Name: PSN is 50 at 2022: Weathering the Storm - Philippine Society of Nephrology
Uploaded: 2021-09-15
Duration: 2 min 53 s
Description: PSN is 50 at 2022: Weathering the Storm

PSN is 50 at 2022: Weathering the Storm

Reina Lynn Antonio, MD

Because the Philippines belongs to the Pacific Ring of Fire and is located along the Typhoon belt in the Pacific, it is frequented by volcano eruptions and earthquakes and visited by an average of twenty-three typhoons per year, of which five are damaging.

And being near the Pacific oceans, the Philippines likewise experiences El Niño caused by the warming of sea surface temperature in the Pacific that affects the air and sea currents, resulting in reduced rainfall leading to dry spells and droughts.

Hence, practicing Nephrology in the country is quite challenging. As apart from the disasters and calamities, Filipino Nephrologists face trials from the Bureaucratic health care system, the poverty rates that affect the economy and access to health care, society’s great expectations, incurable diseases which are also deemed fatal aside from this COVID 19 Pandemic, and the imbalances in the career and personal life.

During the early years of Nephrology in the Philippines and before the advent of hemodialysis, peritoneal dialysis, perseverance and dedication were our predecessors’ instruments in saving patients with acute renal failure. Dr. Antonio Talusan, who was based in Manila, travelled back and forth to Baguio City for weeks with a carload of Inpersol solution, administration sets and stylocath to dialyze patients and train nurses. He also responded to an emergency referral from Zamboanga City to initiate peritoneal dialysis, when a patient with Malaria and kidney failure was not allowed to fly in a commercial plane to Manila. The patient regained consciousness on the fifth day of dialysis.

And necessity is indeed the mother of invention as Dr. Talusan had to use a nasogastric tube, intravenous administration sets for the tubing, and reconstituted fluid for dialysis solution when he initiated the emergency dialysis of a patient in Tagibiliran, Bohol. Materials were not available back then, but through Dr. Talusan’s resourcefulness, the patient was saved and her kidneys’ function recovered.

Peritoneal dialysis too became the tool of Nephrologists to save lives in 1968 when a strong earthquake hit Manila and caused the collapse of the Ruby Tower in Sta. Cruz, as recalled by Dr. Eduardo Gotamco Tan. Many people perished and those who were rescued were suffering from severe dehydration and renal failure as it took a week to find them. Many survivors had their kidney function recovered due to the timely administration of dialysis.

But with advancement of technology and knowledge in Nephrology, practice was streamlined. Efficiency and productivity increased. Everything even became automated. And this progress too reached the shores of the Philippines, equipping Nephrologists to serve a greater number of Filipino renal disease patients to achieve healing and/or comfort at safer and more affordable cost.

However, natural disasters strike unpredictably and could affect any nation and everyone. But the impact is more pronounced on countries and citizens with low socioeconomic status, as destruction to properties, financial losses and personal injuries or sickness and even death, are more tremendous. And unfortunately, with lack of resources and communication, the response and information dissemination seemed slow and inadequate too.

Dr. Myrna Ngo, one of the long practicing Nephrologists in Manila, admitted that during those times when technology in communication was not that advanced yet, she was not informed or asked for any help she could offer, hence, she had no recollection of what had occur with the other chapters nor within the PSN during the 1990 massive 7.7 magnitude earthquake that hit Baguio City, that was also felt strongly in Manila, nor the 1991 Mt. Pinatubo eruption in Botolan, Zambales.

And PSN members were very few back then.

But despite all of those challenges, PSN members were always ready to take up the challenge to serve the community.

Dr. Renne Toledano of San Fernando, Pampanga recalled that he was the only Nephrologist in that province back then. During the Mt. Pinatubo eruption in 1991, he was still in fellowship training. And it was considered the world’s largest volcanic eruption to happen in the past 100 years. And I personally remembered seeing ashes in my whole neighborhood here in Manila that time, as record showed that fine ash of Pinatubo eruption fell as far away as the Indian Ocean and tracked several times to have travelled around the globe according to Phivolcs and US Geological Survey (USGS). Angeles, Pampanga was greatly affected during the eruption, as it was located in the higher grounds, Dr. Toledano recounted. It was nearer Zambales, where Mt. Pinatubo is. Everything was covered in the same shade of grey that time. Gone are the green fields, infrastructures and properties. And everyone thought after the eruption, it was over. But Phivolcs and USGS reported that with the ashfall came darkness and the sound of lahars or volcanic debris with water rumbling down the rivers. Several of the mud flowing across the base in enormously powerful sheets and slammed into infrastructures and cars, scattering them like toys all over the place. While towns were buried in it, nearly every bridge it passed within 18 miles of Mt. Pinatubo was destroyed. And the nightmare of the lahars continued for years. So that when Dr. Toledano was finally practicing as a Nephrologist in 1993, the devastation was more severe especially in the lowlands, like San Fernando, due to the mudflows. As every year there was increase in amount of rainfall, and typhoons even visited the provinces affected by Mt. Pinatubo eruption, hence, lahar continued to form and flow. And the Mega Dike, that could have help mitigate it, was only constructed in 1996. Dr. Toledano remembered during these early years of his practice that there were only two dialysis units in Pampanga. One is in Angeles University Foundation Medical Center (AUFMC) and the other in San Fernando. As lahar sought its way into his newly set up dialysis unit, they were in desperate haste to salvage the dialysis machines. Operation was suspended, as some of the machines were damaged by the lahar. Regular dialysis patients there were transferred to AUFMC, while the indigent patients had to miss their treatments for one week, while Dr. Toledo and his team re-install the HD machines and set up the unit. And they did their best to re-operate for these patient’s sake as soon as possible. His clinic was also drenched in lahar so he had to communicate with his patients through phone calls, as technology in communication did not offer Teleconsult yet. And they passed the crisis and averted further devastation after. And to Dr. Toledo’s knowledge, no dialysis nor renal patient succumbed to death that time, as they were able to immediately resume their treatments.

Then, came the Mayon Volcano eruptions in 2018 in Albay. Fortunately, no major casualties or damages were incurred, but the PSN members in the locality were in constant alert and fear of the worse scenarios the eruptions could result into. But at the same time, always prepared and ready to relocate and serve their patients for the continuation of their renal care.

And in the early part of 2020, another volcano erupted, the small but terrible natural wonder Taal Volcano in Batangas. The local PSN chapter led by Dr. Doray Valenzona responded efficiently as the several municipalities were affected. Phivolcs reported a total of 44 earthquakes in the towns of Calica, Laurel, Lemery, Mataasnakahoy, San Luis, Taal and Talisay in Banatngas and Alfonso in Cavite were experienced and causing damage to roads and other infrastructure. And despite early evacuation of about 14,000 people from nearby townships by the local government, the deadly eruption in that year left 39 people dead and hundreds of locals displaced. Nephrologists in the chapter promptly responded and supported one another as they dialyzed and monitored patients that were relocated to nearby towns to the affected municipalities. Dra. Maria Caridad Pasno accommodated the displaced ESRD patients in their dialysis unit, where other chapter members took turns to go on duty, until Dr. Pasno’s town was also affected by the eruption and earthquakes. No reported casualties among renal disease patients due to their selfless efforts and commitment to service.

But Philippines is more known as the Most Storm Exposed Country on Earth. And we used to designate each storm after women with traditional female names in alphabetical order. And always, all the letters in the alphabet are used up by the end of the year.

Dr. Lorna Wong in Albay narrated how Typhoons Milenyo and then, Reming hit their province in 2006. Damage to infrastructures isolated Legazpi City especially due to Reming that time. No transportation, electricity, clean water supply and cell phone services. Banks were even closed. So everywhere, there was a long queue to procure the basic needs for survival. And the health system was also affected as hospitals were even submerged in water. And as the tool of a Nephrologists in managing renal patients requires electric generators, procuring them that time was futile that Dr. Wong finally came up with the solution to dialyze and help end stage renal disease patients in her area despite no power nor water supply. She selflessly opened her doors to them by setting up an emergency dialysis clinic at her house in Daraga, where an electric generator was available and an existing drinking water refilling station was accessible. Dialysis machines were set by one of her technicians in her living room. And ESRD patients from other parts of Albay came for their treatments. Dr. Wong even recalled some of them were really uremic and congested, thus the dialysis was badly needed for their survival. And to accommodate a greater number of these patients, Dr. Wong had to adjust their dialysis prescription and reduce the treatment duration to as short as two hours or less. She and her staff were dialyzing patients up to five o’ clock in the morning, only resting to have some sleep and to cool down the generator and hemodialysis machines. Then, they would hook the next batches of patients for the day. This went on until the crisis passed. Dr. Wong and her team were their saving grace as they literally bought time for these patients. And as soon as Albay was accessible again, PSN lightened the burden as they sent funds, manpower and medical missions to help Dr. Wong and the other PSN members in helping the community recover.

And support among PSN members was also exemplified during the record-breaking floods brought about by the two consecutive typhoons Ondoy and Pepeng in the last quarter of 2009 that led to the outbreak of Leptospirosis with its major complication, Acute Renal Failure rising in incidence, hence, PSN members were called into action too as hospitals were swarmed with critically ill patients from those areas affected by the prolonged flooding. And the disaster response started becoming efficient and effective that time. Headed by Dr. Imigranda Gueco, Task Force on Leptospirosis was formed and mobilized. Good communication, especially among the members, contributed a lot to its success. Along with the other medical societies and government agencies, a guideline on management of Leptospirosis was collated and disseminated effectively. Expert advice was also provided by PSN to the Department of Health. Volunteer PSN members and fellows in training with the aid of pharmaceutical companies conducted free consultations, treatments, lectures on prevention of Leptospirosis and distributed medications during that time. It was a learning experience for most of us. And a predicament that united us. When leptospirosis outbreaks occur, which usually follows a flood causing typhoon, we became more competent and prepared. Just like in Olongapo City in 2013, when an outbreak of Leptospirosis cases was reported, but PSN members Dr. Beverly Aguila, Dr. Edison Guerrero and Nephrologists from Central Luzon and Manila, who came to their aid due to the overwhelming number of patients infected with Leptospirosis at the James Gordon Hospital, had significantly improved the mortality and morbidity outcomes for these cases.

But those storms were not yet considered the Strongest Tropical cyclones at landfall to hit the Philippines. The country was actually visited by not just one but five of the strongest typhoons recorded in the history of the world. Super Typhoon Zeb or locally known as Iliang in 1998, Megi or Juan in 2010, and the top three super typhoons with wind speed at 190 to 195 miles per hour at landfall were Typhoon Meranti or Ferdie in 2016, Typhoon Haiyan or Yolanda in 2013 and Typhoon Goni in 2020.

Typhoon Yolanda only came in second to Typhoon Goni, the strongest storm with speed of 195 miles per hour, and had same wind speed with Typhoon Ferdie, but the country and the world seemed more devastated by the destruction brought about by Hurricane Yolanda to the Philippines. As Yolanda literally flattened and almost wiped out Tacloban City from the map after the resulting storm surge and then, greatly affected the provinces of Samar and Iloilo too. And it did not only ravaged properties and infrastructures, but also took the lives of thousands of Filipinos and their livelihood. I personally recalled receiving phone calls and text messages from a Gastroenterologist friend practicing in Tacloban hours before Yolanda made landfall. He was referring the case of his renal patient to me, at that time, as most Nephrologists were out of the country for a convention and he had no one to refer to. Later, I learned that there were only five Nephrologists practicing in the areas affected severely by Yolanda and two of them were in that convention.

I was already asking my friend to prime the patient and relatives for possible hemodialysis and was giving a dialysis prescription as he updated me just before the storm surge. Then, communication halted as infrastructures were damaged as Yolanda made landfall. I was also worried for him, his family and his patient, as News was already reporting how bad the situation was in Tacloban. And when he finally was able to contact me, he too was a victim of the disaster. He narrated, in horror, his experience and admitted he thought they were going to die during Yolanda’s passing the city. Everyone there was in danger. Doctors could no longer make rounds nor think of others as their health and safety were also at risk, along with the other members of the medical community. Hospitals were also damaged. My friend’s patient, rest her soul, was one of those who succumbed to death by Yolanda’s wrath while she was admitted. He even described the nightmare of seeing dead bodies everywhere on the streets, on branches of trees and floating in nearby waters after the surge. I pictured a scene in a horror or post-apocalyptic cinema.

But like in the movies, in this one, though very scary, the forces of good ultimately prevailed. The world lamented with the Philippines and sent not only relief goods and monetary support but also, Humanitarian assistance. Yolanda, being the strongest Typhoon on record that time, and hitting a country with relatively low socioeconomic status had many other nations affected deeply. Not only doctors and other medical personnel were being sent but also those from other fields, like engineers, to help rebuild and reconnect the affected areas. It united the world.

And the PSN too sent aid as it could not even locate the three other Nephrologists in those most affected areas right after the storm surge. Facilities like hemodialysis units were down, sources of electricity and water supply were significantly damaged. Realizing that patients who had survived the calamity might succumb to death due to treatment deprivation and that the local medical team members were also victims of this disaster, the PSN along with the other medical societies and government agencies planned and assembled a medical team to bring hemodialysis to ESRD patients who could not leave the areas severely affected by Yolanda. Fortunately for some ESRD Yolanda survivors, they were able to relocate to nearby provinces and even to Manila for the continuation of their treatments. Other Nephrologists welcomed them warmly under their temporary care while the road to recovery in their hometown was started.

And many took heed of the PSN’s call for volunteers to go to Tacloban and do free dialysis treatment on ESRD patients. Nephrologists and Nurses rotated in batches for 5 days in Remedios Trinidad Romualdez Hospital in Tacloban City, where they set up the emergency dialysis unit. Medical supplies, medications and electric generators were also brought to the site. And with the help of the local medical staff, the Tacloban Hemodialysis Relief mission was put in operation from November 17-December 31, 2013. For us members who stayed in Manila and other parts of the Philippines, we became relievers for these brave and selfless volunteer Nephrologists, and donated for the medical supplies and financial assistance they brought there. A total of 418 free dialysis treatments were provided to 48 ESRD Yolanda survivors. And fortunately, there was no outbreak of Leptospirosis in these affected areas that time, as this too was monitored.

The local PSN chapter also donated 20 boats to local fishermen as their livelihood was greatly affected by Yolanda.

And it was in the same year, 2013, just less than a month before Yolanda made landfall, that a very destructive earthquake measuring 7.2 magnitude on the Richter scale shook Bohol province. Phivolcs reported the epicenter was near the boundary of Sagbayan and Catigbian municipalities and felt as far as Southern Mindanao. And according to the World Health Organization, it affected over 1.2 million people, 222 died (195) in Bohol, 976 were injured and eight were missing. Seventy-nine thousand infrastructures, including hospitals and dialysis units, were damaged and about 14,500 were totally destroyed. Leaving about 340,4000 people displaced.

Dr. Cesar Quiza and other Nephrologists in Cebu helped in relocating ESRD dialysis patients when one of the HD units located in a hospital in Bohol was partially damaged, and also came to aid Drs. Mayida Ybañez and Ronald Sales in managing dialysis patients in Bohol. Financial assistance from the PSN National and the local chapter was also donated to the victims of this earthquake.

And since one of the primary tools in management of renal patients is hemodialysis, that requires about 300-600 liters of water per week of hemodialysis sessions, depletion of water reservoirs when there is decrease rainfall or drought could mean disaster for ESRD patients undergoing this form of renal replacement therapy. This was what most of the dialysis patients in several parts of Manila experienced in March, 2019 due to an El Niño. The Angat, Ipo and La Mesa reservoirs were not rapidly replenished, hence, water supply in Manila was interrupted. Many HD patients had to be transferred to other cities for their treatments, hence, some difficulties were faced by the Nephrologists, patients and dialysis staff. And some patients had to be rescheduled too. But due to the prolonged period of water interruptions, some patients were in the predicament of missing more than one HD session. Some dialysis units bought several gallons of water from drinking water refilling stations, but Dr. Agnes Baston, one of the Nephrologists handling a dialysis unit, who also experienced this challenge, communicated with Fire stations and the Maynilad to arrange for water tanks that could be brought to the HD unit she was handling every time they reach a certain critical psi level, which was monitored by a water gauge Maynilad helped them install in their unit. And they too had a reservoir tank in their unit, where they collected water when it was rationed. Waters then passed through their pre-RO filters and RO water system before reaching the patients. And those set ups helped the dialysis units in Manila go through this crisis.

But not all the storm weathered by the PSN and its members are from natural cause.

PSN is a closely knit family, as described by Dr. Coralie Therese Dioquino-Dimacali. And all families experience conflict at some point or another. At the time when the PSN made a stand on Organ Trafficking in Kidney Donation and Kidney Transplantation in the country in 2009, the discussion on the issue almost created permanent rifts among members. It almost divided the PSN. A policy was devised by the PSN leadership led by Dr. Lynn Gomez and Dr. Albert Chua that time, where there was prompt and transparent communication on the organ trafficking issue with the members. Ultimately, the majority of the PSN members were in support of banning foreign recipients and that only deceased donors, living related donors and direct living non related donors with social/emotional ties would be allowed in Kidney Transplantation in the country. And thankfully, in the end, all members maintained a healthy respect for each other’s individual views. Proving that everyone values the solid and cohesive relationship we have within the PSN more than anything else.

Armed conflicts most often lead to forced migration, long term refugee problems and destruction of infrastructures and properties. And practicing in those areas at war, which may even be constantly, exemplifies giving great value to service to others above self.

The siege in Zamboanga City in 2013, that lasted for 2 weeks and 6 days and was brought about by the clashing forces between the Philippine government forces and a faction of the Moro National Liberation Front (MNLF), forced evacuation of dialysis operations from Zamboanga Medical Center to other hospitals. Dr. Marge Abalon, Dr. Jamasali Usman and Dr. Mike Abutazil continued providing medical treatments despite the danger during the conflict.

And on May 23, 2017, while Dr. Nur Hannah Burungawan, the only Nephrologist practicing in Marawi City, Lanao Del Norte, was making her rounds in Amai Pakpak Medical Center, she and the rest of the medical staff were deeply surprised by the sudden appearance of armed men in the hospital. And even killing some of the guards as they entered. And before they realized it, this militant group did not only take control of Amai Pakpak but the whole City of Marawi as well. It was under siege by men who later identified themselves as Islamic State of Iraq and Syria (ISIS) fighters. Roads to and from Marawi City were barricaded as these men burned a Catholic church, city jail and two schools, where Dr. Burungawan attended before, before occupying the streets. The medical staff had to suspend dialysis operations in Amai Pakpak, the only tertiary hospital and caters Dialysis in Marawi city, during the siege for the safety of the patients and the staff, as citizens were forced to evacuate the city also. Everyone was facing fear and uncertainty. Dr. Burungawan was even pregnant at that time but she continued to look after her patients. She tried to endorse some of them to free standing dialysis units and hospitals in Iligan City, Cagayan De Oro and other nearby provinces, and even to Manila, where they could continue their treatments. But for those patients living in the second district of Lanao Del Norte, which was 2-3 hour drive to Iligan City, the nearest city, or could not afford the dialysis fee in those privately operated units there, had no choice but to wait for Amai Pakpak to resume operations. And Dr. Burungawan actually thought that the siege would only last for about three days, like other armed conflicts that frequently occurred in Marawi. But it continued. Not just weeks but even months… that many of the ESRD patients were dying at their homes or on the road. As those patients who needed emergency dialysis would arrive lifeless in the hospitals in the next city due to the long travel duration. Dr. Burungawan and her staff were deeply in pain but were powerless. They were in war. The Hospital administration finally decided to open the dialysis unit one month in the siege to serve those patients who could not receive treatment from other cities. But the unit was only operating five HD machines and 2 shifts everyday as they were understaffed also. To protect the Non-Muslim or Christian staff, only Muslim staff went on duty in the hospital. And so, patients and staff were traveling to and from the hospital, giving and undergoing treatment while hearing gun fire and bombs exploding all around, as the Philippine Government forces and the terrorist group continued to fight. Every day was a Living Nightmare but they all persevered through this crisis. Thankfully, none of them became direct casualties of this war. And when Marawi City was finally accessible again, PSN local chapter sent some financial assistance, which Dra. Burungawan divided among the ESRD patients to help them pay for their treatments.

And these are but only few of the many proof that PSN and its members remain resilient as they survived through any challenge. Keeping in mind the primary reason why the society was established… and later, as guided by its Vision and Mission: To address, alleviate and prevent the burden of serious kidney problems in the country. For the service of the Filipino people. And sometimes, even emerging as unsung heroes.

And through the years, PSN became more prepared, more experienced, open and accepting, hence, disaster response and prevention (e.g. Kidney Shakeout that prepares the dialysis unit staff and patients for the “Big One” or the worse scenario of an earthquake from the West Valley fault) became more efficient and faster, and tackling sensitive issues within, among members and third parties were more effective and diplomatic.

Hopefully, the same goes with how we are facing the COVID 19 Pandemia and individual issues with Philhealth. Keeping the Faith that these too shall pass.

RLGA2021

(some are lifted from Beyond Measure: 40 years of PSN and PSN President’s yearly reports; Special Thanks to Dr. Myrna Ngo, Dr. Renne Toledano, Dr. Agnes Baston, Dr. Beverly Aguila, Dr. Michelle Yau-Otayco, Dr. Russel Villanueva, Dr. Darwin Darjuan, Dr. Maaladdin Biruar, Dr. Donna De Leon, Dr. Nur Hannah Burungawan, Ma’am Rhea Obero and Sir Eric Basco)

Pacific ring of Fire