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

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!

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