Back to work for a new year in Angola

I was lucky to be able to spend 2 weeks at home in Texas over the Christmas/New Year's break, and even though it was difficult to leave my family again, it felt great to return to work excited and energized! Lately, the main projects that the other Global Health Corps docs and I have been working on include strategic planning, developing a monitoring and evaluation plan, quality control projects for our laboratory, and developing our follow-up clinic from the ground up. Our program in Cabinda is moving along pretty well - we have collected over 2700 samples from the 2 maternity centers in the city of Cabinda, and have identified 38 babies with sickle cell disease at this point.  We are also building up our clinic - we saw 3 babies this past week - which makes the work so much more satisfying day-to-day.  Now, we are figuring out ways to keep the nurses motivated to keep testing at the maternity centers (they are paid very little, so we try to express our appreciation as frequently as possible!  In Angola, it is VERY possible, even necessary, to "buy" people's work ethic); how to spread the word within the community so that parents understand the importance of actually bringing their baby to our clinic whenever we first call to let them know that a child has been identified with sickle cell disease; and what the best next step in spreading our screening to other parts of the province would be.  Lots of work to keep us busy!

We are also trying to work with other big groups who run health programs in the country to make sure that our program works with all of theirs since we overlap in some areas.  For example, we currently purchase and administer a vaccine called pneumococcal conjugate vaccine (PCV13) to give to the babies with SCD here.  It is a vaccine that all children have been receiving in the US since the year 2000, but here in Angola it can mean the difference between life and death for our patients because pneumococcal infections are one of the common causes of death for children with sickle cell disease.  Luckily, the country is planning to introduce this vaccine for all children this year!

In our clinic, we have a fun nurse named Ruth (pronounced like "root" in Portuguese) who we have started training to help educate the parents, administer vaccines, and perform heel-sticks for our blood samples.  In between patients, we get to sit around and practice our Portuguese by having interesting conversations with her regarding the differences in the practice of medicine and resources available between the US and Angola.  This past week, she was shocked to hear about the availability of vaccines in the US for varicella (chicken pox) and rotavirus ("stomach virus"); she told me about how the clinic nurses know the importance of measuring and plotting growth parameters like height and weight in children on growth charts, but they are unable to do it in the clinics because no one has any measuring tapes.  It's always a little disheartening to realize just how much the intellectual resources are available here, but far outreach the supplies, like medications or even measuring tapes.  It just makes me even more motivated to find other ways to help improve the ability of the health care workers here to provide the best care possible for their patients.

On a completely unrelated note - I have started a website/blog just for my photography here, because the number of pictures I take has gotten a little bit out of control!  If you are interested, you can check out http://sarahlabuda.zenfolio.com/blog to see and hear about the most recent travels or experiences outside of work. :)

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