Rappler Talk: Ex-DOH chief Esperanza Cabral on the race against time
Bookmark to watch this interview on Thursday afternoon, April 2
MANILA, Philippines – Rappler talks to Esperanza Cabral, former secretary of the Department of Health (DOH) and the Department of Social Welfare and Development (DSWD).
In this interview with Rappler's Maria Ressa, Cabral draws from her experience as former DOH and DSWD secretary to tell us what the politicians must do better - on leadership, deployment, decisive and timely action, which she says is important to stem the societal impact of COVID-19.
Cabral notes the government's preoccupation with lists. Her advice: assume everyone needs aid in impoverished areas so that aid can come when people need it.
It's a race against time.
Below is a 4-point plan, she says is common sense, put together by Cabral, her son Dr Bryan Cabral and Michael Sy. It's endorsed by the TOWNS Foundation.
Watch the interview with Cabral here.
MR: Hello everybody. I’m Maria Ressa, this is Rappler Talk. Joining us is a woman who used to run the public health system of the Philippines, former Secretary of Health Espie Cabral. Espie, it’s good to have you with us.
EC: Thank you, Maria.
MR: Espie, how would you describe what we are living through today?
EC: Well, it is something that none of us have experienced before. So we are all just trying to do whatever we can, and learning from the experience, so to speak.
MR: You and your son came up with a four-part plan. Could you talk to us about that?
EC: Yes, we did this call to action together with Michael Sy - who is somebody I’ve never met really, but I’ve heard about him from my son - and his ideas. So we put everything together and we came up with this call to action. It’s very simple, everybody knows what’s in there. It’s just a matter of going through the details as to how to operationalize this. And basically we said, first we need to know our enemy. Second, we need to deal with the people who got sick from this. Third, in which we deal with protecting the frontliners, the healthcare workers, everybody else who has to deal with this on a face to face basis. And finally, we have to think of the citizenry, and what is going to happen to them not just while we have the problem, but after that.
MR: In the time that you were secretary of health, did you handle anything that would have given you some lessons on how to deal with this today?
EC: When I was secretary of health, fortunately there were no big disasters that we saw. I did not have SARS-CoV, I did not have H1N1, nor Ebola, nor MERS-CoV. But when I was secretary of social welfare and development, of course I dealt with a lot of disasters - earthquakes, floods, armed conflict, things like those.
MR: Could we tap that disaster… Since we go through an average of 20 typhoons every year, is it possible to tap that to be able to mobilize quickly?
EC: Absolutely. I think we need to deal with this particular disaster as a whole of society and as a whole of government. There is no one department that is going to be able to handle everything. We will need not just the Department of Health, but also the Department of Social Welfare and Development, the Department of Interior and Local Government, the uniformed service, everybody.
MR: As a former government official at the top of these very important agencies… I guess this is a question I have, which is, the 4 factors you have - know thy enemy, take care of the ill, protecting the frontliners, protecting the citizenry… I would assume before a lockdown, that a lot of these things would have been thought through and a workflow would have already been laid out.
EC: Yes, that’s what we would have hoped also. But maybe things were developing so fast, all they could do was react and they couldn’t really think this through. What’s going to happen? How are we going to deal with it? I’m sure they’re trying to do their best, but as I said, try your best some more. Because obviously our best at this point is not as good as we want it to be.
MR: Let's take them one at a time. Know thy enemy - the virus SARS-CoV2, causing COVID-19, causing this disease. The epidemiologists have been talking to us about this exponential curve, and they expect tens of thousands, that the numbers will go up, right? What about this enemy should be important in managing the public health crisis?
EC: It's very important for us to know how much it has affected people. And the only way to do that is to make a diagnosis through certain laboratory tests. Unfortunately, we did not have the kind of resources that we needed in order to be able to test many people right at this time. Only now are we trying to catch up from our one and only laboratory that was doing the tests - the Research Institute of Tropical Medicine. We're now trying to accredit other government and private laboratories to be able to do the test. So you see that for two months, we tested less than 2,000 unique individuals. And mostly these are people who were sick and who needed the test so that they could get the treatment that they required. As far as the community is concerned, we did not know where the enemy is, and how many it has actually captured.
MR: How fast - from having dealt with the top of government - how fast can you mobilize a whole of government approach? What needs to be put in place?
EC: Well, we need a very good leader, somebody who will say, “You need to do this.” Give them a time frame, give them targets to meet, so that at the end of a certain period, we know where we are. So we need a leader. We need other generals, and they also have to be knowledgeable. They should have real-world experience in dealing with disasters - not just medical, but everything else. And they must lead in a way that people are inspired, in a way that people will be inspired to follow them, to follow the instructions because they know it is good not just for them, but for their families and everybody else.
MR: There seems to be a very strong top-down approach right now - that people in the bureaucracies that actually know what they should be doing, are waiting. How do we deal with that during a time when delays are life and death measures?
EC: Well, even as I say that we need a leader and other generals, these people must listen to the ground. And they must ask questions, and they must not take criticisms as criticisms against them but as constructive suggestions, because there are many things that people on the ground know that they don't know, because they're not there. So they need to listen. The other thing is our healthcare system is dual in nature. Half of it is private and half of it is public. So the connection between these two - which is very often tenuous - must be strengthened during times like this. Public officials must listen to the private practitioners and the private health organizations because, as you can see if you look at the records, it was the private hospitals that had admitted most of the positive cases - not the public hospitals.
MR: That leads us to number two, which is taking care of the ill, right? What are the key aspects that need to be in your call for action?
EC: OK. The reason why we need to know where the enemy is and how many it has captured is because we need to prepare for who are going to get sick. And if we look at the data from other countries, we know that 20% of all those who are afflicted by the virus will need hospitalization, and about 4% or 3% of them will actually die. So if we have a system that does not have the capacity to take care of all of these people, more will die. So we need to be able to ramp up our facilities, our health personnel to be able to take care of this. It is also the reason why people keep talking about flattening the curve. What we want to do is, if we are going to get sick with coronavirus, we would rather get less people sick at one time. Spread the illness over time so that the system is not overwhelmed. Because if you get 10,000 sick people at once, the system will collapse.
MR: Number three, protecting the frontliners. Again, it would seem like if we were doing a lockdown, that the PPEs - the personal protective equipment - would have already been prepared for them. I guess, talk about what the call to action is now on number three.
EC: Well, you know, we're into the third month of this particular disaster, and it is only now that we have actually ordered, say, 1,000 sets of personal protective equipment. In the meantime, our health workers had been making do with what they had, what the private organizations can donate to them, buy pieces of this one here and that one there - things like those. As of the moment, 17% of all the people who have died from coronavirus are doctors. And, you know, if we have a mortality of doctors that way, we are going to decimate the ranks very soon. So we need for government to be able to protect them with the proper personal protective equipment, with the proper strategies like disinfection and so forth and so on in hospitals and health facilities so that they don't get sick. We need to test them, so that we know that they’re vulnerable and we can take care of them. We also need to know if they're already immune, so that we can put them back to work again.
MR: When you say immune… this is another one of those things that we don't know, right? If when you get… We will all at some point get it, right? But it's not clear whether or not it'll be like the measles where you get it, you’re immune, or…. The health workers who are working out there, given this, is there any other protection we could give to them?
EC: That's really about it. Provide them with the proper personal protective equipment and provide them with all the other strategies that will enable them to prevent getting sick.
MR: Number four, Espie, is protecting the citizenry. What's that call to action?
EC: OK, what we have is a lockdown situation, right? And we are saying that we are doing this in order to prevent people from getting infected, which is fine. That's really how it should be. Except that many of our citizens live in places - if they have homes - that are overcrowded, congested. And if you have a person under investigation - somebody who has been exposed to the virus - going to that community, there is no way this person is going to self-isolate properly. So we need to think of other things to do, so that in case these people are infected with the coronavirus, they will not be able to transfer it to the community.
MR: So that's on a larger scale...
EC: Yeah. If you look at the data now, you will see most of the people who had coronavirus are the affluent. Because they’re the ones who travel, they're the ones who go from place to place, mingle with a lot of people. So far, the poor are relatively protected from the coronavirus. But if in a household that has a stay-out driver, the owner of the house or the head of the household develops coronavirus, then gets in a car with the driver, that driver is going to bring the virus to his community. And we are going to see a conflagration there.
MR: Hasn't this already happened in the Philippines? The local transmission?
EC: Yeah, the local transmission, but so far the local transmission is not among the poor.
MR: Okay, interesting. Interesting. Can I ask you now though, with the lockdown, the people most affected are the poor, the people who don't have daily… No work, no pay, right?
EC: That’s correct. They may not have the virus, but they are most affected.
MR: What things need to be put in place now? Because the last announcement that we had was that they're still putting the list together of who will be benefiting from this. What would you do if you were still DSWD secretary?
EC: I think in this case, with all the money that they have - they said 200 billion just for social amelioration, I heard even 270 billion for social amelioration - if they go to a poor area, they should assume everybody needs the kind of benefit that they're providing. It takes too much time to tease out one or two out of this hundred in that poor area whom you should not be giving to. Just give this person, so that everybody else can benefit in a timely way.
MR: You've had to deal with unpopular decisions and the politics of a government - of different governments, actually. I guess, what advice would you give to our leaders? Because where they go, we all go, right? What advice could you give about how to deal with a public health crisis and the politics that we're living through?
EC: Well, the politicians will always be there, and politics is something that we all have to deal with, every day of our lives. It's just that perhaps in instances like this, maybe they can start to listen to experts, advisors who are more knowledgeable in the subject, instead of thinking of themselves as the authority. There's a difference between expert and authority. So they are the authority, let's put it that way. And the others are the experts. And they must listen to the experts, so that they can exercise their authority for the good of everybody.
MR: In this race against time - and it really is a race against time, right - what advice would you give to the people who will determine where our nation goes?
EC: I don't think that that is something that I should tell them. They know that their actions should be for the good of the majority. Not for their own good, not for the good of their family, but for the good of [everyone].
MR: Last thoughts? We're now in our third week of lockdown in Luzon. Your last thoughts?
EC: Perhaps I can as a private individual now, tell them that as private individuals, we all want to work with government so that we can get through this crisis as soon as possible. Sometimes, government might think that private individuals or private organizations have no business in making policies, and only should be there to provide donations that they need. That is not the case. Government can learn a lot of things from the people, and they should listen to them.
MR: In fact, in the past, government has admitted where it doesn't have the capacity or the expertise to handle certain things, right? Sorry, a last question I have which has to do with the end of the lockdown. As it stands right now, it's supposed to end mid-April. But according to epidemiologists and complex system scientists, that curve will just be increasing. And we could be hitting 75,000 infected at that point in time.
EC: That’s one of the estimates, yes.
MR: How do we decide when we move forward? What does business as usual look like in this time of pandemic?
EC: I think we should consider a phase type of termination of the lockdown. And the first thing that should happen is, all those people who are already immune from the disease are the ones who can be released from the lockdown in order to engage in economic activity. And we can do this by testing the community. Who among them are already immune and can safely mingle with others who are out there, also immune? I think that the employers are going to be interested to know this - [also] communities and local government units, even NGOs that are feeding the poor - because they need to think that there will be an end to what they are doing. But it cannot be an abrupt end. I mean, from April 14, we’ll have coronavirus. On April 15, it is not that we suddenly do not have coronavirus anymore. It is going to be there, and it will be there for a much longer time. We need to be prepared for this.
MR: Fantastic. Thank you so much, former Secretary of Health, former DSWD Secretary Espie Cabral. Thanks for speaking with us.
EC: Thank you. Thank you for having me, Maria.