Monday, April 28, 2008

April in Atlanta (and it's official!)

The weather in Atlanta has gotten beautiful! I have learned that nowhere on earth comes close to Atlanta for pollen counts, but fortunately only suffered for a couple days, although my car was yellow for a good several weeks. Ed and I have spent a lot of free time finishing up the "preparing for marriage" book we were doing, and looking at kitchen appliances, flooring, cabinets, etc., since he's in the middle of remodeling his downstairs. I did get him to the botanical gardens one afternoon, as I'm a complete sucker for orchids (and trying to get good close up pictures of them)!
We also had the EIS Conference, the annual conference where all the EIS officers present their work, and more importantly, where all the new recruits explore their options and ultimately get matched with their positions, like I did two years ago! I managed to get through the entire week without taking a picture. Malaria is a popular position, but we always put a lot of effort into recruiting. We interviewed 12 totally stellar candidates this year - I loved them all! We ended up with a terrific new officer who will be joining us in August - an emergency room physician from Seattle who has had an international interest for many years. I think he'll be great!

.....And, on April 26th, Ed asked me to marry him!!!! (Of course I said yes) So, it's official! We're both somewhere above cloud nine. And I celebrated by ripping the dry wall out of his dining room (with permission - I had been looking forward to that!) and helping him choose curtains. :) (the ring on the left was my gift to self for finishing residency)

To Ft. Lauderdale, Florida to meet Ed's parents

The first weekend I was back in the US, Ed and I went down to Florida to meet his parents - we went to the Everglades and took a tour and an airboat ride - here are Ed and his parents all wearing the stylish protective earwear for the airboat ride.
We had a ton of fun - saw a lot of wildlife, and learned a lot from the Micosukee Indian who was our guide on the airboat ride. I got really close to this great blue heron stalking its prey.
And here I am petting a "pet" wild boar that belonged to our guide's family - it was really friendly and rolled over to be scratched like a dog!
The same family had a family of friendly alligators that live in the swamp surrounding their island - this one had been around for over 25 years, came when called, and did a few "tricks" - but at 12 feet, not one I'd want to get too close to!
Ed and I both enjoyed holding some baby alligators!
Ed's parents live in a great place that backs up to a pond and a golf course - here is his brother Warren with the second large mouth bass he caught out of the pond in the space of 15 minutes!
And here is a look down that "large mouth" before releasing it - I like new perspectives. :)
And Ed and I - oh, and I forgot to mention that we also got to go parasailing, which is so much fun to do with someone you love! I'd been wanting to since I first parasailed 6 years ago! (The Florida sun is tough to squint into!) We had a terrific weekend, and I had a lot of fun getting to know his parents. We ate extremely well (that's what the treadmill is for), packed a lot of chatting into a long weekend, and had a great time wild life watching off the back porch. Can't wait to go back!

Scenes in Luanda

Luanda is such a city of contrasts - this was the view from my 11th floor hotel room over down town, with a Catholic university in the foreground - a beautiful, modern city.
There is construction everywhere you look - roads, homes, skyscrapers, etc... There are some beautiful new roads going in (most of this by the Chinese, who seem to be able to work twice as hard and for much less than American contractors).
And a lot of shiny new health clinics.
A lot of little "subdivisions" are going up in the "suburbs" as part of the government's effort to decrowd the city and ease the housing crisis - some upscale and affordable only to the elite, but some, like these, basic but comfortable (and in this case, very blue). There is even a high end mall in a neighborhood of subdivisions to rival any in the US - the only problem is that it takes 4 hours during "rush hour" to get the 10 miles between there and downtown.
At the same time, there are scenes like this less than 10 miles from downtown, that look very poor and rural.
Here's the neighborhood car wash - and potentially good mosquito breeding habitat.
In most of city the roads are horrendous - any amount of rain, and suddenly the streets are rivers, with mud left over, and jams of cars mixed among the blue and white taxis all trying to get through it. When it really rains, nothing but a 4x4 SUV or truck can get through it.
Even on the good roads, the situation isn't rosy - this is Friday afternoon traffic going down to the "posh" suburb - at a total standstill.
The majority of people live on the edge of existence in this expensive town, sometimes literally, as on the edge of this embankment, which has become strewn with garbage.
Scenes like this are not uncommon - open dumps, with who knows what toxic chemicals in the brew, are all over town, with houses and children playing only feet away. The government is trying to clean up the city, and has employed a crew of street sweepers, but these are focused down town, while the surrounding slums (and the majority of the population) continues to live with a growing waste management problem.
Some people live in buildings like this - these concrete block structures can be 10 stories or more - without electricity or running water! That means no elevator, and someone has to carry water up and carry waste down - however many flights of barely lit stairs. And they may pay several hundred dollars a month for this!
But there were so many little scenes I enjoyed - there is little commerce everywhere. And for some reason, tons of old fashioned popcorn machines. I loved this combination of popcorn machine, soft serve ice cream, and the I Love Angola umbrella on the street!
The last weekend, the PMI driver, Gilberto, was driving me around on some errands, and introduced me to his adorable daughter (above) and niece (below).
We also took a little boat ride across to a spit of land called Mussulo that has a few beach clubs and had lunch - a very fun memory to take home with me!

Malaria study in Luanda, Angola

In mid-March, I returned to Angola to do the malaria study I had been preparing for. I was blessed by a wonderful team - above are Dr. Francisco Saute, the USAID President's Malaria Initiative (PMI) Resident Advisor, originally from Mozambique, myself, Dr. Alexandra Pataca Fernandes, the malaria coordinator for the Provincial Health Department of Luanda, and Dr. Jules Mihigo, originally from Rwanda, the CDC PMI Resident Advisor. Both Jules and Francisco speak excellent English, as well as Portuguese, French, etc... Dr. Alexandra is working on learning English, but we mostly communicated in my "Portagnol" - Spanish with the Portuguese words I had learned thrown in. They were all absolutely fantastic and a delight to work with and I feel so fortunate to have had them as colleagues.

Because Dr. Alexandra was so involved in our study, and got official permission from the director of the Provincial Health Department, she was able to recruit excellent nurses as staff and we had great access to the health clinics, both of which were absolutely key.

The question we were trying to answer was basically, how much malaria is in Luanda? Looking at the clinic records during the previous visit, it looked like roughly 1/3 of all patients at health centers were being diagnosed with and treated for malaria. We chose 30 health centers, and had three teams of nurses. Each team went to one heath facility per day, and enrolled up to 30 patients with fever. (The kids, especially the little girls, are adorable even not feeling well.)
Here is one of my teams at work - there's not a whole lot of unused space at clinics in Luanda, so we used whatever space the clinics could give us. Our lab techs had one table to do their malaria testing, and our interviewers sat on one bench facing the patients they were interviewing on the other. I noticed throughout the clinics that patient confidentiality is a Western luxury. It's not uncommon to have 4 or more doctors sharing one room, and often more than one sharing a desk.
I programmed my questionnaire onto PDAs, which my interviewers learned very quickly, and they became very speedy at administering them. Here's one of my staff administering a questionnaire on PDA, which is in a protective box.
Every patient got a blood test for malaria - we did a rapid test so they would know the results before they left the clinic...
and patients with positive tests received free treatment.
Since I was the one behind the camera, there are not a lot of pictures of me - this is me in one of the clinics we worked in with one of my team supervisors, Madalena.
My supervisor from Atlanta came out for a few days to see how things were going - here he is, hard at work. He's exceptionally good at cluing in to areas that need attention (and speaks excellent Portuguese, which was a big help). It was a lot of fun to get to talk to him at length - he's a really great guy! It was also fun to have some variation in my diet - the hotel buffet was $55 for dinner, so I just had meal replacement bars, milk, and coke that I bought in a little grocery store, along with the complimentary fruit in the room. It was fun to have a buddy to walk around with after dark to nearby restaurants!
In addition to doing rapid diagnostic tests for malaria, we did blood slides, which we brought to our colleagues at the National Malaria Reference lab in Angola for staining and reading. Here are a bunch being stained...
...and rows and rows of stained slides...
being read by an expert microscopist - she's absolutely amazing!
At the end of the survey, at the most rural of the health clinics in our sample, we had a team debrief and team pictures. Here is the whole team, including nurses, lab folks, and drivers. Remember the traffic in Angola? We hired a whole fleet of little Suzuki Jimmys and drivers to ferry our teams to the health centers they needed to get to, so the drivers were very important to the teams! At the end of the survey, because my questionnaires were on PDA, I was able to download all my data, analyze it, and plug the numbers into a powerpoint presentation the same night! (Usually that process takes months) The next morning, an excellent translator at the Embassy translated the presentation into Portuguese, and we were able to give a presentation of preliminary results to the director of the Provincial Health Department within 24hrs of completion of the study! After the necessary higher ups had seen the presentation, we had a "dissemination of results" meeting where we presented the results. All of our staff members, as well as other members of the Provincial Health Department, WHO, UNICEF, and some other agencies were there. Here we are, paying rapt attention. :) (I didn't actually do the presenting - Jules and Alexandra did that in Portuguese.) Afterwards, all the participants talked about the implications of the study and how to put the recommendations into practice - very gratifying to see one's work have a potentially large and fairly immediate impact! Oh, and the results... well, there's actually very little malaria in the city of Luanda, where all the resources are concentrated - less than 2% of patients with fever in the city actually have malaria. When you go 10 miles or more from city center, this jumps to ~10%. What does this mean? There are a lot of febrile illnesses that are not malaria - some potentially life-threatening - that are being diagnosed and treated as malaria, and there's more malaria in the rural areas, where there are currently less malaria prevention and treatment resources. So - we need to figure out how to re-train and resource health care providers and lab personnel to look for and be able to diagnose things other than malaria (and be able to say accurately when it's NOT malaria), and we need to get resources for malaria treatment out to the periphery where there IS more malaria.
We also had a ceremony for all of our staff, who got a certificate and copy of the team picture.
One of the symbols of Angola is the "pensador", or thinker. I bought a particularly beautiful ebony one as a reminder of my time in Angola and the thinking I did there. :)

Friday, April 11, 2008

February in Atlanta

When I got back to home, I had almost 6 glorious weeks in Atlanta in a row, the longest since 2006!
Of course, I spent as much of it as possible with Ed. :) The first weekend I was back, we went to Seattle so he could meet my Grandma Thwing, my Uncle Ted and Aunt Cathy, and Jay and Jennie. We had a terrific time! My Aunt Cathy picked us up from the airport and we had lunch, then Ed and I walked around downtown, took the monorail to the Space Needle (we have pictures at the top, but we both look like icicles), and then met Jennie for dinner.The next day, we took a Washington State Ferry ride with my Uncle Ted.....
and then went up to visit my grandmother, who is recovering from a hip fracture. She had been under the weather with a stomach bug going around the nursing unit, but was very cheerful and excited to see Ed!That night, we watched Jennie play hockey - she plays in a women's league.

The next day, Jennie, Ed, and I drove over Snoqualmie Pass to go snowshoeing - it had been closed for most of the past week due to record snow falls, and there were 6 feet of new snow. Ed had never gotten to really play in snow before, and had a blast!
Ready to set out!
Oh, the fun of gloves!
Ed having fun off the trailWhat a winter wonderland!

Workwise, I scrambled to get the protocol for the Angola survey finished, submitted, and approved, all the supplies ordered, the questionnaire programmed into PDAs, and finally, all of this packed in time to actually do the survey.

A Senegalese colleague from the malaria branch and I had been planning to host a Senegalese dinner for the branch for several months, and were finally able to pull it off. One of his friends catered, my friend Meredith hosted, and I just coordinated on email. :) It was so much fun!Serigne in Senegalese attire...And malaria branch colleagues enjoying it!

And last but not least, Ed agreed to let my cat, Rocky, stay at his house during my month long absence in March, so we gave the cats (his two and my one) a weekend play date at his house to see how they would do. This is apparently the closest they ever got without hissing :) Mine is the handsome black and white cat. :)