HEALTH

The invisible struggle of non-COVID patients

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As our health care system groans under the weight of the pandemic, those suffering from other diseases, such as cancer and chronic kidney disease, are also made vulnerable. Illustration by JL JAVIER

As suggested by neuroscientist Sam Harris, science and morality shouldn’t condemn each other. Somewhere in between are decisions that come with difficult questions. During the pandemic, hospitals grapple with those decisions.

Philippine Hospital Association President Dr. Jaime Almora compared the COVID-19 situation in the Philippines to a doomsday scenario in the movies. The scenario consists of patients waiting to be accommodated in emergency rooms, overworked frontliners, inadequate medical resources, and people dying as they wait to be attended to. Deciding which patients should get access to health care first is a crucial part of a health worker’s job.

Caught in this morass of ethically compromised situations and systemic inefficiencies are not only COVID-19 patients but also those suffering from other diseases, such as cancer and chronic kidney disease.

Deciding which patients should get access to health care first is a crucial part of a health worker’s job. Photo by JL JAVIER

There was a time during the pandemic that doctors could only answer phone calls and text messages from cancer patients, “explaining to them the unfortunate scenario of closed clinics and suspended services, and facilitating the transfer of their care,” according to the paper “The Pain of Sending Away Cancer Patients Amidst the COVID-19 Pandemic in Philippines,” written by Frederic Ivan Ting, Aveline Marie Ylanan, and Dennis Lee Sacdalan and published in the Eurasian Journal of Medicine and Oncology (EJMO).

What goes around

Sandy Mae Gaspay, whose mother was diagnosed with cervical cancer in 2017, can speak to this.

“I believe that, in a way, my mom died because of COVID-19,” she said.

Last year, she would visit her doctor twice a month. When the pandemic hit the Philippines, her chemotherapy sessions had to be done at home.

In August 2020, lumps grew on the neck and chest of Sandy’s mother. It was difficult for her to breathe. She felt like drowning. Sandy’s mother was hospitalized due to a build-up of water in her body. She and her companion were able to enter the emergency room after taking a rapid test. The hospital inserted a tube on the right side of her stomach to remove the accumulating water.

Not all hospitals, especially those inundated with COVID-19 patients, can fully accommodate non-COVID patients. Resources are scarce. The workforce is drained. Metro Manila ICU capacity has peaked many times with the surge of COVID-19 cases. From Visayas to Mindanao, hospitalization capacity is a serious concern. And even if those with life threatening illnesses manage to hold on, they may still walk away from the hospital with a long shadow behind them.

RELATED: Gov’t needs to double COVID-19 beds in NCR – treatment czar

In the case of Sandy’s mother, that shadow has eyes. When she was hospitalized for the second time, an ambulance picked her up from their home. The people who went inside their house were wearing PPE. The neighbors saw them. Shortly after, a rumor spread in their barangay that Sandy’s mother was COVID-19 positive.

Sandy said she and her siblings stopped laughing at the rumor when it started to blow out of proportion. They learned that convenience stores refused to accommodate their helper’s daughters. Another neighbor, a close contact of their helper and a barangay aide, was denied a day’s work.

Meanwhile, Sandy’s mother was placed in the COVID-19 wing in the hospital because of her breathing problems. Sandy said she and her siblings were worried that their mother would be further exposed to health risks. They showed their mother’s previous RT-PCR negative test result to convince them that she had no COVID-19.

“Still, she was treated as if she had COVID-19 as the attending staff all wore PPE every time they entered our room. As a result, our hospital bill ballooned to twice or thrice the expected amount. We wanted to complain further, but mom just said to pay the bill and let it go,” Sandy recalled.

“Normally, mom would want to stay longer in the hospital for a week so her body could stabilize after chemo, she would have enough fluids with the IV, and her condition could be monitored. This time, we had to go home immediately after her procedure as it was riskier to stay in the hospital, not to mention expensive,” Sandy added.

Sandy, who works in Manila, heeded her mother’s request for her to come home to Tacloban after her second hospitalization. Sandy said she had to travel by land due to the quarantine procedures of LGUs. When she came home, she was able to take care of her mother. She and her siblings set up a separate room for their mother inside their house. They placed an oxygen tank and a hospital bed inside the room.

“I feel lucky that we were not totally powerless and had resources when we dealt with our mom’s ordeal. I can just imagine the less fortunate who have no voice and don’t even get to be counted as casualties of this pandemic,” Sandy said.

But on September 12, 2020, Saturday, her mother could not sleep. She was rejecting food and vomiting blood. Had there been no COVID-19, Sandy said they would have brought their mother to the hospital right after her first vomit. The next day, her mother’s condition showed no signs of improvement. They decided to call an ambulance.

Meanwhile, Sandy’s mother was placed in the COVID-19 wing in the hospital because of her breathing problems. Sandy said she and her siblings were worried that their mother would be further exposed to health risks. They showed their mother’s previous RT-PCR negative test result to convince them that she had no COVID-19.

The hospital ambulance was not willing to pick her mother up. They feared that she had COVID-19 after learning that she had difficulty breathing. Sandy and her siblings also asked for help from the city’s rescue office, but it only catered to COVID-19 patients. It was the Bureau of Fire Protection (BFP) that responded to them after hours of making phone calls.

When they arrived at the hospital, Sandy’s mother had to wait for 10 minutes inside the ambulance. Sandy said the hospital was informed about her mother’s condition prior to her arrival, but no staff was there to attend to their mother. Since the ambulance’s blood pressure monitor wasn’t working, her sister used her smartwatch on their mother.

After a while, her mother’s heart rate started slowing down.

Still, the hospital told them to wait a bit more because the staff had to don their PPE first, as well as swab test her mom, though the earliest result would be the next day as the lab was closed on Sundays. Their mother was transferred to the isolation area outside of the emergency room instead of the ICU.

“The lack of urgency was very appalling,” said Sandy. While her siblings were making phone calls left and right, their mother stopped breathing. The hospital staff tried to resuscitate her, but the line on the ECG machine went flat.

Looking back, Sandy felt lucky that they had resources to support their mother’s entire ordeal. “I can just imagine the less fortunate who have no voice and don’t even get to be counted as casualties of this pandemic,” she said.

Science can address the disjunction between the need for urgent care and the inadequacy of health care systems that people from all walks of life deserve. Moral reasoning can and should make that happen. When these two don’t meet, some have to bear the pain or beg for their life.

The weight of waiting

Jon Emmanuel Agad’s back and legs were aching.

He had been sitting in his wheelchair for over seven hours. He was in pain, but like many other patients in line, he could not do anything but wait for a doctor.

Earlier that day, he and his mother, Eleonor, were about to go home after a routinary check-up. But they stayed because he suddenly found it difficult to breathe. The attending medical staff could only check his oxygen and blood pressure. They told him and his mother to wait for a nephrologist, but they couldn’t guarantee somebody would attend to them because there were still other patients waiting to be treated in the ER.

Jon Emmanuel Agad has been battling chronic kidney disease since he was five years old. His monthly check-up was halted when the pandemic hit the country. Photo courtesy of the AGAD FAMILY

COVID-19 patients had to wait for days before admission, according to data obtained by Rappler from the Philippine College of Emergency Medicine (PCEM). Imagine the waiting that non-COVID patients like Jon Emmanuel, or Jeuel, endure.

The number of hospital visits is low throughout the pandemic. Non-COVID patients fear getting infected by the virus and face travel restrictions due to community quarantine measures.

Using claims data from the Philippine Health Insurance Corporation (PhilHealth), the authors of “The Hidden Health Cost of the COVID-19 Pandemic in the Philippines,” examined 12 high burden diseases in the Philippines, including stroke, cancer, hypertension, chronic obstructive pulmonary disease (COPD), gastroenteritis, chronic kidney disease, and pneumonia. They saw a decline in the number of medical claims in both public and private health facilities in 2020. The figure has not returned to pre-pandemic levels in the third quarter.

The paper, published by The Center for Global Development, found stable claims for chemotherapy but declines for cataract removal surgery and child delivery in hospitals. “This supports the anecdotal evidence that many hospitals temporarily halted or reduced healthcare services,” the researchers wrote.

Ting’s paper in EJMO states: “In a situation of an international health emergency such as this COVID-19 pandemic, the principle of justice will ethically dictate the allocation of very limited resources such as manpower and hospital. This involves treating patients fairly and equitably, which means those who are sicker and need more urgent care are prioritized.”

However, in a crisis shrouded by systemic inefficiencies and ethically compromised events, “fairly and equitably” won’t look the same in different situations and to different social classes.

“Wala na po kasing bed. Lahat ng patients sa ER ay nasa tent area. Sa wheelchair lang natutulog ang mga bantay at kanya kanyang gawa ng paraan. Yung iba, humahanap ng karton para mahiga na lang sa sahig,” said Jeuel's mother, Eleonor. Photo courtesy of the AGAD FAMILY

Jeuel has been battling chronic kidney disease since he was five years old. His monthly check-up was halted when the pandemic hit the country. His check-ups resumed, but they were not face-to-face. If they didn’t need to be admitted to the ER, they had to wait at a parking lot where, despite being in a tent, they are largely exposed to the sun and the rain. Only a nurse would attend to the patient and then bring the laboratory results, records, and assessment to the doctor. The nurse would return to the patient to give them the doctor’s prescription, medical abstract, and a laboratory test request for the next check-up.

“Hindi po sapat yung tent,” Eleonor said. Mainit at hindi mapigilan magdikit-dikit rin mga tao kaya dumidistansya po kami. Naghahabol kami ng lilim. Hindi po kasi sila basta-basta nagpapapasok sa building.”

Jeuel was admitted thrice to the hospital in 2020. According to Eleonor, his admission in September was the hardest. They had to wait for the swab test result for more than 12 hours before they were brought to his room.

“Wala na po kasing bed. Lahat ng patients sa ER ay nasa tent area. Sa wheelchair lang natutulog ang mga bantay at kanya kanyang gawa ng paraan. Yung iba, humahanap ng karton para mahiga na lang sa sahig,” she said.

“Ako po ay nakapagdala ng folding stool at dun lang natulog nang nakaupo, pero paggising ko, ay na migraine po ako, na nagsimula sa back pain dahil sa hindi maayos ng posisyon sa pagtulog. Yung iba raw pong patients, ilang araw nang naghihintay ng beds,” she added.

What made their current situation harder for Eleonor is the company she is working for imposed a four-day workweek on its employees when the pandemic started. The new setup reduced her salary to ₱5,000, and it greatly affected her son’s treatment.

“Naputol po yung loan cycle ko. Dahil po sa hindi enough yung salary ko sa gamutan ng anak ko, I resorted to loans. Mangungutang ako para ibayad din. Then yung sobra, idinadagdag ko sa gamot. Pero dahil nag-temporarily stop operation yung ibang lending companies, natigil rin yung pagbayad ko,” she said.

She has asked for financial assistance from government agencies and is trying to look for additional sources of income. However, Jeuel’s medical expenses, including costly maintenance medicines, are piling up.

Young soldier

Rein Reyes froze when she first saw her baby, Primo, 25 days after she gave birth to him.

“He is a lot smaller than I thought he is,” she said.

But that young, gentle warrior put COVID-19 to shame on the day he was born.

Primo and his mother survived an unplanned Cesarean section. Primo was born 11 weeks early in March 2021 because Rein tested positive for COVID-19. At 28 weeks, she had fever, loss of taste and smell, and a terrible headache.

Rein Reyes with her baby Primo. Photo courtesy of the REYES FAMILY

“They can't give me meds for COVID-19  kasi there's no study for pregnant women, and it might harm the baby,” Rein said. “I told her [OB-GYN] let's give the antibiotics some time to work kasi two days pa lang naman.”

However, she still had trouble breathing. When she could no longer complete a sentence, the doctors convinced her and her husband to do the C-section to save her and the baby. When Primo was born, he was diagnosed with patent ductus arteriosus, neonatal pneumonia, and apnea of prematurity.

But the private hospital where they were admitted took good care of Primo, according to Rein. “I felt all the love they have for the babies in the NICU.”

Before joining other babies in critical care, Primo had to be placed in the NICU isolation room for two weeks to make sure he did not get the virus. Meanwhile, his mother stayed in the COVID-19 floor where patients are in separate rooms with oxygen support.

"It was hard because I was alone in the room while recovering from both COVID and CS. Plus the agony of having my baby in the NICU, and I wasn't allowed to see him. I was just crying the whole day. The nurses were very kind and they always tried to comfort me,” Rein said.

Primo is now over two months old. The doctors made sure he would be able to breathe on his own when they were discharged. They took home oral meds for apnea, and so far, he has no more apnea episodes at home.

“We just have to make sure he will be healthy for the first two years of his life,” Rein said. “That's why I also made sure I breastfeed him from the moment he got home. Happy to say now he is exclusively breastfed.”

"It was hard because I was alone in the room while recovering from both COVID-19 and CS. Plus the agony of having my baby in the NICU, and I wasn't allowed to see him. I was just crying the whole day,” Rein said. Photo courtesy of the REYES FAMILY

Rein shared that there were other women who were in the same situation as hers but many of them did not make it.

“I begged for my life. I was praying the whole time and really asked God for a second chance for my family,” Rein said. “It made me feel so depressed, and I kept on blaming myself that my baby was suffering. What happened to us made me want to become a better person,” she added.

As hospitals fill up due to COVID-19 cases, there would be more people like Rein, Eleonor, and Sandy if the government and medical institutions continue to settle with the choices they have now instead of creating reforms and a system where no life is deemed less valuable than the other.

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If you would like to help Jon Emmanuel Agad, you can follow his Facebook page “Jeuel's Journey to Healing.”