Tuesday, September 30, 2008

DOH: Department of Hoodwinking

August 30, 2008

It has happened; I have fallen in love with the Philippines. I know this to be true because at the CHD health sector picket to demand access to cheaper essential medicines outside the Department of Health I feel such a passionate anger that I have to pace around to burn off the energy. What I see painted on the walls of the DOH is in such stark contrast with the reality I witness in the community that I rename the DOH the ‘Department of Hoodwinking’.

Why hoodwink? The government propaganda is everywhere in Manila, convincing the middle class and the upper echelons of the working class that the government responds to the needs to the people and provides adequate health services. Check this out!



First I see a mural lauding the DOH clinics in the community. OK, I am confused. No community I have visited has had a clinic, but rather the odd Barangay health centre, which, when it exists, is far too often little more than a room with a very few supplies, occasionally staffed by an over-worked, under-paid midwife (cum doctor, cum nurse). Patients often have to walk very far for the few services, such as vaccinations, which are offered. Although in government propaganda TB medicines are provided for free for all infected, in reality even if there are TB meds, they are very expensive. Most do not complete the multi-drug formula for the necessary 6 months. What else can the Community Health Workers do but teach about preventing communication! In San Isidro, there is actually an ambulance, which looks terrific; in practice the fee is 1,500P paid in advance for the trip to the hospital! The average daily wage, when sugar work is available, is less than 100P per day, so that explains why the ambulance still looks so shiny and new – people can’t afford to use it!



Next I pass a beautiful mural lauding the provision of safe drinking water. It’s a joke, right? What community is that? Any place I have visited that has safe drinking water, it has been the People’s Organization, and NOT the government, which has ensured clean water to drink and bathe by piping water down from upland springs, or building enclosed cisterns over deep wells to prevent contamination from shallow ground water. Most rural communities I have visited have few toilets so people use the fields as their toilet and then use ground water or stream water to drink and to bathe. Given the incidence and death toll from diarrhea, the 3rd leading cause of death in children, this isn’t merely about good health, but a matter of basic survival.



Now, my personal favourite! The DOH Superman delivering iodized salt to the people. This really is a joke – the irony is sadly hilarious. I can’t even keep track of the number of women I have seen in the mountain provinces with goiter. Keep in mind, women of childbearing age, having many babies, with such a terrible risk to a diet inadequate in iodine; as the mural explains: still birth, cretinism, dwarfism, poor cognitive development to name a few. Women struggle to use iodized salt, as there is little incentive for sari-sari store owners to sell it as they make less profit from it.



Another beauty, the smiling kids with lovely white teeth, visiting the what? The dental clinic? I never saw one, personally, in my many months of travels to rural communities. I did, however, see countless children with poor dentition and many carries, in terrible need of dental care. I saw children who were refusing to eat due to pain from rotting teeth. It was heartbreaking. I can think of several great programs that would increase prevention and provide basic dental care at the community level – but alas, despite the lovely propaganda, the DOH does not really care for children’s dental health.



There were many lovely murals to describe, but in the interest of brevity, I will conclude with the mural lauding environmental protection. Can anyone say “PhilEx”? Let our coming testimonials on the impacts of multinational mining operations attest to the GMA position on ‘environmental protection’ in the Philippines.

Saturday, September 20, 2008

Called to Deliver a Baby ‘Half-Born’: the Struggle to Survive in Rural Philippines



*Warning -- this blog entry is graphic*

After lunch Aiyanas and I were playing chess when there was a commotion in the clinic, and I heard “Martha” and “bata” (baby) and a bunch of excited talking, so I poked my head out front to see what was going on. The ‘ice candy lady’ from the elementary school was in the clinic with Josephine and Erwin, saying that Grace had delivered, but the baby was breech and only half-born; the Lola was there delivering the baby and now they need help. What is going on? I am full of disbelief; the baby is half-born? Why are we standing here talking? Josephine calls to Nanay, who comes running back to the clinic, I grab my backpack with my birth equipment, Aiyanas grabs me some pesos to pay for a hubble-hubble (motorcycle) and Nanay and I are off at a run up to the road to catch a ride to Grace’s house. It must have taken us 20 minutes to get there from the time I first heard the news of the baby half-born; we arrived just after 3:40 pm.

Why didn't they come get us sooner? I learned that Grace was afraid because the military detachment is across the road, and last night they were firing at random.

Entering the house I am struck by Grace’s position; Grace is up on the sleeping platform lying supine, knees bent, legs covered with a blanket, and Lola has her hands under the blanket. It is dark in the house though it is still light outside. Is there a baby I ask? Yes, they say, half-born up to the neck. Without thinking I am pulling off the blanket and calling for Grace to turn so the breech hangs; somehow I have gloves on, but I barely remember getting them and my kit out as we entered the house. I put my hand inside Grace’s vagina to feel what is going on. I feel the baby’s face anterior, his little body is so blue and cold and his back is anterior, his neck is twisted, he is obviously dead. He is so small I am suspicious, since it doesn’t fit with how pregnant we thought Grace was.

I feel another head following - twins. Gently I push the second head back up the vagina; Nanay gives me some suprapubic pressure and the first twin disimpacts and is delivered onto Grace. Then directly the second twin is delivered up onto Grace. I feel the cords of the babies and the second twin has a pulse, so I grab my clamps from my kit and clamp the cords, free the second twin first, and start to ventilate him. I check his heart rate, but it is so chaotic in the house I can barely hear, I think I get about 60 beats per minute. I show Nanay how to do chest compressions while I ventilate, but we can’t get coordinated, so after perhaps 15 seconds I listen with my Doppler and count 100 bpm! We clear the small table and place the second twin onto a pair of soft track pants I grab from the clothes pile nearby. I instruct Nanay how to ventilate, make sure his little chest is rising and he is getting at least 40 breaths per minute.

Time to switch my attention to Grace, who is lying supine with her eyes closed. Is she conscious? Is she bleeding? Is she in shock? I cut the cord of the still born twin, bundle him, and set him next to his brother. I coax Grace awake and up into a squat to get the placenta out, intact, great, just to be safe I quickly draw up one of my precious vials of oxytocin and give it to her. Her BP is good, 120/80. Nanay checks Grace’s perineum, and there is only a very small tear, which is good because there is no time to suture. I am very worried about Grace and her emotional state, so Lola comes to sit with her and hold her hand. Time to switch back to second baby boy and make sure he is doing OK.

Before I take over ventilations again, I listen with the Doppler one more time so I can hear his heart rate clearly in the noisy, crowded hut. Why are there so many people here? We shoo some people outside, and listen, getting a heart rate of 140, with my stethoscope I can hear air entry with ventilations, his lips and face are pink. Why isn’t this little guy breathing? I quickly examine him and can see he is quite premature: smooth foot soles, smooth scrotum, soft ear cartilage, testicles undescended. Grace wasn’t 8 months pregnant, as I thought; I realize she was likely only 7 months but big due to the twins. The lack of adequate prenatal care in the communities is outrageous. This little guy needs intensive care; we need to transfer him as soon as possible. I take over ventilating again, and Nanay is freed to help with the transfer.

This discussion takes a painfully long time. The babies were born at 3:45 and 3:46, and it is now after 4:15 and they are still talking about what to do. I explain, hoping that it will be understood, that they can decide to transfer to the hospital or they can stay home and the baby will die. It sounds crass, but I realized that they have to make the decision about what is right. Now that I write this, I wonder, did it sound judgemental? It is not the way I intended it to sound and I hope it wasn’t taken that way. But this persistent little boy is taking some breaths! The conclusion is they will go to the hospital; now we need to get the truck so we can ventilate the baby on the way. This will require permission and a driver from the Barangay Capitan. There is a problem, I still don’t know what, with the local Barangay Capitan, and so they have to ask in Hilaiton which is 45-60 minutes away.

Nanay and I hunker down to business, and develop a rhythm of adding 3 breaths between each one of little baby’s so that he is getting 40 breaths per minute. I balance my newborn stethoscope on his little chest so I can time my breaths to his heart rate, hear the air entry, and monitor his independent breaths. We request some hot water bottles which we tuck around his body. I place a nasogastric tube, but I do not carry an ET tube and laryngoscope, so we use a mask to ventilate. After an hour or so I am exhausted, and I want to examine the first twin and the placenta, so Nanay does an ambubag shift. I go to pee, and see the military watching from the detachment across the road. This just enrages me – 10 times the funding of the health care system and they sit and watch as babies die.

Very carefully I pick up the first little guy and take him to the adjoining Nipa hut so I can examine him thoroughly without so many observers. He is so tiny, weighing in at 1.5 kilos including the weight of his blanket. It feels like his neck is broken, and he has dark bruises on his abdomen over his palpable liver. I wrap him in a blanket, lay him on the pretty blue fabric of my scale sling, and quickly take his photo for Grace and Randy. My belief is that these are mono-chorionic, mono-amniotic twins, with the first twin transfusing blood, oxygen and nutrients to the larger and more robust second twin, but this is only a guess. There is only one placenta with two cords of close insertion, and for the life of me I can only see one sheer set of membranes, but it is impossible to tell and I am rushing; in any case we will bring the placenta with us.

Now back to business of ensuring the ventilation is going well and preparing for transport. We hear news that the truck from Hilaiton is on its way! Great, this little trooper is hanging in there, so we will make it! I take over ventilations again and Nanay gets a board and some blankets ready so we can ventilate in the back of the truck. Finally after 6:00 pm the truck arrives and we are off on the long trip to the hospital. Sometimes the road is so bumpy the board is bouncing, I try to protect his little head, and the little guy’s heart rate is always over 100. After what seemed like an endless journey of heart beats and breaths, heart beats and breaths, we arrive at the hospital.

As the truck pulls up, Nanay calls out ‘emergency, emergency’ and an orderly comes running. We get baby boy out of the truck and quickly onto the examination table in the ER operation room. I keep ventilating until the doctor comes and takes over care of the baby. The doctor quickly concludes that the baby is premature and needs CPAP (continuous positive airway pressure) and I completely agree! Great! Let’s get it going! But… there is no equipment for premature babies at this hospital, so we will have to go to Dumaguete. Why is the nurse not ventilating the baby? What is going on?

Randy, the father of the baby, shakes his head and sadly explains there is no money for going to a private hospital in Dumaguete. The doctor then asks Randy if he will admit the baby at this hospital, and Randy agrees. But what will they do here? They provide free-flow 100% oxygen through an ET tube, which it takes 20 minutes to place because they can’t find an ET tube small enough in their ancient crash cart; the baby is only breathing ten times per minute and there is no equipment to ventilate. They give him dextrose through an IV. I know that he will die, but my heart still hopes. Randy and I sit with him, and Randy asks me why the first twin died. I gently tell him I think he was born too early and his lungs were not ready, but I can’t bring myself to mention his injuries. Randy thinks his second son is a fighter, and I agree with heavy heart, knowing he isn’t getting the care he needs to give it a fighting chance.

Nanay and I are exhausted, it is now after 9:00 pm and I need to wash and lie down. We will spend the night at Nanay’s Auntie’s. After sleeping in fits and starts we return at 6:00 to learn that the baby boy died at 3:00 am and Randy has already taken him home. I am so angry! I am so sad! The pictures of Gloria Macapagal Arroyo smiling on the wall of the hospital are enraging! How can she justify a national budget where debt payments are 63 times the national health budget? How can the military, which harasses and intimidates the people, be a priority over equipment necessary to save newborn babies? How can the military sit and watch while Randy scrambles to find a ride to the hospital? It is so backward I feel like kicking over that stupid (and grossly under-stocked) crash cart that sits nearby. I cry on the hubble-hubble ride home, thinking how Grace and Randy must be suffering, and my beautiful little patient who didn’t make it.

Now we are home and the story is already widely known. Will anything change? Perhaps more people will join the rally in Guihulgnan Town on Sunday. Perhaps the People’s Organization will gain more members as the string of injustices that lead to the deaths of these boys is discussed in the community. I am moved by the strength of the optimism, even among those who suffer terrible injustices; hope that things will change if the people are united, committed and share a common vision of justice for all.

Hey Terrence and Pipay!

We miss you!

Negros Medical Mission Slideshow

The Negros Medical Mission: Service and Solidarity

September 20, 2008

Kalabaklabakan Mountain Clinic

Last weekend, September 13 and 14, was the large and greatly anticipated Negros Mercy Mission: a Medical and Psycho-Social Mission which brought over a dozen doctors, community health workers, organizers and documenters to three rural communities of Guihulgnan, including Kalabaklabakan, in Barangay Trinidad.

The mission was spearheaded by the local People’s Organization (PO), Kaugma-on, literally ‘future of the small farmers’, and supported by several organizations from Cebu, Bacolod and Manila, including the Negros Island Health Integrated Program (NIHIP), the Council for Health and Development (CHD), and progressive party list Bayan Muna. The mission was one of service to the people, and solidarity with their struggle for justice and against the intensified militarization; Guihulgnan is now identified as a priority area for the AFP aggressive war of counter-insurgency, an operation which causes many human rights violations, physical harm and psychological trauma for the peasants.

Over 460 patients received treatment during the two day mission in Kalabaklabakan, including doctor consultations, essential medicines, prenatal care, psychological counselling and minor surgeries. Despite repeated attempts from the AFP Infantry Battalion (IB) 11 to enter the private clinic premises, and to intimidate and harass those patients entering the clinic compound, the mission was a resounding success, and many patients had their sufferings eased by the mission teams.

While the medical care provided through missions is only but a small band aid for the large wounds of the people, the demonstration of solidarity from the urban areas and the large organizations such as CHD and Bayan Muna is a tremendous boost to the local PO. Missions send a clear message to the military and the government that those struggling peasant farmers in the countryside are not forgotten, rather are of fundamental importance, to those who struggle in the urban areas.

Tuloy Ang Laban!