A Filippino family doctor in COVID-19 – is this a disease of two cities?

DISCLAIMER: I do not intend for these blogs to be seen as giving clinical advice nor as judging public health policy but rather to recount the lived experiences of family medicine physicians from across the world. I recommend you still follow your local guidance but this goes without saying.

Date of interview: 22nd March 2020

Number of confirmed cases at time of interview: 380

Number of confirmed deaths at time of interview: 25

Population: 104.9 million people

Today, I am speaking to Dr Mel Acuavera from Manila in the Philippines. Mel is another family doctor I know from the Asia Pacific young doctors group, the Rajakumar Movement alongside Loretta from Hong Kong and Erfen from Indonesia. You can read their experiences of COVID-19 here and here respectively. I have very fond memories of singing karaoke with Mel in Japan at the Japan Primary Care Association (JPCA) conference two years ago and, as with all good drunken karaoke nights, a beautiful friendship was born.

Some of the awesome guys from the Rajakumar Movement. From L to R: Wee-Sian (Australia), Erfen (Indonesia), Mel (Philippines), Loretta (HK) and your truly

The Philippines lies in South East Asia, just north of Indonesia and just south of Taiwan. Its primary care system is still not fully established and is still battling many infectious diseases alongside the rising prevalence of non-communicable diseases. Mel is a family doctor who used to work in a government hospital but has since moved to a private hospital to work in their emergency department.

Much like the rest of the world, testing is limited so, like the UK, mild cases are advised to self-isolate and only those with severe symptoms (fever and respiratory symptoms) requiring admission can be tested. There are, understandably, times when patients don’t meet the criteria even when they have presented with respiratory symptoms which leaves the healthcare staff wondering whether they should be using PPE or whether they should be self-quarantining. Through this series of COVID-19 interviews, I can see the this is a common reaction. When widespread testing is unavailable, this often leads to a lot of uncertainty and stress for the healthcare workers who are risking themselves to care for their patients.

He tells me that the healthcare system is set up so that when a patient visits the hospital or clinic, they pay out-of-pocket approximately 65% of the bill and the government picks up the rest. There are government institutions where those who cannot afford their own healthcare can attend but he says that not all services are available there. The Health Department plan to convert four of these government hospitals into COVID hospitals and Mel has his concerns about where the patients who have non-COVID related health needs (such as those on dialysis or undergoing cancer treatment) will go. He is also concerned about his colleagues who work in the government hospitals who have not been provided adequate Personal Protection Equipment (PPE) and are having to ask for donations, washing and ironing used ones or making their own (using raincoats as gowns or using home-made face-shields out of acetate paper). He says that it’s not that bad in the private clinics where they are provided adequate equipment but this disparity between private and public institutions is stark.

Interestingly, there are stories of politicians and their families who are being tested even without symptoms and Mel has heard of affluent members of the community accessing testing from private clinics. We hear about this from across the world, often of Hollywood celebrities, which makes you think about the commoditisation of the disease. Is it now going to be trendy amongst the rich and affluent to have tested negative or to have survived a mild disease? Where does this put the millions of people who do not have access, including the millions of healthcare workers with symptoms?

Mel is really worried about the poor because he says that many Filipino workers are on zero-hour contracts thus the community quarantines will have a direct impact on their income in a country with no welfare state. They also live in cramped conditions where transmission will be rife. We also talk about how you can self-isolate when you share your living space with multiple other members. I am sure that COVID-19 will unfortunately be another infectious disease that preys disproportionately on the poor both from a transmission perspective and from a treatment perspective.

Talking to Mel, I really hear his empathy for the under-privileged. It’s something that I’ve heard across the board from family doctors worldwide. He’s happy to hear that the government are delivering food to the houses of the vulnerable although he’s not sure how long that will last. Private institutions, including McDonalds and Jolibee, are also donating foods and a school has opened its doors to the homeless. The Filipino government may call a ‘State of Calamity’ which will mean that they will be able to mobilise funding to those who are in need (such as medical supplies) which may be the only way to look after the poor.

He tells me that a week ago, they started ‘community quarantine’ in the Philippines where businesses were reduced to four days a week and non-essential travel was discouraged. Public transport remained open and it was really left to everyone to follow the rules or not. However, three days later, the government announced an ‘enhanced community quarantine’ where only health sector workers, government workers and those delivering goods were allowed out and a curfew was implemented from 8pm to 5am. Only one person per household is allowed out and I’m really interested in knowing how they enforce this. Mel explains to me that the smallest local government unit in the Philippines is called a ‘barangay’ and the names of the head of the households are sent to them. Then the head of the household can pick up their quarantine ID’s which is essential for travel outside the household. He also tells me that the community quarantines are enforced by the tanod which are local peacekeeping neighbourhood-watch groups. If found breaking these rules, people can be sent to jail. I find the language used here very interesting especially as Mel says that the government are specifically not using the word ‘lockdown’ and they have publicly announced that this is not martial law (i.e. the imposition of direct military control of normal civilian functions by a government). He tells me that the Filipino population experienced oppression and human rights violation during martial law in the 70’s so the current government are very careful not to trigger those memories. I am not a big fan with the vernacular used in the management of COVID-19 at the moment since I feel that words like ‘social-distancing’ and ‘self-isolating’ have a negative connotations. Words with a more neutral tone such as ‘enhanced community quarantine’ (I really love this term) could be the key in maintaining the morale and mental health of a community.

For Mel, the Filipino personality is that of resilience and positivity and it makes me think of the large numbers of Filipino nurses that I have had the privilege to work with in NHS hospitals. I would definitely describe them as hard-working and never complaining. Mel teaches me a Filipino word ‘bayanihan’ which means helping each other in times of need and I love the fact that they actually have a word for this. We both pray that the public all over the world will stop stockpiling and come together as a community and learn to look after each other.

And finally, we talk about the positive effects that the pandemic is having on climate change. We are finally seeing clear waters in Venice, smog is clearing up over many Far Eastern cities and we may actually meet the targets set out by the Paris Agreement. Although we are both unsure about what will happen over the next few weeks but we talk about the respect we have for Mother Nature and the sheer power that she has.

Mel, thank you for the time to be interviewed. I hope to sing karaoke with you again in the not so distant future. Stay safe x

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