True Rural Public Health, African Style

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Geo: 7.95185, 0.60071

Lush green vegetation, pot-holed red dirt roads and a steel gray sky brewing up a storm greeted us at our new home in Nkwanta, a town on the border with Togo. We moved our items into Bungalow No. 4, which was to be our home for the duration of our time in Ghana. We are sharing a three bedroom bungalow with three Swiss medical students. Although we were looking forward to having our own space for a bit, we still have a nice place to live. Power cuts and water shortages are an everyday occurrence and a reminder that, although we have many modern conveniences at our fingertips, we are still in rural Africa.

Nkwanta town is a one-horse town. The green hills provide a pretty view as we meander through town. The main street is the "highway" (unpaved of course) that runs down to more populated areas of the country and continues on up to the Northern Region. The main market branches off this road and the lorry station where one can catch a dilapidated tro-tro out of town is a bustling place. Vendors sell their goods on tables or kiosks made out of sticks. These kiosks do not lend a sense of permanence, but clearly they serve a purpose as we see the same people selling their tea bread, eggs or the few veggies from them that have been brought in from other regions. Ghanaian "Hip-life" music blares through large speakers from a few store fronts, making the scene feel quite authentic and African.

Our first week was not jammed packed with work (partly because of daily power cuts and the laptop we're using has a dead battery). The slow pace has given us the time to get to know people and the town. We found the butcher, the baker and the candle stick maker - well, not quite the latter two; but a bakery would be nice! The butcher provides us with very fresh beef ... slaughtered that morning...and our new "mother, Stella, has provided us with a chicken - a retired laying hen, as well as guinea fowl. The market, every Monday, is scarce of all the fruits and veggies we have dined on around Africa. Not much besides cassava and yams grow here, so the veg is limited to onions, tomatoes, and the occasional cabbage that finds its way up here from Hohoe.

The Medical Village, a hospital complex where we live, is a 25 minute walk from town. By the time we walk in on the dirt path, our faces hurt from smiling and saying "good afternoon" to every passer-by. The people in Nkwanta are extremely friendly and their faces light up when you exchange pleasantries. We feel like we are in a different country than the one we were in when in Accra, the capitol. Now we understand why people fall in love with Ghana.

We are making several friends, and it is sad to think that we have such a short time here. Stella, the coordinator for the Community-based Health Planning and Services Program has become our "mother." She taught Jamie how to make "red red" a bean dish with red palm oil (hence red) and wash clothes the Ghanaian way (Jamie can't wait to use a washing machine again) and has taken her "to farm" to learn how to grow yams and cassava. Stella has also given Jamie a Twi name, "Ata Pini" which means, female first born twin. Barbara would be "Ata Kakra."

Gill, a British ex-patriot who runs the Ghana Education Project - a teacher's resource center - has provided us with lots of insight into Ghanaian life in Nkwanta and hours of beer drinking enjoyment at the "Hilltop Stop Over Spot," one of the "pubs" in town. She also supplies us with a carrot or head of lettuce when one turns up.

In our first two days here, we were invited to a baby naming ceremony. They don't name their babies until they are one week old, and then they have a Christian ceremony to formally name the baby. Perhaps oddly, it reminded Justin of Hillary Rodham Clinton's book "It Takes a Village, which is about the need to have a more child-friendly American society...except here we were, at 6AM in somebody's living room in an African village, surrounded by villagers promising to look after a week-old baby. They then sung hymns. It was quite a lovely experience and much more spiritual and moving than our three hour Evangelical Pentecostal church-going experience in Burkina Faso. That said, religion here, like everywhere in Ghana, has a pivotal role in most people's lives. Since we are nearer to the Northern region in Ghana, which has a large Muslim population, there are a few mosques in town, and we are reminded of the time for prayer by the call of the Muezzin.

In addition to our outings in town, we organized a trip to the Kyabobo National park with the local rangers. The ranger didn't show, but we had Gill, who has been there many times to lead the way. We ended up giving up after 45 minutes as the trails were so overgrown. We couldn't find our way. Unfortunately, we didn't have machetes to cut our way through. Despite having 40 rangers for the park, not much upkeep seems to be done to maintain the trails. This is odd when you consider that they are trying to increase tourism in the park. Despite not reaching the summit of Breast Mountain, we did enjoy spotting some really colorful and interesting bugs.

Living in the Medical Village and living with the Swiss medical students, affords some interesting opportunities. When the call came in for them to attend an emergency cesarean section, they invited Jamie along. Jamie is a bit squeamish by that sort of thing, but she decided to test the strength of her stomach and go. It was a once in a lifetime opportunity - to go to the "theatre" (operating room) in rural Ghana and see a birth. She didn't pass out and was there to witness the birth of twins - a boy and a girl. Never having been conscious in an operating room before, Jamie didn't know exactly how this operating room compared to a Western one. It was clear though, that some things must be different. When the babies were pulled out, there were no fancy bassinets to relax in; the babies were taken to a wooden bench in the theatre, though it was covered with sterilized cloth. After the babies were taken from the theatre, Jamie went to visit them in the maternity ward where they were "hanging out" in the hallway in a plastic bassinet. Things are quite a different from the maternity wards in the West. But, it was an amazing experience for her.

In the second week, work on our projects picked up speed and the days flew by. Jamie sat in on trainings for the Community Health Officers (RNs) and Justin interviewed several of the staff about how medicine is purchased, stored and dispensed, as part of an effort to formally describe the problem of pharmacy costs in Nkwanta. [This is a "needs assessment" in preparation for a program to send donated drugs from American pharmaceutical companies to sites in Ghana.] We spent two full days on long bumpy rides visiting the community health officers at their clinics. Jamie was interviewing them to write stories about what they are doing.

Justin talked with them about their patients' inability to pay for drugs. It was remarkably reminiscent of previous work he had done, except that this time, the discussion was over people's difficulty to make drug payments of 25 - 75 cents instead of $25-75 pharmacy co-payments. Certainly not the first time where the only difference in people's heartache over medical bills is one of scale! Like in the United States, people in Ghana are struggling with changing medical insurance systems; it's just as unnerving for them! When Justin was reviewing patient files, at first he thought he was looking a duplicate of the same chart: "malaria, malaria, malaria, diarrhea, diarrhea, diarrhea." Not too much variety, but these basic, preventable illnesses end up killing a lot of people in Africa.

One interesting anecdote we must share is what one CHO, Mighty, does to get her female patients to come in to get their birth control shots. Family planning is a touchy subject in rural Ghana - especially when people see their kids as free farm laborers. Plus, the machismo thing about limiting the planting of your seed (like the farming analogy?), makes it difficult for women to get their husbands' support for birth control. Unfortunately, many of these women have to resort to secretive means for family planning. Mighty comes by to pay a social visit to the women on the day that they need their Depro Provera shots (injectable birth control that is effective for three months). The women will later tell their husbands they are going to collect water from the bore hole (the well) which is conveniently located outside of Mighty's clinic. While collecting water, they stop in for their shots. It is a creative way to make people put a priority on their health. A very brief public health lesson on family planning: proper spacing of births is healthier for the mother and reduces the chances of maternal mortality.

While we are on the subject of public health, there is another interesting tidbit to share. For all you data collection specialists, you can commiserate with this one. In a training Jamie was attending, the issue of collecting people's names for follow-up arose. Here, most people are not known by their given names, but take on nick names like "Ata Pini" for Jamie. Most people are called after the day of the week they were born, so that "Kofi" for Kofi Annan, the Secretary General of the United Nations, means "Friday born." So, when you have 10 Kofis in a village, it is hard to remember which one had malaria and which one had diarrhea to follow up and make sure their outcome was 100%!h(MISSING)ealthy.

We feel that visiting the villages is a special opportunity for us this year, but even more interesting is learning about the amazing way that health care is delivered to the villagers who are so isolated from sophisticated machinery like MRIs that can do complete body images. Because resources and diagnostic equipment is either limited or non-existent, the health care providers learn to know their patients and rely on instinct much more than they would if they had all those fancy gadgets at their finger tips.

Volunteering physicians have told us that they may be examining a patient for a complaint, but then come across a symptom that makes it quite likely that the patient also has a far more serious illness like colon cancer. Do they order a colonoscopy as our doctors would do in an instant? No, because they have neither the equipment to do the test, the laboratory to screen the sample, or the chemotherapy for treatment. They may refer someone to the hospital in Accra, but the chances of them getting there, due to transport and the cost of care, make it extremely unlikely that they will go.

That said, the work that is being done out here is true public health and the statistics prove that much of what they are doing here is working to improve health and reduce the number of deaths. That has been truly inspiring for us - and motivates us to give 110% effort to our work.

In addition to health, we had a peek into the education system here in Nkwanta. We are told that in the villages, education is abysmal. Teachers don't show up to class, and the formal lecture-style of teaching isn't so effective for many of the younger students. In one conversation, we learned that the television has had a positive impact on education. Once electricity came to the northern region, people got TVs. They then saw how children the same age as their own could speak eloquently in English and that they were getting a good education. This created a demand for education and parents sent their children to schools in these rural areas. Of course this is anecdotal, but it is interesting how electricity can lead to tv watching that has a positive outcome.

We have been engaged in several interesting discussions with the locals, which has provided us with some insight into life here in Ghana. Jamie was having a conversation with Gill's watchman and he asked how many kids she had. She replied none. She asked him the same question and he replied "only eight" and then began laughing. He followed that statement with, "that is why Africa's has such problems with poverty - too many children."

Other discussions with Ghanaians have been about the profound wealth differences between the West and Africa. Sometimes, it is simply begging: on numerous occasions, we have had children come to us and say, "Obruni (white person), I am hungry." Ones first instinct is buy them food, but when it happens to you several times a day, what do you do? It's a really heartbreaking situation. As we did in India, we do not give to them, rationalizing that the public health work we are doing will do more for more Ghanaians. Still, there are few situations more unnerving.

Sometimes, it is horribly psychological: several different Ghanaians have told us that there is a belief among Ghanaians and maybe Africans in general, that the white people are superior. Perhaps it's due to far too much viewing of Western TV shows; perhaps it extends from the colonial days. Regardless, it made us sick to hear.

Fortunately, these uncomfortable moments are more than balanced out by the positive ones. In one village, it was such a novelty to see white people, that the entire village was alerted to our presence. As we walked down the main road, everyone was out to see us. We might as well have been Brad Pitt and Angelina Jolie, as we felt like we were famous - giving the parade wave, shaking hands and greeting "good afternoooooon" to everyone. Some Peace Corp Volunteers here said it's going to be an adjustment returning home where they blend in and no longer will feel like they are famous. After that village trip, we could understand what they mean, although we are looking forward to being anonymous once again.

We want to comment on the photographs. Throughout our journey, we have always asked individuals if it's okay to take their picture portrait-style, and usually they say "yes." The guide book stated that rural Africans are reluctant to have their pictures taken; not "its-going-to-steal-my-soul" mindset, but more "if-I'm-going-to-be your-model-you-should-pay-me" way of thinking. But we have found the opposite to be the case: in every village, little kids and a few adults beg us to take their pictures. The kids let out squeals of glee when the flash goes off. They are really interested in the instant playback feature of a digital camera; many people have never seen themselves in a picture. Every once in a while people ask us to send the picture to their address - we will.

We can only conclude that our time in the "bush" has proven to be 180 degrees from what we experienced in Accra. We know the work we've done here has yielded concrete beneficial results; the people have been lovely (we are picking up British-isms) and the scenery spectacular. To top it all off, we will leave with the general awe of having been in rural Africa. We not only now know the people who are behind all of those nightly-news stories about disease and poverty in Africa, but more importantly, we also know the people who are helping to pull Ghana out of its current problems. They have inspired us (and deserve more attention from Western media).

So, we sign off here from Africa - the last of the developing countries we will visit on this year long journey. From here we head back up to Italy to see Jamie's sister and brother-in-law (and meet bugaboo the unborn baby) and Marc, Amy and Aviv will join up with us for a few days of indulgence in gelato, wine and other tasty Italian tidbits. After Italy, we will head to Eastern Europe, to explore countries that were once ravaged by war, but now friendly places to visit.

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Comments

[Joady]

thanks for posting these photos. My daughter is currently volunteering in Nkwanta and it was great to get an insight.