Into the perfect storm

Tomorrow, would be our last day into the next extension of our enhanced community quarantine (ECQ), otherwise called a lockdown.

While I try to make sense of the numerical values that are being provided by the government, one cannot help but be skeptical about the kind of information that is being gathered.

During one of the online meetings, the easiest question asked was – “what do I make of the numbers” that are being announced daily regarding the aCOVID-19 statistics?

After all, it’s been 45 days since the lockdown.

The anatomy of disappointment are expectations.

We expect that the government has and is doing enough at addressing the pandemic in the Philippines. Although we know that politics plays a role in how this pandemic is addressed, I will not delve into this. (But I would still caution any government or anyone for that matter that utilizes politics as a means for future political mileage to check their moral compass.) After all, no one will ever be prepared for a crisis of this magnitude. No government will have concrete immediate answers to the crisis at hand. All they can do now, is try the very best to approach this issue in a scientific, sensible, feasible, realizable, rational manner.

I am sure most of us were expecting that with the initial 30 days ECQ, the number of cases – admission and deaths – would have gone down, and see more recoveries. But the first 30 days simply showed dismal numbers. Plotted on a linear graph, Figure 1 below shows the see-saw of daily data being reported.

So we go back to the question asked. How do you interpret this data?

The answer is simple. With caution.

The numbers that come in are just numerical values. Considering the various constraints the Department of Health is encountering in the transmittal, accuracy of information being given to them from the various local government units, and verification of data – it is difficult to make heads or tails with the numbers. These factors account for latency in data. Many people look at the numbers and jump to the conclusion that we have too many deaths and too few recoveries. A quick look at daily data being churned out makes one presume that all these may have happened “the day before”.

Figure 1. Daily number of new cases, new deaths and new recoveries in the Philippines.

On the other hand, if I converted the graph to a logarithmic scale, the data of the Philippines would look like what we have in figure 2. Instead of the see-saw pattern, you’d get a curve.

Figure 2. Daily number of new cases in the Philippines using logarithmic scale (Y-axis).

A logarithmic scale is very different from a linear one. In short, a logarithmic scale best expresses the exponential growth of what we want to measure. In this case on Figure 2, the total confirmed COVID-19 cases and how rapidly they are increasing.

The logarithmic scale can only be plotted once the first 100 patients are reached (so that we can measure exponential growth). The Philippines reached that on March 15, 2020 with 111 confirmed cases. The X-axis shows the cases over time (number of days since the 100th confirmed case). The light grey colored lines at the background show where we are in terms of doubling time based on the data we have. Twenty (20) days after our first 100th confirmed case, our doubling time was approximately 3-5 days (~4.2) with 3,870 confirmed cases around April 4. Forty days after our first 100th confirmed case, our doubling time is now between 5-10 (~7.5) with 8212 total confirmed cases to date.

Which means, we’re now bending the curve because the growth rate has markedly decline to an average of 2.8%.

But all these data have no meaning when you take into consideration the inaccuracy due to reporting errors and problems seen on the ground.

Why do we need to be obsessed with data accuracy?

It’s a simple answer.

The decisions being made for and on behalf of this crisis hinges on quality data. Any decision for that matter cannot be drawn from gut feeling. Decisions and recommendations made need to make recommendations backed up by solid data that will withstand scrutiny. While there will be acceptable gaps, these gaps when recognized early on should be addressed immediately because the extension of the ECQ was primarily based on the issue of not being able to “flatten the curve” or in this case, bending the curve.

The second important parameter will always be death.

Deaths (more than recoveries) provide closure to any event. Looking at the curve for death from an overall number of cases (see Figure 1) may give us a false sense of security. One glance and one can see that on a linear scale, our deaths are but a handful each day. But the latency in death reports in the Philippines average ~6.5 days, with more than 35% being reported after 8 days or more. As of yesterday, 316 of the deaths were reported posthumously – they died before they were even declared positive from the virus.

The quality of these numbers is disappointing because the other ramifications of good contact tracing, isolation and quarantine and work-up of patients exposed to those that have had the disease becomes a work nightmare and is hazardous to healthcare workers who are falling off the grid like flies.

Figure 3. Logarithmic scale of deaths in the Philippines. Y axis is in logarithmic scale. X axis begins on the day the first 5 deaths were reported.

Figure 3 transforms the linear data into a logarithmic scale. It reported its 5th death on March 28. On the 20th day up to the publication of this article, it has remained above 10. Those numbers need to be “bent” in order to see the impact of the ECQ on death rates due to SARS-CoV-2.

So why do I feel that we’re into the perfect storm?

As a general rule, COVID is not the only health problem we currently have. The nonCOVID cases, far outnumber the Coronavirus cases. In short, SARS-COV-2 or COVID-19 has served as a major distractor in seeing the real health picture of the country. At the beginning of this storm, we were battling poliovirus. Last year we hardly recovered from the onslaught of measles and dengue. One infectious disease after another. Where are we now with cases of polio and dengue and measles? I would appreciate it if someone could give us clear data that the war against COVID is a far greater one than other vaccine preventable diseases. After all, at the current crisis, I am sure that the Department of Health has all hands on deck with COVID. We also need clear data on the other noncommunicable diseases (NCDs) and the mortality from NCDs.

Based on published data from the Department of Health’s website, in 2013, there were 531,280 registered deaths from all causes in all age groups. That’s an average of more than 44,000 deaths a month. Deaths mostly came from the most dense populations – 13.4% from NCR (71,050) and 14.3% from Calabarzon (75,743). How are the 558 deaths (from January to April 29, 2020) from COVID-19 impacting the overall health care of the Filipino people? Focusing our attention solely at COVID-19 is poor planning in the allocation of health resources and healthcare because the greater majority (those with cancer, heart disease, on dialysis, had a stroke, accidents, infants with sepsis, dengue, etc.) will need equally, if not greater attention, than COVID cases alone.

June is fast approaching.

And the onslaught of the rainy season brings with it a cycle of other infectious diseases the present in a similar way as Coronavirus would present at the onset of illness.

Fever. Colds. Chills. Cough.

Dengue. Measles. Seasonal Flu…to name a few.

Hence the urgency in getting out of this pandemic really quick.

It is a difficult and arduous task ahead for the head of state to bring its people out of this pandemic. But it needs to be done in unison. It needs to make policies based on worthwhile real-time factual data that is not confusing. People in government cannot just make senseless statements that there’s nothing we can do about this pandemic because there is. Other countries are able to bring down their mortality rates and eventually the cases by doing more testing and channeling more resources at contact tracing and practical measures in isolating those who come in contact with positive cases.

While it may be a tall order, it is one that requires a sense of urgency not only through ECQs or praying that a cure or vaccine be made available soonest. The most practical and doable is getting the numbers right from the get go. Only then can we make valuable and sensible plans on how to win the war against this virus.

I cannot overemphasize the urgency in getting out of this Coronavirus pandemic. Otherwise, like a ship that sails into a deep vast unknown ocean with no tracking device, we’re heading into the perfect storm.

The story that numbers tell

I always tell my students that data can always be interpreted correctly or end up confusing to the reader.

I have provided the link of the Department of Health’s Covid-19 tracker. There are various sources where one can obtain good data analytics from. If you go to this link, you will find out that the improvement in the COVID-19 tracker.

Then there’s the down side. The data analytics is wanting in useful information. The kind of information that should make us decide on how bad this Novel Coronavirus pandemic is in the Philippines and whether we’re actually “flattening the curve”.

Once you get into the site, this is what you see.

It gives you a pretty good picture of the daily information on the epidemiology of COVID-19 in the country. 4,932 confirmed. 3082 currently admitted (they don’t identify how many are critically ill and the rest are probably mild and quarantined.) 315 died so far. 242 recovered. Then in the gray bar are the ones “for validation”. There’s a caveat that says that “around 25% of province-level data are still undergoing validation”. But wait…there’s more!

If you scroll down a bit, you will see the table on testing capacity. Here’s where the data actually differ. The testing capacity as of April 11, 2020 showed 4,913 positives. The total confirmed as of April 13, 2020 is 4,932. On April 11, the DOH officially reported 4,428 confirmed cases. What accounts for the discrepancies in the numbers coming from the agency?

The 1,293 case for validation (said to be province-level data) is confusing.

I would assume that province-level data would point to tests coming from Southern Philippines Medial Center, Baguio General Hospital, Vicente Sotto Memorial Medical Center, Western Visayas, and Bicol Regional Diagnostic Laboratory. If you total their positive cases, that would just be 204 positives from the provincial testing centers.

We can assume that some specimens were sent to Manila for analysis. How many were sent to Manila? These inconsistencies in the numbers makes one wonder if they just deduct the total cases from the remaining cases in order to arrive at the discrepancy?

Let’s look at the numbers again.

4932 total confirmed. 3082 currently admitted. 315 died. 242 recovered.

Assuming the numbers are correct, that’s 3639 cases (admitted currently, died and recovered). What are remaining 1,293 cases “undergoing validation”? What does undergoing validation mean?

First, if they’re still not yet validated they shouldn’t even be part of the total statistic.

Second, is why are the numbers in the provincial testing centers not tallying (202 from all the provincial testing sites vs 1293 cases at the national level)?

The third and most vital query is – does the DOH actually have data on the patients that tested positive but were sent home for quarantine? How many of them returned for retesting? When you look at the numbers – of 4932 confirmed only 3082 are currently admitted. Or 1850 cases distributed as follows: 315 deaths, 242 recovered and 1293 for validation(?).

Data integrity is important in the analysis of outcomes and planning of mitigation strategies. It is, after all, the basis of our life after April 30.

The new site, while providing information on cases, deaths, recoveries, is wanting in the type of severity of the illness. We all know that not all admitted cases are in the ICU or are critically ill.

If we scroll down a bit, there’s interesting information regarding the availability of beds and mechanical ventilators in various hospitals.

This above information above while helpful is disturbing. If you look at the ICU beds, only 391 beds (out of 1,085) are filled. The remaining 2/3 are unoccupied. There are more than 87.29% mechanical ventilators still available. Yet reports coming from various private hospitals are that they are filled to the brim and that the healthcare system is overwhelmed by the coronavirus infection that some hospitals had to turn away patients.

Based on the data provided in the DoH website, of the 3082 currently admitted, 391 are in the ICU (as of this writing). That means only 12.7% are critically ill (needing intensive care).

There are more deaths than daily recoveries among those currently admitted. The graph below is a screenshot of the new daily deaths and new daily recoveries on the website. Implying that of the 391 cases in the ICU, 315 have died. An 80% mortality rate when intubated or in intensive care.

Of the 3082 cases admitted in the hospital, assuming that only 391 are in the ICU, what happened to the remaining 2691? That’s the majority of the patients. Who happen to be mild or moderate and probably recover.

Finally, there’s the interpretation of the data.

Cumulative is the operative word in the presentation of data.

Which means that regardless of patients getting better or dying, the total cases is what you see. But in reality it is not. Minus the deaths and recoveries, we actually are tracking 4375 cases that are still active. The deaths and recoveries are considered closed.

The red herring here? The ones for validation. They form the inconsistent information that needs an explanation so that it is not misinterpreted.

I’ve always told my former students in biostatistics that all the numbers should have an explanation. It is imperative that data gathered is accurate, valid and not confusing to the reader. It is also important that all tables and graphs are reconcilable. Otherwise, any conclusion or decision that is made with this kind of data is confusing and simply leads to bad decisions in preparation and planning.

The bottom line of good solid data? The April 30 deadline.

Life after April 30…

…well, that’s wishful thinking. But let’s pretend it happens…


We all know that the only reason for people in government to consider re-extending the extension are the “numbers”.

Larger number of cases. Longer recovery time from more critically ill patients. Poorer recovery rates. Increased doubling rates. These are the numbers and endpoints that matter from an epidemiological point of view. And because these numbers matter, we need a unified accurate data in order to predict whether we’re getting out of April 30 alive or not. The Department of Health has made an announcement that this is currently in the works and that perhaps the deadline they set on April 11 for syncing all data should be helpful to the decision makers on any exit plan.

It cannot be a mathematical modeling that is predicted based on several assumptions that are not constant. Mathematical modeling has its limitations, because while it incorporates available actual data, its accuracy depends on the number of actual data into the various incorporated variables. If the variables used in the prediction model are “constants” and “assumptions” as well, then the modeling accuracy is compromised. Hence, my caution in using modeling parameters because this virus does not recognize the variable nor the constants of a mathematical equation. It will behave the way it does. Unpredictably.

All data must be coming from the National Government. Seriously, it is difficult to make heads or tails with the discrepancies in data between the Local Government Units and that of the National Government (Department of Health). You get reports from LGUs that report more cases than what the National Government releases, while other LGUs report less cases. You actually have this feeling that you don’t know who’s actually running the show.

Let’s use one website: as reference for all discussions in my blog (unless otherwise I use a different reference). I think it’s a very good one considering that it provides both national and local government data as well as the global data. While it is not in real-time, it is updated at least before 4PM (Manila Time).

Figure 1

Figure 1 above shows the data as of yesterday. Note also that this website started with information on March 27 at a 803 cases, 54 deaths and 31 recoveries. In short, by March 30 (3 days later) we stood at 1546 cases, 78 deaths and 42 recoveries. A doubling rate of 3 days. Which means that on April 2 we should see more twice the number of cases we saw on March 30. Did we? Well almost. On April 2, we had a total of 2633 cases, 107 total deaths, and 51 total recoveries. Which moved the actual doubling rate now to around 3.3 days. If you used a constant mathematical model, you would have expected that by April 5, we would have more than 5200 cases, on April 8 more than 10,400 cases on April 11 more than 20,800 cases and so on and so forth. The slope (rise in numbers) would be steep. The casualties would rise disproportionately as well. Yet on April 5, the total cases was 3246; 3660 on April 6; 3764 on April 7; 3870 on April 8; and 4076 yesterday April 9. Note that the doubling time also became longer from 7 days to 10.76 days.

Doubling time is the number of days it will take confirmed cases to double and is based on the 7-day daily average growth rate. The other variable that’s important to look at is the daily growth rate. The lower the growth rate, the more contained the outbreak is. (Table 2 below)

Table 2

This is why accuracy in data is important. This is the first trigger that will decide on life after April 30, 2020.

As the growth rate slows down, and the doubling time is prolonged, there is no reason why there should be an extension of the ECQ.


The second trigger in determining whether we’re getting out of this lockdown alive on April 30 is the capacity of the testing centers in the country. The backlogs in reporting. The backlogs in printing out the results. The number of accredited centers. How many tests are done per day and all these numbers I mentioned – should have a denominator. Out of how many tests are the reported cases? This will give us a better grip on the the first trigger because they are co-existent. A backlog in reporting is bad data mining.


This is the third trigger. Regardless of data, talking about the disease versus jobs and the economy that has faltered is moot and academic. We all want to come out of this pandemic in one piece. No one wants to be a statistic. I’ve lost too many colleagues close to me to this virus. And yes, we’re all afraid of the unpredictability of this virus. As of this writing, there are several promising experimental treatment models that are being conducted – from the Japanese experimental antiviral Favipiravir (Avigan) developed by a subsidiary of Fujifilm to Hydroxychloroquine + Azithromycin +/- Tocilizumab to the recently US FDA approved protocol for convalescent plasma. We see some light at the end of the tunnel, but that’s a topic that I will discuss some other day when we have better and more reliable clinical trials are available. And then there is the promise of a vaccine on the horizon.

Which means that there’s a waiting period. We need to sit back and wait. The magic potion is not within our midst. But the economic backlash is hurting not only the country but the world as well. As to how long a hungry stomach can withstand the wait is a different story altogether.


I cannot tell media how to report. Every media outlet will have its way of trying to grab the attention of the viewer. As the late Mr. Felix Bautista once taught us, the first line of your story is the most important. It is what will enthrall your readers to read on or ignore your writing.

But I can teach my readers how to interpret the data.

Figure 3

The data on Figure 3 shows you that we have 4,076 confirmed cases. I think what the media outlets should be reporting are the new cases. The 4,076 cases include all the cases since the beginning of when we were registering them. Again, if you look at the recoveries and deaths, these are closed cases. In short, of the 4,076 cases, 327 have had outcomes. They either died or recovered. In short, we’re just monitoring 3749 cases. And waiting for their outcomes.

We will not really know how many will recover (or die) until a few months when we’re seeing the trough of the curve.

Figure 4

Figure 4 above shows the data from China who had exited from their lockdown last April 8, 2020. They are still reporting new cases (in beige) and new deaths (in red) but their overall recovery is 77,455 cases (94.56% recovery rate), with 1,116 active cases remaining (no outcome yet, and 144 of them being in critical condition), and 3336 deaths (4.07% case fatality rate).

Their new cases are mostly foreigners or people who have returned from foreign travel.


We need to learn from Wuhan, Singapore, Taiwan and HongKong the lessons of the aftermath of a lockdown when it was lifted.

Figure 5

Figure 5 above shows the glaring data where there were so few cases after the lockdowns and a resurgence in cases after lifting it. Taiwan was hit most with the surge in new cases (orange bars) imported from other countries. Local transmission remains low. In HongKong, Singapore and Wuhan, the stories are similar, except that Singapore is reporting a surge in local transmissions.

Some normalcy should be brought back slowly. To ease the restrictions will require a concerted effort from every sector. Like a master conductor for a Philharmonic orchestra, he must be able to create a harmonious exit out of this lockdown.

Easing it will be the way to go.

Address the triggers. Set a deadline for the respective agencies. The deadline was yesterday. Obligate and hold responsible agencies that are part of the problem instead of being the solution.

Schools in the Philippines are literally jampacked. Online learning when applicable should be the mode for the rest of the remaining school year for college and graduate schools. Those in grade school should be made to stay home and allowed to move up in August. All schools should now be synchronized to open at at specific time. My suggestion – August 1, 2020.

Social distancing, hand washing, hygiene and wearing masks should be the new normal. Malls can slowly be opened (for essential goods) with strict social distancing and allowing people up to probably 1/4 the parking capacity of every mall. Restaurants can only operate if there are reservations made so that only half the capacity of the place is occupied at any one time. Take outs are encouraged. Drive throughs as well.

Hospitals should open its doors to NONCOVID patients. A triage should be in place at every hospital. Patients should be honest enough to disclose why they are there. Patients who fulfill the criteria as PUIs or PUMs should automatically seek medical consultation at a COVID designated facility. Hence, every private hospital should be encouraged to have a designated facility only for COVID patients separated from the rest of the hospital. This is so that other patients (which is the majority) that have other acute or chronic illnesses can be seen by the respective doctors. HMOs should put up their own facilities outside of the hospitals for COVID patients. For example, if you are a COVID-suspect, you can only be seen at the hospitals accredited by the HMO for COVID patients. This will partly address the issue of local transmission and contact with COVID patients. Remember, the majority of patients that require both elective and urgent care are NONCOVID patients.

There should be limitation of travel in and out of the various regions for the next 2-3 months in order to limit other sources of local transmission. Those who live outside of the NCR but work in the NCR should consider renting a place near their workplace for awhile. Regional travel can be reassessed after 2-3 months or earlier depending on the state of the pandemic.

Public transportation should be limited to the locality. Perhaps in order to avoid crowding, people who are unemployed or do not have work should not be allowed outside the homes in the meantime unless for essential errands (marketing or buying food). The type of transportation is important. Public transportation should only be filled to 1/2 its capacity.

Children and the elderly are encouraged to stay at home during this transition period.

Gigs, concerts, crowds, bars, night outs, movie houses, conventions, and other nonessential activities should remain cancelled until after the transition period is reassessed.

I cannot overemphasize the reintroduction of another wave after we have “flattened the curve”. The only way to sustain it is to close the borders into and outside of the Philippines in the meantime. This means that anyone who decides to travel outside of the Philippines or is a foreigner who wants to visit the Philippines will need to undergo BOTH of the following upon arrival: (1) PCR or rapid testing (2) mandatory quarantine for the next 14 days. If symptoms appear or patients test positive, they should be admitted to designated centers for PUIs and managed accordingly.

We should not overlook one other fact.

The flu season in the Philippines is the rainy season. That’s usually June. Encourage everyone to get flu shots. That’s one virus less that will complicate the management of any respiratory infection.

As the rainy season is around the corner, it would be disastrous that we’re going to be seeing a mix bag of infections – from dengue to flu – breaking out in the midst of an uncontrolled coronavirus pandemic.

I hope we get it right in the next two weeks. This is your best time the government can practice on what it intends to do after April 30. Seriously – we are left with no other option. Because life after April 30 must go on…

The extension

In a dazzling (dizzying) display of desperation (?), a visibly confused rambling of frustration on how to control the novel coronavirus pandemic and how it was affecting the dire economic resources of the Philippines was seen in the face of the president over a live announcement last night.

He didn’t mince words.

Behind all the garbles on afterthoughts from his trip to the toilet to urinate, asking the secretary of finance to generate money whether he steals or borrows, telling the people that there is a limit to what the government can offer and offering to sell Dewey Boulevard (so retro), asking for patience (which I am sure has run out of especially for the daily wage earners) because the virus has torn the very frail economy of this nation, and finally ending with the vast unknowns…I could understand his annoyance at the circumstances he’s in.

Huwag ka mahawa. Huwag ka lumabas ng bahay. Paano pagkain namin? Maghanap ka ng paraan.

Hindi ko alam kung [hanggang] kailan ko kayo sabihan. “bahay lang kayo”.

Hindi ko alam kung kailan ako makapaghatid ng pagkain sa lahat.

Hindi ko alam saan ako magkuha ng pera.

Hindi ko alam kung ano ang ipagbili ko. Kung may magbibili.

Hindi ito trabaho ng abogado. Trabaho ito ng medical experts, scientists. I just happened to be here. To my chagrin, bakit sa panahon ko tumama.

I end this with a prayer. Whatever be the correction – ang anomaly sa mundo. He created the world. And if God wants it ended, so be it. Salamat po.

The live telecast surely didn’t sit well with the audience.

It was not surprising then that after that exasperated moment, the announcement came this morning – the lockdown would be extended. Period.

The objective for extending it till the end of the month?

According to Secretary Nograles, it was necessary “in order for the government to determine the impact of the ECQ and further increase health capacity in Luzon and other areas, including ramping up COVID-19 testing to 8,000 to 10,000 tests per day with a turnaround time of 24 hours.”

Let’s give people credit where credit is due. I actually see how hard the IATF (Inter Agency Task Force) is working trying to complete the arduous task of containing this global pandemic among our islands. As I’ve said in the past, in pandemic, some things will require decisive action immediately. Waiting for tomorrow is another day wasted.

And that’s what happened with the first ECQ and the night before the extension. The first lockdown sent people into a frenzy. Panic buying for the those who could afford. For those who had less in life, it was just pure panic. An exodus for the unemployed. A wait and see for those that are still holding on to jobs, which probably some will have none to return to when this crisis ends. The last three weeks was spent in prayer and hope. That life would be what it used to be on April 14.

I am sure that most (if not all of us) are glued to the daily numbers – new cases, new deaths, new recoveries. Media are quick to draw conclusions or confusions to the numerical values that are being churned out by the Department of Health. If you ask any grade school student to draw a graph based on the numbers culled the past 3 weeks, they’d tell you that there’s no consistency. And that’s probably because of the backlog in reports. The death of a 7 year old in the Ilocos region is a glaring example of how long it took for the results to come back. Five days after her death. And that’s just one case. How many more cases have had dismal reporting timelines? This is important because the management of patients (from treatment to contact tracing and quarantine measures of exposed individuals) highly matters on how quickly (and accurately) we get back the results and the number of people tested based on the released report. Moreover, accurate and timely data provides us the best picture on whether the lockdown is “flattening the curve”.

I understand the frustration of the president. I, too, share his frustration. And I’m a doctor already! When you can’t make heads or tails of the data, the frustration is real.

The first lockdown has shown us how much more work there is to do, and how unprepared we are at crisis management in a pandemic. Let’s face it, the only way this virus will ever go away is sadly – probably never. Even with the availability of vaccines for flu or any other disease, we’ve hardly eradicated many vaccine-preventable diseases except for smallpox in the last century. The search for a cure or treatment is at best for now, a trial and error method. A lot of theories and anecdotes, with little science (robust clinical trials) to back up various treatment regimens.

As a people, it’s only when we accept our shortcomings can we realize that there’s much more we don’t know. There are few short-term plans plotted out but a dire lack in medium- and long-term plans.

Those short-term plans are panned out at providing measly change for the poorest of the poor. The people who work in government are better taken care than those in the private sector. After all, no one will lose a job when you’re with the government unless there is no more government. How does the government plan to assist the private sector with respect to repayment and restructuring debts particularly for the micro, small and medium enterprises? Supplies purchased from large companies should be given a longer term grace period for payment rather than the original payment dates. But many multinational companies will not agree to this because they have employees to pay and their own needs to fill. While people in government are willing to take a cutback in salaries, are the people in the private sector willing to negotiate a 90 days payment option instead of 30 days for various goods? Mall tenants and other stall/store owners are in a similar situation. How many landlords are willing to forego rent to tenants who did not use the rented spaces due to the lockdown? These are just examples of incongruence in the “bayanihan” spirit of the Filipino people. The irony here is that it’s mostly these same people who provide donations in times of disaster as public relations promotions that are in disguise of being concerned with the poorest of the poor but take from the small and medium entrepreneurs. That is why I am not a believer of these corporations who give out “donations” yet don’t look after the smaller companies that keep them afloat. This domino effect, trickles down to the vendors and consumers in the end. And as the pandemic deepens, the economy will continue to falter to the point of collapse.

Then there’s the medium- and long-term goal. The idea of having designated centers for COVID cases in every local government is both doable and a good one. Remember, isolating infectious diseases and waiting out the course of illness until the patients recover on their own is the oldest method of containing an infection. Before the end of this week, every local government unit must be able to put up one. There are many unused edifices in the local government and placing their city health office in charge of such centers will free up the communities from having the cases monitored where they reside as well as the hospitals in having PUIs and PUMs occupy the necessary space for the hospital to operate regularly once more. People don’t know that there are more patients sick with other acute and chronic diseases who will require hospital care than COVID19 patients. Segregating the COVID19, PUIs and PUMs is vital in reducing the spread of the virus and thereby restoring some sense of normalcy in the community. It will also allow other sick patients without COVID19 to get better healthcare, and hopefully be at less risk or when they do get infected with SARSCOV2, be immunologically stronger at combatting this virus. Comorbidities that are well controlled have better outcomes than those that are not.

The real problem I see are actually the local government units. They’re like little kingdoms. There are those who have best practices. Then there are those who are a bit off not only in science but common sense as well. And that’s where the difficulty lies. There is no consistency in the implementation of recommendations. When the mantra is “every kingdom for itself”, it will be difficult to curb a pandemic of this proportion.

A long-term plan should also be discussed today. Not a week from now. Not after April 30. As the president mentioned, this is after all a battle. And a prolonged drawn out battle it will be. At the end of the war, only one will emerge victorious. Our fate depends on the strategist who put this plan together.

What do we do on April 30, 2020?

Is another extension in the horizon? And that’s the question that’s begging for an answer. I hope and pray not.

But I guess that depends on whether we’ve gotten our act together or not. At the rate we’re going, the plans the IATF have put forth should be strengthened and every LGU should abide by the general guidelines (if any) of the IATF. Additional local strategies must be in congruence with the general guidance provided by the IATF. Any local plan that deviates from the IATF should not be allowed. There should only be ONE agency responsible for the success OR failure of the mitigation efforts during the next 2 weeks extension period.

Allow some flexibility in mobility. We need to mobilize not only frontline workers but some other essential business establishments vital to the economy of Luzon (where the lockdown is limited to). Some form of public transportation should be restarted with conditions on how many to accommodate and the practice of social distancing. Trains and MRTs should not be operational yet. There should be no crowded places or events for quite awhile. Schools will be out probably till the upcoming school year but that’s the least of our problem because the kids will get their wish – long vacation – at last. To keep the crowd down, malls and bars and other recreational facilities should remain closed until such time that we have actually reached the lowest part of the flattened curve. Nonessential travel (both in and out of the country) should be avoided in the meantime.

We must set the expectations early on as we approach the deadline and prioritize the economy while taking into consideration the general health of our people (not only COVID19). Both the economy and health are inseparable in the equation of a healthy nation, with each of them being dependent on each other. We cannot care only for the COVID cases. There is a greater majority of patients who are sick with cancer, hypertension, diabetes, measles, dengue, hyperthyroidism, cardiovascular problems, COPD, etc. yet one case of COVID overwhelms a whole community and healthcare system.

In the spirit of transparency that there was a well-thought plan to begin with, the public should know the basis or criteria on when the lockdown can be lifted, the restrictions that remain after the lifting, and when and what to expect as we monitor the lifting in the next year or so.

Sadly, this is one virus that will never go away. It will have its peaks and troughs all year round. As doctors, we will probably look at every fever, sore throat, cough or colds and diarrhea in a different light from now on. The general public will not forget this pandemic for awhile. But for everyone’s sake (physically and mentally), we will need to get back to some sense of normalcy. That’s why we need to sing the song in the same tune now. And get our acts together in how to deal with this invisible invincible enemy in our midst.

Exit strategies

It’s almost 3 weeks since the lockdown in Luzon.

I’m sure we are already at the edge of each others nerves. And for good reasons. When the norms of daily life are perturbed, it gets crazy. An unseen enemy. Unknown cure. A race against time. The number of cases rising. The death toll insurmountable. The last century alone, all the gains and accolades of medical science wiped away with one virus. A microscopic pathogen indisputably eroding governments, economies, and lives.

The battlefield in the hospitals are at a different level. We’ve never been more fearful of a disease as this. Every front liner is fearful for their lives but still serve the sick. In our communities, paranoia and fear has hit the core of every family – from the gated villages to the informal settlers surrounding them. But let me say this for the record and with certainty – the informal settlers have the least to lose here in terms of health and wealth. It’s the middle and upper class that are panicking. The poor, well, they’re just worried about their day to day existence. Work for daily wages, food on their table, a house over their heads. They don’t have bank deposits or stocks and investments and businesses to worry about. They’re used to what they have. All they worry about is a tad of health care, their grumbling stomachs, somewhere to lie down on after a weary day. Day in. Day out.

So my readers asked me one good question.

Will (or should) the lockdown be extended?

My disclosure is that what I write are based on all the data I can cull available for public access. Other “unpublished” or unreported information are factors that may change the opinion later on.

So here we go.

The answer is YES.

It should, however, be modified because we have now seen its promises, and gaps.

As the number of new cases rise (and it will rise because we have more testing kits now), the number of daily deaths will be the predictor of whether the lockdown is working or not. Let’s remember, the number of new cases IS NOT a reliable predictor of whether the lockdown of a community works or not because when the lockdown was declared, the number of cases were already on the uptrend.

Figure 1
Figure 2

Figures 1 and 2 above show that the slope began toward the middle of March. I cannot overemphasize the fact the importance of testing here. It was an outbreak waiting to happen. We slept while the enemy was awake. Complacency and poor foresight. As long as we see those numbers go up for awhile, don’t expect the recoveries overnight. They won’t go down until 2-3 weeks from the time they went up. We started the steepest climb only last week. How steep will we go depends on multiple factors.

The good news is that if this lockdown did not happen, there would be more new cases and new deaths.

The bad news is that, as in all lockdowns, the lockdown came too late. By the time an outbreak has occurred or is recognized, the virus has already taken over a proportion of the population for it to spread. The R naught (R0) of SARS-COV2 is low. Scientists say it’s round 2-3. The R0 tells us the infectivity. For every case, 2-3 patients probably get infected with the virus. Compared to the seasonal flu where the R0 is around 1.3 or chickenpox virus where the R0 is 10 or measles virus where the R0 is 15.

Why do these numbers matter? Because they are part of the basis in decision making for our exit strategies.

What works?

  • 1. We know that physical distancing works. The less crowded the place is, the less infectivity rates are. That’s common sense.
  • 2. Unlike the World Health Organization, I disagree that masks should not be worn. The WHO has flip flopped several times on various recommendations or whatever it recommends. They are, a political organization. They are not a regulatory agency. What may be effective in Uganda or the Philippines may not necessarily apply to Japan or the United States. Every country has its own vulnerable spot. And ours is relying on the WHO for an opinion. Their observations are noted. Do we need to follow it? No.
  • Masks should be provided and worn outside of the home, in public, when tending and seeing patients. The proper mask is also essential. Those washable porous masks that have Dora or whoever character etched all over don’t work. Wearing a mask should be the norm now. I cannot overemphasize how much a highly useful preventive equipment it is for many respiratory pathogens. The mere fact that SARS-COV2 is a respiratory virus, protecting your face with a barrier is just common sense.
  • 3. The surge of OFWs returning home is scary. Not that we don’t want them home. We do. What do we do when they get here? More than anything, they must all be swabbed. Their absence of signs and symptoms, fever or other factors ARE NOT reliable. Majority of our patients do not reveal a history of travel. Travel has become a stigma suddenly. We learned that with the death of a doctor from a patient who lied. The patient had a travel history. Got sick. Got people infected. Didn’t tell the truth. And a doctor died. Where’s the fairness in that? Swab them all. Quarantine them for 21 days. For patients that are positive, they need to have 1-2 negative swabs depending on the clinical status of the patients on discharge. Patients that develop symptoms and are critically ill must have 2 negative swabs before being discharge. And its not only the OFWs. Even those that have arrived in the Philippines in the last 30 days should get swabbed. The Department of Foreign Affairs and the Bureau of Immigration surely has a list of all these people who have arrived. They should look for the travelers and swab and quarantine them until all results are available.
  • 4. PUIs with mild symptoms should be segregated and admitted to a facility only for PUIs. They must not be allowed to be part of the home or community. This is to make sure that they are not violating any quarantine measures. You know how ingenious the Filipinos are. Segregating them will minimize having a total lockdown in the communities.
  • 5. All PUMs should be monitored properly. There are many ways that the local governments and barangays can assist. The identities of these patients can be provided and the data privacy act can and should be waived under these extreme circumstances , otherwise we end up in a catastrophe. The barangay can monitor the household 2-3 x a day. Everyone in the household should isolate the PUM in one room dedicated for the patient. Protocols are in place for self-quarantine. For the informal settlers or those that have no dedicated room for PUMs, the government should be able to provide makeshift places for these. Tap the public and private schools which are currently closed. PUMs have no signs and symptoms and will need very little monitoring except for food, water, shelter and keeping them locked in a room for the next 14 days.
  • 6. Malls, stores, movie houses, bars, offices and restaurants should remain closed until May 3, 2020. We can reassess later the situation. Restaurants can serve take out food only but no dine in. Businesses that can work from home should be encouraged to work from home until May 3. Businesses that will need physical presence of workers should have a minimum work force or skeletal schedule so that it is not packed.
  • 7. Curfew should remain in place from 9pm-5am every single day. This will minimize movements in any community.
  • 8. Schools should remain closed until the end of May. The highest transmission of a virus will always be a crowded environment and believe me when I say that the physical distancing is least observed in pediatrics.
  • 9. All children and the elderly (> 60 or 65 years old) should stay at home as much as possible. Unnecessary travel should be avoided among this group.
  • 10. Public transportation should be limited. Jeepneys and Buses and Taxis can be allowed but the number of passengers should be limited. No tricycles or bike riding apps should be allowed. Trains and MRT/LRT should not be allowed until such time that we have seen flattening of the curve.
  • 11. Every region must have its own accredited testing center before you can even consider lifting or modifying the lockdown. We need to capacitate every region because the delayed results due to backlogs are deadly. Some patients will present in an unusual manner. By the time you get the results, some of them can end up infecting 2-3 patients who in turn have infected 2-3 more people and so on down the line depending on the day the results come out! Without this being in place, you cannot lift the lockdown OUTSIDE of the National Capital Region.
  • 12. The Bureau of Immigration and Department of Health need to work together and we cannot rely on patient information. Every patient that is a PUI, PUM, positive (dead or alive) should be verified with the BI for a travel history – when, where, and what aircraft? This is for documentation and contact tracing purposes. Contact tracing is much easier when the patients are truthful with their information.

These are all common sense. They will work. If our government officials can work together. It’s disappointing that there are government agencies that create issues that are divisive in times of crisis so that they can lick the ass of people in power. Hey – this pandemic is about all of us, not about your political future. Get a grip on reality! If and when we all get out of this alive in the next few months, believe me, it will be payback time. Accountability among the government officials shall be made. And those that stole, corrupted, abused, and conspired evil during this pandemic should be held responsible for the outcome.

So yes. The lockdown should stay unless these issues are addressed. Then we can work on a week to week basis on how we can go back to our “normal” lives. In the meantime, this will be our new normal.

Oh before I end, the kit is still the most important tool we have here. I started blogging about this virus way back in January. It started with one simple article entitled “Pandemonium”. The rest is history.

How we tell the story, who we listen to and how factual the information is, and how it impacts on peoples lives and futures – that’s what matters. Let’s hope and pray that this government has an exit plan. Not one out of ranting but one that is well thought of. Because you accepted the role to lead, you have no choice but to lead us out of this pandemic with the least casualties.