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.

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.