August 11th, 2015 by Jessie Standish
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CEML has a program for women who need repair of their obstetric fistulas. These women are usually young and from backgrounds with little financial resources or education. They often leak urine or stool down their legs and this problem causes considerable discomfort, embarrassment, and rejection by their partners and family. Almost all of their babies died during the difficult childbirth that caused the fistula and they also carry this sadness with them. CEML works together with the Fistula Foundation to provide operations, a teacher, and a stipend to support the women. The stipend is enough for basic needs but the women usually don’t have enough money to buy the large amounts of pads or disposable diapers that they need to get through the day.

We approached this group of about 10 women who are currently here being treated for fistulas to see if there was something that they wanted to discuss as part of an educational class. There was no definitive consensus and the women had to keep running out of the meeting due to leaking urine. The obvious response was to create a re-usable pad sewing lesson to help the women sew their own pads that they could wash out and re-use every day. I am from Northern California and teaching a Do-It-Yourself Reusable Pad workshop seemed to make perfect sense to me but I wasn’t sure if I wasn’t placing my somewhat “hippy/environmental” solution in a cultural context where such an activity would seem too embarrassing or unusual.

I was very pleased today when the activity turned out to be a hit. During a 3 hour time period each woman hand-sewed a medium and/or a large pad. Each on them had to cut the pattern out of a large piece of flannel (a tablecloth which we found in our hospital break room) and sew all the components together. The pad has an inner compartment where a large rectangular piece of cloth can be doubled over several times and placed inside. This design helps to absorb the maximum amount of urine and also helps the pads to dry quickly on a clothesline. It was a joy to sit around a large table with 10 women happily sewing and chatting in various languages. I understood very little of what they said to each other but helped them whenever I could in Portuguese to describe how to get a better stitch or strengthen a weak area. They begged for more sewing tomorrow. I told them that I would be at the Pediatric Hospital tomorrow and they happily told me “we can do it ourselves now.” These are probably the happiest words that a person in public health can hear! With the help of another flannel tablecloth and some thin towels bought by my roommate Sandy they will create more pads tomorrow. Hopefully the protection from these pads will help them to be able to avoid embarrassment and allow them to live more freely while they await an fistula operation that will hopefully solve their problem.

July 25th, 2015 by Jessie Standish
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Yesterday I had quite a bit of fun “translating” a pictogram into Umbundo, one of the most commonly spoken local languages. The topic was diabetes and I had about 60 graphics mostly taken from the internet or the “Where There Is No Doctor” book representing different concepts in diabetes including causes, symptoms, complications and treatment. With the help of several scrub techs, nurses, the OR secretary and a multitude of patients I slowly was able to write the Portuguese word and the Umbundo word under each picture. It was quite touching to hear the patients, some of them post-operative, call out from their beds in an attempt to help me to find the vocabulary for a difficult diabetes-related concept such as “heart attack” or “ taking your blood sugar.” Even “diabetes” is a difficult word to translate. We decided on “Sugar in the blood” or Osukar vo sonde which seemed to make sense to people.

It was also a great experience in part because the people with extensive Umbundo often have less knowledge of Portuguese are often dependent on their Portuguese fluent relatives in a Portuguese centered environment. Suddenly these same fluent Umbundo speakers, usually elderly patients, became the center of attention as the medical workers sought them out for help with a difficult word.

After finishing I printed out the pictures and the workers felt very happy with the final product. They asked to pin it on the wall in the operating room. Many people laughed at my inability to pronounce Umbundo words but also thanked me for trying to speak words in their language. In the process of translating the words and trying to find the correct words it turned into an informal talk on diabetes. For example when it came time to translate “eat only a little bit of funge” (boiled manioc) patients and nurses talked about what the concept of “a little” means and how for some people, they can only afford “a little” funge. We talked about words for portions and discussed the word koncha which apparently means “an amount that fits into your hand.”
It was a very simple but enjoyable exercise which gave me new respect for the complexity of the local language and the cultural hurdles that people must overcome to understand frustrating medical topics.

July 22nd, 2015 by Jessie Standish
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I can’t believe that the halfway point on my trip is already approaching. There is research that shows that the brain creates a sense of recollection of time based on plotting of events that are new/unique/noteworthy on a sort of neurological timeline of life and estimating the distance between them. As many of my days have been new and unique here it feels like it has been much longer than 3 weeks.

Yesterday some of the nurses in the operating room gave us some interesting insight about some common local beliefs. “Paludismo” and “malaria” (which are both words for malaria in Portuguese) are reportedly considered by many people around Lubango to refer to different things. “Paludismo” is thought to be mild malaria without CNS symptoms such as coma or convulsions. “Malaria” is basically used to refer to severe malaria or cerebral malaria. There are some frustrating half-truths here. It is true that many people who get malaria will not get cerebral malaria and that plasmodium falciparum is the main responsible etiology for this type but that does not mean that a child can be declared “safe” if their symptoms are initially mild. Parents must still be wary of the new onset of severe symptoms.

Another interesting misinterpretation of a term is “maligno” or malignant. Apparently maligno is also a term used to refer to “evil” or “cursed” in this part of Angola. Apparently many people have been interpreting a doctor saying “you have a malignant tumor” as meaning “you have an cursed tumor.” They may interpret this as a doctor reinforcing that someone has cursed them to cause their cancer and therefore believe that undoing the curse may be part of the treatment. Unfortunately there are very few alternate terms that we can use to help people with little education to understand this concept. I have heard other doctors describe malignant cancer to patients by saying “you have a horrible bug with is eating away at your insides until it eats you entirely.” This seems to make more sense to some patients with less education but then again this may potentially create false hope as many people are aware that “bugs” like worms and parasites can usually be killed with medicine.
It seems that many people who come in from the countryside are badly in need of education about different medical problems. I wish that my level of Portuguese was higher so that complicated discussions about the origins of common issues would be more feasible to me. I feel that my hands are tied. In the meantime I am going to look into the cost-effectiveness of making several print-outs for patients from the Where There is No Doctor series and giving them to patients who are waiting for consults or who have come to see us in consult. Perhaps this might be a way to start the conversation. Literacy levels among patients are reportedly about 40% so some of these pamphlets may be only a collection of pertinent pictures regarding a certain topic.

July 11th, 2015 by Jessie Standish
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It has been a joy to work with Dr. Foster who seems to have an endless supply of patience in the face of an endless stream of sick patients. His sense of humor and ability to connect with patients is very impressive. I have also had the honor of working with Dr. Ana Neves, a pediatric cardiologist and incredible force for positive change at the Pediatric Hospital- Pionero Zeca.

If I had my wish for the public health system in Angola it would be to launch a widespread HIV awareness campaign in Angola like I saw when I was working in Cuba from 2006 to 2012. Cuba and Angola were both sheltered from high levels of HIV in part due to lack of transmission from foreigners during the 80s, 90s and 00s. Cuba has gone out of their way to publicize information about HIV prevention in the media, with public health campaigns, in hospitals, concerts, etc. Condoms are inexpensive and available in most stores. I have yet to see the same push in Angola although I have seen a few public service announcements on television. I have been told by nurses that condoms are readily available but I have not yet seen them on display in stores.

The hospitals in Angola must already combat malaria, tuberculosis, intense intestinal parasitism, schistosomiasis, typhoid fever and rheumatic fever which seem to take on a startling array of presentations. Adding HIV/AIDs to that mix will add so much more fuel to the fire of suffering. I dearly hope that Angola can keep their HIV infection rate at 4% of the adult population or less.

July 5th, 2015 by Jessie Standish
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I just arrived in Lubango, Angola a few days ago. The first few days in the hospital have been quite humbling. I feel as if I have “back-tracked” in my knowledge base. The variations in culture, pathology, availability of medications, beliefs and language makes it quite difficult to follow a typical patient history. Multiple boils on the legs of a female patient were not from shaving or uncontrolled diabetes but rather wading through contaminated water. A headache could be from stress, a migraine or hypertension but meningitis or malaria are also quite probable.

I was surprised to learn that diverticulitis, appendicitis and biliary colic are very rare.   Liver failure or liver damage from traditional medication appears to be a fairly common problem here but the offending agent(s) are unknown. The wards are full of women with fistulas secondary to obstructed labor and men with osteomyelitis secondary to traffic accidents.   It is lovely to see how the women with fistulas help each other and offer advice to new fistula patients.

Yesterday, after a morning at the hospital, Bridget took me to the impressive Tundavala cliffs. It was an extremely peaceful place. The swallows that lived in the cliffs seemed to be doing their best acrobatics in the last few minutes before sunset. The rock formations near the cliffs seem almost like cairns made by some sort of playful giant.   I felt so lucky for having the opportunity to come to Angola.

June 26th, 2015 by INMED
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Hello! My name is Jessie Standish. I am a family medicine resident physician at Glendale Family Medicine Residency in California, and I’m starting my INMED service-learning experience at Lubango Evangelical Medical Center in Angola beginning in July 2015.