Category: philippines

we spent half our time in tacloban at the regional tertiary care hospital – i spent the time in the pediatrics ward. interestingly, pediatrics in the philippines is the most challenging and draining rotation for medical students and residents, with malignantly harsh professors and the strictest of expectations. this is in sharp contrast to the general culture of pediatrics in the west. we had to sign in and out every day to make sure we were there for all of the required hours. the interns work 32 hour shifts every third day (q3 call) without any weekends or breaks, which is insane. we did these overnights sometimes but thankfully they didn’t make us do them every three days. then, in the morning, the young doctor’s verbal presentations were picked apart and absolutely destroyed by the attending physicians and director of the department, often with unveiled and unnecessary personal insults.

and this was one of the least sad things about the pediatrics ward. the place was grossly underesourced. not a single person used gloves the entire time i was there. there were often 10 or 20 patients and their families in a room, and privacy was nonexistent. when a patient died the family would be told and left to mourn in a room full of onlookers. while technically there is a government payment scheme that most in the area belong to since being struck by the typhoon, not much was covered. little things like caps for intravenous catheters or bigger things like certain drugs had to be purchased by the parents in the streets outside the hospital. in the pediatric intensive care unit when babies went into respiratory distress (which happened on a daily basis) they asked the parent if they could intubate, using the english term without any explanation of what that meant. sometimes the parent refused, nothing was done, and the baby promptly died. the parent almost certainly said no out of ignorance or misunderstanding. in the west, lifesaving interventions for children are done even if the parent does not give permission. in tacloban, even when the patient was intubated, there were sadly no ventilators. so the parent was expected to manually ventilate their child with a bag. no one from the hospital staff had the time to relieve the parent, and often there was no support to bring them food or water. so what would typically happen is that the parent would bag nonstop for 24 or 36 hours without food or water, and then give up, and the child would die. completely preventable deaths. and this happened almost every day. it is terrible.

one interesting program at the hospital was for rehabilitation of malnourished children. the program was funded by unicef. one mother brought in her infant who was obviously starving to death, and told us that she had been feeding him exclusively watered-down rice water since birth. the program pays for children like this to stay in the hospital until they are deemed rehabilitated enough to return home. the problem is, the issue will undoubtedly recur when the patient does go home. the family only earns one dollar or so a day and has 11 other children to feed. even the parents were subsisting off just rice. it’s a rough world when you don’t have resources. i suppose that is the moral of this story.

my commute each day brought me past the historical site of the leyte landing, which is where u.s. general macarthur first came ashore during the liberation of the philippines from the japanese at the end of world war two. the site is commemorated with bronze statues of the americans – wearing aviators – wading onto the beach. interestingly, tacloban was actually the capital of the philippines for a few short months at the end of the war, until manila was liberated.

we were invited a birthday party feast one afternoon in mayorga, one of many feasts thus far, which has been great. the hospitality is wonderful, but i’ve got to say that the food here is as unhealthy as you can imagine. filipinos eat white rice for every single meal. if they have the money, the addition will be pork; the fattier the better. at a more impressive meal, the rice will be supplemented with other empty carbohydrates, such as white wonder bread, chow mein noodles, rice cakes, and cooked cassava (for the uninitiated, similar to a baked potato except drier and with less flavor). the fatty pork will be supplemented with an alternatively flavored selection of fatty pork, fried chicken, and fried fish. absolutely never vegetables, which is disheartening. though the fruit is amazing, it is enjoyed by the average person as a rare delicacy maybe just a couple times per year. little wonder pretty much everyone here that is middle aged and older has rampant hypertension, diabetes and kidney failure.

while on the topic of food, i will end with a couple of the few bright spots. one is halo-halo, literally “mixture.” it is shaved ice soaked in sugary milk, topped with various selections of jello, ice cream, pieces of fruit, red beans, yellow beans, taro jam, crème de leche flan, and corn flakes. another is belut, a 14 day old chicken or duck fetus that is still in the shell. the fetus is killed when the egg is boiled, and the belut tastes best immediately afterword, doused with vinegar. seriously, it is delicious!

i spent last week in the town of tanauan, about one hour south of tacloban. tanauan was the hardest hit area during typhoon haiyan, which occurred just over one year ago. a 20-foot storm surge, or sudden increase in sea level secondary to wind and profound changes in barometric pressure, swept over the town. it killed somewhere between 5% and 10% of the population. no one really knows how many people were killed, as there were many undocumented workers from other provinces who had moved there for informal work. the storm surge came in very quickly, moving one kilometer inland, demolishing everything in its path. the water moved back out to sea much more slowly, leaving rubble and dead bodies behind in the ditches. after a few days the dead bodies began decomposing and blew up like balloons. they were buried in numerous mass graves along the side of the road – many of the bodies never identified. some graves are marked with touching memorials; others are unmarked and will likely soon be forgotten. one mass grave is beneath the town square, which is now being revitalized as a basketball court. the town’s new official slogan is “every day is a better day in tanauan.”

i was assigned with the local interns, but their schedule was different this week than most. a massive medical mission was being held in the newly built civic center, led by a group of 40 volunteers from california. dr. gabriola, an internist at stanford, was in charge. five physicians from california and 15 from the philippines (as well as tim and i) saw 5000 patients over four days at no charge. most of the american volunteers were ethnically filipino, wanting to give back to the country of their youth.

though missions like this were clearly necessary following the typhoon, a critic could rip holes in the ethics of continuing to hold these types of events over a year later, when the local healthcare system is already back in full swing. we’re way past post-disaster medicine now; access to healthcare is now about the same as it was before the typhoon, and missions like this lack sustainability. critiques could include that a mission like this undercuts the livelihood of local healthcare professionals. but the interns enlightened me, telling me that the patients who attend these free missions are a completely different demographic than can afford to pay a physician. another critique is that many patients depend exclusively on these missions for issues they should be seeing a primary care physician for. for example, we saw numerous patients who experienced strokes, only to wait weeks for the next free medical mission to see a medical professional. of course, without the missions, some would see a doctor sooner, and some never would. undoubtedly, many of the patients were feigning “cough,” in an effort to procure free amoxicillin, believed here to be the ultimate cure for everything. and most of the legitimate medical concerns we saw were chronic in nature (hypertension, diabetes, etc), meaning that being seen by a different doctor every few months at a mission isn’t really doing any good.

dr. gabriola did actually have a very nuanced perspective on global health. she waxed poetically on the pros and cons of a major mission like this with tim and i, and it was quite inspiring. ultimately, in some contexts, perhaps such as this, the benefits of this type of mission may overshadow the drawbacks. but it should always be done as collaboratively as possible, and with the goal of strengthening the local system instead of competing with it. tim and i got name tags that said “dr” on them, more autonomy than we’ve ever had before, and tried not to give out too much amoxicillin.

the week ended with a good-bye party held by the town for the american volunteers, and we were invited. we traveled to the event hanging off the back of a jeepney; others were sitting on the roof of the speeding, swerving vehicle watching movies on their laptops. in what would appear to be filipino-american fashion, at the opulent event there were two full hours of speeches, followed by a presentation of a certificate to every single volunteer, all before dinner. the dinner was worth waiting for, though, as it included lechon, an entire suckling (hence fattier) pig cooked on a spit. then there was dancing, complete with dance instructors. i was unable to elicit who was paying for all this extravagance – the american volunteers or the town. it was unequivocally over the top for some people who volunteered for a few days. oh well, parties are always fun!