Money, not Tears

Ugh. And so it goes. I missed my flight today. That's what I get for diligently checking the flight status beforehand. So my flight was delayed from 12:30pm to 2pm, and when I saw that online I decided to just stay here at the hostel a bit longer. I arrived at the airport at 11:30am and was promptly told that the gate for my flight was closed...despite the flight delay they had processed it at the original time. So there I was, and they refused to let me on even though the flight wasn't leaving for 2.5 more hours! They must have already given my seat away.

So for the first time in months I began crying, and I'm never the type of girl able to turn on the water show when she wants something. But even my beautiful tears of sorrow failed to sway the hunch-backed Delta man from getting me on the plane.

Because Delta only offers one flight to NYC a day, and no other flights in North America, the flight was booked until the 10th. So I could either wait another five days and sight see some more, or pay $233 for the emergency seat tomorrow.

Flight delays on your way home are one of those events that so gleefully mess with your emotions. Even yesterday, if I knew I had the option to extend another five days I would have jumped at it. But today, having psyched myself up for "finally going home" it was such a blow - "not just a later flight today but in five more days ?!!" So I took the option of paying to fly home tomorrow. Either way I'd have spent the same amount of money.

When I finally arrived back at my hostel (via an hour and a half taxi ride through the ghettos of Cairo when it should normally takes 30 minutes) I told one of the hostel workers what had happened. I told him I had cried and still I wasn't able to get on and now was going to pay for a flight tomorrow. He asked me increduously, "You mean youi didn't try and pay the man to get you in?!"

Another lesson learned in Cairo: money not tears my friend, money not tears. I should have known bribery was the best option....silly American.

In any case, I now have one more day/night to eat my favorite Ta'mayya (falafel) and rice pudding while inhaling the black Cairo air. Life is still good.

My last Day of Travel: Seeing Everything in Cairo in ONE DAY....

I finally arrived in Cairo after pulling myself out of the quicksand of Dahab, giving me exactly one full day in the tourist treasure of Cairo.
I began this morning at 7:30am with the Great Pyramids of Giza. They truly define awesome. I got haggled into a camel ride by a man named Sallah and his camel Mickey Mouse, which ended up being a blast as he was all about helping me get my requisite jumping photos in front of the Sphinx and the Pyramid. And in the end he had Mickey Mouse lie down adn I stood on him for a bunch of rather amusing photos.

After eating my breakfast i'd taken from my hostel consisting of hotdog buns and fig jam, I caught a taxi to Khan-al-Khalili, the famous Cairo market. I wandered through the Islamic quarter where the locals buy their undergarments, spices, toiletries etc., and continued into the tourist quarter full of Egyptian purses, jewlery and shoes. I sat at a famous little alley cafe that has been open supposedly for 200 years while I sipped mint tea and smelled the wafting aroma of apple sheesha being smoked by local men and people-watched. I made a stop at a traditional pasteries, fruits and nuts store and bought some delicious Persian yellow raisins and amazing peanuts coated with honey and sesame seeds, before catching a third taxi to the Egyptian Museum.

Entering the Egyptian Museum is like finding the door to an immense mansion attic full of someone's life treasures: the museum is covered with sarcophagi, vessels, mummies, jewelry and a million other things, many of which are left uncovered/unprotected and look like they were simply dropped off by the movers and never properly put away. My favorites were the animal mummification room, the Royal Mummy room which houses the best preserved mummies in the world frmo the Valley of the Kings and all other famous locations in Egypt, and the King Toot ankh amoon (my Egyptian friend's spelling) wing which houses the most famous death mask, largest sarcophagi, most extensive jewelry etc - all for a king who ruled for just nine years!

Next I decided to wander around the downtown area, since my hostel is only a ten minute walk from the Egyptian Museum and the main dowtown streets of Tarir Haab and El Nile are so close and full of the latest Egyptian fashion. I wandered and window shopeed, and stopped for a refreshing lemon juice, and wandered some mroe...before finally returning to the hostel for a much needed shower.

There are a million things I did not see today, least of all the Citadel, Islamic Cairo, and the Saqqara step pyramid. But this [rovides me with yet another great excuse to return. Tonight my plan is to see a Sufi dance and to go on a sunset falluqua (traditional Nile sailboat) ride on the Nile, since I wasn't able to do a 2-3 day Nile river trip.

It is so hard to believe my time traveling is up. I feel that for me, life is most in perspective when I am traveling. And I feel uncomfortabel not knowing when the next time is that I will leave the States again - although I know it will likely be less than 6 months (fingers crossed). While I am not ready to be done traveling, I am very excited to be back home in the most beautiful location off all the travels I have ever done: my hometown of Missoula, Montana. I have been dreaming of sitting on my back porch, gazing out at my mom's incredible flower garden while sipping on Sangria that my dad and I make. And I am equally excited to begin my last year in my master's program so I can begin compiling the qualitative and quantitative data from my three months in Ghana, and hopefully get the findings published before I graduate.

I feel at a loss of elequent words to summarize my experiences, thoughts and emotions over the past 100 days. Suffice it to say I am thankful for the amazing experiences I have had and everything I have learned, and I hope that it will all contribute to some small change for the better as I continue my work in public health.

Camels and Commandments

I am EXHAUSTED. But in a very good way. The past three days have been filled with nonstop scorching hot adventure.
It began with a two-day camel/scuba dive trek. Myself and six others took a jeep ten km to a diving outpost where our scuba tanks, gear, food etc was loaded onto 6 camels, and finally ourselves, for a two hour trek to Abu Galum, a small Bedouin village comprised of maybe 20 huts. Apparently, this is what Dahab used to look like 20 years ago before it began its rapid expansion into tourism. The 4km trek on camel was beautiful, with the ocean to my right and the desert mountains to my left. Have you ever heard a camel before? They constantly are making throaty gurgling sounds have way between a meaty burp and serious indigestion. But they have really funny personalities and like to kiss on the lips.

One thing I love about the jeep/truck rides out to diving locations is the Egyptian form of free public transportation. At any time that a vehicle slows down to go over a speed bump or to take a turn, a number of small children or adults run after the vehicle and climb aboard for a free lift, simply yelling at the driver when they want to get off. So we had two adorable young boys sitting in our jeep on the way to the starting point of our trek.

Once at our destination, we tried to forget about our sore butts by immediately suiting up for our first dive. The dives here were the best so far in Egypt, with lots of lion and scorpion fish, stone fish, a green turtle, and pristine corals. After our first dive we were treated to our first of many filling traditional Bedouin meals: for breakfast we had foul ( a mashed bean dip), the essential diced cucumber and tomato in cow's cheese, more slices of cucumber and tomatoes, with pita bread to wrap it all in. It was very delicious. After a quick break for digestion we had our second dive, then ate lunch : fresh fish caught right outside our hut, with long-grain rice, a potato and vegetables stew, and diced tomatoes and cucumbers. The Bedouin tradition of providing far more food than can possibly be consumed was well observed. Each meal is followed with Bedouin tea, a delicious tea almost ruined by the heaps of sugar poured in.

Afterwards we attempted to nap as the midday heat reached 115 degrees. We read, played cards, ran into the sun for quick dips in the ocean. Dinner was fresh fish, the traditional Egyptian coushery (imagine a spaghetti-ohs type ensemble of short spaghetti, tomato sauce, and a few spices), vegetables, and honey melon for dessert.

In the evening we played Frisbee on the beach with the Bedouin children, before settling down to watch the incredible desert night sky. There are few times in my life where I've witnessed as many stars as I did that night, and a fair number of shooting stars too. Unfortunately, the desert heat lasted all through the night and my sleep on the sand was less than restful. Nonetheless, it truly felt magical to look out over the Sinai Straight, with the stars above and the outline of the Saudi Arabian mountains across the channel.

Yesterday morning we went on a morning dive, then had another wonderful breakfast. I was unable to go on the second dive because I was planning to climb Mt. Sinai that night and as a rule a person should not climb a mountain or fly within 12 hours of one dive or 24 hours of two dives. So I attempted again to nap despite the waving heat and pesky flies who for some reason really wanted to go up my nostrils.

We made it back to Dahab around 5pm, exhausted and content from amazing diving, food, tranquility and adventure. I probably should have slept but instead took care of postcards, banking, gifts etc. My tour was leaving at 11pm to start the drive to Mt. Sinai.

I thought I'd be able to catch a few zzzzz's on the "bus" there, which turned out to be the same type of van as used in Ghana and everywhere else I've traveled for public transportation where they cram in as many people as possible. Sleep remained elusive and we arrived at the base of Mt. Sinai at 1:45am.

We were given a Bedouin tour guide and started off. While some tours had provided the guests with flashlights, our group had mostly forgot with the exception of the two overly prepared Germans who looked as if they had brought all possible gear for spelunking. So the entirety of our climb was in partial to complete darkness, and it is a wonder that more people don;t fall and get injured on the slippery sandy rock path.

We first passed St. Katherine's Monastery, which actually looked stunning with its lights illuminating the gardens. It really appeared as a beacon of light and safety, and made me think of Monty Python's Search for the Holy Grail when they come upon the Castle in the rain with all the half-naked women in it....

On the way up we had to navigate not only the 500+ people also making the trek, but a whole host of camels carrying the lazy and "less fit" people up the mountain, while simultaneously dodging camels coming down the mountain to carry up the next round. Nonetheless, it felt wonderful to be out finally exercising, and again with the brilliant starry sky.

After 2 hours of climbing, we reached the second half of the pilgrimage, the 750 rocky and uneven steps to the summit. By this time everyone is tired, and can't see, and people are slipping and stopping in the middle of the narrow path...tons of fun. But I made it to the top with about an hour to spare before sunrise.

Sunrise on Mt. Sinai was truly incredibly beautiful, as it bathed the surrounding rocky desert mountains in a red light. And as soon as the sun was fully risen, 500+ began the trek back down. At first I was pretty worried, as I was so tired I was literally falling asleep while climbing down the rocky steps! I chose to take the 3750 Steps of Repentance (laid my a monk as a form of penance) down, rather than the path we took up, to get a different view. Whereas the other path wound around and up Mt. Sinai in a spiral, this path went straight down a gully in the side of Mt. Sinai and had some beautiful arches carved into the path.

Back down at the bottom, it was time for a quick tour of St. Katherine's Monastery and a glimpse at the Burning Bush, before heading back to our van.

I am now safely and exhaustedly back in Dahab, where I am planning my bus to Cairo tomorrow. It is hard to leave this town, but I am excited for the sights of Cairo and the chance to compare its supposed worst traffic ever with that I've seen in Bangkok. Apparently, there are 32 million people in Cairo during the day, and just 24million at night, representing the 8MILLION PEOPLE who commute each day to work in Cairo! Now that's insane...

Now I am off the follow the only commandment I knowingly received while on Mt. Sinai : "Thou shalt take a long nap."

A Day in Dahab

Ahhhhh. This morning I woke up at 6am to do some sunrise yoga on top of the cafe next to my "camp" (guest house). Afterwards I changed while my friend We'il who works at Dolphin Camp made me Egyptian pancakes with bananas and honey and I drank Bedouin tea. Then I was off for an hour horseback ride along the beach to a gorgeous lagoon, racing the guide Mohammed (My mare was named Madonna - fitting isn't it?).

After the morning ride I had to jump into my bikini to make it in time for my morning scuba dive at a place called Blue Hole. To get there, we take a jeep along a winding, dirt road between the red desert mountains and the blue-green Red Sea waters, passing through two security checkpoints (which I found out have been set up throughout Egypt by the government as a means of employing some of the numerous unemployed men). Along the way I stopped counting at 450 the camels in huge groups ly8ing down, some standing, others in a long line walking - all ready and waiting for the massive 100+ tourist groups coming from the Ritzy Sharm-El-Sheik Resort area an hour south of Dahab.

By 11am I was descending straight down through a jagged coral hole to the vast "blue hole." At 35 meters deep (110ft) I suddenly felt giddy and realized I was saying "Wheee!" to myself as I rolled in horizontal 360 degree turns...when I realized I was narced from the depth (nothing like a little oxygen deprivation and utter weightlessness to really enjoy oneself). On the coral we spotted a huge (2 foot diameter head) octopus who was madly flashing from white to black to blue-gray in an attempt to hide from us. Unfortunately out dive had to end about 15 minutes short (only 32 minutes long) soon after as a man with me was unable to equalize his ears, and 34e had to make an emergency ascent. Nonetheless, it was a great dive, made all the more so by the fact that it was given to me for free due to the shorted time and emergency ascent, Woot!. (However, I must admit that I find both the coral and the fish here extremely lacking when compared to all of my dives in Thailand and the Philippines - I didn't realized how spoiled I had been starting in those locations).

I decided to break from an afternoon dive and instead spent the afternoon sunning and swimming, eating Greek salad, drinking a pineapple-orange lassi, and smoking apple sheesha as I read a book.

Tonight there are parties at the two clubs, so I'll be dancing the night away and playing some pool with new friends I've made from Quebec and London, as well as my dive masters.

As you can imagine, for most of the people I've met here, a day in Dahab quickly becomes a week and then months with such a relaxed atmosphere, great food, gorgeous beach and generous locals.

What else: The cats! Everywhere else I have traveled in the world mangy, homeless dogs are the norm. But here the place is crawling with gorgeous Egyptian cats - tall, long-legged with long pointy ears. (There are definitely a fair share of dogs as well). Both the cats and dogs are well-cared for compared to everywhere else I've been, and if you are not an animal lover - or at least capable of accepting five cats at your feet under the dinner table - then maybe Egypt is not for you.

So far everyone has been very kind and helpful here, especially when I was making my way via buses from Cairo here. The men love to try and woo you into their restaurants and shops, but it has yet to ever make me feel uncomfortable in the way it did in Jamaica and other places I've been.

The scenery is absolutely spectacular. From the Peninsula, I look across the channel to the desert mountains of Saudi Arabia, and at night the lone city over there sparkles while the crescent moon rises above it. Behind the ocean front on the back side of the hotels, camps, shops and restaurants of Dahab lie stunning jagged desert mountains. the beach front is filled with large huts and giant parasols housing restaurants and cafes with sleep-inducing floor cushions surrounding a low table. Evenings are spent enjoying the desert breeze over tea and sheesha and good company, before heading to one of the clubs for some dancing or pool.

Apparently this is not the high season for tourists here in Dahab - that comes next month when the weather cools down a bit. But the mix here is good : single travelers such as myself, European and Egyptian families with their children, ex-pats working the diving schools, and amorous couples. It's truly one of those places with something for everyone.

So far Dahab has been a much needed "detox" for me after Kumasi as a place to really lie back and allow my thoughts to wander and coalesce over the past three months in Ghana. I already miss it a great deal - both the country itself and the people I became so close with. And my mind is constantly whirring over the data we collected and how I can use it to best improve maternal mortality in Ghana and elsewhere. I find myself constantly starting to speak Twi instead of Arabic or English. And I already miss red red and palava sauce.

Travel always reminds me that life is so good, makes me realize how fortunate I am, and challenges me to constantly broaden my world view and become a better person.

On my Way to Egypt: A Sad Goodbye and a New Adventure

I am leaving tomorrow night (Friday) for Cairo, where I will catch a bus over to Dahab on the Sinai Peninsula for 10 days of scuba diving and sight-seeing.

It is always weird to say goodbye for me when I have been living/traveling in another country: I cannot say for sure I will not come back, and always hope I will. When I travel, I know that I will eventually leave the incredible friends I meet, and while it doesn't make me hold back from creating lasting friendships, it does make me appreciate the ability to connect with people across the world, and know that immeasurable friendships and experiences are stronger than measurable distances.

I've learned far more from this experience than i anticipated, and am looking forward to the process of uncovering the myriad ways in which my time here has influenced me as a person and in terms of my perspective on maternal health. Much love to Ghana and all of my friends here! I'll post lots of pictures as soon as I get to a place with stable, high-speed Internet.


Now, onto Egypt, where I promise to continue blogging on my undersea, camel, Cairo, and Mt. Sinai adventures.

One more thing: My amazing sister Kelsyn is now in South Korea on a Fulbright teaching scholarship, and has a stellar blog. Check it out at kelsyn.blogspot.com

The Midwives in Our Lives: Much love to Auntie Lydia and Auntie Mary

Today is the last day of work. I simply can’t believe it. The past three months have absolutely flown by, filled with wonder, excitement, generosity, courage and struggle.

Just last Monday Ember (the med student in our group, an amazing girl who got her master’s in public health at Emory University) and I received IRB permission to being a second study on nurse-midwives here at Komfo Anokye. Through our conversations with our own two interpreter midwives we had come to learn of some major themes: the struggle to provide adequate care to their patients despite extreme over-crowding, lack of equipment, and understaffing of midwives due to the brain drain as the younger ones “leave for greener pastures.” Along with covering a number of other topics, we’ve so far conducted 6 interviews and hope to reach at last ten in the next two days before we leave.

I am soo thankful for doing this second study: listening to the stories of these midwives – many nearing or already hitting retirement – has been a much needed inspiration here when sometimes the weight of the intensity of the hospital can feel so overwhelming.

The real inspiration for this study has come from the time we have had getting to know our two amazing, brilliant, compassionate midwife-interpreters for our project, Auntie Mary and Auntie Lydia. They have been so patient in answering our endless questions about pregnancy and caring for and delivering their patients. Most of all, they represent the spirit of midwifery to an extent that has made me seriously consider the profession.

Auntie Mary recently retired from Komfo Anokye where she was the head midwife-in-charge for the antenatal ward. However, she has continued to supplement her income by working night shifts at a maternity ward. So she comes to our hospital to interpret for us from about 10 am to 2-3 pm, and then goes home to sleep before working from 8pm to 8am at the maternity ward. Auntie Lydia – at 65 years of age – is still working at Komfo Anokye on the official ward (“VIP ward) where she follows her patients from antenatal, through delivery and then postnatal care. She comes to work for us the same time as Auntie Mary (around 10am), and then begins her shift from 2pm to about 8pm or later.

Every day these women come to work with more energy than I can muster at less than half their age, ready to assist their patients as best they can under the conditions they are given. When asked about how they handle the lack of proper compensation for their time and effort, they – and all the midwives we interview – insist that to be a midwife is to dedicate oneself to one’s country and the women who make it. They truly love their profession, and despite the endless hours would do nothing else and would not change their choice to stay in Ghana for anything.

It seems this point of view has largely been lost (according to them) on the younger generation, who concern themselves first with making the income they want to allow them to buy the material objects they feel are necessary to live well, and adjust their job location accordingly. I wonder if this is the same with my generation in the states. It certainly is true that my age group and those below me are concerned with being able to provide themselves with the material goods and comforts that our parents have and more. Being ofmr the states, this has les to do with looking for jobs out of our country and more to do with the type of job one chooses. For instance, it is clear wqith the major lack of incoming professional teachers and nurses in the States that money comes first over a civic duty for our country.

Sometimes I worry that my choice to focus on health behaviour and health education in my master’s program is a mistake, since it is in many respects like an international social worker degree, that to say, one that does not exactly bring with it a substantial income. And sometimes – rarely but sometimes – I question my choice of this path. But after listening to the stories of these courageous midwives here, I am reinvigorated with a passion for striving to provide every woman and newborn with a safe passage through pregnancy and birth. I am so inspired to do more, to not just be able to recite statistics on maternal health and authors recommending how to scale up the health care system, but actually have the knowledge of how to help a woman deliver safely and with dignity.

The midwives in our lives – often over-looked and under-appreciated – are an inspirational force in the maternal health community and deserve the utmost respect for the love they show for their work and their patients.

Thank you Auntie Lydia and Auntie Mary, and everyone else for reminding me of why I chose to become involved with maternal health, and how each one of us does in fact have the potential to change the lives of mothers and in doing so – the world.

Maternity Homes in the Kumasi Area

A week ago Tuesday I had the fortune to accompany two of my UM research friends on their facility assessments in Kumasi. Brooke and Tina are second-year med school students at UM, and arrived here with our fifth research team member three weeks after I did to begin their facility assessments. They are conducting research related to ours, by going to all of the district and private hospitals in Ghana that refer their women to our Hospital (KATH) for pregnancy complications. Specifically, they are looking at the extent to which these hospitals are seeing women with pre-eclampsia and eclampsia, and what medications, if any, they are giving them before referring them to our hospital. They also check to see what kind of drugs they have present, the types of tests and procedures they can do, how many health care staff they have and of what type, and the working condition of the equipment.

They finished the referral hospitals, and this week began going to maternity homes that refer women to KATH. Maternity homes are privately-operated, usually small clinics that offer any where from just a few services such as antenatal care (ANC) and standard vaginal delivery (SVD), to an extensive array of services including prevention of maternal to child transmission of HIV (PMTCT), voluntary counseling and testing (VCT) for HIV and other STIs, circumcision, ANC, nutritional counseling, family planning etc.

We managed to visit 6 maternity homes in as many hours on Tuesday. It was striking to see the variety of maternity homes in terms of patient capacity, services offered, equipment available (and actually working), overall cleanliness and amount of good lighting. Most of the smaller ones we visited saw very few pregnant women each year, and delivered maybe just five babies in that time. Why would a midwife choose to open such a small maternity home that sees so few patients each year, and how does she manage to stay in business if she is receiving so little money?

I don’t have to look farther than our hospital to understand the first question: at KATH the midwives work double shifts, have a head midwife to report to, witness numerous deaths of their patients, and are paid very little for their physical and emotional contributions. Like anyone who dreams of opening their own business, the prospect of being one’s own boss is enticing, and as I can imagine, so too is the knowledge that one won’t have to be around so much death and suffering (because they immediately refer any women with pregnancy complications to our hospital).

However, the monetary factor is far more complex and I’m trying to get a better grasp of how it works. Three years ago the government of Ghana implemented a National Insurance Scheme, in which all health care facilities had to register with the government and pay a fee in order to be eligible to receive the insurance funds from their patients. And of course all Ghanaians were eligible for insurance, provided they could pay the “small” fee. Now if the individual hospital/maternity home/private clinic does not register with the NIS, they are ineligible to receive the insurance money for the care they give their patients, and thus their patients leave to find health care facilities that will accept the insurance so they don’t have to pay out-of-pocket.

Now this all began three years ago, and there still remain a large number of health care facilities that are. But even for those who do register, the government is often months behind in paying the facility the insurance money owed, so that the health care workers end up paying out of pocket for medicine for their patients.

Hence a number of the maternity homes hadn’t actually delivered any women in the past couple of months to even the past year, and had provided antenatal care to only a handful.

As for the question of how such a place can remain open…I have no idea. Except that if the center is only employing one person besides the midwife who opened it, her costs would be pretty low beyond the rent.

What really struck me was that every midwife we interviewed said she immediately refers patients with any obstetric complication – eclampsia, haemorrhage, obstructed labor etc – to KATH where we work. Komfo Anokye Teaching Hospital where I work is incredibly overcrowded, with patients we’ve interviewed often waiting overnight for care. Furthermore, it is also considered by many in Kumasi to be the “last stop” in care: if you are referred to KATH, you are probably going to die. And the doctors/midwives are always complaining about two intertwined factors affecting their work: 1) referral hospitals and maternity homes refer patients as soon as they see a problem because they are unwilling to have a patient die at their hands rather than give them very basic medical treatment (at least for pre-eclampsia and eclampsia) that could prevent them from needing referral; 2) Alternatively, many of the health centers’ hold on to their patients until their condition worsens, so that by the time they finally do refer them to KATH they often do die.

These two factors are really difficult to overcome simultaneously, which is really how they must be approached. Timing in obstetric complications really is everything. For instance, a woman with high blood pressure who is immediately referred to KATH from a maternity home may arrive at our hospital only to wait outside overnight, and during that time develop pre-eclampsia and then have a seizure…whereas if she had been kept at the maternity home and given basic BP medications to see if her condition would improve, she would have gotten much better care without delay. Conversely, if for instance a woman is not progressing through labor and she is kept at a maternity home while they wait and see, her obstructed labor may cause internal bleeding and her uterus to rupture, whereas if she had been referred to KATH she would have been given a c-section before that could happen.

Thus KATH where we work is overcrowded with patients who either could have been treated elsewhere, or who have been referred too late and often do not survive. Any intervention must tackle both of these problems, either by organizing education workshops for midwives of maternity homes or going out to each facility. Most of the maternity homes Brooke and Tina have gone to do in fact have magnesium sulphate to control pre-eclampsia, but have not used it and instead referred straight to KATH. And for those that don’t, a greater effort needs to be made to equip health centers with such life-saving drugs.

It is often a fine line between whether a patient should be given care and wait to be referred unless absolutely necessary, or to err on the “safe side” by referring to KATH where the overcrowded conditions may not allow for the best of care and patients not in serious condition take up valuable space.

“Now don’t forget to wash your hands….”

So yesterday I went as usual to the Friday morning meeting where the medical students and house residents gather for a summary of the ward statistics for the past four days. But this time there was a power point set up instead. The man was a representative of the “sanitarization committee” at the hospital, composed of representatives from each general area within the hospital. And he was here to remind the doctors and medical students to wash there hands – among other things.

The first half of the presentation was basic, 2^nd grade information about the importance of hand washing and the types of soap/antiseptic available. After going through this embarrassingly basic reminder, he went on to say that “Now we have barriers at our hospital to hand-washing…there is a lack of accessible sinks, running water and soap, and there was overcrowding and understaffing on the wards. But nonetheless, “be sure to wash your hands after you touch ANYTHING!”

Next he went on to introduce the new color-coding scheme for waste, involving three different colored trash bags to distinguish between pharmaceutical waste, sanitary waste such as bloodied pads, and general garbage that would be “found in an office.” He then explained that there would be one of each for the ward – a ward containing 15 doctors, 30 nursing staff, and up to 60 patients in a ward. The idea that there would be only one set of these color-coded trash bins per ward was ridiculous.

The third part of his talk was to introduce new needle-cutters that would be given to each ward. They were nifty little contraptions really – a small plastic box with a hole in the top in which you placed the syringe after using it and you press the box which causes a razor blade to close the hole, cutting the needle and dropping it into the box for safe keeping. Of course, there were to be all of two per ward…. A nurse then got up and they handed out the boxes to all of the med students and residents present along with sterile syringes to practice cutting it with the box. While it wasn’t difficult, it was important that the syringe was plunged all of the way before cutting it, or the remaining liquid would spray out. Additionally, it was important to make sure the syringe was pushed firmly into the hole so that the razor blade cut the rubber part of the syringe and not the needle itself. It would only take once for that to happen to cause the razor blade to dull and become ineffective at cutting any more syringes.

Nurse: “By the way, it is important to show and teach all of your many colleagues who can’t be present right now how to use them correctly so liquid doesn’t squirt out and the razor blade doesn’t break or become dull….we haven’t got extras….”

After the demonstration, the rep opened the floor to questions/comments. The first was from a house resident suggesting that they put more than two needle-cutters on a ward, seeing how it would cause staff to wander around with the needle in hand looking for an available box – or alternatively wasting time waiting for one to be available before treating a patient. The man agreed that it would be better to have more, but explained they simply couldn’t afford more.

The next comment was by a medical student recounting how a British med student (one of my friends) had told him that the British were phasing out long-sleeve white coats because studies had shown that the cuffs pick up a large number of pathogens from the patients and medical instruments. Additionally, they had mandated the removal of ties, or sticking them under the shirt, for the same reasons. The rep, in a truly Ghanaian fashion, responded by talking in circles about how there are two sides to evidence and research always had mixed findings…and the hospital couldn’t afford to buy all new short-sleeve white coats (never mind they could simply roll-up their sleeves!)…and besides it took nearly a year just to get the idea of color-coded trash bags to actually happen today. He finished by suggesting that the student write a letter to his committee and they would look it over.

The final comment was from the back – one of the chief house officers: “Please, every day we are in surgery doing caesarean sections, and we only have short gloves to wear. We only are allowed to use the long gloves (past the elbow halfway to the shoulder) if the patient is known to be HIV positive. But we have many patients who have not been tested for anything, and are therefore potentially even more of a risk. And everyday we are splattered with blood the length of our arms and it is very dangerous and worrisome…can we please have long gloves for all of our surgeries…we need to protect ourselves and not just our patients.” The rep was sympathetic and admitted it was very important for the doctors to be protected, but explained that as of now there was not the money for the expensive long gloves, and that he should write a letter to the committee…

I was incensed, appalled, frustrated and angry after the presentation. How could he open the floor to suggestions and comments and then shoot them all down with a “write us a letter and we’ll think about it”? Not to mention his round-about bull responses to very important, valid questions and suggestions. But I suppose it isn’t really his fault – if there’s no money there’s no money. And it is also Ghanaian fashion to do everything veeeeery slowly without any concern – even when it comes to trying to save someone’s life. So maybe in a year they will get around to applying for funds to provide surgeons with long-gloves…

As I waited with those same house residents for our rounds to start, I asked one of them if he felt frustrated for being told to wash his hands and then told that there is no soap or water to do so, and to use the new trash bags and needle-cutters despite the fact that there aren’t enough, and he shot down the evidence for rolling-up sleeves, and that their request for long-gloves was shot down. He laughed (which always frustrates me- they laugh about death, about the lack of resources etc.. which I recognize as a coping mechanism but still bothers me) and said that yes it was very frustrating, but that that is how it has always been. Nothing happens fast, if at all.

One of the major things that shocks the British and us about being at the hospital is how slow everything moves: A woman will go into an eclamptic fit and the nurses will just watch her seizing and then stroll over to give her an injection; a women will come crawling to the delivery bed with the baby’s head already out and the midwife will yell at her for pushing and then saunter over to put on gloves just in time to catch the baby. And it is clear that this is a major contributor to the rate of mortality. It makes me want to yell at the doctor’s and nurses to DO SOMETHING. But after witnessing the woman with no insurance who died of renal failure, and the inability for the doctors to even secure surgical gloves, I recognize that the slow, apathetic responses of the health care staff are coping mechanism for their lack of support by the hospital in terms of necessary supplies, patient insurance, and the feeling of inevitability of death.

It makes one want to wash her/his hands…of it all.

Breathing Desp(air)

The past two days have been the hardest for me so far here at Komfo Anokye Teaching Hospital. Since I arrived, I have heard the nurses, midwives and doctors say that many of the women die here because they lack insurance or money to pay for simple life-saving procedures. Some days I come to work and see a woman in the “dark room” (where the pre-eclampsia and eclampsia women are) and see a woman with her eyes rolled back, gasping for breath. And the next morning she would be gone, having passed away. I have also arrived on the ward to watch as the mortuary workers have come and collected these same women. But it has always remained impersonal – abstract and hollow. The imposing smell of death, despair and despondency engulfs me, sneaks up amid the silence where crying and grieving ought to fill the air. It’s as if, at the end of the day I leave the hospital feeling exhausted and empty without really knowing why exactly, despite what I see.

This detached state of being was shattered on Tuesday for me. It was my day to interview, and I was interviewing a woman my same age that had come here with severe ante-partum haemorrhaging. She described how she began bleeding heavily at midnight. She immediately set off walking for the nearest maternity home/midwife about 2 miles away while her husband frantically went around the rural village trying to secure a car. She had to stop on the way more times than she can recall to catch her breath, and each time she did, she would bleed profusely on the road. Her husband caught up with her on foot when she was almost at the maternity home- I took a full hour of walking, resting and bleeding before she arrived. Once there, the midwife referred her here, and drove her here immediately. But she arrived at 2:30 am, and had to wait another 6 hours to get a caesarean section, at which point two still born twins were delivered. The story was heartbreaking and made me so angry at all of the delay- to have to walk an hour!

While she was telling her story, a woman walked by who I’d been introduced to three days previously – she had just lost her baby and was wandering aimlessly through the hospital.

Throughout this entire interview, we were constantly interrupted by a woman in a bed across from us (there is no way to get the privacy we should have for these interviews in this hospital when women sleep two-to-a-bed). She was sitting cross-legged in her bed, moaning, screaming, gagging and coughing. She seemed incoherent, one minute talking to herself or singing, the next minute screaming out for the doctor or nurse- all of whom just stared at her and ignored her. It was so disturbing for me, especially amidst the despair of the story I was collecting.

I asked about this patient, and found out that she had renal failure. She had come to deliver, and had a stillbirth. She was discharged, but our hospital has a policy that if you have no insurance and are unable to pay the bill, the hospital essentially holds you hostage until your family pays it (so for instance there is a woman with her now month-old son who has been here since she delivered, waiting for her husband to come up with the necessary money). And during this time, her kidneys began to fail. The doctors weren’t going to put her on dialysis because she hadn’t even paid for her delivery. But a med student begged and was able to get them to front four dialysis sessions for her, after which she had greatly improved (although was still not totally cleared of the toxins in her blood).

Meanwhile, the government’s “social welfare” officers had gone to her home and assessed somehow that her family should be able to pay for ¼ of the bill. However, her family couldn’t even come up with that. So by the time I saw her on Tuesday, her kidneys had degenerated so badly that she was severely edematous – her whole body swollen from all the fluid in her tissues – and more disturbing was that the poisonous toxins building in her blood due to the kidney failure was making her delirious as the blood poisoned her brain.

Thus the current situation in which I saw her. She kept yelling out to the nurses, who were laughing and told me that she wanted to drink bleach…she wanted to die. Their laughter was both incredulous and pained, as they stood helplessly as they watched her fade. Meanwhile the women in beds around her tried to tune out her screams….

I felt so claustrophobic then – as if I was in an asylum where women were sent to die – and suddenly the full weight of the stale air dropped on me and I wanted to run out as fast as I could, my heart in my throat. Unfortunately, I had to finish my interviews and data entry.

On Wednesday I prepared myself to hear her or see her when I returned in the morning. But her bed was empty. She has died around midnight.

I was not ready for her to pass so quickly – for the full force of injustice to pass so swiftly – and to witness the ward continue as if nothing had happened. I could sense her soul in the air, and it was then I think I decided that the stale, heavy, opaque-tasting air may well be made up of all the grieving souls who have died in this ward without any of their family by their side – without ANYONE by their side. And maybe this is the cause of the indescribable weight I feel in these halls.

While I am confident that the research I am doing will have some sort of impact on the state of maternal mortality in Ghana, it is painful to watch helplessly as so many women die who might have been saved if born in a different country.

Travelling in Ghana on Friday the 13th: B Prepared

We decided to spend this past weekend in Aburi where two of our research members are analyzing traditional herbs used to induce uterine contractions to stop hemorrhaging in women who are about to or have just given birth. Aburi is famous in Ghana for its botanical gardens which were planted back in the mid-1800’s by the English colonists. Interestingly, I found out that Aburi, due to its location on a hill/mountain side, was one of the few places where colonists did not succumb to malaria as there used to be no mosquitoes (this has begun to change as travel has increased and with the effects of global warming).

BUSES

Anyway, we opted to take Friday off of work as the bus ride is more or less an all day affair. On Thursday, it dawned on us that Friday was the 13^th. Ooooooooooh. We woke up early Friday morning, and as we were having breakfast it began to pour rain in torrential cascades. We hopped into a taxi and arrived at the STC bus station. I decided to buy a newspaper as we waited to board. As I turned away and looked at the front page, I saw that the giant front page picture was of vehicular carnage – with the caption “21 Die in Two STC Bus Crashes!” The crashes were pretty bad, but we were slightly reassured by them both having occurred late at night when it was dark.

While the girls fretted over the crashes in the paper, I made my way to the little snack shop for a soy milk. Somehow I managed to lose my boarding ticket in the process and spent the next 15 minutes searching high and low among the cockroaches and dirty feet to no avail. Luckily, it only cost a dollar to get a ticket reprinted, and off we went.

The bus we boarded was a standard large travel bus, only it was very run down with the seats starting to break and stuffing pouring out, and the curtains stained and a nasty dirty floor. But we settled in as best we could. As we were pulling out of the station, two of the girls prayed for a safe journey on Friday the 13^th. They should have prayed for that AND a bus with no bugs.

BUGS

One of the girls spotted the first cockroach about an hour into the ride, coming out of the crack where the seat meets the back of the chair. As the girls are deathly afraid of cockroaches and pretty much every creature that moves, they quickly stuffed the crack with our “STC Bus Crash” newspaper. Shortly after, the bus stopped for lunch.

I ate my PB&J and put the bag in the front seat. The other passengers got back on and started munching away at their fried yam chips and pork kabobs. And then it began….a steady stream of cockroaches pouring out of the seats, ceiling, curtains, and worst of all – my purse (EEWWW! It must have been because the sandwich was in there)! Now normally I am extremely annoyed from having to sleep with the lights on every time my roommate sees a cockroach, but even I was freaking out. And to make matters worse, as the cockroaches descended on us in an increasing frenzy, our bus was stuck in the insane Accra traffic – so close and yet so far away from the bus station. So there we were, cockroaches streaming out of the sandwich bag I’d put in the seat net of me, the other three girls standing out of their seats the last hour (one of them cried at one point when a cockroach was on her lap) and a bus that was not moving. Needless to say, we were beyond thrilled to jump off the bus, although that itchy feeling of bugs crawling on us took a while to subside.

Our fortune turned when we arrived at the bus station and a medical resident friend of ours was there (he had done a short residency at U of M this past fall and we’d met him then and now worked with him at the hospital). He’d just finished a clinic on maternal and child health, and was so generous as to give us a ride. Of course, the awful traffic from a Friday afternoon persisted, and it took a while to get to Aburi – but no complaints! We were in an air conditioned SUV cockroach-free.

We arrived at Aburi in the botanical gardens where our guest house was, exhausted and dreaming of a clean, good night’s sleep. Wrong! We were given the keys to our rooms, located across the hall from each other and accessed from an outdoor hallway, illuminated by a giant fluorescent light. Unfortunately for us, it had just rained heavily, and apparently it was just the right conditions for a frenzied hatching, mating and dying festival by what looked to be small cockroaches with huge wings.

Now, I am not kidding when I say that we were both laughing and crying at this point. The hallway was filled with thousands of the flying bugs, attracted to each other and the light above our doors. And our keys were of the old kind that are impossible to correctly insert to unlock the door. So we would take a deep breath, run into the sea of flying fornication, and attempt to unlock the door while yelling and jumping up and down as the bugs descended. On the floor were massive writhing orgies of them. It took a good five minutes of this before we finally got the doors open. And of course the bugs had been crawling into our filthy rooms under the door, so there were about fifty in each room. To add insult, as the bugs mated they lost their wings, so there were thousands of wings lying around, and little bugs running around gasping for their last breaths. It was…disgusting, even for me. Sleep did not come peacefully that night my friends.

BOTANICAL GARDENS

We were supposed to begin a bike tour at 9am, but as usual things were running on Ghanaian time, so we took a walk around the botanical gardens. The gardens were so relaxing, and we had the quaintest breakfast on an outdoor pavilion overlooking the forest canopy. Breathing fresh, cool air was something none of us had experienced in 5 weeks. The gardens are absolutely stunning: giant palm trees majestically lining the main entrance to the gardens and our guest house, massive mahogany and other trees stretching over 300 feet high, hundreds of different species of flowering trees and bushes with benches under them…and an old helicopter. What? This amazing old helicopter had crashed into the gardens back in the 60’s and was still in its spot. I had a great time climbing around in it and taking a couple of pictures.

BICYCLES

Saturday turned out to be the best day I’ve had here in Ghana. I hadn’t realized how much I’d been missing exercise, and how good it felt to get out and break a sweat not caused simply by the scorching sun. It was a cloudy day, and we had signed up for a 12km biking tour of the surrounding area. Now it didn’t sound too taxing or long. But we were in for something else.

Our bikes had all at one point been nice mountain bikes, with front and rear shocks and suspension. But now, the brakes felt pretty shady and the tires not quite centered. We rode off, all ten of us girls and two guides, through the town of Aburi. As it is situated on a beautiful mountainous ridge, our first 10 minutes were cruising down hill as we wound through the town. It actually felt dangerous and I went very slowly. For one thing, it wa a pretty sharp descent and the brakes didn’t feel so hot. But mostly, it was on account of there being a large funeral celebration in town, which took up all of the street with chairs, dancing, singing and hundreds of guests – which we were working hard to avoid. As I was bringing up the rear, I could see that some of the girls were pretty out of practice of riding and I was afraid they’d crash into a mourner ( I myself was having flashbacks of a crash I had trying to take a steep turn riding downhill in Jamaica…).

Of course, as soon as we got to the bottom of the valley between two ridges we had to ride back up. I suddenly found myself at the front as I pedalled hard to the top. It felt so good to be breathing fresh air and working my lungs in a beautiful location. Once we reached the top of the road and recovered our breath, our guide turned us off the gravel road and onto a 1.5 foot wide trail heading straight down the ridge through the amazing array of agricultural crops. I’ve never been mountain biking as off road as this: careening down this steep narrow path full of rocks and roots, corners and streams. We often had to get off and walk the bikes as the path was too steep and rocky! But it was amazing. We got to stop and eat one of my favorite sweets: sucking on the sweet white pulp encasing cocoa beans. And we saw every crop in Ghana, from yams and cassava to bananas and plantains to mangoes and papaya to cocoa and calabash gourds.

I was enjoying myself so much and felt so full of life (something that the hospital has been sucking out of us all) that I began to sing random songs. I know that if I start to sing it means I’m in a really happy place, because it usually only happens when I’m riding my horse in Montana. Aburi was the best break from the dusty hot monotony of Kumasi and the stealthy cloud of despair and resignation that cloaks us in the hospital. And although we were surrounded by bugs, at least we couldn’t see them.