He was training to be a cardiologist. Checkered polo shirt, short-sleeved white coat, a stethoscope around his neck, eyes on the verge of disappearing as he tilts his head to the right and breaks into a gentle smile—his photos that circulated on social media ticked all the boxes. Before pursuing this career path, he had chosen to serve for two years as a doctor to the barrio in Occidental Mindoro, and immediately one would have known that this cardiology fellow’s heart was in the right place. On March 21, the news of Dr. Israel Bactol’s death reverberated throughout the Filipino medical community, as everyone tried to make sense of what was happening, too fast, too soon. He was 34.
In the days that followed, it became difficult to keep track of how many doctors were admitted in hospitals where they worked, hooked to mechanical ventilators they used to manipulate. Their names were tentatively whispered during ward round, out of respect more than anything else. Our messaging apps were flooded with prayer requests and offerings. To most people who read the news, they were mere numbers. To us, they were our teachers in medical school, mentors in residency and fellowship training, juniors in the hospital, lifelong friends, colleagues and their loved ones. I have been a doctor for over a decade and I deal with life and death on a fairly regular basis; it had never occurred to me that I could possibly die serving in this profession, until coronavirus disease 2019 (COVID-19).
The spread of COVID-19 infection among health care workers in the country must be addressed. As of this writing (May 11), 2,067 Filipino health workers have been diagnosed with COVID-19, leading to 35 deaths. Overall, that represents 19% of confirmed cases, or almost one in five patients. For comparison, Thailand has documented 103 health care worker infections among 3015 cases (3.4%) during the same time period. Singapore’s Ministry of Health reported 66 health workers among 13,624 patients (0.5%) in late April. The World Health Organization has already expressed concern over the Philippines’ infection rate, which is among the highest worldwide, approaching that of Wuhan’s at the start of the pandemic. The numbers do not account for Filipino health workers who have died from COVID-19 overseas.
The health workforce plays a central role in the diagnosis and treatment of patients with COVID-19. It includes not just doctors and nurses, but everyone at the frontlines providing direct and indirect care to patients: nursing assistants, midwives, medical technologists, radiation technologists, respiratory therapists, dentists, laboratory staff, administrative staff, barangay health workers, and even the cleaners who ensure that COVID wards are meticulously disinfected. Shortage in health personnel is bound to hamper any country’s response to the current pandemic.
Moreover, we have learned from severe acute respiratory syndrome (SARS) in 2002 that infected health care workers have the potential to significantly drive the spread of the virus. Uncontrolled disease transmission within health care facilities eventually leads to outbreaks in the community, which would be more difficult to contain and would affect a higher percentage of the vulnerable population.
Why have so many Filipino health care workers been infected with COVID-19? While the Department of Health’s official data have shown a decrease in the number of new infections among Filipino health care workers in the last two weeks, it remains unclear how many of them acquired COVID-19 from the workplace.
Some argue that the higher numbers are due to the preferential testing of health workers in the country. This reasoning, however plausible, dangerously deflects from the root causes of the problem, which are lack of personal protective equipment (PPE) and failure to adhere to infection control measures in the workplace. This has been consistently shown in studies that looked at health personnel infected with SARS in Hong Kong and Singapore, and COVID-19 in Wuhan.
At the start of the COVID-19 crisis in the country, when people were not yet fully aware of how the virus behaves, strict rules on wearing PPE during patient encounters had not yet been in place in most emergency departments and clinics. We screened the general public for fever and cough in hospitals, airports, and malls, when we now know that contagious patients can be completely asymptomatic. The Philippines’ limited testing capacity and failure to perform meticulous contact tracing had also prevented early identification and isolation of cases. Any combination of these factors would have resulted to occupational exposure among our health workers early on.
Many have blamed patients for not disclosing accurate medical and travel histories, but the holistic practice of medicine compels one to pause and ask, “Why would a patient lie?” If it’s fear of being refused hospital admission or the social stigma attached to the acronyms PUI and PUM, could you really blame the patient?
At present, the government keeps reiterating that there is “no shortage of PPE,” but the constant pleas from administrators, doctors, and nurses on social media tell a different story. In the last six weeks, I have been in charge of allocating PPE for the health personnel of Philippine General Hospital, and we have never had more than two weeks’ supply of N95 masks. We have been forced to create contingency plans, including the disinfection and reuse of N95 masks. The quality of PPE, whether from commercial sellers or donors, is also highly variable. The Centers for Disease Control and Prevention maintain a list of respirators that are counterfeit or do not meet certification requirements, putting health workers at risk when they use them. The global supply chain for PPEs has become unpredictable, with some local distributors unconscionably demanding ridiculously high prices.
Providing adequate PPE is just one aspect of ensuring health workforce safety. Compliance to PPE guidelines must be compulsory, especially during high-risk procedures. Health workers have to be continually trained in the proper donning (“putting on”) and doffing (“taking off”) of PPE. The latter is particularly tedious and poses a high risk of contamination, considering that health workers often work long hours under stressful conditions. This burden on the health worker is lifted, and the risk is minimized, when a trained observer is always present to supervise the process.
Social distancing has to be maintained, even during breaks or at the end of the day, when staff usually gather to have meals or engage in casual banter, inherent to Filipino culture. The hospital must have a defined pathway for immediate testing and treatment of health workers who manifest with symptoms. To prevent burnout and exhaustion, psychosocial support must be readily available, and assistance with housing and transportation provided to staff as necessary.
Failure to take care of our health workers during the COVID-19 pandemic will lead to long-term consequences in the Philippine health care system. It will only exacerbate preexisting workforce shortages from geographic maldistribution, migration of health workers, and underemployment. The delivery of essential health services at all levels may be paralyzed, especially crucial as the country tries to recover from the socioeconomic consequences of the pandemic.
During this global health crisis, we must not forget that health workers are people with their own families and loved ones. They are individuals who have been reminded of their sworn duty to serve when everybody else had been ordered to stay home. Entire hospitals can be built in a matter of weeks, but to train a health worker takes years of commitment and sacrifice. If we truly believe that health workers are heroes, applause will never be enough. Let us act, and not just watch them die at the frontlines.
This essay was first published in CNN Philippines: Life.