Philippines Fieldwork Experiences

In the late evening, I finally reached Hotel Kimberly, where I and other students would stay for a week in Metro Manila. I met one of the other students there. Her name is Audrey. She is from California. Not feeling adventurous to try anything new yet, we went to Texas Roadhouse at Robinsons Place Manila. I got along with her right away. Our trip was followed by a meeting with another student, Sophia. She is from Minnesota. We spoke until 1 a.m. Everyone was on a high trying to comprehend the past 32 hours of travel we had just endured and how we found ourselves on the beautiful Philippine islands.

We all woke up at 7 am, and we headed down to have some Filipino breakfast that our hotel offered. As a Filipino, I’ve had Filipino breakfast before, but it was nice to revisit a traditional breakfast with new friends. As we get adjusted to the 10+ hours time difference, we head to Robinsons Place Manila for some currency exchange, shopping, and coffee. We met with Dr. Ged and Dr. Paolo, or as he was known, Dr. Lopao, at 2:00 pm. To Rizal Park, we rode an e-trike for the first time. As Dr. Lopao explained to us, Dr. Jose Rizal is revered as the national hero of the Philippines for inspiring the Philippine revolution against the Spanish colonizers through his writings. Additionally, he explained the Centennial Clock, which has witnessed many changes in the city’s history. In Rizal Park, right next to the statues of tamaraw and carabao, it serves as the point of reference for measuring distances across the country, referred to as the “Kilometer Zero”. Dr. Lopao brought us here as our first stop because hopefully, it will also serve as our ground zero for our journey with Global Health Philippines.

The Philippines is made up of 18 regions, 81 provinces, 145 cities, 1,489 municipalities, and 42,046 barangays. The smallest political unit in the country is the barangay. This is a government unit consisting of both elected and appointed officials, also known as barangay officials, who are responsible for keeping general peace and order within their jurisdiction. In our second e-trike ride to the National Museum of Fine Arts, we passed through Barangay 666. The road was lined with street vendors selling food such as fish balls/kwek-kwek, peanuts, and “dirty” ice cream. Several jeepneys, e-trikes, motorcycles, and cars polluted the air with exhaust fumes. This was one of the major public health concerns I noticed right away.

In the National Museum of Fine Arts, Dr. Ged and Dr. Lopao showed us Carlos “Botong” Francisco’s art called Filipino Struggles Through History. A matriarchal, spiritual, and animism-based health system characterized the Philippines pre-colonial period. Historically, Filipinos believed that everything has a spirit, including rocks, trees, animals, and humans. A major religion in the southern part of the country at this time was Islam, since it is one of the most important ways Filipinos identify themselves during this time period. Maritime trade was also centered in the Philippines, with silk playing an important role. When Spain came to the Philippines, mass conversions to Catholicism/Christianity occurred after the 4 Gs (Gold, Goons, God, and Guns) conquered the country.

Dr. Jose Rizal is recognized for his important books like Noli Me Tangere. There is a common perception that Jose Rizal was more passive-aggressive, while Andres Bonifacio was more active in defending the Filipino people. Others argue that Jose Rizal was passive aggressive as a tactic to wait before attacking the Spanish. Filipinos were devastated by the Philippine American War, which caused Manila to become the 2nd most devastated city from World War II. During the United States’ three-year rule, they were also responsible for the improvement of public health in the Philippines. Filipinos were taught reading, writing, and arithmetic. They gave the Filipino people education and assimilation.

Dr. Lopao tied this Filipino culture with the importance of engaging the faith healers instead of alienating them, especially during COVID-19 because individuals often visited faith healers instead, unaware the faith healers were spreading the disease rather than helping the community.

After this, we took our third e-trike through Barangays 655 and 656 to Plaza de Roma to watch people. A Filipino wedding was taking place at the time, so there was a huge line outside to enter the church for Sunday mass. Since the plaza is where young Filipinos play, I was very pleased to see a free book library box while I was people-watching. We briefly entered the church. We then passed through an impoverished part of Barangay 655, where the Plaza San Luis Complex contrasts with the area beyond on cobblestone streets.

In the evening, we had dinner at Barbaras, a fancy restaurant. There were more Americans and other foreigners there. They had a cultural performance planned for us to watch. Through art and dance, I learned more about Filipino culture, and they invited us to dance tinkling after. At first, I found it challenging, but it was fun and exhilarating.

Monday was officially our second day in Manila. Sophia, Audrey, and I pretty much created a system, where we’d have breakfast everyday in our hotel since it was free, so we got ready in the morning and ate. Then, we met with Dr. Ged and Rosewynn. Rosewynn is a medical intern, aspiring to become a doctor. Lunch was at Jollibee, the most famous fast food restaurant in the Philippines. We all had a piece of chicken joy and rice with sweet iced tea and mango peach pie for dessert. Jollibee is located in the mall, so we walked around for a bit and stumbled upon an ice cream place, so we had gelato, and some of us tried the famous ube flavor for the first time.

After that, we returned to the hotel for Dr. Ged and Rosewynn’s cultural sensitivity and Filipino language basics presentation. In their presentation, they discussed seven important themes in Filipino culture: resilience, hospitality, “utang na loob”, respect for elders, sharing, non-confrontational nature, and tampo. As a Filipina, I have also experienced these themes in my daily life, but it was good to refresh my memory. During this presentation, I learned the dangers of presenting Filipino resilience when they are facing extreme poverty and famine. Because Filipino resilience is used to cover up the true issues in the Philippines, this results in these issues being overlooked by the government. The extreme hospitality or otherwise people-pleasing nature of Filipinos also caught my eye because I thought about how easily this trait can be exploited. Rosewynn and Dr. Ged also discussed the importance of tabo, which is a small bucket with a handle used when flushing the toilets and taking showers in the CR (comfort room). Since our placement sites would not be equipped with automatic toilet flushes and shower heads, knowing this was crucial.

Then, Dr. Joel presented an overview of the Philippine health system. He gave a very elaborate and conversational presentation. The presentation ended up lasting two and a half to three hours because he is very engaging.

My takeaway from his presentation is the Triple Burden of Disease Filipinos experience, which includes communicable diseases, non-communicable diseases, and natural disasters. It lists Acute Respiratory Infection, Hypertension, Animal Bites, Acute Lower Tract Respiratory Infection, and Urinary Tract Infection as the leading causes of morbidity in 2022. As far as mortality goes, Ischemic Heart Disease, Cerebrovascular Disease, COVID-19 Virus Identified, Malignant Neoplasms, and Diabetes are the leading causes. This triple burden of disease illustrates how difficult it is for Filipinos to advance in healthcare because every time they catch up, a typhoon or earthquake threatens to sweep away what they have already built and accomplished. Because of the looming global effects of climate change, learning this information was very upsetting.

Dr. Joel also shared the devolution of Philippine government as it provides decentralization and autonomy for local governments to manage their own resources.

As of 2016, the health expenditure by source of funds was allocated towards private: out of pocket (54.2%), social health insurance (17.4%), national government (12.4%), other private sources (8.9%), and local government (7.1%) (Source: PSA, Philippine National Health. Accounts 2014-2016).

Healthcare is a public-private partnership throughout the country. As with most other countries, private treatment offers several additional benefits to patients. There is a heavy reliance on private healthcare providers in the Philippines. Filipino population relies on the private healthcare system. The majority of hospitals are also privately owned. Additionally, medical tourism is a major part of the economy, which explains the large number of private hospitals, so the data above makes aligns with research.

We also talked more about PhilHealth, which was briefly discussed by Dr. Lopao from the previous day. Residents of the Philippines are eligible for the PhilHealth system. There is no fee to apply. PhilHealth is similar to the health insurance in the U.S. in that, Filipinos pay a premium. The Department of Health (DOH) owns and operates PhilHealth, a tax-exempt, government-controlled corporation. It is primarily financed by general taxation and member premiums. In addition to collecting premiums and accrediting providers, PhilHealth also established benefit packages, processed claims and reimbursed providers (Querri et. al., 2018). Based on Philhealth’s computation for this year, they said those earning P10,000 and below would pay a premium of P450. Those with an income of more than P10,000 up to P89,999.99 would contribute P450 to P4,050, while those making P90,000 or more would chip in P4,050. As of early 2019, PhilHealth now covers consultations and lab tests as part of the Universal Healthcare Act. Additionally, the national program will automatically register all Filipino citizens. The other health insurance offered in the Philippines is Health Maintenance Organization (HMO), Prepaid Health Cards, and Private Health Insurance.

Lastly, Dr. Joel said, “The Philippines is a major source of health professionals to other countries.” This is true. I am a daughter of a Filipina nurse, who immigrated to America because she met the requirements to work there. The Philippines is the leading source of nurses in the world and second major source of physicians, which further depletes the Philippine healthcare system of useful, helpful staff.

References:
Querri, A., Ohkado, A., Kawatsu, L., Remonte, M. A., Medina, A., & Garfin, A. M. C. (2018). The challenges of the Philippines’ social health insurance programme in the era of Universal Health Coverage. Public health action, 8(4), 175–180. https://doi.org/10.5588/pha.18.0046

On Tuesday, we will observe Dr. Lopao and his intern Salvan at the Intramuros Health Center. On the way to Intramuros, we took what looked like a hybrid e-trike/jeepney.

Manila’s Intramuros district is one of the oldest districts in the country, built by the Spaniards in 1571. In Fort Santiago, you will find Intramuros Health Center. It is built under the walls of Intramuros, which is a wall mainly built as a defensive curtain to defend the occupant from outside aggression. Upon entering the health center, you see the stone wall covered in grass. There are plastic chairs filled with patients waiting for their turn to see Dr. Lopao. Several electric fans are positioned in front of where the patients get their check-ups, under a large gazebo.

During our observation, a senior citizen complained about swelling in her feet. According to the patient, her feet feel heavy and her pee is orange in color. She used a Popeyes bag as an example to show to Dr. Lopao of how orange her pee has been. To avoid minimizing or invalidating patients’ situations, Dr. Lopao emphasizes not putting them in a box and having a suggestive/informal tone instead of demanding tone when speaking. I noticed Dr. Lopao and another intern ask multiple clarifying questions to ensure the patient feels heard. Furthermore, he asks about their budget so that they can either recommend a social worker to them, or if not, they can at least hear the concerns and take note of the needs of that community. I asked Dr. Lopao how the patient pays for her service, and he said she is part of 4Ps. The Pantawid Pamilyang Pilipino Program (4Ps), which is implemented by the Department of Social Welfare and Development (DSWD), is a government strategy to reduce poverty that offers grants to very poor households for the improvement of their health, nutrition, and education, especially for children (Pantawid Pamilyang, n.d.).

There is little infrastructure and a staff shortage in the Philippines, so even though the patients are receiving treatments or medications for free, it will take 2-3 months for them to get their results, especially if they are processed in the labs.

During these check-ups, they also consider Filipinos who did not finish school since a lot of these medications are in the English language. Prior to releasing the patient, they make sure the patients understand what they are doing. His intern was able to provide a holistic approach to the check-up by repeating to the patient what the next steps are and asking the patient to repeat them to him. As well as repeating the dose, pronunciation of the medication, reason for taking it, what it does, and when to take it, he asks the patients to repeat what they have been prescribed. After this, I saw the intern photographing the patient’s paper information on his phone. He said he would transfer the information to the computer later. I immediately thought about how this would be considered a HIPAA violation in the U.S. Dr. Lopao also pointed out that the paper-based records also lead to incomplete health records, but they make do with what they have. It is all about capacity building in the Philippines. My mind also kept going back to the Popeyes bag the senior citizen patient we observed brought and how America has really westernized the Philippines. My thoughts turned to the concerns and opportunities that came with this.

Lastly, we went to Calderon Hall, the building for public health and medicine at UP Manila. We watched a video called “The story of Rosario – Zuellig Family Foundation” (found here: https://www.youtube.com/watch?v=YNzs1O2hgrg).

We had a two hour discussion about what caused Rosario to die, and we tried to make further connections and found that there were three main themes that emerged from our analysis of each variable: generational wealth, economics, and natural disasters. After this, we discussed what we discovered, what we were surprised about, what information(s) were affirmed, and questions we still have. I shared my experiences growing up in the rural and urban areas of the Philippines and now when I stayed with my tita in Makati for the night, and how our environment is very similar to Rosario’s. I found the same themes of overcrowding, misinformation, and little to no opportunities. When I opened up, I felt myself getting emotional and holding back tears as I was faced with the bittersweet realization of the difference between my life in the Philippines and the U.S. and how the rest of my family in the Philippines must remain resilient and settle for these types of conditions. Thanks to Dr. Ged and Rosewynn for taking the time to receive my information and making me feel like it was a safe space to share, I feel grateful to have had my concerns addressed effectively.

Sophia and I ended the day by visiting Dolomite Beach. It was the only beach near our hotel and just a 14-minute walk away. The objective is to encourage pro-environmental behavior in Filipinos through a white sand beach to make them more conscious of their duty to help keep Manila Bay clean. On the other hand, Filipinos claim Dolomite Beach is controversial and problematic due to the possibility of burying marine animals and plants on the beach, lowering oxygen levels in the water, and blocking their access to sunlight. According to another study, dolomite contains crystalline silica, which is classified as a potential carcinogen. Knowing this information was important because despite being Filipino, it is imperative that I maintain cultural sensitivity as a visitor since I have not been exposed to their everyday living for the last 16 years.

Reference:
Pantawid Pamilyang Pilipino program (4PS). DSWD Field Office CAR Official Website. (n.d.). https://car.dswd.gov.ph/programs-services/core-programs/pantawid-pamilyang-pilipino-program-4ps/#:~:text=4Ps%20is%20a%20poverty%20reduction,needs%20(short%20term%20poverty%20alleviation)

We met up with Dr. Ged and Rosewynn at 7:30 AM and took a jeepney to UP-PGH (University of Philippines – Philippine General Hospital). We met Dr. Lopao there, and we walked through the crowded, hot and humid hospital. We were already sweating and bothered after just a few minutes; the patients, however, had been waiting since the night before. According to Dr. Lopao, some of them spend some time at the mall just to get some air conditioning, then sleep outside the hospital to be the first in line. The hospital gives patients traveling from a far place 3k-5k Philippine pesos per person without taking into account the cost of food and transportation. Despite plastic chairs and electric fans, there were not enough fans to prevent everyone from sweating in the hospital. Through their expressions, posture, and eyes, you can observe the patients’ injuries, malaise, and sickness. Due to the small size of the hospital rooms, there is also not much privacy. A pregnant woman in labor is treated as a disease because there are so many patients waiting to be seen each day. There will be an induction of labor for the pregnant woman. Previously, everything was recorded on paper in the clinic, but they started using technology in 2020.

During our visit, we passed through their COVID-19 isolation room, which houses people who test positive. I found this very interesting, since we do not have that in the United States. It is just a matter of asking them to isolate themselves in their room at home. Unfortunately, not all Filipinos are able to afford their own bedrooms. Overcrowding is a major issue in Philippine housing, with many people sharing an area.

We then took a Grab, the Philippine version of Uber, to the Bonifacio Global City area, where St. Lukes is located. Their goal was to show us the difference between public and private hospitals. As we drove, I noticed multiple signs that said “Don’t Text and Drive” with their famous beer logo. There is irony in this because are they advocating drunk driving? In response to my question, Dr. Ged explained that the Philippines rely on their endorsers, so they have ads like that.

As soon as we arrived at St. Luke’s, all of us were awestruck by the difference. There was a hotel-like entrance to this private hospital. There are multiple fancy coffee shops and restaurants inside. Furthermore, they provide janitorial services and air conditioning throughout the building to maintain a clean environment. Advertisements from sponsors play on huge TVs. A person was stationed in each elevator to press the buttons for everyone as we ascended to the second floor using the elevator. We saw a lot of doctors with super specific practices on the second floor. This was a very luxurious hospital compared to PGH, and Dr. Ged asked “How much excess is too much? Instead of building a new restaurant at St. Luke’s, why not fund PGH?

My attention was also drawn to the differences between the paintings. PGH’s paintings often depict a hopeful environment to strengthen the patients’ faith, rely on God for guidance and strength, and use your community to help you through these challenging times. While St. Lukes’ artwork depicts more of an “escape” than a deep understanding of Filipino culture. Not to mention their hospital’s grand piano situation in front of it.

St. Lukes’ patients also showed their wealth by dressing in luxurious clothes, carrying high-end bags, and by looking relaxed and content. As there was no immediate sign of sickness, we assumed it was a lot of preventative visits rather than immediate care.

In a discussion with Dr. Ged and Rosewynn about this situation, I thought about how disgusted I felt when I saw St. Lukes for the first time. However, I realized that I shouldn’t see it in a negative light since I would have liked the patients at PGH to have experienced such comfort when going to the doctor, so I wished that it was the same for everyone, but it should not be excessive. Dr. Ged inspired the title of this blog when he said something along the lines of, “you can’t become jaded in this jaded world.”

Our day ended at BGC outdoor mall where we ate and unwinded.

Our second to last day in Manila, we woke up early because we had a 2 hour drive to Ternate, Cavite. Ternate is the smallest municipality to have a health forum. We saw many outdoor vendors selling seafood, especially oysters, as we walked to the event location. Once we arrived, our first sighting was of a handful of nurses, medical interns, and doctors. There is a large gazebo set up in the middle of the road, and a projector is set up to show their presentation. There was music playing and plenty of food was available. Nurses and medical interns projected their voices using microphones, so the barangay could hear them. I was invited to join in one of the icebreaker activities, where we played a game called “Hep-Hep-Hooray!” In this game, you either say “Hep-Hep” or “Hooray!”, but if they put the microphone on you consecutively, you’re supposed to say both “Hep-Hep” and “Hooray” right after, and that’s when I messed up because I said “Hep-Hep” twice instead of saying “Hep-Hep” then “Hooray!” because that is the order. It was me and another person from the barangay, and she won a prize. Games are crucial for engagement and participation in events such as these, because that is the only way Filipinos will engage themselves. Otherwise, they will not listen, find the event boring, and won’t attend, according to one of the municipal doctors in the area.

After the games, we were divided into four groups: a group including senior citizens, barangay leaders, and two other groups I was not able to get. I was placed in the senior citizens group, and we discussed questions such as “What is a healthy barangay to you?” They gave the senior citizens cut-outs of oysters and fish, representing their barangay. The medical interns helped many senior citizens form sentences and elaborate on their answers by helping write and spell their answers. Most of their answers were related to “talaba” and “ayuda”. The sale of oysters is the primary source of income and livelihood for a healthy and thriving barangay. Ayuda was the financial assistance provided by the local government during COVID-19. Just like when we received the $1,200 refund check from the U.S. government. Funding was also provided to the barangays, but not on an individual basis. The grant was for the whole barangay, so it was not a lot, but it was better than nothing.

The answers were followed by a follow-up question: “what steps are you going to go about achieving this?” Most of them said to strengthen the community by helping one another. For example, if someone’s home and yard needed cleaning, to help them, so the barangay looks clean. Moreover, they stressed the importance of solidarity, so barangay councilors and local leaders should be more involved and easier to approach instead of being this “authoritarian figure” who residents are afraid to approach. Residents fear retribution for speaking out.

Following this discussion, each group picked a representative to speak in front of the group. I observed how dismissive the barangay councilors and leaders were of residents’ concerns and how superficial their answers were. Rather than looking at the underlying issues of the barangay itself, they only cared about how it was perceived, so their answers consisted of tying up residents’ pets in their posts instead of having them roam around anywhere, and cleaning their yards. No mention was made of the need for funding. Afterwards, the municipal doctor reiterated what the barangay councilors/leaders said because money is not available. The lack of money in the barangay causes many problems.

We then had lunch with the interns and doctors again, and I ordered pork sisig like I said I would. We had a great discussion about how it would be more effective to have the barangay leaders and councilors sit down for drinks rather than have these community events to get them to plan and implement changes. Sadly, that is one of the sad reality of the culture in the Philippines.

The Philippines has a strong tradition of taking photos, so we took several at the end. It is a source of happiness for the Filipino people, and that inspired the title of this post, as we all recited the words “abante for tres, walang aatres, lahat aabantres”. It is a play on words because the event took place in pobalcion tres (3), so they are saying poblacion tres will only move forward, not backwards, and everyone will move forward together.

Dr. Ged and Rosewynn brought us to Quiapo Medical Center on our last day in Manila. To get to Carriedo station, we took the LRT (light rail transit). According to Dr. Ged, there is a designated area for females only to ensure their safety at night. Due to the fact that he was the only male with us, he had to stay on the other side and take a picture of us.

As we entered the Quiapo Medical Center, we all thought we were going inside a building, but it was all outdoors with faith healers and vendors selling herbal medicine. This amusing term of Quiapo Medical Center describes the conglomerate of stalls, booths, and even Quiapo Church itself providing what might be considered alternative health care (Mae, 2014).  Having explored all the different health systems in the Philippines, the Quiapo Medical Center was another one that is completely different from the others, yet still considered a very real health center for Filipinos.

The Filipinos have been very spiritual since pre-colonial times, and some still hold this belief. In English, “pamparegla” means to menstruate. When a female wants to abort her child, this pamparegla herbal medicine will cause her to menstruate, meaning she is no longer pregnant or has miscarried. Since sex is taboo in the Philippines, many women resort to taking this route.

 In addition, they sold a lot of candles on which you could make wishes before burning them. There was a specific meaning associated with each candle. The color peach was associated with excellence in exams and education. I wanted to support the small businesses, so I bought a whole pack of candles. All of the colors were included in the pack, so I made three wishes and burned them. There was also a line of tarot card readers. Besides alternative health care, there was a lot of jewelry, produce, and other items for sale.

Then, we had a “merienda” (snack), which I would consider a full meal. We also tried palabok, another traditional Filipino dish. I actually love this dish. Our next stop was Manila’s Chinatown, which had many jewelry shops selling real gold from Saudi Arabia. While walking around, I noticed a lot of things that I would consider health hazards, like the gasoline pump placed in the air. In my mind, I imagined how the gas could be poured into the streets and possibly cause a fire. However, Dr. Ged ensured that it is safe no matter how dangerous it looks. Despite being unconventional, Filipinos appear to take the pragmatic approach to life.

We had our real lunch at a restaurant in Chinatown. I say real lunch because in the Philippines, we eat multiple times a day. It’s part of the culture here. A typical day would consist of breakfast, a snack, another snack, lunch, another snack, dinner, and yet another snack.

After this, we took a break in the hotel since we had a long journey to our island placements the following day. At night, Sophia, Audrey, and I ate dinner at Greenwich, a famous fast food pizza restaurant in the Philippines, and explore the Robinsons Place Manila mall one last time together.

On Saturday, Dr. Jobin, my local preceptor, picked me up from the Hotel Kimberly at 1 pm, and we took a bus to the Batangas port to take the ferry to Odiongan. Odiongan is the Romblon’s (Tablas Island) most economically developed municipality and its commercial entry port. Our ferry ride took 8-9 hours, so we arrived at 4:00 AM on Sunday, and the ride to Alcantara took almost an hour, so I arrived at 4:44 AM at my host mom’s house. There was an immediate difference between life in the province and the city. The “tabo” has been given to us for use as a toilet flushing device and a shower head. Rooms lack air conditioning and only have electric fans. The bugs here are huge, and they jump, so my fight-or-flight response was immediately activated. Upon entering my room, I was greeted by a giant tokay gecko (or “tuko” in the Philippines). It hung at the top of the wall. Because I lived this way before when I was a child, I encouraged myself to go back to my 9-year-old mindset so that I could survive all of these changes.

My orientation took place at Binucot Beach Resort in the afternoon. I did not expect to visit such a beautiful place on my very first day, so it was a pleasant surprise. During my orientation, I learned that Romblon is comprised of three big islands and multiple little islands. Located in southern Luzon, they speak Asi (a dialect of Visayan language), Romblomanon, and Onhan dialects. Locals speak Tagalog as a second language. There are 12 barangays in Alcantara, where I stay, with a population of 16,999. Farming and fishing are their main livelihoods. This region is a mix of coastal and mountainous areas. The tourism industry is huge. Several local partnerships exist because there aren’t enough resources and staff in the health system, which is a devolved unit.

Local health systems and partnerships include the DOH Central Office, the Center for health development, and city or municipal governments. The Center for Health development consists of provincial DOH representatives, provincial governments, provincial health boards, and provincial district hospitals. When it comes to the city government, it comprises either the city hospital or the city health office, followed by the barangay health station. In the municipal government, there is the municipal health board, rural health unit, or municipal hospital, as well as the barangay health station.

The Rural Health Unit (RHU), where I will work 8 hours every day of the week, has a mayor, a health officer (my preceptor), a nurse, a sanitary inspector, and a dentist as part of their main staff. After this, there are three midwives, nurses from the Nurse Deployment Program of the Department of Health (DOH), midwives from the Rural Health Midwives Placement Program of the DOH, HRAPs (Health Resources Allocation Planners), casual encoders, casual utility, and three drivers.

Some of the RHU integrated services include the following:

• Outpatient consultation (adult and child clinics)

• Immunization Services (children and senior citizens)

• Maternal and Child Care Services (Prenatal, BEMONC/EINC Delivery, Post Partum, and Newborn Screening)

• Family Planning Services (FP commodities and counseling)

• TB DOTS (Directly Observed Therapy Services)

• Animal Bite Case Management and Treatment Services

• Issuance of all Health or Medical Certificates and Sanitary Permits (including Medicolegal/External Forensic/Autopsy Report)

• Emergency Care Services (Ambulance conduction, referrals, minor surgical care, and home care visits).

• Laboratory Services (Sputum AFB Exam, Gene X-pert, Glucose, Cholesterol, Uric Acid Screening, Urinalysis, Fecalysis, Pregnancy Test, Hepatitis B, and RPR Screening, HIV-PICT Screening Test, COVID-19 RAT Test).

• Smoking Cessation Services

• PhilPEN Services (BP monitoring and Risk Screening)

• TeleMedicine Services (Referral, TeleHealth)

• Provision of Free Medicines Services (PhilHealth & Indigents)

• PhilHealth Services (Konsulta, TB DOTS, MCP, NCP, ABTC packages)

• Dental Services

• Dangerous Drug Abuse and Treatment Program Services/Community-Based Rehabilitation Program.

They have a local referral system that starts with the community and goes either to a barangay health worker or a rural health midwife. After that, either the patient goes home or to the public health nurse at the Rural Health Unit. Their next step is to see the Municipal Health Officer, Dr. Jobin. The last option is to go to the district, provincial, or regional hospital if Dr. Jobin cannot help.

Alcantara faces many health challenges, including vulnerable mothers and children, poor health seeking behaviors, and dilapidated and incomplete health facilities.

In 2022, acute upper respiratory infections, animal bites from dogs, and wounds of all kinds accounted for the majority of morbidity. Hypertension, cancer, and diabetes mellitus, type 2 are the leading causes of mortality.

Today is my second day in Alcantara, Romblon. Upon arriving at the RHU, Dr. Jobin took me to the mayor’s office to meet the mayor of Alcantara, Dr. Riza G. Pamorada. It was a proper way to inform the mayor of my plans to spend three weeks in their municipality, working alongside the RHU. It was very interesting to learn that she is also a doctor in Poblacion who specializes in gynecology. There was no doubt that I was in good hands. It’s wonderful to see women empowered.

After this, I return to the RHU. Our location is the covered basketball court of Barangay Bagsik. They have their vaccinations here because these spaces are open, so the air can flow in and out. The public can also see what is happening, which would encourage more people to come see and get their children vaccinated. We used an ambulance van to travel to Barangay Bagsik. It was one of the farther barangays in Alcantara. Due to it being their second time visiting the barangay and some parents deferring their children due to illness, there were only a few children who showed up when we got there. As a result, the nurses of the RHU decided to make house-to-house visits.

Things began to get more interesting at that point. The nurses enlisted the barangay captains to help them with transportation. There is less infrastructure in barangay Bagsik, so getting to houses is more difficult. Some of the houses sat high on the hillsides, so we had to ride motorcycles to get there. For me, seeing the nurses riding a motorcycle carrying vaccine supplies was a very moving experience.

A muddy trail and a scorching sun greeted us when we arrived. In Filipino culture, umbrellas are a vital part of sun protection, so everyone pulled out their umbrellas and walked to the houses. We visited two to three. All of the parents had the same reason for not coming to the vaccination event for the second time in a row, which is that their child was not feeling well. As long as the child doesn’t have a fever, it is okay to vaccinate them with the measles and rubella vaccine, so two out of three children were vaccinated.

In my observation, the nurses articulated their concerns clearly and educated parents about the vaccine’s safety. In addition, I noticed how poor the living conditions were in the houses we visited. Around the houses were stray dogs being kept as pets, as well as farm animals. Because the stray dogs are untrained, they were leashed. The Philippines is one of the countries with the highest animal bite morbidity. I can understand why.

Our group then went back to the covered basketball court, where we were served fresh coconut juice by the BHWs. It was around 11:30 AM, and we had left the RHU at 8:30 AM. We decided to call it a day and travel back to Poblacion for lunch. My host mom prepared lunch for me at her house, so I returned there for lunch. The food is always delicious!

I return to the RHU at 1:00 PM, and Dr. Jobin and I travel to the municipality of Odiongan, where the Provincial Health Office (PHO) is located. The ambulance van ride to Odiongan takes about 45 minutes. The Provincial Health Officer, the public health staff, the nutritional nurse, and more were there to greet me. They were introduced to me by Dr. Jobin because I will be working with them on one of my outputs. In the PHO, several boxes of medical supplies sat in the open space, which was given to the Philippines by the Department of Health, which was a gift from the Ministry of Health. My first reaction was, “They better! ” At this moment, I cannot help but think about how the Philippines has been robbed of its resources in the past. In my opinion, this is one of many reparations that must be made. Dr. Jobin took some medical supplies to replenish the resources in the RHU. It was necessary to do some paperwork to record this, so I watched them do that. Afterward, we returned to Poblacion and celebrated one of the staff’s birthdays at the RHU. He was the only dentist in Alcantara, so we ate our second lunch before returning to work. I observed Dr. Jobin for a while. We all went home at 5:00 PM, so I walked back to my host mom’s house. I always take the scenic route since it has an excellent ocean view.

It is the first day of the Chikiting Ligtas vaccination campaign on Barangay Madalag’s covered basketball court. Additionally, it was brought to my attention that they use a covered basketball court for this campaign, so the kids are not intimidated because they won’t be going to a clinic at RHU. There is nothing to dwell on since they are just going to the basketball court. Each barangay and the way they operate offer something new to discover. The kids’ hanging weigh scale caught my attention this time. They are weighed by putting these straps on, and I thought it was so old-school, yet still effective. It’s the first time I’ve seen anything like that. Maybe I experienced it when I was a child living here, but I do not remember it. There is already a fear of the weighing scale itself among the kids. There were many children who cried when their parents put them in there. For them, it’s a foreshadowing that they’ll be seeing a doctor.

After seeing multiple children get vaccinated, I decided to ask the barangay health workers (BHWs) some questions since they play such an important role in the success of this vaccination campaign. It depends on the population size of each barangay how many BHWs there are. BHWs are people who love volunteering in their communities. To become a BHW, you do not need a degree or education, although it would be helpful if you had one. Most of the BHWs in Madalag do not have a degree. Their ages varied from late 30s to 50s. As a BHW, you may no longer work after 65 years of age, but once you become one, you must stay until then.

In most cases, BHWs are recruited by observing how much a person volunteers in their community, once they find people who are passionate, they are asked to apply. After that, they are interviewed and accepted. A BHW only makes 500 pesos a month, which isn’t much. As well as getting respect for their work, they do it because they want to help and see their barangay prosper. Each of them has a particular position. These positions include president, vice president, barangay nutrition scholar, health aid team, and more. As part of their work, they have close ties with the barangay captains, which is more political. A barangay nutrition scholar is one of these positions that creates reports for the RHU regarding malnourished children 0-59 months of age.

According to one of the RHU nurses, one of the greatest assets BHWs possess is their gossiping skills because gossiping allows the RHU to learn more about each barangay’s residents.

Despite finding this funny, I also thought about the importance of protecting patient privacy. Though it isn’t as strong here in the Philippines, it works to their advantage medically.

After spending the whole day doing the vaccination campaign, I returned home and rested. Ate Glaiza, a nurse from RHU invited me to join her at Clouds-by-the-Sea, one of Poblacion’s biggest attractions. There was a lot of children playing on the playground, and Filipino street vendors and bubble teas were everywhere. I ordered a few of my favorite foods, including kikyam, fish balls, and kwek-kwek, pictured below. Basically, kikyam is just ground pork and shrimp seasoned with five spices. The fish balls are made from fish paste and then boiled or deep-fried. Last but not least, kwek-kwek consists of deep-fried hard-boiled quail eggs dipped in orange batter. Their sweet and spicy dipping sauces make them 100x better. I truly missed this.

Kwek-kwek

At this point, I have a lot of bug bites. I usually woke up with four to eight mosquito bites on my body a day despite wearing bug-repellent lotion and doubling it with picaridin spray. The RHU provided me with a mosquito net that they also provide for any patient in need. I was also told to purchase Calmoseptine from the pharmacy, which helps with insect bites, so with all of this new information, I was able to improve my living situation.

As part of the Chikiting Ligtas vaccine campaign, today we are at Barangay Comod-Om. As it was already the second time they came by, there were only a few children. I spent some of my time writing some of the blog posts already posted. I did this in order to retain and properly communicate everything I have learned thus far in Manila and Romblon. While we waited for more children to come, the BHWs brought us halo-halo, one of the most popular Filipino sweets, so I spoke more with the BHWs and the RHU nurses. I got a chance to practice my Tagalog and bond with them a bit more.

The ambulance van picked us up from Comod-Om to take us back to Poblacion to the RHU. So far, I have developed close relationships with Joy, ate Leah, and ate Aimie. They wanted to give me a tour of one of the beautiful resorts in Alcantara, so we made a stop at Aglicay since it was on the way. Fortunately, the people of Romblon are friendly and chill, so they let us see the beach. During our walk, we snapped a few photos for me to remember this moment.

At the RHU, the nurses and I debriefed what happened today at the vaccine event. I watched them encode everything on their laptops. We have one encoder, which is ate Aimie, but ate Glaiza, one of the nurses, help out as well. The island has a really bad signal, so we have to write everything on paper, and the signal is still poor at the RHU as well.

Data show that the number of animal bite cases reported in the [Philippines] increased by 462% from 20009 (206, 253 bite cases) to 2018 (1,159,711 bite cases). Conversely, the confirmed number of positive human rabies cases increased by 13.5% in the last 9 years, from 243 cases reported in 2009 to 276 in 2018 (National Rabies Prevention, n.d.).

I saw a list of over 400 animal bites in Alcantara between January and May 18. This is a difficult problem to resolve since there are stray dogs everywhere in the Philippines, and Filipinos are still careless despite the precautions they are provided with. It is not uncommon for Filipinos to take in stray dogs and cats as pets even though they are not vaccinated, and they are not vaccinated because most Filipinos cannot afford to vaccinate their pets.

In Alcantara, they assess animal scratches and bites and categorize them. There are three categories. Scratches from the face down fall into category 1. In category 2, a bite occurs face down, and in category 3, a scratch or bite occurs face up. This is the most severe case. Then they ask what the patient did to resolve the bite. Was the bite washed or left alone? Did it bleed? As well as determining the severity of the bite, this provides an opportunity to educate the patient. The patient is instructed to also observe the scratch/bite and the animal that bit them if they possess access to that animal in case it dies and needs to be sent to the agricultural officer. Research Institute for Tropical Medicine (RITM) tests the brain of that animal to see if it contains rabies virus. On days 0, 3, 7, and 28, nurse Ariel discussed the 4 Speeda shots 0.1 ml administered to adults on the deltoid and babies not yet 1 year old on the thigh. Tetanus shots must also be administered to the patient. In order to prevent the rabies vaccine from going to waste, patients were asked to return at 1:00 PM again, so they can all receive it at the same time.

After lunch, another nurse administered the rabies vaccine to the patient. To make sure the patient was not allergic to the vaccine, they performed a skin test. Before being called back, the patient had to wait 30 minutes outside the clinic. During the vaccine administration, children with bites cried and screamed, and adults held back tears. I felt really sorry for them because it looked extremely painful.

After witnessing such an emotionally charged event, nurse Ariel took me to the TB Dots clinic. Despite wearing an N-95 mask the entire time, nurse Ariel did not want me to be exposed for too long there, so he explained everything to me quickly.

The Philippines ranks fourth worldwide in tuberculosis incidence. (The social determinants, n.d.).

Alcantara also categorizes TB cases. Category 1 is any new case, a case with treatment before/relapsed, a case with incomplete treatment or loss to follow-up (LTFU), or a case with an unknown outcome. Before category 1 was used only for new cases. A tuberculosis diagnosis is clinically confirmed if they test positive by a gene expert, shows abnormal results on X-rays, and show symptoms. Treatment for TB is rifampicin and isoniazid, accompanied by three follow-up sputum tests that should be negative. They determine if a patient is cured if the three sputum came out negative for the 2nd, 5th, and 6th month. If the sputum is still positive, the treatment is only marked as completed. If the patient wants to move somewhere else, they must first obtain a referral to a new physician. Due to the opportunistic nature of TB, many patients get tested for HIV. If you have TB, you may have HIV. It is free for the patient to take the HIV test. To date, Alcantara has a 100% success rate in getting patients tested. Contacts of TB patients are also traced and enrolled in prophylactic isoniazid treatment for adults and isoniazid for children 5 and under. A PPD test (also known as a skin test) is usually administered to anyone 15 years or younger. Since the Philippine healthcare system needs more staff, gene experts are only available on Mondays and Tuesdays, so patients have no choice but to wait. I was only able to observe one patient, and nurse Ariel was given a sputum test, which was placed in the refrigerator. For her results, he told her to come back on Monday or Tuesday.

If you were wondering, I have taken all the pictures using my Canon G7X Mark II camera.

Reference:

National Rabies Prevention Control Program Manual of Procedures. (n.d.). https://thepafp.org/website/wp-content/uploads/2020/11/Leptospirosis-2019-Guidelines.pdf

The social determinants of tuberculosis in the Philippines. (n.d.-b). https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(21)00516-7/fulltext

The new week has begun, and I am no longer alone. When I was in Manila, I learned that two physician assistant students would join me in Alcantara for my second week. On Sunday, I met Sydney and Bailey, both students at Pacific University in Portland, Oregon. This program was one of their final rotations before they graduated from PA school. Additionally, I met Dr. Arlene, a doctor in New York, and MD candidate Gyra, who is in her final year of medical school at the University of the Philippines. We had a proper dinner at Tankey’s with Dr. Jobin, where we got to know each other better.

This was our first day with the Chikiting Ligtas vaccine campaign at barangay Tugdan. It was a gorgeous location. Instead of a covered basketball court, we were near the beach with fresh ocean air. Since they let me mark the children getting vaccinated with the immunization marker, I was more interactive during the vaccination event. To make sure the children can identify themselves as part of this vaccination campaign, we put an immunization mark on their left pinky. I did this for an hour and a half. After the children got vaccinated, they also gave them vitamin A capsules as well as liquid vitamin C to take home. Afterward, the other students arrived. Having just finished their orientation with Dr. Jobin, I had to share with them what I had been up to during the last week with the vaccine campaign.

As the two other Filipino students in the group, Gyra and I tried to make the American students feel more comfortable about the merienda (snack) the BHWs prepared for us. It was jackfruit cooked in this coconut sauce with other vegetables. Fish and rice were also served. We all had a taste of it, but we did not want to eat a lot since Mama Li, our host mom, prepared lunch for us at home. There, we spoke a bit more. During our conversation, we expressed gratitude for this new environment and our host mom’s tasty cooking.

Dr. Gyra is my new roommate now, so I spoke more with her after lunch. Then, we were all off to the RHU again since we only get one hour of lunchtime. Sydney and Bailey showed me the pamphlet they are working on as part of their program output. It was about diabetes since it is also one of the most common chronic illnesses in the Philippines. The pamphlets were aimed at educating Filipinos about healthy eating habits to prevent diabetes, which I found extremely helpful and essential since Filipinos really enjoy rice. Diabetes occurs frequently here because most people eat two cups of rice per meal and eat more than three times a day. The remainder of the day was left for everyone to work on their outputs, and Dr. Gyra offered Sydney and Bailey assistance with translating English words into Tagalog for their pamphlets. They were scheduled for distribution the following week.

I am shadowing a dentist, Erick, today. Despite not being in my field of expertise, I decided to look into the public health implications of his work. The other students were doing vaccinations today, so I was alone.

I immediately noticed how difficult and inconvenient the setup was, but this is all part of the capacity-building process. The BHWs have already interviewed the patients. When the dentist and I arrived, there were about five to six people waiting. Before any of the procedures were performed today, the patients were checked by the dentist first.

The consultation is free, but the anesthesia is fifty pesos. Dental cleaning is commonly called oral prophylaxis. Dentist Erick receives resources from the Department of Health (DoH), but he brings his own supplies that he purchased with his own money because the DoH forgets a few essentials. Patients under the age of 18 without a guardian are not allowed to have an extraction or consultation, but parents are not required to be present. Patients can bring their nannies. While watching Dentist Erick with the patients, I tried to keep an objective lens, but I couldn’t help but feel for them since this was a very painful experience. They didn’t have numbing creams because the DoH has not provided them with any for months. As I thought about how babied we have been in America, I also thought about how the American experience of going to a dentist should be universal. A comfortable environment must be provided for us.

As a result of the procedures taking longer than expected, we stayed until 12:30 pm in that barangay. BHWs prepared pancit as a thank you for the free services they receive from the RHU. I tried it, but I never want to overeat since my host mom cooks me free meals. It is not a big issue in the Philippines, but you have to disappoint someone when it comes to food, at least on this island, food is abundant. I met with the other students and ate lunch with them at Mama Li’s house. Then, I went back to the RHU, where I shadowed Dr. Jobin.

I observed him talking to seven patients. As a result of a motorcycle accident a week ago, the first patient suffered facial/temporal and nasal bone fractures. As advised by Dr. Jobin, the patient should not have a faith healer massage it as it is not a cure and would definitely worsen the fracture.  A second patient got his finger caught on a rope that ran out, so he has a suture on his finger, and he will come back tomorrow to check its blood flow. The third patient needed only a medical exam for work. Both the fourth and fifth patients were bitten by animals. The sixth patient suffered a wound from a wire, so they are getting him a tetanus shot and checking for infection. The seventh patient just needed a record clearance for the sports Olympics that will take place the following week for athletes with intellectual disabilities and autism.

After work, the students and I took a tricycle to the municipality of Looc, only 20 minutes from Alcantara, to have merienda (snack) again with Dr. Jobin and Dr. Arlene. We had mais con yelo and halo halo, both popular desserts native to the Filipino culture. Then, we watched the sunset and went home.

In my opinion, this was one of the most eventful days of my life. It was Wednesday. As we headed to the RHU, we were there by 7:30 AM because we could not risk being late for the flag-raising ceremony, where the students and I were introduced to the entire town. We began by singing the national anthem, called “Lupang Hinirang.” I remembered some of the words, but I definitely need to refresh my memory. Government workers gave the rest of the town some updates. We were then introduced. It was very important that everyone in town understood the purpose of our visit. As the island is so small, everyone knows nearly everyone who lives there, so new faces are definitely noticed. Our presence in the town just needed to be reaffirmed as a positive thing.

After that, I started the day at Barangay Gui-Ob again with one of the RHU midwives, mama Nery. Gui-Ob is one of the closest barangays to Alcantara’s main barangay, Poblacion, which is where the RHU is located. The small building where mama Nery will do family planning was already filled with six to seven pregnant women when we arrived. The BHWs interviewed the pregnant women again just as they interviewed all of the patients seeing the dentist yesterday. We save a great deal of time by doing this, so we are very thankful to the BHWs for the work that they do.

I notice the pregnant women carrying a book with them. Mama Nery explains to me that the DoH gave pregnant women a “Healthy Buntis [translates to pregnancy], Happy Baby” book, but RHU usually hands them out when they learn of a pregnancy. Every checkup they have had during their pregnancy is recorded in this book. This encourages pregnant women to get checked in their first trimester and to receive health education sessions at clinics, and through community health volunteers. As I thought about it, the booklet would not be effective if everyone could not read it.

Mama Nery showed me how to calculate the LMP (Last Menstrual Period) and the AOG (Age of Gestation). Then, she filled out the book. Since there is little privacy in the back, the pregnant women lay down on a small bed and covered half of their bodies with a blanket. Mama Nery let me try a pocket fetal Doppler on a patient to check for a heartbeat.

We then had a patient take a pregnancy test that resulted in a positive result, so we placed the patient on the Target Client List for prenatal care. As this was the patient’s fifth child, this baby would be delivered in the hospital rather than the RHU. It is written in a law that the fifth children and pregnant women with high blood pressure must be delivered in hospitals. Pregnant women were also given ferrous sulfate and folic acid to help prevent anemia for the pregnant women and prevent some major birth defects of the baby’s brain (anencephaly) and spine (spina bifida).

While observing these women for a little over an hour and a half, I started thinking about how they are alone. My curiosity was piqued by what the fathers are doing while their babies’ mothers get checked. It’s a common practice in the U.S. to use preventative methods to prevent pregnancy, so I began asking how it’s done in the Philippines. As a result, I held a discussion with Mama Nery, the patients, and the BHWs about this. In general, they said that condoms are used mostly by the LGBTQ community and that heterosexual men are opposed to using them. Preventative methods include “widthdrawal”, also called “pull out,” and calendar days, which restrict sexual activity when women ovulate. In the Philippines, sex before marriage is taboo, so there is limited discussion between the partners. In general, the RHU did not provide sex education. Usually, they’re given once there has already been a pregnancy. As a follow-up question, I asked if high school students receive sex education, and they answered that they are just beginning to implement it.

Also, I noticed that Mama Nery advised pregnant women not to make their babies too big in the womb so they could have a smoother delivery since they will get bigger once they are born. As not everyone can afford to give birth in a hospital where they can be monitored more closely, safe deliveries are even less likely despite having very qualified midwives assisting them.

At last, we have seen all of the patients, and Dr. Jobin calls to inform us that a woman will be giving birth at the RHU very soon, and he needs all of his students to be there to witness it.

When we got there, the patient was already 6 cm dilated. Due to the uncertainty of when the labor would occur, we weren’t sure if we should eat an early lunch. We decided to wait as long as possible and have a late lunch if necessary, while we checked on the patient. Due to the intense heat in the waiting room, we fanned the patient with handheld fans as her contractions increased in intensity. It was the least we could do for her. A few minutes later, it began. Dressed in surgery gowns, surgical bouffant caps, protective shoe covers, and N-95 caps, we moved the patient to the labor room. Keeping the room sterile was very imperative, so we couldn’t leave once we were inside. Since this was not my area of expertise, the PA students and aspiring doctor were more hands-on than I was. As I stood there, I observed and provided moral support. For the life of me, I could not stare at blood for so long, so I did not envy Sydney, Bailey, and Dr. Gyra at all. It all happened so quickly. Within 11 minutes, the baby came out. We started at 11:59 AM, and a healthy baby boy was born at 12:08 PM. Astonished, I held back tears. Following this morning’s positive pregnancy test result from one of the patients at the family planning, it was a full-circle moment. I have never seen a smoother delivery and it was my first time witnessing one. During the entire delivery, the patient did not scream or make any sounds. There was no labor induction, numbing cream, or anesthesia administered to her. Despite everything, she managed to get through it all. She had no name for the baby yet. It was her third. A midwife stitched the patient’s vaginal tear, and the baby was given a shot and eye prophylaxis as well. We brainstormed name ideas to give to the mother. She handled it like a champ. Within minutes of birth, she was walking. The midwives handled the rest, and we left for our late lunch at Mama Li’s. After a very emotional and mentally exhausting day, Dr. Jobin gave us an hour-and-a-half break.

Upon returning to the RHU, Dr. Jobin gave us a lecture on how Filipino outbreak investigations are conducted. Outbreaks occur when there are more cases than expected in a given area and an immediate response is needed.

The following six steps were presented in order to conduct a proper outbreak investigation.

1. Control and Preventive Measures
2. Research Operation
3. Program Considerations
4. Strengthen surveillance at a local level
5. Public, political, or legal concerns
6. Provide training opportunities

Dr. Jobin shared the systematic approach as well.

Step 1. Prepare for fieldwork

Step 2. Establish the existence of an outbreak

Step 3. Verify the diagnosis

Step 4. Define and identify cases

Step 5. Perform a descriptive epidemiology

Step 6. Develop a hypothesis

Step 7. Evaluate hypotheses/analytic epidemiology

Step 8. Executive additional studies

Step 9. Implement control and prevention

Step 10. Communicate findings

Step 11. Follow-up recommendations.

After this we discussed the rabies and cholera being exceptions of the communicable outbreaks in the Philippines. As the PAs and aspiring doctor were also present during the presentation, we asked them to share their thoughts on public health since they are pursuing a more clinical path. They shared their appreciation for it because it is definitely needed.

On Thursday, we spent six hours in Barangay San Isidro to raise awareness about cervical cancer. This event took place in all provinces of the MIMAROPA region, including Mindoro Oriental and Occidental (MI), Marinduque (MA), Romblon (RO) and Palawan (PA), as well as Calapan and Puerto Princesa. It was attended by all the doctors on the island, including the municipal health officer (Dr. Jobin), the provincial health officer, an ENT doctor, a pediatrician, an internal medicine doctor, a gynecologist, and others. The students and I decided to do a rotation, in which we observed each doctor attending to their patients for about 30 to 45 minutes, but first, we all had to prepare the patients for the visual inspection of the cervix with acetic acid (VIA), so we interviewed them and filled out the questions on the paper. There was no privacy because patients sat right next to one another around a rectangular table. We asked questions about sexual intercourse since we were screening for cervical cancer. Having more than one sexual partner is frowned upon in the Philippines, so I felt like the patients did not feel comfortable saying the truth when we asked about the age they became sexually active and how many partners they have had altogether. To maintain confidentiality and comfort, I even invited them to whisper their answers. I interviewed about four patients and practiced my Tagalog.

After our interviews ended, I began my rotation with the pediatrician, Dr. Aubrey Solano. Prevention is something I am passionate about when it comes to children’s health. Whether it’s clinical or public health, I always approach work with a public health lens. Her patients complained of consistent coughs, colds, and fevers, and Dr. Solano prescribed medication for them, which my friend Joy was handing out for free at the medicine dispensary table. I then observed Dr. Lian Visande, an ENT (Ear, Nose, and Throat) doctor. She worked with both adults and children. Both public and private practices are part of her practice. The majority of her patients had ear issues and blurry vision. Hearing loss was present in some, as well as impacted and wax-filled ears. After prescribing medication, she recommended following up with an ear cleaning or hearing test at her clinic in Odiongan. During the free consultation, she tells them the cost of the procedure since her clinic is no longer free but private.

As I rotated, I also observed how people who aren’t getting checked behaved. In order to increase engagement during health events like this, Filipinos need music and free stuff. So the kids received free masks, seniors who had birthdays in May received whole cakes, and pregnant women received free baby bags. I knew incentives were important to get people to come to the event, but I also felt like it was a bit performative because no explanations were given to any of them as to why they were receiving free stuff. It should have been explained to the children who received free masks why they should wear them and the importance of wearing them. There should have been a discussion about the free items in the bag given to pregnant women. Since San Isidro is farther from Poblacion, we had lunch there. There was food catering for all the people in the RHU. Carbonara pasta and apple juice were served along with vegetables.

My third rotation was the VIA and breast exam. A VIA involves examining the uterine cervix naked eye after applying 5% acetic acid for one minute and interpreting the results. This test is for early cervical cancer and cervical precancerous lesions and is simple and inexpensive.

First, every patient underwent a breast examination to check for lumps. Then, mama Tess, the RHU midwife, administered the VIA test to every patient. As for sterilizing the vaginal speculum, they just placed it in 2% glutaraldehyde solution and waited a few minutes before using it on another patient. I was concerned that the old solution wasn’t thrown away and replaced every time a new patient was assessed. I’m not sure if a shortage of resources played a part in this or if the sterilizing solution was really strong enough. Afterward, the gynecologist, Dr. Rhaiza Enriquez, discussed the patient’s results and whether further examinations were necessary. As part of the check-up, the gynecologist showed visuals to the patients of what cervical cancer looks like, what it entails, and the importance of yearly screenings. That showed how much public health is incorporated into check-up conversations, which I appreciated because it is an important opportunity to educate.

Last but not least, I observed the internal medicine doctor who is also the provincial health officer. Individual treatment records were already available for each patient. It is common for his patients to be malnourished. Some had neuropathy pain, almoranas (otherwise known as hemorrhoids), acid reflux, and stomach pains. All of these health issues can be caused by certain foods, so he advised them to avoid them.

It was a very long day filled with lots of enlightening information, so when we got back to the RHU, we had a debrief. Dr. Jobin and I discussed my outputs and how I could get started on them since I only have one week and a half to complete all three. He gave me some documents to read to help with each outputs. Then, we all went home at 5:00 PM.

It’s Friday once again! It’s the last day of the vaccine event, and we’re stationed at Barangay San Roque in another covered basketball court. Since one of my first outputs was about the implementation of the Chikiting Ligatas vaccine campaign, I was multitasking by observing the vaccine event and writing about it at the same time. I spent an hour and a half reviewing documents and writing before Sydney, nurse Alvin, and I decided to take a break and played PIG basketball game while waiting for more children to come. Each time I had the ball towards the last three times, I consecutively made the shot and won the game. There was more luck involved than skill in this case. After this, we went back to Mama Li’s house for lunch, and it had been raining heavily on the island at this point.

Upon returning to the RHU at 1:00 PM, I conducted my first focus group discussion (FGD) with the public health nurses and encoder of the municipal health unit, which is the RHU staff. Due to his role as my local preceptor, Dr. Jobin declined to be interviewed to avoid bias. This was for one of my outputs, an assessment of the Philippine Integrated Disease Surveillance and Response System (PIDSR). While I conducted the FGD in the RHU’s lab room, the other students attended an event at Barangay Camili to celebrate the newly created isolation room. For the FGD, I had 12 questions to ask, and the interview took about 45 minutes to complete according to my voice memo records.

After that, I asked Dr. Jobin if I could join the event. He said yes since it has significant public health implications, so I was taken by ambulance van to the event. The panel included all the important government officials and Dr. Jobin. There has been a long-standing shortage of isolation rooms and proper healthcare facilities within the Philippine healthcare system. Disease outbreaks or pandemics, such as the COVID-19 pandemic, have particularly highlighted this issue. In rural and remote areas, where access to healthcare is limited, isolation room shortages are more prevalent. Overcrowding is a result of a number of factors, including a large population and limited healthcare facilities. Since they were so unprepared when the COVID-19 pandemic struck, funds came from DoH to have these rooms ready for next time when isolation rooms are needed.

Since a Filipino event wouldn’t be complete without entertainment, the BHWs prepared a dance between lectures to keep everyone engaged. They performed a dance in front of everyone, and they asked us to dance with them, so Bailey, Sydney, and I danced. It was a nice break from all the important information. We had an early dinner with them afterward since it was almost the end of the workday. After the ribbon cutting, we were able to enter the new isolation rooms, which consisted of cement-bound rooms. It looked like a foundation had been created, but it needed furniture and doors to create comfort at a very isolating time. It was still a great success, and we discussed the need to create more isolation rooms in other barangays.

A new week has begun. At the RHU, I observed Ate Kate, also known as Ate Kring-Kring, our laboratory technician. When patients come to the lab, they knock on the window of the RHU, and that is how she usually takes them. In talking with Ate Kring-Kring for a few hours, I learned more about her, how she got the job, and what a lab technician does. Typically, patients come for routine urinalysis, blood uric acid test, fecalysis, and lipid panels. All of these are free as well. In her opinion, the patients should be seen by Dr. Jobin first since that will allow the correct tests to be requested, instead of the patients requesting tests that they might not even need initially. There are a lot of patients who have to come back the next day because some tests require patients to fast before getting screened.

While waiting for patients, she checked my blood type since I had never had it checked before. As she explained to me, blood typing uses reagents containing antibodies that bind to antigens on red blood cells’ surfaces. The ABO and Rh systems work like this:

• Antigen A serum contains antibodies that bind to antigen A. Anti-A serum reacts with the blood sample, indicating the presence of antigen A on the red blood cells.
• Anti-B Serum: Antibodies react with antigen B. The presence of antigen B on red blood cells indicates blood type B if the blood sample reacts with anti-B serum.
• A blood sample that reacts with both anti-A and anti-B serums indicates the presence of both antigens A and B, indicating blood type AB.
• If neither anti-A nor anti-B serum reacts with the blood sample, blood type O results from the absence of both antigens.
• Anti-Rh (Anti-D) Serum: Contains antibodies against Rh factor. Resulting in a positive Rh blood type if the blood sample reacts with anti-Rh serum.
• Negative Rh blood type results from a blood sample that does not react with anti-Rh serum.

In the picture above, you can see I have a Type O positive blood type, which explains why mosquitoes love me so much. After this, the other students and I went home and had lunch at Mama Li’s.

Tomorrow, Dr. Gyra will ride the ferry back to Manila, ending her medical rotation in Alcantara. As soon as we returned to the RHU, we took pictures with Dr. Gyra and the RHU staff, so she would have a memory of her rotation. My remaining time was spent analyzing the recording of last Friday’s FGD and preparing and printing the survey questions I plan to give to the provincial health office staff at Odiongan, which I will be going to tomorrow for half of my day to complete my FGD for my PIDSR output.

After work was over, Dr. Arlene, the doctor from New York, invited us for dinner at Tankey’s, a fancy restaurant on Tablas Island, with her children, whom we met on Saturday when we went island hopping to Romblon, Romblon.

Dr. Gyra was leaving today to go back to Manila, so she is not at the RHU but packing for her trip home. She is my roommate at Mama Li’s house, so selfishly, I did not want her to leave. In addition, Typhoon Betty is looming over us, so her ferry ride might be canceled if a gale warning is issued.  The plan was for me to travel to Odiongan today to continue my project work. My lunch was packed by Mama Li along with ate Mariju, who will accompany me at the PHO all day. As usual, we were taken by ambulance van. PHO is about 45 minutes to 50 minutes away, so it is a long drive. I was sad that day because Dr. Gyra had to leave. However, I knew I had to finish this output since my time with the program is close to its end as well. It was a windy ride to the PHO. When we drove past the shoreline, the waves were wild and turbulent, so I anticipated a gale warning.

When we arrived, I was disappointed to find that the rest of the provincial epidemiologic surveillance unit staff were absent due to a training taking place elsewhere. The public health disease surveillance nurse was present, but she had to attend a meeting first. While I had to wait for her to finish their meeting, she also attempted to get the two disease surveillance officers to come back to the PHO, so I could conduct the FGD quickly with them. As the public health disease surveillance nurse attended her meeting, I interviewed the two disease surveillance officers for about 30 minutes. I let them fill out the survey questions, and they left. I waited some more, but the storm got worse and all power was out, so they couldn’t connect to the meeting. After waiting for 5 minutes, the public health disease surveillance officer initiated the FGD, which lasted for 51 minutes. After that, ate Mariju and I took our lunch break at 11:30 AM. At 12:30 PM, we resumed working. At the PHO, the power was still out. Due to the storm, the public health disease surveillance nurse received a text saying all work has been canceled for the rest of the day, so everyone should head home before the weather worsens. As soon as Dr. Jobin received the government-issued announcement, the ambulance van was en route to come pick us up.

Bailey, Sydney, and Dr. Jobin were also in the van, so we rode back to Alcantara during the storm. Since work had been canceled, and Odiongan City had the best internet connection, Dr. Jobin dropped us off at a cafe so we could continue working. Dr. Gyra was still at Mama Li’s house. Her ferry ride was canceled due to the typhoon. We were glad to be in the cafe since it gave us a taste of home. There were yummy cheesecakes and lattes there. Before Dr. Jobin picked us up to go home to Mama Li’s, we spent an hour there. The storm was finally starting to calm down. Also, it was Chok’s birthday, which is Mama Li’s granddaughter, whom I became close to during the course of my stay there. My daily routine after work included playing with Choks since she had no one to play with at home.

Mama Li hosted a gathering to celebrate Choks. Chok’s birthday was the most important thing to Dr. Gyra, if her ferry was cancelled.  We felt the same as we all got closer to Choks as well because she is so likable and adorable. Mama Li invited the neighbors’ children for the celebration. Choks had party games like the pabitin in the picture above, where they hang a wooden lattice tied with various goodie bags up in the air for the children to jump and try to grab as many as they can. The fact that this tradition is being continued makes me extremely happy since it is the same games I used to play as a child when I lived in the Philippines. The night ended with a birthday gift for Choks that we all bought together.

It is Thursday today. As a result of typhoon Betty, our entire work day was canceled on Wednesday. All day long it rained. There were intermittent blackouts all day, and we barely had any internet connection. During the rain, the temperature rises dramatically, and all the bugs emerge. Though it was hard, we had no choice but to go with nature’s flow. Finally, the rain was not as heavy today, so I returned to PHO for the day. I completed the FGD with the disease surveillance assistant and data encoder, and they answered my survey questions as well. Then, they guided me step-by-step through using PIDSR online since the internet connection worked again. I wrote up the introduction, background, methodology, results, and discussion of my PIDSR evaluation report in the remaining time I had in PHO. I had my lunch there again with ate Mariju. We left around 3:30 PM that day. As I only had a short time left in the program, I found it easy to focus from the pressure and typed 18 pages. Dr. Jobin picked me up and took me back to the RHU. After the hour-long ride, I had only 30 minutes left before work ended. Dr. Jobin reviewed the work I’ve done so far and gave me feedback, so I could fix it up outside of work. On top of that, I had to complete two other outputs, so I was definitely feeling the pressure. I was so focused that I almost forgot to mention that Dr. Gyra left and made it back safely to Manila.

As this was my last weekend in Romblon, Dr. Jobin rewarded me with a weekend trip to Boracay, which was only two hours away by ferry. With Bailey and Sydney, I have already established a closer friendship, so we all went to Boracay together with Dr. Jobin as our chaperone. My heart ached when I realized that after this weekend was over, I only had 3 days left with the people I have grown used to and trusted.

Monday started my last week at the RHU. In the time I had remaining, Dr. Jobin allowed me to finish my three outputs, so I stayed at the RHU sitting and writing for the entire time. Since the internet was working well in the RHU for the first time, I was able to complete 80% of my output. It felt good to be at the RHU again. Having spent the past two days at the PHO, I missed the friends I’ve made at the RHU. My output was conveniently available to Dr. Jobin, so I could ask him questions about it.

Throughout Tuesday, I continued to write until I finished all three outputs. Dr. Jobin reviewed them and made minor adjustments throughout the day until we officially capped them off. As an alternative to the daily blogs that I have been posting, it felt so fulfilling to finally put all that I have learned into an official written work. A weight lifted off my shoulders, and I was able to enjoy and reflect on the time I’d had with my friends at the RHU since tomorrow, I also have to pack and get all my stuff ready for my travel back to Manila early on Thursday.

That night, I decided to invite the nannies and cooks at Mama Li’s house to dinner at Tankey’s. They’re the ones who have been providing our meals, doing our laundry, and helping us in any way possible to feel more welcome. Thank you ate Jo and Irene for everything.

On Wednesday, I had my last full day at the RHU. It was important to me to take everything in without distractions. As a life-changing experience for me, I just wanted to feel everything and have no regrets about my time here. I hosted a party and ordered some of my favorite food I had in Alcantara. The Filipino tradition is for the host to throw the party and serve the guests, not the other way around, so if it’s your birthday, you should treat everyone, not everyone should treat you. It was important to me that my last memory at the RHU be a memorable one. At the RHU, Dr. Jobin and I had a debrief, and he gave me a marble nameplate with CFHI on it. At night, Mama Li, Bailey, Sydney, and Dr. Jobin prepared a nice, intimate dinner for me with them.

To all the wonderful people in these pictures — I am so grateful from the bottom of my heart. My professional and personal lives have been greatly enhanced by your contributions. I am amazed by everyone’s commitment to their community. It is truly inspiring to see how willing you all are to lend a helping hand, share your expertise, and collaborate on projects. My days were brightened by the positivity and genuine enthusiasm of the group. No matter what you do, whether it’s a warm smile in the morning or encouraging words, everyone’s presence brought me some sort of comfort and reassurance especially being away from my family.

To Dr. Jobin — You have shown me unwavering dedication, continued support, and unwavering kindness throughout this process. I am so thankful to CFHI for giving me you as my local preceptor. Thank you for your outstanding leadership and guidance and for showing me your beautiful home, the island of Romblon.

To Mama Li and family — As my host mom, your home has truly become a home away from home for me. Thanks for making me feel welcome and comfortable, and I am truly grateful for the care and support you provided. My experience would not have been the same without your kindness and generosity – I am grateful for all you did for me.

With warmest regards,
Thea

On Thursday morning, I was given an emergency seat on a flight back to Manila. I landed at around 9:45 AM. Luckily, Dr. Ged managed to get me a ride back to the Hotel Kimberly, where it all began. Being back in Manila was bittersweet since Audrey and Sophia, the people I started with, were not there. After completing their program, they returned to the U.S. a week ago. I was put in a room with a new group of girls just starting their program. Since I have already experienced what they are experiencing, it felt like a full-circle moment for me. I spent the entire day by myself since it was my first day outside of my rotation. As part of my reflections on my time at Alcantara, I created PowerPoint slides for my CFHI Global Health in Philippines Exit Report presentation. I will present for Drs. Lopao, Ged, and Ken the following day. On that night, I had dinner with half of the new students and met the two girls, Isabella and Elizabeth, whom I am rooming with for the next two nights in Manila. Having taught them what I knew and warned them of what was to come, I felt like a big sister.

The next day, I spent the day reviewing my presentation again before meeting up with Drs. Lopao, Ged, and Ken. At the public health building, where Dr. Lopao has his office, I presented. I performed what they call “Pecha Kucha.” Pecha Kucha means “chit-chat” in Japanese. This Japanese presentation style keeps presentations concise, engaging, and visually stimulating. They requested 20 pictures, which are the pictures I have already included in past blog posts. I explained why I chose the four images I put in the slides to represent each week of my CFHI experience. They also asked me questions, which I have pasted below with my answers.

Discover

• Different Capacity Building Efforts
  • Community-driven initiatives RHU supports to improve health outcomes in their community
  • Taking on multiple responsibilities due to staff shortage
  • Using social media to get patient information
  • Barangay Health Workers super involved role in the health  community

Surprise

• The level of responsibility and hands-on experience I got to experience during my practicum
• The number of things that would be considered HIPAA Violations in the U.S.
• The entire process of rabies and Chikiting Ligtas vaccination campaign
• Some things feel performative or end up being seen as performative instead of actual help
• The occupations that makes up the rural health units
• The crazy amount of times Filipinos can eat

Affirmed

• Filipino people are one of the strongest groups of people I know!
• The program was a perfect fit for me, and I am thankful for having to observe all the amazing healthcare workers I met in the program.
• Any work to advance the health system is destroyed by natural disasters.

Questions

• How much coverage does the 4 Ps include?
• Does it cover the surgery? Daily chronic diseases checkups like blood glucose testing?

How did the practicum contribute to your understanding of Global Health?

• Learn about the social, cultural, and economic factors affecting health and healthcare in the Philippines.
• Witness how healthcare is delivered in resource-limited settings.
• Analyze Alcantara’s unique health challenges, the local healthcare practices, and the strategies used to deal with them.
• Work with professionals from different fields and learn from them.
• Understand and reflect on my global health experiences, cultural biases, and ethical considerations
• Enhance cultural humility and sensitivity by developing a nuanced understanding of challenges and ethical dimensions in diverse healthcare settings

How does your practicum experience impact your career and future practice as a Global Health Practitioner?

• Developing a deeper understanding of global health’s unique challenges.
• Developing cross-cultural communication skills, resource management, community engagement, and interprofessional teamwork skills
• The opportunity to network with professionals from diverse backgrounds also broadens my understanding of global health.
• Working at a policy-level as that’s where the community’s issues are rooted.

Drs. Lopao, Ged, and Ken gave me very encouraging feedback that I will never forget. I was treated to an All-You-Can-Eat buffet, which I enjoyed to the fullest since it was the last time I would not have to pay for food. There, Dr. Joel met up with us. We discussed a little more about my experience since he was not able to make it to my presentation. Then, they gave me my certificate. I was officially a CFHI alumna!

I would like to thank the entire team for organizing such an informative and comprehensive program. I am excited about the long-term impact that CFHI Global Health Philippines will have on my career as it has undoubtedly accelerated my growth. With the insights I gained from health professionals and the practicum skills I acquired, I have already made significant progress in my career.

During my three weekends in Alcantara, I explored the surrounding islands. On my first weekend, I visited Carabao Island with three new friends I made from RHU staff. My second weekend was spent exploring Romblon Island, which is the capital of Romblon. The marble capital is located here. On my third weekend, we went to Boracay Island. These are some pictures we took during our “R&R” (Rest and Recreation). The fact that I was able to explore so much of Romblon surprised me since I thought my weekends were only going to be spent in Alcantara. I even downloaded many podcasts to listen to on Spotify during the weekends, so I can spend time listening and reflecting. I am grateful that I was able to do this instead. I have enjoyed discovering what these beautiful islands have to offer with new friends.