Sure A Not

When 99-year-old Eleuthera Abus lifts her right arm, she winces as the broken bones move. It’s been six months since her fall.

“All I can do is manage her pain,” says Alena Yap, the 28-year-old doctor who is examining her on her porch. “She really needs to have the bone pinned. But the family is refusing to take her to hospital.”

Eleuthera’s daughters are not heartless. They are poor.

The nearest surgical facility is hundreds of miles away across the sea from the tiny island of Diit where they live. It’s one of a cluster of islands that make up the Agutaya archipelago, stranded in the middle of the Philippines’ Sulu Sea.

For the 13,000 or so people who live here, Dr Alena, as they call her, is the only doctor. Petite, with glasses and long hair tied back in a ponytail, she always wears a broad smile that masks quiet determination.

There is only one island in the archipelago she does not visit – Amanpulo, named after the luxury resort on it, which has reportedly hosted Tom Cruise and Beyoncé. On a clear day, it’s visible from the beaches of Diit, just 20km (12 miles) away.

Dr Alena arrived just before the coronavirus – and learned to live with the death threats that came when she insisted people isolate. But the pandemic that swallowed the world was far from her only challenge in this oft-forgotten corner of the Philippines. She battled new diseases and old, and came up against her country’s biggest challenges. She says she came to Agutaya to make “real changes” – but she left deeply disillusioned.

These remote, volcanic islands are not where you expect to find a graduate of the country’s top medical school, who had spent all her life in Manila, the teeming Philippine capital. Unlike so many of her peers who have left to seek careers in Australia, America and Britain, Dr Alena volunteered to join a government programme that sent her here, to one of the poorest municipalities in the country.

The main island of Agutaya is a two-and-half day journey from Manila. It includes one flight, followed by a sleepless 15-hour night crossing on an open-deck ferry from the port city of Iloilo to a bigger island called Cuyo. Then the only way in and out of Agutaya is a drenching, two-hour roller coaster ride in an outrigger canoe.

As the skilled boatman guides the outrigger across the reef and into the shallows, Agutaya looks like a piece of paradise. Below the palm-fringed shoreline, a broad swathe of white sand stretches in each direction. Colourful outrigger canoes bob around on water so clear they could be floating in mid-air.

But geography is both a blessing and a curse. Scattered over hundreds of square kilometres of sea, the dozen or so islands that make up the archipelago are cut off for days, even weeks, when the monsoon comes, winds in tow. Covered with dense forest, the hillsides sit atop large fields of basalt boulders. There is little tillable soil. The islanders rely almost entirely on the ocean.

Dr Alena made her first crossing to Agutaya in February 2020. “When I started here, I was 26 and a lot of people would mistake me for a high school student,” she says with a chuckle. “People wouldn’t believe I was a doctor.”

Her first challenge arrived within a month when the coronavirus sent the Philippines into a lockdown. The islands were sealed off.

“The first year wasn’t too bad,” Dr Alena says. “There weren’t any local cases. But the second year [2021], that is when the government allowed everyone to travel back to their hometowns. Suddenly we had people coming back from as far away as Manila.”

Dr Alena was in charge of enforcing their quarantine. “When people learned they would be quarantined they reacted violently,” she says. “I received death threats. People said they wanted to shoot me.”

She understood why. People here live day to day. What they catch in the morning they eat for dinner. If they couldn’t leave their homes to fish, they would go hungry.

So far from being embraced by the local community, Dr Alena, who had left her fiancé in far-away Manila, was now resented as a government enforcer. “There were days when I couldn’t do anything but cry. There were a lot of tears,” she says.

To ease the loneliness she began adopting dogs. Bruno is large with a big tail that never stops wagging, while Vigly is small and shy. They follow her everywhere.

“I spent a lot of time going to the beach with them and watching the sunset. I also started to draw. My pictures aren’t any good, but it’s a type of art therapy.”

The next challenge emerged when the vaccines started to arrive in the summer of 2021.

“We had to go house to house to every island baranguay [village],” Dr Alena says. “The farthest island is nearly three hours away by boat, and many people can’t afford the fare [to come to the clinic]. So they wouldn’t come.”

Gruelling as it was, the distance wasn’t the only problem: “There was a lot of hesitancy, a lot of fake news about the vaccines being bad or that they can kill people. A lot of people get their news from social media here, and they were not getting the facts.”

By autumn 2022, the threat from Covid had begun to abate. Despite the resistance, the vaccine rollout was successful. Only eight islanders across the archipelago had died of the virus.

But that brought little respite.

A line starts to form on every weekday morning outside the main clinic on Agutaya while the daily meeting between Dr Alena and her team is still under way.

On that day, first in line is a man in his 50s who has had a suspected stroke.

“Before I came here, I thought everything would be fresh and organic,” Dr Alena says, laughing at her own naivete. “But it’s very difficult to get a nutritious diet here.”

For one, locals salt and dry their fish, leading to high blood pressure. Diabetes is also common because it’s easier to find soft drinks than clean water.

A sign at the entrance to the clinic announces the other major health problem: “sputum sampling” for tuberculosis or TB.

Dr Alens says they recorded 45 cases in 2022, but many more go undiagnosed.

A bacterial infection, TB is fatal if left untreated. It killed millions yearly until a combination of vaccines and antibiotics eradicated it from much of the world by the middle of the last century.

But the Philippines is still estimated to have more than a million cases. “The long-term plan is to eradicate it,” Dr Alena says, adding it’s “impossible in the near future”. She says because of poor access to healthcare people often relapse, and have even begun to develop drug-resistant strains.

Later that morning, a woman brings her young son to the clinic. Pale and listless, the boy slumps on a chair. Dr Alena suspects he has dengue. A few minutes later, it’s confirmed. She prescribes paracetamol, and tells his mother to keep him hydrated.

Dengue is new here. The one case in January turned to 10 by March even as Dr Alena and her team sprayed school grounds to kill the mosquitoes that spread it, and handed out treated nets.

By 11:00 the doctor is extricating herself from the growing line of patients. They will have to be dealt with by her capable nursing staff because she has to get across to Diit, 40 minutes away by boat.

It is more beautiful than Agutaya, but poorer. It has no electricity or a mobile phone tower, and only one concrete road that runs out after a few hundred metres.

The arrival of the “medicine lady” as Dr Alena is fondly called is greeted with much excitement. Dozens of school children come running down the beach. They’ve been given the day off so Dr Alena’s dengue control team can spray their school grounds with insecticide. As she walks through the village, she’s like the pied piper, with a long stream of laughing children following.

She visits an elderly couple sitting outside their house along the beach in wheelchairs. Both have had strokes and are partially paralysed. She checks his blood pressure – 150 over 90. “It’s high, but acceptable for his age,” she says.

A woman in her 40s pushes her way through the crowd that has gathered around. She is carrying a boy, who is perhaps five or six years old. Dr Alena tells her to sit down on a chair and begins to examine the child. He has a hugely enlarged left testicle. The torch reveals a hernia in his lower abdomen. A part of his intestine has penetrated the bowel wall, pushing into his testicles.

“He will need surgery,” Dr Alena tells the mother. The hope in the women’s eyes turns to anxiety.

Dr Alena asks her if she knows anyone who she can stay with on one of the bigger islands. Yes, the woman says – in Culion, a 12-hour boat ride away.

“Once I tell them they need to have an operation, you see in their faces the fear and the sadness because they realise there isn’t any medicine I can give them to cure this,” Dr Alena says. “You see in their minds [the thought] how are they going to afford this? It’s hard being the one to deliver the news.”

In another part of the world, a hernia is a minor medical procedure. But here it can wipe out a family’s savings, leaving them in debt for years.

“If we could make travel easier that would make a lot of difference,” she adds. “But that’s hard because it will take a lot of resources.”

After three years on the island, Dr Alena’s optimism and ambition have given way to the disheartening realisation that resources – or money – will always be the biggest challenge.

A concrete all-weather road runs along the base of the rocky hills that circle the main island of Agutaya. Construction began alongside campaigning for the local election last year. One lane was finished before election day, but islanders say work stopped after that. There is no second lane yet.

“We’ll have to wait for the next elections to get the road finished,” quips one local.

On the other end of the island, rusting steel bars stick out of an incomplete concrete structure that is gradually being overrun by vegetation.

It was supposed to be the new rural health unit, Dr Alena says. Work stopped last year because the local government ran out of money. “But they haven’t completed their part of the deal,” she says, her frustration palpable.

Philippine politics is not driven by parties, but personalities, and dominated by large, powerful clans whose chiefs promise resources from Manila in return for votes. As one local woman put it, Agutaya is too small a community: “There aren’t enough votes here that make it worth the money.”

Local politicians have little incentive to change and come election time, vote-buying is common enough that it now seems to have a well-worn price: 500 pesos, or $28 (£22). Corruption runs deep, and the money pouring in doesn’t seem to reach its destination.

“I came here very idealistic,” Dr Alena says, sighing. “I was very aggressive to try and change the way the local health system worked. But then as time goes on you realise that three years is far too short to make any big changes.”

As her time on Agutaya – a three-year-contract – drew to an end, many islanders told her they would be sad to see her go. “Time flies fast,” said Ricardo, one of the senior nursing assistants, who described her as “selfless and hardworking”.

But in the weeks since returning to Manila, Dr Alena says she has felt disappointed and even cynical about her experience working for local government. She was offered a job at the provincial health administration in Palawan but turned it down. Instead she wants to work in a medical charity or NGO.

Last week, she returned to Agutaya as part of an NGO-run programme with a group of specialist doctors who visit once a year to do minor surgeries.

But this time it didn’t take her two-and-half days. Dr Alena and the other doctors arrived there three hours after taking off from Manila – they touched down on a runway in the luxury island of Amanpulo in a private plane funded by international donors.