MANILA — On the evening of March 16, Philippine President Rodrigo Duterte announced on national television that he’s putting the whole of Luzon — where half of Philippines' 100 million people live — on “enhanced community quarantine.”
The directive, in response to the growing spread of the novel coronavirus outbreak, comes just two days after a botched attempt to restrict movement of over 16 million people that live and work in Metro Manila. As of March 24, there are 552 confirmed COVID-19 cases in the Philippines, and 35 deaths, according to the Philippine Department of Health.
“Are we better prepared now than we were during the time of SARS? And the answer there is our systems have improved … but really the systems did not exponentially improve.”— Manuel Dayrit, former Philippine health minister
This time it’s no longer just class suspensions and prohibition of mass gatherings. All travel to and from Luzon has been suspended, and all establishments, except for those providing essential services such as food and health care, were ordered to be closed. All kinds of public transportation is shut down.
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But frontline service providers — such as health care workers; vendors in grocery and public markets; airport staff; and those working in business process outsourcing firms — are still required to go to work. A representative of each household is still allowed to go out to purchase food and other basic necessities.
Lockdown: A necessary measure?
Wuhan city in China, the original epicenter of the pandemic, was the first city known to have gone on lockdown to stem the spread of COVID-19 infections.
COVID-19 around the world
Several cities and countries soon followed. In Europe, countries such as Italy and Spain — where COVID-19 cases are now over 60,000 and over 35,000, respectively — are on nationwide lockdown. Other countries shuttered nonessential travel and businesses. In UNESCO’s latest data, over 130 countries have imposed country-wide school closures, affecting over 1 billion students.
Experts have varied opinions over lockdowns. But as cases rapidly rose in the Philippines — in just over a week, from March 5 to March 12, confirmed cases rose from 5 to 52 — authorities had to make a decision, fast.
“In the end the choice lies between the devil and the deep blue sea so to speak,” said Manuel Dayrit, adjunct professor and former dean at the Ateneo de Manila University School of Medicine and Public Health.
“Not imposing community quarantine will risk a Wuhan-like situation in the early days of the epidemic when thousands became infected and died. Prolonged community quarantine on the other hand, assuming it is implemented well, will have severe economic effects which in and of themselves, will impact the lives of people so negatively,” he told Devex.
In 2003, when Dayrit was the Philippines’ secretary of health, health authorities also put an entire village of about 35,000 people in Pangasinan, a province in Central Luzon, under quarantine for two weeks after a returning nurse from Toronto tested positive for SARS.
But the situation today is larger in scale, and authorities have to work out the protocols of the quarantine as it is being implemented. Dayrit said the COVID-19 situation is also more complex.
With SARS, symptomatic patients were known to spread the infection. But with COVID-19, data analysis suggests asymptomatic individuals can begin spreading the infection two days before they experience any symptoms, he said, although the World Health Organization said catching COVID-19 from an asymptomatic person is very low. In addition, tests for COVID-19 are “not perfect,” Dayrit added. Some people can get tested and receive negative results when they do in fact have the virus.
“I keep being asked … are we better prepared now than we were during the time of SARS? And the answer there is our systems have improved … but really the systems did not exponentially improve,” Dayrit said. In addition, the magnitude of the threat today is different, as the virus is more contagious.
Asked if the decision to quarantine came too late, Dayrit said: “From the point of view of how these bureaucratic processes work, that was already quite fast. But from the point of view of keeping up with the virus, you might say that that was late, because theoretically ... you could have imposed a community quarantine as early as February, but who would have agreed to it? … there was no local transmission that was being evidenced at that time.”
WHO has underscored the importance of aggressive testing for COVID-19, but limited test kits and laboratory capacity in the Philippines has meant only cases with severe symptoms are being tested for COVID-19.
When the quarantine was imposed, Dayrit said less than 1,000 tests had been conducted among suspected patients in Metro Manila.
“Thus quarantine, while an important strategy to slow the spread of infection, will not totally prevent it, even if implemented perfectly,” he said.
Dr. Rabindra Abeyasinghe, WHO Philippines country representative, said quarantines should be used in combination with other measures such as testing, contact tracing, and social distancing to be effective.
“You may not die from illness, but you’ll likely die from hunger.”— Marilou Corpuz, 60, local fruit vendor
WHO also advises setting up community treatment centers for patients showing mild symptoms of the disease to ensure they don’t put other family members, particularly the elderly, from contracting the virus. This would also help manage overcrowding in hospitals, he said.
This is already taking place in some municipalities, where the local government has identified hotels to house and manage non-high-risk, mild symptomatic patients testing positive for COVID-19.
Another approach which is likely challenging to implement in the Philippines is social distancing within families. The Philippines has a close-knit, extended family structure, but also many families live in overcrowded, cramped spaces.
“We need to go that extra mile to actually make social distancing meaningful in our families and our homes. We recognize that in many situations in the Philippines, people are living in overcrowded housing systems. So socially isolating yourselves, sleeping in a separate room, is impossible, [and so] we need to find solutions that can be practiced,” Abeyasinghe said.
With more countries adopting the measure, the question becomes not if they are effective, but how to make them effective. But data is sparse on best practices in implementing them.
“No one is doing this very well at this stage,” said Amanda Glassman, executive vice president and senior fellow at the Center for Global Development.
Dr. Kalipso Chalkidou, director of global health policy and also a senior fellow at CGD, said what’s happening globally today serves as a natural experiment.
“Being able to record exactly what’s happening to the extent we can trust the data and then observe and draw conclusions and dynamically adjust the response, is the key to all of these,” she said. “It’s not easy right now to understand exactly what is working best, and we don’t have the single, one recipe for a successful response.”
A major issue with the quarantine in Luzon is the work stoppage and loss of public transportation. Daily wage earners and informal workers won’t have income sources for a month. Without public transportation, some essential workers, such as hospital staff, janitors, and food vendors, are forced to walk as the directive only allows the use of private vehicles.
On the first day of implementation of the enhanced community quarantine, reports of health workers and even patients walking for hours to reach the hospital filled the news.
In the days that followed, the Inter-Agency Task Force for the Management of Emerging Infectious Diseases has tried to address some of the issues in the quarantine implementation. These include the provision of shuttle services to some health care workers, and a government program to provide some cash aid during the quarantine period.
Meanwhile, some local governments have started distributing food packs, vitamins, and disinfectants to households. Nonprofits, businesses, and individual crowds have also started their own initiatives, such as distributing personal protective equipment to frontline workers, and feeding programs for marginalized members of the population. Some are raising funds to augment the income of daily wage earners.
But gaps remain.
Project Duyan, a local nonprofit organization that works with institutions to provide sustainable health programs for the elderly, is working in partnership with the Coalition of Services of the Elderly to provide elderly individuals with personal protective equipment, hygiene kits, and food packs.
Ma. Via Roderos, a physician and founder of Project Duyan, noticed that elderly institutions are not getting the resources they need. Even harder as there’s a dwindling supply of items such as personal protective equipment and many shops are closed because of the quarantine. The lockdown also makes it challenging for them logistically to get health care.
Most elderly individuals are already suffering from some form of chronic disease, and this can be complicated with communicable diseases, making them susceptible to infections, she said.
“The elderly population is mostly overlooked,” she told Devex.
Health care needs of patients suffering from other diseases and conditions are also affected as several hospitals are forced to suspend outpatient services such as chemotherapy to protect these vulnerable patients from potential COVID-19 infection.
Transport for market vendors is also a challenge. Mary Anne Rivera, 28, who sells salt and charcoal outside a wet food market in Quezon City, told Devex she either takes the tricycle — despite the ban — or walks with her mother-in-law, aged 52, for almost three hours to reach the market. The same journey usually takes them under 30 minutes with public transportation.
But Rivera said the quarantine has also affected her family’s income as most people are confined indoors. In hopes to augment it, Rivera and her mother-in-law have started selling bananas, in response to circulating rumors on social media that bananas can help prevent COVID-19 infection.
Meanwhile, Marilou Corpuz, 60, who sells fruits and vegetables in the same market, is afraid that the government’s promise of relief won’t be sufficient to meet her family’s needs, including milk for her grandchildren.
This is why she chooses to sell in the market, despite the threat of COVID-19 infection, particularly for senior citizens like herself.
“I’ll leave it to God,” she said in Filipino, spouting the common narrative, “you may not die from illness, but you’ll likely die from hunger.”