Immunization: Children falling through the cracks in Manila’s slums
Garbage and human feces bake in the sweltering summer heat in a slum called Happyland in Tondo, located in Manila, the capital city of the Philippines. Rosemarie Biay, a volunteer health worker, makes her way home amid tiny alleys and ramshackle houses stacked on top of each other. On one side, a family rummages through trash to recycle while on the other, small children play with dirty toys recovered from the rubbish.
Such is the environment that Rosemarie lives and works in. As a health volunteer for the government’s immunization program, she is caught in a seemingly never-ending chase to stop the spread of diseases such as measles, hepatitis B and tuberculosis in one of the world’s fastest-growing megacities.
Behind the urban sprawl of ritzy malls and tall residential towers hide entire communities where the poorest of the poor live.
“Our community is growing so fast, I can’t even keep track of all of the new babies that need to be vaccinated in this area. It’s good that my neighbours trust me. I’ve gone to the lengths of borrowing the babies and taking them to the health center myself because they do not have the money for the ride going there,” she says.
A widening gap
The Philippines, the 12th most populous country in the world, enjoys steady economic growth and a growing middle class. But behind the urban sprawl of ritzy malls and tall residential towers hide entire communities where the poorest of the poor live. The City of Manila is the third-richest city in the country, but it has a high number of poor households.
Of those who live in urban areas in the Philippines, 15 per cent live in informal settlements in 2011. While other Filipino children live happy and healthy lives playing, learning and going to school, the poorest children are born undernourished, do not complete their vaccines, get sick and are most likely to die before their fifth birthday.
A community comes together
As a way to respond to the immunization challenges in the City of Manila, community leaders like Barangay (Village) Captain Elenita Reyes gathered volunteers like Rosemarie to talk to their neighbours about immunization. Having someone from the community builds a sense of trust in the family-centred culture of the Philippines.
“When I saw that we are a red zone in the immunization map, I felt sad because it told us that we are falling short as officials,” says Reyes. Being marked as a red zone means that there is a heightened risk of infection. “I gathered and met with the volunteers and gave them uniforms and IDs. I told them that we have to work hard and persevere so that every child will be immunized,” she says.
Jessica Argobano, one of Rosemarie’s neighbours, is caught in a vicious cycle of poverty like most families in Happyland. Already a mother to twins at 17 years old, she found a second mother in Rosemarie who carries one of her two babies when they visit the health centre to be vaccinated.
“One of my twins had an asthma attack at two months old. I felt the life sucked out of me when I saw tubes sticking out of her body. But she’s a survivor. She was the only one who survived out of all those babies in the hospital. It’s now even more important for me that they receive complete vaccines so that they will not get sick anymore,” Jessica says with a sense of accomplishment.
A double whammy
As a new mother, Jessica had to learn how to protect her twins from sickness the hard way. In the Philippines, immunization faces a double whammy of low supply and low demand. The government faces numerous challenges including vaccine stock-outs, lack of manpower, security issues and lack of coordination between community leaders and health workers. In Rosemarie’s community alone, there is only one doctor serving 47,000 people.
With immunization rates in the Philippines declining, an outbreak is waiting to happen. In the Philippine National Demographic Health Survey of 2013, only 68.5 per cent of children aged 12–23 months were fully immunized, a drop from 79.5 per cent in 2008.
The national immunization coverage for all Vaccine-Preventable Diseases is decreasing. In 2015, BCG, DPT 1, DPT3, Polio and MCV2 vaccination rates are below 80 per cent, far from the ideal coverage of at least 95 per cent. A measles outbreak in 2013 resulted in more than 3,700 confirmed measles cases affecting mostly the urban poor.
“When I saw that we are a red zone in the immunization map, I felt sad because it told us that we are falling short as officials.”
Changing the behaviour of parents when it comes to immunization is another big task. Mothers and fathers do not take their children to a health facility to be immunized because of various reasons. Most parents prioritise buying food with the little money they earn rather than going to the health centre. Those who make it to the overcrowded health centres have to endure long queues and long waiting hours. Some still believe that children will get fever or will only get hurt by needles. Those who are not fully convinced of the benefits of immunization often realize it when it’s already too late.
Hiding in plain sight
On the southeast of the Philippine metropolis is a similar highly urbanized city, Taguig City, where the Bonifacio Global City district is located. A highway separates the opulent high rise buildings and stylish shopping centres from dense shantytowns that remain unreached by even the most basic of health services.
Wednesdays and Fridays at the Western Bicutan Health Centre in Taguig City are always busy. Hundreds of parents bring their babies and wait for their turn to be checked and immunized. Dr Marigen Malipot is the only doctor serving this community of 90,000 residents.
“I don’t have enough time to visit patients in the communities. In this centre alone, as you can see, it is already very toxic. There are many children that need to be immunized, undernourished children, people with tuberculosis. I need help from the barangay (village) officials and the city health officials,” she says.
12 and counting
With a serious shortage of doctors and nurses able to go directly to the poorest families, more and more children are falling through the cracks. Anisa Sandag is only 34 years old and already has 12 children. With no education and with her husband barely making ends meet as a scavenger, she gave birth to all 12 children without a single prenatal visit. Her youngest son Rodrigo, eight months old, has a cleft palate and is severely malnourished.
“I didn’t go to the health centre because I was feeling okay. I just gave birth at home with a midwife. I know having children immunized is good for them but with 12 children I cannot leave the house. This is what God has given me and my husband,” she says.
The urban divide
The widening gap between the rich and the poor in the Philippines claims children as its most vulnerable victims. Posh gated communities exist side-by-side with slum settlements where children lead very different lives. As the UN children’s agency, UNICEF is trying to bridge the gap by advocating to leaders at all levels of government to invest in health care to protect children from diseases.
At the highest level, UNICEF’s health governance experts work with the Department of Health to strengthen routine immunization and improve vaccine procurement processes and distribution systems to prevent stock-outs. UNICEF, as one of the world’s largest buyers of childhood vaccines, also offers quality and best-value vaccines by forecasting demand, encouraging competition and engaging with manufacturers around the globe.
Because the Philippines is an emergency-prone country, typhoons and earthquakes put the system of keeping vaccines potent and effective, called cold chain, at risk. After Typhoon Haiyan in 2013, UNICEF helped make the cold chain in the affected areas resilient by providing solar refrigerators, generators and cold rooms.
“When UNICEF gave me the training, I gained more confidence in explaining to mothers that having their children immunized is the best thing for them.”
At the barangay or village level, UNICEF works with local leaders and community health workers to create local ordinances, establish functional local health boards, allocate budgets and augment human resources. UNICEF also works with local health staff to improve data and logistics management, conduct regular assessments, monitoring and surveillance, and respond to training needs to plan and implement immunization programmes. UNICEF also helps local health workers communicate health messages to target communities in the best way possible.
“When UNICEF gave me the training, I gained more confidence in explaining to mothers that having their children immunized is the best thing for them. It gives me a feeling of happiness when I can share what I know with my neighbours. I don’t like hearing about children in my community getting sick when it can be prevented with vaccines,” Rosemarie says, cradling Jessica’s healthy baby girl in her arms.
Jessica is now waiting until the twins reach their ninth month for their last vaccine. She wants her children to be strong and healthy, and have a brighter future.
“I want my children to finish their studies. I don’t want them to be like me. I wish that someday, all their dreams will come true,” she says.
By Marge Francia
Commission on Audit Annual Financial Report for Local Government Units, 2015
Department of Social Welfare and Development: Cities of the National Capital Region with the Highest Number of Poor Households, 2015
Habitat III: The Philippine National Report. The New Urban Agenda, 2016
National Demographic and Health Survey 2013
National Demographic and Health Survey 2008
Philippine Statistics Authority
WHO/UNICEF, Philippines: WHO and UNICEF estimates of immunization coverage, 2015 revision
WHO/UNICEF: Joint reporting form on immunization, 2015
World Health Organization Measles-Rubella Bulletin, March 2017
World Health Organization Measles-Rubella Bulletin, November 2016
UNICEF: One year after Typhoon Haiyan progress report
World Bank Population Ranking 2015
To learn more about UNICEF’s work in the Philippines, visit www.unicef.ph.