Comments on Health Security in the Philippines

Blogger's Notes:
Commentary of an Academic 
(Copyright @ 2010 by Chester B Cabalza. All Rights Reserved).

by Chester B. Cabalza

Update on Health Issues in the Philippines

Based on the country studies report on the Philippine health security, the struggle against disease has progressed considerably over the years. Health conditions in the Philippines in 1990 approximated to those in other Southeast Asian countries but lagged behind those in the West. Life expectancy, for instance, increased from 51.2 years in 1960 to 69 years for women and 63 years for men in 1990. Infant mortality was 101 per 1,000 in 1950 and had dropped to 51.6 per 1,000 in 1989.

In 1923 approximately 76 percent of deaths were caused by communicable diseases. By 1980 deaths from communicable diseases had declined to about 26 percent.

In 1989 the ratio of physicians and hospitals to the total population was similar to that in a number of other Southeast Asian countries, but considerably below that in Europe and North America. Most health care personnel and facilities were concentrated in urban areas. There was substantial migration of physicians and nurses to the United States in the 1970s and 1980s, but there are no reliable figures to indicate what effect this had on the Philippines. Hospital equipment often did not function because there were insufficient technicians capable of maintaining it, but the 1990 report of the Department of Health said that centers for the repair and maintenance of hospital equipment expected to alleviate this problem.

In 1987 a little more than one-half of the infants and children received a complete series of immunization shots, a major step in preventive medicine, but obviously far short of a desirable goal. The problem was especially difficult in rural areas. The Department of Health had made efforts to provide every barangay with at least minimum health care, but doing so was both difficult and expensive, and the more remote areas inevitably received less attention.

Although very few Filipinos have been infected with acquired immune deficiency syndrome (AIDS), concern about the disease has caused authorities to give it considerable attention. By April 1979, only three people had died from AIDS, two of whom were overseas Filipinos visiting the homeland and one an American civilian who had contracted the disease outside the Philippines. In 1985 the Department of Health and the United States Naval Medical Research unit tested more than 17,000 people, including some 14,000 hospitality girls in Olangapo and a number of other Filipino cities. They identified twenty-one women as human immunodeficiency virus (HIV) carriers.

The American sponsorship of the study was seized upon as argument for ending the Military Bases Agreement with the United States. A June 1990 Philippine government study reported that at that time AIDS was growing at the rate of four cases a month and that twenty people had died from the disease. The study indicated that most AIDS cases in the Philippines were transmitted by heterosexual activity. An April 30, 1991, Department of Health report indicated that 240 Filipinos were infected with AIDS.

Like many other countries, the Philippines has a problem with illicit drugs. Official Philippine government statistics for 1989 indicate only 1,733 addicts, but the assumption was that the real number was from ten to a hundred times as great. The government has instituted both education and treatment programs, but it was uncertain how effective these programs would be. There also was a problem with inadequately tested legal drugs. In 1983, more than 265 pharmaceutical products were sold in the Philippines that were banned in many other countries. The Department of Health succeeded in eliminating 128 of them by 1988. Attempts to eliminate others have been blocked by the courts, which ruled that the department had acted without due process.

Malnutrition has been a perennial concern of the Philippine government and health care professionals. In 1987 the Department of Health reported that 2.8 percent of preschoolers were suffering from third-degree malnutrition and 17.6 percent from second-degree malnutrition. To alleviate this problem, the government targeted food assistance for nearly 500,000 preschoolers and lactating mothers.

Nutrition has shown some improvement. In 1955 government statistics estimated the daily per capita available food supply at only 80 percent of sufficiency. In 1986 it had improved to 101.8 percent. In the same period, the consumption of milk nearly tripled and the consumption of fats and oils more than doubled.

The Philippines has a dual health care system consisting of modern (Western) and traditional medicine. The modern system is based on the germ theory of disease and has scientifically trained practitioners. The traditional approach assumes that illness is caused by a breach of taboos set by supernatural forces. It is not unusual for an individual to alternate between the two forms of medicine.

One type of traditional healer that attracted the attention of foreigners as well as Filipinos was the so-called psychic surgeon, who professed to be able to operate without using a scalpel or drawing blood. Some practitioners attracted a considerable clientele and established lucrative practices. Travel agents in the United States credited these "surgeons" with generating travel to the Philippines.

Although medical treatment had improved and services had expanded, pervasive poverty and lack of access to family planning detracted from the general health of the Philippine people. In 1990 approximately 50 percent of the population was listed below the poverty line (down from 59 percent in 1985). A high rate of childbirth tended both to deplete family resources and to be injurious to the health of the mother. The main general health hazards were pulmonary, cardiovascular, and gastrointestinal disorders.

The Philippines had a social security system including medicare with wide coverage of the regularly employed urban workers. It offered a partial shield against disaster, but was limited both by the generally low level of incomes, which reduced benefits, and by the exclusion of most workers in agriculture. In April 1989, out of more than 22 million employed individuals, a little more than 10.5 million were covered by social security. In health care and social security, as with other services, the Philippines entered the 1990s as a modernizing society struggling with limited success against heavy odds to apply scarce financial resources to provide its people with a better life.

Epidemics and Government Effectiveness

In epidemiology, an epidemic (from Greek epi- upon + demos people) occurs when new cases of a certain disease, in a given human population, and during a given period, substantially exceed what is "expected" based on recent experience.

Defining an epidemic can be subjective, depending in part on what is "expected". An epidemic may be restricted to one locale (an outbreak), more general (an "epidemic") or even global (pandemic). Because it is based on what is "expected" or thought normal, a few cases of a very rare disease may be classified as an "epidemic," while many cases of a common disease (such as the common cold) would not.

Early humans were no strangers to disease. They encountered the microbes that cause illness in drinking water, food and the environment. Occasionally an outbreak might decimate a small group, but they never encountered anything close to the widespread illnesses of the ages to follow. It was not until humans began gathering in larger populations that contagious diseases had the opportunity to spread to epidemic proportions. An epidemic occurs when a disease affects a disproportionally large number of people within a given population, such as a city or geographic region. If it affects even greater numbers and a wider area, these outbreaks become pandemics.

Epidemics affecting the Philippines

AIDS

The Philippines is a low-HIV-prevalence country, with less than 0.1 percent of the adult population estimated to be HIV-positive. Since 1984, when the Philippines’ first case of HIV was reported, approximately one-third of diagnosed HIV/AIDS cases have occurred among returning migrants. However, because HIV testing for these workers is mandatory in most host countries, this number may be disproportionately high. As of September 2008, the Department of Health (DOH) AIDS Registry in the Philippines reported 3,456 people living with HIV/AIDS (PLWHA) - www.plwha.org . UNAIDS estimates that 12,000 Filipinos were HIV-positive by the end of 2005.

Up until 2007, heterosexual intercourse accounted for the majority (61 percent) of the Philippines’ reported HIV/AIDS cases, followed in descending order by homosexual and bisexual relations, mother-to-child transmission, contaminated blood and blood products, and injecting drug use, according to UNAIDS, with men comprising 66 percent of reported cases. However in 2007 the proportion was reversed, with homosexual and/or bisexual modes of infection surpassing heterosexual transmission — 56% versus 43%, with the figure rising to 67% for the January to September 2008 period, as against 34%.

Most-at-risk groups include men who have sex with men (MSM), with 395 new human immunodeficiency virus (HIV) infections among within this group from January to September 2008 alone, 96% up from 2005’s 210 reported infections. A spokesperson of the National Epidemiology Center (NEC) of the Department of Health says that the sudden and steep increase in the number of new cases within the MSM community, particularly in the last three years (309 cases in 2006, and 342 in 2007), is “tremendously in excess of what (is) usually expected,” allowing classification of the situation as an “epidemic". Of the cumulative total of 1,097 infected MSMs from 1984 to 2008, 49% were reported in the last three years (72% asymptomatic); 108 have died when reported, and slightly more MSMs were reportedly already with AIDS (28%).

Among MSM's, ninety percent of the newly infected are single (up to 35% of past cases reported involved overseas Filipino workers or OFWs and/or their spouse), with the most of the affected people now only 20 to 34 years old (from 45 to 49 years old in the past). The highest number of infections among MSMs is from Metro Manila, though increasing infection rates were also noted in the cities of Angeles, Cebu, and Davao. 1 to 3 percent of MSM's were found to be HIV-positive by sentinel surveillance conducted in Cebu and Quezon cities in 2001.

Other at-risk groups are injecting drug users (IDUs), 1 percent of whom were found to be HIV-positive in Cebu City in 2005. A high rate of needle sharing among IDUs in some areas (77 percent in Cebu City) is of concern. Sex workers, because of their infrequent condom use, high rates of sexually transmitted infections (STIs), and other factors, are also considered to be at risk. In 2002, just 6 percent of sex workers interviewed said they used condoms in the last week. As of 2005, however, HIV prevalence among sex workers in Cebu City was relatively low, at 0.2 percent.

Several factors put the Philippines in danger of a broader HIV/AIDS epidemic. They include increasing population mobility within and outside of the Philippine islands; a conservative culture, adverse to publicly discussing issues of a sexual nature; rising levels of sex work, causal sex, unsafe sex, and injecting drug use; high STI prevalence and poor health-seeking behaviors among at-risk groups; gender inequality; weak integration of HIV/AIDS responses in local government activities; shortcomings in prevention campaigns; inadequate social and behavioral research and monitoring; and the persistence of stigma and discrimination, which results in the relative invisibility of PLWHA. Lack of knowledge about HIV among the Filipino population is troubling. Approximately two-thirds of young women lack comprehensive knowledge on HIV transmission, and 90 percent of the population of reproductive age believe you can contract HIV by sharing a meal with someone.

Wary of nearby Thailand’s growing epidemic in the late 1980s, the Philippines was quick to recognize its own sociocultural risks and vulnerabilities to HIV/AIDS. Early responses included the 1992 creation of the Philippine National AIDS Council (PNAC), the country’s highest HIV/AIDS policymaking body. Members of the Council represent 17 governmental agencies, including local governments and the two houses of the legislature; seven nongovernmental organizations (NGOs); and an association of PLWHA. The passing of the Philippine AIDS Prevention and Control Act in 1998 was also a landmark in the country’s fight against HIV/AIDS. However, the Philippines is faced with the challenge of stimulating government leadership action in a low-HIV-prevalence country to advocate for a stronger and sustainable response to AIDS when faced with other competing priorities. One strategy has been to prevent STIs in general, which are highly prevalent in the country.

The PNAC developed the Philippines’ AIDS Medium Term Plan: 2005–2010 (AMTP IV). The AMTP IV serves as a national road map toward universal access to prevention, treatment, care, and support, outlining country-specific targets, opportunities, and obstacles along the way, as well as culturally appropriate strategies to address them. In 2006, the country established a national monitoring and evaluation system, which was tested in nine sites and is being expanded. Antiretroviral treatment is available free of charge, but only 10 percent of HIV-infected women and men were receiving it as of 2006, according to UNAIDS.

The Government of the Philippines participates in international responses to the HIV/AIDS epidemic. Most recently, in January 2007, the Philippines hosted the 12th Association of Southeast Asian Nations Summit, which had a special session on HIV/AIDS.

The Philippines is a recipient of three grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria (2004 third round, 2006 fifth round, and 2007 sixth round) to scale up the national response to HIV/AIDS through the delivery of services and information to at-risk populations and PLWHA.

Dengue

Dengue fever (DF) and dengue hemorrhagic fever (DHF) are endemic in the Philippines, where the reporting is not as ideal as in some other countries because DF and DHF are not reported separately. Heightened public awareness during peaks or epidemics has improved the reporting, which is greatly influenced by a physician’s suspicion rather than the true identification of DF or DHF.

The 1998 dengue epidemic in the Philippines was the worst in the country’s history but it underscored the bold and sometimes innovative approaches that were made to contain the epidemic. It is true that there are no existing formulae for success but sound judgment based on relevant information always saves the day. That "communities determine their own death rate" is one observation we do not wish to prove again.

Laboratory surveillance aimed at identifying the circulating viral serotype(s) is limited to two laboratories, each using a different method: viral cultures at the Research Institute for Tropical Medicine (RITM), the national reference laboratory of the Department of Health (DH), and the polymerase chain reaction technique at the St. Luke’s Medical Centre in Manila, which is one of the leading and biggest medical centers in the country. Some laboratories make use of rapid serologic tests, which have remained imperfect.

Beginning 1988, each cycle brought about significant increases in the morbidity, sometimes resulting in isolated epidemics in vulnerable communities. After the 1996 epidemic, it was predicted that another upsurge would be observed between 1999-2001, possibly aggravated by the effects of the El Nino phenomenon.

Since 1996, the DH has adapted a hierarchy of dengue warning signals (Table 1) which are aimed at alarming communities so that appropriate interventions can be taken in a timely manner. These include a dengue alert, dengue hot spot, and dengue epidemic.

The dengue alert is advised just before the start of the rainy season when DHF cases begin to peak. All 14 regions in the country have a Regional Epidemiology and Surveillance Unit (RESU) which reports through the National Epidemic Sentinel Surveillance System (NESSS) of the Field Epidemiology Training Programme (FETP) in the Central DH in Manila. Weekly trends are analyzed for the occurrence of epidemics. Dengue hot spots are defined as areas (from barangays to villages to large cities) where a clustering of cases is observed for at least two consecutive weeks. Where cases have been reported to exceed the expected range, including a significant reporting of deaths, a dengue epidemic is declared. Interventions are targeted for each of these warning signals. These include, but are not limited to, environmental and chemical vector control as well as the establishment of dengue treatment centers.

A Dengue Operations Centre (DOC) was established in the Central DH as well as in areas with widespread epidemics. The DOC was a quick-response central hub aimed at coordinating all intervention activities based on available surveillance data. The DOC had four main components: 1) prevention and control; 2) information and education campaigns; 3) case diagnosis and treatment; and 4) surveillance. Each of these components had defined goals and objectives as well as established roles and functions. All activities were supervised by a DOC manager. By synchronizing these activities, optimal utilization of existing resources prevented unnecessary costs and impractical methods of dengue control (e.g. widespread fumigation campaigns) which local government officials resorted to as a means of offsetting the public’s sometimes angry reactions.

Malaria

Malaria in the Republic of the Philippines is caused principally by P. falciparum and P. vivax, with the former as predominant species. P. malariae is occasionally reported, while P. ovale is very rare and has been reported only in the island of Palawan. Malaria is widespread in distribution with prevalence varying from one area to the other. In 1970, the malaria morbidity rate was reported to be 77.6 per 100,000 while the mortality rate was 1.8 per 100,000. Case detection activities revealed that, in 1973, the slide parasite rate was 7.2%, the annual parasite index was 6.1% and the annual blood examination rate was 8.4%. The principal vector of malaria in the Philippines is An. minimus flavirostris which breeds in clear, fresh-water streams in foothills and mountain slopes.

An. mangyanus and An. maculatus appear to play a secondary role. The vectorial capacity of the former appears to be confined only where conditions are primitive, while the latter is associated with malaria transmission in high altitudes. In the absence of fresh-water streams, the salt-water breeder mosquito, An. litoralis, assumes the vectorial role.

The epidemiology of malaria in the Philippines is addressed. Emergence of strains of P. falciparum with diminished sensitivity to the commonly used antimalarial drugs is reported in Palawan and Rizal provinces. The development of malaria control activities in the Philippines are presented. As of 1972, Cagayan Valley, Palawan, Mindoro, Sulu and circumscribed areas in Mindanao are still considered hard-core malarious areas with on-going persistent transmission.

In the Philippines, the isolation of villages or ‘barangay’ as they are known, deep in the forest or in the mountains, makes it difficult for patients with malaria symptoms to seek medical help. Malaria seriously affects six million of the country’s population of 72 million. The Global Fund is helping to achieve the national goal of a malaria-free Philippines by 2020 through support to the Tropical Disease Foundation and the Pilipinas Shell Foundation by giving the responsibility for diagnosis and treatment to locals.

Nearly 300 women from remote villages have been trained to use a microscope to detect the presence of malaria by identifying the parasite from a blood smear. Some have no education, but their skill in detecting disease in their local community is helping to save lives. Hundreds of microscope centers have been set up around the country. Enabling locals, with no prior medical training, to help in the fight against malaria is drastically reducing the number of people getting sick and dying from the disease.

SARS

Severe Acute Respiratory System (SARS) is an atypical pneumonia or a respiratory disease. Its symptoms and signs include cough, shortness of breathing difficulties, and higher fever (greater than 38 degrees Celcius).

In 2003, the DOH has reported a total of 12 probable SARS in the Philippines to the WHO. However, only two cases of death were reported. 20 days after the last detection of probable SARS case in 30 April 2003, the WHO has removed the Philippines from its list of areas with recent transmission of SARS locally.

A(H1N1)

The Department of Health (DOH) expressed gratitude to the World Health Organization (WHO) over the commendation it gave to the government agency for its swift and tireless efforts in dealing with the novel virus A (H1N1).

The WHO letter dated June 30, 2009 and signed by WHO Regional Director Dr. Shin Young-soo put on record “my personal appreciation of the exceptional collaboration established between the Government of the Philippines and the World Health Organization in the fight against Pandemic H1N1 2009. She commends the leadership and tireless efforts of the Philippine government in responding to this emerging threat to the health of the Filipino people”.

Because the DOH is set to abide by the newly recommended reporting system of WHO for A (H1N1), it is now reviewing and adjusting its surveillance systems to fit the monitoring of the novel virus in its regular surveillance of Influenza-like illnesses (ILI) in the country. Health Secretary Duque stressed that globally and locally, the novel virus has caused mild illness in the majority of affected patients with expected full recovery even without medical treatment. However, there are some cases that become serious especially if the patients have underlying pre-medical conditions. Like the other seasonal flu strains, A (H1N1) can cause severe viral pneumonias and other flu complications.