The Fight Against Tuberculosis on Guimaras Island

There is an island in the Philippines situated in the Panay Gulf, home to some of the world's sweetest mangoes and bursting with beauty, from its turquoise blue water to its renowned religious shrines and monasteries.

It's called Guimaras.

Soon, we hope it will be known worldwide for another accomplishment: tuberculosis (TB) elimination.

The Philippines faces one of the highest burdens of TB in the world, ranking third in TB cases. But that is not a reality Partners In Health (PIH) and our partners are willing to accept.

Despite being viewed as a romantic illness of artists and poets in the 1800s, TB is anything but beautiful. The disease, caused by Mycobacterium tuberculosis, is an airborne infection that most often attacks the lungs, but can also attack the spine, brain, and kidneys.

TB is the world's deadliest infectious disease, killing more than 1.23 million people a year-about as many deaths as HIV and malaria combined.

For some patients, the disease causes symptoms ranging from coughing up blood to fevers to unexplained weight loss. Others may appear outwardly healthy, even as X-rays reveal severe damage to their lungs.

It's been preventable and treatable for decades.

As PIH co-founder Dr. Paul Farmer liked to say, these are "stupid deaths." There is no reason someone with TB should die. Yet, an estimated 150 million people have died from TB since a cure was discovered-nearly all of them in low- and middle-income countries-and an estimated 43 million people will develop TB between 2023 and 2030, resulting in 6.6 million preventable deaths.

Still, there is reason for optimism. Advances in diagnostics, shorter and more effective treatments, and preventive therapies make elimination possible. We can choose a TB-free future.

The TB-Free Guimaras Project is just one way we are acting now-together-to make TB a disease of the past.

Falling in Hate with TB

When bestselling author John Green set out on a trip with PIH to Sierra Leone in 2019, a doctor took him to Lakka Government Hospital located just outside Freetown. There, he met a young man named Henry who had multidrug-resistant TB (MDR-TB).

Green was already a dedicated partner to PIH, having pledged to donate millions of dollars to support the creation of the Maternal Center of Excellence in Sierra Leone alongside his brother, Hank Green, and their spouses, Sarah Urist Green and Katherine Green. He is a staunch advocate for global health, participating in numerous Congressional meetings with United States politicians, attending United Nations conferences, and becoming a PIH Board of Trustees member.

And as Green learned about TB and the inequities surrounding it, he began talking about TB publicly: to friends, family, online followers, and eventually in the form of a book titled Everything Is Tuberculosis: The History and Persistence of Our Deadliest Infection.

Green began to "fall in hate" with TB, as he termed it in that book.

Like Paul Farmer, Green understands these deaths are not inevitable. The tools needed to prevent and treat TB already exist, but structural violence and poverty stand in the way.

Then, in 2023, the U.S. Agency for International Development (USAID), decided to fund a TB-elimination project in the Philippines-where a whopping 7% of all new global TB cases originate.

While the majority of the funding for the project came from USAID and the Government of the Philippines, Green also joined as a private philanthropist. His donation enabled PIH to serve as a technical accompaniment partner to the Guimaras Provincial Government.

Over the past 40 years, PIH has set a higher standard of care for TB and become a trusted advisor to governments and global health agencies, driving bold action to end the disease. PIH has shaped global treatment protocols and has been a leader in research to create shorter and more effective treatments for patients with MDR-TB.

Initially, the idea was to do comprehensive TB elimination across five provinces in the Philippines using the Search, Treat, Prevent approach. PIH is using this methodology in other countries, including Lesotho, where PIH is leading TB research while equipping frontline clinics with innovative case detection tools like AI-assisted portable x-rays, and medications allowing clinicians to search out, treat, and prevent TB more effectively than ever before, even in remote communities without access to a health facility.

PIH knows the Search, Treat, Prevent approach works, and implementing it at full force in partnership with the Government of the Philippines across the country was an exciting and promising idea.

But in January 2025, the Trump administration began dismantling USAID, dealing a devastating blow to global TB programs around the world.

Recommitment Amid Government Turmoil

The Trump administration's decision to shutter USAID is a heartbreaking setback in the global fight against TB.

It is estimated that this decision could directly result in another 10.7 million people developing TB by 2030, leading to some 2.2 million additional deaths.

Without the massive chunk of funding from USAID, the project could have collapsed.

Instead, the Government of the Philippines, Green, and PIH regrouped around a new plan: the TB-Free Guimaras Project, focused on proving what TB elimination could look like on a single island.

"We didn't just want to leave our partners in a lurch because USAID left, especially when we had independent funding," said Dr. Salmaan Keshavjee, the program technical director for the TB-Free Guimaras Project.

The strategy remained largely the same-just concentrated in one province instead of five.

From there, PIH began designing a program alongside our local health department counterparts centering on PIH's ambitious Search, Treat, Prevent method. While many governments use the "search, treat, prevent" approach, patients are often missed under each pillar without universal access. PIH's tenacious take on the historic standard means reaching virtually everyone in a community, no matter how hard they are to reach.

Only about 50% of TB cases show symptoms. That means people may never go to a clinic showing symptoms, unknowingly transmitting TB in their community.

The first prong, "search," aims to find these hidden cases-an essential piece of turning off the spigot of transmission.

In Guimaras, mobile chest x-rays will be used in all 98 of Guimaras's barangays, meaning care will reach across the entire island. In just the last quarter of 2025, over 12,000 Guimaras residents underwent chest x-rays-that's 6.2% of the population in just three months.

Paired with rapid diagnostic testing, these methods allow for swift diagnoses of TB.

Within seven days of a TB diagnosis, patients in Guimaras are connected to treatment, bringing in the next prong of this method: "treat." TB patients in Guimaras are already achieving a 90% treatment success rate.

Finally, the last prong, "prevent" can be the most challenging. This involves finding all contacts of an infected person and evaluating them for TB-whether active or inactive. It also means enrolling direct contacts into TB Preventative Therapy to break transmission chains.

"It's something that we've been doing and that we know is effective in wealthier countries, but that (people) often don't implement in poorer places, especially rural areas, because it's really, really hard to do," said Keshavjee. "You're getting to very, very remote communities. You're asking people to take a preventive medication for something they don't necessarily believe in because they don't even know they have it."

While the Search, Treat, Prevent method may sound straightforward, implementing it at scale requires significant coordination and infrastructure.

For example, effective screening and treatment require an electronic medical record system.

"If you're thinking you're going to screen lots of people, you've got to know whether they were screened last week somewhere else, were they not," said Keshavjee." Do they have comorbidities? Do they not? You've got to have real-time data."

That means not only having an electronic medical record system, but reliable internet connectivity to support it.

"We've been thinking about the details," Keshavjee said. "There's the Starlinks. The Starlinks have to talk to something-we're trying to figure that out-then you need tablets or some instrument to use in the field. And you need to have X-rays that can then transfer data to that instrument. There's lots of pieces to this puzzle that you have to put into place."

This technical accompaniment is where PIH comes in. Unlike in some countries where PIH works, accompaniment in the Philippines has not meant rebuilding an entire health system. Instead, PIH has focused on supporting TB elimination strategies and strengthening the infrastructure needed to make them successful.

The end goal, however, remains the same: TB elimination. With this project, we hope to show what is possible when groups come together in the fight against TB-each bringing their own skills, resources, and passion to make TB a disease of the past.

"Despite significant progress over the last twenty years, the Philippines continues to experience a very high burden of tuberculosis," Green said. "We hope that this project can provide a blueprint for how to eliminate tuberculosis from a community, and that other regions in the Philippines will get the support and funding they need to implement similar projects. We know that through partnership and shared commitment a world without tuberculosis is possible."

As we continue to treat TB around the world, from Lesotho to Peru to Guimaras, we hope to show that a world without TB is possible-not just in wealthy countries, but globally.

"Part of PIH's advocacy has always been that we do these at our own sites and then we show people what's possible," Keshavjee said.