Fighting Cancer in the Philippines
The house in Royal Valley was the same. With a doorway missing a door and a window missing its glass panes, the tiny house built of surplus materials offered little separation from the outside world. Moist air settled in the living room, bedroom, and kitchen.
It was a Sunday, a few hours after sunset. Only three hours before, I had exited a Cebu Pacific plane and entered the terminal of the small airport 10 kilometers northeast of downtown Davao, the capital city of Mindanao, the poorest and southernmost large island in the Philippines. The city had a population of 1.5 million, much smaller than Manila where I had stopped for two days.
In the living room, my eyes caught the shape of a person lying on a mattress on the floor in the shadows. After a few seconds, I recognized Gia, 34 years old, wearing a thin cotton gown.
“I have a fever,” she said, turning toward me and adjusting a bandage on her forehead. She was 33 years old and had long, dark hair. She switched on a small lamp next to the mattress. A single bulb cast an orange light in the moist air. Above her, attached to the wall, I glanced at the air-conditioning unit which emitted a steady stream of cool air and made a low humming sound.
It was late October with the sky threatening rain once again. I sat in the same plastic chair I had occupied on previous visits. I felt as if this one would be my last. I knew that Gia was fighting the pain and that she was losing hope.
Report on Cancer
On November 1st of 2016 the American Cancer Society and the pharmaceutical company, Merck, released a sobering report, “Global Burden of Cancer in Women.” The number of women who will die from cancer each year, according to the report, will rise from 3.5 million in 2012 to 5.5 million in 2030, an increase of 60 percent in two decades. Where many people assumed the death rate would drop, with advances in technology and medicine, it rose.
Cancer kills one in seven women worldwide, making it the second most lethal cause of death after cardiovascular disease. The report compared data for women with cancer in a developed country, such as the United States, to data for women with cancer in developing countries, such as the Philippines. In developed countries, breast, lung, and colorectal cancers were the most prevalent; in developing nations, breast, cervix, and lung malignancies were the most common. But in 39 of the poorest nations cervical cancer was at the top of the list.
Gia had a modest business selling health and beauty products over the Internet and had been looking forward to getting married before she got sick.
The oldest of five children, Gia lost her father when she was nine. While her mother, a woman with little education, took whatever jobs she could to support the family, Gia took care of her three sisters and one brother. When Gia was 19, she decided to move to Japan to start a career in Tokyo’s karaoke bars. Then she learned that the Japanese had cancelled the visa program for workers from the Philippines.
Instead of moving to Tokyo, Gia moved to Manila, the Philippine capital, on the island of Luzon, where she lived for the next 12 years, working in various call centers as a customer service worker.
Now Gia lay on a mattress under her mother’s roof, too sick to take care of herself.
Globally, cervical cancer is the fourth most common cancer and the fourth leading cause of death among women. However, in poorer nations, it is the second most common form of cancer and the third leading cause of death.
Almost 90 percent of all deaths from cervical cancer occur in developing nations, such as the Philippines.
Medical researchers now consider the human papillomavirus, or HPV, transmitted through sexual intercourse, the cause of cervical cancer. More than a hundred types of HPV exist, but only a few of them cause cervical cancer. The International Agency for Research on Cancer has classified 12 types of HPV as carcinogenic for humans, including types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59. Of these 12 types, the most common are 16 and 18. They cause 70 percent of cervical cancers worldwide.
“Yesterday I went to the hospital,” said Gia. “The results of my latest urinalysis were ready. I have a urinary tract infection.”
A small child burst into the room, almost falling with every step she took. It was Cookie, the daughter of Gia’s youngest sister, Mabel. The little girl stopped, three feet in front of me. She stared at me, uncertain what to do next. The last time I had seen Cookie she was not yet walking.
The catheter attached to Gia deposited urine into the bag at her side. I watched the flow of yellow liquid. “The urologist told me there was nothing he could do,” she said. “The only one who could help me now, he said, was the oncologist. I have cervical cancer, stage III b.”
Cervical cancer, like other forms of cancer afflicting women, is, however, preventable. A vaccine exists to protect women against HPV. Also, screening tests, such as the Papanicolaou or Pap test, enable doctors to detect and remove pre-cancerous lesions.
According to guidelines which the World Health Organization sets, girls between the ages of nine and 13 should be the primary targets of the vaccine. Older adolescent girls and young women can receive the vaccine, too, but they should be considered secondary targets, depending on the availability of supplies.
The two to three generations of women around the world who have not received the HPV vaccine or who already have been infected with HPV must turn to screening tests. For such women, the objective is to check for a lesion that can progress to cervical cancer if left untreated.
The Pap test is the conventional screening method, but access to it, as to the HPV vaccine, can be problematic in developing countries.
For Gia, no vaccine or screening test would help her now. She needed treatment for the cancer in stage three of its four-stage progression. With radiation therapy, the oncologist could shrink the tumor blocking the flow of urine. Until then, Gia would not be able to urinate on her own. But only chemotherapy would kill the cancer.
The previous Monday, Gia finally had started radiation treatment. Three months had passed since doctors at Southern Philippines Medical Center, the government hospital in Davao, confirmed their diagnosis. But for weeks Gia had languished on a bed in the cancer ward of the hospital, receiving only pain medication. The tumor had doubled in size.
Gia, with little money, was not a priority.
Now, with funds from two aunts, one in the Philippines and one in Germany, Gia was able to start radiation therapy. She had a radiation session once a day, five times per week at Davao Doctors Hospital, the most modern health care facility on the island of Mindanao. She was supposed to have a total of 33 sessions of radiation therapy. Also, she was advised to have six sessions of chemotherapy and three sessions of brachytherapy.
But Gia still didn’t have enough money.
The global economic burden of cancer, according to the report from the American Cancer Society and Merck, is growing every year. Expenditures for the early detection of cancer and for treatment continue to climb.
Around the world, high costs lead to inadequate treatment. Larger cities are more likely to have the infrastructure for cancer care, as well as a higher proportion of people who could afford the care. Lower-income individuals in rural areas are less likely to have access to cancer care.
Rodrigo Duterte, the new president of the Philippines, soon may allocate funds to vaccination programs as part of his plan to boost investment in the island of Mindanao, especially its capital city, and also his hometown, Davao. But to date Duterte has focused on waging a war on drugs, not on health care.
Due to high costs, many chemotherapeutic agents are not part of essential medicine lists in poor countries. The median number of oncology-essential medicines in a recent study ranged from 11 in low- income countries to 18 in lower middle-income and 26 in upper middle-income nations.
The high costs of treatment attest to the importance of cancer prevention measures in developing countries. It has been estimated that an investment of $11.4 billion in preventive health care in developing countries could save up to $100 billion in cancer treatment costs.
“The Baptist church next to SaveMore donated the air conditioner,” said Gia. “Mama went to them and asked for help.” Gia laughed. “I don’t think I could survive without the air conditioner. My stomach feels like it’s on fire after a radiation session. If I can have the chemotherapy, the burning sensation will be even worse.”
“Arequa,” Gia said, uttering a word in Bisaya. “I don’t know what I will do when the money for my treatment runs out. Mama will have to ask for more charity.” She started to turn over on the mattress, then stopped, reaching down toward the catheter between her legs.
“You better go now,” said Gia.
If a poor country such as the Philippines had a national immunization program including the HPV vaccination, it could greatly reduce the number of victims of cervical cancer.
In one recent global study of the net cost of HPV vaccination, analysts from the World Health Organization found that Africa and Southeast Asia are the regions of the world in which the cost-effectiveness of HPV vaccination programs are highest.
While spending in Southeast Asia is almost $400 million, or 10 percent of spending worldwide, the number of cervical cancer deaths prevented in the region is 150,000, or 36 percent of all such deaths worldwide. In another recent global study, analysts found that a screening program based on HPV DNA testing of 70 percent of women at ages 35, 40, and 45 can prevent 25 percent of all cases of cervical cancer.
“My only hope is to make it through this month,” said Gia. It was a Friday at the beginning of December. I was back in the primitive living room of the small structure on the outskirts of Davao City, in the southern Philippines.
“In January, my health insurance benefits will renew with the new year,” she said.
For 2016, Gia had exhausted her benefits from the Philippines’ national insurance program, called PhilHealth. Now she was able to pay for treatment only through charitable contributions. “I’ve completed 23 radiation sessions,” she said. “My oncologist says I need only five more in December. The goal is to shrink my tumor to three centimeters by the end of the month and, then, in January to target it with high doses of chemotherapy.”
Gia’s tumor had grown from four-and-a-half centimeters at the end of August, when Gia received her diagnosis, to seven centimeters at the beginning of October, when she started receiving treatment.
“But I need $500,” she said.
I had given her all the money I had.