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

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!