Philippines - lockdown success, but how long?

PHILIPPINES: LOCKDOWN SUCCESS BUT HOW LONG?

Checkpoint for quarantine in Laguna, March 15

Philippines

I lived in the Philippines for three years, on and off, and have family connections there.

Of all the places I have worked - apart from refugee camps - Manila strikes me as potentially the most vulnerable to a globalised epidemic. It is a vast metropolis, the world's most densely populated city yet sprawling at the outskirts. Including boundary regions 'Greater' Greater Manila has about 30 million people, in a country of 108 million. The population is increasing very rapidly through a birthrate unhindered by contraception, and through galloping urbanisation. The country is an odd mix of the very devout, of ordinary people struggling to make a living and enjoy life, and some hardened criminals that prey on them. It is probably the most Catholic and fatalistic place in the world, and occasionally dangerous - the only place of 63 countries I have worked my life has been threatened, when I asked some unnecessary questions in the wrong place one evening.

Because it is English speaking and democratic, it is used as a hub for international agencies and firms, and receives many business travellers. It has great inequality: as well as up-market high rise business zones, Manila contains some of the worst slums within a lower-middle income country. Internal travel in the city is difficult ("Traffic!") and sanitation is fairly poor, especially in rural areas .

The Philippines was effectively a colony of the USA for over 50 years and many of the governance arrangements are American in style. There are a plethora of poorly coordinated independent local governments and authorities who cannot agree on how to clear even storm water. Corruption is rife.

Medical staff are well-qualified, and hospitals are reasonably well equipped but inadequate. They are very expensive, even for Westerners - every clip and bandage is charged daily. Much of the nursing is done by relatives - everyone has many relatives. The people are famous for their friendliness and cooperation, which is why they are hired in hospitality roles all over the world, but they are passive about public health matters and rarely complain.

Rodrigo Duterte

The country is run by 'strongman' President Duterte, who was elected in 2016 on a law-and-order mandate. He was previously prosecutor and mayor of Davao in strife-torn Mindanao. Here a political rival accused him of 1400 extrajudicial killings of drug users, petty criminals and street children by "death squads". Although many of these were actually the result of gun battles between police and drug runners, Duterte was unfazed, and vowed to "litter Manila Bay with the bodies of criminals".

As well as vigorously prosecuting the war on drugs he has pursued an independent international policy. As a result of his uncompromising stance, he has one of the highest approval ratings of any leader in Asia.

Epidemic

Beginning

The earliest cases occurred on an almost identical timeframe as the USA.  A few travellers came to the Philippines from Wuhan in late January and were diagnosed with the illness. After a gap of a month, on 5 March a local transmission to a Filipino national was recognised. In the following days, the number of cases increased, but there was not yet an  epidemic explosion. This is where the similarities with the USA ended.

Lockdown

About 15 cases were discovered in March 6-7. On March 8, the President declared the entire Philippines under a state of public health emergency. Travel bans from China and South Korea were finally issued. On the next day, a congressman  recommended a lockdown of all Manila for a period of seven days. At first, Duterte turned down the idea because it would hamper the flow of basic commodities, but on March 12 he announced a "community quarantine" on Metro Manila. This was extended to all of Luzon and to the eastern islands next day.

On the first day of lockdown, President Duterte declared the entire Philippines under a state of calamity for a period of six months. All law enforcement agencies were rallied to maintain order. He  ordered the freezing of price of basic goods, emergency medicines and medical supplies.  

The two-week community quarantine was extended to an 'enhanced quarantine' till the end of April. A heavy lockdown was now in place.

All travelling was suspended. Public transport was closed. Only Filipino nationals could arrive from abroad, subject to quarantine, and foreigners had to arrive through Cebu in the Visayas. Food producers and cargo forwarders could travel locally, through a comprehensive series of quarantine checkpoints.  

 Mass gatherings were prohibited and schools and public transport were closed. Only a single person per household could  go outside to buy basic necessities, and quarantine passes were issued to this designated person. Social distancing protocols were required in public places. Curfew was also put into place. 


The businesses allowed to operate were food and medicine, financial institutions and utility providers. High-export value businesses such as Business Process Outsourcing and call centers were allowed to continue subject to social distancing protocols. 

Several local governments applied their own version of lockdown. 

The President has threatened to shoot anyone who breaks quarantine or deliberately tries to spread COVID-19 - but so far this has not happened. Nevertheless, 42,826 arrests were made in the first 11 days of the quarantine, including people who were protesting about having no food. Critics are saying the poor have been criminalised. 

The epidemic today

Relative to the USA and Europe, and given the potentially calamitous situation, the forcible lockdown has been an outstanding success. Notified COVID-19 cases at 10 April are 4648, and deaths are less than 300. This should be compared to the USA and Spain, who both initially operated on a similar timetable, where deaths are now around 20,000.

Daily cases have been under 300 a day for over a week - normally a good sign the virus is under control. However, the government is aware these numbers are 'artificial', reflecting only what testing has taken place.

Nevertheless, it is clear that the immediate lockdown was successful, and the Philippines, like other developing countries who instituted early travel bans, has kept the number of infections down to a low level so far. How long this can be sustained remains to be seen.

A study from the University of Philippines regarded this tremendous success as only temporary, and expects 140,000 to 250,000 to be infected in Manila, peaking from late April till June. A further report suggests the quarantine has reduced cases by 83%, and there will be only 12,000 cases by May. 

Technology 

The Philippines is strong on information technology - it was one of the first places in which cellphones and texting became the norm, and in 2000 was the first place I used one. Call centres are a major employer.

For the expected COVID-19 explosion, phone hotlines for COVID emergency were established immediately (some American states are doing this only now). A GIS reporting system and a COVID  app were developed.

Manila no thriller. COVID cases 10 Aprl

The GIS count in the diagram is only for a few cities in Manila. Deaths do not include those outside hospitals, and there are informally reported cases of people "being sent home to die." The President, in his inimitable style, has threatened to fire all the staff of any hospital that turns people away.

The government intends to run 20,000 COVID tests per day from mid-April.

Tradeoff between economy and mortality

Sofia Tomacruz writes 

Like most countries on lockdown, the Philippines faces a balancing act: calibrating its response to ensure that the health system does not buckle from a surge in coronavirus cases, and making sure that those who are most adversely affected by draconian measures are able to survive a prolonged quarantine. There are fears, too, that risks from social distancing measures – like upended routines, growing hunger, and lost jobs – are quickly taking their toll on the public, while benefits from the lockdown have not been in place long enough to arrest the spread of infection.

As everywhere in the developing world, lockdown cannot be applied for long or many people will starve. Local government social security payouts have been extended, but the support is minimal and very short term.

Despite the early success of the lockdown, the Philippines will need assistance with test and trace to move the number of new cases lower and possibly eradicate the disease. In the current worldwide panic, this may not be forthcoming.  

Better planning capacity in developing countries?

This will strike many as unusual and unlikely, but having worked in this area for nearly 30 years I can assure you it is true. Western countries have hollowed out their central planning capacity, almost eliminating it, while transferring the skills to developing countries through capacity-building aid programmes.

The Philippines appears to be much better prepared at the planning end than Western countries are. There is a coronavirus task force which has a sub-technical working group on data analytics. Its responsibilities are  monitoring trends in the epidemiological curve, availability of isolation and treatment facilities, and capability to mount contact tracing. Exactly the things that one would automatically assume would be present and acted upon in any country with any preparedness. This group has been assembled from a wide cross-section of institutions - exactly as I would advise in that position.

As far as I know, no such capacity exists in any Western country, as they have all stripped themselves of higher-level numeric planning capability. These disciplines have all been transferred to developing countries by experts such as myself, since we have been unable to find work in our home countries.

As well, we have not had the opportunity to train young researchers at home, nor do we have access to government decision makers as we did in the past - we do not exist as far as policy is concerned.  It is only in a "black swan" event like this one that the need for rapid planning capacity even becomes apparent. The highly industrialised countries are now paying and paying very heavily for the loss of expertise and for failing to 'build capacity'.

Much worse infrastructure in developing countries

On the other hand, the weakness of developing countries is their lack of medical and other infrastructure. Planning expertise is cheap to buy, but infrastructure is expensive and takes a long time to acquire. There is no substitute for effective sanitation, clean water, medical facilities and personnel..

In the Philippines, hospital ICUs were all overextended even before the epidemic began. If the disease does become established and resistance to infection is similar to the West, a swathe will be cut through the population of the Philippines.

The outcome remains to be seen - will developing countries do worse than developed countries in the face of this novel virus, or the reverse? Which is most important, planning capacity and readiness, or infrastructure? We are about to find out - but ideally there should be both.

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