Caring without borders
From Iraq to Ukraine, New Zealander Jessa Pontevedra has put herself in harm's way to help others. She’s now fighting a resurgent disease killing Manila’s poor. Investigative reporter Nicholas Jones and visual journalist Mike Scott travelled to the Philippines to document the life-saving work.
The shack is a patchwork of scavenged materials — plastic sheets, warped plywood — smaller than most New Zealand living rooms. A family of eight live here. Like other slums in the Tondo area of Manila, the Philippines, there’s no clean water supply or sanitation.
Residents pay to fill water containers from a nearby condominium, and trenches funnel sewage into a blackened river.
Every spare centimetre has been claimed — alleyways between the twostorey shacks are barely shoulderwidth, and the air is stagnant.
Disease proliferates, including tuberculosis (TB), which is caused by a bacterium that usually attacks the lungs, and spreads through the air, including when an infected person coughs or speaks. Not everyone who gets infected develops TB, but the death rate for those who do is about
50 per cent, if no treatment is given. The grandfather in this extended household died with TB in 2020, during Covid-19 lockdowns.
Now, one of his sons is sick. His TB was identified through free screening provided by the Doctors Without Borders/Medecins Sans Frontieres charity.
Its medical team are visiting the home to start two 3-year-olds and a
6-year-old on a preventative course of drugs. Among them is a New Zealander, Jessa Pontevedra, who is the medical co-ordinator for an ambitious and ground-breaking programme combating TB in Tondo.
The children’s mother — young enough to be mistaken for their sibling — and grandmother watch intently as Pontevedra and outreach nurses demonstrate how to measure the drugs.
A dosage schedule is taped to the wall, across from a shrine to Mother Teresa (more than 80 per cent of the country’s 114 million population is Catholic), and a framed school photo.
Cheska, 3, is wary of the medicine’s bitter taste, but soon beams at the strangers’ applause and her reward of a lollipop and square of chocolate. Success. However, Pontevedra is worried about malnutrition, especially in Althea Jade, who at 6 isn’t much bigger than her younger brother and sister.
On the walk out of the slum, Pontevedra asks a resident how much it costs to fill a waist-high container with water. It’s 15 pesos, about 45 NZ cents.
That’s prohibitive for people who sometimes can’t afford enough food.
“When we are talking about preventing tuberculosis, you need to have a clean space,” says Pontevedra.
“But, a) you don’t have water to clean your space, b) you don’t have enough space, and c), you don’t even have the basics of a toilet. Their place is not even the size of a studio unit. This is the reality — lots of people, living on top of each other.”
TUBERCULOSIS STILL occurs in the developed world — about 300 cases are diagnosed in New Zealand each year — but with early detection it can be cured by a six-month course of drugs. Countries with the greatest burden include the Philippines, India and Indonesia.
Globally, TB is one of the leading causes of death, taking an estimated 1.6 million lives in 2021. Because those tragedies are almost entirely confined to low and middle-income nations, it has been called the “forgotten pandemic” by Western media.
The World Health Organisation (WHO) wants the disease eliminated by 2030. Case numbers and deaths were falling, until Covid-19 stalled or reversed that progress. Lockdowns and restrictions in the Philippines were some of the longest in the world.
Schools were closed for two-anda-half years. Casual work and scavenging opportunities fell away, as did the ability to get help for health problems (medics were pulled into Covid roles, including as vaccinators).
TB cases went undiagnosed and untreated. Nationwide daily deaths now number about 70, and are forecast to rise until 2025 at least.
“Global TB targets are off track,” the WHO recently warned in a monitoring report.
“Intensified efforts backed by increased funding are urgently required to mitigate and reverse the negative impacts of the pandemic on TB.”
Into that breach has stepped Doctors Without Borders. The group, which also goes by its French acronym MSF, was founded in 1971 by doctors and journalists, in response to the war and famine in Biafra, Nigeria. It delivers emergency medicine aid internationally, including in war zones, using local and international medics and staff.
From May 2022 to September this year, MSF screened close to 15,000 residents in Tondo, and found nearly 800 cases of TB — a positivity rate more than double the Philippines’ national average.
Screening events move around different barangay, which are small administrative districts that form the most local level of government.
Activities are centred near Barangay 93 when the Herald visits. Residents wait on plastic chairs for registration, a medical assessment, and chest X-ray in MSF’s mobile truck.
The images are sorted within two seconds by artificial intelligence software, alerting MSF workers to who is a probable case (through a heat map showing possible areas of abnormalities associated with TB, and an “abnormality score” out of 100.)
Those who are clearly negative are through in 20 minutes. People needing more investigation, including tests on saliva and mucus for bacteria, generally wait no longer than an hour.
On the way out each person gets 1kg of rice — a major drawcard for those getting tested.
While this goes on, a team winds through nearby slums, handing out flyers and calling out: “Come for a free X-ray, free rice, we’re back on Friday too”.
Children happily say “Hello” and offer high fives to us foreigners, but a few sit in listless hunger, scratching too-skinny limbs.
At one spot, shacks are roped to the side and underside of a concrete bridge — some hang like the portaledge tents climbers attach to cliff faces.
The black, sludgy water flowing underneath swarms with midges, and so much rubbish has collected around some structures that it looks like a solid floor, on which a stray kitten is happily sitting. Fumes from the heavy trucks rumbling overhead mix with the stink of garbage.
Asnairah Solaiman, who leads the MSF team trying to convince people to be screened, says they encounter common misconceptions, including that TB spreads via pollution.
Other residents think they can’t be contagious without obvious symptoms, and some believe rubbing diesel on their skin will cure any fever.
A bigger barrier, however, is hunger.
“Going to the health facility is a burden for them. They are daily earners, so they choose to go and find work,” Solaiman says.
EVEN WHEN time is found, patients can be turned away without treatment.
TB drugs can only be distributed by government health centres, but medication is often out of stock, because orders made to manufacturers have been outstripped by demand.
Amgelex Espiritusanto is a lifelong Tondo resident, who volunteers to ensure TB patients start and complete the entire six-month course of medication (drug-resistant TB is on the rise, and can occur when doses are missed or stopped early.)
The newly diagnosed can be in denial or ashamed, she says, and it sometimes takes weeks to convince them to start treatment.
That fragile momentum is halted if drugs aren’t available.
In contrast, private pharmacies are well stocked. The generic drugs cost around 216 pesos a week (around NZ$6.50).
Different medications are taken from months two to six, which aren’t in short supply.
Some residents can afford to pay — Tondo is home to middle class people, too — but Espiritusanto can only encourage those who can’t to keep checking if drugs have come in.
She sometimes dips into her own pocket to ensure they can at least start treatment, despite only making a modest income herself from selling vegetables.
MSF is lobbying the Government to increase drug orders. Data from its work is also supporting research into the feasibility of using AI detection of TB in large cities.
Pontevedra hopes the tool will be implemented around the world, making screening faster, cheaper and more accurate.
Currently, the 2030 elimination goal is unlikely, she says. “I don’t think [elimination] is realistic unless the Government — and not just the Philippines but every country that is suffering from TB — actually gets their act together, and walk the talk.”
The WHO has called on governments and private donors to back the development of new TB vaccines, saying Covid-19 had shown more investment “can be a game-changer”.
The only licensed TB vaccine was introduced in 1921, and provides moderate protection against severe forms of TB in infants and young children.
There is no vaccine that prevents TB disease in adults, either before or after exposure to infection, although some in late-stage trials have shown promise.
In June, the Wellcome charity and Bill and Melinda Gates Foundation announced US$550m ($945m) for Phase III trials of a vaccine, expected to take four to six years and involve 26,000 people.
Testing will see how effective immunisation is at preventing latent TB, and include people with HIV, who are more vulnerable to illness and death.
“The world has made a huge mistake not investing more in TB,'' Microsoft co-founder and philanthropist Bill Gates told Reuters of the century-long wait for a breakthrough in fighting the disease.
PONTEVEDRA WAS born in the Philippines, and emigrated to the United States with her family as a teenager.
After school she chose New Zealand to study midwifery, sociology, and emergency nursing, and fell in love with the country, its people and the trekking, snowboarding and fishing on offer.
She applied to MSF for assignments while still studying public health, and in 2014 moved to South Sudan, where millions had fled internal fighting, and worked at a large MSF-run hospital, including treating malnourished children.
Another programme involved
training South Sudanese to diagnose and treat malaria, a leading cause of sickness and death.
The work was hard but rewarding, and Pontevedra didn’t hesitate to shift to Yemen at the end of 2015, as a civil war there worsened.
Hers was one of the only flights into the country.
The first night she woke at 2am to airstrikes, and amidst the terrible noise and shaking saw the window in her guest room crack.
She helped set-up a temporary hospital “from the ground up”, and witnessed the way war destroys generations.
“There were many child soldiers … at each checkpoint there were children, with their big kalashnikovs, and chewing [the stimulant] khat. They were probably 10, 11 or 12.”
In August 2016 she helped MSF establish a hospital in Iraq, where in October the Government and other forces began an operation to retake the city of Mosul from Isis (Islamic State).
MSF used inflatable tents to build a portable hospital, complete with an ED, surgical and recovery wards, an ICU, toilets, water systems, sterilisation and a pharmacy.
“It was one of the most fun things I’ve done I think in my life — setting it up, packing it up …we were following the needs, as the frontline evolved.”
Pontevedra was one of the first humanitarian workers to enter east Mosul and in early 2017 moved into the just-liberated west of the city.
They treated patients, mostly women and children, who had been held captive by Isis and were terribly starved. Not all of them survived.
“They were kids … that is one of the memories that I wish I didn’t have. I have seen malnutrition in the African context, but malnutrition during war, it is different.”
The next assignment was in Syria, from late 2017 to 2018, where MSF was rebuilding a large hospital in the northeast of the war-torn country, and establishing a temporary version — this time in shipping containers.
Travelling to the site, Pontevedra suffered a serious head injury when a motorbike smashed head on into their van.
“I was very, very stubborn. Instead of going home to New Zealand I chose to recover in Iraq, so I could go straight back into Syria.”
That led to “a level of burnout”, Pontevedra says, and 18 months in Aotearoa to heal. Walking the Hillary trail on Auckland’s west coast was a balm, as was working with children at the Refugee Resettlement Centre in Ma¯ngere.
She accepted a return to South Sudan, and was there in March 2020 when borders snapped shut in response to Covid.
MSF wanted her in Bangladesh, to prepare for the possibility of Covid ripping through camps of Rohingya refugees, but there were no commercial flights anywhere.
“I contacted the New Zealand Embassy in Egypt; they put me in touch with the Prime Minister [ Jacinda Ardern], so I asked for help, and she personally responded, ‘Sure, let’s get you out’.
“Next thing I know, there’s a call saying, ‘Go to the airport right now, there’s going to be a flight going out, of Japanese students, get on that flight’.”
Pontevedra later moved from Bangladesh to Sudan, to help care for more than 630,000 people who had crossed the Tekeze River, escaping conflict that began in the Tigray region of northern Ethiopia in November 2020.
From river banks overlooking the border she watched Tigrinya people cross, “hearing the shooting following them”. During long days she dug latrines and, at times, went hungry because of food shortages.
A decent stretch back in New Zealand — she bought an apartment near her work at the Refugee Centre — ended when Russia launched its invasion of Ukraine in February 2022.
MSF established medical evacuation trains, which are equipped with staff and equipment and take patients from near the frontlines to hospitals with more capacity, mostly in the country’s west.
Another focus was helping the millions of people with long-term conditions like cancers, cardiovascular disease and diabetes, who had their care disrupted when they fled their homes.
Pontevedra spent time in the east of the country near the fighting.
“It is exhausting. I feel like I’ve done 30 missions in total here,” she told TVNZ’s Breakfast show in May last year, in a middle-of-the-night video interview that surprised her parents, whom she generally keeps in the dark about her riskier placements.
“But it is a very resilient country, full of resilient people.”
SHE LEFT Ukraine last December, and by February was in Manila. This assignment — her 23rd, and first longterm placement — appealed because Pontevedra considers the Philippines home, along with Aotearoa.
When she lived in New Jersey her family returned each year, and her grandmother made a point to take her and her brother to the Smokey Mountain dumpsite in Tondo, where tens of thousands lived and scavenged. The landfill was closed by authorities after becoming globally infamous as a symbol of extreme poverty, and rubbish is now dumped in another area of Tondo, fittingly known as Aroma.
When we visit, bare-chested boys and men unload large plastic bags of rubbish from a truck, surrounded by the detritus of previous deliveries, already picked through for anything of value.
A large rat runs over the tangled electrical wires overhead, and two preschoolers sit by their mother as she sifts through an opened bag.
Some families were moved into nearby housing units after Smokey Mountain closed, but most live in shacks squeezed on to both public and private land, and enabled by a 1992 law that criminalised squatting, yet discouraged evictions except in certain cases.
(In the 1970s former president Ferdinand Marcos used martial law to criminalise and evict squatters, and impoverished areas have been periodically walled-off ahead of major events, including a Miss Universe pageant and papal visits. The “informal settler” population in metro Manila is now estimated at over two million.)
It’s often necessary to crouch when walking through the labyrinth of alleyways between the buildings, to avoid the plastic sheets, drying clothes and wires overhead.
At ground level, the pathways act as drains and sewers — rubbish and plastic collects in puddles, as do swarms of flies and mosquitoes — but also living rooms and communal areas.
Tiny stalls sell vegetables and “pagpag” — thrown-out food that’s recooked — and people do the washing while watching children play among dogs, kittens, and roosters tethered by the leg.
The path narrows and darkens as we go deeper — a maze known only to locals, and the MSF workers here to check up on recent patients.
Genevieve Sael, 47, sits peeling garlic into a plastic tub, as some of her eight children dart around, excited by our presence.
This work is irregular, and she mostly survives by scavenging.
She’s the sole earner after her husband’s stroke, and the family sometimes borrows food, or money, from neighbours.
Sael had a relative with TB who coughed up blood, so she took the chance to be screened. She tested positive, as did one of her daughters, Crystal, 6.
Mother and daughter are now cured, and Crystal is gaining weight.
The family share a small tworoom, airless shack.
Christian Jay Hontiveros, the MSF worker checking on Sael, has seen worse overcrowding.
“One household had 32 family members. This is just a small room, like a studio. They cannot sleep all the time, but they were able to survive because half of them work in the morning, and half at night.
“There are multiple TB cases in the household.”
Other residents have nobody — down the alleyway Wilfredo Dionisio sits by the curtained entry to his home, which is a windowless plywood box, about the size of a narrow single bed.
The 65-year-old moved to the area in 1994 with his late wife. Unfit to work or scavenge, he survives off hand-outs from neighbours and a Catholic charity.
Dionisio was diagnosed in July. “Before he had difficulty breathing, you could really see that he was very sick. Small movements made him exhausted. But he can now move again, he is gaining weight,” Hontiveros says.
Such results keep Pontevedra and the team going.
Her placement ends in February,
That’s one of the scariest things I have seen in my life … the more you scare children, the quieter they become.
Jessa Pontevedra
and she longs for a Kiwi summer — blaming insomnia on the lack of open and green space in traffic-choked Manila.
However, she concedes it could also be related to her time in conflict zones.
In one recurring nightmare her old workplace, North Shore Hospital emergency department, is filled with children, who are awake but quiet.
“That’s one of the scariest things I have seen in my life … the more you scare children, the quieter they become,” she says.
“I saw that in Iraq, in Yemen, in Syria. And I’m thankful, because I live and work in New Zealand, and the kids are never quiet.”