Medicine & Management: Curing our country
“Whether tis nobler in the mind to suffer the slings and arrows of outrageous health misfortune, or to take arms against a sea of economic troubles and by continuing to lockdown, end them.”
You can’t manage what you can’t measure. But what happens when there is a move to manage what should be measured, resulting in confusion that will inevitably affect far-reaching economic decisions? Take the DOH COVID Situationers, which seem to be at odds with what we see happening at work (The Medical City) and in our neighbourhood (Quezon City).
At the end of February, 2021, active cases were below 30K. But now the incidence of COVID at our subdivision is twice what it was last year. By April 8, active cases topped 167k, or over 5x in a little over a month. That data point is clear and unquestionable.
But what is intriguing is the reported number of severe and critical cases that require hospitalization. In our experience, severe and critical cases typically move in lockstep with COVID cases- in February, 5% of active cases were severe and critical, consistent with what we have seen in the past year. But in April, even as active cases sky-rocketed, severe and critical cases were reported to have gone down to just 1%.
Have severe and critical cases really gone down as a percentage of active COVID cases? Or are they being addressed by hospitals turning their Emergency Departments into pseudo-ICUs, with effectively 20% more bed capacity? Are more people also dying in their homes unreported as COVID? Or are some of these deaths being misclassified as mild?
Even the R naught rate has become a source of confusion. According to the World Health Organization (WHO), countries need to do more testing to bring the positivity rate down to a manageable 5%. Yet, it now appears that the more tests we do, the higher our positivity rate, hitting 20% on some days. Again, confusingly, reports have been issued that our R naught rate is improving and that we are bending the curve – even in the midst of higher positivity rates.
Which is which? Or all of the above? There certainly was complacency (no, we did not see a surge after the Black Nazarene procession on January 9 per OCTA), more infectious virus variants (10% of all cases and widely spread throughout NCR), lack of foresight on test-trace-treat (insufficient surge capacity because of inadequate NG management). The list goes on.
We need not create excuses to blame, beg, or bleed. The short-term fix – expand capacity in testing, tracing, and treating – is being worked on, albeit again belatedly. But we have enough time now to properly think through vaccine distribution, and the inevitable issues of inequality and unfairness it may raise.
As of April 9, NCR, with 12% of the population, received 42% of the initial vaccine doses. On the other hand, the region has 50% of the active cases, and with its deadly congestive spacing is the prime manufacturer of the recent surge and the top exporter of COVID to the rest of the country. Inequality is also manifest in people priority filters. HCWs (A1). Seniors (A2). Comorbids (A3). With vaccination prioritization, ICU access, which creates the most fear, can be better managed.
Here’s what’s clear from the HCW side, as per TMC and another major hospital, with around 5000 vaccinees each. First, the infection rate was 3-5% post-vaccination, which looks high, but then again this happened in the middle of a COVID surge. Second, NONE of the cases fell into the severe and critical categories, which is what vaccines were meant to do. Third, in the case of TMC, there was no difference in the infection rates of either Sinovac or AstraZeneca. While these are small samples, they bear the science of vaccination out. But we need to convince the 40% of the population, who refuse to vaccinate based on fear, religion, belief in prophylactic solutions and unproven alternative medicines and the Dengvaxia scare, to get inoculated.
By end-May, 8.5 million doses will have arrived. That should take care of first jabs for 7 million registered A1-A3s. This list though is likely understated. Our A2 (60+ population) is 9.4 million, while the masterlist shows 5.2 million. Our A3 (co-morbids) is 14 million, while the masterlist shows 500k.
Can this first phase vaccination all be done by end-May? As of April 13, we averaged 48k/day over the last 7 days. We need to triple this daily rate to 151k in order to complete 8.5 million doses. (Indonesia does 500k daily.) The 15.5 million more doses in May-June should cover the remaining 5 million A1-A3 nationally, 9.5 of the 11 million A4 economic frontliners (with probably the highest asymptomatic exposure), and of course, second doses for 1 million A1-A3.
Between the P70 billion in government and P15 billion in private sector funding for vaccine purchases, and a projected global surplus of vaccines by 4Q 2021, we have a good shot at herd immunity – provided we can execute on vaccination productivity. LGU capacity will need to anchor this build-up, in the context of elections forthcoming in 2022.
But healthcare costs money, which means we also have to nurse our economy back to health.
Economic bubbles are associated with prices for assets rising way above their intrinsic value. COVID bubbles are associated with lockdowns, where physical movement screeches to a grinding halt, staying within the bubble alone. Can economic growth be compartmentalized within health bubbles?
Construction contributes 7% to GDP. Its Gross Value Added (GVA) declined by 25% from P1.5 to P1.1 trillion in 2020. But construction is the enabling actor for investment plays. Properly disbursed as a project ramps up over time, it is noninflationary. Properly spent on forward-thinking energy, infrastructure, utilities, it is foundational for economic multiplier effects on growth. Why should it be given to lurching stops and starts? More project employment for laborers with shelter-in-place measures works. Construction, and its supply chain, including imports of critical raw materials and equipment, should be given a permanent free pass across LGU borders.
Construction projects, as well as agriculture, can and should be bubbled.
GVA for Agriculture, Forestry and Fishing, was P1.8 trillion in 2020, a 6% growth from 2019 despite the pandemic. This sector, which accounts for only 10% of GDP, drives 42% of the consumer price index (CPI), and is thus the leading harbinger of inflation. Of the P3.2 trillion 2020 GVA in manufacturing, P1.8 trillion, or 57%, came from food, beverage and tobacco (FBT) manufacturing.
Because 80% of the FBT price index movement is driven from outside NCR, IATF can lock down NCR, but probably not the +4 provinces, and certainly not for business channeling initiatives toward growing FBT. From designated agri zones with minimal gating, to free passes for operators of farms and ancillary processing, a free-up instead of shut-down perspective should emerge.
Remittances from OFWs and migrants totaled P1.6 trillion in 2020, a drop of 0.8% from 2019. Along with the fledging tourism (P2.3 trillion) and robust BPO (P1.5 trillion) industries, they are our labor liaison to the rest of the world. So what do we do? In March, the Philippines locked down to 1500/day the number of visitors who can enter the country. By comparison, Germany has a love visa, moniker for German nationals to bring in foreign loved ones with a 48-hour valid PCR test.
The Philippines vs the Rest of the World bubble is all about gating, which is ultimately an execution issue. Proper testing cadence, enforced with proper accommodations, ensures that BPO foreign stakeholders, OF workers visiting family, and tourist shelters with direct fly-in-fly-out access to islands, can be properly secured against COVID.
We can gate better. We have RFID, CCTVs, QR codes. We already know where the virus lives — in large gatherings of people talking without masks and without distance.
To cure our country, we need to drive vaccination forward with an education program led by a credible health leadership, and mass vaccination anchored on an empowered LGU initiative. This also means having transparently accurate and consistently available data from the DOH. We don’t need a beggar’s bowl to the rest of the world to build resilience and self-sufficiency in health care. Instead, we need to manage our economy with sectoral bubbles that can continue to drive key industries forward. We should stop burdening business with poorly executed locks, clamps, rules, filters and chains. Let’s find better ways to free them up to grow. Let it not be said, as we drown our sorrows in our woes, that “We have met the enemy, and it is us.”
The article was written by Jose Xavier ‘Eckie’ Gonzales, The Medical City Chairman of the Board.
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