Interview performed and written by Gokul Kalyanasundaram, 2nd-year medical student at Albany Medical Center
August 9, 2021
In an effort to shine a light on the wonderful humanitarian work being done by Dr. Tud and her colleagues at the Philippine Orthopaedic Center, we recently interviewed her by phone and wanted to share the amazing things we learned about sarcoma care, medical care in general, the hardships the Covid-19 pandemic brought to most of the country and the unbelievable heroic efforts being made day in and day out. Truly an inspiration to have met and have her institution’s engagement with SarcomaStrong. Leading the way this year with over 50 participants for SarcomaStrong’s Global 5k this weekend, far surpassing any other country this year.
The entire Orthopaedic Oncology unit at the Philippine’s Orthopaedic Center is composed of a secretary, 3 chemotherapy nurses, one medical oncologist, one fellow and two active orthopedic oncologists. There are two residents rotating at the Center every month.
- The care of sarcoma brings unique challenges. How are sarcoma patients cared for in the Philippines?
In the Philippines, we don’t have universal healthcare care, so almost all the expenses associated with healthcare are out-of-pocket. Only a few people have enough money to purchase their own healthcare insurance. As is the case with many other countries, in the Philippines, we have two types of hospitals: the government funded hospitals and the private institutions. Right now, I am a consultant at the Philippine Orthopaedic Center which is the only orthopaedic subspecialty government institution in the country. Most of our patients are indigent and do not make the minimum wage which is $11 a day in the Philippines. It is very difficult for these patients because they need diagnostic imaging and laboratory exams for neoadjuvant treatment, surgery, and adjuvant treatment. This often means that they have to pick between eating versus getting labs or diagnostic imaging done. If we ask some of our patients to get an MRI done today, a lot of them will have to save to get the MRI done after 2 to 3 months. This is very difficult for us because sarcomas are very aggressive, and they will have changed by then. Also, not everything that is necessary for treatment of the patients can be covered by the institution. Often, I have to spend for my patients because you get to a point where you are tired of seeing people endure negative consequences just because they don’t have the money to pay for treatment.
In a private institution, you can really see the disparity between the income sizes. In the private institution where I spent my residency, if I requested an MRI today, it could be done tonight or maybe tomorrow because they have the means to pay for the diagnostic imaging. For patients in the ER who have a fracture, if we schedule them for surgery the next day in the private institution, they would be able to afford it. In contrast, at a government institution, they would need a month or two to prepare for the implants. So outside of the tumor unit, we get a lot of malunions and nonunion just because we are waiting around. In this country, patients who can afford it can get a lot of the imaging and other ancillary procedures done right away and we can provide them with the optimal care as is the case for the US.
- How is care provided in the Philippines similar to the care provided elsewhere internationally?
The focus often tends to be on the differences in sarcoma care between different countries, but in a lot of ways, the care is still the same. In general, the idea is to get to the patients early, provide them with the best care, and increase public awareness of the disease. Our goals are the same and the care for sarcoma is a lot more similar than we think. It is just the logistics and circumstances that make it difficult. I’m glad I could do this interview because this is something I have wanted to get across. It is unfair that some patients have to contend with worse care than others just because they don’t have the means, but that is the sad reality for us here.
- How is your team working to improve care for sarcoma patients?
As a specialty, orthopaedic oncology in the Philippines is relatively young. The two main programs for orthopaedic oncology are the Philippine Orthopaedic Center and the Philippine General Hospital, and they both started around 1993. Because of economic and sociopolitical reasons, not every government institution gets the same funding, so each institution is kind of forced to find ways to be creative to deal with challenges. At the national level, we have the Philippine Musculoskeletal Tumor Society where we exchange ideas about how to help patients, but at an institutional level, it comes down to individual units. For my college and medical school training, I attended a Jesuit institution where the focus was finding creative ways to serve others in need, and I have brought that experience to the Philippine Orthopaedic Center. I have joined organizations like Sarcoma Strong and performed research which allows me to visit other places outside of the country. My thinking is that it is not sustainable for me to keep paying for my patients but if I bring awareness of my patients and the situation in my hospital, then maybe we can get more attention and people can see how difficult the situation is. It actually worked a little bit last year since we received a lot of donors that provided implants for patients, and that was a really big blessing.
- What drew you to Orthopaedic Oncology?
For most orthopaedic surgeons in the Philippines, throughout their 4-5 years of training, they only get 10-20 orthopaedic oncology cases. However, in my residency training, I was part of an institution where there were five orthopaedic oncologists. That’s a big deal because there are only 40 orthopaedic oncologists in the Philippines. I started by writing a case report when I was a first-year resident and it got picked to be presented outside the country. Then, I started being asked to assist the orthopaedic oncologists at my institution and that developed my interest. Initially, I was interested in spine surgery, but I became more interested in orthopaedic oncology after I started assisting and writing papers. It was really gratifying, especially the limb salvage procedures!
- How has the COVID-19 pandemic affected your practice?
We felt the brunt of it last year, and the Philippines has been in various lockdown iterations since March 2020. We were not able to do effective contact tracing and testing, so the spread of COVID-19 was hard to control early on. In Manilla, the general hospitals were converted to COVID-19 centers, and they received COVID-19 patients from other hospitals. The Philippine Orthopaedic Center is a specialty center, so it was not converted to a COVID-19 center. We stayed open while other orthopaedic centers closed so we started getting 30-40 sarcoma and carcinoma cases every day. Right now, our inpatient census never goes down below 20-30 inpatients just for sarcoma and carcinoma patients. Another difficulty is that vaccinations have been slow and less than 5% of the 100 million Filipinos have been fully vaccinated. The majority of health care providers have been vaccinated, but we face a lot of exposure because we go to work every single day and we have so many patients. By January of this year, everyone was getting tired of the endless lockdown, and the Philippine Orthopaedic Center was getting 300-500 general orthopaedic patients a day at the outpatient department and between 30-50 were tumor cases. Inevitably because of all that exposure, I caught COVID-19 despite wearing PPE. In March of this year, there was a week where over 100 of us healthcare workers in the hospital caught COVID-19 because we were handling so many patients. For the patients, COVID-19 has led to new requirements before their surgery. They have to get a swab, and it has to be negative, and before diagnostic imaging, they need an antigen test. Because most patients cannot pay, the unit often covers costs, and that has been quite difficult. Last year, because the lockdown restrictions were so strict, one of the main challenges to treatment was transportation. Patients couldn’t make it to the hospital because many of them don’t have a car, so they need public transport. Some of them come from different islands so they need boats and because many of those modes of transportation stopped, they would come in very delayed with huge sarcomas and metastases. Sometimes, they would need a transfusion but all the blood banks in Manilla ran out because no one could go out to donate blood. It was a really tough time, but we somehow made it through. I did do an analysis of our cases and compared to the previous year, there was a 15% increase in amputation surgeries compared to limb salvage procedures in 2020. That was the main objective thing that we found because people were arriving so late and so sick.
- How did you hear about Sarcoma Strong and how did you recruit your team?
I am responsible for trying to make a social media presence for my unit and many of the Filipino patients are on Facebook. Funnily enough, most of our patients cannot be contacted via cellphone numbers but will somehow be able to respond via Facebook. There were also more people responding to calls for help on Facebook versus all the other platforms. I encountered Sarcoma Strong because I was already following the Sarcoma Foundation of America on Facebook and Sarcoma Strong showed up on my feed. My team includes many friends from college and high school who want to help but are not in the medical field. They have been seeing my posts and asked how they could participate because it was such a good cause!