Busy! Field visits, hiking, and settling in to work

It's been a busy week and a half! Some highlights:

The three of us STOP Team members, as well as a dozen or so staff from the Expanded Programme on Immunization, the National Epidemiology Center, the WHO Country Office, and the Philippine FDA set out across the country to evaluate the surveillance system for adverse events following immunizations. I won't get too technical here, but it meant visiting every level of the health system, from the Region (roughly equivalent to the US States), down to the Barangay (village) Health Stations and local communities. It was a fascinating week. We moved around more or less non-stop, saw some beautiful areas of the country, and met some lovely people. We went to a remote fishing village and the the bustling regional capital city. Spoke with officials in their air-conditioned offices and with moms and community health workers in their homes. We got back to Manila late Thursday night, a bit tired and annoyed at the heavy traffic (my counterpart swears that it was "the lovers" out for Valentine's Day clogging the roads into the city).

The weekend brought a lovely hike to Taal Volcano (a lake within a volcano island within a lake within the island of Luzon, the largest of the Philippine archipelago). It was hot and dusty, and lots of horses passed us on the 2-mile hike up the crater, kicking dust into our faces and our surgical masks (sold to each of us by intrepid sales kids at the start of the hike, and much appreciated), but the view from the top was well worth it. I'll attach some photos below. We stopped for fresh fruit on the way to Tagaytay, and had an amazing lunch overlooking the lake after the hike. It was a splendid day, and I only got a *little* sunburned.

This week, we're starting field visits within Metro Manila (The National Capital Region) to assess immunization, surveillance, and child survival program effectiveness at the health centers. It's definitely going to be an adventure to navigate through this city. It took over an hour by taxi to return to our hotel from the regional office this afternoon. But it's also exciting, and will certainly give us a good idea of the challenges of implementing health programs in one of the world's most densely packed cities.

About that. I just don't have the words to express how full of people Manila is. I had dinner last night with a grad school friend who is working here in Manila, and he jokingly welcomed me to "the zoo." I have certainly never been anywhere as jam-packed as this city. Riding the LRT commuter train, you have to physically push yourself aboard, and elbows, shoulders, and handbags all just sort of meld into one solid mass of humanity. The train sways to the right, and the crowd, as one, sways. The train skitters to a stop, the crowd lurches forward. It's a bit jarring, but there's also a measure of camaraderie in the experience. I catch a smile occasionally from a fellow traveler as I shake my head about some aspect of the commute. Walking down the streets is equally overwhelming. Traffic comes at you every which-way--road rules seem to be loosely enforced at best. Pedestrians of all stripes, moving at all possible gaits, street vendors, beggars, food stalls, motorcycle tricycles for hire. It's noisy with honking cars, shouted phone conversations, the tinkling of bike-powered ice cream truck bells. It's smoky and polluted. It's all one big, well, zoo. It's really not hard to believe that this is one of the densest cities on the planet. It's an interesting (challenging?) place to be as an introvert, and particularly as an introvert grappling with learning a new culture. Overwhelming is not too strong a word.

But honestly, I kind of like Manila, and I certainly deeply appreciate the warmth, grace, and hospitality of our Filipino/a colleagues and hosts. This is a tremendously friendly place, and it's easy to feel welcome here. It's a brand new dynamic, though to be here as a short-term international consultant. A friend serving in STOP in Ethiopia wrote an email about the differences between Peace Corps and STOP and the PC attitude toward people like us consultants. I found her message particularly poignant and relevant. This experience is light years away from my Peace Corps service, and not only in terms of the monumental differences between my small city home in PC and the sprawling mega-city I find myself in. I have a fundamentally different role here, and my instincts to get to the grassroots level, to learn the language and to find my favorite local dishes and songs don't work in this role. I have no need to learn the language beyond friendly greetings and words of thanks, no need to ride arduous public transit for hours on end, and in fact, my time and energy is probably better spent elsewhere. I honestly will never know this country the way PCVs here do, nor in the way I knew Ethiopia. And it makes me a little sad. Not that I particularly want to go back to the days of sweaty interminable mini-bus rides, awkward family dinners with my host family, and linguistic and culture foibles. But I do miss that on many levels, and am grappling with what my new role here should look like and how I can interact with my local hosts and colleagues in a way that feels meaningful, in addition to providing the technical skills and assistance I've been brought here to provide.

Anyhow, a long post at the end of a long day. My brain is churning. This city and this experience certainly provide a lot to think about! More soon... for now, a few photos:

Taal volcano

Outbreak investigation? Or just dusty?

The view from the top of Taal Volcano

Lake Taal

Sunset from my balcony, Manila (it looks peaceful like this, doesn't it?)

Colleagues from the Region I Center for Health Development, Ma'am Johnna and Dr. Rosie

Checking out the vaccine storage facilities at the Regional Health Office

A quick stop on the road the catch a glimpse of the Hundred Islands National Park

Snack time at the Agoo health center (a very important time!)

Nurse epidemiologist Eloisa interviewing a family in a small fishing community. The baby had a fever after DPT immunization, but the family was willing to go back for her third dose anyway.

Vaccine vials missing labels because they've been carried in vaccine carriers with ice packs that melted.

Doctor Joyce from the National Immunization Program enjoying a sumptuous lunch of crabs, fried bananas, and sweet corn, at the Barangay (village) Health Station in San Manuel Norte.

Week One Update

I've been in the Philippines a full week as of tonight. It has flown by! I'm beginning to feel that I have my feet underneath me again, and I'm looking forward to sinking my teeth into some meaningful, interesting work here.

Our WHO and Department of Health (DOH) colleagues set up a fantastic orientation for us this week. We met with WHO offices at both the Western Pacific Regional and the Philippines Country Office, as well as with National DOH staff, including the people responsible for surveillance, routine immunization, and laboratory testing. We heard about the measles outbreak of 2010-2011 (which is still causing cases across certain regions of the country), about Philippines's 'high risk' status for polio importation, about the challenges of administering an immunization program (or a surveillance system) in this very geographically diverse nation,  about workforce issues and dedicated staff working on immunizing the nation's children, and about exciting plans for pneumococcal, rotavirus, and pentavalent  introduction here.

We spent the day on Friday gearing up for next week's adventure--a countrywide assessment of the surveillance system for monitoring adverse events following vaccination. Adverse events following immunization (AEFIs) are any problems following an injection, including those resulting directly from the vaccine (e.g., fever after DPT vaccination, which is normal, but can cause anxiety for parents, or an allergic reaction), those resulting from administration errors (say an abscess developing because of poor injection technique), as well as those that are purely coincidental (maybe the child was already infected with another illness, or just happened to develop symptoms that were linked in time to the immunization). Good systems for tracking AEFIs are important for ensuring vaccine safety and monitoring the quality of the immunization systems in a country, and are especially important for maintaining the public's confidence in immunizations.

So a team of about 16 of us are splitting up across the country tomorrow to complete site visits assessing the surveillance systems for these events at health centers and at the provincial and regional level. I'm headed up north, about 6-8 hours north of Manila, to Region I, Ilocos, where I'll be traveling with a colleague from the Department of Health and a local representative from the region. I'm excited to see more of the country (though less excited about the long bus ride), and about the project. We will all return to Manila next Friday to debrief and discuss our findings. It will be good, after a week of theoretical introduction to the health system here, to see its strengths and challenges up close.

In between all of the work introductions, the team and I have also done a good job of exploring the Manila neighborhoods around our hotel. I'm struck by the bustling crowded streets--there is no rush hour in Manila, because it's all rush hour!--but also by the respectfulness of people on the street. No leering, no street harassment, nothing but warmth and friendliness (so far!) toward the four of us as foreigners. We have ridden the LRT (light rail transport) train to and from work most mornings, and despite having to push through truly incredible seas of people, it's actually quite comfortable and navigable. It's also a funny experience to suddenly be *tall*! The average Filipina woman is just 4'11", so at 5'5" I'm nearly a giant. I've thought often of my dear friend who is a 6'2"-tall woman, and how very much she would tower over these crowds!

The four of us went on a guided morning tour of Manila this morning. We saw the monument and cemetery for WWII dead, which is a gorgeous green expanse of grass and lovely gardens commemorating the more than 45,000 Americans and Filipinos who died in the Pacific Theater. We also toured the thriving financial district, Makati, which felt like driving down Wall Street, and, in contrast, the ancient walled city of Intramuros, which was built in the 1500s during Spanish colonial times. It was nice to get a sense of this sprawling, vibrant city. Because Chinese New Year is tonight, there was a lot of activity all over the city. We saw fireworks and lion and dragon dancers last night, and the city feels abuzz with activity.

Sunset over Manila Bay

Early morning view from my hotel balcony

The WHO Regional Office

Monument and Cemetery to WWII Deaths

Cathedral of Manila, in Intramuros, the walled city

Manila traffic. That's a pedi-cab and a horse cart in front of us, and a "jeepney" shared taxi beside. Also note the Jollibee franchise on the right--it's the Philippines's answer to McDonald's.

Safe in Manila

I arrived in Manila late Saturday evening, after a long series of flights (Boise to Seattle to Tokyo to Manila). The 24-hr journey was long, but relatively comfortable and uneventful. I met up with one of my colleagues, Eugene, in Tokyo, where he graciously got me into the Delta Lounge with him (note to self: start earning more frequent flier miles--that place was sweet!). Got to the hotel around 12am, my body still believing that it was 9am.

I've been a little disoriented and tired from the journey, but it has been nice to have a day to adjust to the changes in time, climate, culture, currency, etc. It's hot and muggy, though not unbearably so (probably in the low eighties), and my hotel has a good little air conditioner. I have a kitchenette and a small living room, in addition to bedroom and bath, so I'm quite comfortable here.  I have lovely free WiFi, and was even able to Skype with Ryan briefly this morning (the time change, though is going to be a beast in terms of finding time to talk once I start working!). Despite the hotel being in a crowded, bustling area of Manila, roosters woke me up around 6:30 this morning.

I was surprised, on the way to the hotel from the airport, at how Westernized Manila is. We passed a Starbucks, KFC, and Krispy Kreme, and Visa appears to be accepted everywhere. This is a far cry from my Peace Corps experience just five years ago. I've seen iPads and iPhones and other iParaphenalia aplenty. It really does feel like you could find just about anything you might dream of wanting in this city. It's a huge, metropolitan place, and I'm looking forward to exploring some of its hidden gems.

The four of us (Eugene--a CDC EIS Officer, Chinyere--another PHPS fellow like me, Jackie--a Canadian Field Epidemiologist, and I) ventured out from the hotel a little before noon, and found the enormous Robinson Mall just a couple of blocks away. This is a mall unlike anything I've ever seen. Five floors of stores, a mixture of American, European, and Japanese chains mixed in with local stores, kiosks, food stalls, a movie theater, and a full-sized grocery store. A hustling, bustling place. We had delicious and slightly mysterious pan-Asian food, which we selected using mostly the pictures in the glossy menus. Jackie and I tried calamansi soda, which was like a less-sweet (better!) version of Sprite (calamansi is a native fruit of the Philippines, something like a cross between a lime and and orange). We then wandered the massive mall for a few hours, gawking at just how very much was there. We found some groceries, including a tremendous variety of tropical fruit. I am going to eat more than my fair share of mangos and pineapple during the next few months.

Things still feel just a little overwhelming, though I think that the Philippines will be very easy to negotiate, when all is said and done. People seem to be very warm and friendly, and English appears to be spoken widely. I'm sure that this will be a pleasant place to be!

We will meet with the WHO Country Office tomorrow morning, and I hope that I'll then have a little more information about what types of projects I might be working on. They have a series of site visits scheduled for us at the end of next week, so it sounds like we'll be jumping in with both feet!


I'm enjoying the quiet warm afternoon. I'm boiling some drinking water, enjoying a sweet snack of pineapple, and relishing the down time after a busy couple of weeks getting ready for this trip, and after the long journey itself. I have no doubt that there is plenty of work to keep us busy over the next twelve weeks. I'm excited to get started (and I'm sure that a good night's sleep tonight won't hurt either!).

Robinson Mall, Manila. The lanterns are in preparation for Chinese New Year, which is next week.