Anna in the Philippines: 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.