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.

The Labor Ward: Life, Death and Plenty to Ponder

Last Wednesday was another day collecting data from the labor ward. The labor ward is simultaneously coveted and avoided by our team members. It is coveted because you get to witness births as you copy the deliveries entered in the book. And it is usually followed by avoiding having to go there the next day because it takes so long to enter the 30+ recorded deliveries into our database.

I really enjoy the labor ward. I have been thinking a lot this year about going on to an accelerated nursing degree program after I finish my MPH, or at least becoming a certified doula. So getting the chance to see the midwives at work is really special.

When I entered the delivery area, I immediately noticed that both women occupying the two delivery beds had a baby’s head already sticking fully out. Soon after I sat down behind the desk, the midwife closest to me delivered the rest of the baby. But the midwife with the other woman seemed to be taking her time and not really paying attention to the woman before, who was lying back quietly. I kept worrying the baby would pop out while she was looking away. But then the midwife left the woman, and I kept glancing up the next couple of minutes, looking at the scrunched up face protruding from the vagina. Finally it dawned on me that this other baby was probably an IUD – inter-uterine death. I asked and it was confirmed. Apparently, when a baby dies inside the womb, the woman’s body fails to properly expel it through contractions. Furthermore, babies actually assist in getting themselves out by squirming and rotating. So if a baby had died in utero, in is very difficult for it to be delivered.

Finally after about 15 minutes, the midwife came and spent the five minutes very forcefully pulling and yanking out the baby. It looked so painful. The poor baby’s body was already macerated- caving in on itself- which meant it must have been dead for a week or so.

The mother never cried, held the baby on her stomach as the midwife cleaned it off. She allowed no signs of mourning. This is one of the things we often muse about at this hospital: does the lack of emotion we witness among women as they watch their babies die – or the women in the beds and on the floor next to them die – have more to do with an emotional blunting they use to guard against the anguish of death, or the sad fact that nurses yell and hit them anytime they cry or scream out, telling them they are disturbing the other patients?

The former is something that has already set in for me. I am witnessing or recording at least one death each week, yet I have yet to cry or feel any extreme emotion other than an empty sadness. It should not be this way. Maternal and infant death should not seem so normal, especially in one of the best hospitals in Ghana.

The next delivery came with its own double – twins! I was asking the midwife questions about what she looks for when she examines the placenta, when a women came waddling in crying out. The nurses yelled at her and smacked her arm as her water broke all over the floor (apparently they yell at the women for pushing too early and not holding back), and she barely made it up onto the table before the baby’s head popped out. The nurse barely had time to put on gloves before catching the newborn. I thought the excitement was all over until 2 minutes later I glanced up in time to see another baby slide out. They were both beautiful, health little girls.

It seemed to be the week of twins and doubles- the two side by side births, the twins I saw born, plus two more women we interviewed who had twins. We also had two women die in one day from obstetric complications. But then today the spell was broken as we ran into triplets! A woman who had suffered from ante-partum hemorrhage had delivered three, healthy girls vaginally! Auntie Mary said I should try for the same so I could get it all over in one pregnancy. I told her it was triple the pain. She told me that no, giving birth was just like when you accidentally bite your tongue…

Being here at this hospital, I am constantly witnessing an intricate dance between Life and Death. I keep trying to find a pattern in it, but it is sort of like a Celtic knot. One minute I am witnessing a still birth, the next minute I have the privilege of bringing one of the women I interviewed her baby whom she had yet to see after she recovered from eclampsia. Here in Ghana, so much of life and death is left to chance, to fate, to God, to witchcraft. There is little room left for western medicine.

Connecting the Dots: Slavery and Identity

Three weekends ago my group traveled down to Cape Coast, a beautiful coastal region of Ghana west of Accra. This area boasts gorgeous postcard-perfect scenes of palm trees lining the ocean beach and women carry bowls of pineapple on their heads for sale. It also represents the heart of the West African slave trade in the 16^th and 17^th centuries. I have not managed a post on this trip until now because it is difficult to put into words – as is obvious to me as I sit and try to write it now.

The importance of the Cape Coast Region lies in its position as the main link between the maritime trade routes of the European powers and the terrestrial trade routes through the Western Horn of Africa. Through the 1700’s, Cape Coast economy was most consumed by its role as the heart of the slave trade – up until its abolishment in 1807 by the British parliament. Most of the slaves were captured in modern-day Nigeria, Mali and Burkina Faso, but also included many other West African countries. Of the forty-something European castles/forts that line the coast of West Africa that were at some point used for the trade and shipment of slaves, 31 of them are found along Ghana’s shores.

Our first stop was in a small town called Assin Manso, an hour from Cape Coast. This used to be the most important stop along the slave trade routes. As the exhausted, dirty captives made their way towards Ghana’s coast from the interior of West Africa, this spot on the banks of the Ndonkor Nsuo (Slave River) was where the slaves were made to bathe before being rubbed down with palm oil to make them look healthy, then sold to slave traders before making their final trek to the dungeons of St. George’s and Cape Coast castles, where they awaited the ships bound for the new world.

Our next stop was at Elmina. St. George’s castle in the fishing village of Elmina represents the oldest remaining colonial building in sub-Saharan Africa, having been built by the Portuguese in 1482. Our tour took us through the male and female slave holding cells, in which 200 hundred years of feces and urine combined to raise the ground 3 and half feet from the original stone floor. It was horrible to stand in the dank dungeons which lack light and air, and imagine the terror and anguish felt by so many people. Indeed, we could actually see it, as fingernail clawings were still very distinguishable on the floor and walls. We also saw the secret trap door that took the female slave of the general’s choice up to his private quarters where he would rape her, and on the way down she would be made available to anyone who wanted “sloppy seconds.”

The most intense part for me was the “door of no return,” which apparently all such slave castles had. This door opens from the final dungeon out of the castle wall to the ocean, where small boats would ferry the captives to the giant ships waiting further out in the water. This door thus represents the end of Africa and the beginning of a long and arduous trip in which only one in four slaves would survive. It was intense to gaze out of that passage, facing towards America and all of the struggle it held in store.

After Elmina we went and did a tour of the Cape Coast Castle, a similar but even larger castle compared to St. George’s. It is reputed to be one of the largest slave-holding sites in the world during the colonial era. At any given time, the Cape Coast Castle held as many as 1500 slaves awaiting shipment to the “new world.” The castle has beautiful white-washed walls and boasts a stunning scenic view of the coast, making it all the more haunting as we descended into the claustrophobic dungeons. It was disturbing to see how similar it was built to the St. George castle in terms of the way it housed the slaves and the tunnel passageway to the door of no return.

One of the most interesting parts of these tours was observing how the context of race in the past and present was handled by the tour guides. The castles actually offer race-segregated tours (that we never actually did), which I think is an important option. One of our tour guides took the opportunity to stop our tour group and announce that he realized that those of us who are white did not directly contribute to the slave trade (awkward), while our other tour guide made a more subtle acknowledgment of the race and power equation by explaining how even before the Europeans came, Africans would enslave other Africans as trophies of war (I however find this to be an entirely off-based comparison). In any case, it was clear that all of us Americans were trying to grasp slavery and our identity within it from a different angle than that we are familiar with: looking outside of America in.

As I watched my African-American friends grapple with the truth that most of them will never actually know which country their ancestors originated from, I couldn't help but think about the basic human need for belonging and identity. Is it enough to know where you were born, and where your parents were born and possibly your grandparents? America is unique in that with the exception of Native Americans, a great number of us do not know exactly where we come from when we try to go back to the continents on which our ancestors left - by force or through the hope of a better life. When I lived in South Korea, most everyone had detailed family trees that went back hundreds and hundreds of years. Traditions are formed upon the basic knowledge of where one came from in the course of history. In comparison, I find myself a bit lost from time to time in America, as I have not attached myself to a certain religion with which to belong, nor do I feel I have a particularly strong link to my ancestors who came to America as far back as the 1600's. But I have been raised to search for such identity within myself, which I believe is one of the reasons why travel has become such an important part of my life. It is through the experiencing of other cultures, religions, traditions and history that I can gain understanding of my identity as a person - as someone trying to understand themselves through the world around them.

Pentacost, Pastors and Palava Sauce

As an agnostic undecided in what exactly I do or do not believe in, I have always been intrigued by religion, and happy to join in on religious events/festivals of my friends in the States or around the world. During my time in Jamaica, I would go every weekend with Mummy (my host mother) to her tiny church in the mountains. As a Seventh Day Adventist, her church brethren and sistren spent much of their time being “taken by the spirit,” which I found quite intriguing and a little bit disturbing. I always managed to dodge the weekly attempt by the pastor to convert me by singing for the church members one of the religious songs I had burned in my memory from years of choir.

I suppose Easter in the Philippines last year would have to take the cake for the most insane and extreme of my religious spectating, where I watched the town drunkard allow himself to be nailed to a giant cross and paraded though the town as Jesus (which he apparently does every year on condition that the town will feed his alcohol addiction for the coming year).

Today I had another wonderful opportunity to witness a religious celebration. Auntie Lydia, one of our two wonderful translators and a still-practicing nurse-midwife, invited us all to attend her church’s Pentecost celebration. I am still a bit foggy as to exactly how it works, but I think the gist is that she is Pentecostal, and therefore attends church on Saturdays, but because today marked the Pentecost – the time when Jesus rose to heaven 50 days after his death – there was an all-day festival today (Sunday) as well.

We arrived around 10:45 and it was clear the sermon had been going on for a while. The “assembly hall” is typical for third world countries- a bare cement structure with no walls (it’s waay to hot for them) and plenty of wooden benches and plastic chairs to sit on. We sat down and I managed to pay attention to the pastor for the next 45 minutes, despite not understanding anything he said as it was in the local Twi language (with the exception of “Amen!”).

But then the uniquely Ghanaian sermon turned to something I’ve been trying to escape – American religious doctrine. An American preacher with a very strong southern drawl appearing to be about 90 years old stood up to present the key sermon. He tried to convince the church that the idea of all its members being “taken by the spirit” is “hogwash.” His incomprehensible stories about Kansas in the 1800’s were lost not only on all the church members, but those of us Americans in the audience, and felt like they dragged on as many hours as he is old. The only thing that kept my attention was that a church member had to translate everything he said from English to Twi. And somehow his Americanisms didn’t quite make it in the translations (“It’s hogwash that any person can be taken by the spirit.”) This was indeed the case, as Auntie Lydia leaned over and explained that the reason the members kept laughing was that the translator was prefacing most of his translations with “Now I don’t really have any idea what he saying, but it’s something like…”).

I was beyond thrilled when he finished the hour sermon and it was time for lunch. The next hour and a half was probably the best time I’ve had here in Ghana. We spent it playing with the approximately 100 children ages 2-12, taking photos together, playing clapping games, and hanging out. Auntie Lydia served us a delicious lunch of one of our favorite traditional Ghanaian foods – Ampesi, which is boiled yams and green plantains with Palava sauce (a spinach sauté with garden egg, which resembles a small zucchini).

After our wonderful time with the kids, we went back into the church for the singing and dancing portion of the festival. I swear, their songs last an average of 40 minutes. That’s forty minutes of dancing and swaying and yelling and parading in front of the congregation and then throwing some money in the pot and then dancing again. I thought I was going to pass out form the heat and sweat. But it was very entertaining and far better than the morning half for sure. During this loud and crazed hour, I noticed the floor covered with sleeping toddlers, which were placed on top of blankets on the floor by their mothers. I can’t imagine how tired they must have been to sleep through all the singing, stomping and clapping.

It was actually sad to leave. Everyone – especially Auntie Lydia – was so generous and inviting, and the kids were such a joy to be with after the last few weeks of intensity at the hospital. However, after the praying session I was ready to go: the four pastors took us into a back room and we stood in a circle as the four of them prayed out loud all at once, sometimes yelling out suddenly as if about to be taken by spirits (while they were praying for me, I was praying that they wouldn’t start speaking in tongues). It actually made me really nervous to be shouted at in prayers by these four men, and I certainly did not feel more relaxed afterwards. But it was a very heartfelt gesture nonetheless – although they failed, once again, to convert this pagan.

I find religion to be fascinating, absurd, and dangerous. Its ability to simultaneously instill love and hate between people has always filled me with awe. I have been fortunate in my life to have only directly experienced religion in a positive and inclusive light through the people I know and meet.

Data Collection Hazards: Fountains of Labor Waters

Yesterday was my lucky day. I had been waiting impatiently to witness births here at the hospital, but had yet to really have a chance beyond glimpses from afar when the woman gave birth on the floor, or peeking into the labor ward when trying to get ahold of the elusive delivery book. But yesterday, the nurse-midwife in charge had me copy the data from the book at the nurse's desk right in front of the two birthing tables (usually they give me the books and I take them to the waiting room where the women in first stage labor are waiting to reach second stage- this is where the "floor births" take place).

As it was Monday, we were having to collect data on every delivery from Friday, Saturday and Sunday, which ended up amounting to 117. Needless to say, I spent a good 3+ hours in that delivery room copying the delivery information onto my data sheet (which is then taken back to our work room where we upload it into our computer databases).

And during this time, I witnessed 8 births. Births in the labor ward - I can assure you - are nothing like ones back home (although truthfully I've never witnessed one in the States). Besides the occasional "floor deliveries" in the first stage labor waiting room, the labor ward boasts of 8 beds with mostly naked women in various stages of 2nd stage labor, some naked, others half clothed. Some screaming, some moaning, and some snapping their fingers (a sign of pain). Meanwhile, doctors, nurses, med students, and occasional research teams such as mine are wandering through. Although there are curtains hanging from the ceiling in front of each bed, they have remained tied up. When a woman must relieve herself, she does so in her "hot bucket", a small plastic pail with lid that the women must provide themselves to urinate and defecate in. They simply get off the bed and squat over the pail between the beds.

In the adjoining room is the delivery room with its two labor tables and newborn assessment area in the corner. Across from these is the nurse desk where they write down the delivery information in the patient files and record them in the delivery book. It is also the resting place for the nurse-assistants, nurse-midwives, and any other helpers or researchers such as myself - all approximately 3 feet from the table where the laboring woman is lying with her legs spread.

The deliveries were fascinating: the women are not given any drugs - no epidurals or easy ways out like we have - and yet most women remain incredibly in control, although there is of course a number of women who make plenty of noise. Part of the reason they are often so quiet is that it is a Ghanaian belief that a woman should be quiet during birth to prove her maternal strength. And part of it is that the nurses often yell and sometimes even hit women who choose to scream or cry out.

From my sitting point three feet from expanding vaginas I was able to watch (amid writing names, dates, times) the nurse-midwife as she aided the baby's head to first emerge, then checked with her finger to make sure the cord was not wrapped around the baby's neck, then watch carefully for the shoulders to rotate before pushing the head down and freeing the shoulder as the rest of the grey body quickly followed.

Birth number four was interesting from the beginning. The young woman was put in the stirrups, and after abour 5 minutes her contraction slowed, and then seemed to cease altogether. Now normally, the woman is in and out of the stirrups in 10 minutes by the time they get her in there (because there are only two delivery tables they can't afford to put women in them until they are literally delivering, because there are so many more waiting). But this young woman (about my age) had been on the table for about ten minutes making no sounds. I was hardly surprised, therefore, when the nurses gave her an IV drip with oxytocin, which is a drug used to induce uterine contractions to progress the labor development.

The nurses, nurse assistants, nursing students, janitors, and myself were all looking on intrigued, asking about the treatment and how long it would take to kick in etc. Within two minutes, the woman began groaning and fidgeting, and I suddenly saw her stomach contract down as if the baby was about to burst out....when suddenly her waters broke, shooting a HUGE projectile stream three feet out, and directly onto three of the nursing students's laps. I was mostly spared - it only got on my shoes. We were all pretty shocked, as none of us had realized her waters hadn't yet broken.

But this was only the beginning. As the time between contractions became closer, it was apparent that the baby's head was not going to fit through the small vaginal opening. The nurse-midwife made the decision for an episiotomy, and using a small razor blade, told the woman to push and cut the perineum little by little with each push so that the woman would not feel the cuts through the other pain.

The baby's head soon followed, and was delivered shortly after. It didn't take long for the placenta to follow. The nurse took the pail where the blood had dripped into and poured it into a large measuring cup - 800 ml of blood, she nnounced. This is quite a lot, given that most women we record average 150-250 ml of blood loss. Anything over 600 ml is a potential case for a blood transfusion.

I then watched a different nurse suture her episiotomy closed, and as aweful as a comparison it was, I could only think about how similar the technique seemed to the stitches I received from my skiing accident a few years back...

I thought I might have had to interview this woman today if she ended up indeed having a blood transfusion, but luckily she never showed up today on our list of complications. I was greatful for the opportunity to see how hard the nurse-midwives work to safely deliver babies as easily as possible for the laboring mothers. I was in total awe of this young woman's strength and courage - of every woman's - to sacrifice her body in order to bring a new being into this world. And I was relieved for having a lap free of her labor waters.

Soccer Insanity: Mosh Pits, Pick-Pockets and GOOOOOALS!!!

So I have been greatly anticipating today's Ghana versus Libya Word Cup qualifying match here in Kumasi. It has been apparent from the moment I landed on Ghanaian soil that people here live and breathe soccer ("football"). And after this evening's match, I think I can say that the football fans here are more passionate about the game than the players themselves.

This weekend, the four other students here on my program (two who are doing research on sickle cell genes in Accra and two doing research in Aburi on native herbs that have been used for centuries in obstetrics here to induce uterine contractions during labor or slow post-partum hemorrhage) have come to Kumasi to visit. We arrived at the football stadium two hours before the game began, and had some late lunch. Kofi, our Ghanaian liaison here (without who we'd still be sleeping in the cement jail cell) warned us we'd better get inside before all the seats were gone.

We made our way around the stadium to the side we had tickets for. When we approached the entrance - two turn styles about 8 feet apart going thorough a huge concrete wall - we were met with utter football fan chaos: about 150 crazy fans fighting in a massive mosh pit to get through the turn styles. I mean, there was absolutely NO line whatsoever, just a sea of sweaty fans screaming, pushing and cajoling each other. When someone would finally get up the turn style, they would try and get their friends up there too, and people were elbowing each other even when they got to the turn style, using any body parts the could to push people back.

As we joined the craze, we noticed a young man getting yelled at and slapped in the face by a couple of other young men. I was able to get the gist of the argument, which was that the guy had been pickpocketing and had been caught. I yelled to the other seven girls to hold tightly onto their purses and not to keep anything in their pockets. As we slowly got shoved, pushed and elbowed towards the turn style, I started having fun with it- what else could I do? I pushed back, stuck my butt out so the guy trying to push past me got stuck, jabbed a couple of men in the ribs, felt myself get actually lifted up off the ground and moved forward by the surge of the crowd. The other girls weren't finding as much sport in it as I was: their hair was being pulled, their necklaces torn off, groped (it pays in such circumstances to be tall as I am...) - one of the girls actually started punching the guys around her. A football fan and I caught each other's eye and he saw my wry smile and the other girls getting upset and yelled to me "football is everything to us fans, welcome to Ghanaian football!"

I managed to make it to the turn style before most of the girls by perfecting the skills of knowing when to push back and when to let myself be carried by the crowd. I was laughing and high-fiving the girls who made it through before me, and shook hands with the football fan I'd spoken with on "the other side." The whole thing took about 15 of the sweatiest, exhilarating minutes of my life, and I found it hilarious. Until I realized I'd forgotten to take my own advice and had left my phone in my front pocket. Gone. I'd even felt hands in my pocket in the mass of limbs, but had thought to myself that I had nothing in them.

But the rush of it all made it impossible for me to be upset - especially because I knew to be thankful that it wasn't my wallet, passport or credit cards (like in Barcelona). The last time I'd had my phone stolen was in Kingston, when I had been in a similarly crowded scenario in the back of a route taxi.


We all finally made it in and found seats. The game was amazing: thousands of excited fans, the Black Stars of Ghana scoring three magnificent goals against Libya, and an incredible sunset as a backdrop.

Football here truly is a sport for all - for the players on the field, and the fans jostling to get a chance to watch. Todays' experience reminds me of the absolute passion of the fans I experienced in S. Korea during the World Cup. It is such a shame that those of us who grew up playing and adoring soccer in the States never got to experience soccer with such nationalistic religiosity. It's worth a cell phone any day.

Nurse-Midwives: A Hazardous Occupation

Before I begin, I wanted to say that internet connection here in Ghana is very intermittent, and has been a frustrating experience in terms of trying to check my email or write this blog. So please be patient, and between posts, you can always write me!

Incentives, Pay and Brain Drain in the Health Care System.

During my data collection rounds the other day, I happened to take a break in the nurse’s lounge with my translator Auntie Lydia and the head nurse for the labor ward, Auntie Mercy (we call everyone here auntie, uncle, sister etc). Auntie Lydia is one of our two translators, and is currently on leave from the labor ward here as a nurse-midwife. Auntie Mary, our other translator, just recently retired from her position here as head nurse-midwife of the antenatal ward. However, both of them have been working here on and off to help with the shortage of nurse midwives. As we sat, Auntie Lydia and I listened to Auntie Mercy tell of her difficulties in desperately trying to hire two more full-time midwives for the delivery ward.

Currently, Komfo Anokye Teaching Hospital (KATH, where we work) is experiencing extreme shortages of staff, most notably among the nurse-midwives, who contribute far more throughout the maternal wards than the doctors. Many of the nurse-midwives have been taking double shifts to assist their coworkers when short of staff.

Many of the newly-trained nurse-midwives being trained here leave immediately for district hospitals because the work load is lighter and the work incentives are better (KATH is famous for overworking and underpaying its staff). Lydia and Mercy talk about this new generation of nurses as being more concerned about making money and less about caring for their fellow Ghanaian sisters than the older generation of nurse-midwives. Lydia and Mercy refer to these younger nurses as the “computer generation” – one trained for money and new technology, and less for quality patient care. They explain that the older generation of nurse-midwives are very close friends, and so are willing to work double shifts to help each other when they are overburdened.

In the past, nurse-midwives (okay, I’m shortening them to NM, this is getting tiring) were trained solely in the maternity ward. Today, NM-in-training spend three years doing rounds that include other departments in the hospital, including oncology, pediatrics, and even psychology. Mercy and Lydia think it is beneficial to have a more well-rounded NM, unfortunately it also means having to wait longer for potential new workers.

Where as KATH doesn’t provide any work incentives such as reimbursement for the cost of transportation or providing free meals, district hospitals usually do – accounting for the majority of new NMs wanting to work there. While both are government run, District hospitals have much more financial discretion because they employ so few workers, and are therefore able to provide meals and money for transportation, as well as a yearly bonus. For instance, according to Mercy, last year one of the nearby district hospitals gave each worker a bonus of 35 cedi, while here at KATH each received just 8 cedi (one cedi is approx. $1.01).

Brain drain to other African countries, especially South Africa, is extensive. However, with the recent riots in S. Africa over international workers and the deaths of 7 Ghanaians and the burning and pillaging of many of their shops, Mercy and Lydia, are hopeful their Ghanaian workers will return. They note that Ghana is a stable, peaceful country relative to other African countries, and they can’t understand why their fellow Ghanaians leave to work elsewhere- even if the pay is better. They believe that Ghanaians can plan out and budget their earnings and should live according to their means and not what fancy accessories they see others having.

“Occupational Hazards”: Putting oneself in danger to help others.

As Kumasi expands, many nurses are living farther away from KATH – some as much as 40 km away. And for these women, many of them must walk 1-2 km from their homes to the nearest tro-tro stop (Ghana’s form of public transportation - small mini vans that pack in 20 people). If they work in the morning at 7am, they must leave up to 3 hours ahead of time, and add an hour if it is raining.

These long distances and the transportation hubs involved put these women at a much greater risk of being attacked, and such dangers are considered “occupational hazards” by Lydia and Mercy. The attacks usually involve robbing for phones (which use SIM cards and so are easy to immediately sell off) and money, but have become increasingly violent to include rape and murder. Two days ago, the TV reported on a pregnant nurse-midwife who was returning home at night from her shift at the main teaching hospital in Accra when she was attacked with a machete while waiting for the tro-tro, killing her and her unborn child.

Mercy and Lydia argue that in the old days, it was the district hospitals in and near the mining towns that were the most dangerous to work at. Now, they assert that all hospitals are somewhat dangerous to work at, including KATH. They believe this change began in 1983 when the Nigerian government decided they were too many foreign workers, and deported them all (including 10 million Ghanaians of every profession) back to their home countries. This massive influx of returning Ghanaians fostered high unemployment, housing crunches, and massive burdens on the health care system, all of which led to an increase in violent crime.

Since 2001, KATH has been transporting a number of its staff on new hospital-owned buses. This has reduced the chance of these workers being attacked. However, there are not enough of these buses for all of the staff, and they do not run during the night, when many of the doctors and nurse midwives begin or end their shifts. Mercy and Lydia argue that providing more buses for transport along with providing accommodation close to the hospital for doctors, nurses and their families would greatly reduce attacks and would increase the retention of workers, ultimately reducing brain drain.

Ghanaian Soccer Fans: Testosterone and Stinky Pits

Soccer - or "football" as it is called in every other place in the world besides the States - is the national pastime here in Ghana. On our first full day here in Kumasi, we were walking to find a bank to exchange money. Everyone on the street had their radios turned to a station with a man talking so fast I thought it was an auctioneer. All of a sudden, the entire city erupted in a roar of victory, completely stunning me and the rest of the researchers. Kumasi had just beaten Accra- their arch enemies - in the Ghana premier league championships. We soon found out the game had been here in Kumasi, for shortly after as we driving back to our hostel we encountered thousands of fans running wildly in the streets, waving their shirts frantically, honking horns, and jumping up and down as they poured out of the stadium. This was my first introduction to the extent to which Ghanaians live and breathe football.

My second introduction occurred last night. It turns out that Ghanaians are nearly as passionate about the European leagues as they are about their Ghanaian ones. The talk of Ghana the past couple of days has centered around last night's match between Manchester United and Chelsea as they faced off in Moscow for the Champions League final. Since we arrived here, we have met and made friends with a number of medical students who will be coming to the University of Michigan this fall to do 6 weeks of rounds at our hospital. The guys made us promise to join them for the match at the medical school hostel, located close to our own hostel.

Now, in the States, I picture the TV viewing of championship matches as a time for eating drinking, and swearing at the TV. You know - chips and salsa, beer, pretzels, cheese, popcorn, swearing at the TV...unfortunately we found out that in Ghana they replace food and drink with sweat and B.O., although they still retain the foul language. We arrived to find ourselves in a small, stuffy dark room with approximately 60 guys and no women save us. The air was the most awful smell of testosterone, sweat (it is soo hot here, and I'm guessing few if any of the guys managed a shower between hospital rounds and the game...eeew!) and hoooribble B.O. We were packed into the room, and I thought I'd pass out from the lack of fresh air - thank god I didn't have any food I was hoping to eat!

I was cheering for Chelsea, but they were playing lousy and Man U wasn't looking much better. When each team scored, guys would jump up, tear off their shirts, run around the perimeter of the room and then jump over all the couches and chairs where everyone was sitting, screaming and pounding their chests and body-checking the guys cheering for the opposing team. By the time the game finished its double OT and went into shoot-out, I pretty much didn't care anymore who won or lost- I just wanted to shower! And of course, just as the first round of shootouts ended and Chelsea stepped up to take the first sudden death kick, one of the excited fans kicked out the electricity cord and the TV went off - by the time it came back on, Chelsea had missed and Man U were the victors.

The Man U fans screamed as they ran out of the room, the scent of testosterone trailing behind them and into the street. Meanwhile, I couldn't even count on both hands the number of Chelsea fans I saw crying, including our med school friends.

Needless to say, I don't think us girls will choose to watch the next big game at their hostel, our own has a much bigger screen and an OUTDOOR LOUNGE WITH PLENTY OF FRESH AIR. Oh, and beer, too.

The game reminded me of being in Seoul at the town hall square with 60,ooo other S. Korea fans watching the World Cup, only of course it was outside, and their was food drinks, and yes - plenty of swearing.

Musings on what this research is really all about.

One of the most difficult aspects of working here at the Komfo Anokye Teaching Hospital is witnessing the horrible conditions under which the doctors and nurses must work to ensure the health of laboring women and their infants, and the squalid conditions under which women give birth. It is not seeing a woman give birth on the floor of the ward, or the lack of sanitary instruments, or even hearing of the woman who died the previous night after she delivered a still born baby. Rather, what makes bearing witness to such events so trying for me is learning to deal with seeing such daily happenings, without becoming numb to their significance in the broader global context of countries that have versus countries that desperately need. As my directer of this research Dr. Anderson pointedly remarked before he headed back to the States this past weekend, "Don't forget the significance and implications of what you see here. When you see two women to a bed, or hold the maternal death registry in your hands and feel its weight, don't ever forget that it should not be this way - that this is unacceptable." And yet, how does one allow oneself to feel so indignant at what one sees, when day after day one witnesses it and it becomes "normal." It is an intense exercise in emotional and intellectual compatibility.

Today was a glimpse for me of what lies in store for me as I work here. This week we are piloting our research, practicing collecting data and interviewing patients before we officially begin next Monday. When we made our way down the stairs from the 5th floor labor ward for the "VIP" women to the first floor where the delivery ward and "dark room" (the room housing all post-delivery complications) are, we were greeted with a loud, rather chaotic scene. On the tiny landing between the stairs, the elevator and the entrance to the delivery ward were about 20 men and women milling about. The elevator door was open - but there was no elevator. Men were shouting loudly up and down the shaft, below the elevator was stuck due to power failure with a laboring patient inside. Meanwhile, just inside the doors to the delivery room, people were peering through the windows to the floor. Inside is a very small waiting room where women who have begun labor but are not yet fully enough dilated to be brought to the delivery table wait. And as we arrived and walked up to see what they were looking at, I saw a woman lying, slumped against the doors, giving birth on the cement floor. It was over in seconds, there were two nurses there, one of which quickly cut the umbilical cord and carried the baby to the delivery room. The other one attended the new mother, and pulled her to her feet about 2 minutes later to walk to the recovery room. The woman was naked, covered in blood, and watched by over ten pairs of eyes through the door. We waited around a few minutes to see if we'd be able to get inside the doors to find our data books, but upon seeing the large amount of blood on the floor left to be cleaned up, we decided it was time for lunch.

Later today I told one of my medical resident friends what we had seen, and he laughed gravely and said that it was very common for women to give birth on that floor, and that the elevator ride was never a sure thing.

Last night, a woman died after giving birth. Two students here from University of Michigan to observe the wards saw three infants pass away today, all from asphyxiation - a cause of death that would never happen in the States where every newborn has access to assisted breathing machines.

As I left the hospital this afternoon, I noted the 30+ women sitting and lying under the tree in front of the main hospital entrance. these are the women who have no friends or relatives in Kumasi with who to stay with as they wait for their family members to be seen for their various illnesses.

Witnessing today's events and knowing that they are in no way unusual makes me evermore sure that my research matters. The death of these women and newborns will not be forgotten - through our careful recordings of their delivery, determination, and sometimes death, our research will contribute to the reduction of obstetric complications in this and other hospitals in Ghana.

As my sister Kelsyn graduates from college today, the world her oyster and the sky the limit, I can't help but reflect on the privilege American's have in growing up where we do, the opportunities we take for granted, and the relative ease with which we are able to secure clean water, safe shelter, education and medical care. One of the most important things about traveling is being able to witness what the majority of this world's population lacks, and to be humbled by the strength, resiliency and determination with which people in developing countries summon each day.

And it is because of my privilege as an American - as a middle-class white woman - that I feel compelled to travel around the world, learning from others and finding out how I might assist them in overcoming barriers to living their lives in dignity. This is what brought me to Kumasi, Ghana, West Africa.

Kelsyn, I am so proud of you for graduating today, and I know your time in South Korea will humble you as well, and that you too will find a way to use your English teaching to touch the lives of your students.