A mission with Project HOPE in the Philippines
I traveled to the Philippines in December, and by then, three weeks had come and gone since a Category 5 storm called Typhoon Yolanda whipped across that island country, killing and injuring thousands and leaving many more homeless and hungry.
I have been a nurse practitioner and midwife for years, but this was my first overseas mission, and on the flight over I reflected on a quote by Amelia Earhart: “Better [to] do a good deed near at home than go far away and burn incense.” I wondered if I was doing the right thing.
The Nov. 8 storm, called Typhoon Haiyan outside the Philippines, had been devastating. By early December, the periods of intense emergency relief, along with the search and rescue efforts, had ended. The affected towns were in a period of early recovery. But serious problems remained with the country’s infrastructure, including running water and electricity.
When I landed in Manila, it was not at all evident the Philippines was in any sort of crisis. But during the hourlong flight from Manila to Roxas City on Panay Island, another passenger told me she had received news from her family that food was scarce. Ten people in her relative’s family had received a total ration of only about 2 pounds of rice a day.
At Roxas City, I could see signs of the typhoon’s heavy winds — downed trees and the absence of a roof on the arrival section of the airport. Nevertheless, and perhaps foretelling the upbeat attitude of the Filipinos I was to encounter, a group of local guitar-playing folk singers greeted us with song as the flight offloaded at 6:10 a.m., Dec. 4, and I began my two-week stay.
The Project HOPE volunteer mission director and two other volunteers greeted me at the airport.
Project HOPE, an acronym for Health Opportunities for People Everywhere, is a nonprofit organization founded in 1958 to deliver humanitarian medical assistance worldwide. Volunteer doctors, nurses and other health care providers, accompanied by medical equipment and pharmaceuticals, travel to their destinations aboard the SS HOPE, a former U.S. Navy vessel that became the world’s first peacetime hospital ship.
I had long been familiar with Project HOPE from afar, and now, without a school-age child at home, I wanted to participate in its programs.
Before long, I was heading to Tapaz, the central municipality that would be the base of our outreach operations. I was with the three other HOPE volunteers, a driver and plainclothes military escort. There had been al-Qaida activity in that part of the region, and I was told when I arrived that we were going to a site where other humanitarian organizations did not want to go.
Along the road was more evidence of the storm’s devastation. Snapped or totally uprooted utility poles were the rule. Clumps of power and telephone lines lay on the ground or had been re-assigned to jobs as clotheslines. Young children skipped over the downed lines in their neat school uniforms — oblivious to the latent danger.
The main road had been under construction when the storm hit. Parts were in excellent condition. Parts were flooded and completely washed over. Trees littered the roadsides — many sawed into board lengths on the spot. Tangles of trees obstructed countless driveways or small side roads.
Scores of homes were severely damaged or totally destroyed. Concrete houses still stood, but some had been unroofed — or now sported a tree or two sticking through the roof.
The vast majority of homes had been constructed much as you might expect when someone is building out-of-pocket and raising a young family at the same time. They were put together with readily available materials suited to the typical climate, usually bamboo, and little attention was paid to the foundation. Roofs were made from grass thatching or corrugated aluminum. Structures of this type that survived Typhoon Yolanda were simply lucky enough to have been out of the storm’s path.
Twisted roof lines and collapsed walls — with remnants of previously organized bamboo and thatching — often shadowed newly constructed lean-tos or other temporary housing. Later, patients told me that extended families lived in these cramped structures.
After reaching our Tapaz headquarters, we settled in with 17 other volunteers at the generously offered home of the mayor’s sister. While there, a call came in: The staff at the hospital was having difficulty getting an IV started on a baby.
En route to the hospital, our mission director — who had taken the call from a team member at the hospital — laid out the problem for us. The baby was premature – 29 weeks gestation — and her twin sister had not survived birth. The mother had four previous full-term pregnancies and healthy children. Typhoon Yolanda hit when she was at 27 weeks gestation, and the family had lost its home. No doubt the premature labor resulted from the stress of the storm on a woman with an already higher-risk pregnancy. The baby, now 1 week old, had been kept alive with an IV line and breast-feeding.
On the way to the hospital, I had convinced myself that the reported gestational age must have been incorrect. A baby at 29 weeks gestation could not still be alive, given the lack of neonatal intensive care capabilities — and certainly was not capable of breast-feeding! The sucking reflex would not be well-coordinated or efficient. A baby of 29 weeks gestation would not have enough strength with her immature sucking ability to get an adequate supply of breast milk for survival.
We arrived at the hospital, an old, battered building with parts of the roof missing. Patients and visitors used umbrellas in some of the rooms. The windows were open. Flies, mosquitoes and ants were at home there.
Upon seeing the baby, I could not take a breath. The infant appeared to be about a pound. (There was no birth weight available. Later, we weighed her, and the scale registered 21 ounces.) Her anterior fontanelle, the soft spot on the head, was sunken. Her nostrils were flaring. Her chest retracted with every breath.
She was lying on an adult hospital bed that looked as though left over from World War II. Her mother and four brothers and sisters were close at hand. The window was open. The temperature was in the 80s with near 100 percent humidity and frequent showers.
Despite the heat, the baby was in a swaddling blanket, and a gooseneck lamp was positioned fairly close to her. I feared this was contributing to dehydration. It was impossible to conceal my alarm. The words shot out of my mouth. “We’ve got to get this kid out of here. Let’s see if we can get the Navy to help us.”
Volunteer nurses from Massachusetts General Hospital, who were also on the scene, explained to me that they had already talked with the family about moving the baby and were told the family didn’t want to do that — and could not afford it. There is no health insurance. Families must pay for all the supplies, down to individual cotton balls.
The IV did not happen that afternoon. An oral gastric feeding tube, however, was deftly installed by one of the volunteer nurses from Massachusetts General.
The mother was then shown how to express milk from her breast. But without a strong suck a mother’s milk supply will dwindle. This mother’s supply had been minimally encouraged by the weak suck of the newborn. The mom was able to produce only about half a teaspoon every couple of hours. Nevertheless, in the milk went – through the feeding tube so the baby wouldn’t have to spend her energy sucking it in.
The Massachusetts General nurses were able to purchase formula at the local market, but there was nothing suitable for the immature digestive tract of this premature infant. And so there the baby stayed, a tiny creature clinging to life under the expectant watch of nurses, volunteers and a worried family.
On my second day in Tapaz I was introduced to the municipality’s community health team during its annual meeting and election of officers. The team consists of a handful of public health nurses, midwives and liaison health workers. They had traveled from outlying communities, including places classified as “geographically isolated depressed areas.”
There were more than 200 people at the meeting. I was impressed by the number of trained providers. Not all the birth attendants are nurse-midwives, but they have formal training and are providing relatively low-tech obstetric care, primarily due to their low-tech supplies.
I could see when I later traveled to outlying birth centers that they have practices not aligned with nurse midwifery in United States. For example, episiotomies are done routinely, and all mothers basically deliver in the same position on a narrow and rigid birth table. (But it is outside the scope of relief work to address changes in styles of medical practice.)
Most of the communities have a birthing center. First-time mothers, any moms with a complicated pregnancy and grand-multiparas (those on their sixth pregnancy or more) are encouraged to travel to Tapaz to deliver at the hospital.
The community health team provides pregnant mothers with care that includes routine prenatal exams, prenatal exercise classes and breast-feeding education. The team also addresses immunizations, protective treatment for worming and infectious-disease screening, tracking and treatment.
Posted on a floor-to-ceiling board inside and sometimes outside the clinics is a proclamation of the community’s family planning statistics: number of births per year, various types of family planning methods, the number of users of each type and complications including postpartum hemorrhage.
I became convinced that the community health team is doing a great job. The infection rate associated with childbirth is very low. The breast-feeding rate is close to 100 percent. Because obesity is relatively rare and nonhospital deliveries are limited to the second through fifth babies, delivery complications are minimized. Mothers certainly seemed very happy with the care they were receiving.
As part of Project HOPE’s first land-based mission, we had some additional responsibilities: hauling, unpacking and inventorying supplies, which arrived a few days after we did in about a hundred 40- to 80-pound boxes, and sorting and counting medications.
I texted my husband: “Your skills might be more useful here than mine ...You’re good with a chain saw and lifting heavy stuff.”
Our workday was affected by the lack of electricity. Although there were headlamps and a generator that we could use a couple of hours in the evening, it made sense to go to bed early and wake up with the morning light.
“Is he a doctor or a priest?”
At last, we were organized and ready for our outreach missions. The local public health nurses and midwives pointed us in the direction of the communities with the greatest need. Our group of five primary care providers, with the support of nurses and a paramedic, saw more than a thousand patients in five days, including some who had walked for hours to receive care.
The nature of the health care problems surprised me — somewhat. Often the needs were routine: untreated hypertension and standard prenatal visits. I think many of the expectant mothers came to see me not for my midwifery abilities but for the Doppler that enabled them to listen to fetal heart tones. Always fun!
Insomnia was rampant among our patients. We learned that almost all had lost their homes. We also heard about the loss of a loved one or how lives had been disrupted.
We were fortunate to have an incredible psychiatrist on our team, Dr. Todd F. Holzman, on loan from Harvard Vanguard Medical Associates in Boston. His interventions left a lasting and positive effect on the people he interacted with — patients and co-professionals.
His emphasis on compassion as the antidote for the helplessness and hopelessness that accompany disasters will be incorporated into my practice permanently. During our five outreaches, he saw a remarkable number of patients, 85 in one day alone. One patient leaving his session was overheard asking, “Is he a doctor or a priest?”
The most recurrent and potentially long-term problem I saw was dental decay in very young children. Breast-feeding, great for tooth development, is the rule in the Philippines. Public health policy discourages formula feeding, making it hard for mothers to find any infant formula or baby bottles. But during my first outreach mission, I noticed toddler after toddler with molars and incisors totally rotted away or broken off.
I learned the problem is attributable to drinking soda from a very early age. It seems young children go right from breast milk to soda. There is very little milk consumption, and the diet is relatively low in calcium.
I shared that information with my co-workers and every mother I saw from that point forward. I also talked with groups of schoolteachers about the future problems associated with dental decay of the baby teeth.
Did the Project HOPE team actually do any good? It is hard to say. And we are not the correct people to ask. I think that the Filipino nurses and midwives at the public health clinic might be able to give a better answer.
Did I actually do any good? The 21-ounce baby died nine days later.
I ask myself if there is anything I did that would not have been done by someone else. Perhaps. Some of the patients I saw would not have received care because of the cost.
But I think my most important action may have been my campaign to reduce the cola consumption of young children and to encourage better dental hygiene. The cascade of adverse health events that can result from lack of dental care is huge. And this is an area where more education and intervention is needed.
Perhaps our biggest contribution was compassion and showing that someone cares. And because most of our group was from the United States, that showed our country cares.
So Amelia, while I reflected upon your recommendation more than one time during my trip, I think the world is a smaller place now. And even though it took about a day of flying to get to Panay Island, I’m not sure it’s that far from home.
Mary-Beth Gardner is a family nurse practitioner and nurse midwife who spent the past 24 years practicing in Alaska. She now resides and practices in New Hampshire.
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