Code Red: Reviving hope in a chronically ill health system
Fourth of a series on the legacy of the Duterte administration
Some 2 years into the COVID-19 pandemic, the Philippines has eased mobility curbs and infections have gone down to manageable levels. But the road to recovery was far from a smooth journey, with some even paying the ultimate price.
THE STRUGGLE IS REAL
“We bested 80 countries, richer countries. UK, US, Switzerland, Israel, Japan, Canada, Australia. Even Singapore!”
Anyone watching could feel the sense of pride in then-Health Secretary Francisco Duque’s voice in that television interview. Climbing over 80 rungs from consistently being last in a series of pandemic recovery indices was, after all, no easy feat.
News of the country’s leap to the 33rd spot in Nikkei Asia’s COVID-19 Recovery Index came in the last month of the then-outgoing chief of the Philippines’ health department.
But just months ago, government had lamented that the index and other global rankings like it, which put the country in the last spot in terms of resilience and recovery, were unfair.
“I think the alert leveling system is a best practice that the Philippines can showcase because maganda. Under alert level 1, there are no more widespread community lockdowns. Those days are over,” he said.
“The reasons for this are good compliance to public health standards in general, masking in particular. Good vaccine rollout. Then of course, loosening up a great deal of our social mobility restrictions.”
In the weeks before President Duterte stepped down from office, the Philippines was logging, on average, over 200 daily new COVID-19 infections, most of whom presented with mild or no symptoms at all.
For several weeks, the number of deaths was nil, something which at times came as a surprise, even raising questions on whether or not government data systems were once again experiencing a glitch.
But the data was consistent with other metrics that both government and independent researchers measure. Ward beds and intensive care unit beds were nowhere near full – a stark contrast to how circumstances were just several months ago.
It is therefore not at all difficult to surmise that the Philippines may very well be on its way to overcoming the coronavirus that once brought the world to its knees.
While no country was ever prepared for the disruptions that SARS-CoV2 caused, some had well-established and resilient healthcare systems that could withstand not only emerging threats but actual impacts of a health crisis.
The Philippines had hopes of treading the same path through what the Duterte administration considered a landmark law: Republic Act 11223 or the Universal Health Care Act signed in February 2019.
But on Jan. 30, 2020, barely a year since it was enacted, the country recorded its first case of novel coronavirus. The months that followed proved to be the most turbulent period for the country’s healthcare system.
Much like soldiers in times of war, doctors, nurses, medical technologists, among the many others, were in the frontlines of the medical battlefield. Waging war against an unseen and unknown enemy proved to be much more difficult than anyone could ever imagine.
On the second month since the country’s first COVID-19 case, the death toll began to rise, with health workers among the fatalities.
Their deaths were a hefty price to pay for a country that had only just begun its journey to uplift the quality of healthcare – because now more than ever, it’s what the Philippines needs.
During the rare times that she was able to take a break at the height of the pandemic, nurse Jaymmee De Guzman allowed five minutes of random thoughts to play in her head. But the situation didn’t give her the chance to get lost in happy ones. At the end of each thought was the hope time would somehow slow just so she could delay facing every health worker’s nightmare.
The years of experience as a nurse in San Lazaro Hospital, an infectious diseases medical facility, has not contributed much in diminishing her hesitation of returning to what many now know as the hot zone – a battlefield for her likes against the unseen.
She recalled that a particular return to the hot zone was even more difficult because it was to visit a colleague who, just the week prior, was walking the halls of the hospital collecting plants – a hobby many people turned to during the pandemic.
Set to retire from the service in a few months, that was the last time Jaymmee saw her up on her feet and well.
“Nung binisita ko kasi siya, sobrang init na init siya. Hindi siya makapagsuot ng damit. Nakapatong lang yung blanket kasi parang 'on fire' daw yung katawan niya sabi niya. Sabi ko 'o sige na ate'. Sa susunod, paglabas mo dyan, maghahanap tayo ng maraming halaman. Mangunguha pa tayo ng halaman.”
(When I visited her, her temperature was beyond the roof. She wasn’t even wearing clothes. Only a blanket covered her because she felt she was “on fire”. I told her that the next time we'd see each other after isolation, we’d look for plants. We’d collect plants from around the hospital.)
De Guzman never got to see her after that.
Unlike ordinary times, one death wasn’t reason enough to hold back because there were so many more who were ill and probably on the brink of crossing over. And with health workers also falling sick, it just didn't feel right to allow sorrow to set in and slow them from saving others in need.
“Minsan you just cannot find the right words. Minsan hindi mo alam kung basa na yung mata mo sa luha o basa sa pawis. It’s hard to tell someone na 'wag ka mag-alala. Kasi pano ka hindi maga-alala? Hindi mo pa alam kung mabubuhay siya kasi from time to time bumababa yung oxygen level niya.”
(Sometimes you just cannot find the right words. Sometimes you don’t even know if your eyes are wet from tears or sweat. It’s hard to tell someone not to worry because why wouldn’t you worry? You don’t know if that patient will even survive because from time to time the oxygen level goes down.)
COVID-19 had forced health workers to take on double, sometimes triple shifts. At a time when a lot of hospital staff contracted the virus, those who were well stepped up even if, technically, they didn’t have to. As in any job that lasts more than the required hours, the first thing that runs out aside from their strength are their breaths.
“Imagine wearing layers of personal protective equipment (PPE), suppressed yung hininga mo, tapos gagawa ka ng strenuous activity like lifting heavy patients. And then makikita mo yung patient asking kailan siya gagaling, ano na ba mangyayari sa kanya?”
(Imagine wearing layers of personal protective equipment, your breathing is suppressed and you take on strenuous activities like lifting heavy patients. Then you see the patient and he asks if he’ll recover, what will happen to him.)
Questions like these made De Guzman realize that more than physical, the pandemic left deep emotional scars.
“You can come back from physical trauma. You can exercise, you can eat well, sleep better. But when there is that mental trauma, psychological trauma, that is something that you cannot get over with.”
“Yung paglabas mo, you wish you could have done something else, something more. Pero you cannot do that. You want to be there longer pero kailangan mong i-limit because you will get exposed and at the end of the day, baka you may also lose your life.”
(When you’re done with the patient, you wish you could have done something else, something more. But you can’t do that. You want to be there longer but you need to limit your time with the patient because you will get exposed and at the end of the day, you may also lose your life.)
For De Guzman, the profession is more than just checking one’s vitals and making sure that patients receive the medicines they require. Unknown to many, nurses are heavily invested in their patient’s needs -- to make them feel secure in moments of disquietude, alienation even. This couldn’t have been emphasized more in COVID-19 Intensive Care Units (ICUs) where patients are immobile, dying, alone.
And even if they wanted to appear as human as possible, being under layers of PPE for hours made it almost impossible.
“When they see you and you are covered in white, parang (it’s like) you look like a toy…a robot. You look like a personal protective equipment rather than a human being.”
“Gusto mo i-numb yung sarili mo (you want to make yourself numb). But you still want to show that you are human. We will come back from this. And that’s the hardest way. No one can tell you, no one can teach you how to comfort another human being. Kasi sometimes, yung simple touch is enough to comfort. But your movements are limited.”
“The worst feeling yung (is) despair. Kasi wala kang sasandalan (Because you can’t rely on anyone). The government that should have been there to support you was too busy doing their own thing. They were not listening.”
In times of solitude, De Guzman often imagines herself and her colleagues as pawns being knocked off the board by a chess master's hand.
“Ang nangyari, it was a chess game between two chess masters. And yung pawns talaga yung health workers. But this time, parang a child’s game of chess. Parang kung ano nalang yung ma-move. Kung ano na lang yung matira. Kung sino na lang yung mauubos. Lahat ng nasa frontlines, specially the health workers, kami na ‘yun.”
(What’s happening is like a chess game between two chess masters. And the pawns in this game are the health workers. But this time, it’s like a child’s game of chess; whatever move is ok, whatever piece is left, whatever piece is eaten. All those in the frontlines, specially the health workers, we are those chess pieces.)
Fortunately, the likes of her are not mere mindless chess pieces.
At the outset, De Guzman has been vocal in expressing dismay over what she calls government’s “brushing aside” of the then-looming health crisis.
Shortly after the World Health Organization (WHO) coined SARS-CoV2 as a Public Health Emergency of International Concern, the Filipino Nurses United (FNU), a national labor group for nurses to which De Guzman belongs, called for a special assembly urging the government to “fight COVID and ensure public safety.”
But despite the promises of security and fair access to healthcare by government and the then-newly enacted Universal Health Care Act, for the FNU, for De Guzman, their appeals seemingly fell on deaf ears, and what ensued were months of affliction, fear, and loss.
The Universal Health Care Bill was crafted for one thing – to make health care equitable, affordable and accessible for all Filipinos.
Signed in February 2019, the Universal Health Care (UHC) Act gave hope that difficulties in seeking health care, especially for the marginalized, would be lessened. But unlike other laws, UHC is one that requires years, if not decades, before being fully realized.
Then-Health Undersecretary and now Officer-in-Charge Maria Rosario Vergeire, the woman tasked with the challenge of braving the tough questions, even criticisms, explained why the UHC Act is not one that will be felt immediately after its enactment.
At least 60 policies and operational guidelines essential for the implementation of the UHC Act have been developed by the Department of Health (DOH). All of them are geared towards the realization of universal healthcare. But in order to work seamlessly, all policies must be in force from both ends of the governance spectrum.
“Ang mga istratehiya na ginagawa sa ngayon, we have our financial integration, our operational integration or technical integration and we have managerial integration or the governance part. Ito yung pinakaimportante sa systems ng universal healthcare. Kasi you’ll never implement it in an area kung hindi ka integrated technically, financially and sa governance part,” she said.
(The strategies that we are doing now include financial integration, operational integration or technical integration and managerial integration or the governance part. These are the most important systems of universal healthcare because you’ll never be able to implement it an area if you are not integrated technically, financially and in terms of management.)
At present, at least 71 local governments are what they call UHC integration sites where, little by little, the implementation of various policies jumpstarts the shift towards better healthcare.
Vergeire admitted that the journey towards Universal Health Care will be long and slow, especially for a system that has been devolved for decades.
A devolved system, according to a group of health workers, has been a perennial problem because the basis of whether or not health is a priority lies with local chief executives.
The DOH agrees.
“Before, everybody used to do things on their own. Provinces will do their own thing, so will municipalities and barangays. But now with universal healthcare, we are integrating them. So we now have this province-wide and city-wide health system.”
Such a health system would avoid the frenzy experienced during the August 2020 surge where those struck by COVID-19 had to wait in tents for hours, sometimes even days, before finally getting admitted. There were stories of patients who didn’t make admission at all.
It was also during this time when health workers got together to call on government to take better action. For the first time since the pandemic broke out, they took a firm stand to call for a “timeout” because they were extremely exhausted.
An example of this integration at the national level is the One Hospital Command Center (OHCC). Borne out of the difficulties of that surge, the OHCC facilitated a “comprehensive and coordinated response to the pandemic by ensuring effective and efficient health facility referral in Metro Manila.”
The aim was to reduce the waiting time of patients by referring them to health facilities that could best provide the level of care they need.
Imagine such a system fully operational in different localities.
“Kapag meron kang ganiyang sistema, may network ka na sa loob. Lahat ng facilities, nakanetwork kayo. Meron kang patient navigation system kasi meron kang network within. That is the beauty of these province-wide and city-wide systems.”
(If you have such systems, you have a network. All facilities are in a network. You have a patient navigation system because of that network.)
Perhaps the easiest aspect tNo measure in the UHC Act is its provision to automatically make Filipinos included in the National Health Insurance Program. Now, whether paying contributions or not, Filipinos are automatic members of PhilHealth.
“So, there are two paths: either you are a paying member or, if you cannot pay, government will pay for you. Kelangan lang ng recognition na pag dating sa facility, bibigay sayo yung nararapat na benepisyo especially if you are an indigent (It just needs recognition, that when you go to a facility, you will get the due benefits, especially if you are an indigent).”
Only recently did PhilHealth, Philippine Amusement Gaming Corporation (PAGCOR), Philippine Charity Sweepstakes Office (PCSO), and agencies like the DOH and the Department of Finance and sign the joint circular that will operationalize fund allocations for universal healthcare.
Under the law, 50 percent of the National Government share of the income from PAGCOR and 40 percent of charity funds, documentary stamp tax payments and mandatory contributions of the PCSO shall be transferred to PhilHealth, which will be used to improve benefit packages for its members.
The funds will be released through the General Appropriations Act beginning 2023.
As to when the entire nation will feel universal healthcare at its optimum remains unknown. But what the DOH can assure is that with a blueprint in the form of a compendium of policies now in place, the Philippines is on its way to realizing what its neighbors have been enjoying for years.
The only hope is, even with a continuously evolving pandemic, health workers will not tire and continue to hold up. After all, what is universal healthcare without its most important facet?
AN AILING HEALTH SYSTEM
“We are waging a losing battle against COVID-19.”
It was a statement that didn’t really inspire confidence.
But coming from groups representing thousands of healthcare workers who battled against COVID-19 seven months into the pandemic, it was something they must have really felt; something true.
In the first few weeks after the nationwide lockdown, the public already got a glimpse of the dire situation health workers had to bear with on a daily basis – the lack of PPEs, testing facilities and time for rest.
For Maristela Abenojar, FNU national president, government reacted rather slowly to a health crisis that was already affecting all nations. In an assembly they convened during the early days of the health emergency, they had already expressed concern over the pace of viral transmission, and anticipated a shortage of nurses considering the likelihood of some getting infected.
It eventually happened.
“April 1, nagkaroon ng death sa hanay ng nurses. Si Nurse Arvin Pascual mula sa regional hospital ng Nueva Ecija ay na-ireport na namatay that time. Pagdating ng November 17, in two-weeks time, umabot na sa mahigit 700 yung healthcare workers na infected; 339 ay doctors at 242 ay mga nurses. Tapos nagkaroon na rin ng 22 deaths, nurses and doctors. So naalarma talaga kami,” she recalled.
(April 1 marked the first death from the nursing force. Nurse Arvin Pascual from the regional hospital in Nueva Ecija was reported to have died that time. Then, two weeks after November 17, more than 700 healthcare workers became infected; 339 doctors and 242 nurses. Then there were also 22 deaths, nurses and doctors. So we were really alarmed.)
With more and more healthcare workers falling sick and their close contacts needing to undergo 14-day quarantine, those who were well had to fill in the gaps in staffing. The usual 8-hour shift dragged on to 12 all the way to 36 hours.
To address what the FNU called “chronic understaffing” -- Abenojar said the term “shortage” implies supply problems -- government resorted to reaching out to medical groups and associations for volunteers.
Vergeire said tapping on volunteers to help out during a crisis is not as difficult as it sounds.
“Kinausap namin sila sa national, tulungan niyo kami. Kailangan na ng mga ospital namin ng mga additional na tao. And they readily responded. During this time of the pandemic, hindi mahirap humingi ng tulong. Isang tawag mo lang, as long as you coordinate with them, they will readily help.”
(We talked to them and said, “Help us. Hospitals are in dire need of additional personnel.” They readily responded. During this time of the pandemic, it’s not hard to ask for help. It only takes one call, as long as you coordinate with them, they will readily help.)
But not too long into the lockdown, the DOH released a Department Memorandum outlining the guidelines for emergency hiring of health personnel. This, after Abenojar said they didn’t subscribe to nurses volunteering their services in exchange for a P500 allowance.
Despite producing thousands of healthcare workers every year, not all intend to practice their chosen profession in the country.
The problem of low wages is undeniably the primary reason why health workers would rather work outside the Philippines. Nurses in government facilities with a salary grade of 15 earn around P35,000. But not all. Those under a contractual employment status earn lower, around P22,000 under salary grade 11. For nurses employed in private hospitals, Abenojar said they earn much less.
“Hindi kaaya-aya yung sweldo na binibigay. Sa private sector, ang sweldo ng nurses, sinusunod nila yung minimum wage law which is 537 pesos/day. Last month, nagdagdag ng P33 so P570 a day. Ang equivalent niyan P12,500 a month. So kahit yung mismong nurse, hindi niya mabubuhay yung sarili niya. How much more kung meron siyang pamilya?”
(The salaries offered are not attractive. In the private sector, nurses are paid the minimum wage which is P537 per day. Last month, P33 pesos was added to the minimum wage so it’s now P570 per day. That’s equivalent to P12,500 a month. That isn’t enough for the nurse to support her needs. How much more if she has a family?)
What the FNU is lobbying for now is to level the starting pay for nurses in both private and public hospitals at P50,000. It may not be as high as the salaries offered to nurses in the UK, Germany, Ireland, Singapore and the United Arab Emirates, but it’s a good start.
Distribution estimates from the DOH show that as of December 2021, of the 96,893 licensed physicians, less than half or only 40,850 were practicing in public and private health facilities in the country.
For nurses, the numbers are much lower.
Of the 617,898 licensed to practice, only 172,589 were in health facilities around the country. Almost half of those licensed or 308,949 chose to take on permanent or temporary employment overseas. Thousands were either employed in other fields or did not specify whether or not they were practicing the profession.
But health facilities are not run by physicians and nurses alone. Other healthcare workers, including midwives, medical technologists, radiologic technologists, pharmacists and many others, comprise around 1 million health human resources licensed to practice. Unfortunately, only around 307,000 or 31 percent were practicing in health facilities in the country.
But understaffing had been a problem even before the existence of COVID. In 2019, the nurse-to-population ratio was 8.30 for every 10,000 population. It was even lower with physicians where for every 10,000 Filipinos, there were only 2.64 physicians.
One would think that a raging pandemic would drive an increase in healthcare workers. Instead, the numbers decreased even further with a ratio of 8.03 nurses for every 10,000 population and 2.62 physicians for every 10,000 Filipinos.
These figures are way below the WHO-recommended ratio of 1:1,000 people.
For Vergeire, the problem lies with production and the lack of policy that will orchestrate and streamline the number of health workers that public and private educational institutions produce.
“Now we have this national master plan for health ng workforce natin. Dun palang sa planning stage, we are already looking. Mag-inventory ka kung ilan ang kailangan mo. Every region should be able to produce their own so that they can replace their own as well. It is not only national to work on this, but all. Dapat yung regional areas natin working with us. All of these universities,” she explained.
(Now we have this national master plan for health ng workforce natin. As early as the planning stage, we are already looking. Make an inventory of how many you need. Every region should be able to produce their own so that they can replace their own as well. It is not only national to work on this, but all. All of our regional areas should be working with us. All of these universities.)
“Our private counterparts, facilities, universities should also have that kind of intent to help government so that we can be able to manage our shortages in the country. Because if this will not happen, when the next pandemic emerges, we will then again be faced with these kinds of issues.”
During the 2-day Duterte Legacy Summit held in the latter part of May, Duque noted that they were able to scale up several UHC programs aimed at supporting capacities of local governments in delivering health services, including the deployment of human resources for health to priority areas, like those which are geographically isolated and disadvantaged.
“An average of 27,400 Human Resources for Health per year were deployed to underserved areas in LGUs [Local Government Units] from 2017 until 2021,” Duque said.
Along with human resources for health, the pandemic also highlighted the lack of facilities, capabilities and equipment.
In a June 2020 policy paper on the Philippine health system by UP National College of Public Administration and Governance senior lecturer Paul Quintos, majority of the over 400 online survey respondents said that their “health facilities do not meet even 50 percent of what they perceive as the adequate number of health personnel and the sufficient number of infection, prevention and control (IPC) supplies and personal protective equipment.”
The survey was conducted from April 24 to May 3, 2020 – the period when COVID-19 was most potent and raging throughout the world.
Being most vulnerable to infections and having no form of protection at that time, healthcare workers relied solely on defending themselves through personal protective equipment (PPE) – the first batch of which was distributed on April 2, 2020.
“Yung 1 million PPE sets na ang halaga ay P1.8 billion, na-distribute lang yan sa 7 ospital, pakonti-konti. By the end of April, hindi pa umabot sa one million ang sets habang tumaas naman ang surge at bilang ng healthcare workers,” Abenojar noted.
(The one million PPE sets which cost P1.8 billion, was only distributed to 7 hospitals, in trickles. By the end of April, the sets didn’t even reach 1 million during the time a surge was happening and the number of health workers increased.)
Notes collated by the FNU show that a little over 12,000 sets of PPEs were distributed to different hospitals on April 2. These included San Lazaro hospital (2,780), Philippine General Hospital (2,000), East Avenue Medical Center (770), Lung Center of the Philippines (2,800), Dr. Jose Rodriguez Memorial Hospital and Sanitarium (2,590), and the AFP Medical Center (1,100). All but the AFP Hospital were later on tagged as a COVID-19 referral facilities.
Abenojar lamented what to her was government’s thrift in protecting healthcare workers.
“Halimbawa, ang PGH [Philippine General Hospital] tumanggap ng 2,000 PPE sets. Kung meron kang 100 patients na may COVID, sa dami ng nurses, doctors na magsusuot, yung 2,000 sets na yun, tatagal lang ng 10 days. Lumabas pa sa Senate Blue Ribbon Committee investigation na noon palang, March 25, meron nang total of P8.8 billion contract sa Pharmally na ang mamahal ng PPE.”
(From example, the PGH received 2,000 PPE sets. If you have 100 patients infected with COVID, because of the number of nurses, doctors who will need protection, the 2,000 sets will only last for 10 days. It was learned from the Senate Blue Ribbon Committee investigation that as early as March 25, there was a total of P8.8 billion contract with Pharmally, where PPE prices were high).
“So habang namamatay ang mga health workers at maraming pasyenteng nade-deny ng ospital, may nangyayaring pag gamit ng pondo ng bayan para sa anomalous transaction.”
(So while health workers were dying and so many patients were being denied admission in hospitals, public funds were being used for anomalous transactions.)
Earlier in June 2022, only 9 senators signed a draft report on the Senate probe on Pharmally which recommended filing cases of graft and plunder against Pharmally executives and several government officials, including Duterte. Eleven signatures were required for Committee Chair Senator Richard Gordon to sponsor it at the plenary.
At least 2 senators cited the inclusion of Duterte among those recommended for charges as the reason for refusing to sign the report.
Although other countries also grappled with the pandemic, they were quick to respond to immediate needs such as testing and other COVID-related facilities. This was evidenced by the slow rise in infections rates at a time when infections in the Philippines began to soar.
But no matter how much criticism the DOH received from an anxious and weary public, they say they have done the best they can.
“We only had one laboratory then. And that’s RITM [Research Institute for Tropical Medicine]. But now, how many do we have? We have over 300 laboratories. In just a matter of 2 to 3 months, we were able to set up almost 100 laboratories from just one laboratory,” Vergeire explained.
“Dati ang ating isolation or quarantine facility, iisa. Nasa New Clark City diba? Ngayon, gaano na karami? Libu-libo na ang isolation and quarantine facilities sa ating mga local governments. So these facilities, these laboratories, isa yun sa weakness. Pero ang kagandahan, even though there were weaknesses, agad agad na-address.”
(Before, we only had one quarantine facility and that was in New Clark City right? Now, how many do we have? We have thousands of isolation and quarantine facilities in local governments. These facilities, these laboratories, were among the weaknesses. But the good thing is, even though there were weaknesses, they were immediately addressed.)
Amid the countless disagreements between the public, the government and the experts, one fact can be agreed upon: no country was ever prepared for a health crisis of this magnitude. The difference lies in each country’s system, dedication, and political will.
For the DOH, the pandemic has, in fact, hastened the implementation of some components of the UHC Act. And no matter how harsh, absurd or valid criticisms thrown at them may be, they continue to bank on 2 things – public service and the right information.
“Sanay kami na we are being criticized (we are used to being criticized). But at the end of the day, the DOH together with the officials continue to work. We just continue to show people that we will always protect you because this is our mandate,” Vergeire said.
“We answered every question that was thrown at us. Based on science, based on evidence. We did not give false information to the public. And that is what we are very proud of,” she added.
At the height of the pandemic, infectious disease specialist and member of the government’s Vaccine Expert Panel Dr. Rontgene Solante usually began his day at 3 am.
One would think that for his age and stature, he would opt to work behind a desk, attend virtual meetings, sign important documents, and conduct online seminars. But at a time when human resources for health was scarce, he too was at the frontlines doing rounds in both private and public hospitals.
On average, he saw between 150 to 200 patients per day. With his clinical eye, he said he knew when he’d see a patient for the last time.
“It’s so depressing because you see people dying everyday. You’d be able to predict that this patient will no longer be here tomorrow. It’s usually the old ones,” Solante said.
“When we talk to the relatives, it’s also something that hits us. Sometimes, we cry with them. You can’t prevent that.”
Back when optimism was clouded by precariousness, he would always ask himself a question no one would ever want answered: When will I be next?
Thinking about the answer was chilling. But like everyone else in the medical community, he is quick to brush off any thought that would rattle his focus away from the goal.
“My goal is really helping the healthcare workers and the patients. Whether it will affect me or not, I don’t think about it, as long as we can help those who are really in need. When I look at the emergency room, people there are gasping for breath. My goodness, I ask when will this all end?”
Sitting in his office during our interview, he said it felt like he asked those questions many years ago.
Two and a half years since COVID-19 ravaged the world, the Philippines, once perceived to be one of the worst countries to be in during the pandemic, is actually doing quite well.
Since the omicron-driven surge earlier this year, the country has managed to keep numbers at low levels. This, despite occasional upticks observed in specific areas in the country in June.
What’s important to note, according to the DOH, is that even if people are catching the virus, admissions in wards and ICUs were on a plateau across the entire archipelago as of early June or over a month ago.
In the week of June 7, available beds actually increased by 160 or 0.6 percent compared to the week prior. For this period, healthcare utilization rate remained low risk at 19 percent.
The number of available ICU beds, however, decreased by 52 or 2 percent, in the same period. Admissions to ICUs also decreased by 5 or 2 percent.
If only for the low number of fatalities, Solante said the country responded rather well.
“Above average. Why? Because comparing with other Asia countries, our mortality rate is not as high as compared to them,” he said.
Numbers have a way of blinding people to certain realities. For example, Solante said public perception would be very different if the only numbers presented are those getting infected and needing hospitalization.
“'Pag nakita kasi nila yan ng ganon, ang conclusion niyan, pangit ang control natin kasi ang daming nagkasakit, ang daming namatay (When the public only sees these numbers, the conclusion is the management wasn’t very good because a lot fell ill, a lot died). But it’s a pandemic, we could have been worse than that, like India or Indonesia which has a higher mortality than us,” he said.
India and Indonesia were among the countries badly struck by the delta variant, the most virulent variant of concern recorded so far.
Looking at countries in Southeast Asia alone, the Philippines ranked second to Indonesia in terms of having the highest number of fatalities at 60,461 as of June 15. Vietnam, which is similar to the Philippines in terms of population, was at a distant third.
But, for Abenojar, assessing the Duterte administration's performance on pandemic response should not be merely based on the number of infections, mortalities and vaccination. Rather, she chooses to highlight the plight of healthcare workers and the disparity of health services between regions.
“I feel it’s a failure. Wala namang naging improvement at all sa usapin ng health distribution ng healthcare services. In terms of availability of healthcare services, ganon pa rin. Kulang-kulang ang mga primary healthcare facilities.”
(I feel it’s a failure. There have been no improvements at all in terms of distribution of healthcare services in terms of availability. It remains the same. There is a shortage in primary healthcare facilities.)
“Tapos yung 1,235 hospitals in the country classified as level 1, level 2, level 3, almost 40 percent is concentrated in the National Capital Region, Central Luzon and Calabarzon. So, ang iba, wala na (other areas have none).”
If there’s anything the government has done that health workers are satisfied with, Abenojar said that it’s, to some extent, they listened. The DOH and health workers are now in regular talks through forums, just so they could be more sensitive about what those on the ground are going through.
It is, after all, health workers who know how to best emerge victorious from a health crisis.
It was during the pandemic when Filipinos saw the birth of groups like the Vaccine Expert Panel and All-Expert Group. While many have criticized government in taking a more “militaristic approach” in battling COVID-19, a perception that Solante considers valid given the background of various heads of agencies who comprise the Interagency Task Force for Emerging Infectious Diseases, he acknowledged that health workers were still given great importance.
“Even the vaccine czar was also a military man. But every decision of the vaccine czar came from the All-Expert Group. There was a time when government convened all the experts to help the DOH in drafting guidelines in the management. Part of that is the private medical societies so a lot of medical professionals really helped out.”
The system is not perfect. But COVID-19 has given government the opportunity to revive and improve a system that’s been under extreme malaise for years.
The Duterte administration demonstrated great political will on certain issues which, according to Solante, included the pandemic. Measures to strengthen the healthcare systemaa like the development of isolation and quarantine facilities, as well as promoting vaccination, are just some of the things supporters of the current administration will remember Duterte for.
For the DOH, what is clear is that the former administration laid the ground work for pandemic response. The COVID-19 pandemic will not last forever which is why as the situation improves, current measures will also have to eventually hibernate. But it must also be ready for rollout when the next pandemic strikes.
“We need to institutionalize everything that we have done. We cannot be at this level where our facilities, our reforms and strategies are temporary because of the pandemic. When we talk about quarantine facilities, isolation facilities, schools can’t always be the go-to,” Vergeire said.
“Local governments should have the flexibility. They have to have their own areas for these when circumstances require and not repurposing any facility,” she added.
Aside from local government facilities, the DOH said time will come when hospitals will also need to set up their own infection prevention control units for whatever outbreak of an infectious disease.
Abenojar hopes that President Ferdinand Marcos Jr. will veer away from a militaristic approach in ending the health crisis, and find ways of maneuvering through and overcoming problems with the public’s greater good in mind.
“Itaas nila yung budget for health.... Magsisimula nanaman ang budget hearing. Dapat sana, matuto na sila. Aral na ‘yung nangyari the last 2 years,” Abenojar said.
“Kailangan nila makinig sa basic sectors. Hindi yung maglalabas ng policies na hindi kinokonsulta ang taong bayan tapos mali-mali ang nilalabas nilang polisiya na sa tingin natin ay hindi nakakatulong,” she added.
(They should raise the budget for health. The budget hearings will start again. They should have learned from what happened in the last 2 years. They need to listen to basic sectors instead of issuing policies without consulting the people, which we think are not helpful.)
The FNU said it will work with other sectors and, more importantly, it will continue pursuing and advancing the struggles of health workers and push for what is due the Filipino people.
FIGHT NOT YET OVER
As Dr. Solante removes the stethoscope from around his nape and tucks it away in his drawer, a crease subtly forms at the corner of his mouth, a short but thankful smile.
While the virus has been so unforgiving, claiming lives of people he knew, people who mattered, at the end of each working day he gives off a sigh of relief.
“I always ask myself, 'Totoo ba ito?' At the end of the day, you just have to say, 'Thank you Lord na buhay pa ako. Buhay pa ang pamilya ko.'”
(I always ask myself, “Is this for real?” At the end of the day, you just have to say, “Thank you Lord that I am still alive, that my family is still alive.”)
As he steps out of San Lazaro Hospital, he knows that things are better now. Until when, he cannot say.
But a quick gaze at one portion of the parking lot, where instead of cars are tents almost worn out by heat and rain, sends an eerie reminder that the fight is not yet over.
For Dr. Solante, reminders are good. Because in this most critical period of our history, in terms of health, he is reminded that even though life is short, it shouldn’t stop one from living a life that’s meaningful.
“If you have the expertise to help government, the government needs you. Lend your hand to the Filipinos,” Solante said.
A NEW DAY
Several months after the omicron-driven surge, the virus is once again making its presence felt.
The National Capital Region and some areas have noted slight upticks in cases, stirring concern among the public yet again, with some even asking on whether or not an escalation of the least stringent alert level is necessary.
But the DOH has repeatedly pointed out that even as cases rise, indicators like healthcare utilization rate, average daily attack rate, and severe infections remain low.
The agency said part of the shift towards living responsibly with COVID-19 is understanding that beyond daily new infections is the more important reality that severe forms of the disease are becoming less and less of the norm.
Aside from minimum public health standards, the game changer was the vaccines.
“Nakikita natin na mukhang kahit pumapasok ang mga variants (we see that even if subvariants are coming in), we are able to manage because of the high wall of immunity. What would be the key here are the right vaccines,” said Vergeire.
The Philippines is the only country to issue an Emergency Use Authorization (EUA) to 9 vaccines against COVID-19. Health experts have deemed this decision vital in controlling the pandemic as it enabled the entry of more vaccines for the Filipino people.
While the procurement of the much-needed jabs has also been hounded by controversy, health experts have said that they arrived just in time.
Even though hospitals were already overwhelmed during the alpha and beta surges in early 2021, things would have been worse had the government’s vaccination program started beyond March.
“I think it was just enough when we procured those vaccines. Even if it was just Sinovac. I think it made us less vulnerable to the severe form caused by the delta variant,” a health expert said.
While reaching previously set vaccination targets has proved to be a challenge in past months, the Philippines is among the less than 100 countries which has vaccinated at least 70 percent of its target population.
Though reaching 70 percent is an undeniable feat, for the WHO, it’s not enough. Along with the 70 percent is the need to vaccinate 100 percent of the vulnerable population and 100 percent of frontline workers.
As of June 16, almost 70 million Filipinos have been fully-vaccinated for COVID-19. Among those fully jabbed are 95 percent of healthcare workers, 77.5 percent of senior citizens and 94 percent are those with comorbidities.
Juxtaposing this figure to that of the WHO’s target, the Philippines just needs to push a little bit further.
The end of the pandemic is still nowhere in sight. It also bears repeating that the virus is here to stay, and that an endemic state of COVID-19 does not mean its end in the literal sense.
But there is light at the end of the tunnel. The WHO says it hopes to see the end of the acute phase of the pandemic this year. That’s if the world will allow it to happen.
In the Philippines, there have been calls to end the state of calamity due to the pandemic -- a move that the DOH says it will not immediately do given the implications on vaccine EUAs, tax exemptions and price control for COVID-19 commodities, among others.
The Philippines’ state of calamity, declared by Duterte through a proclamation, will expire on Sept. 12, 2022. The decision on whether or not it will be extended now lies with the Marcos administration.
More importantly, getting out of this pandemic and living under a new normal, in its truest sense, is up to the country’s new leaders.
Further executing the UHC Act, the passage of a bill for the establishment of a Center for Disease Control and Vaccine Institute of the Philippines are just some of the grand aspirations health experts have for the country in the years to come.
The situation may be better now, but Nurse Jaymmee’s daydream of the chess game still lingers. What’s worse are the images that reappear in her head as she walks the empty hallways of San Lazaro Hospital at night. Looking at the length of the hallway now, from end to end, will never be the same.
“It’s dead silent. You would never imagine how chaotic the situation once was in these halls. Now, the chaos may be gone, but the unsettling feeling remains,” she said.
De Guzman said the pandemic has changed her.
“I’ve become paranoid. I remember the last two years and I fear that what was before may come back to haunt me. That it may return and when it does, it’s much angrier,” she said.
But like all those who are serious at what they do, she channels her worries and fears into energy that would sustain her; that these only mean the job is never finished. Everyday, she remembers the struggles of those in their ranks.
She remembers most especially the 36,018 health workers who caught the virus and fought a long and tiring battle. A lot of them defeated the enemy. But there were also 121 others who didn’t, according to DOH data as of June.
Their lives serve as constant reminders that the fight against COVID-19 should continue. That even if masking rates remain relatively high, the administration of vaccines and boosters are ongoing, the work never stops and there is still so much more to be done.