The Philippines is at a crossroads. It must make a turn.
One way sends us down the path of Italy. An ineffective quarantine, a total spread of the disease, and eventually a strict lockdown across the entire country. Thousands of people have died as the healthcare system has been overwhelmed and doctors are having to choose who to treat, because they can’t treat them all the patients.
At the time of writing, Italy has 47,021 confirmed cases and 4,032 deaths, for a death rate of 8.6%.
If we turn the other way, we could be like South Korea. Early tracking and widespread testing meant South Korea had a good handle on the situation early and until one patient at a fringe church refused to stop going to church services and infected many more. South Korea ramped up testing and quickly got the situation back under control.
At the time of writing, South Korea has 8,799 confirmed cases and 102 deaths, for a death rate of 1.15%.
Which way the Philippines turns, down the path of Italy or South Korea, is up to us.
The Year of the Coronavirus
2020 will soon be known as the year of the coronavirus. The coronavirus dominates the headlines and now dominates our daily lives as we near the end of the first week under lockdown in Metro Manila.
With countries around the world adopting different strategies to deal with the virus, some successful, others disastrous, it’s worth looking at what has worked and how we can translate that to the context of the Philippines.
Who are the high performers, the best case-studies right now? Hong Kong, Japan, Singapore, South Korea, and Taiwan, and a small town in Italy. Why were they so good? As noted in this excellent Financial Times article, the Asian countries took swift action, largely due to their experience during the SARS outbreak. They tracked cases early, quarantined early, and had medical facilities which knew how to deal with outbreaks. We’ll get to the little Italian town too.
While most countries see +33% daily growth in confirmed cases of coronavirus, there are four outliers on the graph above who dramatically slowed the outbreak. You may also notice Taiwan isn’t on the graph – despite Taiwan’s proximity to China and the large number of visitors. Taiwan were so good at stopping the outbreak they didn’t reach 100 cases until after this research was done (Taiwan have 153 confirmed cases at the time of writing).
Meanwhile in the Philippines, at the time of writing, there are 307 confirmed cases and 19 deaths, a death rate of 6.2%. The low number of confirmed cases masks an important fact: these are just those who have been tested. The real number of cases could be in the hundreds of thousands in Metro Manila alone. I’ll get to why shortly.
What Can The Philippines Learn From The High Performers?
The Philippines desperately needs to learn from the best countries if it is to curb the outbreak. While many of us were in the ‘it’s just a bad flu’ stage, these countries were very quick to track the virus early on:
“Hong Kong has turned to a police ‘supercomputer’ normally used to investigate complex crimes to trace potential supercarriers and hotspots in the city following its successful deployment during Sars.”
It is a month or two too late for most countries to do this, so what can we do now? The best countries offer us several lessons that we can turn into three major steps for the Philippine context so we can slow and eventually stop this outbreak.
Step 1: Testing, Testing, Testing
South Korea is the poster-boy for widespread testing after administering more tests per capita than any other country in the world. With ‘drive-through’ testing clinics, over 300,000 tests have been conducted in the country so far. As Dr. Tedros Ghebreyesus, director general of the WHO, said to the NY Times: “You cannot fight a fire blindfolded. And we cannot stop this pandemic if we don’t know who is infected.”
Right now, testing in the Philippines is done at hospitals. Very few hospitals have testing kits and unless you have serious symptoms you will not be tested. The Philippine healthcare system is not close to the capacity and quality of South Korea’s, but it is possible to establish special testing sites, separate from any existing hospital facility and designated only for COVID Testing (and treatment after).
What about that little town in Italy?
While the entire country of Italy is on lockdown, with 4,000+ deaths and tens of thousands more predicted, it’s worth looking to one small town for another story. Vo, in the region of Veneto, now part of the ‘coronavirus red zone’, was where the first confirmed COVID-19 death in Italy happened.
As ABC reports, when the first person died in Vo, a 78 year old man, the town decided to lockdown to test everyone for coronavirus: “Researchers from the University of Padua, along with Veneto regional officials and the Red Cross, decided to test all residents for COVID-19. Around 3,300 people were tested, even if they had no symptoms.”
When the results came back they found 89 confirmed cases; almost 3% of the entire town had the virus. This was the purpose of the lockdown: stop the spread to other towns, test everyone, treat them, and stop the return of the virus by not allowing anyone back into the town until the all-clear.
Philippines At Bottom of World Testing Table
The Philippines is way behind on these testing measures. As of March 20, the Philippines has conducted 1,269 coronavirus tests and confirmed 307 cases. If these official numbers are correct (some sources suggest more tests done), roughly 1 in 4 tests are coming back positive. This indicates so many more unconfirmed cases are out there.
As I write this in Quezon City, there are 40 confirmed cases here but no widespread testing. If we assume the same rate of infection as Vo when they tested the entire town, 2.6%, it would mean almost 80,000 unconfirmed cases in Quezon City alone.
While there are obvious difficulties translating testing in small towns to big cities, the number of real cases in Quezon City is likely much closer to 80,000 than 40, not least because of population density (noted below) and that most coronavirus cases are ‘covert’, meaning they show no symptoms or mild symptoms only. Extrapolate this to other regions with confirmed cases in the Philippines and we could be looking at hundreds of thousands to a million unconfirmed cases of coronavirus in the country. They just haven’t been tested yet.
Why is this so much drastically higher than the official counts? Because the Philippines has one of the worst testing rates in the world, at 12 tests per million people (1,269 tests for a population of 104 million people). If it were included in the graph above, the Philippines would be at the bottom left between Indonesia, Pakistan, and Brazil. Each of these countries, Brazil, Indonesia, and Pakistan are all expected to report thousands more cases soon, with the coronavirus threatening their healthcare systems.
If we are to have a chance of stopping this outbreak in the Philippines, we need to quickly establish separate testing facilities and test, test, test. There are methods for testing which can help, random sampling of particular towns and cities which will help identify where best to focus, for example. But to reach the levels of South Korea’s testing, the Philippines will need to be doing 10,000 tests per million population. Right now, it’s doing 12.
The news that China and South Korea sent 125,000 testing kits to the Philippines is positive. Arriving on March 21, this will be between 1/4 and 1/10 of what will be needed throughout the outbreak and gives time for the Philippines to ramp up production of its own tests. What will be needed now are the separate testing facilities to administer those testing kits. We cannot do these at the hospitals and barangays or we risk spreading the virus to vulnerable populations and communities not yet hit by the outbreak.
Meanwhile in Vo, that little town in Italy, despite the outbreak surrounding them, “local officials say there hasn’t been a new case of COVID-19 there since March 13.”
Step 2: Separate Medical Facilities For the Coronavirus
Currently we are in a situation where 150 medical staff at The Medical City in Pasig were put under quarantine, effectively putting their hospital out of action. This is why the medical advice right now is if you have mild symptoms, stay at home and isolate, so you don’t infect hospital staff. However you will infect those at home. Indeed, as noted in this excellent interview with Donald McNeil, 75-80% of infections in China were spread at home.
Worryingly, Metro Manila’s lockdown is happening in one of the mostly densely populated areas in the world. Six of the top 30 most densely populated cities in the world are in Metro Manila. Combine the population density and 75-80% home infection rate and we have a potentially deadly combination in Metro Manila.
The size of most family homes in Metro Manila is probably smaller than the room you’re reading this blog in. Now imagine another 10 people in your room and you have some idea of what that’s like for many families right now. As people get hungrier, they will get more desperate. And desperate people will do desperate things.
What can we do? Well in the interview, above, McNeil notes that a lockdown serves the purpose of allowing these medical solutions to happen. After creating the special testing sites, it becomes more possible to quarantine those testing positive immediately. Importantly, this also reduces the burden on already overwhelmed hospitals. Medical personnel do such a critical job and we need to support them and ensure they can stay active. Setting up separate medical facilities for the coronavirus is crucial to taking the burden away from overwhelmed hospitals.
This need not be a long process. Germany are repurposing a local trade fair ground. China’s dozen makeshift hospitals are already beginning to close as coronavirus cases diminish there. As the saying goes, if there’s a will there’s a way. The biggest question right now, who has the political will?
Step 3: Free Healthcare
This leads us to the final step to make this happen: make sure the testing and treatment is free. Simply put, if you can’t afford to get tested, you won’t go for testing. So you end up spreading the virus. As Kolas Yotaka told NBC News:
“Taiwan’s health insurance lets everyone not be afraid to go to the hospital. If you suspect you have coronavirus, you won’t have to worry that you can’t afford the hospital visit to get tested. You can get a free test, and if you’re forced to be isolated, during the 14 days, we pay for your food, lodging, and medical care.”
Think universal healthcare is too expensive for the Philippines? Just think how much this lockdown is costing us. Generally, universal healthcare saves money but with the Philippine economy essentially grinding to a halt, it’s worth learning from Taiwan and the others here. Suspected cases can be removed from existing hospitals immediately, barangays can shuttle suspected cases to the testing and treatment facilities, and we can go back and track the people who flew in from countries with treatment, among other solutions.
Without These Steps, The Lockdown Could End Up Doing More Harm Than the Coronavirus
As it stands, the lockdown could end up doing more harm than good. In theory, a lockdown makes sense; stop the virus from spreading, give yourself time to establish separate medical facilities, and get people tested and treated. The lockdown in Vo did just that. It stopped movement, found the virus, and treated it. The lockdown wasn’t the end, it was the means to an end.
In practice, however, the lockdown here in Metro Manila remains the end goal. Barangays and cities are spending their time focused on administering the lockdown, rather than establishing the medical solutions it is meant to support: special testing and treatment facilities separate from existing hospitals, all done for free. This is what the best cases have shown us.
The path we are on right now is more similar to Italy’s than South Korea’s. If we continue down this path it will only get worse. The death toll would reach somewhere between 10,000 and 50,000 from the virus itself, and more would die from lack of access to medical treatment and related problems.
Yet the lockdown could still be worth it if the proper medical solutions can be implemented in time. City Mayors especially have a great opportunity to enact the three medical steps: set up special sites for testing and treatment of the coronavirus, and ensure it’s free.
With these measures, the Philippines can hope to end up more like South Korea than most of Italy.
We are at a crossroads. We need to make a turn.