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!