Did the Philippines make the right decision when it eased the lockdown on NCR, the country's coronavirus epicenter?
On 1 June 2020, the Philippines decided to relax lockdown measures in Metro Manila, the epicenter of the country’s COVID-19 epidemic. Public opinion on this decision is mixed. Some say it’s too early as the coronavirus is still beyond the government’s control, while others say the government has successfully “flattened the curve.”
In this article, we will examine the wisdom of this decision (or the lack of it), by comparing the Philippines to other countries that have significantly relaxed their lockdown measures and how the number of daily active cases changed afterward.
To further explain this paper’s methodology, let me start by discussing the rationale behind a COVID-19 lockdown.
The spread of disease starts when the first infected individual (Patient Zero) enters a country and gets into contact with its erstwhile COVID-free population. The spread begins slowly at first because still few are contagious. However, the spread accelerates as more people become carriers, and the total number of infected individuals increases exponentially, generally following a logistic growth curve[1].
COVID-19 will not have been much of an issue if a tried-and-tested antiviral is available. However, it’s not the case, as vaccines and other pharmaceutical interventions are still in highly experimental stages.
If a scantily understood but contagious disease like COVID-19 is allowed to spread unabated, there’s a high likelihood that the number of infected will overwhelm a country’s healthcare system. And when demand breaches supply, mortality rates rise. After all, a COVID-19 victim is far less likely to survive without medical attention.
Flattening the Curve, Raising the Line
By this time, most people are already aware of “Flattening the curve,” a public health strategy focused on slowing the spread of disease to keep healthcare demand within the capacity of a country’s healthcare system[2].Usually, “flatten the curve” involves pharmaceutical interventions that mitigate or eliminate the disease. But COVID-19 antivirals are unavailable right now, so governments resort to non-pharmaceutical interventions that focus mainly on vector control, or restricting contact between persons, thereby reducing the likelihood of coronavirus transmission.
That is, governments focus on prevention since there is no cure yet.
COVID-19 vector control measures include[3] (a) closing down of schools, (b) isolation of the elderly and those with co-morbidities, (c) self-quarantine of suspected and confirmed cases, (d) social distancing, and in extreme cases, (e) a lockdown, i.e., the forcible home quarantine of a vast majority of the population.
Complementing “Flattening the Curve” is “Raising the Line,” where the line represents the country’s healthcare capacity.
Raising the line includes increasing the number of hospital beds, medical personnel, and medical equipment. For example:
- The Philippine Government has converted various public buildings into ad hoc COVID-19 treatment facilities[4], thus increasing the number of hospital beds.
- Philippine Senator Bong Go, on the other hand, seeks the creation of a Medical Reserve Corps, aimed at increasing the number of medical personnel[5].
- The #PPEniTP Project[6], a partnership between Thinking Pinoy and the Filipino-Chinese Community, provides essential personal protective equipment (PPE) to COVID-19 frontliners, helping make medical equipment more available.
Oxford’s Government Response Stringency Index
Most countries enforce some form of lockdown, but the severity of such policies varies widely, making it challenging to compare performance data between two different jurisdictions.To address this, the University of Oxford’s Blavatnik School of Government created the “COVID-19: Government Response Stringency Index”, which the website defines as[7]:
“The Government Response Stringency Index is a composite measure based on nine response indicators including school closures, workplace closures, and travel bans, rescaled to a value from 0 to 100 (100 = strictest response).”
More specifically, the index is based mainly on nine policy and response categories, namely:
- School closures
- Workplace closures
- Canceling public events
- Restrictions on gatherings
- Public transport closures
- Public information campaigns
- Stay at home
- Restrictions on internal movement
- International travel controls
As can be seen above, the UK started to enforce drastically stringent policies until 23 March 2020, which coincides with when British Prime Minister Boris Johnson placed the country “under a virtual lockdown[8].”
From the same graph, we can also see a significant relaxation on 13 May 2020, which coincides with the easing of the UK lockdown “as data shows economy (was) hit[9].”
Focusing on the Philippines
Now, let’s look at the Philippines:
President Duterte declared a Luzon-wide lockdown in mid-March, which explains the rise in Stringency in the graph. A sudden drop in Stringency occurred on 01 May 2020, or when it started enforcing a “General Community Quarantine (GCQ)” in select parts of the country[10].
The graph shows lockdown policies are still pretty strict for the Philippines, but Stringency will drop drastically as Metro Manila and Central Luzon transitioned to GCQ[11] on 01 June 2020.
Significant Policy Relaxation
High Stringency flattens the curve, but when applied for too long, it also flattens the economy.Of course, no government wants its people to survive from COVID-19 just to let them die from hunger. Hence, governments change Stringency to balance Public Health and Economics. Such changes affect the rate of spread of disease. The bigger the change in policy, the bigger the difference in the rate of spread of disease.
The Philippines, as explained previously, has enforced its second significant policy relaxation on 01 June 2020 when it let Metro Manila transition to GCQ.
Was this the right thing to do? That’s the question.
Of course, there are many ways to define a “significant policy relaxation” based on the Stringency Index. But for this article, we shall set it as the date where the Stringency decreased by 9 points or more from its highest peak. A more optimal value may be found, but 9 points suggest at least one minor relaxation in each of the nine indicators or a significant easing in one or more.
More formally stated:
Let S(x) be the Stringency at date x. We define peak date P as the latest date at which S is at its maximum, i.e.:
P := maximum { d | S (d) = maximum {S(x)} }.
Further, we define significant relaxation date R as the earliest date after P where S decreased by more than 9 (ΔS > 9), i.e.:
R := minimum { d | S(p) - S(d) > 9; d > p}.
That is, a Significant Policy Relaxation happens on date R.Many countries have yet to significantly relax policies so that their R’s may not exist, but we are just concerned with those that have already done so. Using data from Oxford’s Stringency Index, the table below lists down countries that have significantly relaxed policies (ΔS > 9).
The Philippines is not the first country to significantly relax policies, as the table above shows 14 others who have done so in the past, but did the Philippine make the right decision to follow suit?
Active COVID-19 Cases
Recall that flattening the curve and raising the line are both aimed at keeping the total healthcare demand within the limits of a country’s healthcare system, but how do we get an idea of aggregate demand?In an interview[12], infectious disease specialist Dr. Edsel Salvana of the UP Manila National Institute of Health used “doubling time” as a gauge, which he defines as the number of days it takes for the cumulative COVID-19 cases to double.
Doubling time is a very reasonable indicator of aggregate healthcare demand. Still, this metric is essentially the first derivative of the epidemic growth curve, making it less readily correlatable to healthcare demand.
As an alternative, this article uses total current active COVID-19 cases, as it arguably directly correlates with a country’s aggregate healthcare demand. After all, a fully recovered COVID-19 case likely won’t need much medical attention.
In this light, here are histographs of active cases of each of 15 countries with significantly relaxed policies, as listed in the previous section.
Data for active cases come from the Worldometers Coronavirus Tracker[13]. The histograph titles contain the name of the country and the date of significant policy relaxation R, with red vertical lines denoting R’s approximate location.
Based on these histographs, active cases in 12 out of 15 countries with significant policy relaxations have fallen or plateaued. The three remaining countries – the Philippines, Indonesia, and Pakistan – have significantly relaxed policies despite respectively experiencing a continuous rise in active cases.
The Philippine Dilemma
Exacerbating the Philippine Pandemic is the accelerated growth in active cases over the past several days. The Philippine Health Department said the spike is attributable to late reporting[14], but the fact remains that total active cases undeniably continue to rise.And this is a problem.
Continuously rising active cases mean it’s just a matter of time before demand breaches healthcare capacity. If and when that happens, mortality rates increase as COVID patients spill on the streets.
The Philippines has arguably slowed down[15] the spread of COVID-19 through Stringency measures, but the more important question is whether it has restricted it enough.
It appears that it didn’t. Worse, data suggest that the rise is accelerating.
Given that the curve didn’t flatten enough, the remaining option is to raise the line.
That is, given the failure to sufficiently control healthcare demand, the government will have no other recourse but to increase healthcare capacity. But it is uncertain as to how long the government can sustain this, as it will only manage to strain the country’s already strained resources further.
Case in point, the national budget has been realigned[16] to the nation’s COVID-19 response.
Raising the Line, but not that much
While the Bases Conversion and Development Authority and the Public Works Department are doing an excellent job building new COVID-19 facilities, the fact remains that the country has nowhere to get more medical personnel and equipment.Worse, the country’s medical workforce is shrinking, as evidenced by the Philippines’ coronavirus infection rate among healthcare workers.
Abdi Mahamud, the World Health Organization’s COVID-19 incident manager for the Western Pacific Region, said health workers comprise as many as 13% of cases in the Philippines, which he attributed to the PPE shortage and levels of coronavirus exposure.
Even at the onset of the pandemic, most Philippine hospitals already lack not only doctors and nurses but also PPEs, so just imagine how much worse it will be as the number of active cases rise further.
Three basic options
There are three primary courses of action left for the government:
- Lower Stringency: further relax policies
- Maintain Stringency: continue with the status quo
- Raise Stringency: reinstate the lockdown
As explained in previous sections, maintaining the significantly relaxed policies post-May will ultimately result in higher mortality rates.
A vast majority of COVID-19 patients will recover, and the nation will ultimately still survive. However, (a) a large number will likely die, a number that many Filipinos will likely perceive as unnecessarily larger due to lack of healthcare, and; (b) many of those who will triumph over the sickness will inevitably undergo torturous near-death experiences, which they will likely blame on the government.
The Health Department can try to hide cases as it did during the Dengvaxia Fiasco[17], but hiding bodies, given the far greater magnitude of the COVID-19 epidemic compared to the 2017 Scandal, will be an impossible task.
And when people see bodies pile up, people get angry.
President Duterte may manage to at least partially assuage unrest by terminating Health Secretary Francisco Duque. Still, he remains reluctant[18] despite massive clamor from both sides of the political fence[19], the healthcare community[20], and the general public.
That is, maintaining the relaxed status quo will likely result in a political nightmare for the Duterte Administration and whoever it will anoint as a successor.
Meanwhile, the third and last option – reinstating the lockdown – may save lives but ultimately cause economic devastation and, subsequently, massive civil unrest as the masses starve.
The President is between the devil and the deep blue sea, and the Filipino People fervently wish him success, which is more easily achievable if his Chief Public Health adviser Duque has competence, which unfortunately isn’t the case.
Mr. President, Good Luck and Godspeed. May the Force be with You.
(RJ Nieto / Thinking Pinoy)
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SOURCES:
[1] Hethcote, R. The Mathematics of Infectious Disease. SIAM Review. Vol. 42, No. 4 (Dec., 2000), pp. 599-653. https://rjnieto.me/3eH3PVt[2] Osmosis and LifeBridge Health. Beating Coronavirus: Flattening the Curve, Raising the Line. 20 March 2020. https://rjnieto.me/2Mn658c
[3] Imperial College London COVID-19 Response Team. Report 9: Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand. 16 March 2020. https://rjnieto.me/2XOIeUk
[4] Philippine Information Agency. PhilSports Arena's Mega Community Quarantine now takes in COVID-19 patients. 27 April 2020. https://rjnieto.me/2MnfVXS
[5] Manila Bulletin. Go pushes bill establishing medical reserve corps. 24 May 2020. https://rjnieto.me/3dpe9Bv
[6] Manila Bulletin. #PPEniTP and the Filipino-Chinese community. 15 May 2020. https://rjnieto.me/2AzYtMU
[7] COVID-19: Government Response Stringency Index. University of Oxford – Blavatnik School of Government. Retrieved 02 June 2020. https://rjnieto.me/2U31pJ1
[8] New York Times. Britain Placed Under a Virtual Lockdown by Boris Johnson. 23 March 2020. https://rjnieto.me/2BpDtJp
[9] BBC News. Coronavirus: England lockdown eased as data shows economy hit. 13 May 2020. https://rjnieto.me/3eKusJ5
[10] Canberra Times. Philippines eases virus restrictions. 01 May 2020. https://rjnieto.me/3coUiRq
[11] CNN Philippines. Metro Manila eases to GCQ on June 1. 28 May 2020. https://rjnieto.me/3ckAGhf
[12] CNN Philippines. Specialist says new normal is needed after enhanced community quarantine. 18 April 2020. https://rjnieto.me/3gMHkQL
[13] Worldometers. COVID-19 Coronavirus Pandemic. Retrieved 02 June 2020. https://rjnieto.me/2U3u4h1
[14] Philippine Star. With 'fresh' COVID-19 reporting protocol, DOH 'late' again in case update. 30 May 2020. https://rjnieto.me/3gDZLHo
[15] Straits Times. Coronavirus: Philippines 'flattening the curve', seen easing lockdown after May 15. 05 May 2020. https://rjnieto.me/2U4fDJL
[16] Manila Bulletin. Solon says Bayanihan Act already empowers President to realign budgets, generate funds for SAP 2 aid to poor families. 23 May 2020. https://rjnieto.me/2XL1SQY
[17] Thinking Pinoy. #DengGate: Botched Tarlac Dengvaxia case hints DoH-led coverup. 06 December 2017. https://rjnieto.me/2Xn2ayB
[18] CNN Philippines. Duterte consoles Duque: ‘Don’t be too touchy on issues’. 26 May 2020. https://rjnieto.me/306VFl8
[19] CNN Philippines. At least 14 senators want Health Secretary Duque to resign over COVID-19 crisis response. 16 April 2020. https://rjnieto.me/2U1Ninr
[20] Philippine Star. Private hospitals ask Duterte to fire Duque. 25 May 2020. https://rjnieto.me/2U1N9Ap
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