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).

This and that

A very brief post with some things that have made me smile/think/wonder in the past few days and weeks, in no particular order:

- Store signs. Amazing. "Cutting Remarks" hair salon. "We sell all types of batteries" (apparently someone impugned their honesty at claiming all types. "Cold aircon, cold drinks, hot dancers" (in Subic, home to a former US Naval Base here, which is now an odd cross of port, beach resort, and brothel). Some good typos too. I'll have to continue to keep my eyes open. None quite as egregious as the "humburger with chesses" in Ethiopia--cheeseburger, obviously--but enough to make me grin a bit.

- There was a "Mango Festival" going on in the province we visited today, which we sadly missed, but I did bring home my souvenir: I bought 10 mangoes for $2.50. My colleagues were in shock when I told them that $2.50 would buy one or two large mangoes in the US, on a good day.

- I continue to be impressed with the way that Philippines deals with varying expressions of gender and sexuality. I have met many "out" gay men and lesbians here, which is simply taken as a matter of fact, and I've also met a number of people with non-binary gender expressions. For instance, about half of the clinic staff addressed one of my coworkers today as "Sir," and the other half as "Ma'am," and this person seemed to be equally comfortable with either (though I suppose even better would have been to ask what (s)he preferred). Likewise, one of the waiters at my hotel presents as male, but wears bright pink lipstick and dark eyeliner to work. Which I honestly just love--what a gift to be able to be yourself in that way. I've been continuously amazed, in a country as conservative and Catholic (there is a strong lobby here right now against a proposed Reproductive Health bill, for instance), that gender and sexuality are so fluid and so openly discussed. Kudos, Philippines. We could learn something from you in the US.

- Saw a three-year old child this week with crazy chicken pox. I had never seen chicken pox before, amazingly. With the advent of the varicella vaccine in the US, and with my age (I obviously saw kids with chicken pox when I myself was a kid, but I don't remember it...), it's become a thing of the past. This kiddo was suffering. Swollen little ankles, blistering skin, scratching at himself and being swatted by grandma... he was just miserable. I'm going to use him as an example to the families back in Idaho who don't want to immunize against varicella because it's such a "mild" disease and because "natural" illness is preferable. They certainly don't want their kids as sick as this little guy was. He did still manage to pull at the strap to my camera after I put it back in my pocket, wanting to see--again--the picture of himself with his granny, so perhaps he's on the mend.

- I continue to be amazed by the difficulty facing some of the health workers in this country, and impressed with how they're doing despite all the challenges. (And, to be fair, at the same time, I've honestly been appalled at some egregious errors in vaccine management). Immunization is at a critical juncture in this country, and the Philippines is going to be very lucky if the tide turns for the better and they can avoid a major outbreak. There is a lot of work to be done here. To be honest, I think that I felt a bit like I was going to a "cushy," "easy" country for my STOP assignment (which, in many ways, I am...don't get me wrong...this is no Afghanistan or Democratic Republic of the Congo). But I have realized that there is still a long way to come here, and that there is lots of meaningful work to be done. I still struggle with my role as a foreigner and a short-term consultant (we called short-timers "helicopter practitioners" derisively in grad school) in helping with the task, but I'm simultaneously grateful to be here, and hope that my work is contributing... somehow.

- Turnip pie. Suprisingly good.

I haven't disappeared!

I apologize for the lack of updates. I had a minor computer disaster this week. In a rush to get to a meeting, I closed my laptop quickly. And closed the screen directly onto the hard plastic top to my USB modem, which was apparently sitting on the keyboard. Screen ruined--a Rorschach inkblot or Mandlebrot fractal of pixels, and no change with rebooting the computer. Thankfully, I was able to use a projector (the computer itself works fine!) to retrieve my data, and was able to borrow a very tiny little netbook that one of my WHO colleagues had on hand, so I haven't lost much speed with work or with being connected to the outside world.

I've spent the last couple of weeks in a blurry time-warp of conferences and supervisory visits to health facilities (both City Health Center and Rural Heath Units, the more provincial equivalent), and have spent a lot of time out in the community doing rapid coverage assessments door-to-door. I am happy to report that I have built up enough of a tan (read: one large freckle per arm) that I no longer fry within seconds of stepping out into the Philippine sun, but my colleagues are still very insistent that I should carry my umbrella with me at all times. To be fair, it does keep things ever so slightly cooler to be in the semi-shade of an umbrella. There's honestly not much you can do about the combination of humidity and heat, as the Philippine summer kicks into high gear here. I don't think I have ever been as warm as I was last Monday, walking around several communities in Bulacan Province. The Village Health Worker who was showing me around kept fanning me with her notebook--I think because she could see the beads of sweat dripping nonstop from my brow!

Region III (Central Luzon) has been home to a number of STOP Team volunteers over the years, and I am essentially repeating what a team did 4 years ago--assessing health facilities using a checklist, and providing feedback and skills-building sessions in a conference after the monitoring. The coverage assessments are meant to look--quickly and unscientifically--for "missed" children, and, unfortunately, we've found quite a few. Immunization delivery in some of these contexts is downright hard. I went to a 'village' (neighborhood, really, on the outskirts of a large municipality) that was all built on stilts over a stinking, neon green river. I have no idea what was floating in the river, but it was not a particularly healthy body of water. To get to the village, the health worker and I walked a few hundred yards on a concrete dam/embankment at the edge of a large tilapia fish farm/pond, then crossed a rickety bamboo bridge which bowed and bounced with each step. We sat on bamboo benches in front of one family's home, our feet dangling five or ten feet above the surface of the water, while mothers brought their babies and immunization records to us. Imagine the difficulty of getting to a health center (where you'll likely just have to wait in line) if you lived there. And the difficulty, as a health worker, in providing outreach immunization there. I wouldn't want to carry my vaccine box across that bridge! And that's certainly not the hardest place to reach in this country. A colleague walked 3 hours or so to reach a far-flung community on another island. And to be fair, Philippines isn't even the most rugged country in the region--I met the WHO immunization coordinator from Papua New Guinea this weekend, and he said that PNG has villages that are a full 14-day's walk from a health center. Which is just mind-boggling.

Anyhow, these health facilities here are facing some real challenges, and I feel a bit at a loss, in the short time I am here, in terms of helping to provide much tangible guidance or assistance to improve practices. Sure, I can help to sort out vaccines stored in a disorganized mess in a fridge, teach a midwife to use a monitoring chart to track her progress over the year, or refresh a nurse's memory on the surveillance protocols for measles. But there are some more fundamental changes that need to happen here, and I know that many people much smarter than I have been working on these challenges for years and years. This is the fundamental issue, as I see it, with practicing global health. What my role as a foreigner, with some specialized training and experience, but without a lot of insight into the local context, can be in helping to "move the needle" on these hard problems. It's certainly given me a lot to think about these few months.

Unbelievably, I am halfway through my assignment here. Time has both flown and crept along. I have six more weeks here, and am determined to make the best of them.More soon, including more pictures. I'll be in Manila for a week or so starting on Friday, and then have a short beach trip planned over the Holy Week holiday before Easter. It will be good to be in Manila to let some of these ideas and findings percolate, and to talk through them with my STOP team members and WHO/DOH colleagues. My mind is churning. Off to bed tonight, as we have another handful of monitoring visits scheduled for tomorrow.

Another week!

It's a lovely cool-ish evening (for once!) in San Fernando City, Pampanga. It's misting slightly, and there's enough breeze to move the mosquitoes on their way. I just had a lovely dinner of Chop Suey (Chinese Stir Fry) full of vegetables (I picked the organ meat out of it--it would be hard to be a strict vegetarian here!). Sat on my patio and watched the rain fall into the somewhat-murky pool in my hotel courtyard.

It's been a big day and (another) big week, and it felt lovely to have a little reflective solo time with a beer and a peaceful dinner. I'm also loving escaping from the craziness and noise of Manila, though there is still plenty of activity going on in this industrial little city a couple of hours  to the North.

I arrived in Pampanga on Tuesday morning, and jumped right into a conference already underway. The Regional EPI (Expanded Programme on Immunization) is smack dab in the middle of a five-week project monitoring health facilities throughout the region, so I was able to slot right in to the work already underway. There was a conference for Public Health Nurses (maybe 50 of them) on Tuesday, and then we visited, as two teams, 15 health centers over the next two days. There was another seminar on Friday to feed back our findings and to work with the nurses on how to improve their practices. It's amazing to feel totally at ease presenting to a group of 50 nurses and public health officials...I don't know when I finally started to feel like I know a little bit about what I'm talking about, but it's a grand feeling.

My part of the assessment was mostly Rapid Coverage Assessments (RCAs) to validate what the health centers are reporting and saying about their immunization coverage. Some health centers are reporting that they have immunized 150% or more of their target population, which we all know isn't quite true. There's some over-reporting, some poor population estimates, and/or some transient populations at work here, and we set out to try to get a better picture of how many kids are actually missing doses of vaccine. The team of four of us, along with local village health workers in each community, visited 20 households in a Barangay (village/neighborhood) around the clinics and checked vaccine histories for kids under 5. It was hot, exhausting work, but also pretty fascinating. It's nice to be out in the community so much, though I feel extremely limited by my crummy Tagalog. I can say thank you, good morning/afternoon, count to 6, ask if there are children here, ask how many Tetanus vaccines a woman received while she was pregnant, ask for an immunization record, name a few dishes, find a bathroom, tell a driver to stop, continue, or go straight, and  can point out dogs, cats, children, and babies. I also know the words for mother, woman, baby, and child. This is pretty limited conversation. 

We've found a number of kids missing immunizations, particularly the last in the early-childhood series, which here in the Philippines is the Measles-Mumps-Rubella vaccine, given at 12-15 months of age. It's a relatively new vaccine here, introduced in the last couple of years, and parents (and some health workers) are still not too focused on it. There's some worry about low coverage with that MMR vaccine though, because of an ongoing measles outbreak in the country, and the fact that a single dose of measles vaccine is only about 85% effective at 9 months of age. So immunizing 80% or less of your eligible kids with an 85% effective vaccine doesn't actually protect the whole birth cohort nearly as well as you'd like (the second dose confers immunity for about 95% of kids). There's also some risk with low coverage of rubella vaccine that the unimmunized population moves to a new age group--older adolescents and adults--when you break transmission among kiddos but don't fully immunize the population. And the scary thing is that when women contract rubella during pregnancy, there can be some pretty crummy outcomes (Congenital Rubella Syndrome) in their infants. So the MMR coverage and epidemiology is one of my major interests here, as is the sensitivity of the surveillance system (that is, would the health system "pick-up" or notice a case of a vaccine-preventable disease like measles or polio if it really happened in a community). It's amazing how small-scale you have to get to look at and strengthen these things. Systems-level changes at the national and regional level go part of the way, but it's really engaging the nurses, public health personnel, and community health workers at the local level--the implementers themselves, who do the front line work--that gets us where we need to be with immunization, and that's hard, ongoing work. Smart people have been working on these problems for years...it's a bit tough to think how I will be able to contribute much of anything in the next few short weeks, but I'm certainly learning a lot.

Enough technical talk.Other events of note/musings from this week:

• I took public transit (a "Jeepney," which originally started post-WWII as converted US Army Jeeps, a long SUV with bench seats facing inward that carry 18-20 passengers for about $0.20 a ride, often named/decorated) by myself for the first time. I tried my best to blend in, and failed miserably, but was proud of myself for not getting horribly lost.
• I saw a movie ("Oz," two thumbs down) in a theater by myself today. Movies seem to play on a loop here with about 15 minutes of dead air in between. At least 15-20 people sat through that dead time--I got there just as the previous screening's credits rolled--and watched the movie, or at least part of it, again.
• I hit my head, hard, three times this week. I am too tall for this country, which is hilarious, given that I am 5'5".
• I met a 12-hour old baby and a litter of kittens not much older than that.
• I went for a very muggy run, looping around and around a small oval in a subdivision near my hotel. It garnered quite a bit of attention from the neighbors. Someone applauded me, though they might just have thought I was crazy for running mid-afternoon. To be fair, I might have been crazy for running mid-afternoon. 
• Went a whole week without getting sunburned.
• I've found myself missing Spring. I was 0% sad to miss February in Boise, but it will be a little sadder to think of missing daffodils and those first warm sunny days.
• I have eaten more rice in the past month than in the rest of my life combined. Even an omelette came with a neat little pyramid of rice on the plate. I was given a knife (a virtual first in a Filipino restaurant, where food is generally eaten with a fork and spoon only) today, probably because I am a foreigner.
• Beers at my hotel come with a napkin wrapped around the neck of the bottle in just such a way that it looks a little like the Pope's hat.
• A Starbucks latte (shamefully) goes a long way in comforting homesickness. Amazing that it can taste the same 10,000 miles from home.

My fabulous team for Rapid Coverage Assessments

So tiny! One of the youngest infants I've met. 12 hours old, in the Health Center for his BCG (tuberculosis) and hepatitis B vaccine.

Snack time is a very serious time. We are fed like kings/queens at these local health centers. A heaping platter of pancit (noodles) for Ma'am Lai, Ma'am Kamille, and Sir Rolly.

Cute kiddos, very interested in what I was doing in their neighborhood.

Kittens, each about 4 inches long. Fuzzy and cute, and I'm worried about where momma cat was.

We checked Sofia's medical record to see her vaccination history. She had contributed this.

Rice for sale at a kiosk in one of the neighborhoods we visited.

Feeling like a giant with Ma'am MaryLou, a surveillence officer for Region III.

Nurses work on filling out an Immunization Monitoring Chart at our interactive workshop on improving immunization practices.

This has been making the rounds on Facebook

It's worth watching. Apropos of what I've been thinking about inequality. (I wish that I was 1/10 as clever as this analysis is...)

http://mashable.com/2013/03/02/wealth-inequality/

A few photos

Here are a few pictures from the past couple of weeks. Thanks to Jackie for snapping several of these :-)

Heading out to interview some families.

A slightly scary bridge over a creek which dumps into Manila Bay. Tireless team having fun despite the heat!

This neighborhood doesn't do so well when it floods.

Cute kiddos. The littler of these two girls was fascinated by me.

Veggie stand.

The team at a local health center.

A pile of index cards this nurse is using to keep track of when her patients are due for their next shot.

Gorgeous beach in Donsol

Eugene and the "road" through Donsol.

Life is rough here in the Philippines. 

Beach relaxation

Late night preparing a presentation.

Fancy brunch at the Sofitel Hotel

168 Mall. I love all the colors!

Some thoughts

Manila is a place of intense contrasts. I had a sumptuous brunch this morning at a five-star hotel. I mean, this was the fanciest brunch (indeed, maybe the fanciest meal) I have ever had. A buffet including lobster, decadent desserts, fresh-made pasta, the most incredible Thai food, gorgeous sushi, unlimited champagne. It was over-the-top, and we decided to splurge--majorly--to give it a whirl.

In the taxi on the way home, a pair of perhaps ten year-old boys ran up to the car window and plastered their faces against it plaintively. They were selling flower garlands for about ten cents each. Half of Manila's population reportedly lives in "informal settlements," which is development-speak code for "slums." That picture is awfully hard to reconcile with the polished marble and dark wood of the luxury hotel. The contrast is jarring.

I've visited some of Manila's slums in the past couple of weeks. We're doing monitoring visits at health centers throughout the seventeen cities that comprise Metro-Manila, and we've been going out into the communities around these local healthcare providers to talk to mothers and to review immunization records to get a rough-and-dirty estimate of vaccine coverage. They are not nice places. Dark alleys, covered with tarps to keep out the rain and the sun. Meager homes built from whatever materials could be scraped together. Tiny, dim, bare rooms, holding entire families. Narrow pipes (bringing water to the hundreds of shanty-houses) hovering a few feet above fetid sewer water. (A good flood would easily mix the two). Rickety bridges over "creeks" teeming with garbage. Multi-story tenements with shaky ladders leading to upper levels. Hot hot hot--electric fans humming uselessly against the humidity. Families who lost everything in the last typhoon. Skinny, flea-ridden dogs. Families who can't afford the $0.25 or so for a motorcycle taxi to the health center. These are places of intense poverty, and it's made all the more striking because of the absurd wealth that lives just down the street.

I don't see this kind of wealth disparity in the US, although I know that it is there. According to Wikipedia (would look up better sources if I had energy and/or a fast enough Internet connection...), the ratio of the income of the top 10% of Filipinos to the income of the bottom 10% of earners is 15.5. The same ratio is 15.9 in the US. I saw an incredible talk a couple of years ago at the University of Washington about the consequences of income inequality (by the authors of The Spirit Level, which is still on my to-read list, and may be inching its way toward the top of the pile). Income inequality is good for no one. The rich fare worse, too...health, social welfare, crime...just about every index of well-being is highly (and negatively) correlated with inequality. That's pretty evident here in the Philippines, and it's making me think about the situation back at home too. I have been thinking a lot about wealth and poverty here. It's a particularly interesting perspective to be a relatively well-paid international visitor who is working on issues intimately tied up with poverty. I can't help but think of my own identity here and how I fit in to the whole socioeconomic picture.

Anyhow. It's been a good couple of weeks here. I feel like I've been running more or less non-stop, which is both good and exhausting. I've criss-crossed the city from one health department or clinic to the next, and have seen a lot of people working really hard on some incredibly tough problems. (How do you figure out how well you're doing at covering your target population with immunizations when you don't have a reasonable estimate of how big that population is? How does the government sector convince private pediatricians to report their immunization numbers when there is no obvious incentive? How do you keep track of three new vaccines when the paperwork and reporting systems haven't yet caught up and added them to the forms?). I've seen some brilliantly creative solutions. A Public Health Nurse using her own cell phone to text families when their baby is overdue for vaccines. Midwives who go door-to-door each week with vaccine carriers and provide shots right there on the spot. Beautifully color-coded low-tech log books to keep track of how the program is doing. Homespun EpiInfo electronic medical record systems. There are lots of challenges, and no magic bullets, but there is certainly a lot of innovation and dedicated hard work going on. I'll be proud to be able to spread the word about some of the good work that people are doing here, and to be able to help brainstorm and troubleshoot solutions for tricky issues. I'm heading out to another Region, a few hours North of Manila, next week, to continue the same kind of work, as well as helping to strengthen surveillance systems and response to a measles outbreak that has been smoldering here for the past couple of years. I'm excited about the work and the travel.

I've still had time for some fun, too. Last weekend, I went with a friend (the CDC Epidemiologist who is working here with us) to try to swim with whale sharks (google them if you don't know what they look like). We weren't lucky...no sharks made an appearance, but we enjoyed the beach, some firefly watching, and a little time outside of the city all the same. And I only got a little sunburned :-) I've still been enjoying exploring the neighborhood and the city around me. We went yesterday to the discount shopping mall where many Filipinos buy clothing and appliances, which was an incredible experience (so many people! so much stuff!).

It's been a jam-packed first month here. It's hard to believe that I'm already a third of the way through the assignment. I'll try to be better about updating regularly.