The Tuberculosis Problem in the Philippines

MIGUEL CANIZARES

Chest 1948;14;759-765
DOI 10.1378/chest.14.5.759
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1948, by the American College of Chest Physicians
 The Tuberculosis Problem in the Philippines
MIGUEL CANIZAREB, M.D., F.C.C.P.'
Quaon City, Philippine Islands

In the Philippines now, in a so-called era of peace, three years

after Phillpqlne liberation, tuberculosis still kills a t the rate of
four persons every hour around the clock. Due to the ravages of
tuberculosis alone, the government looses one and a half billion
dollars every year. I t is the prime health and socio-economic
problem in the Philippines; has been so for decades. From Pearl
Harbor up to this date two wars have been raging in the Islands--
one fought with shell, shrapnel and other infernal implements
of destruction; another wherein the Four Horsemen plus parasitic
infestation and moral and physical tension have been preying
upon the populace facilitating subsequent invasion by dlsease.
The prewar tuberculosis death rate among Filipinos was 230
per 100,000 nearly six times as high as the 1945 rate for the United
States. The Philippine death rate is certainly higher now. Whereas
there are a t least 500,000 cases of tuberculosis among the 18,000,000
population today, there are not more than a total of 1,200 institu-
tional beds now available throughout the Philippines for this
disease.
The Philippines has a total area about half the size of Texas.
Its 18,000,00 inhabitants equal the combined populations of New
Jersey and New York states.
To New Jersey's four million people, a t least 4,203 beds (1942)
for tuberculosis patients are available. In the entire Philippines,
with a death rate nearly six times as high as that in New Jersey,
not more than 1,200 beds can be found. Even before the war, this
number was never any higher.
In the Philippines, tuberculosis has headed the list of causes of
death for decades. Not even malaria can compete with tuberculosis
mortality. At the war's outbreak, tuberculosis morbidity was 6.22
per cent, or 1,119,600 suspect cases, according to field surveys
made in 1940. If half of these cases did not survive the war and
if no new cases have cropped up since 1940, a t least 500,000
tuberculous persons are probably still alive today. That figure
is the minimum that can be arrived at.
Why is this so? What local conditions obtain whlch tend to
-
*MedicalDirector, Quezon Institute. Presented at the International Ban-
uet of the American College of Chest Physicians, Atlantic City, New
3
er8ey. June 5, 1947.

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1948, by the American College of Chest Physicians
make the disease so prevalent and the campaign against it so
limited in the Philippines?
Two organizations, which just before the war had some sort
of mutual understanding, are concerned with antituberculosis
activitiesa voluntary organization, the Philippine Tuberculosis
Society, and the government agency, which is the tuberculosis
control section of the health bureau. The Philippine Tuberculosis
Society was affiliated before the war with the National Tuber-
culosis Amxiation and Le Union Internationale Contre le Tuber-
culose. There was an arrangement according to which the Philip-
pine health bureau unit was to take care of health statistics and
case finding in field surveys while the Philippine Tuberculosis
Society was to attend to the home and institutional management
of cases. The educational work was jointly undertaken by both
agencies. To this end, the Society operated four provincial tuber-
culosis pavilions, fourteen dispensary clinics, and a central sana-
torium known as the Quezon Institute. The health bureau con-
ducted a dispensary in Manila, provided 150 hospital beds for
advanced cases, and operated four mobile x-ray units in field
surveys. In 1940 these combined agencies examined by f l u o m o p y
and roentgenogram a total of 510,843 persons, or approximately
2.8 per cent of the population.

A Bit of History
The Philippine Tuberculosis Society was founded in 1910 by a .
small group of civic minded citizens. Initially it operated two
small clinics in the slum districts of Manila, but gradually its
activities expanded until in 1918 it was able to open a sanatorium
in the outslrirts of Manila. The sanatorium at first consisted of
a few nipa huts or ramshackles. Year by year additions were built
until in 1935 there were some twenty-seven cottages and huts.
A diagnostic x-ray unit was acquired in 1927, and in 1929 seventeen
patients were under pneumothorax therapy. Two years later,
phrenic nerve operations and thoracoplasty were introduced in
the Islands. Collapse therapy found such wide acceptance that
a t the outbreak of the war the Quezon Institute alone had 1,547
pneumothorax patients. Intrapleural pneumolysis was introduced
in 1937. The Philippine Tuberculosis Society and the Quezon
Institute started sending members of its staff abroad, especially
to the United States, for advanced training.
The sanatorium operated by the Philippine Tuberculosis Society
was renamed the Quemn Institute in 1938 after its sponsor,
Manuel L. Quezon, who later died at Saranac Lake. I t may be
stated here that the late Resident Quezon was as interested in
tuberculosis as the late President Roosevelt was in infantile

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1948, by the American College of Chest Physicians
Vdumc X N TWERCUUXBIB PROBLEM IN TIiB PKILIPPPlEs 761

paralysis. He it was who sparked the antituberculosis campaign

in the Philippines. Under Quewn's administration the sweepstakes
law taok effect, most of the income from which was set aside
for use in the campaign against tuberculosis. These funds sup-
plemented the proceeds from the Christmas Seal Sales.
After 1938 the activities of the Philippine Tuberculosis Society
steadily expanded. Dispensary clinics and tuberculosis pavtlions
were opened in populous areas of the Islands. The wooden and
nipa structures gave way to modem concrete sanatoria with
accommodations for as many as 1,400 patients. A planigraph unit
operated from 1939 to the outbreak of the war; clinical and
research laboratories and a medlcal library were founded; an
orthopedic service was established; a powerful O.E. apparatus
with a miniature 4 x 5 x-ray unit was acquired in 1940; and a
scientific publication was issued semi-annually containing the
products of staff research. In 1938, the Society began training
physicians, sent by the tuberculosis control section of the health
bureau, in tuberculosis work for a minimum period of two years.
Undergraduate medical students from three local medical colleges
and nurses from schools of nursing also received clinical instruc-
tion and trainlng in tuberculous and other chest diseases. Large
industrial firms were starting to have regular x-ray check-ups
of their employees, and x-ray examinations were also belng made
available for government employees, school teachers, and students
and the public in general.
Into this setup, which gave promise of becoming nation-wide
in scope, burst the attack on Pearl Harbor and the Pacific cam-
paign like a thunderbolt from the blue.

Predisposing Factors
The following factors contribute to the prevalence of the disease
in the Islands:
( a ) Poor housing. Housing was a problem even before the war.
During the Pacific battles more than 300,000 homes were destroyed
as a result of fighting and bombings so that the problem is now
much more acute. Whole families have to double up, not in houses,
but in makeshift sheds, shacks, and lean-tos (the barong-barong)
without sanitary facilities. In the razed areas of Manila and its
suburbs, it is not uncommon to find three or four families squeezed
into a shed measuring four by five yards, which leaks like a sieve
during the rainy season and which is as hot as an oven during
the summer months. Thus, spread of infection by close and con-
tinued contact is supremely easy. The War Damage Commission
could do a lot to aid in rehabilitatlon by hastening the settlement

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1948, by the American College of Chest Physicians
 of claims although the results will be limited by the fact that an
individual claimant cannot get more than $500.00.
I t must be mentioned here that whole communities have been
wiped out in some areas, the majority of their inhabitants mas-
sacred or maimed. I n Manila virtually every federal building has
been demolished, century-old historic buildings gutted, and some
churches, museums, and libraries burned down. There is no ques-
tion but that there is a dearth of public buildings and private
dwellings in the entire young republic today.
(b) Malnutrition. Even before the war it was an admitted fact
that the Filipino race was so undernourished that every year
beriberi killed more infants than did respiratory diseases. During
the forty months of Japanese occupation not only did no imports
reach the Philippines due to the blockade but the countryside
llgewtse was stripped to feed and maintain upwards of one million
unwelcome guests (the Japanese Imperial Army had no quarter-
master supplies to speak of). The Japanese saw to it that their
troops lived off the fat of the land, not caring whether the civilians
starved. Hence, avitaminosis reared its head, and malnutrition
contributed to the death of thousands.
Even now when nutrition is better, the high cost of living (the
purchasing value of the peso is only one-fifth of its prewar level)
is still taking its toll. Statisticians are agreed that for the next
few years llving costs wffl remain higher than the prewar level.
(c) Parasitism. Intestinal parasitism infests about 70 per cent
of the population. Ascariasis. Schistosomiasis, hookworm disease.
tineasis, and amebiasis form the bulwark of Philippine parasites
that choose man for their host. The ascarids, hookworm, schisto-
somes and strongylids, as they pass through the lungs in their
life cycle, may cause some injury to the pulmonary tissue on their
way to their respective habitat in the human body. Whether in
this manner they predispose the lung to subsequent lodgment of
the Mycobacterium tuberculosis has not yet been fully ascertained.
I t is a fact, however, that widespread parasitism in the Islands
not only contributes to the production of secondary anemia but so
lowers the resistance of the human host that either latent tuber-
culous foci or other intercurrent diseases may readily break out.
(d) Dust and Fly problem. These two are peculiar to the tropics
-as is the mosquito problem. Tropical dust is the most abundant
in the world. Most Philippine highways were concrete or asphalted
before the war, but the Japanese did no maintenance, and thous-
ands of heavy U. S. Army vehicles have pulverized the best of the
asphalted roads during the past two years. The dust of the high-
ways, carried away by tropical winds, gets into your eyes, your
nostrils, and into your every pore. Hence, respiratory diseases

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1948, by the American College of Chest Physicians
 Volume XIV TUBWCUU3618 PROBLEM IN IAE PHILIPPMEs 789

enjoy a Roman holiday during the dry months, thereby activating

many a quiescent tuberculous focus.
As for flies, they can be found in droves every day of the year.
With garbage and sewage disposal extremely inadequate since the
end of the war, fwd, milk and water contamination plays a con-
siderable role in the spread of infectious dlsesses.
(e) Economic condttfons. In addition to inadequate housing, the
traditional low wages prevaliing in the Orient and inflated prices
of fwd and all other commodities contribute to a low constitutional
resistance resulting in malnutrition. Mlipinos were never milk
drinkers, for, in a large majority of cases, fresh milk produces
either diarrhea or tympanism.
As examples of these low wages, the common laborer earns an
average of $1.50 a day; physicians in the health service in charge
of a county receive not more than $75.00 a month; clerks and
teachers about $65.00 a month. Is it any wonder then that the
children are so undernourished that they are easy prey to tuber-
culosis and other contagious diseases?
I t must be stated here, in passing, that World War II's aftermath
w i l l be felt in the Islands for the next decade. While vital statistlcs
for the whole Philippines is incomplete, tuberculosis incidence in
the city of Manila, according to the Philippine health bureau, has
risen from the pre-war figure of 9.07 per cent to 21.84 per cent,
or an increase of 251 per cent. Last year there were 2.144 deaths
due to tuberculosis in Manila, or a city incidence of 280 deaths per
100,000. At the war's end in 1945, 11,258 cases were found by the
health bureau in the same city out of 51,550 fluoroscopic and x-ray
examinations, or an incidence of 21.84 per cent.
Prewar Activities
The Philippine Tuberculosis Society's fourteen dispensary clinics,
four provincial tuberculosis pavilions, and the Quezon Institute,
for a twelve-month period from 1940 to 1941, reported the following
activities:
Total dispensa attendance 249.700
(examinedxy fluoroscopy, miniature or regular x-ray films)
Home visits 114,620
Artificial pneumothorax
-
insufflations
-
. - .-
66.959
Other major and minor operations (at Quemn Institute) 1,109
iaboratory examinations 65,455
Number of pneumothorax patients fat Quezon Institute) - - -
1.547
Number ofadmkdons (at Quemn Institute) 1236
Number of discharges tat Quezon Institute) of which 61.5 per cent
had positive sputa and 38.5 per cent had negative sputa 1,148

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1948, by the American College of Chest Physicians
 The tuberculosis control sectlon of the Philippine health bureau,
during the ten-year period from 1933 to 1942. made 1,037,571fluor-
oscoplc and roentgenographic examinations with an incidence rate
of 8.54. The average was 103.757 examinations a year.
War Damage and Casualties
The war ln the PacUlc theater crippled the tuberculosis organiza-
tion in the Philippines. There is no other health unlt which was
harder hit by the war than the Phillppine Tuberculosis Society
and its dependencies. Seven physicians on the staff died during
the Japanese occupation. One was killed or beheaded by the
Japanese. Over 100 male patients and employees of the Quezon
Institute were bayonetted to death in the last days of fighting
during the liberation of Manila. Most of these patients were
advanced cases and so weakened by disease and malnutrition that
they could not walk alone.
Eleven dispensary clinlcs and four tuberculosis pavillonstwo of
the latter brand new-were damaged beyond repair; all their
equipment and suppliea lost or burned. The Quezon Institute
proper, commandeered and occupied by the Japanese as a milltary
hospital, was burned and greatly damaged by the Japanese be-
fore they evacuated it. What equipment and utilities remained
after the conflagration were looted. Not only our research and
clinical records since 1919 but ward, surgical, x-ray and laboratory
equipment and supplies also perished in the Walled City fighting.
Our medical and research libraries perished in the same fashion.
Damage sustained amount to a t least two million dollars; irre-
placeable are our burned medical books and literature, research
records and x-ray and clinical records of patients dating from 1919.
The tuberculosis section of the bureau of health likewise lost all
their mobile x-ray units, four In number.
Present Handicaps
I t has been sixteen months now since the Quewn Instltute
started reoperatlng. The 80th U. S. Army Base Hospital, which
occupied the Quewn Institute for almost a year after liberation
and made some repairs of the damaged buildlngs, turned over their
surplus to us in late December of 1945 on memorandum receipt.
&me essential x-ray, surgical and clinical equipment is still lack-
ing, and some of us have grown rusty and turned into nervous
wrecks with the war years, but most of the old crowd is back and
new hands are being trained again. Present handicaps are many.
The condition of the sanitary facilities is one of the most serious
of these handicaps, for most of our plumbing and electric fixtures
were lost. Water mains remaln unrepaired, hence there is water

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1948, by the American College of Chest Physicians
Volume X1V TUBERCUU38XB PROBLEM IN THE PHILIPPINE8 165

shortage in the Manila area. At the sanatorium it is very trying

to have water for only three or four hours out of the twenty-four.
That really poses a big problem when there are some 1,200 sana-
torium residents to be taken care of.
Our sincere thanks are due to the Natloyal Tuberculosis Asso-
ciation, which has aided the Philippine Tuberculosis Society in
various ways. The NTA has given us an outright financial donation
of $5,000--when we were without any funds--Christmas Seals,
medical books, magazines, journals, educational posters, pamphlets
and moving picture films. all of whlch not only have been of great
practical and material help but also have bolstered our morale
considerably. We desire likewise to express our appreciation to
many American doctors who have sent us relief supplies and med-
ical literature and books.
At present we have been enabled to reopen five provincial dis-
pensary clinics although only three of them have x-ray facilities.
The biggest problem of all is an insufficiency of funds for tuber-
culosis work. Even the governmental tuberculosis control section,
which L being aided directly by the USPHS, has the same financial
problem. The USPHS has given u s a $5,000 donation for surgical
equipment and two small x-ray units for whlch we are deeply
grateful. There are now two miniature x-ray units and 230 hospital
beds for the tuberculous sponsored by the bureau of health agency.
The present tuberculosis setup in the Philippines has a group
of trained men and the spirit to combat tuberculosis. But It has
only 1,200 beds whereas 70,000 are needed; not more than ten
x-ray unlts when a t least twenty times that number are required.
A program of expansion is on its way, depending upon available
funds. The spirit is there--the spirit that gave birth to Bataan
and Corregidor-even after the echoes of the most horrible war
have only barely receded into the distance. Yet there is still "war"
in this era of peace, the war against tuberculosis, as an already
prostrate people succumb from tuberculosis alone a t the rate of
four deaths every hour.
Notwithstanding whlch, the people of the Philippines go ahead
calmly, and without complaining endure their suffering In silence.
The new Republic marches on with the Captain of the Men of
Death stalking just behind. He carries a dark mantle in both
hands, but life in the Philippines now, after the terrible W r y
and agony and devastation and cruelty of the war year?, is wm-
paratively sweet even if It is but a "tiny gleam of time between
two eternities."

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1948, by the American College of Chest Physicians
 The Tuberculosis Problem in the Philippines
MIGUEL CANIZARES
Chest 1948;14; 759-765
DOI 10.1378/chest.14.5.759
This information is current as of October 10, 2010
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1948, by the American College of Chest Physicians