In agony from broken bones that cause her discomfort when she moves her right arm, 99-year-old Eleuthera Abus has endured six months since her fall.

Alena Yap, a 28-year-old doctor, examines Eleuthera on her porch and acknowledges that all she can do is alleviate her pain. However, the necessary treatment of pinning the bone is being denied by the family. Eleuthera's daughters are not devoid of compassion; they are simply impoverished.

The closest surgical facility is located hundreds of miles away across the sea from the small island of Diit, where they reside. Diit is part of the Agutaya archipelago, a cluster of islands stranded in the middle of the Sulu Sea in the Philippines.

For the approximately 13,000 inhabitants of this region, Dr. Alena, as she is fondly called, is the sole medical practitioner. With her petite frame, glasses, and long hair tied in a ponytail, she always wears a warm smile that conceals her unwavering determination.

The only island in the archipelago she does not visit is Amanpulo, named after the luxury resort that has reportedly hosted celebrities such as Tom Cruise and Beyoncé. On clear days, it is visible from the beaches of Diit, just 20km (12 miles) away.

Dr. Alena arrived just before the onset of the coronavirus pandemic and had to grapple with death threats when she insisted on implementing isolation measures. However, the global health crisis was not her only challenge in this often-neglected corner of the Philippines. She battled both emerging and long-standing diseases while confronting the country's most significant obstacles. Her intention in coming to Agutaya was to bring about "real changes," but she ultimately departed with deep disillusionment.

These remote volcanic islands are an unlikely location to find a graduate from the country's top medical school who had spent her entire life in the bustling capital of Manila. Unlike many of her peers who have sought careers in Australia, America, and Britain, Dr. Alena volunteered to join a government program that sent her to one of the poorest municipalities in the country.

Challenging Journey

The primary island of Agutaya presents a formidable challenge, requiring a lengthy two-and-a-half-day voyage from Manila. This arduous journey entails a flight followed by a sleep-deprived 15-hour overnight crossing on an open-deck ferry from the port city of Iloilo to the larger island of Cuyo. From there, the sole means of accessing and departing Agutaya is a soaking two-hour roller coaster-like ride in an outrigger canoe, subjecting travelers to a thrilling yet drenching experience.

Guided by a skilled boatman, the outrigger gracefully traverses the reef and glides into the shallow waters, revealing Agutaya as a slice of paradise. Along the palm-fringed shoreline, an expanse of pristine white sand stretches in both directions. Vibrantly colored outrigger canoes gently sway on the crystal-clear water, creating an illusion of floating in mid-air.

Yet, the geography of this region is a double-edged sword, both blessing and curse. Scattered across hundreds of square kilometers of sea, the dozen or so islands that comprise the archipelago become isolated for days, even weeks, during the monsoon season when fierce winds arrive. Covered in dense forests, the hillsides rest atop vast fields of basalt boulders, leaving little arable land. The islanders depend heavily on the ocean for their sustenance.

In February 2020, Dr. Alena embarked on her new journey to Agutaya. Despite being mistaken for a high school student at the age of 26, she amazed people when she revealed her true profession as a doctor. Reflecting on her early days, she chuckles, remembering the skepticism she faced.

Within a month, the COVID-19 pandemic struck, leading to a nationwide lockdown in the Philippines. Agutaya became isolated from the outside world.

"The first year wasn't too challenging," Dr. Alena recalls. "There were no local cases. However, in the second year [2021], the government allowed people to return to their hometowns. Suddenly, individuals from as far as Manila began coming back."

Dr. Alena found herself responsible for enforcing quarantine measures. "When people learned they would be quarantined, their reactions turned violent," she shares. "I received death threats. People expressed a desire to harm me."

Dr. Alena deeply understands and empathizes with the islanders, as their very survival relies on daily fishing. The thought of being unable to fish and facing hunger weighs heavily on their minds. However, rather than receiving a warm welcome from the local community, Dr. Alena, who had left her fiancé behind in Manila, was met with resentment as a government representative. She openly admits, "There were days when I couldn't hold back the tears. I shed them frequently."

To combat her feelings of loneliness, she found companionship in adopting dogs. Bruno, a large and perpetually happy canine, and Vigly, a small and shy companion, faithfully accompany her wherever she goes. Dr. Alena shares, "I spent a lot of time taking them to the beach, watching the sunset. I also turned to drawing as a form of art therapy, even if my artwork may not be outstanding."

Despite the awe-inspiring beauty of the surroundings and the challenges of isolation, Dr. Alena remains steadfast in her mission to bring positive change to the lives of the people she serves on the islands of Agutaya.

However, the arrival of vaccines in the summer of 2021 introduced a new hurdle. Dr. Alena describes the arduous task ahead, saying, "We had to navigate from one house to another in every village across the islands. The farthest island requires a nearly three-hour boat ride, and many people cannot afford the fare to reach the clinic. As a result, they are unable to come for vaccination."

The distance proved to be just one facet of the challenge. Dr. Alena elaborates, "There was significant hesitancy, fueled by misinformation circulating that the vaccines were harmful or could cause fatalities. Many people here rely on social media for news, but they were not receiving accurate information."

By autumn 2022, the threat posed by COVID-19 began to wane. Despite the initial resistance, the vaccine rollout proved successful, with only eight individuals from the entire archipelago succumbing to the virus. However, little relief accompanied this achievement.

Every weekday morning, a queue begins to form outside the main clinic on Agutaya, even as Dr. Alena and her team are still in their daily meeting.

At the forefront of the line that day is a man in his 50s, exhibiting symptoms of a suspected stroke.

"Before I arrived here, I had this idealistic notion that everything would be fresh and organic," Dr. Alena confesses with a laugh, reflecting on her own naivety. "But obtaining a nutritious diet in this region is incredibly challenging."

One contributing factor is the local practice of salting and drying fish, which can lead to hypertension. Moreover, diabetes is prevalent due to the easier accessibility of sugary beverages compared to clean drinking water.

A prominent sign at the clinic entrance highlights the pressing issue of tuberculosis (TB) with the words "sputum sampling." Dr. Alena explains that they recorded 45 TB cases in 2022, but many more cases remain undiagnosed.

TB, a bacterial infection, can be fatal if left untreated. Although vaccines and antibiotics have eradicated it from many parts of the world, the Philippines still grapples with over a million cases. "The long-term plan is to eradicate it," says Dr. Alena, acknowledging the challenges. Poor access to healthcare often leads to relapses, and the emergence of drug-resistant strains compounds the problem.

Later in the morning, a woman brings her pale and lethargic son to the clinic. Suspecting dengue, Dr. Alena's diagnosis is confirmed a few minutes later. She prescribes paracetamol and advises the mother to keep the boy hydrated.

Dengue is a new concern in the region. What started as a single case in January quickly escalated to ten by March. Dr. Alena and her team take proactive measures, spraying school grounds and distributing treated nets to combat the mosquitoes that spread the disease.

By 11:00, the growing line of patients necessitates Dr. Alena's departure to Diit, a 40-minute boat ride away. Diit, though picturesque, suffers from poverty. It lacks electricity, a mobile phone tower, and has only one short concrete road.

Dr. Alena's arrival in Diit is met with excitement, especially by the schoolchildren who have been given the day off for the dengue control team to spray their school grounds. She walks through the village, followed by a joyful stream of laughing children, akin to the pied piper.

During her visit, Dr. Alena checks the blood pressure of an elderly couple sitting outside their beachside home in wheelchairs. Both have had strokes and experience partial paralysis. The man's blood pressure reads 150 over 90, which, given his age, is deemed acceptable.

In the midst of a gathering crowd, a woman in her 40s makes her way forward, carrying a young boy of about five or six years old. Dr. Alena instructs her to sit down on a chair as she begins examining the child. It becomes apparent that he has a significantly enlarged left testicle. Using a torch, Dr. Alena discovers a hernia in his lower abdomen, where a portion of his intestine has protruded through the bowel wall and into his testicles.

"He will require surgery," Dr. Alena informs the mother, causing the hope in her eyes to transform into anxiety. Dr. Alena asks if she knows anyone on the larger islands where she can stay. The woman mentions Culion, which is a daunting 12-hour boat ride away.

"When I inform them that surgery is necessary, you can see the fear and sadness in their eyes because they realize there isn't any medication I can provide for a cure," says Dr. Alena. "In their minds, they contemplate how they will afford it. Delivering such news is challenging."

In other parts of the world, hernia repair is a relatively straightforward medical procedure. However, in this setting, it can deplete a family's savings, leaving them burdened with debt for years.

"If we could facilitate travel, it would make a significant difference," Dr. Alena remarks. "Yet, it's challenging because it requires substantial resources."

After spending three years on the island, Dr. Alena's initial optimism and ambition have given way to a disheartening realization that limited resources, particularly financial constraints, will always pose the most significant challenge.

Along the base of the rocky hills encircling Agutaya's main island, a concrete all-weather road has been constructed. The road-building commenced during the local election campaign the previous year. Before election day, one lane was completed, but according to the islanders, work came to a halt afterward. There is still no second lane in sight.

"We'll have to wait for the next elections to get the road finished," jests a local resident. On the opposite end of the island, an incomplete concrete structure stands, its exposed steel bars rusting, gradually succumbing to encroaching vegetation.

Dr. Alena explains that it was intended to be the new rural health unit. However, work ceased last year due to the local government's financial constraints. "But they haven't fulfilled their part of the agreement," she expresses, her frustration evident.

In the realm of Philippine politics, personal affiliations overshadow party politics. The landscape is dominated by influential clans whose leaders promise resources from Manila in exchange for votes. As a local woman describes it, Agutaya is too small a community to command sufficient votes that would justify significant investments.

Local politicians have little incentive to bring about change, and during election time, the common practice of vote-buying seems to have established a fixed price: 500 pesos, equivalent to $28 (£22). Corruption runs deep, and the influx of funds appears to vanish before reaching its intended destination.

"I arrived here full of idealism," sighs Dr. Alena. "I was determined to aggressively transform the local healthcare system. However, over time, you realize that three years is far too short to achieve substantial changes."

As Dr. Alena's three-year contract on Agutaya nears its conclusion, many islanders express their sadness at her departure. "Time flies fast," remarks Ricardo, one of the senior nursing assistants, who describes her as "selfless and hardworking."

However, during the weeks following her return to Manila, Dr. Alena confesses to feeling disappointed and even cynical regarding her experience working for the local government. Despite being offered a position at the provincial health administration in Palawan, she declined, opting instead to seek employment with a medical charity or NGO.

Recently, she made a return visit to Agutaya as part of a program organized by an NGO. This initiative involved a team of specialized doctors who visit the island annually to perform minor surgeries. However, this time, the journey was significantly shorter. Dr. Alena and her fellow doctors arrived on Agutaya just three hours after departing from Manila. They landed on a runway located on the luxurious island of Amanpulo, facilitated by a private plane funded by international donors.