The middle way
How the Philippines successfully navigated the Covid-19 pandemic
CLINICAL MATTERS
DR. EDSEL SALVANA
A recent report from China’s National Health Commission stated that nearly 60,000 Covid-19 related deaths occurred in the country between Dec 8, 2022 and Jan. 12, 2023. Of these, more than 5,000 succumbed from respiratory failure from Covid-19 and the rest had comorbid conditions, which contributed to their demise. To put things in perspective, the Philippines officially recorded under 66,000 deaths since the start of the pandemic. This is a per capita death rate, which is 130th in the world and several times lower than that of the US and most of Western Europe. Our relatively low number of Covid-19 deaths is a testament to the pragmatic choices our government and people made during the pandemic.
The pandemic responses of China and the US represent the extremes of Covid-19 country policies. The US resisted lockdowns, with very short periods of stay-in-place orders as well as mask mandates, which ended prematurely. Widespread vaccine hesitancy also meant that despite early availability and supply, the uptake of vaccines was not ideal, and booster uptake has been lackluster. All this resulted in the highest documented number of deaths due to the pandemic at over 1.1 million.
China, on the other hand, employed a heavy-handed and isolationist approach. This worked very well at the beginning of the pandemic and they were able to contain the spread of Covid-19 in their country with mass testing and isolation. Unfortunately, by the time highly transmissible variants like Delta and Omicron came along, these measures were no longer adequate. With very little natural infection, there was almost non-existent hybrid immunity. Hybrid immunity is the result of previous vaccination and breakthrough infection, which seems to protect against severe Covid-19 much better than vaccination or natural infection alone. When China suddenly lifted its restrictions partly as a result of increasing public outcry, infection rates soared with Omicron sublineages dominating. This quickly overwhelmed their health care system and we are seeing deaths in the tens of thousands because of this sudden reversal of policies.
To be fair, it is not expected that the Covid-19 death toll in China will be worse than that of the US. This is because there has been a decent amount of uptake of vaccination ever since these became available. Unfortunately, just like in most countries, boosting has been inadequate, especially in the elderly population. Available effective treatments against Covid-19 such as dexamethasone, remdesivir, and Paxlovid, however, can further decrease deaths. Many of the deaths in the US occurred among the unvaccinated population and this was exacerbated in the early part of the pandemic when there were still no effective interventions.
From an economic standpoint, both countries have suffered major setbacks in their financial standing. The US opened up much earlier and therefore its economy rebounded faster. The restrictions imposed by China not only slowed down its growth but had global consequences as the second largest economy in the world. This has significantly affected global trade and it is expected that even with reopening, the effects of the last two years of lockdowns will be felt for years to come. Even when China lifted the first local lockdown in Wuhan, their economy took a while to recover as people stayed away from physical interactions and did not leave their homes due to fear of infection. With China shut from the rest of the world, it had to rely mostly on domestic consumption and tourism to get by. These were frequently disrupted by precipitous lockdowns when new cases were detected.
For instance, Disneyland in Shanghai was suddenly shut down in October 2022 and people already inside the park were not allowed to leave for days. Shutting down cities with millions of people as a result of a handful of cases is not sustainable. Once the hypertransmissible variants like Delta and Omicron rendered mass testing, contact tracing, and quarantine ineffective, there was little justification to continue with these outdated and draconian policies.
The Philippines, with much fewer resources than either China or the US has performed better because of more pragmatic, science-based policies along with a healthy helping of serendipity. Our early and stringent lockdown was able to suppress the spread of Covid-19 in the first year when there were few therapeutic options and no vaccines available. A US-style pandemic in 2020 would have killed hundreds of thousands of people, given the population density in our crowded cities and the lack of health facilities. People readily wore masks and stayed home, which stymied the spread of the virus.
When the vaccines arrived, we used all the vaccine types available as long as there was a supply. Uptake was still good despite politically motivated attacks against Chinese vaccines and a clear preference among some sectors for mRNA brands. The use of multiple vaccine types with heterologous boosting (mixing two kinds of Covid-19 vaccines) proved to be more effective against the emerging variants and further tempered the Alpha, Beta, and Delta waves. Early boosting in December 2021 kept deaths from Omicron low despite a record surge in cases. Gradual risk-based relaxation of restrictions allowed the economy to recover. Continued mask mandates in the face of more transmissible variants meant that even with breakthrough infections, the amount of virus being transmitted was low and less likely to cause severe disease. This also built up hybrid immunity little by little without overwhelming the healthcare system. When mask mandates were finally lifted, people had gotten so used to wearing masks that most kept using them. As a result, despite the entry of new Omicron sublineages, the number of cases has remained low. Daily case numbers have not exceeded 1,000 in 2023 despite the lifting of the mask mandate.
The World Health Organization is meeting on Jan. 27, 2023 to decide whether to end the Covid-19 global public health emergency. With over 600 million documented cases and nearly seven million deaths and likely millions more left uncounted, the impact of Covid-19 on our world has been profound. Different countries had different responses according to their priorities and chose the pathway that was most acceptable for their people. No single country had a perfect response. Some countries that did quite well at the start eventually ended up with millions of cases when the new variants emerged. Some countries with relatively high cases at the start eventually found their footing and kept cases and deaths at a minimum. With the benefit of hindsight, it is clear that the Philippine Covid-19 response has succeeded in protecting the Filipino people from the worst of the virus. The government followed the advice of the health experts, and the people followed. Thanks to this science-based response and the inherent empathy of Filipinos in looking out for each other, we did okay.