OPINION: The Philippine health care system was never ready for a pandemic

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Unless the vulnerable are identified and protected, they will die by the thousands, and they will not even be part of the statistics. Photo by IYA FORBES

Editor’s note: Ronnie E. Baticulon is a physician at the Philippine General Hospital and an associate professor at the University of the Philippines College of Medicine. The opinions in this article are his.

Manila (CNN Philippines Life) — Last Tuesday morning, after doing patient rounds in Philippine General Hospital, I came across two nurses from the emergency department, walking in the opposite direction towards the hospital. It was the first workday after President Rodrigo Duterte put Luzon on enhanced community quarantine, in an effort to mitigate the spread of the novel coronavirus pandemic. Out of curiosity, I asked the nurses, “Paano kayo nakapasok ngayon?” To my disbelief, they told me that they were from the graveyard shift, and they could not find transportation to go home to Cavite. After working for eight hours at the frontline of the country’s largest public hospital, they decided to walk to Baclaran in Parañaque and take their chances, only to walk back to Pedro Gil in defeat. When they asked policemen for help, their pleas were dismissed with “PGH dapat ang mag-ayos niyan.”

Head nurses from different units shared the same lament: they didn’t have enough staff. “Gustong pumasok pero walang masakyan,” they all said. On that day, even cancer patients and those needing dialysis had been forced to walk to hospitals. Never mind if the latter had hypertension or heart disease that led to kidney failure. Shuttle services and bus routes for health care workers have since been organized, but only after 24 hours of chaos.

When the number of COVID-19 cases began to rise in the National Capital Region, it became immediately apparent that there was a staggering shortage of masks and alcohol in hospitals, forcing PGH to launch a call for donations. Now let that sink in: the national university hospital put out a call for personal protective equipment for its frontliners. In a message to the PGH community, Director Gerardo Legaspi explained that it was “not much due to the shortage of funds, but due to the difficulty of purchasing the goods because of unavailable suppliers. If they were [available], the transactions that [the suppliers] were demanding and the price they were quoting were beyond what [the] government will allow us.”

Outpatient clinics are closed. Elective surgeries and admissions are suspended. Dedicated wards and intensive care units are being vacated, in anticipation of the surge of COVID-19 patients requiring admission over the next few weeks. Hospital staff have been divided into cohorts to avoid putting an entire department or specialty in quarantine. PGH serves over 600,000 patients every year, half a million in the outpatient department. Of its 1,465 hospital beds, 1,088 are service beds (i.e. public). The situation is similar in regional and district public hospitals, and even in the private hospitals where the majority of patients remain admitted.

A colleague serving as a doctor to the barrio in Batanes is concerned because he has symptomatic patients who fall under the Person Under Investigation category of the Department of Health algorithm, and yet he can’t do anything because his hospital doesn’t have the capability to test patients. They have only two critical care beds and limited supplies. To say that this pandemic will have profound effects on health care delivery nationwide is no exaggeration.

On March 18, the country breached the 200 mark with 17 deaths, as cases surpassed 200,000 around the world. There is the lingering doubt on the accuracy of the reported Philippine figures, likely an underestimate of true prevalence, as the country awaits the arrival of more test kits, and out-of-protocol tests are being done on politicians and their families. According to Health Undersecretary Dr. Maria Rosario Vergeire, modeling data predicts as many as 75,000 cases in three months.

The Philippines is not ready for this. We never were. In a 2018 review of the Philippine health care system, Manuel M. Dayrit and his co-authors report that the country has 101,688 hospital beds, distributed in 1,223 hospitals across the country. Even if just 1 percent of the Philippines’ 107 million population (as of 2018, according to the World Bank) get infected with COVID-19 (i.e. one million patients), assuming a 10 percent hospitalization rate, it is easy to see how our hospitals will be quite easily overwhelmed. We have not even talked about the distribution of the specialist workforce or the number of mechanical ventilators and ICU beds (required by 3 to 5 percent of infected patients), nor have we taken into consideration patients with stroke and heart attack who would need the same resources in the same time period.

The Imperial College London COVID-19 Response Team predicts that 81 percent of the population of Great Britain and the United States will be infected throughout the duration of the epidemic, leading to approximately 510,000 and 2.2 million deaths, respectively, if the epidemic were unmitigated. They recommend an aggressive suppression strategy that involves population-wide social distancing, case isolation, and closure of schools and universities, but even in the most optimistic scenario, both countries’ capacity limits would still be exceeded. For how long these measures have to be implemented, nobody knows for certain. Experts agree it would take at least 12 to 18 months to develop a vaccine.

In the Philippines, 6 out 10 patients die without ever seeing a doctor. When Filipinos get sick, they shoulder 56 percent of total health expenses, out-of-pocket. As a result, every year, one million patients are driven to poverty because of catastrophic health expenses. Although COVID-19 can infect anyone — regardless of race, social class, or beliefs — the public must realize that specific segments of the population will be more vulnerable to the social and economic impact of the current pandemic. It is not as simplistic as “Stay at home and watch Netflix.” How can you expect contractual employees to stay at home if their employers enforce a “no work, no pay” policy? If a person living in the slums gets the disease, would it be second nature for them to seek consultation before infecting many others? Or would they dismiss it as “ubo at lagnat lang” because the hospital is not accessible and they are worried about fees the consult would entail? Unless the vulnerable are identified and protected, they will die by the thousands, and they will not even be part of the statistics.

And what about the “indirect” deaths? Who keeps a tally of Filipinos who will die from lack of available blood for transfusion, skipped dialysis sessions, delayed surgeries for cancer, rescheduled radiotherapy sessions, missed antiretroviral medications, uncontrolled hemorrhage from childbirth at home, or even from hunger? If the Philippine health care system had been more robust and had safeguards in place, we would not even have to worry about these. In a few months, when the world gets back to normal — and we all hope it does — we will be, sadly and inevitably, counting lives lost. Let us not make the mistake of blaming just the virus.