Filipino Barrio Doctors Scale Mountains, Cross Rivers And Seas To Deliver COVID-19 Vaccines
The barrio doctors face a lot of challenges to get the COVID-19 jabs to residents in far-flung areas. Upon reaching them, they have to deal with a bigger problem. Experts also said the government is missing out on the so-called “cocoon vaccination.”
When Weijin Sto. Domingo applied to be a doctor to the barrio, what he had in mind was the routine checkups of indigent residents living in far-flung villages in the Philippines.
Sto Domingo said he chose Dinagat Islands in Caraga region in Mindanao as his area of assignment not knowing what it would take to reach the people he wanted to serve.
Just a month into his deployment last year, the COVID-19 pandemic struck. With the first case in the Philippines reported on Jan. 30, 2020, he was assigned to be the acting municipal health officer of Libjo town.
The task to head the municipality’s pandemic response was unexpected.
Sto. Domingo also did not expect to traverse dirt roads and ride boats, with water splashing on his face, to conduct routine checkups and deliver medicines and COVID-19 vaccines to geographically isolated and disadvantaged areas (GIDAs).
“I was suddenly head for health concerns being the doctor to the barrio municipal health officer,” the barrio doctor said. “We had no choice,” Sto. Domingo told OneNews.PH/ The Philippine STAR in a recent phone interview.
As frontliners, one of their biggest tasks was to prevent the coronavirus from reaching the isolated areas as it would be difficult to provide residents medical care once they’re infected.
Riding the boat to the farthest village takes over an hour, he said.
In delivering vaccines to provide residents protection against COVID-19, Sto. Domingo said his nurses would store the vials in a cooler to maintain the required temperature of two to eight degrees Celsius.
But heat is not the only problem when it comes to vaccine delivery. Sto. Domingo said he heard the news about the 1,600 doses of CoronaVac vaccine that went underwater after the boat carrying them capsized off Quezon province in May this year.
The vaccine vials were not damaged in the incident, but Sto. Domingo feared it would happen when they transport the vaccines by boat.
They don’t have any choice, however. So when the boat ride would become too rocky, his nurses would do what a parent does to a child in fear – hug the cooler, and scream their nerves away, relying on good luck that the boat would not turn over.
“The sea would spray its water on our faces, and we had to stick to our passion. We (would end up) dripping wet,” Sto. Domingo said of the boat trips of barrio doctors.
He laughed as he recalled a trip on Aug. 3 this year where the nurses had to hug the vaccine cooler. At the time, Sto. Domingo said his team delivered vials of CoronaVac, AstraZeneca and Janssen vaccines. This was five months after the vaccination rollout began in March.
The archipelagic nature of the Philippines, home to isolated coastal villages and hard to reach island provinces, poses challenges to a nationwide vaccine rollout in a country with poor health infrastructure, according to experts.
The pandemic has made all the more important the task of barrio doctors in providing medical services to these isolated areas without a healthcare system of their own, Coalition for People’s Right to Health convenor Dr. Josh San Pedro said.
It would be even more disastrous for GIDAs if a COVID-19 outbreak happens as healthcare workers would not be able to respond immediately and adequately.
In the sixth-class Datu Blah Sinsuat municipality in Maguindanao, a province in Mindanao, rural health doctor John Paul Valencia disclosed delivering the vaccines to the municipality’s mostly coastal GIDAs involves not just by riding boats, but also scaling mountains and crossing rivers.
The intermittent power supply also poses risk to the vaccines if these are stored in the rural health units, which is why they keep them in the nearest district hospital and delivered on the day of the vaccination, Valencia, who has been serving in the area since January 2019, said.
An ambulance transports the vaccines from the district hospital back to the rural health unit. The trip takes at least an hour.
When the jabs arrive at the municipality, a so-called “vaccine administrator” will carry the cooler to the port just behind the rural health office and bring them to the GIDAs – mostly coastal barangays – which would take at least another hour via boat ride.
All the 13 barangays there are considered GIDAs, so delivering the vials to the vaccination sites entails much effort to maintain the cold chain system, Valencia said.
To the village called Upper Tambak, which his team visited last August, they went on a one-hour dirt road ride and another three-hour hike just to bring the vaccines to an indigenous community.
To save one hour of the hike, his team had to take a donkey ride up the mountain slope and cross rivers to reach the village as photos courtesy of Valencia would show.
To keep the cooler above water, two of his team members had to carry them with sticks, taking extra care to keep them from being wet.
Valencia said the cooler could keep the vaccines safe from spoilage for 24 to 48 hours during the hike, but his team could not risk carrying more sensitive brands. They had to rely on the CoronaVac shots, he added.
“We put the vaccines on these carriers to maintain the cold chain when going to far-flung areas,” the barrio doctor said. “So we need to deliver the vaccines and use them up as fast as we can. We can’t keep them overnight, because we have no freezer to store the vaccines.”
The difficulty of maintaining the cold chain in GIDAs limited the supply to select vaccines.
Valencia wrote about his municipality’s plight in terms of vaccine delivery in an essay for the United Nations Children's Fund or UNICEF, with the hope of exposing the difficulties there and putting to light their efforts to still deliver health service.
“The cold chain is critical to vaccination because it ensures that the vaccines we give are potent and effective. However, storing and transporting vaccines (are) far more challenging in areas like ours,” Valencia wrote in his blog posted on May 24.
“The journey that the vaccines make to get to Datu Blah Sinsuat is a long one. (From Manila, the vaccines) will then be commercially flown to Awang airport near Cotabato City (one hour, 30 minutes) and will be received by the provincial vaccine storage facility. Some are island provinces that need to be traveled by sea,” Valencia wrote.
“In Maguindanao, it will be received by the Integrated Provincial Health Office (one-hour travel), before being distributed to 36 rural health units (RHUs). Once received in our RHU, unreliable electricity threatens the proper storage while long sea travel (two hours) and hike through mountains (three to five hours) (makes the vaccines) vulnerable to sun exposure,” he added.
The experience of poorer municipalities in delivering vaccines to GIDAs only showed that the country’s health infrastructure was not ready for a massive vaccine rollout, according to Dr. Jamie Dasmariñas of the group “Bantay Bakuna” (“Guarding the Vaccine”).
“Even before the vaccine rollout, the Philippines was never ready for a pandemic. For decades, our status has been: seven of 10 people have never consulted a doctor when sick,” Dasmariñas said.
Delivering medical services and life-saving jabs by boat or mountain hike is just an everyday reality barrio doctors had to contend with in the name of public service despite lacking government support, she said.
“This is the landscape young doctors have to navigate right now. We have been used to the bare minimum, which shouldn’t be the case,” Dasmarinas added.
The difficulty in accessing vaccine brands also dispel the Philippine government’s claim that the nationwide vaccine rollout is equitable, Dr. Josh San Pedro, co-convenor of the Coalition for People’s Right to Health noted.
The country’s “vaccine czar,” retired military general Carlito Galvez Jr., has repeatedly said the government’s aim is to provide equitable access to the vaccines.
But spotty vaccine delivery to the provinces paints a different picture, compelling a committee at the House of Representatives to conduct an inquiry last Sept. 9 to look into why vaccines hardly reach rural areas.
“Some people are saying we are slow in the vaccine rollout. But we are 21st (in the world) in total doses administered,” Galvez claimed during congressional hearing, where he was barraged with pleas from lawmakers to give them more doses, and complaints that the country’s capital region, Metro Manila, seems to be getting a bigger slice of the pie.
Galvez said the national government is aiming for “equitable distribution” of vaccines by giving supply to areas where there are more unvaccinated people and higher rate of infection.
The vaccine czar also cited the global supply shortage of vaccines that make it hard for developing countries like the Philippines to secure shots for its people.
“The problem is not our contracts (with vaccine manufacturers). It really is a global supply problem. It is not the delay, but the availability of supply that is the problem. We can’t sign a contract if the problem is supply,” Galvez told the lawmakers.
According to ABS-CBN News’ tracker, 15,466,087 doses of vaccine doses have been administered in the National Capital Region as of Sept. 27.
In contrast, only 817,386 doses of vaccines have been given in Caraga region, where Dinagat Islands is located.
The Bangsamoro Autonomous Region in Muslim Mindanao, where Maguindanao is located, placed last among the regions with just 439,798 doses of vaccines administered.
It seems that the government’s own data would disprove any claim of equitable vaccine access, the health experts said.
“It means we don’t have enough supply to be equitable in the first place. We can’t spread out our already limited supply,” Dasmariñas pointed out.
The Philippines also leads the world with the most number of approved vaccines and yet still struggles with vaccine supply, San Pedro stated. “We have the most approved but we don’t have enough. That shows our desperation.”
The Food and Drug Administration has approved the following COVID-19 brands for emergency use: Pfizer-BioNTech, AstraZeneca, Sinopharm, Sinovac, Gamaleya’s Sputnik V, Janssen, Bharat Biotech and Moderna.
The allocation of the jabs depended on an area’s risk status, number of active COVID-19 cases, and ability to maintain the vaccine cold chain, according to the Department of Health’s vaccine deployment plan.
“Since the delivery of vaccines to the country is in tranches, the deployment of vaccines in specific geographical areas shall be based on the burden of COVID-19 cases,” according to the deployment plan dated January 2021.
Among the indicators that would be the bases for vaccine allocation are the number of active cases, as well as the attack rate per 100,000 population in recent weeks. Even population density of the region is figured in, the report read.
This means isolated areas, where cases are not as high as in urban centers, are placed at the bottom of the priority list.
By not giving enough supply to isolated areas, the national government is missing out on another strategy in controlling the rate of infection, which is through “cocoon vaccination” or vaccinating the population surrounding a highly infected area to prevent the virus from spreading further.
“That’s one concept that is unfortunately forgotten if you really look at COVID-19 vaccination focused on high-risk areas,” San Pedro emphasized.
“The underdevelopment of the countryside still persists, now that we have a major task ahead of us. Our healthcare system is unable to cope with the times,” San Pedro said. “These isolated communities should be vaccinated so that if they have an outbreak, they would be less vulnerable, knowing that the health care system there cannot respond immediately. But the real answer to that is improving the quality of life and access to healthcare.”
The bigger problem
The lack of supply, poor health infrastructure, even the perilous trips just to deliver the vaccines did not discourage the rural doctors from their sworn duties during a pandemic.
These only fueled their drive to provide healthcare to isolated areas when they can.
Sto. Domingo even said the vaccine delivery was not the main stumbling block in his municipality’s rollout: it was the difficulty in convincing rural residents to get inoculated amid misinformation that getting the vaccine could turn them into “zombies” for two years.
The sources of this false information are social media and word of mouth, the barrio doctor said.
It takes them a great deal of effort to fight this misinformation and convince the population to get vaccinated amid existing supply problems and cold chain challenges.
“Delivering the vaccines (even in GIDAs) is doable,” Sto. Domingo said. “There are other resources we can tap into. But what’s the point of delivering if no one wants to get vaccinated? That’s our goal – make sure people are interested before supplies are delivered,” Sto. Domingo said.
The barrio doctor also expressed hope that vaccine supply to the country becomes more stable, so that low-risk areas with slimmer chances of getting more supply could get a more equitable share.
“Supply problems affect the momentum of people who want to get vaccinated,” Sto. Domingo said. “When the supply arrives later, we have to start over our campaign.”
“We want to focus on the campaign rather than the delivery,” he added.
Sto. Domingo said it really is their passion that keeps them going, when asked how they were able to cope with the rocky boat rides, for instance, on their way to the GIDAs.
It also happens that their destination during the scheduled vaccination last Aug. 3 was an isolated village called “Bayanihan,” the Filipino word for civic unity and cooperation among Filipinos.
The barrio doctor laughed at the coincidence. Now that he thought of it, Sto. Domingo recounted that his team would shout “For Bayanihan!” when the waves would become too high.
“Right there and then, we felt the heroism in what we do,” he said.
Upon arrival, they were able to vaccinate 126 people in Sitio Maytubig and another 50 at the elementary school, a total of over 170 vaccinated residents.
The village’s vaccine status jumped from the second lowest inoculated population to the highest despite its isolated status, Sto. Domingo said.
“It was a good achievement for us,” the barrio doctor noted.
This story is supported by the Internews Health Journalism Network as part of its story production grant on the science, access, logistics and confidence behind the COVID-19 vaccines.