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. :)