The Philippines has been under some form of lockdown or strict quarantine for 17 continuous months, yet it finds itself with thousands of cases a day. Patricia Denise M Chiu asks why
In August 2020, the Philippines, already under quarantine measures involving shuttered businesses, enforced curfew hours, and limited access to basic supplies, was at a crossroads.
Overwhelmed by quickly filling intensive care units amid rising cases of covid-19, the country’s healthcare workforce had had enough. They called for “time out” measures to restrict movement and reduce infections, but more importantly to buy time to assess and plan for a way forward in managing covid-19. The call forced President Rodrigo Duterte to order two weeks of stricter lockdown that involved longer curfew hours and militarised checkpoints.
A year later, the country remains in one of the longest running, strictest quarantines in the world—518 consecutive days, at the time of writing, in various flexing levels with restrictions on movement that risk fines or even beatings from law enforcement if broken. Those arrested are made to do hard physical labour or are confined in cells which further risk their exposure to the virus. At least one minor, a 12 year old, has died after local watchmen chased and hounded him. Another man died after police forced him to do 300 push ups when he was apprehended outside his home buying drinking water after curfew hours.
The see-sawing restrictions come down hardest on people living in poverty, as those who cannot provide proof of employment are usually arrested and tagged as quarantine violators. Day labourers and those in the informal economy make up 38.3% of the country’s more than 110 million population.
With the looming threat of the SARS-CoV-2 delta variant, the Duterte government is further tightening restrictions, but healthcare workers say previous lockdowns have done nothing to ease the burden on the healthcare system, as the time has not been used to make a better plan.
“We’re worse now. Our surge this year is bigger than last year’s. It’s in all the regions, and doctors are already demoralised,” says Antonio Dans. He and Leonila Dela Fuente-Dans are co-convenors of the Healthcare Professionals Alliance Against Covid-19 (HPAAC), the group of medical workers that called for the two week time out.
Both epidemiologists, Dans and Dela Fuente-Dans say the country is struggling in its covid-19 response because of the “disconnect between policy and implementation.”
“When we called for a time out, the main purpose was primarily to discuss what we were doing wrong and to find solutions, it was only secondarily to help control the ongoing surge,” Dans says. He says the August 2020 time out failed.
During that time, the more than 160 professional medical organisations that make up HPAAC called on President Duterte’s government to address seven issues: overloaded hospitals, inefficient case finding and isolation, inefficient contact tracing and quarantine procedures, the prevalence of workplace outbreaks, inadequate and unsafe transportation options, growing inequity, and complicated rules that make it difficult for the public to comply with safety protocols.
Of the seven, only two have been tackled, Dans says. The Duterte government installed 500 km of bike lanes, after the government’s decision to stop public transportation pushed healthcare workers and others to cycle to work. More controversial is the Social Amelioration Program, which was meant to distribute 206.6 billion Philippine pesos (£2.94 billion; $4.08 billion; €3.49 billion) to 18 million low income families. But this was fraught with allegations of corruption and slow disbursements before being suspended at the end of June 2021, leaving 6 billion pesos unspent and returned to the Treasury.
Meanwhile, covid-19 infections continue to rise. At the time of writing, new cases numbered 15 000 a day (up from about 1000 at the turn of the year), with just 10% of the population vaccinated.
In February 2021, the Philippines was due to receive its first shipments of vaccine—doses of the Oxford-AstraZeneca vaccine produced in South Korea and distributed by the World Health Organization-affiliated global COVAX facility, which aims to deliver fair and equitable access to covid-19 vaccines. But the government failed to supply the necessary paperwork on vaccine indemnity on time. The delay meant the first vaccines arrived in the country a month later in March, and consisted of Coronavac (Sinovac) donated by the Chinese government.
In December 2020, foreign minister Teodoro Locsin Jr admitted that a high ranking official “dropped the ball” in the country’s negotiations with US drugmaker Pfizer. Locsin has since named Francisco Duque III, the health minister, who allegedly failed to sign necessary paperwork to process the purchase, a claim Duque has since denied.
“As a result of this, we did not get the vaccine that we may have wanted to get, when we wanted to get it,” says Esperanza Cabral, who served as health minister from 2009 to 2010.
Duterte’s covid-19 task force has constantly shifted the country’s vaccination target, first pegging it at 70% for “herd immunity,” and then lowering it to 50%, for “population protection” to minimise hospitalisation and death. “When they move their targets around, it is an admission that they can’t do what they said they will,” Cabral says.
The president, known for his outspokenness, has at times escalated tensions. In a 3 August speech, Duterte threatened to have unvaccinated individuals arrested if they ventured outside the home during the lockdown, prompting massive crowding at vaccination sites the day before tightened measures took effect. This caught local governments unawares and forced them to turn thousands away because of a lack of available vaccines.
In May 2021, the president was inoculated with Sinopharm before it was given emergency regulatory approval in the country. His bodyguards have also admitted to using smuggled Sinopharm as early as September 2020. Duterte has favoured the Chinese brands Sinopharm and Sinovac, as well as Russian made Sputnik V, over western made vaccines.
Duterte and his allies have also picked fights with the country’s healthcare workers, accusing them of inciting insurrection after many took to social media to sound the alarm on long waits to get into emergency departments and covid-19 wards. The posts have described patients dying in cars parked outside hospitals and increasingly younger, otherwise healthy unvaccinated individuals dying of covid-19 because the limited supply of vaccines means they are at the end of the long waiting list.
The escalating situation and controversies are harming the vaccination effort, says Dela Fuente-Dans. “There are a lot of distractions. These incidents erode vaccine trust,” she says.
Cabral, the former health minister, says “The vaccination rate is slowly increasing, we just have to sustain it. People are now willing to be vaccinated, but it is an issue of vaccine supply.”
Locked down anew
Manila is once again under the strictest lockdown classification—for the third time—since 6 August 2021. Restaurants and shops are closed, and mobility is again limited.
On 14 August 2021, the 1500 bed Philippine General Hospital, the largest training hospital in the country, announced that it would stop accepting non-covid patients, and that outpatient clinics and services would be closed. The hospital also said elective surgeries would be reduced, and that more covid-19 wards would be opened.
Two days later, the Health Ministry said 71% of all 3900 intensive care unit beds in the country were already in use, while 63% of all 13 700 covid-19 ward beds were occupied.
Maria Leonor Robredo, the country’s vice president, and a staunch critic of Duterte, said in a televised interview that the country is not conducting enough covid-19 tests to offer an accurate picture of the pandemic situation. “If our positivity rate is already at 21% per day, and we are conducting just 50 000 tests, we are not testing enough,” she said.
The Health Ministry insists it is prepared for another surge. Spokesperson Maria Rosario Vergeire told The BMJ the ministry hopes to contain the spread of the delta variant through “three critical action points”—improving community response, enhancing hospital response, and continuous vaccination against covid-19.
Vergeire said the Health Ministry is hoping for a “more synergistic” response between national and local government, public and private institutions, and the public in general. The ministry said it had added 30-50% more beds by repurposing hospital facilities and minimising elective cases, doubling oxygen supply, and hiring nearly 10 000 additional hospital staff.
But, says Dela Fuente-Dans, in the face of a delta fuelled third wave, the Philippines’ response is too heavily reliant on local governments, which have poorly staffed clinics and hospitals.
In Bataan, a province two hours away from the capital, a nurse at a government hospital working in a covid-19 ward earns just 7000 pesos a month, despite the Labor and Employment Ministry saying that nurses in government hospitals should earn on average 13 500 pesos a month.
Pandemic benefits and bonuses promised to healthcare workers have yet to be paid in full. This includes the 9.02 billion peso Special Risk Allowance that was supposed to cover 300 000 medical workers for shifts worked between December 2020 and 30 June. A healthcare employee working directly with patients in a covid-19 ward is entitled to receive up to 5000 pesos a month, but the distribution has been delayed, nurses say.
HPAAC has called on the government to rethink its strategy of using lockdowns to stem the rise in cases, says Dans. “The August 2020 ‘time out’ led to some new policies, but it didn’t lead to change,” he says, “It’s frustrating, this separation of policy and implementation is a problem of a decentralised government.”
Cabral says the Philippines is suffering from the effects of years of chronic underinvestment in health—from the 1990s to around 2007, the operating budget of the department had been largely flat at around 11 billion pesos per annum. It rose to around 24 billion pesos during Cabral’s term in 2010.
“We simply do not have what is necessary. While patient care is better now compared to a year ago, when a surge occurs, unfortunately we will be in the same position: lacking beds, equipment, medicines, and oxygen,” she says.
Says Dans, “Let’s not just lockdown, let’s think of why this is happening to us. Our policies should be resistant to whatever variant of the virus there is.” This means adopting a strategy that will allow the public to live with the virus, he says. For instance, “Why isn’t the government doing more to highlight that covid-19 is airborne?” he asks, adding that every time there is a slight loosening of restrictions, the cycle starts again.
Competing interests:“I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.”
Provenance and peer review: commissioned, not externally peer reviewed.