[OPINION] Collateral damage in the coronavirus pandemic

This is unprecedented. The coronavirus pandemic spreading quickly around the globe is a war that is ruthless and merciless. The frontlines in this war are the hospitals and their heroic health care workers, as they battle to save lives while keeping themselves from getting overrun or infected. The direct victims of this war will be the thousands of COVID-19 patients who will die, including many of the frontliners.  

In the Philippines, the death toll includes 4 doctors (two cardiologists, one anesthesiologist, and one medical oncologist). Several of the biggest, most modern private hospitals are already overwhelmed.  These include The Medical City (TMC), both St Lukes Medical Centers (SLMC), Cardinal Santos Medical Center, Makati Medical Center, Asian Hospital and Medical Center (AHMC), and Chinese General Hospital. The top two government hospitals swamped with COVID-19 patients are the Research Institute of Tropical Medicine (RITM) and San Lazaro Hospital, which is expected as both are supposedly the lead DOH hospitals for infectious diseases. 

Emergency rooms and intensive care facilities are full to the brim, while testing kits, respirators and PPEs, so critical to winning this war, are in short supply. As of writing, TMC, SLMC, and AHMC have announced that they cannot accept new patients. When these hospitals can no longer accomodate COVID-19 patients, the spill-over will be to other hospitals in a domino-like contagion that, if left unchecked, will bring all our hospitals and healthworkers down to their knees. Our front lines in Manila, and perhaps in Cebu, are buckling and in danger of collapsing within weeks. The other provinces have perhaps only a week to prepare before they suffer the same fate.

Recently, Congress passed a bill granting President Duterte emergency powers, while the Department of Finance announced it will roll out a P27.1 billion war chest for this raging crisis.  

As in any war, there will be the inevitable collateral damage, and I am highlighting them here for the sake of discussion, and to gain a more comprehensive view of the battlefield, as we strategize how to defeat our common enemy.

The first collateral damage in this pandemic are the other patients stricken with diseases not related to COVID-19, but are just as deserving of life-saving care. When we look at the mortality rates of COVID-19, we need to also see the collateral mortality rates of other cases left untreated due to the unavailability of hospital beds or treatment.

For example, the Philippine General Hospital (PGH) historically sees over a thousand other types of patients daily. At present their main ICU is being renovated. There are burn patients in the surgery ward still in need of intensive care, while hundreds of cancer patients are receiving chemotherapy. And to the great misfortune of their existing patients (and future patients needing specialized care), PGH has been designated as a COVID-19 center (to the credit of the PGH leadership and staff, they wholeheartedly accepted this challenge like good soldiers). They even had to stop giving outpatient chemotherapy.

I’m afraid we may have created more collateral damage by belatedly assigning PGH to be a COVID-19 center. And once the COVID-19 contagion engulfs PGH, the only option left is to bear the brunt of a contagion run wild, hoping the outlying provinces can prepare themselves a little better.

As soon as a hospital sees its first few COVID-19 cases, the highly infectious nature of the disease makes it quickly necessary to shut down and/or limit other services in order to contain the spread to uninfected patients and other areas of the hospital, while protecting the health and capacity of its workforce.

This is what is happening in our big private hospitals in Metro Manila. They are filled to the brim with COVID-19 PUIs or confirmed cases. It’s so hard to get a room now, even if you’re rich. But the reason is not because of a lack of rooms or space, but mainly because their workforce is stretched to the limit, with not enough testing kits, respirators, and PPEs. They also cannot fully attend to the other types of cases requiring their services, contributing to collateral damage. (READ: Coronavirus patients sent home as PH hospitals reach limit)

The early lesson for us to understand during the height of this pandemic is that a centralized, integrated approach is best, assigning each hospital to either be exclusive for COVID-19 patients, or exclusive for the other patients requiring specialized care. In this way we can focus manpower and resources for COVID-19 in selected hospitals, while minimizing collateral damage by keeping other hospitals free to exclusively see other patients. 

These big private hospitals currently in the thick of battle are also our best battalions against COVID-19. They have our most modern facilities and equipment, particularly in the emergency room and intensive care units. Their infection control and sanitation processes meet world standards, important in containing viral spread and protecting healthcare workers. Their teams in the emergency room, intensive care unit, and infection control are some of the best in the country, headed by renowned specialists and scientists (who must be recognized for doing such great and heroic work at this moment). Management of their hospital-wide quality systems is also first-rate. It would be much faster and easier if some of them were to be immediately designated exclusive COVID-19 centers, with full government funding and support. This move would allow them to re-open rooms and service areas, get more respirators and staff from outside, take better care of patients rich or poor, contain exposure, with better protection for its frontliners.  This would also spare them from transferring critical COVID-19 patients already in their ICUs, which will be a logistical nightmare.

There have been laudable proposals to establish COVID-19 centers away from existing hospitals, similar to what was done so effectively in Wuhan, China. The Quezon Institute in Quezon City or the Mega Drug Abuse Treatment and Rehabilitation Center at Fort Magsaysay in Nueva Ecija have been mentioned as possible sites. Dean Cenon Alfonso from the Ateneo School of Medicine and Public Health has also proposed using container vans that can be quickly set up within a week.

However, we are limited by the glaring scarcity of our national health care workforce. It would be nearly impossible to hire a completely functional staff for this COVID-19 center, quick enough to change the tide of battle. Nor would it be wise to pull out existing staff from already beseiged hospitals. Again, the quickest, most feasible solution is to designate selected big private hospitals as COVID-19 centers, fully funded and supported by the government, addressing the dire needs of our COVID-19 patients, while freeing other hospitals to minimize collateral damage. This may buy us time in case we decide to go ahead and open a new COVID-19 center.

Collateral damage also extends to the frontliners of our already stretched health care workforce.  The sad fact is that our total number of hospital beds, ICU beds, and health care workers are markedly below WHO recommendations, and are certainly insufficient to meet the demands of this pandemic.  Each loss of a frontliner to the disease further diminishes our capacity to care for patients and win this battle. Proper PPEs and infection control processes are paramount. Yet there is a woeful lack of these in most of our government and smaller private hospitals. Even big hospitals currently with good PPE supplies (some acquired from generous donors) are faced with the frightening prospect that stocks may run out if this pandemic stretches beyond a month. The practical solution is to draw the battle towards designated centers, and concentrate supplies and meager resources with them.

The death of one of our medical oncologists is another example of the kind of collateral damage we should minimize. Their services are certainly important for cancer patients, and losing one oncologist deprives hundreds of his/her services.  Placing designated health care workers out of harm’s way in a COVID-19-free hospital (while still practicing basic personal protection), allows them to continue treating other patients not infected by COVID-19, with minimal risk to themselves.

The other obvious collateral damage from this COVID-19 pandemic is the economy. But before we address this from a macro level, we need to focus on the front lines, where the battle is raging. The operational costs for a private hospital to fight this disease are huge, and probably unsustainable if the pandemic lasts longer than the set quarantine period. The usual services that drive revenues are either minimized or shut down completely. Bed occupancy falls as focus is shifted to COVID-19 patients and on measures to avoid cross-contamination, while other patients stay away or seek facilities free from COVID-19. 

Private hospitals in the Philippines make sustainable profits within our mostly fee-for-service health care model, with a smaller contribution from both government and private insurance. This out-of-pocket model is generally acknowledged by economists to be the weakest in terms of providing universal and equitable access to health care. It is also most vulnerable during a pandemic and economic downturn.  In contrast, the health systems in Europe, South Korea, and China (including Hong Kong and Taiwan) are in varying degrees socialized, allowing them to launch strong, coordinated, and centralized responses to national health emergencies, through a well-salaried workforce. 

Hospital care, particularly in the ICU, is expensive. As this pandemic rages and the economy falters, many in the middle class will have difficulty paying out-of-pocket, contributing to hospital losses. There must be financial support for the medical care of all hospitalized COVID-19 patients. If any of our large private hospitals come close to financial collapse, the government should intervene to keep its services running, something the populace cannot afford to lose. Government response during a pandemic has to be centralized, integrating all hospitals into its battle plan. 

At the core of this battle lies our healthcare workers, taking terrifying risks for themselves and their families. In private hospitals where most of the battles now rage, the pay scales of resident doctors, nurses, and staff are much lower than those in government. Furthermore, the specialist consultants are not salaried, and are uncertain if they will be paid for current services rendered. Yet they are all on the front line every day, crossing checkpoints, donning PPEs, and caring for highly infectious patients. If we are to win this war, economic support from government must be prioritized for all COVID-19 patients and the frontliners who care for them.

Finally, there was some controversy generated by the term “nationalize” in my previous commentary, which was actually spurred by a New York Daily Report dated March 16, 2020, stating that Spain had nationalized all its private hospitals in the fight agains COVID-19. Interestingly, using the same term sparked some confusion and mixed reactions.

Let me clarify that – whether we call it “nationalize,” “designate,” or “commission” – the main intention was to point out the need for strong and immediate government action, recognizing the key role of all hospitals in a centralized, integrated, and well-coordinated response, with robust financial support for the front lines. In this war, there should be no distinction between government and private hospitals, as the disease affects everyone, rich and poor. We are in only one health ecosystem. Fragmented we fall. – Rappler.com

Dr Ramy Roxas is the Director of the Philippine College of Surgeons Cancer Commission.  He is a consultant surgeon affiliated with UP-PGH, Ateneo School of Medicine and Public Health,  The Medical City, Asian Hospital and Medical Center, and Ayala Healthcare, Inc. He has a Masters Degree in Healthcare Industries Management from the ESSEC Business School, and is a Harvard Medical School Global Scholar in Surgical Leadership