jtoews – Page 27 – ToewsTravels

wild west(ern samar): torpedos, coconut wine and vote buying

i spent last week in the rural region of paranas, which is about two hours north of tacloban on the western edge of the almost entirely undeveloped island of samar. there is one town, but paranas is a vast municipality, roughly equivalent to an american county. it is the type of place where foreigners are required to meet with the mayor and the legislative assembly upon arriving, where mayors walk with limps because of past assassination attempts, and where the mayor hasn’t even been to some of the villages in his region because they are so inaccessible. yes, if you’ve noticed, everything is about the mayor.

after a refreshing hair-tousling ride from tacloban in the back of a pickup truck, i was ushered before the municipality’s legislative assembly for formal introductions. the dozen or so politicians sat in one of the only air-conditioned rooms for miles, on ornately carved hardwood thrones (a status symbol in these parts), and referred to themselves as “the honorable____”. that was just the legislative branch; next i needed to meet the mayor, who seemed like a great guy. later i learned that he payed everyone who voted for him in the last election the equivalent of $10. the guy he was running against payed $40 per vote. the municipality offers identity cards, but only those who voted for the current mayor get one. exclusively those with these cards are eligible for free municipality-sponsored raffles for televisions and new cars – all this in a place that claims not to have the resources to buy an ambulance.

while we were small-talking with the mayor a woman was brought in who had a bulging eye and desperately needed to travel to the nearest city for a ct scan. the mayor agreed to pay for it, presumably pending future favors. he peeled the required cash off the huge wad of bills that he pulled from his pocket. no one knows for sure if this is the town’s money or his personal benevolence; he’s doing a great job of giving folks the impression that it’s the latter.

the mayor spent an inordinate period of time assuring all present that the safety of this foreigner (me) would be sacrosanct. apparently western samar is home to some leftest rebels who may be interested in kidnapping a caucasian, or as the mayor put it, someone with such a “pointy nose” (to raucous laughter). he told me that i would not be allowed to to the barangays (villages) in the “hinterlands.” that is where we were panning to spend most of the week, so after the meeting i petitioned him to let me go and he relented.

the next day four great local interns (mel, jc, christine and karen) and i, along with a very flamboyant male nurse and a midwife hiked for two hours through the mud and waded through a thigh-deep river to an isolated barangay (village) called tipul, where we stayed for two nights. rubber boots were required, as the area has endemic leishmaniasis. part of the way i got to ride a carabao, or local water buffalo. the village’s dwellings were constructed of thatched palm and elevated from the ground on sticks. the village was full of of naked kids, stray dogs, roaming pigs and blaring taylor swift (they did have electricity). we stayed in the home of the barangay captain (the village political leader), where we slept on the floor on banana-leaf mats and pillows filled with rice and ate exclusively rice and fish broth for each meal. apparently they brought in the fish just because we were there, the implication being that all they usually eat is rice. even the rice was donated, as unfortunately the village has had a really tough time recently with their crops (predominantly rice and coconuts). according to the interns, the food we ate in the three days may have been the family’s food for the next month. we justified our sustenance by requesting more food aid for the village from the mayor upon our return. i carried in my own eight liters of drinking water, and it ended up being a good idea as there were plenty of folks with gastroenteritis from the village water source. all that water filled my backpack, so my only clothes were the ones on my back. gotta love putting on the same disgustingly sweaty clothes each day. no running water either. nothing makes you thankful for cold showers like no showers at all. the hospitality of the family who hosted us was profoundly humbling.

we held a medical “consultation” in the town square, dispensing an extremely small selection of medicines from the one box we had carried with us. most of the complaints were pediatric upper respiratory issues secondary to everyone having wood fires for cooking in their homes, and skin infections. everyone seems to believe that amoxicillin will solve any problem, including muscle pain and rhinorrhea. i got to see patients myself, with expert interpreting from the nurse. patients continued trickling in throughout the nights, and late one night some local men caught us some huge frogs, which we devoured in their entirety as part of a spicy coconut-based soup.

basically nothing is known about the health status of this community. no one knows what the leading causes of morbidity and mortality are, so part of the mission was to sign up and teach some new local health volunteers to fill out surveys to that effect. also to plan for emergency health events, which require the villagers to carry the sick in a hammock across the river and through the mud to the nearest road, at which point they need to send a messenger to send for transport as there is no cell phone service in the area. most everyone is illiterate – though there are teachers assigned to the village school, it takes them days to get there each week, such that classes end up only being held one or two days per week. one of the more concerning medical cases was an elderly woman with suspected pulmonary tuberculosis. this should be aggressively treated to prevent the infection of others, through direct observed treatment (dots). but the woman was too weak to walk to the clinic to get tested, and would not have the resources to stay for treatment. there is not currently anyone in the village who can administer dots, and there are even bureaucratic obstacles to collecting a sputum sample, so the case remains untreated. not cool.

we also held a clinic in the town of paranas. doctors (and everyone else) around here love to spend their afternoons drinking the local coconut wine, called tuba. a red bark is added to give a slightly bitter taste and a red hue. interestingly, it takes three years to grow a coconut, and while coconuts remain on the island of samar, none remain on the island of leyte (where tacloban is), as they were all destroyed by typhoon haiyan. in practical terms, in addition to more pressing concerns, this means no alcohol for the common man for the next couple years.

i stuck around samar for the weekend, and on saturday we took an excellent excursion two hours up a river in a “torpedo,” a 25-foot long narrow boat. there are three people manning the boat – one to drive it, one at the front to help steer, and a kid whose job it is to continuously bail out the accumulating water, as the boat leaks and also the entire trip was whitewater so we were constantly being soaked! at a point in the river there were some huge rapids, and we needed to disembark while the boatsmen expertly guided the boat through the rapids, using a pulley system set up for that purpose. we were able to do some swimming in the rapids as well! tula, the barangay (village) that was our destination, was heavily hit by typhoon ruby late last year, demolishing many dwellings and taking down lots of big trees.

after docking the boats, we still needed to wade through another river with knee-deep mud to get to the village. we brought along some vaccines, so i got to hone my baby-poking skills, just because we happened to be there! there was also a child there with hydrocephalus and an untreated meningomyelocele, issues i am very familiar with after a stint volunteering with a pediatric neurosurgeon in kenya prior to medical school. the required (partially corrective) surgeries would be free in the city, but his family doesn’t have the money for transport and accommodation once they’re there, so no surgery. he’ll probably die soon; profoundly sad.

this epic week ended with a saturday night trip to the local city, catbalogan, to our attending physician’s house, to sing non-optional late-night karaoke and to spend the night. everyone wanted me to sing until i started, then they wanted me to stop. i got off easy, as apparently when some people mess up a karaoke performance in the philippines they get lynched (multiple deaths after bad renditions of frank sinatra’s “my way”). we were fed the classic karaoking snack – sigsig, fried pig brains. an outrageous end to and outrageously amazing week!

santo nino festival, samar style

samar is a large island, the third largest in the philippines, which lies just northeast of tacloban. it is one of the poorest and most undeveloped areas of the country. yesterday ariella and i joined a local intern, mel, on a trip to see the annual santo nino festival in a town called paranas, about two hours north of tacloban. the festival is modeled after a much more famous one in cebu, an island to the west. it is a syncretistic festival that combines elements of catholicism and the animistic religions of the area prior to colonization. the different barangays (villages/neighborhoods) of the town each prepared their own large and elaborate dance presentation, complete with ornate costumes, for a massive weekend-long competetion between neighborhoods. each troupe had a theme, examples being fishermen, birds, shellfish, and fairies of the night. each group of performers had about 50 participants, mainly children, as well as their own musical emsemble, primarily drums and trumpets.

first they had a parade around the streets of the town, which ended at the town square. everyone crowded around, folks teetering on plastic chairs, hastily constructed bleachers, and the roofs of surrounding structures, all to catch a glimpse of the presentations. the festivities began with an arduous and underwhelming 20 minute reading of the official rules of the competition in english, a language which almost none of the attendees know. then, each group presented their ten minute long, cirque-de-soliel-style choreographed dance routine. it was truly amazing!

the last group to go had a feathered theme, and their dance centered around a morbidly obese teen, evidently the town’s most popular individual. she fluttered around the stage decked out in real feathers to deafening roars of excitement from the crowd, while her physically diminutive peers danced voraciously in the background. a winning team will be declared, and will be gifted a statuette of a saint to parade around, as well as a cash prize for their neighborhood, ideally used to purchase supplies for next year’s elaborate costumes. great way to spend a day!

filipino approaches to rural community health

the medical school we are rotating at here, the leyte branch of the university of the philippines, uses an interesting model. it has a special mandate to train primary care phyicians to work in rural communities. all its students complete a fifth year of medical school, one more than other medical students in the philippines. this year is spent as an “intern” in an assigned rural community, and major focus is placed on becoming an integral member of the community as opposed to just its physician. to attract students, medical education at this school is subsidized by the government and provided free of charge to the students, provided they pay back the time working in rural areas. prior to typhoon haiyan last year the school was based in the nearby town of palo, but the campus was completely destroyed, so it was moved to some buildings in tacloban which survived the typhoon.

this week all of the local class of interns returned to tacloban from their work sites to attend a training session on how to train community health workers. we were priveleged to be able to attend as well. the village units in the philippines are termed “barangay,” and it is at this level that many decisions are made, as government in the the philippines is in general rather decentralized, thanks to geographic isolation and countless disparate ethnic groups and languages. the intern’s focus is on developing good relations with the mayors and other leaders of the barangays, in an effort to address some of the social determinants of health – a preventative effort at the community level as opposed to simply dealing with individual’s acute health needs. the training session focused on how to give good presentations and effectively run a meeting while remaining cognizant of the best interests of all stakeholders. icebreakers and frequent dancing were a major theme. also discussed were strategies for identifying public health issues and how to go about fixing them using the community’s ideas. this was primarily in english, which all educated filipinos speak, thanks to the history of american occupation. often however, talk will trend into “taglish,” a combination of english and tagalog, the national language which almost everyone speaks. filipinos love acronyms, indeed even more than americans do. the medical system here, at least at this school, is profoundly non-hierarchical. the faculty and school leadership attended the training, and if we didn’t already know who they were we could never have guessed, as they were following orders and joking around just as much as the interns. get a group of filipinos together and there will be a joke told at least every 30 seconds, and everyone will laugh even at things which aren’t meant to be funny. people here love laughing, and its great!

made it to tacloban!

we finally made it to tacloban! our flights were delayed for a day due to a tropical storm that was bad enough to cut the pope’s time here short, and then delayed further as a plane carrying prominent filipino government officials had crashed and remained on the runway at the tacloban airport. it is far warmer and more humid here than it was in manila. tacloban is an endearing little dirty city of about 200 000 that only really became famous after it was decimated by typhoon hayain last year. most of the downtown has been entirely rebuilt, and the place really seems to be booming. it has apparently become a lot more cosmopolitan since the typhoon, as lots of businesses (western-style coffee shops, fine dining establishments, and even used book stores) have opened up to cater to all the aid workers and to take advantage of the influx of aid money. seemingly the first things rebuilt after the typhoon were shopping malls and fast food restaurants. there is a dunkin donuts franchise quite literally every block, but none of them have coffee. its on the menu, they just don’t have it. despite the fact that one can live a luxurious life here with money, obviously most people don’t have those kinds of means, and life remains very tough economically, not to mention all the terrible loss of life from the typhoon.

tacloban is on the island of leyte, on the eastern edge of the philippines about half way down the archipelago. the vernacular of the area is called waray-waray, although the national language tagalog is spoken by everyone as well, and educated people speak english quite impressively. after much searching we found a place to stay. with all the aid workers who came after the typhoon the prices for rent increased exponentially. an average room with air conditioning, hot water and wifi rents for about us$1000/month. we weren’t prepared to spend that kind of money for rent in the philippines, so we found a couple rooms with none of the above amenities at a hostel called ron and fire’s place on the outskirts near the bus station. ron is an australian and fire is a filipina, and there are occasional travelers sifting through which is cool! something (we can only speculate that it is a trapped bat) flaps around in the rafters when the fan gets turned on, and the neighborhood rooster ensures we wake at the crack of dawn.

quick trip taiwan!

thanks to the pope’s visit to the philippines and the declaration of days of national holiday, we had some time before we needed to report to our clerkship site in tacloban. so my friend ariella and i made an impromptu three day trip to taipei, taiwan! it was a great decision. super nice place – so clean and verdantly green and densely populated and western for being in the far east.

on day one i took a long nap, and then we went up what is currently the fourth tallest tower in the world, the taipei 101 tower. really great view from the top, and the elevator that takes you to the 90th-something floor does so in about 11 seconds- currently the second fastest elevator in the world! then we went to the largest and most tourist oriented night market in taipei, shilin. night markets are vast expanses of hawkers selling everything imaginable at night, especially snackish foodstuffs of usually exotic varieties. really probably the best place ever!

on day two i headed out into the surrounding hills to a hot-spring strewn place called beitou. there is a public outdoor hot spring that costs just a dollar to enter, and it is full of elderly taiwanese retirees who spend their days there. it was glorious. the pools are extremely hot, and one can alternate them with an exceedingly cold pool. that night we headed to a cutting edge “for the youth” neighborhood called ximending, inspired by the subcultures of tokyo’s harajuku. we got hotpots, and the highlight of the trip was, when it became clear to those around us that we didn’t know exactly what we were doing, the tweens at the table beside us called their english-speaking friend on speaker and had her explain to us how to use the hotpot – “dip meat hot water some seconds, when change color can eat.” they were really nice.

on day three we visited the chiang kai-shek memorial hall, a huge memorial ediface not dissimilar to the lincoln memorial in washington dc. chiang was the founder of the state that is now taiwan, and i found the history lesson presented on the ground floor of the mausoleum to be quite enlightening. chiang was the leader of the chinese nationalist camp following world war two, and opposed communism. he found his side losing to the communists in the civil war that erupted in china within the power vacuum that followed the defeat of the japanese. chiang retreated to taiwan, a place where he had never before lived or even visited, and created a state called the “republic of china” (r.o.c.), with the ultimate goal of reclaiming all of mainland china for the nationalists. obviously that hasn’t happened. chiang and taiwan were favorites of the west during the cold war and indeed remain so today. we then visited an ancient buddhist/taoist/folk religion temple called longshan to smell some wafting incense and listen to some chanting. then we grabbed some sushi and headed to the airport to return to manila.

manila vanilla pope fever

some background: i’m off to tacloban in the philippines with three of my classmates for a two month clerkship in global health! all of my classmates are somewhere in the developing world for these two months. this is the capstone of my medical school’s global health curriculum, and being that global health is the reason that most of my classmates chose the school we’re at, this is something that we’ve all been looking forward to with eager anticipation!

i had a quick layover in tokyo, just long enough to leave the airport, eat a bunch of sashimi off a conveyor belt, and take a dump while sitting on heated toilet seat and subsequently have my bunghole rinsed clean by a pressurized stream of hot water.

in manila, i quickly began to learn about filipino public transportation. the primary mode is the jeepney, extra-long world war II era jeeps with benches in the back. we stayed in a hostel in malate, which is apparently the red light district of manila. not so bad though, really. we were allotted a week in manila to complete the registration formalities with the university of the philippines. we explored intramuros, a remnant of colonial manila, which is home to a selection of centuries-old catholic churches.

we arrived in the philippines at around the same time as pope francis, and the place is going insane. 80% of the philippine’s population of 100 million is catholic, making it the third most populous catholic country in the world. add to that the rock-star status of this pope and his particular penchant for the poor and destitute, whose prevalence here is high, and you’ve got chaos of epic proportions. roads in a many-kilometer radius are closed for days in anticipation, the airports shut down for hours when he is transiting through, and the entire duration of his stay was declared a national holiday. 25 000 police officers were brought in from around the country to line the streets; only a few of them had to be fired for taking selfies as the pope passed. i set out to glimpse his motorcade in the pouring rain, and was almost crushed. its got to be tough being elderly or a child! i found myself on the second level of a mcdonalds with hundreds of screaming fans pushing against a glass wall to catch a glimpse of the pope-mobile. thankfully the glass wall remained intact. he came to tacloban, the site of our clerkship, to express solidarity with the survivors of typhoon haiyan, the worst natural disaster in modern filipino history. more about the rebuilding of tacloban in a future post, to be sure.

the pope also held a mass at what they say is the largest mall in the philippines, the “mall of asia.” in our experience we think we found much more extensive malls in manila. this country, like the rest of southeast asia, is absolutely obsessed with shopping malls, and very little could excite me more than that fact. actually, religion and malls have a unique symbiotic relationship here, as chapels are ubiquitous in the malls, with multiple daily masses which are remarkably well attended by shoppers carrying their bags of merchandise; the sound of the liturgy being poignantly broadcast throughout the mall in much the same way as the muslim call to prayer echoes through the alleyways of much of the middle east. it is special.

we spent most of our four days in manila wandering around amazing shopping malls, interspersed by a quick impromptu trip to taiwan. our flight to tacloban was cancelled and delayed repeatedly, so i spent an extra night in a hotel where i appeared to be the only customer not paying by the hour. a mouse shared the tiny room with me until i was finally about to scare it out the door. i was able to spend a night (yes, a night – I was picked up at midnight and dropped off at 6 am) with my good friend prajjwal from college – he now attends medical school in the philippines. turns out ihop pancakes at 3 am in manila are just as good as you’d expect!

this mannequin was as close as i ended up getting to the pope

a day in doha!

i got to spend a day in doha, qatar on the way to my family reunion in kenya in december, which was a place i’ve always wanted to be able to visit. qatar is famous for being the richest country in the world thanks to its exports of natural gas, and recently for punching well above its weight in the sphere of international relations. it is scheduled to host the 2022 fifa world cup despite concerns over the treatment of many of its foreign workers, a demographic which constitute 90% of its population. my south indian taxi driver in doha ranted about how they took away his passport for the duration of his five year work contract, and how qataris are so entitled and do nothing with themselves, treating foreigners with zero dignity. his words. i went to the new atmospheric museum of islamic art, built on the waterfront with a view across the gulf to the impressive doha skyline. the building is probably more impressive than the art inside. i then spent the rest of the day visiting malls, including one themed after venice, where you can take gondola rides through the mall’s canals.

lobby of the museum of islamic art, doha

impromtu trip to kenyan family reunion!

in december i was lucky enough to travel to kenya for a truly epic and once-in-a-lifetime family reunion! 67 family members convened for a week that had been in planning for years. due to the fact that it was residency interview season i didn’t think i would be able to make it, but i managed to avoid scheduling any interviews for that week and a couple days prior, when airfares remained exceptionally cheap, i decided to go for it!

it was so great to see my extended family, many of whom we hadn’t seen for years. also many young children who i had not yet had the chance to meet. we stayed at a mission-run guesthouse in nairobi for a few days, visiting an elephant orphange one day. another day we went to the town of kijabe, where all my mother’s siblings grew up. we visited the gravesites where some of our ancestors are interned. the family has lived in kenya since the american civil war!

we took some crowded buses to tsavo game park for one night, where we stayed in an opulent game lodge! then we continued through mombasa to turtle bay, a resort on the indian ocean! it was all-inclusive and amazing! then it was quickly back to america, with a residency interview dinner on the day of arrival. it was a really special trip; memories forever!

my parents in the place where my mother grew up, kenya

baja road trip

while i was in san diego i had a few days off, so decided to drive down into baja, mexico to visit my good friend austin, who works at an orphange. he lives in a desert city called colonia vicente guerroro, about a five hour drive south of tijuana. the orphange is expansive, and unfortunately there is no shortage of orphans. austin and his mexican friend deborah have a special place in their hearts for disabled children, and austin has basically adopted a severly delayed kid named jesus. it’s a lot of fun! austin and deborah have since established their own orphange nearby called eternal anchor. definitely an excellent place to support if you have some resources!

one day we left jesus with some neighbors and drove south to a place called catavina, about half way down the baja peninsula. it is famous for its unique rock formations, and it was quite impressive. we found a cave with indigenous pre-european era drawings. along this road there is no fuel available for more than five hours, so guys sell it from jerry cans along the road at grossly inflated prices. it was good times and lots of cheap tacos, and an enjoyable middle of the night saunter around downtown tijuana on the trip back up! viva mexico!

6 month tour of ‘murca!

i came back to the glorious united states from the end of june until the beginning of january. on the schedule were four month-long fourth year medical school electives. first i did pediatric emergency medicine at morgan stanley children’s hospital, which is at columbia university’s new york presbyterian hospital in washington heights, at the northern tip of manhattan. i rented a room close to the hospital in the heavily dominican neighborhood, and frequently ran back and forth across the george washington bridge at night for awe-inspiring views of the manhattan skyline. this as well as the next elective were sub-internships, meaning that i was expected to assume the responsibility level of a first-year resident, which was a huge (but great) learning curve and kept me extremely busy. that first month i also took the clinical skills (cs) portion of step 2 of the united states medical licensing exam (usmle), which is a practical test in which you enter a series of exam rooms with actor patients who simulate a variety of medical scenarios.

my next elective was in baton rouge, louisiana, at our lady of the lake hospital, where i was on the pediatric wards basically 15 hours every day.

next i made a quick stop at home in alberta to pick up my car, as living in the south for a month without a car really reminded me of the value of wheels. then, to rady children’s hospital at the university of california – san diego for a month of pediatric endocrinology (and many long runs on the beach)! thanks to friends from the past kimberly and brian for being so welcoming! san diego was truly amazing, and i stuck around for a couple weeks after my elective to go to mexico and also to attend the american academy of pediatric’s (aap) annual conference, whose attendees included, among others, hillary clinton.

then i drove quickly back across the country to new york city, where i did an elective in dermatology at mount sinai – beth israel hospital in midtown manhattan, commuting daily from the cheapest place i could rent in caribbean brooklyn. then, i drove all around the country for a little over a month, attending residency interviews! they were quite fun. special thanks to all the people who helped me out by hosting me, like mrs breckenridge in san diego, will in phoenix, mayaan in western mass, isaac and camille in south bend indiana, ryan and jess in minneapolis, joel in chicago, mr and mrs burns in cincinnati, and a potpurri of motel 6s. even made the impromtu decision to go to kenya for a week for a family reunion! finally, it was home to canada for christmas, with about 30 000 more kilometers on my college-era honda civic.