Case studies

In medical school, one of our first activities was an analysis of a case study called “Ang Kuwento ni Rosario,” which is used by health groups and educators in teaching the social determinants of health. It was a short narrative about a poor family, led by a father making P165 a day, and his wife Lucy. All four children were malnourished and had intestinal worms. Lucy, told by her doctor that she should not breastfeed, had been feeding her youngest with woefully diluted formula milk. Two children were not vaccinated.

One day, Rosario, the youngest, came down with measles. The rest of the story is about Rosario’s parents’ journey in seeking health care only to be met by difficulties and hard decisions—lack of available medications in the barangay health center, expensive medicine, and later the shattering expense of a hospital stay for Rosario, which caused her parents to bring her home against medical advice. She died at home.

The last line went: Why did Rosario die?

Was there any one factor that caused her death? Was it her socioeconomic status and her father’s income? Was it malnutrition, caused in part by wrong health education given to her mother? Was it the fault of the local government unit which did not have resources to manage her, or the national government which failed to equip its local health centers and hospitals? Was it all of these things?

The chief priority in educating us, young doctors and health professionals of the state university, was to cultivate an understanding, not of anatomy, physiology, or biochemistry, but of the flawed health system into which we would be entering, and of the need to identify and serve the underserved. It was a leveling of expectations, an introduction to sober realities. Our understanding of the lesson grew as the failures, new and old, of our government and existing systems became more apparent, persistent road blocks in achieving the optimal health outcomes that we heard so much about in our readings, but which could be impossible for those at the fringes of society.

The ideal treatment for cases of acute appendicitis, we were told, was urgent surgery, but we watched patients wait for days because of the sheer number of equally urgent cases that came before them, and their own difficulty in accessing health care closer to home. We advised new mothers about optimal nutrition and vaccines, though we knew their families could barely eat and one day off work for a check-up meant no income for the day. In our minds, the words “In an ideal set up…” became appended to the beginning of any diagnosis or management. We were not the ones deciding who lived or died; more often, the circumstances decided for our patients.

Why did our patients die? On our reports we wrote only their diagnoses, because there was no room for the entire web of ways in which their circumstances had failed them, and how much those circumstances were shaped by money, power, and all the myriad things beyond their control at national and local levels.

Two days ago, one of our own died as a casualty of the COVID-19 pandemic. (As of this writing, two have since followed.) Tributes and cries for justice ring out across social media. Even those of us who did not know him mourn the loss of a young doctor, one who was just doing his job amid a national situation that was handled so poorly by those who had the ability to impact the situation the most.

I do not mean to reduce this young colleague’s life and work, as well as the lives of other casualties of COVID-19, to a political issue. But in the future, on the other side of this pandemic, I hope that the groups that matter will be able to sit down and ask: Why did he die? Why did the others die? Was it because patients lied about their travel history (as social media keeps repeating)? Was it because of failed and late reactions to the building international emergency? Was it the pre-existing health system where health has been a privilege and not a right? And I hope that asking the question won’t be a mere exercise, but the impetus for a million badly needed changes.

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