Neglected for Years : Health Care: Philippine Crisis Looms

MANILA â€”  There was no room on the operating tables this week for 64-year-old Apolonia Ramos. So doctors performed her gastrectomy in the hallway of Manila’s Tondo General Hospital.

Tondo General is in the heart of one of Asia’s worst slums, two blocks away from Manila’s main garbage dump. There are no screens on the windows. Filth, soot and bacteria constantly blow into the hallway where Apolonia Ramos’ cancerous stomach lay gaping under the surgeon’s knife. And, because of shortages, the disposable surgical gloves that the doctor was wearing had been used and reused after they had been washed and hung up to dry in the same filthy air.

But it hardly mattered. When the surgeon found the tumor in Ramos’ stomach Monday morning, he realized that the cancer had spread too far for the woman to be saved.

No Doctors in Barrio

Like most unemployed, lower-class Filipinos, Ramos had not been to a physician in years. There are none in her poverty-stricken barrio. When the pain became unbearable, the only care available was at a government hospital, facilities generally so understaffed and poorly equipped that one American relief worker this week called them “the last step before the grave.�

That was true for Apolonia Ramos. The surgeon said she had only a few days to live.

Ramos was merely a single statistic in what is fast becoming one of the world’s worst--yet least-known--health and medical crises, a nightmare of needless death and chronic disease caused largely by two decades of manipulation, corruption and neglect under deposed President Ferdinand E. Marcos.

According to statistics gathered from the World Health Organization, the United Nations, Philippine government physicians and health officials and several international relief agencies working in the Philippines, tens of thousands of Filipinos die each year simply because there are too few hospitals, too few doctors, too little medical equipment and medicine and too little money to help the government cure its national disaster.

Declined Under Marcos

For years under Marcos, the nation’s health was gradually deteriorating into what has now become a seemingly insoluble crisis; yet the danger signs were not only ignored but deliberately hidden by a government determined to show the world that the nation was healthy and strong.

According to documents obtained by The Times and interviews with present and former political leaders, many of the national and local officials in the Marcos administration routinely diverted huge sums of government health-care funds to favorite or political projects.

“They just juggled the funds and then lied,� said Msgr. Antonio Y. Fortich, the bishop of Negros Island, where hundreds of children continue to starve to death each year despite millions of dollars in foreign aid that has been pumped into the island.

“In the Marcos regime,� Fortich said, “Marcos was very careful not to release the statistics regarding undernourished children. He (Marcos) told the international relief people, ‘Nobody is dying here of hunger, so it is better you send your aid money to other countries.’ �

Dr. Rodolfo Maceda, now the director of Tondo General and former vice chairman of a national nutritional council under Marcos, said that four years ago he sent First Lady Imelda Marcos a report showing that 20% of the children whom his council surveyed were severely undernourished.

“The next day, the first lady said, ‘No, it is only 2%,’ � Maceda recalled this week. “That was a signal that we had to be careful with the real statistics.

“During Marcos, there was censorship of our true health conditions. We were told not to show those things.�

Aquino Ordered Increases

Since President Corazon Aquino’s rise to power a year ago, though, she personally has lifted the lid on one of the nation’s best-kept secrets. Aquino ordered immediate increases in health department budget allocations, and appointed a professional secretary of health who is now struggling with still meager resources to re-equip and retrain the nation’s medical service.

In the recently approved national constitution drafted by Aquino’s handpicked commission, health is specified for the first time as a basic right of the people, and the government is bound by law to “instill health consciousness among them.�

The nation’s prognosis has slowly begun to improve. Tondo General, for example, which is built on a landfill and is sinking into the ground beneath it, has just received hundreds of thousands of dollars to relocate. Dozens of district and provincial hospitals nationwide have received money for the same purpose.

Health Problems Listed

But the true picture facing Aquino and her technically bankrupt government in the wake of those 20 years of statistical manipulation remains staggering. Here, based on studies and surveys by international aid agencies, private foundations and Philippine government figures, is just a glimpse of the nation’s critical condition:

-- Seventy-nine percent of all preschool children in the Philippines suffer from malnutrition.

-- Forty-four of every 1,000 Filipino babies die before the age of one, primarily because four-fifths of all babies here are delivered by unskilled hands in rural, unsanitary conditions.

-- Measles has reached epidemic proportions, killing thousands of children each month, yet the nation lacks both the vaccine and an effective delivery system to inoculate its largely rural population.

-- The Philippines has the highest incidence of whooping cough, diphtheria and rabies in the world, and the largest number of tuberculosis, schistosomiasis and polio cases in the Western Pacific.

-- A recent Asian Development Bank study showed that Filipinos have the lowest average food intake in Asia, lower even than that of Bangladesh.

-- The Philippines has the third-highest number of blind people in the world, most of the cases resulting from a deficiency of vitamin A.

-- Eighty percent of the population suffers from communicable, but preventable, diseases, and 43% of all deaths in the country could have been avoided if the patients had been given even the most basic medical care.

-- Yet, 62 of every 100 Filipinos who die each year do so without receiving any medical attention.

-- More than half of the nation’s 1,600 municipal districts do not have health centers or hospitals. Forty-six percent of all hospital beds in the nation are in Manila, where only 12% of the population lives. On the neglected southern island of Mindanao, for example, there is only one public health doctor for every 38,520 residents.

-- The regional, provincial and district hospitals that do exist are so poorly equipped that, statistically, some patients are safer staying away. A recent study at one rural hospital on Negros Island, for example, showed that its water supply was so polluted with fecal waste that patients grew sicker every day they stayed there.

Lacked Blood Bank

The medical director of the island’s largest hospital says that he could have saved at least half of the 1,368 people who died there last year if only he had a blood bank. Yet another Negros hospital is still using a 1930s-vintage X-ray machine so dangerous that one visiting American medical expert this week said, “That thing has probably caused more cases of breast cancer than it has diagnosed, just from the radiation.�

At every hospital visited by The Times during the past several months, though, medical directors said their biggest problems are not just inadequate equipment but understaffing--even though the Philippines has more medical schools and better trained doctors than most other Third World countries.

The explanation is contained in a recent study indicating that 68% of all Filipino doctors are living abroad, as are 80% of all Philippine-born nurses. The country ranks as the biggest exporter of nurses and second-biggest exporter of doctors in the world, according to figures released by a California-based hospital group this week.

Discussing the problem Monday with a team of 25 visiting American doctors and hospital administrators sponsored by the Los Angeles-based Hospital Council of Southern California, Aquino’s health secretary, Alfredo Bengzon, said it, too, has its roots in the Marcos administration.

A Marcos Legacy

“That is one of the unhappy legacies of the Marcos years,� Bengzon said. “You could put up a medical school with political connections. It was a political tool to get votes.�

But Bengzon added that the nation’s economy had deteriorated so badly under Marcos that government salaries for medical personnel were too low and regional facilities too few to keep Filipino doctors and nurses from emigrating to the United States, Hong Kong, Saudi Arabia and other countries where they would be paid far more.

Even today, the government can afford to pay its physicians at government hospitals nationwide just 3,000 pesos ($150) a month. And in many rural regions of the country, where a burgeoning Communist insurgency produces most of the hospitalized casualties, many doctors and nurses are simply afraid to work.

As a result, 17.8 million of the Philippines’ 57 million people do not have access to medical attention when they are sick.

Antonio Mabayag was a stark illustration of the problem.

Caught in Crossfire

Mabayag was shot and hit in the head last Dec. 17 by soldiers pursuing Communist rebels through his barrio in a remote region of Negros. He was one of the hundreds of civilian bystanders who are caught each year in the insurgency’s crossfire.

Mabayag’s 8-year-old son was killed that day, and he himself was left for dead. But his family noticed that Mabayag was still breathing. They rushed him to Negros’ regional hospital in the capital city of Bacolod.

A government physician examined him just once, the day he was admitted. The next day, he received a blood transfusion. But, despite the fact that he remained in the hospital for three more weeks, Mabayag got no more treatment.

He was scheduled for a second transfusion on Dec. 19, but the hospital staff was too busy and forgot. They forgot him the next day, and the day after, and every day after that. It was not until Jan. 5 that a nurse discovered the expiration date on a second bag of blood allocated to Mabayag days before. The date was Jan. 4.

During his entire stay at Negros Regional Hospital, Mabayag received only a constant stream of intravenous dextrose solution, even after he was well enough to eat and swallow medicine.

Demanded Explanation

On Jan. 9, still ill, scarred and angry, Mabayag finally asked a visiting team of independent health-care workers why he was in the hospital if the hospital was not caring for him.

“We told him there was absolutely no reason for him to be in there, and we got him discharged to his village, where we are caring for him when we can,� said Dr. Remy Ortaliz, the head of the independent health-care team.

“There are so many cases just like him, not only in Negros but all over the country. There just aren’t enough resources in the government to take care of our people.�

Ortaliz’s group, a volunteer, nonprofit organization, may well be the model for a short-term solution to the nation’s health-care crisis.

It is called Concern for Health, and all of its 33 members are upper-class doctors, nurses and concerned women of Negros society who travel at their own expense to the island’s most remote villages, where the government has not managed to reach.

The women, whom Bishop Fortich has nicknamed “the Valiant Women,� help to treat the sick. They dispense medicine that they buy with their own money, and they survey village elders about local medical needs.

Use Traditional Remedies

“Because they have no access to modern medicine, most of these people are using herbal medicines and acupuncture to treat their sick,� Ortaliz said. The so-called primitive medicine actually does work, she said, but the women are trying to deliver modern antibiotics and other drugs for more complex diseases such as tuberculosis, which is endemic in the villages.

But the Concern for Health group, whose members are close friends and relatives of prominent political and business leaders, has also become a powerful lobbying force for the villagers. It was through their pressure, for example, that the district hospital in the town of Himamaylan secured government money to replace its polluted water system.

The group also helped to secure millions of pesos from the government to pay for a major expansion of the regional hospital in Bacolod, and, through its lobbying efforts, helped to direct the Southern California medical team, which brought in 15 tons of donated medicine and equipment, to their provincial medical facilities.

The American team has been able to give immediate help. An American medical technician in the group toured one provincial hospital’s dental facilities, where all of the equipment dated back to the 1930s. None of it worked, and the chief dentist said the only service he provides his daily average of 60 patients is to pull out teeth.

Repaired Equipment

The technician spent the next two days repairing much of the equipment, and the dental room was fully operational for the first time in years.

Ortaliz’s group also directed the team to the hospital’s laboratory, where two of the three spectrometers had been out of order for months, as had the centrifuges and all but one of the microscopes. The team promised to try to find donated equipment in the United States to replace them.

But at one hospital that the team visited in the southern Negros city of Kabankalan, there were also signs of inequity in the Philippine medical-care system and of how politics has played a key role in it for years.

The tiny, 25-bed hospital actually was better equipped than the island’s 400-bed regional hospital in Bacolod.

A new, unused X-ray machine sat in a storage room, still in the crate that it had arrived in more than two years ago. The hospital has no space for an X-ray room. The machine came courtesy of a powerful national politician who served under Marcos; the same connection brought the hospital’s four microscopes, two of them still sealed in their original bags.

The hospital’s head nurse and its medical director both said the equipment will be used when the facility relocates in May to an abandoned resort hotel that it is converting into a hospital with the help of a $100,000 government grant.

Cites Examples of Waste

Health Secretary Bengzon, in his meeting with the American medical team, cited other examples of waste in the health-care system resulting from political deals under Marcos.

Among the most expensive examples overall, Bengzon said, has been a virtual monopoly on the supply of intravenous bottles, solutions and a wide variety of drugs that was signed with two private, multinational corporations during the Marcos years.

John Battaglia, a medical consultant from New Jersey who was among the visiting Americans, said he has investigated the arrangement. Among his discoveries, he said, was that, because of the monopoly, the Philippine government is buying hundreds of thousands of intravenous bottles for $2 each, items that Battaglia said cost 37.5 cents on the open market. Similarly, the government is locked into buying 2.5-cubic-centimeter syringes for 23 cents each, which Battaglia said can be bought for six cents.

“On the whole, I think the situation is very bad,� he said. “I think the people in this government now are dedicated. They just have nothing to work with. But there are a lot of ways they can do more with what little they’ve got, and I think they’re trying to do that now.�

A similar opinion was voiced by Sister Marie Therese Kholes, assistant administrator at St. Joseph Medical Center in Burbank.

After touring Tondo General and wincing as she watched Apolonia Ramos’ hallway operation, Sister Therese said, “I’m just amazed by how they survive; how they do so much with so little.�

Dr. Ortaliz was asked whether she still has hope for her nation’s ultimate recovery.

“You know, in the last nine months, a lot of improvement really has happened,� she replied. “Mostly, I think, the government has really recognized how great the problem is, and it has made a sincere commitment to solve it.�