Gerry Alcantara shares her brother’s story – a painful one that she admits she has not processed fully.
At the start, Gerry Alcantara’s older brother treated his symptoms with a hint of defiance. Sure, he had a cough and a fever. But he was also just 39 years old. The flu? Young people ace the flu. All the time.
But Gerry’s brother was also diabetic, making him part of the sector vulnerable to COVID-19 regardless of age. Gerry, who works in the health sector, had a feeling something was wrong. She begged her brother to get checked. It was then that she heard his other reasons, which sounded a lot more like fear instead of the nonchalance he was projecting.
“Ayaw niya pa, ayaw niya pumunta sa hospital,” recalled Gerry. “Kasi iniisip niya, andaming beses na kasi siyang na-hospitalize before because of diabetes. Maxed out na daw yung insurance niya. Hindi naman daw ganun kalala yung sakit niya, so parang hindi pa priority.”
(He really didn’t want to go to the hospital. He was thinking of all the times he’s had to go because of his diabetes. He was saying his insurance was already maxed out. It wasn’t that bad, he said. It shouldn’t be a priority.)
The fever didn’t go away, and soon he was having difficulty breathing. On March 14, Gerry’s brother went to the hospital with his wife.
COVID-19 was only starting to sink its teeth into the nation at this time, and people were not quite sure what to make of it yet. In the Quezon City hospital where Gerry’s brother ended up, his wife was still allowed to stay with him. She watched helplessly as her husband found it harder and harder to breathe.
“May mga times na yung brother ko, kine-kwento ng sister-in-law ko, natutulog dun sa lap niya – kasi nahihirapan siyang huminga. Tapos nahihirapan na ring matulog. Nakahiga lang siya sa lap ng sister-in-law ko,” said Gerry.
(There were times when my brother had to sleep on my sister-in-law’s lap, she told us. He was having difficulty breathing, and he found it hard to even sleep. He would just lie there on my sister-in-law’s lap.)
His breathing only worsened as the days passed.
“Yung most difficult was nung ii-intubate na siya,” Gerry said. “I think with any family, or any relative, ‘pag intubation, parang ay, shit, ano na yan. Yun yung pinaka-sign na nahihirapan na yung loved one mo. Kailangan na niya ng help to do something as simple as breathing. For the family, and for the patient, ‘pag narinig yon, iba. Iba yung dating.”
(The most difficult part was when they were going to intubate him. I think with any family, or any relative, intubation means something grim. That’s the ultimate sign that your loved one is suffering, because now he needs help doing something as simple as breathing.)
Her brother used whatever strength he had left to act strong for his wife.
“Yung brother ko, ayaw din niya. He was regretting pa, na bakit pa sya nagpa-hospital. Bakit ba? Kailangan ba ‘tong gawin? But then hindi na kasi talaga eh, hindi na siya nakaka-breathe properly.”
(He didn’t want it. He was already regretting why he even went to the hospital in the first place. He asked why they had to do this, was this even necessary? But they had no choice, he couldn’t breathe anymore.)
Doctors put a tube in him to help him breathe, but it was too late. Gerry’s 39-year-old brother passed away less than a week after taking himself to the hospital. With the outside world being on lockdown, his wife -- now alone -- walked home from Commonwealth to Caloocan City in the middle of the night. Gerry never got to say goodbye.
They didn’t even know then if it was COVID-19.
In the same city but in a different setting, supervisor Paolo Hipolito stood resolute between a crematorium furnace and a pair of funeral workers trying to carry a wooden coffin in.
“Hindi po kasi pwede yan eh,” said the young man to the funerary staff. “Protocol namin na dapat naka-balot yung katawan.”
(That’s against the rules. Our protocol says the body has to be in a cadaver bag.)
Quezon City -- the city with the largest population in Metro Manila – now also has the greatest number of confirmed COVID-19 cases in the national capital region. The local government turned Baesa Crematorium operational on March 24, anticipating that they would have to deal with more deaths at the height of the pandemic.
All COVID-positive remains are cremated in Quezon City, but the city has tagged for cremation even deaths they deem “COVID-related,” too. These are the deaths caused by respiratory and cardiovascular illnesses, or those who have comorbidities commonly associated with COVID-19, according to the Quezon City Civil Registrar’s Office.
These people, local authorities said, died without ever having been tested, or died before their test results came back.
Those who can afford to have loved ones cremated in private crematoria are free to do so. The rest who cannot, go to Baesa, where the local government offers cremation for free.
Baesa Crematorium had cremated 145 bodies in its first 23 days, with the furnaces burning eight bodies a day for the most part.
But only eleven of these are “COVID-positive.” The remaining 134 are “COVID-related.”
Records of these “COVID-related” deaths bear a striking similarity with the COVID-positives. Their average age: 60. Leading causes of death: respiratory and cardiovascular diseases. The difference: they died without tests telling their story definitively.
High-Risk Pneumonia was the leading cause of death among those cremated at the Baesa Crematorium [figure 3.A.], followed by Acute Myocardial Infarction or Cardiac Arrest [figure 3.B.]. Other respiratory illnesses and variations of pneumonia followed closely.
The “COVID-related” deaths at Baesa Crematorium far outnumber the confirmed COVID-positive deaths, and this reflects the figures that the entire city is seeing. From March 13 to April 17, Quezon City registered 90 COVID-positive deaths, while COVID-related deaths totalled 308.
Despite the national government requiring all COVID-19-related cadavers to be placed in sealed cadaver bags, and the handlers be in full Personal Protective Equipment (PPE), the funeral staff standing in front of Paolo were in collared shirts, and the body in the coffin was exposed. They implored Paolo not to send them back with an undelivered body that had already thawed in the noonday heat.
At the driveway of the crematorium, two other funeral vans were parked under the sun, also with cadavers inside, waiting for the next available furnace. They would be the seventh and the eighth to be cremated that day alone.
Paolo looked at the scene, and saw a long day ahead for all of them. With a sigh, he waved the wooden coffin in, with a promise to report the funeral home to City Hall for breaking the rules. Relieved, the transporters eagerly carried the coffin into the crematory chamber, hoisted the dead woman’s body out of the coffin and into the furnace, and carried the empty coffin back to the car – clearly with the intent to reuse it.
In Makati City, which had the third highest number of COVID-19 cases as of May 4, Mayor Abigail Binay subscribes to the same classification of COVID-positive versus COVID-related.
“Dalawa lang naman yan,” she explained. “Kung mamamatay ka, either COVID-positive ka, or COVID-related. Kasi ang problema natin ngayon, lahat tayo ay considered PUM (Person Under Monitoring) na. So once magkaroon ka ng sintomas at mamatay ka, considered ka as PUI (Person Under Investigation), unless sasabihin na, for example, vehicular accident. So, obviously, that’s not COVID-related. But unless you can rule out, or sigurado tayo 100% na hindi COVID-related ang cause of death, we consider it as COVID-related.”
(There are just two ways to look at it now – if you die, you are either COVID-positive, or COVID-related. Because the problem is that we’re all PUMs now. So once you get the symptoms and you die, you’re considered as a PUI, unless say, you die in a vehicular accident. Obviously that’s not COVID-related. But unless you can rule it out or be 100% sure that COVID-19 wasn’t the cause of death, we consider it COVID-related.)
The city has also recorded more “COVID-related” than “COVID-positive” deaths. From March 14 to April 18, there were 27 COVID-positive deaths, and 59 COVID-related or “PUI” deaths. Like Quezon City, most of Makati’s COVID-related deaths were caused by pneumonia – the most common medical complication of severe COVID-19.
Pneumonia is again the leading cause of death among Makati residents who were never confirmed to have COVID-19. These are classified by the city as merely “COVID-related” or “PUI” deaths.
“Death certificates do not say ‘PUI’ since that is not an illness but a classification of patients,” Binay explained. “As far as our records are concerned, they are PUIs, whether they are being monitored by the health center or the hospitals.”
IN THE MORGUES
Especially in the early weeks of COVID-19, hospitals themselves noted an abnormal spike in the number of deaths, evidenced by the times that morgues ran beyond their capacity.
The Lung Center of the Philippines only has four body freezers, but on Good Friday, 12 bodies had to be stored in the morgue – with most lying on stretchers outside the freezers. Dr. Tony Ramos, the Lung Center’s administrative service department manager, said they had to aggressively call funeral homes just to have them collected. The bodies that could no longer fit inside the freezers were starting to smell.
“Hindi mahirap tingnan na may difference talaga. Na mas madami ngayon [ang namamatay],” Ramos said. “Syempre dati, nagkakaroon ng inatake sa puso, nagkasakit sa baga. Pero hindi kasing dami ng katulad ng ngayon. Katulad ngayon, napupuno nga yung mga morgues.”
(It’s not hard to see that there's a difference now. That there are more deaths now. Of course, people were dying of heart attacks before, or of lung problems. But not as many as those who are dying now. Our morgues sometimes get filled up now.)
Ramos can only point to one reason.
“Dati, yung mga ospital, nabubuhay na lima lang [ang freezer sa morgue]. Kami, nabubuhay na apat lang. Pero ngayon lang namin nakikitang nao-overwhelm. So, by sheer number, makikita mo, ano ba ang bago ngayon? COVID.”
(Before this, hospitals could survive on just five body freezers [in the morgues]. We could even survive with just four. This is the first time that we’ve experienced being overwhelmed. So by sheer number, you can already see. What’s new here? COVID.)
Epidemiologist Dr. Troy Gepte believes many more Filipinos have died of COVID-19 than what is reflected in the official count.
Epidemiologist and public health expert Dr. Troy Gepte said it is important to seriously look into the many deaths that look like COVID, but were never confirmed. These deaths, Gepte said, may actually be silent indicators of just how bad the COVID-19 problem in the Philippines is.
“Some of the hospitals have somewhat been observing that nahihirapan sila to coordinate with funeral services to pick up yung mga namamatay. So maybe, yung surge din ng cadavers and remains is something for us to think about,” said Gepte.
(Some of the hospitals have somewhat been observing that it’s been getting harder to coordinate with funeral services to pick up the dead. Maybe this surge in number of cadavers and remains is something for us to think about.)
“Everyday, we are seeing an increase of how many - 100, 200 cases, and so many number of deaths. But there might be more. We don’t want to alarm the public, but we also want them to understand that the numbers we are getting may be an under-representation of what we really have.”
‘WALKS LIKE A DUCK, TALKS LIKE A DUCK’
The Philippines in the past few weeks has been trying to catch up on testing capabilities - both to detect new cases and make data as representative of the present time as possible.
The Real Time – Polymerase Chain Reaction (RT-PCR) machines remain the gold standard in confirmatory testing for COVID-19. But in the mad dash to save lives, another superior standard steps in while test results remain in backlog - the trained doctor’s eye. The skill of detecting the likely presence of COVID-19 just by looking at the symptoms is something only years of experience can give.
“‘Pag ang isang pasyente pumasok. Nahihirapan huminga. Inex-ray mo, bilateral pneumonia. CT Scan mo. Progressive yung infection. Previously-well patient. Any clinician would label that as a COVID patient. Clinically,” said Dr. Ramos. “Iba pa rin yung mayroong back-up by a laboratory examination. Pero ang treatment ng pasyenteng yon ay COVID treatment na. Kasi wala namang ibang logical cause of the acute respiratory failure or the viral pneumonia kundi yung COVID, COVID-19.”
(For instance, when a patient walks in and cannot breathe, gets an x-ray that shows bilateral pneumonia. They get a CT scan and it shows progressive infection. Before this, they were well. Any clinician would label that as a COVID patient. Clinically. It’s always a reassurance to be backed up by a laboratory examination. But we will already treat the patient as a COVID case, because there is no other logical cause for the acute respiratory failure or the viral pneumonia than COVID, COVID-19.)
This skill – called clinical judgment – is the practice of reading the patient, not just reading the chart.
“Alam natin na ang doctor, mabilis talaga ang appreciation,” said Dr. Gepte. “Based on their training, on their expertise, yung skill nila on diagnosis, once they see a certain combination of symptoms, they are already thinking of how to manage them. So ang reliance talaga natin on clinical judgment o yung astuteness ng doktor, it’s important. That comes with a lot of training. Unfortunately, it also comes with a lot of exposure to patients.”
“Yung sinasabing ‘walks like a duck, talks like a duck, is a duck’ nagkakaintindihan ang mga doktor dyan,” said Ramos. “Ito, naglalakad, bigla na lang nilagnat, nahihirapan huminga, ini-CT scan mo, ganito… wala ka nang multiple choice don. Talagang COVID yon,” Ramos said. “Wala lang resulta. Eh ang tagal ng resulta eh. Minsan namamatayan na tayo, saka lang dumadating yung resulta.”
(That saying, ‘walks like a duck, talks like a duck, is a duck,’ we doctors understand that. Let’s say we have this person, just walking around and suddenly getting a fever. Having difficulty breathing, you get a CT scan done… there’s no multiple choice there anymore. That’s COVID. It’s just that the results take too long to come out. Sometimes when it does come out, they’re already dead.)
This is the reason why doctors have also noticed the many deaths that fit the bill of a COVID-19 case but just did not have the finality of a test result. Clinical appreciation of these unconfirmed deaths tell them that more people in the Philippines are getting infected and dying of COVID than the RT-PCRs can catch up with.
“Most definitely. Kasi if you look at the COVID-positives, it’s just an indicator of the output ng laboratory eh. Dapat pagsamahin natin yung clinical presentation sa pagko-consider kung ilan na ba talaga ang namatay dahil sa COVID,” said Ramos.
(Most definitely. Because if you look at the COVID-positives, it’s just an indicator of the output of the laboratory. We need to include the clinical presentation in considering just how many have died of COVID.)
“Kailangan talaga nating maintindihan na it’s not just those that we see, which is only a portion of yung dami ng mga kaso at mga deaths. We need to maybe estimate it, multiply it by 5 or 10 times more, depende sa mga projections that we are seeing,” said Gepte.
(We need to understand that it’s not just those that we see, which is only a portion of the real number of cases and deaths. We need to maybe estimate it, multiply it by 5 or 10 times more, depending on the projections that we are seeing.)
But no matter how telling this spike of deaths may be to doctors, because these deaths remain unconfirmed, they may never figure in the official data that paint the official picture of COVID-19 in the country.
In the Philippines, pneumonia and cardiovascular diseases are among the leading causes of death even before the spread of COVID-19. To distinguish a non-COVID death from a COVID-related death with the same clinical presentation requires data analysis that most health experts and local governments do not have time to do, with their hands full keeping the virus at bay.
Atty. Cris Tenorio, civil registrar of the City of Manila, said there is just no time for any comparative data analysis at the city level. All their skeleton force is able to do at the moment is process the papers of all the new deaths.
“Masyadong busy. Hindi namin gaanong tinututukan yan,” said Tenorio. “Ngayon kasi sa amin, may mga listahan kami ng mga lahat ng namatay, at ganun din ang sanhi ng kanilang kamatayan. Pero as to yung comparison doon sa mismong sakit ay hindi namin nagagawa sa opisina.”
(We’re too busy. We can’t handle that right now. We have a list of all who died and why they died, but to compare these with COVID, we can’t do that in the office this time.)
Local governments also seem to classify their dead differently, something that will make it even more difficult to count just how many people could have possibly died of this disease.
The City of Manila – with the second highest number of COVID-positive cases nationwide – sticks only to what is written in the person’s death certificate, without taking note if these deaths could be “COVID-related” or not.
“Inisa-isa namin yung death certificates, at nakita naming may mga nilalagay naman talaga mismo na talagang PUI, PUM. Tapos may nilalagay din naman sila mismo na confirmed na COVID patient,” Tenorio said. “May mga pneumonia din na walang nakalagay kung PUI, PUM or COVID, so nilalagay namin sila sa Others.”
(We went through the death certificates one by one and saw that some of them were labelled PUI, PUM, and COVID.)
Based strictly on the remarks found on death certificates, Manila recorded 8 COVID-positive deaths, 38 PUI deaths, and 3 PUM deaths from March 11 to April 10.
The document Death Compilation Based on Death Certificates Registered, made by the Manila Civil Registrar’s Office, shows that 957 deaths were registered in the city between March 11 and April 10, with 8 of them dying of COVID-19.
But the total number of deaths in Manila within this period is 957. Nearly all of these deaths – or 908 out of the 957 – are classified as “Non-COVID-Related” or deaths by “Other” reasons. Respiratory and cardiovascular illnesses counted by other cities as “COVID-related” fall under “Non-COVID-related” in Manila’s list.
“Ang pinakamarami ay yung may kinalaman sa puso. Heart disease, coronary heart disease, pumapatak na may numero tayo na 227 na namatay doon,” Tenorio said. “Tapos meron tayong acute myocardial infarction, 92 naman ang bilang. Again, may kinalaman din ito sa puso. Hypertension, 90. Tapos, pang-apat yung pneumonia high-risk. Hindi ito nakalagay na PUI PUM or COVID, pero 74 ang namatay dito.”
(Most of the deaths have something to do with the heart. Heart disease, coronary heart disease, 227 people died of those. And then 92 people died of acute myocardial infarction, another heart affliction. 90 died of hypertension. Fourth major cause of death is Pneumonia High-Risk – it didn’t say that they were PUIs, PUMs, or COVID, but 74 died of this.)
These are all comorbidities commonly linked with severe COVID-19. But Tenorio said they must remain faithful to what the Death Certificates describe.
“Hindi namin sila sinama sa COVID-related dahil unang-una, walang nakalagay sa dokumento na COVID-positive siya, or PUI, PUM,” said Tenorio. “So kung ano lamang yung nakikita namin dun sa Death Certificate na nakalagay. Para at least hindi namin masira kung ano man yung nakalagay sa Death Certificate.”
(We didn’t put them in the COVID list because nothing in their documents say they are COVID-positive, or PUIs, or PUMs. We just log what we see in the Death Certificate so we don’t destroy its integrity.)
THE DEAD THAT COUNT
There exists no national total of how many Filipinos have died of circumstances that resemble COVID-19, but were never confirmed by lab testing. Even the Department of Health (DOH)’s COVID-19 Tracker only counts the deaths of confirmed cases.
At best, the recognition of these people is anecdotal. Dr. Jonas del Rosario, spokesperson of the Philippine General Hospital (PGH), shared the same experience with other doctors in the largest COVID-19 referral hospital in the country.
“Realistically, there are some patients who had COVID, na unfortunately hindi natin na-classify as COVID dahil walang test. But marami yan,” he said. “You are on the right track if you think na underreported yung deaths, secondary to COVID. I’m not saying all of the people who died of pneumonia were due to COVID, no. I’m just saying I’m sure there are cases there na hindi na lang nasabing COVID dahil hindi na sila na-test.”
(Realistically, there are some patients who had COVID but were never classified as COVID because there was no test. But there are many. You are on the right track to think that our deaths have been underreported, secondary to COVID. I’m not saying all of the people who died of pneumonia were due to COVID, no. I’m just saying I’m sure there are cases there that weren’t tagged just because they weren’t tested.)
As more testing kits and confirmatory machines become available, the Philippines is slowly trying to catch up on COVID-19 testing.
The Philippines’ testing capacity has gradually been improving. As more people get tested, more cases are coming out of hiding.
Dr. Ma. Rosario Singh-Vergeire, undersecretary of the DOH, also said the Philippines took a turn for the better when it abandoned the use of the old classifications of PUM (Persons Under Monitoring), and PUI (Persons Under Investigation), and adopted the new classifications of Suspect, Probable, and Confirmed.
The new DOH and World Health Organization case classifications, said to cast a wider net over possible cases.
Under the old labelling, PUMs – or people who were exposed, but are asymptomatic - were essentially left to themselves to self-quarantine without testing. PUIs – or those with exposure and/or travel history – were also merely asked to self-quarantine if their symptoms were mild, and could only avail of COVID-19 interventions if their symptoms worsened or if they were elderly and with prior illnesses.
With the new classifications, Vergeire said the clinical judgment of doctors now bears more weight. Physicians can now officially tag a patient as COVID-Suspect based on clinical assessment alone, or tag them as COVID-Probable even if their tests come out negative, as long as they show COVID-like symptoms. This applies to the living and dead.
“’Pag ang isang tao namatay, kahit walang test, pero clinically nagpakita na para siyang COVID, considered COVID na yan,” said Vergeire.
(When a person dies, even without a test, but clinically looks like COVID, we now consider it COVID.)
This paves the way for the unconfirmed to be counted somehow.
“Itong mga Probable, bibilangin na natin kasama nung ating mga Confirmed. And this time, it’s going to be official, because it’s part of our protocol already, “Vergeire said. “I think with this, makakakuha tayo ngayon ng mga impormasyon, makikita natin at maikukumpara - itong mga Probable na ito, ilan ba to, mas marami ba ito kaysa sa mga Confirmed cases? And then we can determine itong assumption, kung talagang bad na ba talaga yung ating picture.”
(These Probable cases can now be counted like the Confirmed cases. And this time, it’s going to be official, because it’s part of our protocol already. I think with this, we can get more information, we can start to see and compare – how many Probable cases died? Are they more than the one Confirmed? And then we can determine the assumption if our picture is really bad.)
Doctors are now erring increasingly on the side of caution, too, tagging “COVID” if it ‘walks like a duck, talks like a duck.’ Del Rosario said many of the Filipino doctors who died in the early days of the pandemic were not immediately flagged because their symptoms looked like ordinary pneumonia. They would be damned if they let any more of their comrades - or countrymen - fall the same way.
“I would like to let you know that the hospitals now, more and more, are leaning towards this diagnosis that once someone has pneumonia, it’s COVID-19 Suspect unless proven otherwise,” Del Rosario said.
But while all of this bodes well for the future, both the DOH and Dr. Del Rosario said the hundreds of other people who died untested before these new labels came out will never be counted, and may never be acknowledged as part of the victims of COVID-19 in the Philippines.
“Wala na. Hindi mo na mababawi yon. Kung ang pagbabasehan natin ay death certificate, hindi mo na mababago. Kasi kahit pag-suspetsahan mo, wala ka nang panghahawakang evidence eh,” Del Rosario said.
(They’re gone. You can’t change that anymore. If we can only base on death certificates, you can’t change things anymore. Even if you suspect they are COVID-19, it will already be impossible to prove.)
On the 40th day of her brother’s death, Gerry watches from her laptop as a priest hears mass for him. Other family members were watching the virtual blessing from their respective homes, too.
In the cities, mayors like Abby Binay of Makati would like to know just how many of their residents have died of this disease, and just how far it has spread into their community.
“Sa akin it’s more of the bigger picture,” she said. “Ilan ba talaga sa buong Pilipinas ang namatay ng COVID? Ilan ba talaga sa buong mundo ang namatay sa COVID? Yun yung mas importante sa atin, because this will tell us, give us guidance on future policies.”
(To me, it’s more about the bigger picture. How many Filipinos really died of COVID-19? How many people in the world really died of COVID-19? That’s more important to me because this will tell us, give us guidance on future policies.)
But in the homes of those left behind, the need for their dead to be counted is personal.
A sister like Gerry wants her brother to be counted, because her brother counts to them.
“It’s sort of… na-count ba siya?” she said, her voice trailing off. “It’s a growing problem, so at least, somewhat, dapat kasama naman sana siya sa mga na-count na victims of that problem. I guess there’s some sense of justice in that.”
(Was he counted? It’s a growing problem, so I wish he could have at least been counted as one of the victims of this problem. I guess there’s some sense of justice in that.)
Gerry found out her brother tested positive for COVID-19 eight days after he died. She logged on to the DOH COVID Tracker to look for him. And there he was – or at least what resembles his profile – on the list of cases For Validation.
In the days that followed, Gerry found herself checking and refreshing the website, waiting for PH723 - her Kuya - to be moved into the group that was absolutely, positively, killed by COVID-19.
“Never siyang lumabas dun sa report of Deaths,” said Gerry. “Tapos nagpalit na ng sistema si DOH, never ko nang nakitang nagreflect siya as a death,” said Gerry.
(He never appeared in the official report of Deaths. And then the DOH website changed. I never saw him reflected as a Death.)
When asked why it mattered to her, Gerry paused, unsure why.
“It’s the grieving process. It’s really knowing with certainty why my loved one died. That COVID took my loved one away from me, with certainty.”
(Editor's note: This article was written on May 3, 2020 and published on May 15, 2020. Some data on coronavirus cases and deaths may have already changed since it was written.)