We can’t make the same mistakes
CLINICAL MATTERS
The Covid-19 pandemic laid bare the inadequacies of our country in tackling a highly virulent new pathogen. Most countries were caught flatfooted, and even the venerable United States Centers for Disease Control and Prevention (CDC) was unable to prevent over one million deaths among Americans. So why is there a lot of talk about setting up a CDC for the Philippines? Did we not do better than the US and many other countries despite our limited resources?
It isn’t just an issue of whether we did okay. Our deaths of about 61,000 and nearly 3.9 million confirmed Covid-19 cases are modest, especially when taken at a population level. Our fatalities per million (34,408 cases/million, 152nd in the world) and deaths per million (548 deaths/million, 128th in world) are many times lower than much more advanced countries.
It is also true, however, that our economy is in tatters and there was a lot of misinformation that could have been better addressed. Several senators and congressmen have now proposed the creation of a Philippine CDC, something which many of us in the infectious diseases and public health fields have been pushing for years. Unfortunately, the current proposals may be attempting to replicate the US CDC as an institution, even as the current CDC director Dr. Rochelle Walensky is calling for its reorganization following its dismal performance during the pandemic.
It is useful to look at what a CDC is and what it is not. A CDC, first and foremost, is a public health institution. This means that its mandate is to generate and implement policies that safeguard people’s health. This requires expertise in epidemiology, statistics, diagnostics, disease modeling, health policy, and operations research. The US CDC started out as a malaria control program that morphed into a communicable diseases program, and eventually into its present state, which now includes non-communicable diseases. It is also considered a federal uniformed service with a commissioned corps, with police-like powers to implement quarantine and isolation.
While some parts of the US CDC setup are desirable for a good pandemic response, it should only be a partial template for a Philippine CDC. The last thing we need is more bureaucratic bloat. Replicating the current structure of the CDC in the US will just bring the same problems that it is experiencing, adding to the inefficiencies of our healthcare system rather than improving it.
Looking at the Philippine Covid-19 pandemic response, the putative functions of the CDC were spread out and shared across different government agencies. The DOH Epidemiology Bureau had the epidemiologic and public health policy functions along with the LGU Epidemiology Surveillance Units (RESUs, PESUs, CESUs, and MESUs). DILG, LGUs, and the PNP had the police powers. Health policy advice and clinical practice guidelines were generated through an All-Experts Group constituted by the DOH, which included the Technical Advisory Group who were sourced from the academe and professional societies. Operations research was conducted by the Research Institute for Tropical Medicine. Overall, the IATF-EID and its component departments set policy while and the National Task Force against Covid-19 (NTF) implemented these policies.
While all these bodies were able to perform their jobs with varying degrees of success, there were a lot of growing pains as policy had to be generated on the fly. Some agencies had duplicate functions, while other tasks were not clearly assigned. There was a lot of inefficiency and miscommunication. Even though many of the problems were eventually overcome, it would be a grave error not to institutionalize the lessons learned into an agency that can coordinate and plan for future pandemics.
A Philippine CDC should be defined by its objectives to prepare and be ready to respond to outbreaks and pandemics. Noncommunicable diseases can stay with the DOH, especially with the implementation of the Universal Healthcare Law. LGUs can retain police powers since it would be very impractical to set up a commissioned corps like that in the US.
A Philippine CDC in my opinion should be focused on communicable diseases, with quick response powers for emerging outbreaks and pandemics. Since infectious diseases multiply exponentially, early interventions result in many, many more lives saved. The IATF decision to lock down early saved at least 200,000 lives. It was fortunate that we were able to convince the Philippine government to lock down with only 52 emergent cases. The unprecedented decision was a serendipitous result of experts and academics having the ear of the DOH secretary, the Cabinet, and the President. Some of the major issues that got in the way of implementation were the novelty of the virus as well as rampant misinformation and disinformation. There was also a lot of partisan politics, which unfortunately led to sometimes unreasonable accusations and grandstanding even as policy was being made in real time.
The Philippine response was still successful despite all these setbacks. It could have been even better, however, if mechanisms were in place to anticipate problems, insulate healthcare experts from politics, and ensure that nonpartisan, science-based policies are crafted with little interference and with the full support of the highest levels of government.
With these parameters in mind, a Philippine CDC led by an executive director should have the ear of the President and the secretary of the Department of Health. One of the major strengths of our pandemic response is that the Technical Advisory Group sat in with the IATF-EID, was regularly consulted by the DOH secretary, and was asked to regularly brief the President. This ensured that the latest scientific evidence informed the most crucial decisions being made. Similar to the Philippine General Hospital, a Philippine CDC should be attached to the Office of the President, with its own yearly budget. It may need contingency funds for outbreaks, especially for essential medicines, PPE, and equipment. Since experts are needed to vet and formulate policies, housing it in an academic institution like the University of the Philippines will be synergistic with its public health goals. Like the Philippine National Institutes of Health, which is the national health research institution of the Philippines, a Philippine CDC can draw upon the expertise of professors at the UP College of Public Health, the NIH, and the UP College of Medicine in partnership with the Department of Health. Faculty and experts from other universities and institutions will also be essential to these functions and can be incorporated in the final plans. Communication experts will be needed to ensure accurate and timely public messaging. Many such experts are already engaged with DOH and can be incorporated into the organizational framework. These suggestions are by no means exhaustive or final, but it is important to focus on the interventions that will save the most lives and avoid inefficiencies.
The pandemic has shown us how a single novel virus can completely transform our lives. It is very important to prepare for forthcoming infectious threats. With hope, a Philippine CDC will do the job and save more lives in the future. It is essential that we get this right.