Angola is located in southwestern Africa, bordered to the south by Namibia, to the east by Zambia, and to the north by DR Congo. Most of Angola is temperate interior plateau with a small coastal plain that is semi-arid. Lubango is a city located in south-western Angola on the edge of the interior plateau. Lubango is the capital of the Huila province and has an estimated population of approximately 500 000. Given the elevation, Lubango is quite temperate with a wet but warm season January to April and the cold season May to August.
Religious, ethnic, political, historical and economic background
Angola is a former Portuguese overseas province, given independence in 1975 after years of fighting by rebel factions. In the wake of independence there was a 27-year civil war that ended in 2002, in which an estimated 1.5 million people died with an additional 4 million were displaced. Land mines were used by both sides and parts of eastern Angola remain land mined. The first legislative election since 1992 is scheduled to be held in September 2008.
Angola has many resources including both diamonds and oil, both of which were used to fund the civil war and later to benefit politicians. Angola could be a very rich country but the money does not reach the average person, instead benefiting a small number of people with power.
The largest ethnic group in Angola is the Uvimbundu (37%), with numerous other tribes making up the rest of the population. 2% of the population is mestico (mixed European and African) and 1% is European, mostly Portuguese. Many Portuguese fled during the civil war. The largest percent of the population follow African traditional religions, followed by closely by Catholicism and many fewer Protestants. The official language is Portuguese but many people do not speak Shaun Cleit outside of the cities.
B. Population Health
The majority of people survive on subsistence farming and 70% of the population live below the poverty line. Most Angolans subsist on less than 70 cents a day while in 2003 “...there were thirty-nine individuals in Angola worth at least $50 million and another twenty reportedly worth at least $100 million.” (Meredith, Martin, The State of Africa: A history of fifty years of independence. pg 616, The Free Press, London, England, 2006.) Most of the richest of these people are present or former government officials.Unemployment and underemployment affect at least half the population. Living conditions are generally poor, and the majority of people live without running water and electricity. In the city, there are areas with running water and electricity, but neither come consistently, and the water is not potable. Five million of the country’s 12.5 million inhabitants live in the capital city of Luanda, where overcrowding, crime, and traffic congestion are serious problems.
The infant mortality rate is 182 deaths/1000 live births and life expectancy is 38 years of age. There is an extremely high rate of death and disability due to accidents, as safety is not a high priority. TB is also very prevalent, and the HIV rate was estimated to be 4% in 2003 but is likely quite higher. Malaria as well as diarrhea due to unclean drinking water are rampant.
C. Health Care System
The health care system is a private/public mix, with public health care being free, at health clinics and hospitals. The standards of public health care appear to be quite low, and frequently the drugs that are supposed to be free are not available at the public hospital, and patients are sent to the market or the doctors' own private clinics to buy medications. Private health care tends to be quite expensive and not necessarily of a much higher standard, but some NGOs and faith-based organizations are attempting to provide quality private health care at an affordable price. In cities there are many options for private and public health care but in villages there is frequently only a health clinic and people with more serious illnesses must travel long distances at their own expense to access hospitals.
Human resources is a complicated issue. There are Angolan-trained doctors and nurses, but the level of education is fairly low. Basic nurses take a short program after finishing 8th grade. There is not a sense of cooperation between health professionals. Many doctors stay in Luanda and set up lucrative private clinics, leaving much of the population without access to doctors.
D. Disability and Rehabilitation
Primary issues encountered by people with disabilities
People with disabilities generally do not have access to rehabilitation. Children with disabilities tend to not be educated and get left at home out of sight. Adults with more severe disabilities tend to be well cared-for, but everything is done for them and they are not encouraged to do things for themselves, limiting their recovery. There are many people who have amputations or disfiguring fractures from the war or accidents, and it is common to see people with crutches. Wheelchair accessibility is very limited and people in wheelchairs many times have to propel themselves on the streets but they are not well-paved.
The state of rehabilitation professions and the status of physical therapists
There is a physical therapy program in Luanda at the bachelor level, which recently graduated its first class, but many of the graduates stayed in Luanda. Physical therapists are very rare, and are mostly expats. There are some nurses who have been trained to provide physical therapy, but their tendency is towards passive treatment. Physical therapist are regarded highly though, and are addressed as “doutor” or “doutora.” I am not aware of an occupational therapy or speech-language pathology program in the county, or in fact of any OT or SLPs in the Lubango area.
E. Personal Experience
As I write this, my husband and I are living in Lubango for 8 months, from January to August 2008.
We came to Angola with SIM Canada, an international Christian mission organization. SIM's website is www.sim.ca, and there is information on their website about how to apply with them. With SIM, it is possible to raise money from friends, family and acquaintances, who can get a tax receipt. They did require that we spend 3 months in Portugal to learn Portuguese, and this was well worthwhile. While in Angola, we are working at Centro Evangélico de Medicina do Lubango (CEML). It is also possible to go to CEML independently, and there is contact information for how to do this on their website at www.ceml.net. Currently, getting a visa to go to Angola is quite difficult, especially for more than 3 months, and it is necessary to have a contact within the country to provide a letter of invitation for any length of stay.
Project components.
The CEML hospital attempts to provide quality care to patients at an affordable price, while being financially sustainable. It has outpatient clinics, an emergency room, a 50-bed ward, and 2 operating theatres. At this point, the only full-time doctor is an ex-pat general surgeon who also does some orthopaedics, and so the focus of the hospital is mostly surgical. The nursing staff and administration are all Angolan. Volunteers are quite welcome in any form: observational (students), to provide a specific skill, or to do education. I am the only rehabilitation professional at the hospital.
My role
I am at the hospital to work full-time as a physical therapist. I see both outpatients and inpatients, and provide training to the nurses, in both a formal classroom setting and one-on-one. I am training one nurse specifically to try to continue with some physical therapy after I leave.
A typical day…
The day is usually 8-5, and I see outpatients in the morning, both returning and new cases. Later in the morning or in the afternoon, I go to the ward and see the inpatients. The case load fluctuates widely, and patients are not always consistent at returning on a designated day.
Some of the successes
Probably my biggest success was working with a patient with an incomplete L1 spinal cord injury. He came to us only able to move his toes on one leg, and with a pressure ulcer. After 5 weeks of intensive therapy, he left walking with crutches. Although he still had some residual deficits (grade 2- quads) it felt like a great success. It was also good for the nurses to see the improvements and the benefits of long-term physical therapy.
Other successes are about things that I have learned. I am now better at identifying red flags that might suggest that a patient has TB in their joint or an old fracture that was never set properly and would benefit from surgery rather than physical therapy.
Some of the challenges
One of the challenges is what I mentioned above in successes – you get stretched beyond what you would normally do in Canada. It is frustrating to see misdiagnoses or improper treatment that leaves people with ongoing disabilities. I once had a child sent to me with a report from a “neurological specialist” in Luanda saying that he had flaccid paralysis in his legs. On assessment, his legs moved fine but he had severe pain in his left knee. On x-ray, the doctor identified that he had a pathological fracture of his distal femur, due to TB.
Another challenge has been the lack of interest in ongoing education by the nurses. In general the nurses are happy to refer patients to me or let me do the work on the ward, but are not interested in learning. Also, the level of education of many nurses is quite low, so it is difficult to decide what is best to teach. In general they do not have the anatomical background to be taught assessment skills.
F. Recommendations
Are there any references or related websites that would be useful to those interested?
