“Spot sa baga, mahina ang lungs.” These are just two of the euphemisms Filipinos use to refer to tuberculosis (TB), the disease caused by Mycobacterium tuberculosis. Historically, a lot of shame and stigma have been associated with a diagnosis of tuberculosis. It is still seen as a disease of extreme poverty, and people mistakenly assume that you lack the resources to take care of your health, which is why you ended up with TB. While crowding in slum areas and poor air circulation contribute to the transmission of tuberculosis, both rich and poor people can be victims of this infectious disease.

President Manuel Quezon, the second president of the Philippines, died of tuberculosis. Many famous people throughout the world were victims of what was also known as the “white plague,” including Charlotte and Emily Brontë, Franz Kafka, Frederic Chopin, George Orwell, and Robert Louis Stevenson. Kings and emperors were not spared either. Without proper treatment, more than half of people with tuberculosis die within five years of the diagnosis.

Tuberculosis has been afflicting humans for thousands of years. Egyptian mummies with disease manifestations of tuberculosis have been documented, and written accounts of tuberculosis infections exist from ancient China and India. On March 24, 1882, Robert Koch announced that he had discovered the causative agent of TB. Since then, March 24 has been memorialized as World TB Day.

The latest Global Tuberculosis Report from the World Health Organization shows that tuberculosis infected 10.7 million people in 2024, with 1.23 million deaths. The good news is that effective treatment programs have saved over 88 million lives since the year 2000. The Philippines has the third-highest burden of tuberculosis infection worldwide after India and Indonesia. We are one of only four countries in the world with a TB incidence of at least 500 cases/100,000 population, along with Lesotho, Kiribati, and Papua New Guinea. Needless to say, we still have a long way to go in terms of addressing our tuberculosis problem in the Philippines.

Tuberculosis manifests itself in different ways. Most Filipinos get exposed to tuberculosis as children since there are so many people infected in the community. Some children develop active lung TB when they are first infected. This is known as a primary complex, which requires medical treatment. Some immunocompromised children develop disseminated or miliary tuberculosis, which can be life-threatening. Fortunately, most children can mount a competent immune response, and so the disease does not progress. This condition is known as latent tuberculosis, and up to 70 percent of Filipinos fit this category. The TB bacilli are trapped by the body’s immune cells and are unable to multiply. The body, however, is unable to kill them due to the nature of the bacteria, and the body and bacteria reach a stalemate. We do not usually treat latent tuberculosis locally since most people have been infected for a long time, and the benefit of treatment is uncertain. Many countries, like the US, however, do treat latent tuberculosis with a short course of medication because they are trying to eliminate tuberculosis. If a person with latent TB experiences a waning of immunity, he or she can lose control of the TB bacteria, resulting in reactivation and progression to active tuberculosis.

The form of TB that most people are familiar with is active tuberculosis in the lungs, which is formally known as pulmonary tuberculosis (PTB). The symptoms of PTB evolve over several weeks to months and include a chronic cough, weight loss, and afternoon fevers with sweating at night. If it is not promptly diagnosed, blood in the sputum (hemoptysis) can start to appear. As the bacteria eat further into the lungs, a potentially fatal lung hemorrhage can develop. PTB gradually destroys the lungs and can lead to respiratory failure and death. People with PTB are contagious. Mycobacterium tuberculosis bacteria can be aerosolized with each cough and infect other people, especially those who live in the same household as the patient.

Another common manifestation of TB is an infection of the lymph nodes, usually in the neck area. The lymph nodes enlarge, and some eventually burst open, with thick, cheese-like pus coming out. This is known as TB adenitis, or scrofula. Unlike PTB, scrofula is generally not contagious, but it can be painful and disfiguring. Virtually any organ can be affected by TB, from the skin, the gut, the kidneys, the bones, and the brain. TB in the brain, known as TB meningitis, is uniformly fatal if untreated, and has a high mortality even with treatment, especially if diagnosed late. Those who survive can have significant neurological impairment, such as strokes, hearing loss, and hydrocephalus (increased pressure from water in the brain).

Prior to the discovery of effective antibiotics, the treatment of TB consisted of rest, a healthy lifestyle, and any number of folk remedies which weren’t very effective. Some patients underwent lung surgery to remove the diseased parts as a last-ditch effort to cure the infection, but this was very risky. I remember encountering some elderly patients during my time in medical school who had had this kind of surgery and survived.

It wasn’t until the discovery of streptomycin in the 1940s that TB finally became treatable. Unfortunately, tuberculosis proved to be a very hardy opponent. It can become resistant to single medications, and modern regimens use combination treatment with multiple antibiotics for months at a time.

As with most diseases, the earlier tuberculosis is diagnosed, the better it responds to treatment. Anyone with a chronic cough, unintentional weight loss, and/or persistent afternoon fevers should see their doctor and be worked up for tuberculosis. Since the Philippines is committed to decreasing the burden of tuberculosis in the country, diagnostics and treatment for tuberculosis are available for free at the nearest TB DOTS center. If you are diagnosed with PTB, it is very important that the full six-month course of medication be completed because tuberculosis may become drug-resistant with inadequate and haphazard treatment. The ultimate solution to defeating tuberculosis in our country depends on a strong partnership between the government, the private sector, healthcare workers, and the patients themselves. The success of the program depends on overcoming stigma so that patients seek care early, complete their entire course of treatment, and stop the cycle of infection.