On Monday, Philippine President Rodrigo Duterte met with health experts, including former heads of the Department of Health (DOH) to discuss the current situation surrounding the coronavirus pandemic.
One of the experts who attended the said meeting was former Health Secretary Esperanza Cabral. The cardiologist submitted a comprehensive paper, called, “Responsible Easing of the Enhanced Community Quarantine: At Scale, With Speed and Everyone Working Together.”
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In the paper, she suggested factors that the government should consider before the “responsible easing of the ECQ [Enhanced Community Quarantine].” The paper had inputs from Brian Michael I. Cabral, M.D., Minguita Padilla, M.D., Junice Melgar, M.D., Kenneth Hartigan-Go, M.D., Eugene Ramos, M.D.
In Dr. Cabral’s report, Metro Manila has a satisfactory score in terms of flattening the curve (with the number of cumulative cases and new cases as the primary indicators). In the current situation, the doubling time of daily new cases has either become stable or has increased over the past week. The “doubling time” is the time is takes for the number of COVID-19 positive cases to double in a certain period of time. While we have reached a plateau (around 200 daily new cases), there is no consistent downtrend observed yet.
The goal should be to keep increasing the doubling time and, finally, reduce the number of new cases to zero. To do this, according to the doctor, there should be more tests done, and COVID-19 positive patients should be isolated faster.
In the present, we are doing 4,000 tests a day, which is only 40 percent of the goal, with 100,000 test kits available. It is best, she said, to mobilize the local government units (LGUs), and ask help from the private and the non-government (NGO) sectors.
Health system, resources, and financing
The data that informs people of the current situation in the health system, human health resources, and health financing is incomplete, and needs lot of improvement, wrote Dr. Cabral. For this, she suggested increasing the number of competent and efficient testing facilities. While various tests may not be exclusive, they should be used to “complement each other.”
“Pool testing may be considered as a cost-efficient way of using tests,” she wrote. (In pool testing, multiple samples are tested in a single test. If the pool yields a positive result, the samples will be tested individually.) In her report, 80 percent of the cases were admitted to private hospitals, which means that the public healthcare system has yet to produce accurate data on how they are reacting to the pandemic.
The financial burden of COVID-19 positive patients has been a hot topic in the recent days. There are various reports stating the cost of hospitalization of COVID-19 patients could exceed way beyond the million-peso mark, depending on the severity of the case. Dr. Cabral suggested that financing (of lab rates or case rates) must be rationalized.
“PhilHealth [Philippine Health Insurance Corporation] reimbursement must support the triage strategy,” she wrote. For example, hospital bills of patients who are treated at public institutions must be fully paid by PhilHealth. For those who are treated at private centers, PhilHealth may opt for partial coverage. She said there should also be a fixed mark-up for consumables, such as laboratory tests and medicines, “dictated by PhilHealth, specifically for COVID-19 cases.”
One of her other major concerns is the disposal of medical waste: “Mountains of medical waste, particularly PPEs are anticipated. Their proper disposal is imperative.”
Risk in vulnerable areas
There aren’t enough plans that focus on vulnerable areas in society, such as jails, mental institutions, home for the aged, schools, havens for women and children, transient homes, dormitories, etc., the report stated.
“For jails, consider moves to temporarily parole certain prisoners, such as those that are medically vulnerable individuals, and those who simply could not afford bail while awaiting trial,” she suggested. “Urban poor households can be provided shelter in unused housing projects.”
She added that vulnerable individuals, like senior citizens, those with preexisting conditions, and those who are immune-suppressed, should be prioritized for antibody-testing.
There should be increase in preventive and protective measures in the workplace. This is specially crucial when the ECQ is lifted. Physical distancing should be highly implemented, and lavatories and toilets must be consistently sanitized. Wearing of masks, proper ventilation, and waste management should be top of mind.
While companies may slowly try to go back to regular working schedules, they should still be wary of mass gatherings, regardless of purpose.
Management of imported risk
The travel industry is taking a beating because of the quarantine rules imposed by different governments worldwide. While travel restrictions are already implemented, there should be clearer rules on how to impose them in the foreseeable future, said Dr. Cabral.
She wrote, “On top of international travel, there needs to be clarity on inter-island and provincial border-crossing and restrictions. LGUs should coordinate action on the movements of essential goods (e.g food) and quarantine violators. Physical distancing must be observed even in transport vehicles.”
Community participation should be improved
“Essential economic activity must be restarted,” according to Dr. Cabral’s paper.
There is still a strong need to mobilize the education system and the accessible media platforms to educate people on COVID-19. Every day, there are reports of people getting arrested for leaving their house for non-essential trips. Proper information dissemination will “engender mutual concern and responsibility,” she said.
Overcoming the effects of this pandemic requires the cooperation of everyone, but this won’t be possible without accurate information from their leaders.
“People's participation in the national COVID-19 response also depends on their economic wherewithal,” she wrote. “While it is true that DSWD [Department of Social Welfare and Development], DOLE [Department of Labor and Employment] and LGUs have allotted cash and food support, there are still a sizeable number of people who fall through the cracks in the system. It is uncertain how far the government can sustain these safety nets. In this situation, validated Rapid Antibody or Antigen Testing are valuable because they can identify people with infection or immunity.”
Dr. Cabral also called for a “unified messaging from the government.” Many LGUs have provided daily reports to their constituents through their social media accounts. However, Dr. Cabral said, these data should be explained. “This would create credibility of government and sensible/relatable education to the public.”
Government should also continue to strictly monitor social media accounts and fake news to prevent the spread of wrong information.
“Data management is poor,” she wrote. “Monitoring and evaluation are not yet the efficient tools for planning that they should be.” The systems for data management should be compatible with each other. Furthermore, there should be transparent, timely, and complete data, so they can be subjected to independent validation.
Preparation for the next pandemic or health disaster
It can happen again. To be prepared for a future outbreak, Dr. Cabral suggested that the government create a Council of Pandemic Preparedness.
Whoever is in charge of dealing with pandemic and health disasters must be transparent when it comes to expenses: How much cash do they have? How much in-kind donations did they receive? Transparency should be practiced even for donations given to private agencies.
An online network would also be helpful to potential donors. This network may be used to identify areas that are most in need of help, and to decrease duplication of efforts. These measures should “make helping others easy.”
Reservists are also necessary. They may not be medical doctors of nurses, but they should be trained in bio-threat/hazard management and other skills. They can then do certain tasks that help manage a pandemic, like performing medical triage outside COVID-19 centers, doing sampling or laboratory work, doing quarantine activities between provincial borders, etc.
She also suggested other areas that need further improvement, to prepare for the future: manufacturing and provision of local PPEs, essential medical supplies, equipment, and other materials. Local innovations, such as sterilization techniques, disinfecting areas, ventilators, etc. should have support from the government.
As early as now, she said, the government and other private agencies should strengthen the training of organic medical and non-medical personnel and reserved medical corps. A clear legislation should also be put in place.