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.