Should i get pre-exposure rabies shots before traveling?

What i’ve learned about rabies prophylaxis after being attacked by a dog on a long-term cycle tour


A dog bite during long-term travel is not a problem until it becomes one. When it does become one, what to do about it might not be immediately clear, and local customs and perceptions might not necessarily be the best source of guidance. I felt like greater “rabies awareness” might be warranted, and it shouldn’t be that much of an extra effort to promote it. I hope travelers planning to be on the road for a long time and/or going to regions where rabies is present will find this article useful  —  especially those coming from places where rabies is not an issue, who might not have a good enough intuition of how big of a deal it can become.

Now, i am not a rabies or dog expert myself, and this article is for your information only  —  the following is based on my personal, anecdotal experience being attacked by a dog on a cycle tour, the conversations with doctors and Internet research in that context, and my personal travel and life philosophies. By continuing to read, you acknowledge that i am not liable under any circumstances for what you decide to do or not to do in reaction to this article. My only recommendation is that you inform yourself about the risk, and consult with your doctor and local health authorities before making any decision.

Sometimes dogs can be real bitches!

I’m currently out on a long-term cycle tour. Among other things, this means i spend much of my time on the bicycle riding secondary roads in the countryside, where farm dogs abound, or entering/leaving villages/towns/cities, which in many cases also means dealing with packs of stray dogs. So far, i hadn’t had any problems with them besides their unpleasant, persistent chasing and barking after you until you leave their imaginary territory. Having traveled by bicycle unharmed through more than 20 countries, including some notorious for their dogs such as Serbia, Romania, Bulgaria and Turkey, i had already come to terms with that annoyance, and pretty much internalized the belief that, as long as i kept my cool and didn’t provoke them any further, or at least their owner was present, they would never bite  —  until one of them did bite!  —  in Lithuania, in front of their owner, while i was pulling near a house to ask for information outside the city of Alytus.

My first mistake

“Fuck  —  i don’t want to have to go to the doctor  —  it’s too much responsibility!  —  can you imagine how much time this might take!?  —  and i’m not even worried about how much money it might cost yet.” I was up to date with my tetanus shots, and the wound was seemingly superficial, there was not much blood in the picture. So, i was not particularly concerned about bacterial infections, and it definitely didn’t look like i might need stitches or whatever. The puncture was indeed a bit painful, and in a way i don’t think i’d quite experienced before. But it was nevertheless tolerable. Rabies was quickly singled out as my only potential concern, and i seemed determined to get away from having to deal with it in the most stupid possible way.

“Might i get sick from this bite?” In the cacophonous haze i was eager to get myself away from as soon as possible  —  the dogs continuing to bark at me, their hopeless owner haphazardly yelling at them, presumably trying to contain them from biting me again, while also trying to give me the attention i was asking for, and mutually unintelligible utterances in Lithuanian, Russian, English and Portuguese  —  that’s what i came up with to type into my phone and have translated into Russian, which the owner said she could understand  —  i had no access to the Internet, and had forgotten to download the Lithuanian package for use offline. Although reading cyrillic seemed to be a bit of a challenge for her, i got the sense that she understood my question, which she quickly dismissed  —  “no, no, no.” Despite the language barrier, i felt validated enough, and moved on to what i had really pulled in to ask them about  —  “alright, so, may i camp near the river for one night?”  —  “sure, do you know how to get there?”  —  “i’ll figure it out, thanks!”  —  like i said, i just wanted to get out of there as soon as possible. But, one last time  —  “do i need to go to the doctor for this?”  —  “no, you don’t need to go to the doctor, wait a minute”  —  she then came back with some hard liquor and cotton, with which she cleaned up the wound, and then applied a bandaid.

Whatever. I’ll clean it up again with my first aid kit once i find my campsite.

Folks, that’s not how you ask if the dog has been vaccinated against rabies. Here’s how you ask if the dog has been vaccinated against rabies: “has the dog been vaccinated against rabies?  —  do you have the documentation?  —  can we please exchange contact information?”

That would have made it possible to monitor the dog. But i didn’t do any of that then, nor did i think about going back there next day in the morning for it. I did remember from a previous dog bite back in Brazil when i was a teenager that one typically has about ten days to start taking the rabies shots though, and that i had already completed a post-exposure rabies vaccination program in that occasion. So, i figured instead of rushing into an emergency room close to dark, i could leisurely look up on the Internet the next day how long the vaccine is supposed to last, the risk of getting rabies from a dog bite in a place like Lithuania, and perhaps swing by a doctor on my way to Kaliningrad.

But let’s figure this out

According to the World Health Organization’s Human rabies transmitted by dogs: current status of global data, 2015, the phenomenon is currently not observed in Lithuania. So, my risk of having been exposed to the virus was slim. But as far as i understand the data, it only tells us that there have not been any recently reported deaths by human rabies transmitted by dogs in the country  —  it doesn’t say anything about potential cases where the dog was eventually found to rabid, and the victim survived because of the vaccines. I could not find anything about that on the Internet, and decided a visit to the doctor was warranted after all  —  if only for the peace of mind and what i might learn from the experience of having to seek medical care on a cycle tour  —  how much trouble would that really be? —  how much would it cost?  —  would my travel insurance be useful, would i get reimbursed?  —  would that be the kind of disruption i’d find interesting dealing with?  —  let’s just do this  —  that’s precisely why i left my previous career, hopped on a bicycle, and started riding around the world, isn’t it?

So, what have i learned about rabies?

The one thing about this disease that has always intrigued me was one of its infamous clinical symptoms  —  hydrophobia, or the “fear of water.” I find it tragically fascinating how a virus can trigger such complex behavior in its host. If you think you can handle it, this heartbraking video of a man suspected to have rabies in a hospital in Vietnam shows what that fear of water might look like. This other video shows a man in Russia confirmed to have had rabies describing his condition to the doctors throughout the development of the clinical disease.

Apart from that, i must admit i’m not terribly interested in all the details though  —  as far as the practicalities of cycle touring/long-term travel are concerned, there doesn’t seem to be a whole lot one needs to know about rabies:

  1. It’s a viral disease that can be transmitted to humans through bites, licks and scratches by infected dogs, bats and other animals carrying the virus.
  2. After the onset of clinical symptoms, it is universally fatal.*
  3. This tragic outcome can be prevented with a relatively simple and inexpensive** post-exposure protocol.
  4. Keeping up with the underlying post-exposure vaccination schedule can be a challenge while on the move, especially if you’re crossing international borders along the way.
  5. Pre-exposure vaccination or a completed post-exposure prophylaxis does not confer life-long immunity, but nevertheless greatly simplifies the post-exposure protocol.

Besides the information i got from talking to doctors in Lithuania, Poland and Sweden, i’ve also consulted the World Health Organization, the Centers for Disease Control and Prevention, and the Brazilian Health Ministry (in Portuguese) websites. There’s much agreement and some discrepancy across their recommendations. For the purposes of writing this article, i decided to follow the WHO guidelines, which i briefly summarize below, and can be read in more detail here, here and here. You should, of course, consult with your own available health specialists and authorities before making a decision.

Post-exposure prophylaxis. The WHO recommends immediate washing and flushing of the wound for 15 minutes with soap and water and other virucidal substances such as alcohol or iodine. If there’s bleeding, or in the case of bites in the head, neck, hand or genitals, which have high density of nerve terminations, along which the virus travels until it reaches the central nervous system, the administration of rabies immunoglobin at the wound site is also recommended. This should be done before suturing the wound. One intramuscular dose of the vaccine should be administered on days 0, 3, 7, 14 and 28 after the suspected exposure to the virus. (Alternative vaccination schedules and delivery methods are available, but they all require three to five visits to the doctor and take three to four weeks to complete.)

Pre-exposure prophylaxis. Consists of one intramuscular dose of the vaccine on days 0, 7, 21 and 28, and is recommended to people in risk of exposure to the rabies virus, including travelers to areas where the disease is endemic. Different delivery methods are available.

Post-exposure prophylaxis for previously vaccinated individuals. Rabies vaccines to not confer long-term immunity to the disease. The wound gets otherwise the same washing and disinfecting treatment. But for those who have previously completed a pre-exposure or post-exposure vaccination schedule, fewer doses of the vaccine are required, and the administration of rabies immuglobin is not needed. One intramuscular dose of the vaccine should be administered on days 0 and 3 after exposure. An alternate, single visit, 4-site intradermal vaccination is also possible.

According to the doctor who saw me at the Pomeranian Center for Infectious Diseases and Tuberculosis in Gdańsk, Poland, where i took my second shot, most doctors will treat you as if you have not been vaccinated before unless you can produce documentation specifying the drug, dosage, delivery method and schedule.

Getting vaccinated while on the move

Now back to my personal experience. Before you read it, i want to first admit to my embarrassent for having taken so much of the time of so many people at so many hospitals  —  but i would have been even more embarrassed, if not plain guilty, had this happened somewhere in the world with already precarious health care available to their own population. So, not to be unnecessarily inflammatory here, but the question of whether or not to take pre-exposure rabies shots before long-term travel might well be an ethical one.

I could not  —  i mean, i didn’t want to consider the possibility of staying in Lithuania for four weeks until completing my series of rabies shots  —  at that point i had still not learned that, because i’d been previously vaccinated, i could potentially get away with a single visit. “Can i take the first shot with you here, and then continue my treatment in Poland?” The first doctor i spoke with, in the Emergency Room at the Marijampolė Hospital, didn’t really know what to say about that  —  he implied that my chances of catching rabies from that dog bite were minimal, and that taking the shots or not was eventually my decision  —  but his professional mandate was still to recommend the 0–3–7–14–28 WHO schedule, and that he could not guarantee that i’d be able to take the next shot elsewhere. I don’t think he ever looked at my wound, though i had told him it had been a superficial one on my left calf. He never mentioned the rabies immunoglobin.

With another nine days to decide whether or not to start taking the shots, i decided to sleep on it one more night. Next day, my last day in Lithuania, i figured that consulting with another specialist on my way to Kaliningrad wouldn’t hurt. I first went to a pharmacist in Vilkaviskis, who then referred me to the town hospital. I explained the situation to them, and it seemed like they were actually interested in whether this transnational rabies vaccination program could be successfully carried out! They finally looked at the wound, gave me the first rabies shot, as much paperwork as it made sense, including marking my international immunization card, and wished me good luck.

After crossing Kaliningrad, i reentered Schengen two days later in Poland, in time for my second shot the next day. Getting it took me almost two whole days though, and proved to be quite a hassle. First of all, not every hospital in Poland has rabies shots, and it seems like most of them don’t even know where you can really get it, or seem willing to make one or two phone calls to help you find out  —  each hospital i visited on my way through Elblag, Gdańsk and Gdynia would refer me to the next one  —  not even the University Center for Maritime and Tropical Medicine in Gdynia had the shots! (Rabies is considered a Neglected Tropical Disease.) It was not until the eighth hospital visit back in Gdánsk that i was finally able to get my second shot.

Would that be easier in Sweden? It wouldn’t have been. Dog-transmitted rabies is nonexistent in Sweden, so not many hospitals in the country have the vaccine either, as i found out after my visit to the first of them in Lenhovda  —  Sandra and Julia were very generous with their time to help me find a hospital further down my route where i’d be able to take that third shot, though i’d definitely not be able to do it on day 7, which was slowly coming to an end. Julia consulted with a specialist on the phone, who said i could wait up to another four days until Monday, which would have in fact been the date of the third shot according to the Swedish schedule. On the one hand, that was good to hear. But this discrepancy led me to take a closer look into the WHO’s recommendations  —  that’s when i found out that previously vaccinated people, no matter how long ago, need only take the two shots on days 0 and 3.

Well, that was my case  —  even though i could not quite document it, i’d been attacked by a dog when i was a teenager back in Brazil, and completed a full post-exposure vaccination program on the occasion. I decided that, if i couldn’t trust that, i might as well not trust the transnational vaccination program i was now undertaking either. But before stopping the vaccines, i still wanted to hear the opinion of a doctor, and even that was very difficult to get in Sweden. At the Medical Center in Eksjö, they were not very friendly, telling me that “it was my decision to come to Sweden with that problem, and that they could not help me there”  —  “are you telling me that it’s not possible to sign me in and put me in line to talk to a doctor?”  —  “we cannot help you here, you need to go to Jönköping, they have the vaccine there”  —  “that’s the point, i might not need the vaccine, that’s why i’d like ask a doctor about” — “we cannot help you here, it was your decision to come to Sweden with this problem, you have to go to Jönköping.” I didn’t want to go through the same hospital-hopping i’d experienced in Poland, so i asked them for that hospital’s number. They didn’t pick it up. Although i’d already tried that before, i figured i’d call 1177 again, the number in Sweden for medical non-emergencies, and express a bit more frustration. I’m really glad Renée was the one who picked it up  —  she kindly and patiently helped me settle the matter. I gave her all the information i had, and she connected me with a specialist who finally confirmed that i didn’t need to continue with the shots afther the first two i’d already taken on days 0 and 3. That was a huge relief.

So, should i take pre-exposure shots?

What are the disadvantages of taking the pre-exposure shots? It costs a lot of time, and probably a fair amount of money  —  i’ve seen figures from $100 to $1000, on the Internet, depending on where you are taking the shots.

On the other hand, not taking the shots can make adequate post-exposure prophylaxis challenging to carry out on the road  —  not to mention the potentially harmful waste of the time of the health care professionals you’re going to need attention from.

I am retrospectively very grateful for that dog bite when i was a teenager, and how it has inadvertently made my present life a lot simpler  —  i was not looking forward to finding out what getting a fourth rabies shot in Sweden and a fifth one in Norway might have looked like. Furthermore, i’m at the mere beginning of my world exploration, which will inevitably take me to areas of greater risk of exposure to rabies in the future  —  the fact that i’ve been vaccinated before gives me the same peace of mind about dealing with potential dog bites as my TBE shots have given me about dealing with ticks.

You may read accounts and thoughts from other long-term/cycle touring travelers and health care specialists here, here, and here.

What would you do?

If you’ve considered this, i’d be very glad to hear your thoughts and experience as well. Please feel especially invited to share your own dog/wild animal/human bite story in the comments below, and how you’ve dealt with it, if you have one.

Acknowledgements

Special thanks to Antanas, the pharmacist i talked to in Vilkaviskis, Lithuania who connected me with their town hospital, Vitalija and Vilija, who helped me with the paperwork at the hospital, the doctor who saw me, the nurse who administered the first shot, and all other anonymous staff involved in the affair. Many thanks to Tomasz, who appeared out of thin air to offer me help as a translator in the Elblag Hospital, and to Simon, the guy who offered to guide me on his bike to four different hospitals in Gdynia, doubling as a translator at each of our stops  —  i cannot possibly imagine what it would have been like to deal with this without their help. I also appreciate the kindness of the doctor and staff at the Pomeranian Center for Infectious Diseases and Tuberculosis in Gdańsk, Poland, where i finally got my second shot. I will thank Sandra and Julia from the Medical Center in Lenhovda, Sweden once again for their time and interest, and Renée from the 1177 service, who helped me bring this to a closure.


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Footnotes

* A few non-vaccinated patients have been known to survive rabies through the Milwalkee protocol. But this expensive treatment has only worked in about 10% of the cases where it was applied, and is certainly not something to rely on — especially for a disease where adequate post-exposure prophylaxis almost never fails.

** By ‘inexpensive,’ i mean, ‘to a typical person with enough resources to be traveling abroad,’ as the $50 or so that adequate post-exposure prophylaxis costs can still be an enormous financial burden to those most in need in poor communities around the world where the disease is still endemic.

But why Serbia!?

If i already got that question a lot after i had decided i was going through Serbia on my cycle tour from Copenhagen to Istanbul in Fall 2016, imagine when i decided to move to Niš after finishing that project! I’ve now crossed Serbia twice with my bicycle, and have spent another three weeks living in Niš in between those two rides. So, what’s so special about that place?

This will be the first in a series of articles on how my expectations and prejudices about each country i’ve visited along my current cycle tour (The North Cape Hypothesis) have been challenged. As such, i’m actually not sure the extent to which it will answer the question of what i find special about Serbia in particular. My goal is that, by reading about what struck me the most my second time cycle touring the country, you will feel invited to tavel to Serbia not for a specific place you must absolutely visit, or a specific person you must absolutely meet, but rather for the overwhelmingly positive experience it may award you with.

The context and notation

The North Cape Hypothesis started in Niš, Serbia, and the first 150Km or so between Niš and Velika Plana pretty much backtracked my path from there to Niš in my Copenhagen–Istanbul tour in Fall 2016. For simplicity, from now on i’ll refer to those as the NC Hypothesis, the CPH–IST tour and the VPN stretch — it seems like there’s still a mathematician living somewhere inside my head after all! But i digress…

I’ve been offered a tremendous amount of hospitality during my cycle tours — especially in the countryside — and especially in Eastern Europe, where asking someone for help with finding a safe place to pitch your tent for the night will often result in an invitation for dinner, a hot shower, and a warm bed in their home. Along the VPN stretch, during my CPH–IST tour, the latter is precisely what happened at the Stoianović’s in Markovac, where i spent one of my most energizing cycle touring evenings to date. They didn’t speak a word of English, and i didn’t speak a word of Serbian. But that was apparently not a problem. We didn’t even need much of our respective phrasebooks, which were not really used for a lot more than the outlining utterances of, “I am pleased to meet you,” or, “Zahvalan sam.”

The day after that, none of the people i asked for help on my way through the village of Ratare were as available as the Stojanović’s. But towards the end of it the gentleman at the food market suggested i try the gas station in the next village, Sikirica, a couple of kilometers down the road. That led me to my first of many gas station camping experiences, a rather insighful conversation about human nature with Nikola, the observant employee on his shift when i arrived, and another evening overcoming language barriers with Jovan, the employee on the night shift. They also made sure my tent was both under a roof and visible to their cameras, and offered me unconditional access to their toilet and kitchen.

So, how would those same people treat me a second time around? In particular, what would that look like just five short months after the first time?

The second cup of tea

To be very honest, my expectations were low. A few days before leaving Niš for the NC Hypothesis, i actually wrote to both Nikola and Nenad (Stojanović), telling them i’d be passing through Sikirica and Markovac again, and was wondering if i could stop by to say ‘hi.’ Neither of them ever replied. Is hospitality towards a traveler a one-off deal? Had their interest hinged mostly upon the novelty the first time around? Did they treat me that well simply because the prospect that i’d ever come back asking for more was so slim? Was two times already too much?

I was not fully discouraged by the lack of a reply though. Perhaps staying there for the night once again would have been a bit too much to ask. Perhaps there was another reason they didn’t reply. So, i made alternate sleeping arrangements through Warmshowers for my first couple of nights on the road just in case. But they would surely be happy to see me again and share a cup of coffee, wouldn’t they?

Well, i was wrong!!

When i pulled into the gas station in Sikirica, Jovan not only immediately recognized me, but also greeted me with a big smile on his face. I still spoke no Serbian, he still spoke no English, but it was nevertheless clear that we were both delighted to see each other. He then called Nikola, who was home the next village over, and would be joining us in about 15 minutes. We caught up with the rest of my journey to Istanbul, what they’d both been up to, and what more we’ve learned about people cycle touring and interacting with customers at a gas station or driving a truck. Because i had a place to stay in Jagodina just another 30Km later that night, i didn’t ask if i could pitch my tent with them again this time. But Nikola nevertheless told me, “You’re welcome to stay here whenever you want, or even come to my home, if you prefer, you’re my hero.” He hadn’t replied to my message a few days before simply because his smartphone was broken, and he had not checked his Instagram in a while. In hindsight, i regret not having tried to reschedule my arrival in Jagodina with my prospective host Vojislav for the day after, and taken that opportunity to spend more time with Nikola. I regret not having taken better notes of Nikola’s insightful remarks — a man in peace, no doubt — i don’t experience any cynicism or even disappointment in his speech — but someone who has surely noticed much of the complexity of what’s wrong with this world — Nikola has this look when he speaks, often not looking into your eyes, but focused half a meter or so to their side, as if there was something standing there only he could see. I want to create another opportunity to interact with this guy in this life.

And what about the Sojanović’s?

Markovac is only some 35Km or so north of Jagodina, so i arrived there quite early this time. There was nobody outside, so i clapped my hands shouting, “Dobar dan!” Shortly after, “Grandma” Snezana comes out of the house, smiling and drying up her hands in her apron, “Miko!!” I’m invited to come in and offered a cup of coffee. Half of the family was out working and at first i saw only her, Dragica, the boy Andrija, and a few rare sights of the girl Ana. They joyfully showed me the postcard i had sent them from Istanbul, and we shared some of the waffles my hosts in Niš had given me over the coffee. Because of the language barrier, the conversation was not as “deep” as with Nikola, but the energy was still certainly there — i want to see all of them again — Ivica, Nenad and “Grandpa” Dušan — and i especially don’t want to make the same mistake as the day before with Nikola. So, when they asked me where i was going to sleep tonight i asked them, shaking as if about to ask a woman out, “Well, i was actually wondering whether i could stay here tonight!?” This particular question was typed into my phone and handed over to Dragica, who took a few seconds to parse Google translate’s bad Serbian grammar while i anxiously watched — “yes, of course!” — my shoulders dropped, my handlebar bag was moved from my lap to my side on the bench, the refletive vest and ankle straps placed with the gloves inside my helmet, now hanging on the bicycle — “is the bicycle OK where it is?” — “OK!” — another cup of coffee.

The rest of the family starts slowly showing up. Ivica walks in and goes straight for a hug — “you’re staying for the night, right? good!” Uncle Jovan pulls in with a car — “come, Mika! take your notebook and your phrasebook” — we’re now on our way to pick up Nenad, and then heading over to Velika Plana, where we meet Aunt Divna and Cousins Bojan and Milica — another cup of coffee, more sweets, peanuts, and next thing i notice i’m helping them unload a truck of mushroom spores! I only internalized what that in particular meant with my hosts Dragan and Vera in Kramijevo a few days later — i’m no longer merely a guest, i’m actually slowly becoming part of the house now!! Interestingly, it all felt as natural to me as it seems to have felt to them. Back in Markovac, the process continues — Ivica takes me to meet one of this co-workers and friend, shows me a bit of the town center, and introduces me to the ladies at the groceries. Back in the house, over dinner, i understand that they expect not only another postcard from North Cape, but another visit in the future.

And that’s roughly why

The above is leaving out the tremendous amount of help i’ve gotten from Miloš and his parents Lola and Dragan, my hosts in Niš in each of the four times i was in the city — and the dutiful keepers of my touring rig while i was away in between the CPH–IST tour and the NC Hypothesis. I’m not telling you about the warm and patient welcome from Gejo, Vesna, Miso, Milica, Alex, Luka, Petar, and all the other folks at the climbing wall, who kindly allowed me to climb with them, teaching me a fair amount along the way — apologies for trying to push the whole tree-climbing deal so much into you, folks, i’m still learning to be a guest! I’m not mentioning Rajko, who besides lending me a Serbian SIM card and much of his time and pleasant company playing pool and chess, connected me with Ana and Marko, all of whom guided me through practice rides to the beautiful gorges around Niš, helped me clean and tune up my bicycle — or should i just simply say, did it for me? — rode with me for about half of the way to Jagodina on my first very first day, giving me waffles, jam, rakija, and friendship — moments before we departed, Rajko apologized once again for not being able to ride with me for the first few days, as he had originally promised, calling me his “little brother,” and telling me he “would ride with me to the end of the world” — words that took tears out of my eyes then, and once again as i write them now. I’m not telling you about how much fun i had with Jelena dancing in the sunset to Rage Against the Machine in Bubanj Park, and how touching it was to hear from her that i spread joy around the world.

And those are mere highlights pertaining to my five days in Niš before the NC Hypothesis, because just to begin giving you a better sense of what my experience in Serbia has really been like, i’d also have to tell you about …

Cycle touring diplomacy

More and more, i’ve been experiencing and humbly framing my cycle touring as the diligent work of a diplomat. I surely have a long way to go, there’s no question about that. What i mean is that this is definitely not merely a gap year of sorts, an absorbed self-discovery journey, or a metaphysically motivated pilgrimage. Of course much of that inevitably arises along the way. What i am trying to say is that i don’t want to think of any of my encounters as mere moments in my life and the lives of my counterparts, but as the seeds for long-lasting connections. Like i said, i genuinely want to meet Nikola again, and also honor my promise to the Sojanović’s that i’ll be back. I want to return to Niš as a reputable tree climber, actually having something of substance to offer the folks at the wall who might be interested. I want to ride again with Rajko, as far towards the end of the world as his family obligations would allow. I want to greet Lola with a hug and ask for her blessing getting back on the road much like i would do with my own Grandmother. Conversely, i also want to be equally available to everybody i’ve met in Niš and elsewhere in Serbia for a second or third or n-th time also — if there’s anything — i mean, anything — back in Brazil or anywhere else i’ve made connections i can help them with.

That’s why!


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