Wrapping Up

I'm back in Manila for my final week here in the Philippines. We have debriefing presentations scheduled with the WHO Country and Western Pacific Regional Offices, as well as with our counterparts at the Department of Health and the National Epidemiology Center, and have the rest of the week to wrap up final reports and administrative details before heading home. It's astonishing to think that three months have already passed. It seems at once lightning fast, and also that I have been here forever. I am looking forward to returning to (late) Spring, long bike rides, the farmer's market near my house, and of course to life with Ryan. That said, this has been an extraordinary learning opportunity, and I'm thankful for the experience. I've seen and done quite a lot here.

We finished up the field work portion of the STOP assignment mid-month. I visited health centers and rural health units in four regions over the past few months, so I feel like I began to get a sense for the varied challenges and strengths that are going on "on the ground" here. I'm finding it difficult to summarize succinctly what I've learned. It's frustrating to see the same "recycled" issues come up again and again, and I'm sure that the scores of people who have been working on immunization here over the past three or four decades feel just as much frustration as I do. I'm convinced that there are no easy answers to the tricky problems here, because if there were easy answers, someone would have already found them, guaranteed. That means that the country, the health system, the immunization and surveillance programs, are in the much stickier situation of having to try to come up with the hard answers. And it's sometimes tough to feel like I can contribute to that in any way during a three-month assignment. I have to fall back on the truism that my experience here will influence the ways that I see and approach the next problems, and that if nothing else, that contributes to the overall global health effort. I hope that my work here will also inform my thinking about immunization back in Idaho.

We were in Legazpi City last week for the National Consultative Workshop on immunization, and presented our preliminary findings. I think that most of what we "found" in these monitoring visits was pretty well known to the immunization program managers...again, I think that it's finding a way to address those issues that is more of a challenge. In the meantime, Legazpi was a great little town to visit. It sits at the base of the majestic Mayon volcano, known as the "most perfect" cone-shaped volcano in the world. It was, indeed, quite impressive. Bicol Region is also know for spicy food, and we even got to try chili ice cream (surprisingly tasty).

I'm trying to savor these last few days in Manila. I found (thanks to my grad school friend Yuzo, who lives here), a lovely little green space--Paco Park--not far from the hotel. It's a walled cemetery, chapel, and park, right in the heart of a busy neighborhood here in Manila. But somehow, perhaps because jeepneys can't pass alongside it, and because of the high walls and mature trees, it feels like stepping outside of the city. They hold free classical music concerts there on Friday nights, and I heard a fantastic show of young (University of Philippines music students) classical guitarists last night. I felt the most at peace I have felt in a long time, sitting in the warm, humid evening, watching the sun set behind the 150-year old chapel and hearing this lovely music. It was one of the best instances of escaping the hurried city that I have found (that and long, lazy lap swims in the hotel pool).

Home next week. I'll try to write a final farewell post sometime in the next few weeks.

Awesome spot-maps made by Barangay Health Workers to identify health and nutrition problems in their community.

Overstocked fridge--rotavirus vaccine taped to the door!

Rural area near a Barangay Health Station we visited. That's a water buffalo.

Mamas waiting to get their kids vaccinated at a Barangay Health Station.

Our fearless (and very fast!) driver Ben does a little babysitting in the Health Station.

Reminders for Barangay Health Workers.

Awesome old typewriter at the Provincial Storage warehouse.

Vince in the Iloilo City ambulance, which gave us a lift home when the vehicle broke down.

Interviewing a mom about breastfeeding and immunization.

That's my supervisor at WHO, Maricel, hamming it up in the background. The view from the foot of Mount Mayon.

Mount Mayon and a jeepney.

Jackie's psyched to be done with the presentation at the National Workshop.

Ideas about why coverage with the measles-mumps-rubella vaccine has stayed so low.

"Perfect" Mount Mayon and Legazpi City 

Doctor Joyce (National Immunization Program Coordinator) helps prioritize health centers in a practice exercise at the national meeting.

At Misibis Bay Beach Resort for dinner

Misibis Bay, near Legazpi

Paco Park, Manila

A feast (that's a whole roasted pig in the foreground) at a local dentist's house. It happened to be her son's graduation the day we visited that health center.

Not so great syringe disposal at a rural health unit. Recapped needles in an open container.

 

Regional EPI coordinators pose during a workshop

A beach vacation, and back to the field

I'm in the Western Visayas Region (Region 6) this week and next, working on the same kind of monitoring/supervisory visits that we were doing in the Capitol Region and Central Luzon. It's amazing how many overlapping themes we see, and it's equally stunning how many differences there are between the regions. Western Visayas has been the epicenter of a major measles outbreak that started in 2010 and continued through most of last year. They saw several hundred cases in 2012, and even the midwives and Barangay Health Workers at the community level are quite attuned to the fact that there's an outbreak, and have their radars up for the disease. It's a big difference from parts of the rest of the country where the attitude of "we don't have that here anymore" can take over and get in the way of surveillance (I think that this is still a problem in the US as well...it's hard to keep your eyes open for diseases that haven't been around in a decade or more!). There are of course other challenges here in this region, and it still remains to be seen whether the measles transmission is done with for now, but it's been interesting to see the intense focus on a single disease here and to see how it has played out. I'm also enjoying hanging out with a team that has a ridiculous, bawdy sense of humor and that loves going on adventures after the hard work is done for the day (chocolate cake! photo shoot at a "mountain resort" with kitschy superhero statutes! visit to a historical site!). It's a fun group to be sure. Incredibly, I have just one more week of field work left, before heading to a national immunization meeting, and then spending a week in Manila wrapping things up and writing reports. This time has flown by, and at the same time, it has felt like a long while to be away from home, work, and my wonderful fiance. I would be lying to say that I wasn't excited about going home, but I've also savored this experience and am glad that I came.

During the Holy Week holiday last weekend, Chinyere (one of the other STOPers, a CDC fellow in my same program) and I went to Boracay, the famous party beach here. It felt like half of Manila was there, and it was incredible that the beach felt somehow both chaotic--swarming with people--and simultaneously incredibly peaceful and restful. We stayed at a sweet little family-owned hotel a couple of minute walk from the beach, and we had a fantastic weekend. Swam in the crystal blue water as many times as was feasible in 72 hours, got a year's worth of Vitamin D, went sunset sailing and on a hilariously boozy island hopping tour with a bunch of backpackers who seemed like spring breakers (we were not anticipating that!). I jumped off of a cliff into the dark turquoise water. Tried SCUBA diving for the first time (best. thing. ever.). Chinyere got two or three massages by the beachside. It was a lovely weekend, and felt like a vacation. How lucky am I to be here in the Philippines??

I'll leave it for now with a few pics.

It certainly wasn't a deserted island but it was still beautiful!

Sunset on the beach

Sail away

EPI (Expanded Programme on Immunization) Team in Region 6, at a mountain resort for a little R&R after a long day of monitoring visits at health centers

Hobbit inspired cottages outside of Bacolod City, Negros Occidental, Western Visayas

No comment.

Doctor Renz working with a midwife to fill out an EPI Monitoring Chart

We might need one of these on the 4th floor at IDHW :-)

Monitoring team at sunset

It's campaign season here. I love how cheesy the posters are!

The Homestretch

It's been a quiet--if not unproductive--week here in Manila. I am feeling rested and re-energized (and imagine that a weekend at the beach which starts tomorrow will only add to that feeling of rejuvenation). Amazingly, I'm already 2/3 of the way through my time here in the Philippines. We're starting our last couple of weeks of field work on Monday. It's mind-boggling how quickly the time has gone (which is not to say that there haven't been days that seemed to stretch on interminably, or that I haven't been homesick). It's just amazing, packing my bags for the next couple of weeks in the field, to think that I'll be on my way home one month from today. We've already started putting together the preliminary results of our work so far, so that also feels like an accomplishment.

I'm headed out to yet another region on Monday. I'll be in Region 6, in the Visayas islands, about an hour's flight South of Manila. This region, and particularly one province, Negros Occidental, has been the epicenter of the country's ongoing measles transmission. They've done a lot already to try to stem transmission, including a national immunization campaign that went door-to-door in 2011, as well as a couple of local provincial immunization campaigns in the past few months. A large school-based campaign in September looks like it may have finally done the trick. It looks like there has finally been some success and that the number of cases is on the wane, but it will be interesting to be there and to see how the response is holding up, 2.5 years into the outbreak. I imagine that people are sick of thinking and talking about measles (which is precisely why we need to keep up the hard work now--so that it doesn't reignite into a larger problem!). Lest you think that measles is a faraway problem or one that only faces middle- and lower-income countries, note that an outbreak in Wales (http://www.bbc.co.uk/news/uk-wales-21950818) is making big news. More than 400 cases, and predicting 1000 by the end of April. Some of the problem in Wales is attributed to a reluctance to vaccinate with MMR because of the fraudulent study that purported to link MMR vaccine and autism more than a decade ago. It's astounding to me that the completely unsubstantiated single finding from that flawed (and ultimately retracted) study just won't go away.

It's tough to keep up the morale with immunization. New babies are born unimmunized every single day, and it's an ongoing struggle to motivate families to vaccinate their children. Vaccines require really high levels of population coverage (up to 95% with the measles vaccine, which also requires two doses!) to prevent disease outbreaks, and it can sometimes feel like an uphill battle. I'm really curious to see the morale of the folks in Negros Occidental in the face of this ongoing outbreak and all of the hard work they've been doing.

Before I head back out to the field, another of the STOPpers and I are headed to the Philippine's most famous beach, Boracay, for the weekend. It's likely to be a complete zoo--this is a national holiday, 4-day weekend, and the headlines in the paper talked about the "exodus" from Metro Manila to the beaches, but I'm still thrilled about some time on an incredibly beautiful (from the pictures!) white sand beach. I'm hoping to snorkel, go for a sunset sail, and drink up lots and lots of vitamin D. It should be a lovely little mini-vacation, and then it's a sprint to the finish with a couple of weeks of field work, a national immunization meeting, and presenting our final results to all of the local, national, and WHO folks who need to hear what we've been up to. It's going to be a busy month!

Rain

I just stood barefoot on my balcony for 10 minutes or so, listening to a hard rain hit the roof above me. It felt like being behind a waterfall. Breathing in the sticky humid night air, it was almost like being in a steam room. I could feel the tiles still warm from the heat of the afternoon underneath my feet, and it felt like all of the grime of the city was being washed away. What a way to start the week fresh.

I'm in Manila for most of this week, catching up on the work that we've done so far and making plans for the final month here. Then it's off to Boracay's famous white sand beach and party town atmosphere for the Holy Week (Easter) holiday, before starting one last stint of field work in the Visayas. It's been lovely to catch my breath after 4+ weeks of constant travel and exhausting field work. I've been relaxing with long swims in the hotel pool, lots of good sleep, and enjoying the variety of international cuisine in Manila. It's also been great to catch up with a UW friend who is here working with the WHO Regional Office.

Short post tonight. I think I might drag a chair onto the balcony and just listen to the rain for a while longer.

More pictures

Little guy examining how the survey is going so far.

A remote barangay (neighborhood/village) where we assessed immunization coverage.

I told myself at least five times while crossing this bridge "It's okay, you can swim. It's okay, you can swim."

"Baby Barangay Health Worker." Cutie-pie daughter of one of the many fabulous BHWs we've worked with.

Lanzones (fruit). As far as I can tell, there's no English translation. Sweet little chestnut-sized guys.

Pup hitches a ride on a motorcycle taxi. That's a yawn, not a vicious snarl.

The Fab Four in Central Luzon--Dr. Lai (center), Immunization Program Coordinator, and Regional EPI Nurses Shiela (right) and Janice (left)

Whoops. Overheated and expired vaccine in a rural health center.

DIY vaccine sorting system using plastic cups. Heck, whatever works.

Janice at work reviewing log books in a health center.

Rural village near the ocean in Zambales Province (that's the water at the horizon). Note the hammock. Would have been perfect except for the nearly 100-degree heat.

Vaccines of the future! Measles-Mumps-Rubella given in 2015? (must have meant 09/15/12?)

Doctor Madonna (seriously) giving feedback to the midwives at a rural health unit. I can't remember what we were laughing about, but at least this shows that it's not all hard work!

Chicken pox! Ouch! Poor little swollen toes won't even go into his shoe :-(

Souvenir take-home turnip pies from one of the health centers.

What kind of cheese do you want? Hmm. I think I'll try the "Strong and Bitey."

My haul of not-quite-ripe mangoes

Cute kiddos hamming for the camera

Something about this vaccine-monitoring chart doesn't look right. Actually, several somethings: it's below the recommended temperature, it's just a bit too perfect, and it looks just like the example drawing on the left. I think somebody misunderstood how this was meant to work. (The temp in the fridge was actually high, not low, when we checked, which is just as big a problem).