How dire is the situation in this country compared to the rest of the world? As of August 14, 2020, the Philippines was 22nd in the list of countries with the highest number of COVID-19 cases throughout the world and it had the highest number of cases among members of the Association of Southeast Asian Nations, even though its population is less than half that of second placed Indonesia. 2 The Philippines also had the highest number of COVID-19 cases per million in the region, and the 14 th highest number of active cases as well as the 32 nd highest total number of deaths in the world. 3 Additionally, the country had the highest number of deaths per million population among Southeast Asian countries as of August 14, 2020. 4 In light of these statistics, it is quite frustrating that the Philippines could only manage to be ranked a lowly 128 th in the number of tests done per million population. 5 Perhaps this is partly due to the economic reality that the country's Gross Domestic Product at Purchasing Power Parity (PPP) per capita in 2017 was only $8,361 -rated 115th worldwide and only 6th among Southeast Asian countries. 6 The rankings using the above COVID-19 parameters have deteriorated even after the country was placed under the longest quarantine period in the world.
The prolonged lockdown is understood to be the reason why Filipinos are experiencing a "recession for the first time since the 1997-98
Asian financial crisis". 7 Before the pandemic started to show its effects in the country in January 2020, the unemployment rate was recorded at 5.3 percent. 8 It quickly rose to 17.7 percent in April 2020, meaning that there were 7.3 million Filipinos in the labor force who were out of a job -a record high for the country. 9
The impact of COVID-19 has been of such magnitude that social, cultural, economic, educational, political, and health institutions have been shaken. The steps taken to address this impact have forced the government to acquire loans since March this year amounting to US$ 6.8 billion, a figure that has worried economists because of what it means for the country's debt to GDP ratio. 10 As the government experiments with ways of jumpstarting a process of recovery for the Filipino people, we have to be very clear about the nature of the issues that we need to address as we put together initiatives based on a vision of the future that we can widely share.
This paper uses a fair allocation approach to identify and analyze ethical concerns arising in the context of the COVID-19 pandemic. Fair allocation is taken to refer to "arrangements that allow equal geographic, economic and cultural access to available services for all in equal need of care." 11 The arrangements can be systemic or politically driven; they can be the product of neglect or indifference. The approach shares the view that "all systematic differences in health between different socioeconomic groups within a country can be considered unfair and, therefore, classed as health inequities, [and these]. . . are directly or indirectly generated by social, economic and environmental factors and structurally influenced lifestyles. 12 While highlighting the existing access or lack of access in the context of very closely intertwined social and health indicators, this paper uses equity and equality interchangeably: "in the public health community the phrase social inequalities in health carries the same connotation of health differences that are unfair and unjust. 13 Hence, the paper's fair allocation approach examines the COVID-19 related events and response measures on the basis of the principle that the pandemic experiences cannot be seen in isolation as strictly health phenomena: "Health equity cannot be concerned only with health, seen in isolation. Rather it must come to grips with the larger issue of fairness and justice in social arrangements, including economic allocations . . . . Indeed, health equity as a consideration has an enormously wide reach and relevance." 14 This approach considers the impact of how health-related resources have been allocated or distributed and looks at the issues over a period that precedes the onset of the COVID-19 emergency and extends beyond the expected end of the current pandemic.
What this avoids is a narrower view that looks at the COVID-19 emergency as a disease-focused phenomenon that started with the transmission of the virus to humans and will end when a medical solution is discovered in the form of a cure for the disease or employment and fair wage, and economic aid. The difficulties often lie in terms of geographic, economic and cultural access. 16 The resources referred to are not readily recognized by non-medical people as having a huge impact on health although they have long been accepted as social determinants of vulnerability to diseases. 17, 18 It is perhaps for this reason that the lack -or unfair allocation -of pertinent resources has been insufficiently addressed or pushed down the priority order in government decision-making. This paper examines an extensive inventory of reported experiences and explores their consequences and ethical implications as they arise from the inequities. It also investigates the interconnected and overlapping health, educational, and cultural fronts in the development of the pandemic and the impact that these have on existing social and economic inequities.
By examining the way that pertinent resources are accessible to different stakeholders, a fair allocation approach highlights how closely the experiences of various socio-economic and political sectors are bound inextricably together. This is very useful because of the nature and character of the pandemic that we are going through.
In the context of the COVID-19 pandemic we are forced to accept that the kind of life that each sector of the country's population experiences is a function of the kind of life that every other sector is experiencing. During better times, we manage to live as if we have separate lives whose mutual and interdependent connections we can downplay or entirely overlook. This happens because the interconnection is not easily perceived even when it is comprehensively present. Perhaps it is partly because we have been conditioned to accept the inequities as an inescapable part of reality in a resource-challenged country.
The pandemic has put the interconnectivity among various sectors under the spotlight through the impact of SARS-CoV-2. By infecting more than 23 million people 19 of various demographics throughout the world, the virus has manifested its ability to penetrate barriers regardless of nationality, age, ethnic origin, or socio-economic circumstances. There is an undeniably real risk of acquiring infection regardless of who we are and what demographic category we belong to. Given the ease of transmission of the virus across the global population, no one can be left untouched by the pandemic's consequences. Even statistical outliers such as billionaires who can pass the time away in secluded vacation spots have to be dependent on other people who maintain their yachts, produce and prepare their food, look after their psychosocial and medical needs, and provide such other services as they might require during their prolonged period of seclusion.
The ability of these people to provide services can easily be affected by the pandemic. This paper proceeds by identifying specific inequities in the Philippines and beyond, exploring how these are being experienced in the context of the pandemic, and examining how problems are being addressed through specific measures in the evolving COVID-19 response. Each section focuses on an area of inequity and discusses the implications of measures being implemented not only for the short term but also for the post-pandemic period. The paper goes on to anticipate the ethical requirements for the post-pandemic new normal and to make broad recommendations for an ethical framework that ought to govern our transition to the new normal. facilities but also on a more general access to prevention and basic treatment.
If we begin to give thought to considerations of ethics and fairness only when we encounter shortages in the filling of prescriptions or the use of hospital facilities then we are likely to be acting merely to limit, or to make up for harm already inflicted on people because of their unmet healthcare needs. Our effort to respond justly to people's emergency health care needs may be too late already at that point. But, using timely preventive measures, or simply well-directed dissemination of information, health problems that send people to emergency rooms can be avoided in the first place. These can even be addressed much earlier by attending to social determinants of health. There is nothing new about this observation, but the reiteration is timely because the emergency we are facing makes it easier to focus on basic principles of public healthcare. The effort to promote healthcare fairness, guided by the principle of prioritization of the worst off, has to be planned across various stages leading up to emergencies. Steps taken to promote fairness at the time of an emergency can easily be a merely remedial measure that ought to have been preempted by proper allocation initiatives way before the existence of an emergency. This paper discusses the fairness of allocation measures in relation to the dispensing of adequate information, the provision of isolation and quarantine facilities, the availability of healthcare services and providers, and the criteria for triage in the hospital setting.
It is important for this paper's approach that healthcare is understood to be a two-way effort that involves people caring and people being cared for. This relationship between the "carer" and the "cared for" involves both parties thinking about the situation and making decisions together. The process stems from the autonomy of human beings or their right to self-determination. Patients in healthcare settings, as well as non-patients who are the intended beneficiaries of public health initiatives, simultaneously have the status of being cared for and being "carers." They are carers in the sense of having to be decision-makers insofar as the care that they need and deserve is concerned. By virtue of their being carers, they need to have access to information that may initially be available only to those who are regarded as having the primary role as carers (healthcare professionals and authorities). This means that information understandable to carers also has to be rendered understandable to the cared for. This is important in the context of public health and health promotion where healthcare providers may need reminding that dispensing care and information is an effort that they jointly carry out with the recipients. The pandemic emergency does not necessarily clothe them with authority to perform their tasks with arrogance and disdain for the ignorance and lack of medical sophistication that they may occasionally encounter in the cared for.
This also means that the perspective of the cared for has to be understood -and respected -by the carer. In this way, the cared for is afforded an opportunity to exercise self-determination. Strictly speaking, the cared for does not shift perspectives. What happens is that the perspective of the cared for is taken into consideration by the healthcare provider because the process of caring, on this account, is being done by the carer on behalf of the cared for. The carer and the cared for are partners in the activity. The relationship between them is not hierarchical but complementary, as healthcare providers or researchers need to be reminded when seeking informed consent from patients or research subjects.
In this section of the paper, the neglect of these principles, especially the prioritization of the worst off, in public healthcare decision-making is examined in relation to three problems within the Philippines in the context of the COVID-19 pandemic: paternalistic decision-making complicated by false information, failure to be mindful of literacy levels, and failure to account for language and other barriers. The first problem is paternalistic decision-making or deciding without consulting stakeholders. The Philippine government has needed to act swiftly to contain the spread of the disease. It has had to enforce quickly crafted rules that could not wait for extended rounds of consultations and confidence building. Quite understandably, the existence of a pandemic emergency compels decision-makers and government officials to act unequivocally and resolutely. However, emergencies also tend to trigger a highly paternalistic stance that can have the effect of reducing human beings to mere recipients of information. Failing to heed instructions for dealing with the pandemic, people may be shunted aside for being obstacles to the implementation of a necessary emergency response. Yet, firm and decisive action is not necessarily incompatible with a compassionate and lawful consideration for the rights of citizens regardless of their level of education and health literacy. Emergencies should inspire creativity in finding ways to implement laws and rules decisively without showing disrespect for fellow human beings who may not have the means or opportunity to understand the full import of new laws and rules.
The arrogant display of power by authorities under these circumstances reflects a paternalistic stance that can deteriorate into a disregard for the interests of the cared for whom they need to protect in the first place.
These paternalistic regulations can pertain to decisions to lock down communities without prior consultation or information dissemination, sending patients home even if they have COVID-19 symptoms without giving prior information about the treatment protocol, etc. For example, 21 persons from an urban poor community in Quezon City were arrested for violating rules enforced during the enhanced community quarantine (ECQ) that took effect in Quezon City in April 2020. Those arrested explained that they were given false information about the distribution of goods to people who could not go out because of the lockdown. Disappointed that the relief goods did not reach them, they wandered off to an area where distribution of relief goods was supposed to be taking place. The Philippine National Police rejected their explanation so they were arrested. Desperately needing food and cash, and possibly exposed to SARS-Cov-2, they were hauled off to jail and told that they were lawbreakers who could not be set free unless they posted bail. 23,24 In the aftermath they must have been more exposed to the infection that authorities should have protected them from. The fact that these people were misled into wandering off because of false information was bad enough. The real situation was made even worse because of the treatment that they got for actions motivated by desperation and ignorance. By acting decisively but with insufficient regard for individual sensitivities, authorities could be missing an important opportunity to process issues of fairness in the allocation of resources in the dispensing of full, accurate, and understandable information about the COVID-19 pandemic. Local media have reported situations reflecting a failure to appreciate pertinent information by people who have needed information the most but were probably not engaged in a meaningful conversation that considered their perspectives and vulnerabilities.
Paternalistic decision-making as illustrated here violates the equality between the carer and the cared for, in the carer (officers) failing to factor into decision-making the specific context of the cared for (those arrested). By not being sensitive to the situation of the economically deprived, the authorities failed to give due consideration to the interests of the worst off. In addition, the authorities may have failed to recognize their own deficiencies in disseminating accurate information in an effective and appropriate manner. com/2020/04/the-phili ppines-coron avirus-lockd own-is-becom ing-a-crack down/ studies abroad have shown that lower income groups have a harder time comprehending health information. 28, 29 There is a direct relationship between socioeconomic status and the level of health literacy. This is a reason why a lot of Filipinos have failed to grasp the full significance of the existence of the COVID-19 pandemic and the importance of cooperating with measures to control and limit its spread.
The failure to account for stakeholders' literacy levels violates the prioritization of the worst off. Understanding this specific context should result in the provision of more assistance to those in more need of health and educational services, not in the easy targeting for police apprehension.
Prioritization of the worst off should also apply to the removal of language barriers, the third decision-making problem addressed in in this section. In the Philippines, Filipino is the national language, and both Filipino and English are the official languages. However, as many as 186 languages are spoken in the country. 30 The OECD mentions in the 2018 PISA that: "Some 94% of 15-year-old students in the Philippines speak a language other than the test language (i.e. English) at home most of the time." 31 Notable efforts have been made by the University of the Philippines (UP) to translate English medical terms related to COVID-19 into the Filipino language. A UP professor, Eilene Antoinette Narvaez, has come up with a compendium of Filipino terms regarding COVID-19, and the university's Department of Linguistics is connecting community translators with one another across the country. 32 The UP College of Education has written a dictionary of COVID-19-related terms in both English and Filipino for children, and this dictionary contains links to videos of the Filipino sign language of the terms. 33 Apart from the language or dialect that is being used, the level and the manner of discourse is also important. Viewed as a matter of fair allocation, the dissemination of information has to be seen in these terms. Communication that is not carried out at the level of understanding pertinent to its divergent audiences or that is not cognizant of their specific information needs can only serve the interests of a select population and thereby contributes to inequity. This inequity arises especially because these divergent audiences are likely to be among the worst off financially and educationally, and deserve to be prioritized. In this country -as in many others -information infrastructures can be fully developed in affluent areas but not in others; access to interesting and high-quality information can be expensive; and training and equipment for the effective use of pertinent technology may not be equitably available." 34 While the capability of new information and communication technology to level the playing field for all citizens has been much heralded, it may also have the reverse effect of exacerbating existing inequalities if access is not widely distributed and benefits are merely integrated into already existing socioeconomic structures. 35
In addition to translation initiatives, telehealth practice illustrates what can be done to address an otherwise crippling lack of access to vital health-related information.
Advocates of telehealth have been taking the opportunity to highlight how the practice can help address inequities in access to health information and to healthcare more broadly. Even before the onset of the COVID-19 pandemic, they were already promoting the use of digital means to address healthcare issues faced by vulnerable sectors. Telehealth has been demonstrated to help close the gaps in healthcare service delivery as a way of ensuring that national health- has certainly accelerated the acceptance of telehealth as a means to improve healthcare. Aside from providing healthcare access to remote patients, the practice of telehealth has served to limit physical contact in order to reduce the risk of contracting COVID-19.
Physicians who previously disliked the use of technology and preferred face to face consultations are now forced to "see" patients remotely. The tide has started to turn and this appears to have happened also in other countries. 44 Multiple studies have shown how telemedicine has enhanced health service delivery. 45, 46, 47 Even before launching the COVID-19 telemedicine hotline, the DOH already launched multiple telehealth initiatives: a non-COVID-19 clinical Helpdesk (through hotlines), email, and chat (including a DOH internet-based messaging app group that is open to lay people and another group for health care workers). 48 Physicians Offer Free Services to Decongest Hospitals. One News. Retrieved July 27, 2020, from https://www.onene ws.ph/the-doctor-is-online-physi cians-offer-free-servi ces-to-decon gest-hospi tals at PGH. The RxBox is now being developed to have telemetry capability, which means being able to connect with a dashboard at the nurses' station where vital signs can be read. The device therefore allows for remote monitoring that minimizes risks associated with the proximity of healthcare workers to patients with communicable diseases. The installation of 100 RxBox devices at PGH as a response to the COVID-19 pandemic will significantly improve access by people in remote locations to health care and information. 53, 54 Another initiative under the UP College of Medicine's Surgical Innovation and Biotechnology Laboratory (SIBOL) in cooperation with UP Diliman's Electrical and Electronics Engineering Institute is a "telepresence" device, a computer programmed to automatically answer calls from authorized accounts using available teleconferencing and remote-control applications, minimizing contamination and allowing effortless access even by patients with no technological know-how. 55 Like the RxBox, a "telepresence" device allows healthcare workers and patients to communicate with each other without need for face to face contact. 56 This paper notes the use of telehealth devices for healthcare providers to listen to stakeholders and not merely to observe them and implement programs without consultation, as we reiterate the view that caring is a two-way exercise.
Measures responding to the pandemic have to maintain and enhance the two-way conversation between the carer and the cared for.
It has significantly improved the quality of delivery by overcoming geographic barriers, increasing accessibility and efficiency by reducing the need to travel, providing clinical support, offering access through multiple platforms that patients can easily connect with, and ultimately improving patient health outcomes. 57 The current pandemic has hopefully provided an irreversible inertia for the DOH and other healthcare authorities and stakeholders to accelerate their preparedness and capability to respond to pandemics and disasters not only in the short term but also in the foreseeable future. This approach can be possible by focusing on removing barriers to inequitable access to healthcare communication and other healthcare resources, an important strategy in support of the prioritization of the worst off.
Paradoxically, the use of telehealth to address one kind of need highlights a problem of another kind. This has to do with healthcare being essentially an expression of closeness, of solidarity, and of removing physical and emotional barriers to well-being. 58,59,60 Thus, we have seen how family members have bemoaned their inability to be close to their loved ones who are being administered critical (possibly end of life) care. 61,62 Physical distancing appears to be antithetical to human beings' emotional closeness. 63,64 But this is another issue that is beyond the scope of this paper. The physical availability of health care workers is a related concern that the next section deals with.
The toll that the COVID-19 pandemic has taken on the country's To keep up with the continuing requirements for HRH, emergency hiring has been going on at a frenetic pace, sometimes to the extent of including interns who still lack the experience that would otherwise have been necessary. 70 As part of COVID-19 measures, the DOH issued a call for volunteer doctors and nurses in three state hospitals. In response, almost 600 Filipino doctors and nurses volunteered regardless of experience and readiness to address the needs in stations for which they have not been thoroughly prepared. 71 This has also been going on in other countries that are more economically endowed. 72,73,74 Here, we are made to wonder how this could be happening when, for many years, the Philippines has, in effect, accepted the responsibility of providing care to patients in other countries by encouraging the migration of its own healthcare professionals. This encouragement can be seen in the country creating bureaucratic institutions and promoting legislation to facilitate labor migration since the 1970s. 75,76 The long-standing dilemma was highlighted again recently when public officials themselves debated a proposal to allow Filipino healthcare workers to leave for abroad in the midst of the pandemic. 77,78 Eventually, a decision was reached to allow the departure of those who already had legally binding contractual obligations but to temporarily prevent others from entering into new contracts to work abroad. 79,80 More recently, the DOH authorized the recruitment of fresh medical graduates to work as deputized physicians without having to pass medical board examinations. 81 Clearly, the measures described in this section to address the lack of HRH in the context of the COVID-19 emergency are intended to be in place temporarily. Emergency healthcare staff are being recruited to work only during the period of the pandemic under contracts lasting only for 3 months. 82 The ban on deployment of HRH to foreign countries will be lifted as soon as the pandemic subsides. disasters for the next epidemic. We know that we need to allocate societal resources for housing fairly to avoid this. If we do not realize how inequities have aggravated our public healthcare situation in the context of the current pandemic, we will not learn our lesson ever.
In order to accommodate the rising number of persons needing isolation and quarantine facilities, the national government has coordinated with local governments and the private sector in converting hotels, sports facilities, school buildings, and churches into temporary quarantine sites. 96 The facilities are meant to accommodate asymptomatic or mildly symptomatic patients who are either homeless or whose dwelling units do not have enough spaces to allow isolation.
The temporary facilities may suffice for now, but certainly not for the near future. These facilities will be eventually returned to their original use; a more sustainable and long-term solution must be developed. It is about time we realized that the need for safe and healthy housing for all is a concern not only for the economically challenged but also for every other member of the community. In times of pandemic emergencies, anyone and everyone can be affected by the lack of safe and healthy housing suffered by disadvantaged sectors of society. When people get infected by a highly contagious virus and they have no safe isolation space to which they can withdraw, everybody else can be adversely affected as they radiate beyond their household. In a world of interconnected and interrelated human beings, anyone's virus has the potential to infect everybody else.
The need for numerous safe isolation or quarantine facilities brings attention to how easily the SARS-CoV-2 virus can spread; one measure for this parameter is the basic reproduction number. The basic reproduction number or basic reproductive number (R 0 ) of a disease indicates the number of people that an initially infected person will transmit the infection to assuming no one yet in the population is immune to the disease. 113 On March 6, 2020, the WHO reported a reproductive number of 2 to 2.5. 114 Another estimate put COVID-19's R 0 at around 3.28 based on figures from different regions in China and overseas. 115 To make sense of R 0 , for instance the 3.28 figure, one person who has COVID-19 will infect around three people with COVID-19; total cases are now four. Each of these three newly infected will also infect three more, adding nine new cases to the previous total of four. Each of the nine new cases will infect three, and so on.
From these numbers, one can make sense of how COVID-19 is said to have exponential growth, seen internationally 116 and in the Philippines 117 . With exponential growth, as more people get infected, the faster will be the rate of new infections occurring. This growth rate is opposed to a linear growth rate where the rate of new infections occurring stays the same over time. From this picture, we can understand how quickly an entire population can be infected.
As a note of comparison, on March 3 of this year, the WHO announced COVID-19's global mortality rate of 3.4%, more than 3 times higher than that reported for seasonal flu's 1%. 118 We have seen how quickly seasonal influenza can be passed on from one person to another and these reproductive numbers are up to more than 3 times higher than that for seasonal influenza's 1.3. 119 because if they succumbed to the virus the food chain could break.
As such, farmers, fisherfolk, food delivery workers, cashiers, grocery baggers, and customer care staff have been hailed as frontliners and heroes. 120,121,122,123,124 Indeed, some people who have lived in near complete isolation have become infected even though they have been minimally exposed to such frontliners. 125 As more people get infected, fewer and fewer safe spaces are left. This is a message that we get from the experiences in almost every community, but especially in high-density spaces such as crowded informal settlements, prisons, workplaces, public transport facilities, supermarkets, or even hospitals. Hence, we are not merely talking about interconnectivity of humans in an abstract sense that is more closely associated with philosophical discourse on concepts such as human dignity or the sanctity of human life in various contexts. We are referring to the physical interconnectivity that gives rise to concrete disease and deprivation that has affected more people with various kinds of social living conditions. We can easily take this for granted in the absence of a pandemic. But recent events have caused an alarming prevalence of the virus and its effects on society.
The interconnectedness of people of varying socio-economic standing as highlighted by the pandemic reinforces the view that inequality needs to be reduced and prioritization of the worst off must be observed in order to achieve the best outcomes. By giving more help to those who are more in need we move in the direction of achieving the best outcomes for more people.
The impact of interconnectedness and interdependence has been felt also in relation to the increased demand for hospital facilities.
In an archipelagic country composed of 17 regions across more than 7,000 islands, healthcare facilities are unevenly distributed. In 2018, around two thirds of hospital beds in the Philippines were in one area, the National Capital Region. 126 The problem of physical As public hospitals become congested, some patients have been forced to consider confinement in private hospitals. But this is a privilege that very few could afford. One patient's bill for a 16-day stay at a private hospital totaled PHP 3 million or around USD 59,000, which is about equivalent to a middle-class Filipino worker's salary for 3 years. 134 An estimate for a private hospital bill for a moderate COVID-19 case amounts to at least PHP 1 million or a little under USD 20,000. 135 To address these financial concerns, the Philippine Health Insurance Corporation (PhilHealth) has come out with new policies for at least partial coverage of COVID-19 cases. 136 The problem with PhilHealth is not everyone is able to use it. In The situation in hospitals is further complicated by issues whose underlying roots are not so easy to explain. A person under investigation for having COVID-19 escaped from a private hospital where he or she was being observed. 144 An overseas Filipino worker with COVID-19 symptoms also escaped from a hospital to probably go back to work abroad. 145 Another patient who tested positive for the SARS-CoV-2 virus escaped by jumping from a hospital window after she was not given permission to go home. 146 Expenses or space limitations are possible explanations but the exact reasons why these quarantined patients have tried to escape need to be probed further. Of course, the reasons may have to do with things that are not unique to hospitals.
For instance, socio-economic conditions characterized by inequity and a lack of safety nets for the worst off may compel patients to ignore their health and avoid long hospitalizations so they can continue to try to make a living for themselves and their families.
As earlier noted, the fair allocation of critical care resources is a concern that arises way before the need to prioritize patients arises about these factors helps one decide which treatment alternatives suit one's financial capability. To be able to fully understand these factors, people need to be functionally literate and to have a minimum level of health literacy. As we address these issues during the pandemic, it should be clear to us that these are also long-standing concerns that have been waiting for durable solutions. Only durable solutions can help us maintain emergency readiness over the long term. In the meantime, during the COVID-19 pandemic, guaranteeing fair access is necessary. One way for authorities to do this is to uphold fair allocation principles in the various areas taken up so far, as well as in emergency critical care. Ethics and COVID-19 distinguishes three levels of scarcity and their corresponding effects on the fair allocation of resources like ventilators: first, with little scarcity, first come, first served may be best for equality; second, with more scarcity, the prioritization of the worst off may be best; and third, "with even greater scarcity, a principle that aims to maximize benefit from the resource may be most justified." 152 Of interest in this section is the scarcest level. In extreme situations where there are simply not enough resources to accommodate everyone in need, giving protection to the vulnerable could take a backseat as medical vulnerability, in the sense of having comorbidities, could be seen to indicate futility of critical care that includes ventilatory support. An early study showed that for COVID-19, the Case Fatality Rate (CFR) was elevated among those with preexisting comorbid conditions such as cardiovascular disease, diabetes, chronic respiratory disease, hypertension, and cancer. 153 Another study of laboratory-confirmed cases of COVID-19 showed that "patients with any comorbidity yielded poorer clinical outcomes than those without" and "a greater number of comorbidities also correlated with poorer clinical outcomes." 154 Moreover, "persons with underlying chronic illnesses are more likely to contract the virus and become severely ill, . . underlying conditions compared with those without reported underlying conditions (19.5% versus 1.6%). 159 Research findings such as these resulted in elderly patients being refused ventilatory support in Italy. 160 The Independent reported that a doctor gave an account of medics being forced to ration care to patients in the wake of the COVID-19 outbreak such that elderly patients were being denied care based on their age and whether they had other conditions or not: "In Bologna, we are working with 80-years-old as our cut off, but between 65 and 80-years-old we still consider comorbidities." 161
There are similar accounts pertaining to Sweden's Karolinska Institute. 162, 163 Yet, the acceptance of advanced age in itself as an indicator of medical futility has to be conclusively established by evidence.
Statistical findings of high mortality rates among patients belonging to the highest age groups can merely be reiterative of the high mortality rates among patients with comorbidities --elderly patients have a higher likelihood of having more comorbidities. If we overlook this point, the elderly could be exposed to unfair allocation of resources based simply on their age rather than on their having comorbidities that leave them with poor chances of surviving with the use of critical care devices. 164 As George Kuchel asserts, "having multiple chronic diseases and frailty is in many ways as or more important than chronological age" and "an 80-year-old who is otherwise healthy and not frail might be more resilient in fighting off infection than a 60-year-old with many chronic conditions." 165 In addition, recent studies have generated optimism about the success of measures to delay or minimize age-related immunological defects. 166 Admittedly, age serves as a useful indicator of the presence of comorbidities that the elderly are likely to have. However, the studies about chronological age and immunological developments cited above indicate that statistical correlation should not necessarily be taken to mean causal correlation. For this reason, age by itself should not be regarded as a valid basis for short-term triage decision-making. In the absence of validated empirical proof that a particular age level indicates the medical futility of applying scarce critical care resources, the vulnerability of patients that is associated with advanced age should instead signify a need for them to be given pro- 
Everybody is hoping that solutions will soon emerge that can facilitate quick recovery and help individuals and families resume stable lives. Solutions being offered are expected to give rise to a new normal. Even when the government decides that the economic consequences are too much to bear for COVID-19 quarantine arrangements to continue, we cannot go back to the state of affairs that had to be suspended because of the emergency. We should now realize that we cannot just revive the suspended state.
Epidemiologists tell us that the COVID-19 pandemic will be with us far longer than we may have expected. While many studies on possible treatments or vaccines are being rushed, it has been observed that the progression of past influenza pandemics "was not substantially influenced by a vaccination campaign." 167 Bill Gates has declared a plan to spend billions of dollars to build seven vaccine factories simultaneously while research is still going on in order to hasten the process of development but this extremely expensive initiative is not estimated to bring us closer than 18 months to vaccine implementation. 168 While we are still waiting for a vaccine, we can only count on non-pharmaceutical interventions (NPIs) to limit SARS-CoV-2 transmission. This makes it necessary to continue with physical distancing and isolation measures for at least 2 years. 169 Even worse, we are reminded that "our record for developing an entirely new vaccine is at least four years -more time than the public or the economy can tolerate social-distancing orders." 170 We appear to be playing a waiting game where the cards are stacked against us.
According to studies, the pandemic is not likely to be under control until 55 to 70% of the population is immune, which has been estimated to be the threshold for acquiring herd immunity in the case of the current COVID-19 infection. 171, 172 If so, this outbreak may take 18 to 24 months. 173 But there are even warnings that herd immunity may not work because of uncertainty concerning the duration of individual immunity to SARS-CoV-2 and the low seroconversion rates even in huge populations known to be COVID-19 hotspots. 174 For instance, a study of 61,075 participants in Spain showed that only 5% developed antibodies. 175 Seroconversion rates were all less than 4% for various subpopulations among 17,368 participants in China. 176 These rates mean that a huge percentage of the population remains at risk for infection despite all the damage from the pandemic. Relying too much on the emergence of natural herd immunity will possibly just increase this damage.
In light of these considerations, there have been many predictions of what we are likely to see in a new normal --wearing a face mask becoming routine, an occasional cough being regarded as a threat, workplaces feeling like hot zones, and public transit being personally dangerous. 177 We can anticipate less travel, disruptions to consumer supply chains, social anxiety, heightened agoraphobia and, overall, greater mistrust in one another. 178 As a corollary to physical distancing, digital interconnection is going to be intensified. We have seen this already in the accelerated shift to phone and internet banking, 179 in the move from dine-in to take-out and delivery modes of restaurant food consumption, 180 in the spike of online shopping activities, 181 and even in the accommodation of online religious worship. 182 In the Philippines, religious services have been broadcast through social media while physical attendance in places of worship has been limited to a handful. 183 A similar trend is going to be part of the new normal for many aspects of healthcare. We have seen how telehealth has taken on an increased role in the country. Telehealth can play a huge role in the new normal and we should make it happen.
Realistic estimates of how long it will take before we can have a vaccine, if possible at all, together with real concerns about the possibility that other infectious diseases (or global disasters) could come and endanger global health security, impress upon us that the radical changes in our way of life are going to persist even beyond the development of a COVID-19 vaccine. A new normal has begun to set in. The new normal is a sum total of the things that we can do as a departure from what we could do before the pandemic, the new things that we have to learn to do and the new ways in which we have to do these things, the political and cultural structures that are developing, and in general, the ways in which we will have to live our lives because of the challenges that have confronted us and are likely to continue to confront us. The new normal also refers to the period in which citizens are expected to become accustomed to the emerging state of things.
As we transition to the new normal and address the challenges that are coming our way, we have to remember that our ability to overcome the problems confronting us during the pandemic has been premised on the equitable sharing of resources. The efforts being exerted to contain the COVID-19 pandemic in the Philippines are being focused on addressing manifestations of underlying inequities -though that is perhaps happening more coincidentally than deliberately, and many efforts have been highly problematic and insufficient as pointed out in this paper. Because the insufficient efforts have been triggered by the existence of an emergency, most of the response measures are meant to be temporary. People on the brink of starvation have been receiving emergency food aid, and those with no financial savings have been receiving cash assistance.
However, these efforts have neither been fully successful nor sustainable. 184,185,186 Those who could not be isolated or quarantined have been evacuated, but these evacuation facilities are also temporary and the occupants are going to be reinstated in their cramped dwellings that cannot protect them from new transmissions or other communicable diseases in the future. If the inequities continue in the new normal, the normal is not going to be really new. The vulnerable are going to remain vulnerable and Philippine society will not be more prepared for the next pandemic.
Clearly, the lesson is that everyone, especially the most economically disadvantaged, need to have access to the resources that relate to their healthcare, inter alia, -adequate and accurate information so they can be properly advised about their healthcare needs; clean flowing water so they can wash their hands properly; and dwelling units that will give them the capability to be isolated from neighbours or from household members who can be infected. In support of these necessities, they will require employment opportunities that can yield fair wages or other opportunities to generate adequate income, and social and health insurance coverage that they can fall back on in times of need.
Subject to certain logistical limitations, the Philippine government has seen the indispensability of temporarily providing the required resources to disadvantaged sectors. However, a lot more needs to be done. The distribution of resources has to proceed in a way that transcends the long-standing barriers associated with structural social inequities. Sustained fair allocation founded on equality, equity, and the prioritization of the worst off is indispensable.
Sustainability is critical because, as has been pointed out, the problems that need to be addressed are chronic pre-pandemic inequities that are being magnified by the health emergency.
There is evidence that the need to improve the plight of the resource challenged has been partially acknowledged by the more economically advantaged sectors of Philippine society. Small and big business companies in the Philippines have made huge contributions to help provide for their emergency needs. The private sector has supported the national government, local government units, and the general population by providing wages to employees who could not work, monetary assistance, relaxed working conditions, emergency transportation, food products, ventilators, test kits, Personal Protective Equipment, and many other goods and services that can help everyone overcome the current crisis. 187 Beyond this, these privileged sectors have to realize that what they have helped provide during the emergency is something that needs to be available in the long term and institutionalized for society to survive future pandemics and for their businesses to continue to thrive. Institutionalization requires arrangements that would provide realistic opportunities for disadvantaged sectors to acquire the goods and services that they need beyond the period of the current emergency.
As we transition to the new normal the most economically deprived should seize the opportunity to establish how important the improvement of their situation is in order for the current widespread problems to be properly addressed. While disadvantaged sectors continue to be dependent on others because of their vulnerability, society should seek to translate the realization that the health and security of the more privileged is dependent on the health and security of everybody else in society into sustainable measures to improve the conditions of the worst off and narrow the gaps between its most endowed and least endowed sectors.
In the new normal, there must be institutionalized safety nets that can be accessed when things go wrong. People should not have to beg and fight for places in dignity-sapping queues for the distribution of emergency social amelioration funds --these should be available to
them as a matter of right. People should not have to be rushed to temporary isolation and quarantine places -prioritizing the concerns of the worst off is essential for the improvement of everybody's health. To provide them with home spaces that will enable them to care for the sick while still protecting themselves also advances the health interests of everybody else in the country. This reality acquires an unprecedented level of concreteness in the context of a pandemic such as the one that we are currently experiencing. In the new normal, those who require medical attention should be protected by universal healthcare; we ought to realize that "those in the greatest need often have the poorest access to care -a striking example of unfairness." 188 Very importantly, people should know all of these, what to do and where to go when they require services because, in the new normal, information will have to be dispensed efficiently and equitably regardless of the people's level of understanding.
We see the entirety of the telehealth movement as a paradigm of how response measures ought to be characterized. It uses advanced technology to promote access by the underprivileged to the most important healthcare services. It listens to patients and gives them an opportunity to participate in their own care. What it is trying to do in the course of the current pandemic is something that is only a part of what it should aim to accomplish in the long term. Thus, it should be part of a sustained effort that can have a good chance to narrow the gap between the economically privileged and the economically challenged. It exists in sharp contrast with measures meant to address the lack of isolation spaces in many people's dwellings. The isolation and quarantine facilities that have been set up are clearly temporary facilities that cannot be retained beyond the period of the emergency. The people currently using them will be going back to their informal settlements without any prospects of having their living conditions improved.
Learning from these comparisons, we see the need to observe a number of criteria for evaluating COVID-19 response options consistent with the principles of equality, equity and the prioritization of the worst off: The short-term efforts exerted to contain the pandemic have to be aimed at addressing the inequities. Having existed for a long time, these inequities deserve everyone's attention not only during the pandemic but also when we emerge from it. This glaring reality may have been overlooked as authorities focus on the short term and see the measures as a requirement to tide us over until we can go back to normal. Thus, addressing the manifestations of the inequities has happened incidentally rather than deliberately, using stop-gap rather than long-term measures.
Yet, what we are going through now is not merely a fleeting disaster but an instantiation of chronic injustice characterized by inequities on many fronts. The totality of our experiences relating to the pandemic constitutes evidence that the inequitable access to essential goods and services needs to be overcome -not only for the sake of the underprivileged but also for the sake of everybody else regardless of economic, political, or social status. What is being asked of us is not merely to provide for people's needs during an emergency but to manifest our realization that fellow 