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Supporting young girls in the slums of Manila

How we immunised 25,000 pre-adolescent girls against cervical cancer

Story by MSF November 20th, 2017

Over 300,000 people live crammed into the slums of Tondo, which cling to the docks of the port of Manila, the capital of the Philippines. Tondo has a paltry number of doctors—just one for every 36,000 inhabitants.

In these deprived districts, Médecins Sans Frontières (MSF) launched a large-scale operation to vaccinate 25,000 young girls against the human papillomavirus (HPV), one of the main causes of cervical cancer.

Children play in rubble after their home was destroyed by fire. © Hannah Reyes Morales
A woman in Aroma district in Manila. Around her is the destruction caused by a recent fire. © Hannah Reyes Morales
Manila’s Aroma district. © Hannah Reyes Morales

In the maze of Aroma and happyland

Every day, 12 women in the Philippines die of cervical cancer. In 2015, the government stepped up its efforts to combat the disease, giving priority to the country’s poorest regions. Manila, also the financial capital, isn’t one of them. And while only a few kilometres separate the city’s affluent business districts from the neighbourhoods of Tondo, the gap between rich and poor is immense.

Young girls with their belongings in a basketball court in Manila. Their home was burnt down in a fire. © Hannah Reyes Morales
A beneficiary of MSF and Likhaan’s free vaccination programme in front of her makeshift shelter. © Hannah Reyes Morales
14-year old Locel in Tondo’s Smokey Mountain district. She’s just given birth at home to baby daughter Richelle. © Hannah Reyes Morales

With the support of Manila City Health and in partnership with local organisation Likhaan, MSF launched a first round of vaccinations in February 2017. Over 25,000 young girls aged 9 to 13 received the first dose of a vaccine which, to be effective, requires a second dose six months later.

Tondo’s slums can feel like a maze, and many of its residents lead unpredictable lives. It’s common for people to move suddenly, depending on their living conditions and economic opportunities.

Manila viewed by drone. Tondo is in the foreground and the port’s on the right.

Manila is one of the world’s most densely populated cities, with over 70,000 inhabitants per square kilometre. And although the names of its slums can sound picturesque, they reflect the challenging conditions its residents live in. One is called ‘Happyland’, a play on the word hapilan, which means ‘dump site’ in a local language. Another, ‘Aroma’, evokes the strong smells wafting from the mountains of garbage surrounding the slums.

Local people in a basketball court. Their home in a Manila slum was burnt down in a fire. © Hannah Reyes Morales
Two young girls, Elyes and Diana, brush each other’s hair. They have been vaccinated free of charge by MSF and its partner Likhaan. © Hannah
Jenalyn de Leon in front of her house in Smokey Mountain. © Hannah Reyes Morales

Most dwellings – and their inhabitants – lack an official address. Vast and disused warehouses have become makeshift shelters, each one accommodating up to hundreds of families. In this chaos, seeking out 25,000 young girls at the beginning of the year was a challenge. Finding them again only six months later even more so.

The relative lack of access to health education in Tondo could have undermined awareness of the second dose’s crucial importance. Moreover, it was not an option to plan appointments six months in advance for these young girls, whose families often live a hand-to-mouth existence in deprived conditions.

This is where Likhaan’s knowledge of the slums proved vital.

A young girl from Tondo in Manila is given free HPV vaccinations in a Likhaan clinic. © Hannah Reyes Morales
A young girl from Tondo in Manila is given free HPV vaccinations in a Likhaan clinic. © Hannah Reyes Morales
Young girls from Tondo in Manila are given free HPV vaccinations in a Likhaan clinic. © Hannah Reyes Morales
A young girl from Tondo in Manila is given free HPV vaccinations in a Likhaan clinic. © Hannah Reyes Morales
A young girl from Tondo in Manila is given free HPV vaccinations in a Likhaan clinic. © Hannah Reyes Morales
Young girls from Tondo in Manila are given free HPV vaccinations in a Likhaan clinic. © Hannah Reyes Morales
A young girl from Tondo in Manila is given free HPV vaccinations in a Likhaan clinic. © Hannah Reyes Morales
A young girl from Tondo in Manila is given free HPV vaccinations in a Likhaan clinic. © Hannah Reyes Morales
A young girl from Tondo in Manila is given free HPV vaccinations in a Likhaan clinic. © Hannah Reyes Morales

Mobilize communities

With Likhaan, Médecins Sans Frontières conducted a large-scale information campaign. Likhaan has supported women’s health and family planning in the Philippines for over 20 years. The campaign’s goal was to mobilise families and encourage young girls to come back for their second vaccine dose.

A social worker walks around Aroma district to find young girls who need the second dose of the vaccine. © Hannah Reyes Morales
A social worker walks around Aroma district to find young girls who need the second dose of the vaccine. © Hannah Reyes Morales
A social worker walks around Aroma district to find young girls who need the second dose of the vaccine. © Hannah Reyes Morales
A social worker walks around Aroma district to find young girls who need the second dose of the vaccine. © Hannah Reyes Morales

Known as community mobilisers, local social workers combed miles of streets, door-to-door, to follow up with as many girls as they could.

They also organised a text message campaign targeting the 10,000 phone numbers registered during the first round of vaccinations, to send reminders about the second dose.

Finally, they held community education sessions in the slums to remind people of the importance of this vaccination, on top of their usual sessions about reproductive health and family planning.

Philippine women from deprived districts listen to a talk on reproductive and sexual health in front of a mobile clinic. © Hannah Reyes Mora
A social worker working with MSF and Likhaan gives a talk on reproductive and sexual health © Hannah Reyes Morales

After weeks of hard work, the teams achieved a result that far exceeded expectations: almost 90% of the young girls received the second injection. In this type of campaign – where patients are expected to come to a health centre themselves – organisers typically manage to remobilise between 60 and 70% of those who received the first dose.

A beneficiary of the vaccination programme in her makeshift shelter. © Hannah Reyes Morales

vanquishing cervical cancer

The World Health Organization recommends vaccinating girls under the age of 15 to reduce the number of women who develop cervical cancer as they grow older. In 2011, the Philippine government integrated the HPV vaccination into the national programme and then extended it in 2015, but older women for whom the vaccine did not exist when they were teenagers are far more likely to contract the disease.

A Philippine woman during a MSF's and Likhaan's mobile clinic consultation. © Hannah Reyes Morales
A Philippine woman during a MSF's and Likhaan's mobile clinic consultation. © Hannah Reyes Morales

MSF and Likhaan have also set up screening and treatment programmes. Their teams provide information on cervical cancer and give consultations and free treatment in their Tondo clinic, as well as a mobile clinic: a van that criss-crosses the poorer districts of Manila to reach a greater number of women.

Routine screening takes just three minutes. Women with precancerous cells are immediately treated with cryotherapy, while those suspected of being at a more advanced stage of the disease are referred to hospital for diagnosis. The team support these women at every stage in the process.

Over 1,200 women were screened between January and September 2017.

Footnote: Copyright : Hannah Reyes Morales
Manila, Philippines