Feelings of shame resonate, especially with the more serious B and C, conditions that to the untutored mind are hallmarks of living it up to unhealthy excesses-indulging in liquor, drugs, and carnal pleasures.

    It doesn't help that many people living with the condition are hard put to tag the circumstances that led to their encounter with the virus. In cases where it is the mother who apparently imparted the scourge to their children, it takes on the dimension of a cruel, life-long puzzle.

    Fear spikes up and becomes as chronic as the disease itself, unless you get off with a light sentence by having "only" hepatitis A. It isn't just the shapeless fear of knowing that you are now a strong candidate for at least one kind of cancer and that your liver has become a ticking time bomb. It is also the apprehension of how the society might judge you and the effect on your prospects of being a part of the workforce.

    The five patients documented in these stories show the different dimensions of the disease that lend it a notoriety beyond what its physical manifestation justifies.

Liquor license revoked

 

When Tony (not his real name), a fifty-something Filipino-Chinese businessman, found out five years ago that his hepatitis-B viral load was very high but that the pathogens were inactive in his body, he took that as a cue not only to continue but liven up his social drinking some more.

    Testing e-antigen-negative and showing up normal for other related tests, he is not about to let an apparently dormant disease cramp his lifestyle, an upper-middle class one with abundant opportunities for leisurely pursuits.

    Social drinking for Tony was no occasional fling with the bottle, nor was he confined to the low-combustion beers and wines for after-work cocktails and convivial dinners. Though not a clinical alcoholic, he ended up drinking hard liquor up to four times a week to grease connections with hard-drinking business contacts.

    This went on for about four years until his middle-aged body began to show signs that payback time has finally arrived. By the time he paid a visit to gastroenterologist Jaime Ignacio, he was already showing signs of cirrhosis. There were prominent veins in his abdominal area and an ultrasound showed a coarse echo pattern in his liver. Most telling was the rise in his level of serum glutamic-pyruvic transaminase (SGPT), a marker enzyme for heart or liver damage.

    Apart from the clinical symptoms, the patient complained of nonspecific symptoms such as loss of appetite and constant fatigue. There already lurked the suspicion that these have something to do with the diagnosis on him a few years back, so he had no qualms about admitting to Ignacio that he was found to be an inactive carrier of the disease.

    "Nabigla ako because of his seroreversion, he was e-antigen-negative before and became e-positive, presumably because of the increased alcohol intake. This is an indication that not only is his virus level high, it is also active, so he needed to be treated," said Ignacio.

    Ignacio surmised that the doctor who looked at Tony's condition five years ago was reassured enough by the findings of the preliminary tests that he didn't deem it necessary for Tony to undergo additional hepa B assays.

    Apparently, there was also no strong injunction for the patient to keep away from alcohol on pain of permanently damaging his liver.

    "The message is, even if you think you are inactive and even more so if you don't know the status of your hepatitis B, di ka na talaga dapat umiinom. Alcohol can aggravate the infection and cause problems," Ignacio warned.

    On the other hand, he quashed a popular misconception that there is a causative relationship between alcoholism and drinking. "Patients usually asks 'paano ako magkaka hepa B e di naman ako umiinom ng alak.' Alcohol intake does not lead to hepa B and vice versa. Drinking can only aggravate, and if you have a preexisting alcoholic liver disease, it can be aggravated by having hepatitis B."

    Tony was given a daily dose of oral antivirals to reduce the viral load. Ignacio found this more suitable to the patient profile compared to another popular mode of treatment, interferon injectables. He reasoned that the patient's cirrhotic condition might be aggravated by administering interferon.

    The decrease in viral load after the first two months of treatment was dramatic, from 620 million copies of virus per milliliter of blood, to less than 100. He has been taking the medication for one and a half years and will continue with it pending the stabilization of his level of ALT (alanine aminotransferase), another enzyme that indicates presence of liver inflammation.

    Beyond the medication, a more fundamental therapy was required of Tony. "I told him to stop drinking and happily, madali naman syang patigilin at painumin ng gamot," said Ignacio. He was also advised to adopt a healthier lifestyle in general through a balanced diet, adequate sleep, and exercise.

    His easy transition to becoming a teetotaler reassured Ignacio that he is not dealing with a clinical alcoholic. However, even if he can exercise self-restraint, the early signs of cirrhosis may have permanently revoked without exemptions Tony's license to alcohol.

    "The level of alcohol intake that may be toxic to a person is 40 grams a day for at least ten years. It takes that much to develop significant liver disease and even then it is still reversible," said Ignacio. Unless, he added, one is like Tony, who has reached a cirrhotic point of no return. M

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Suffer thy children

 

The eight siblings lived in a kind of blessed ignorance well into almost middle age up until their mother, the sixty-something matriarch of their affluent Chinese clan, was found to have liver cancer-a sure sign that she has been living a long time with its precursor, hepatitis B.

    It is hard enough to find one's bearing when the sudden spectre of any life-threatening illness stalks a family member. Compound it with fear for one's own vulnerability, the possible stigma involved and the ground becomes even more unsettled.

    The harrowing implication of possibly inheriting their mother's viral infection was not lost on Darwin (not his real name), the eldest son and a prominent local businessman, and on his brothers and sisters.

    Facing it squarely was another matter altogether. All are well educated and are themselves close to that time of life when every creak and ache in the constitution seems to matter. But they are also from a conservative cultural background and are rich enough for arbiters of polite society to keep tabs on. And hepatitis B is not something anyone would want reported in their "who's who" society profile.

    The siblings couched their initial state of denial by asserting the empirical evidence of the senses, seeing no point to tests when they don't see and feel anything amiss with their bodies. Their mother's attending physician, hepatologist Diana Payawal, finally managed to convince them to get tested on pain of meeting the same fate as their mother, who eventually died last year after nine years of battling her disease.

    Payawal's strong words were no empty threat after all. All siblings were found to be positive for hepatitis B, with Darwin having the most problematic diagnosis. He started treatment with interferon seven years ago in his late 30s and the disease was under control for a while. After three years, it recurred and he is now on oral treatment with no clear prospect of stopping medication as he takes quite a long time to seroconvert to an e-antigen-negative status.

    Payawal notes that Darwin's situation is sadly typical. "If a man is positive, they develop more complications early. The females, on the other hand, are the ones who pass on the disease to their kids who get it very early in life and have a 90-percent risk of developing a chronic case."

    An avid golf player with only a negligible social drinking habit to start with, the only good thing that can be said now about Darwin's condition is he is still so far evading cirrhosis. His medication remains on target toward a goal of lowering his virus load from several millions to only a few thousands.

    And perhaps unlike most of the 50 to 60 percent (roughly equal to five to six million individuals) of local hepatitis B cases that can be traced to either vertical or horizontal mother-to-child transmission, Darwin and his two other siblings who are medicating have the sustained financial means to at least even out odds against an unkind hand dealt by fate.

    Payawal observes that there are whole families of patients in the same sad boat whose only recourse is to rely on free medicine because even the cost of just medicating for one person would waste the wallet of an average wage earner.

    She hopes that recent developments in the legislative landscape may substantially cut this generational transmission of hepatitis B.

    There is now a proposed piece of legislation on the mandatory screening for all pregnant women, with provision for social-insurance reimbursement of the cost of vaccinating an infant born to hepatitis-B-positive parents. It has also been recently recommended that vaccination be done at birth instead of waiting for at least three months for the first shot.

    These may come a bit late for Darwin and others like him who had to deal with an affliction coming out from the left field aside from the usual suspect diseases of middle age.

    Yet amidst their travails, there was room for filial virtues to shine through. "Not one among these patients," says Payawal, "has ever blamed their mother for their condition. And that's a good thing because it would have been even harder to deal with someone sick as well as angry." M

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A burden at work

 

They stand almost opposite each other in their respective career tracks as health-care providers, separated by a full generation of work experience. One is an aspiring nurse and college athlete in his early 20s. The other is a 55-year-old nursing aide and public servant.

    Donny and Mang Jose (not their real names) don't know each other from Adam. But a common fear clouded their professional prospects for a time within an industry they are both devoted to spend their most productive years.

    Donny learned with a shock that the joke was on him days after he himself started tongue-in-cheek speculations about hepatitis-screening results for students going into hospital work. Advised he had hepatitis B and then asked to shift courses by his college dean, he was as good as told that he had no future in what is already his second profession of choice, after a serious knee injury aborted earlier dreams of becoming a professional athlete.

    Hepatitis C, on the other hand, is the bane of Mang Jose's existence, aside from diabetes and hypertension that is. After he was diagnosed two years ago, there was more than a flicker of worry about repercussions on his employment with a Metro Manila hospital.

    A former barangay captain reelected for as many times as the law allows, he was way below his usual buoyant disposition at work in the first few months of coping with the bad news. He kept to himself so much that his family didn't even know until someone else informed them about what's going on.

    Working for the hospital since 30 years ago, Mang Jose got more of sympathy than discrimination from his superiors and colleagues, not least because of a creeping suspicion that he might have contracted the virus during a long stint in the hospital operating room back when hygiene guidelines were not yet so strict. More than a fourth of the estimated PhP1 million medication expenses he required for a one-year treatment was shouldered by his employer.

    He may also have scored points for being forthcoming with a condition that might have been around since the early 90s but in a milder form, presumably as hepatitis A. This earlier tentative diagnosis was in the course of his civic-spirited intent to donate blood.

    Donny has his share of sympathizers also but he was not the first nor will he be the last to fall below his school's stringent guidelines for its students. His case would have been potentially excusable. There were indications that he might have gotten infected by his hepatitis-B-positive mother.

    He has since shifted course to a nonmedical field, but the promising reduction in his viral load after a few months' medication raised his hopes of shifting back to nursing. As for getting a job after graduation with his condition, the feedbacks he gets from people in the know are mixed but not dismissive of his chances.

    With the overseas diaspora of nurses resulting in a local shortage, his chances of getting employment here are said to be pretty good. At least one organization of health-care professionals, the Hepatology Society of the Philippines, has issued guidelines not to make hepatitis B a deterrent for those affected to seek gainful employment in the country.

    For overseas employment, Donny's chances are said to depend on the discretion of potential employers. It is conceivable, he was told, for someone like him to do his job without compromising the safety of people under his care.

    "There are certain safety precautions that can be observed especially when handling things like surgical instruments," he said. "According to my doctor, there is an extremely low chance for me to transmit the virus if my viral load is below 2,000 even if I pricked myself and my blood flows into the open wound of another person."

    Mang Jose doesn't have to speculate that way about his future, except concerning personal dreams like going to the US for a vacation. Now nearing the twilight of his professional life, the most he's had to deal with nowadays are unruly patients from the psychiatry ward.

    For both men, however, some concerns just won't go away and may even imperil their gains during their first bouts with their respective strains of hepatitis.

    Between the cost of his studies and support for an infant son, Donny worries about how to sustain the expensive medication that will confine his viral load to a low-enough level to allow him to regain and maintain his slot in nursing school.

    Mang Jose admitted that the only way he has so far managed to meet his medication expenses despite a measly salary is through his relatives, friends, and other concerned citizens. Now, he doesn't see how he can move forward after the latest lab test showed that his viral load is on the rise again. M

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Imperfect indictment

 

Seventeen-year-old hepatitis A patient Raoul (not his real name) is a classic case. But not because being young, male, and a bit careless, he seems predisposed to treating street food, the commonly thought hepa A stomping ground, as par for the course to having a stomach for adventure.

    What made him typical is his imperfect memory of how the virus could have found its way into his body, and the obvious relief which greeted the news that it was only hepatitis A and not the other ones appended with other letters of the alphabet.

    Jaundiced by the time he consulted Dr. Jose Sollano at the University of Santo Tomas Hospital, the boy ruled out being infected by a classmate. Quizzed on his eating habits, the boy was either sincerely unable to recall details or was not willing to admit in front of his distraught mother that he has been eating somewhere unsafe outside of their home.

    Yes, he grudgingly admits, he has been eating in a street place near the school, but the food was cooked and he has been eating in the same place for months, even years. He was not very forthcoming about other risky instances that possibly go with the territory, like taking his dessert in a halo-halo stand, or snacking on fish balls and other skewered delicacies of the streets.

    His mother and doctor were willing to let it go at that. The boy may have suffered enough to learn his lesson. He has had to absent himself from class, too weak to go out of the house after a 10-day bout with a low-grade fever, two days of loose-bowel movement, and loss of appetite.

    With an SGPT (serum glutamic-pyruvic transaminase ) result of 300, Sollano advised him to take even more time off from school-at least one more week of rest-and then come back to the hospital to check if his viral load had become low enough to permit more mobility. Any higher than 300 or 500 in viral load and Raoul would have been confined to the hospital with a dextrose, to make sure that his rest and food intake is monitored.

    Although it is easy enough to indict street food sellers for what happened to Raoul, Sollano cautioned that such a foregone conclusion might be a bit hasty and unfair, based on his clinical experience with similar patients.

    "Most patients won't be able to tell you anything unless they have been close to an office mate or classmate who is obviously jaundiced. Kalimitan ay haka-haka lang because Filipino patients tend to be not too sharp in remembering things," he notes. "They will only remember if there was a special occasion when they ate something suspicious, like going to Cavite and eating shellfishes."

    Or if feasting on street fare is such a regular thing for the patient that they can readily attest to what they had been eating a month or so ago, the intervening time before the hepatitis A virus becomes symptomatic.

    Sollano adds that while doctors warn patients to be careful and vigilant about what and where they eat, such a warning has a lot of latitude not confined to singling out and condemning roadside cuisine.

    "It's all about being mindful about food preparation, storage, and instances of contamination for both the customer and food sellers. Eating in the streets can be culturally and hygienically acceptable," he explains. He notes that in neighboring countries like Thailand, Burma, and Vietnam, eating on the streets is part of the culture, and yet, reports of hepatitis A epidemics from these parts are rare to nonexistent.

    Such mindfulness is easier said than done, of course, with zillion of things to consider in between harvesting the produce or catching and slaughtering the livestock and laying out the actual meal.

    So short of having food-sanitation inspectors always on the prowl to monitor food hygiene, Sollano sees eating food from the house, where the kitchen environment is more controlled, as the most practical option to guard against hepatitis A, typhoid, and other food-borne bad microbes.

    Raoul's mother is definitely laying out plans to make packed lunches to school an option for the boy, who, as of this writing, is back home eating a lot of pastries, the only food that goes down easy nowadays on his listless stomach. M

 

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