Worst. Blogger. EVER.

Ok, it turns out that I'm not that good at blogging regularly.  I shouldn't be surprised by this, as I am reasonably sure that I have undiagnosed ADHD and get very easily distracted.  ANYWAY.  We have been super-busy here in Angola but it hasn't seemed all that exciting to motivate me to want to write anything about it.  Now that I will be leaving for Texas to spend Christmas with my family in 48 hours (YAY!!!), I figured it was time to update the old blog-er-oo.

In Cabinda, we have been very busy keeping up with developing our sickle cell newborn screening and clinic program.  Each week, we are busy supervising our laboratory's operations (we have 1 lab tech working right now, Lanzi, who is HILARIOUS); visiting the maternity hospitals to update nurses, bring supplies, and pick up the dried blood spot samples that the nurses collect for us; meet with local doctors and officials; and develop more plans for the program.  Recently, we restarted Portuguese lessons with our teacher, Sao, in Houston via Skype for 90 minutes twice weekly.  We have administrative conference calls to attend, MANY spreadsheets to update, emails to respond to, etc etc.  This is the first desk-based job that I've ever had!

Luckily, over the last 2 weeks our babies were finally getting old enough to come into clinic and start taking our vaccines and medications, so we were able to start our "real" doctor-work in addition to all of the public health/program development work that we have already been doing.  Because the children with sickle cell disease are at high risk of death in the first year of life, but are protected by the presence of fetal hemoglobin and maternal antibodies for the first few months of life, we bring the little ones in for their first visit at 6-8 weeks of life.  We are learning as we go what works to convince parents to come bring in their babies, which seem healthy to their parents at this time, to our clinic.  So far we have seen 4 babies and spent lots of time educating the moms about sickle cell disease, giving penicillin (to be given every single day), folic acid (once weekly), an insecticide-treated mosquito net to prevent malaria, and a pneumococcal vaccine.  We also repeat the blood test for sickle cell disease, just to make sure that we are treating the right patient.  Of our 4 patients, only 1 of the moms had even heard of sickle cell disease, so we have a huge job ahead of us in trying to educate the community and advocate for this "invisible" patient group.

At this point, I am basically emotionally and physically exhausted and can't wait to go home for some of my momma's chicken and dumplings.  Oh, and maybe see some family and friends, too.

So...feliz natal, boas festas, and prospero ano novo!

See you all back here next year!  One of my new year's resolutions will be to try to be a better, more consistent blogger. :)

New Assignment: Cabinda!

Ok, I kind of got behind on my intended weekly blog updates!  Since my last post, there have been lots of changes to my work situation.  Kelli, one of the other Global Health Corps docs assigned to Angola, and I move to the northernmost province of Cabinda.

That tiny piece floating by itself is still part of Angola - and my new home/work place!

It is closer to the equator than Luanda was, so it is more rainy, lush, tropical, and hot all year round.  This also means lots of malaria, and coincidentally (we expect, at least) probably more sickle cell disease.  

Over the last 2 weeks, Kelli and I have been busy meeting with local officials and doctors, working with the "maternidades" (maternity hospitals) training nurses and picking up our samples, and getting ready for a fast-growing clinic to get started soon! We already have 400+ samples just from the last 2 weeks, and statistically we should have found 6 or so babies with sickle cell disease, even though we don't even have our lab up and running quite yet.

We are amazed and excited at how quickly everything is already starting up here, and in the next 6 weeks or so, we should have a full and busy newborn clinic getting started as well.  We will be able to provide the infants with prophylactic antibiotics to prevent the severe infections that they are at risk for, vaccines, and mosquito nets to prevent malaria.

Once the assessment/development phase winds down and the real action starts, I'll be sure to post another update!

The view from the window of our lab!

Ummm....what do we do now?  ;)

First baby screened at Primeiro de Maio Maternidade

Lândana beach in Cacongo, Cabinda

Tears of Joy

The last few weeks have already changed my view on my work here in Angola.  Even though I've seen pleny of people, including children and babies, die before, the statistics I studied before coming here were shocking.  If 1 in 5 children here dies before the age of 5, then I knew that I had to be ready for lots more severe illness and death than I had ever experienced before.  And I've definitely seen it already - and seeing children suffer, mothers mourn, and families try their best to care for a dying little one are daily occurrences.  I wrote a whole description of those experiences earlier this week that I am still deciding whether or not to post, so I may do some further editing and put it up at some point.

It turns out that I had done a "good" enough job of preparing that I wasn't particularly emotionally overwhelmed by any of these situations - it was very sad, yet still what I'd expected.  But today, as I watched a 6 year old child who has been in the hospital for over 50 days with tetanus start to take some shaky, wobbling steps with the help of a physical therapist, my eyes immediately teared up.  As it turns out, I was prepared for the disease and death, but completely caught off-guard by recovery and hope.  I know now that, after witnessing his recovery, I will keep that moment in mind as I continue to face so many obstacles here in the future.

Week 4 - DONE!

"You will have amazing days, and you will have devastating days, but you will never have an 'ok' day in Angola"  -Eunice Carvalho, Chevron Chefe (quotation approximated...as I remember it from a month ago!)


How have we already been here a month??  It seems crazy, but it makes sense - I succeeded in accidentally rinsing my toothbrush under the sink instead of with my bottled water this week, so I guess things have settled a bit and formed a routine of sorts and life in Luanda is feeling kinda normal. 

This week, I got some experience with the Pneumologia (Pulmonary) service, which included patients with tuberculosis, pulmonary hypertension, and heart abnormalities, in addition to the tons of empyemas I described in the last post. Rounds are quite different here - they consist of the attending presenting each patient to the student/intern/resident team, and having them record the plan for each. This took less than an hour for 30+ patients, about 30 of whom had chest tubes draining their empyemas. Then, the rest of the day was spent with the intern/resident team writing orders, following up on labs, recording the history and physical for each new patient, and trying to help me figure out what was going on!  My Portuguese is continuing to improve, and we have all found this great Portuguese/English dictionary and verb conjugating app for our iPhones, but once people talk at normal speed, I still get lost very easily!

Friday was a tougher day, because several of the children who had been doing ok throughout the week seemed to suddenly worsen at once.  With (what I consider to be) advanced diagnostic capabilities but limited treatment options available, many of these children who could have easily been prevented from becoming ill in the first place or at least survived with treatments in the US do not have much hope of improvement or recovery here.  The doctors are able to discern that a child has Ebstein's anomaly, a cardiac defect, or pulmonary hypertension, which damages the blood vessels of the lungs, but have very few interventions available with which to treat these conditions.  Instead of IVs, many children receive IM injections (separate shots) for each of their antibiotics.  They also, like any other child, get upset when they have dressing changes or have to have their chest tubes adjusted.  I had to leave the floor early on Friday afternoon because the sounds of so many children screaming in pain was just more than I could handle.  With limited pain medication available - usually, only paracetamol (a form of tylenol) is given, if anything - medical treatment here can seem a bit brutal at times.  I also had the privelege of seeing many of the kids who had completely recovered come back for follow-up visits, so that helped to temper my unease at seeing so many sick kids and their slow progress each day.

Fortunately, we have had some fun this week as well.  One of our lab workers invited us to a party she was throwing; being the silly Americans that we are, we showed up at 8pm as advised, only to find the DJ setting up and a few teenaged girls and boys sitting on opposite sides of the room from each other.  It turns out that this was her daughter's 15th birthday party, and 15 is apparently a big deal here! At about 9pm, food was prepared and we filled our plates with traditional Angolan wonders - funge, a paste-like, flavorless corn meal porridge with an alarming consistency; some sort of fish/cheese/potato dish that was delicious; beans; cakes; and assorted grilled meats.  I decided to try what I falsely hoped to be a piece of chicken breast.  When I sat down at the table and looked more closely at my plate, I saw a fish head looking back at me.  It turned out to still have some very flavorful meat attached, so I survived the experience!  I did have a bit of a battle scar from an ill-advised attempt to copy someone's impressive maneuver of opening a beer bottle with a fork handle. Not a great idea for a person as uncoordinated as me.  Entire families with the most adorable young children were present, and were encouraged to sit on a couch and watch cartoons in a corner of the patio provided.  Parents, relatives, and teenagers alike enjoyed each others' company, ate, and danced the evening away.  We got to see some awesome street dancers perform (Teresa, our co-worker at the lab, grabbed my hand and pushed me to the front of the dance floor; I would have taken pictures, but I was too busy avoiding getting kicked in the face by break dancers!); watch the birthday girl and her friends take a bunch of pictures with their best Blue Steel facial expressions; and then sample some of the 5 cakes that were provided.  Great fun!

This week, I look forward to learning more by observing on the inpatient wards with a different team (this time, probably malaria/meningitis/maybe tetanus or malnutrition?), and then having another 3-day weekend since September 17 is a national holiday!  As Eunice told us when we first arrived, there will be days where we work the hardest we've ever worked, and days where we encounter the most frustrating obstacles we've ever seen, and then amazing days where we love every second - but we will never have just an average day here in Angola.

Cuca, the national beer of Angola - more difficult to open than I had anticipated!

Why, hello there

Owie - teaches me to never try using a fork handle to open a bottle again!

Lots of party-goers, having a good time

Younger sister of the birthday girl, enjoying some cake!

Do you think 4 cakes is enough??  How about 5?

CUTE kiddos!

Birthday girl in the middle, with her younger sister, and friends - posing like their life depends on it!

Time flies when you're having...fun?

Time has started to speed up here, it feels like - how is this already our 4th week in Angola?  It seems crazy that we have somehow been here almost a month, I'm making plans to go home for Christmas, and that life here is starting to feel almost, almost normal. For the last 2 weeks, I was rotating in the outpatient sickle cell clinics, seeing newborns and older kids; the sickle cell screening lab; and doing outreach with the "maternidades". This week, I've started observing rounds with the inpatient empyema ward. Yes, there are enough kids with chest tubes due to severe pneumonia and pus collections in their lungs to warrant having their own ward and service. It's nuts.  Empyema happens in the US - but it would be extremely unusual to have 30 kids in the hospital at the same time with this condition. Here, every single morning during the presenation of overnight admissions, 2-3 new cases have been put in the hospital.  We have a suspicion that a good percentage of these kiddos might have Sickle Cell Disease and just have never been tested. SCD causes susceptibility to what we call "invasive bacterial infections", especially by certain bacteria that cause these bad pneumonias, meningitis, and blood stream infections.  Our main goal in the newborn screening project that we are starting here is to give these children prophylactic medications and vaccines that can prevent these infections.  I am hoping to get a closer look how these kids are treated while in the hospital, and how we can intervene to help prevent these kinds of infections from happening in the first place!  It is unfortunate to have to see so many sick kids, but knowing that I am working on ways to help aleviate this kind of suffering in the future really gives me some hope about what our project can some day accomplish.

Anemia Falciforme

This week, we started work. FOR REAL. Kind of.  We don't actual have medical licenses yet, so we can't legally care for patients.  We don't speak enough Portuguese yet to be that much help in the clinics. And, even though we are at *the* pediatric hospital for the entire country with the highest level of care, the practice of medicine here is incredibly different than what we are used to, and we have lots to learn still!  However, it has felt great to start observing in the clinics, helping out with the flow of information in the lab, and meet with administrators at the Maternidades (birthing centers/hospitals) where babies are born and our screening samples collected. 

Instructions in the sickle cell clinic to help prevent frequent sickle cell crises: drink lots of fluids, keep all scheduled clinic appointments, and take all medications correctly

Dr. Luis Bernadino, an Angolan pediatrician of Portuguese descent who directs the hospital, actually established a sickle cell clinic here in 1977 to care for kids as they became symptomatic and were tested.  Today, this clinic sees at least 70 children per day for check ups every 3 months, along with sick visits and any new patients who come through the door. Adult doctors in Luanda do not see sickle cell patients; there aren't many who survive to adulthood, but there are actually still a few patients around that Dr. Bernadino has seen consistently since opening the clinic 35 years ago.  Though we don't know much about the prevalence of sickle cell disease in Angola in older children, just looking through the waiting room shows most of the evidence you need - there are very few children over the age of 5 present. Because, sadly, most of them die early in life. Already this week I've seen numerous young children with dactylitis, a painful swelling of the hands that is often the first visible symptom of sickle cell; older children with evidence of strokes; and an incredibly pervasive level of severe anemia at baseline in all of the kids screened.  Normal hemoglobin changes with age, and can be lower in young children than older kids and adults and still be considered safe; generally, it should be at least about 12 g/dl.  Here, children walk into clinic with hemoglobins of 3 or 4 all of the time.  It's amazing.

Illustrations of dactylitis, the painful swelling of hands and feet that are often the first signs of sickle cell disease in young babies.

Today, I was able to observe in Dr. Bernadino's personal clinic, and got to see him teach a family about the genetics of sickle cell.  It's really cool to see such seemingly advanced science taught in this type of setting.  Luckily for the family involved, though the mother had died of sickle cell disease, her 3 children were all found to have sickle cell trait, not the full disease. I am excited to keep working on my Portuguese, work with education intiatives in the maternity hospitals to increase our screening rates, and learn more about how we can help the children of Angola who were born with sickle cell disease to endure less suffering.

Dr. Bernadino's teaching charts documenting the genetics of sickle cell disease transmission

T.I.A. - Not only "This Is Africa", but "THIS IS ANGOLA"!

Living in Angola

Since we don't actually start work until Monday, but have had about a week's experience living here, I thought I'd share the ways we have to adjust to get through the basics of every day living.

Our apartment building

To me, these buildings (the SAME EXACT DESIGN, throughout the city) look like Soviet housing blocs

Yay, generators!

View down the block

 We seriously laughed out loud when we saw this down the street

Cost of Living

It never fails to shock people when I tell them that Luanda has been the most expensive city in the world for the last several years; in 2012, it was second only to Tokyo. My stash of American goods that I brought along was limited in size by the insanity of checked-bag fees on international flights. So far, I have paid about $9 for a 4-pack of yogurt; $10 for a box of 50 tea bags; $7 for a quart of soy milk; and $2.50 for 6 eggs. We also pay over $300/month for internet in our apartment. The average cost of a 2-bedroom "luxury" (read: safe for westerners) apartment in Luanda is $6000/month; that is why the 4 of us are sharing this nice, but small 2-bedroom for now.
 

1 kwanza is about 1 cent, so this is $100, even though it looks like a lot more! 

Running Water in Luanda

Public water in our neighborhood, Alvalade, has apparently been out for a few weeks.  It's impressive enough to have public piped water in Africa - much less Luanda, a city of 7 million - that it's not surprising to me that it doesn't work that often. We have a guy come fill our tanks about twice per week with enough water to last for cooking, bathing, flushing toilets, etc.

Water tank

It still isn't safe for us to drink, though, so we have to boil the water for 5 minutes, then put it through a filter to get rid of all of the sediment that results. 

Filling the pot to boil

Water filter that we brought

In order to get actual water pressure in our faucets, we have to turn on our water pump; however, this can only be turned when the water is going to be used, since it uses so much electricity.

Magic switch that gives us water pressure!!

We also have a water heater!! So, at least half of the time, we have the potential to have a hot shower WITH water pressure!  It's great!  To save water as much as possible, we have to take super-fast showers and limit flushing the toilet. This week, we went almost 24 hours without water while waiting for our water guy to make it back to refill the tanks; we had to buy lots of bottled water and take "drip" showers with the little bit that could be squeezed through the system.  There are no predictions on when the water might be back, but elections are coming up soon and apparently very little can be done until those are over, so we get to continue with our back-up system.

Electricity!!

When I went to Tanzania as a medical student, there was infrequent access to electricity, so I was surprised and impressed to see the vast, stably-lit skyline of Luanda as we landed at 4am last Saturday.  Since that time, we have only had to convert to generator power once, for a couple of hours.  I strategically placed flashlights all over the apartment in anticipation of frequent and extensive power outtages; as it turns out, we just have to flip a switch in our circuit breaker box and the generators automatically come on.  Then, when city power is back, the generators go out and our  power goes out again, so we just flip the switch back.

Generator switch, and circuits - we've only overloaded a circuit once so far

 It's an incredibly painless process.  We also have A/C units in the living room and bedrooms, which is really nice.

Driving

We have a driver who takes us around, since traffic in this city is crazy and dangerous ("confucao" in Portuguese!). It really feels strange to call a guy any time we want to go somewhere, but we have plenty of shops, restaurants, and things to do within walking distance, which is nice. I would love to take pictures more pictures of the drive around town, and especially of a lot of the beautiful old Portuguese-colonial-style government buildings, but apparently that can get you arrested.  So I'm going to hold off on that for now.

Ministry of Health building - shhhh, don't tell them I took this picture!

National HIV/AIDS program office

Language

Portuguese is the official language of Angola. We had lessons before arriving, which were great as a baseline level of knowledge, and between the 4 of us we can usually figure out what is going on when we try to talk to people.  Unfortunately, reading comprehension is MUCH easier than understanding spoken language, since our teacher obviously spoke very clearly and slowly for us! We start working in the hospital Monday, so I'm hoping that a combination of immersion in the language with our experience will help us to continue learning.  We also hope to get tutors to continue helping us over the next few months.

Clothes drying system devised by our Brazilian landlady

The minimum receommendation is 20L water per person per day...turns out, that's a lot of work!!

First ever blog post! Bem-vindo a Angola!

Howdy from Luanda, Angola!  It's been a crazy journey to get to this point in my life, and I couldn't be more excited.  Since starting med school, I knew that I wanted to work with underserved populations; somewhere along the way, I decided Africa is where I needed to be.  Nine years, 7 cities, and 2 graduate degrees later, I am an official Americano-Angolano. :)

I have always loved traveling, so getting the opportunity to move to a country where I can (hopefully!) have the opportunity to make a difference in the lives of children helps make me feel like all of those years spent in school were worth it!  Angola has some of the highest childhood mortality rates in the world - 8 out of every 100 babies born alive here dies in the first year of life, and 16 out of 100 will die by age 5 years. For comparison, less than 1 child in 100 dies by in the first year of life, or by age 5, in the US.  The numbers are staggering, and heartbreaking.  Just yesterday we toured the Hospital Pediatrica David Bernadino, the national children's hospital here in Luanda, and were interrupted by the wails and cries of a family indicating that another child had died here.  On average, 7-8 children die per day in the hospital; on my worst week ever during residency in the Pediatric Intensive Care Unit in Little Rock, Arkansas we had 8 children die in a whole week.  Usually, not even that many die in a whole month in that children's hospital, yet here it is an every day occurrence. 

Angola is a large country in southwestern Africa on the Atlantic coast, south of the equator, bordered by Democratic Republic of Congo, Zambia, and Namibia. It suffered through a long civil war for over 20 years which left the country destroyed and covered in land mines. Though there are no official numbers, more amputees are estimated to live in Angola than any other country in the world due to the extensive years of violence. However, there has been stability and relative peace since 2002, and the country's second ever presedential elections are to be held in 2 weeks.

Due to poverty, lack of access to medical care and vaccines, poor nutrition, and many other factors, children here in Angola die of many preventable causes.  Organizations and campaigns addressing many of these are in progress currently; however, sickle cell disease is rarely tested for, very common, and often fatal before the 5th year of life.  Through the Texas Children's Hospital and Baylor College of Medicine's Center for Global Health, we are beginning the first true sickle cell screening AND treatment/follow-up program in Africa. Children have been screened at some of the major maternity centers in Luanda for 1 year now, with follow up at the pediatric hospital where they receive life-saving vaccines and antibiotics.  We will now be working to expand access to this care throughout the city and to the northern province of Cabinda.

Since the moment we landed at the spotless 4 de Feverero Airport, I've been surprised in many ways by the level of development here in Luanda.  There are crosswalks on the main streets with functioning lights and signals in many areas; shops and vendors selling anything and everything you could ever need; all brand-new cars on the roads; and signs of new construction everywhere you look.  The country is rich in oil and diamonds, and has had one of the fastest growing economies in the world in recent years.  There is definitely the possibility and resources available to make a lasting change; I know that my work here will be challenging, but I look forward to sharing all that I see and learn here!