the health of women and children. The earliest surveys focused on family planning, but over the years it has expanded to become the most comprehensive source of information on other health issues in the country.

Just to give a few examples, you can find statistics on the use of tobacco, domestic violence and sexual behavior. There is also information on households’ access to safe water, ownership of durable goods, exposure to mass media. What I find most useful in the NDHS is the breakdown of statistics according to urban/rural residence, region, age groups and, in more recent surveys, income.

Except in 2003, all the surveys have been limited to women respondents, but the information remains important because our women play so many important roles in health care, within and outside the home.

The final results from the 2008 survey, with 13, 594 women interviewed from all the regions in the Philippines, were presented last week. The NSO asked me to respond to the findings concerning HIV/AIDS and TB during the dissemination symposium, and I thought I’d share my thoughts about the findings about TB.

TB has been with us since time immemorial, so it is not surprising women’s awareness of the disease was over 98 percent. But even then, I did wonder why awareness was not 100 percent. In the National Capital Region, 0.3 percent of respondents were not aware of TB and in the Autonomous Region in Muslim Mindanao (ARMM), the figure was 8 percent. In absolute numbers, you’re talking of thousands of women who have not heard of TB.

What was even more disturbing were the figures that came out on knowledge about the cause and mode of transmission of the disease. TB is caused by Mycobacterium tuberculosis, which is a bacteria and which is airborne, mainly spread by coughing.

The awareness of this airborne spread was quite low, ranging from 34 percent in the ARMM to 62 percent in the NCR. Even more shocking, when the women were asked if they knew that TB was caused by bacteria, knowledge of this fact ranged from 12 percent in Ilocos to 34 percent in the NCR. Even among college-educated women, knowledge of a microbial cause was about 33 percent.


The NDHS statistics offer us some clues as to why TB remains so widespread in the Philippines, with one of the highest infection rates in the world. TB is also still the fourth leading cause of death in the country, with about 100 Filipinos dying each day from this plague.

As a medical anthropologist, I would want to have a deeper investigation of people’s perceptions of the disease. I wonder if Filipinos mainly associate “bacteria” and “germs” more with hygiene (“dumi” or dirtiness) and certain ailments like diarrheas (still because of the “dumi” aspect).

The hordes of durarista (people who spit anywhere, who I consider terrorists) among us shows that people don’t think of this habit as a way of spreading diseases, including TB. In fact, people see spitting as a hygienic measure—time and time again, Filipinos have argued with me that it’s “cleaner” to spit out the offensive phlegm rather than to keep it in the body!

So, if people don’t attribute TB to microbes, how do they explain the disease? The most frequently cited causes were smoking (59 percent) and alcohol drinking (44 percent). Inheritance came in third, in a tie with microbial causes, at 23 percent. Again, what was striking was that even among college educated and upper-income women, there was the same ranking, meaning more women attributed TB to smoking and alcohol drinking rather than microbes.

There is an amazing mix of beliefs around TB. For example, the higher the educational status of women, the higher the percentage of those who believed TB could be spread through sexual contact. Only 0.6 percent of women who had no education believed in sexual transmission of TB, increasing to about 3 percent for those with elementary education, 4 percent for those with high school education and 9 percent for those with college education.

What we’re seeing are misplaced fears, where people don’t recognize the risks of airborne transmission but might fear TB from sex. The NDHS did find, too, that 78 percent of the women thought TB could be transmitted from sharing utensils. This is actually a myth, but many households with a TB patient will still segregate their eating utensils.

TB patients also have to live with stigma. The NDHS found 60 percent of respondents willing to work with someone who had been previously treated for TB. In the ARMM, only 38 percent of respondents were willing. Note that this is for someone who has previously been treated. The stigma might be even worse for those who are being treated for TB.

I am certain the stigma contributes to the spread of TB. The disease’s stigma is not just about its infectiousness but about its association with vices like smoking and alcohol use. The idea that it is inherited also contributes to stigma, with families embarrassed to admit having a relative with the disease because it might reflect badly on the entire family.


A few weeks back I wrote about a 19-year-old girl who was brought to Manila from Samar by her family for a respiratory problem. The family had consulted several doctors but refused to accept the diagnosis, which was TB, insisting that it could not happen to a young girl. They insisted that the girl was a victim of barang, or sorcery. Sadly, she died last month, another casualty of the lack of health literacy in the country.

After I got my full report for the 2008 NDHS, I looked up the findings concerning TB in the 2003 NDHS. There had been little improvement in knowledge levels. The 2003 NDHS included a small sample of men, and their knowledge levels about the disease were even more dismal than those for women. In that 2003 NDHS, 24 percent of women, compared to 17 percent of men, knew that TB is caused by bacteria. And while 52 percent of the women knew TB could be transmitted through the air when coughing, only 46 percent of the men had that knowledge.

International agencies have poured in huge amounts of money for TB prevention, as well as treatment, but the NDHS findings of 2003 and 2008 tell us very little progress is being made in terms of people’s knowledge. Beyond the surveys, we need more research to probe deeply into how people look at TB. Maybe the lack of awareness is due to our reluctance to openly talk about the disease and the doctors’ use of euphemisms like “weak lungs.” And women’s fears of sexual transmission may not be totally irrational since a sexual partner with TB can still transmit the germs, not through the sex itself but through coughing.

TB will continue to thrive in the country if we don’t resolve all these accumulated perceptions and misconceptions. The NDHS reminds us that such ignorance cuts across classes, age groups, educational status, and geographical regions.

By Michael Tan, Pinoy Kasi, Philippine Daily Inquirer