In the alleys of Baseco, Tondo, women do their laundry around block faucets. Around them, children dart through dirt alleys that separate makeshift shelters constructed from recovered wood, canvas sheets, plastic tarpaulin signs, and corrugated roof panels with rust peeking through peeling paint. Thick plastic tubes sag onto wet footpaths before ending up in outdoor kitchens, where households fill pails for bathrooms.

This is one of Metro Manila’s most congested communities, with nearly 60,000 people living in just a little over one square kilometer.

Our guide, Ainie Ali, a married woman with two children, augments her husband’s income by hawking slippers, trinkets and clothing on Mabini St., in the tourist district of the national capital, and by online selling.

Her street income slumped by two-thirds in the last two weeks, since the health department started reporting a rash of COVID19 cases in the metropolis.

After President Rodrigo Duterte announced a one-month domestic travel ban by land, air and sea to and from Manila, starting March 15, Ainie decided to shelve her online business.

“I cannot use the courier services now for my customers on other islands, and I can’t receive supplies from Mindanao,” she said.

In Divisoria, the bustling wholesale trading district just a few minutes ride from her home, Ainee’s other suppliers from other provinces on the main island of Luzon also expressed fear over increased costs and slower flow of logistics with police and military checkpoints set up around the metropolis.

• Metro Manila quarantine: Troops at borders, social distancing of 1-meter radius when out in public

Land deliveries in and out of the national capital region will be allowed, according to Interior and Local Governments Secretary Eduardo Año, but drivers and helpers will be restricted to their vehicles. Workers from the provinces can come in and out of Metro Manila, but will need to present proof of employment.

That could work for big business, but not for independent, small traders, who personally pick up and deliver supplies, and who are not registered with government agencies, Ainee pointed out.

“I will lose 70 percent of my P10,000 income for the month,” she told ABS-CBNNews.

That was before Trade Secretary Ramon Lopez gave workers in the informal economy two options: ply their wares in the provinces or register.

• NCR employers asked to encourage workers from provinces to rent in metro

The head of the Metropolitan Manila Development Authority (MMDA) on March 14 said only groceries, pharmacies, banks, restaurants with home deliveries, and other essential establishments should be allowed to operate.

• Curfew from 8 p.m. to 5 a.m. to take effect in Metro Manila under COVID-19 quarantine

Now Ainee is totally without a source of income for a month. Her husband, who is an officer of a faith-based community organization in Baseco, will be busy working with the barangay to implement the government’s orders.

But, pointing to other homes, Ainee said many neighbors face harder economic challenges.

Forced to share air

Most of the 62 COVID19 cases come from middle to affluent classes and were referred to the health department by private hospitals. Most of the most serious cases are elderly patients though people at the prime of life have also been infected. Eight patients have died from the disease, as of Saturday night.

Acitivist doctor Gene Nisperos, however, warned that outside of the elderly, citizens “whose immune systems are poor due to poverty” are also vulnerable to infection and face greater virulence.

Infection spreads between people who are in close contact, within six feet of each other, through respiratory droplets from an infected person’s coughs or sneezes. Those nearby can inhale these or inadvertently touch their mouths and noses with hands that have touched contaminated surfaces.

The mode of infection is what makes social distancing imperative as a preventive measure. But among Metro Manila’s poorest residents, “social distancing”, much less the “stringent” form the government demands, is a pipe dream.

The capital will face a nightmare should community transmission crop up in urban poor communities.

At high risk are patients with underlying conditions like hypertension, diabetes and pulmonary problems. The poor in their crowded villages and small food-and-health budgets are particularly vulnerable to tuberculosis.

The Research Institute for Tropical Medicine said the country registered 22,000 deaths from tuberculosis in 2017, ranking fourth worldwide.

A World Health Organization report, released in March 2019, said about 1 million Filipinos have active TB disease, the third highest prevalence rate in the world, after South Africa and Lesotho.

“It is a highly curable disease. Yet, it is the number one killer among all infectious diseases. Every day more than 70 people lose their lives to TB in the Philippines needlessly,” the international agency said.

Even without COVID19, for the Filipino poor, “home” is a dangerous environment, even without the threat of sudden income loss.

Ainee lives in a two-story, concrete house because her husband is a small builder. But she leads us on a short cut to the main Baseco road, weaving through areas where homes have hardly any windows and entire families sit outside to take in air.

In a roadside canteen near the port that adjoins Baseco, stevedores break into raucous laughter while watching a BBC video of what homeowners should do to prevent COVID19 from spreading in their families. Among the tips: don’t share a bedroom, don’t share the bathroom.

Many of stevedores, whose families live in the province, share rooms, with as many as eight packed like sardines. They also share bathrooms with other boarders.

In Ainee’s community, some families also share bathrooms and generations sleep together.

In a 2015 paper for the University of the Philippines School of Economics, Professor Emeritus Edita Abella Tan said close to 400,000 Metro Manila families or 14.1 percent live in shanties of less than 10 square meters, where people do all their living activities in one room.

Around the same number live in crowded spaces of under 19 square meters.

The better off among the poor, Tan said, live in 20-29 square meters housing – “rented single rooms in old houses in blighted streets,” not far from the shanties, with water and electricity but sharing a common kitchen, bath and toilet, and utilities.

• How we measure poverty understates its extent anddepth: Some results

The capital’s poor live in these communities because they are near their sources of livelihood.

At work and at home, hygiene and sanitation is a challenge.

Health officials place frequent washing with soap as a key preventive measure. But the World Health Organization (WHO) notes that one in ten Filipinos still does not have access to improved water sources.

In in 2016, one of the top 10 leading causes of death in the Philippines was acute watery diarrhoea, claiming over 139, 000 lives, according to the WHO Philippine office.

While rural communities have worse safe water access problems, pockets of informal settler communities in Metro Manila and outlying provinces face similar problems.

Poor water pressure and rotation schedules are perennial challenges and expected to grow worse as summer deepens, with temperatures in the national capital region already hitting 35 Celsius.

Precarious lives

President Duterte has suspended work in in the executive branch of government until April 14 but told most agencies to maintain skeletal workforces, except for health and emergency frontline services, which will remain in full operation.

A report by the International Labor Organization notes that one in five persons of working age in Metro Manila work in the informal sector. Other organizations have estimates of as high as 38 percent of the working population.

Some are unpaid workers for their family businesses, with women and youth earning the lowest income. Most do not enjoy social benefits taken for granted by formal sector workers. Many are also not registered and are vulnerable to shakedowns and harassment by law enforcers.

The fallout from the COVID19 scare has already hit these informal entrepreneurs bad, even without the new community quarantine measures revolving around “stringent social distancing.”

Regular workers have been told they can avail of their emergency and vacation leaves while the quarantine is in effect, unless their positions are essential for operations.

But the country’s booming retail and service industries, which have been told to temporarily shut down, largely employ contractual workers who do not enjoy leave benefits.

The economic think-tank IBON estimates that 42 percent of workers in private establishments are non-regular and agency-hired. Nearly 30 percent of the government workforce is composed of contractuals.

“This means that 27.2 million or a 64% majority of employment in 2019 is still actually poor quality work consisting of: non-regular and agencyhired contractuals,” IBON said in a yearend report.

Poor access to health services

Aside from the first three confirmed cases, all Chinese visitors from the COVID19 epicenter in Hubei province, the next dozen had gone to private hospitals for treatment of their symptoms.

Their private doctors, after getting histories, pushed hard for the COVID19 tests.

The statistics, so far, show eight deaths for 62 confirmed cases. It’s an alarming level of virulence. But medical experts have confirmed the statistics are skewed – and the reason is the real root for fears of runaway contagion.

In a Senate hearing, Health Secretary Francisco Duque III denied charges of under-reporting.

What happened, he said, was under-testing because of the need to conserve limited stock of test kits.

Most of those tested already exhibited symptoms of COVID19 disease.

Department of Health guidelines remain the same from day one: whether or not one has a travel history to a place of outbreak, or exposure to a person who tested positive for COVID19, people are asked to do self-quarantine and monitor temperature and pulmonary performance.

The absence of tests means a yawning gap in tracing the spread of COVID19.

For the poor with no health insurance, there is the added fear of the medical costs. In its 2018 Philippines Health System Review, the

World Health Organization Philippine said more than 50% of the total health spending is out of pocket.

“Despite efforts to reform the provider payment system to increase financial protection, the share of facilities’ bill covered by PhilHealth (Philippine Health Insurance Corporation) is on average 30% and has not gone beyond 52%,” the report said.

The Philippine Health Insurance Corporation (PhilHealth) has assured the public that testing is free and members and their dependents can avail of "isolation package" and "referral package" for members and dependents with possible symptoms of the coronavirus.

The government also said the No Balance Billing (NBB) policy, which enables the vulnerable sectors of the program such as the poor and the elderly to pay no more in excess of their PhilHealth coverage when confined in government facilities, will be applied to COVID-19 claims.

• PhilHealth to shoulder costs of COVID-19 testing

But the WHO report said not all the eligible members are aware of the benefits of the program in general. The problem with most of the latest government pronouncements on COVID19 is the heavy focus on law enforcement, on checkpoints and curfews and possible arrests.

In extremis, the poor will go to government hospitals. The public health sector faces serious problems even in normal times.

There is one public doctor per 31,000 Filipinos, the Center for Women’s Resources (CWR) noted on the eve of the quarantine.

“President Duterte’s announcement of lockdown raises more questions than answers. We were waiting for concrete medical actions like massive free testing in every barangay but then President Duterte mumbles about peace and order through military assistance that makes us more worried than appeased,” CWR executive director Jojo Guan said in a statement.

The WHO acknowledged widespread efforts to improve health service delivery in the country, but it also pointed out prominent “regional and socioeconomic disparities in the availability and accessibility of resources.”

There is maldistribution of infrastructure and human resources across and within regions, which are concentrated in Metro Manila and other major cities.

WHO added that almost two-thirds of private and public hospital beds are in the island of Luzon, which includes the National Capital Region (NCR).

“There are 23 hospital beds for 10,000 people in the NCR while the rest of Luzon, Visayas and Mindanao have only 8.2, 7.8 and 8.3 beds, respectively,” its report said.

There are only five sub-national testing centers for COVID19 and they are awaiting test kits.

When the first two confirmed cases cropped up, officials said RITM was already training personnel of laboratories in the San Lazaro Hospital in Manila, the Baguio General Hospital in the northern Philippine province of Benguet, the Vicente Sotto Memorial Medical Center in Cebu City in the central region, and the Southern Philippines Medical Center in Davao City.

• Philippines works to expand COVID-19 testing centers outside of capital

The question is, are these enough, even with the 4,500 new test kits from South Korea and China? An even bigger question is, are provincial hospitals equipped to handle an exponential increase in number of patients under investigation?

The question, Nisperos said, is no longer academic. Thousands of Metro Manila’s informal sector workers, faced with a sudden loss of income, have joined the exodus to the provinces, creating bus terminals reminiscent of major holidays.