Mea Culpa

In my last entry, I sized up the cultural life of Kumasi, and in my inimitable obruni fashion, found it wanting.  I also discovered that I am not the only person who is not being sufficiently entertained in this country.  A Ghanaian blogger that I read has posted a very satirical “Top Ten Things to do in Accra” which makes a similar point (my apologies to Abena for bringing this up in this context).  However, since I posted my entry, I have had plenty of opportunity to reconsider the tone of my argument.

Two basic realities suddenly became clear to me during one of my regular Gyinyase-crossings in the car.  First, the essence of a culture is that it is derived from the history, social mores, ethos, and language of a discrete nation of people.  These features of Ghana (in general) or the Asante Region (more specifically) could not be more different than those that influenced my sensibilities and taste.  So, am I suffering from a taint of the imperialist attitude that I inherited from my culture?  Was I not taught that there is no way to measure and compare such things.  After all, we are all descended from the same East African ancestors, and we all have the same number of genes.  (Incidentally, rice has more genes than humans, so perhaps the culture of plants is superior to ours.)  If Guns, Germs, and Steel have shaped human cultures, they may have shaped mine differently from others, but not necessarily better.  So, if I have succumbed to the distasteful attitude of past generations of Western Imperialists, I renounce it, and I make no value judgment about anyone else’s culture (except bin Laden’s).

Second, I asked myself why, in addition to the essential cultural features, Ghana is not also teeming with the kinds of cultural activities that Suzy and I enjoy at home – plays, lectures, concerts, Grand Opera, Ethiopian and Thai restaurants, and a Cinemaplex at every Interstate exit.   And the answer came to me like the striking of a gong.  These people are poor!  I’ve been temporarily confused by the fact that they do not seem poor.  They go about their lives with the same affect as Americans.  There may even be fewer depressed Ghanaians than Americans.  People in Ghana, whom most Americans would identify as impoverished, may recognize the lack of material things, but no more so than the vast American Middle Class that habitually focuses on being able to afford the next big purchase.  In Ghana, as in the U.S., one can always find someone worse off.  So, the scale of misery is relative and does not map onto the scale of material wealth.  This may be obvious to anyone who is more reflective or perhaps more spiritually inclined than I am.  I mention it here, because it explains the paucity of cultural activities.  The explanation is simply this: Ghanaian society cannot afford to entertain me in the manner to which I am accustomed.  I have no doubt that the members of the rising middle class here would welcome such niceties, but they are not sufficiently numerous or wealthy to make them a priority.  The reality is that most people are not in this class yet.  They do not have bathrooms in their homes.  Many people have to carry water for drinking and bathing and most cook on open fires or charcoal.  Yes, even in Gyinyase.

. . . which brings me to the topic of first part of this entry – public urination.

While passing through Gyinyase, I saw a boy of 10 or so in front of his house, urinating into the drainage conduit.  He was urinating with authority, aiming upward to create a golden arch the end in the culvert, demonstrating the power and patency of his youthful plumbing.  Later on the Ring Road on the KNUST campus, a silver, late-model Mercedes pulled over in an area of the road bounded by high grass, and a gray-haired man ambled out of the driver’s side and around to the back of the car, after I had passed, to relieve himself.  This is a common sight here.  It is difficult to make a car trip anywhere in the city or country without encountering boys and men of all ages and socioeconomic status emptying their bladders.  Three Ghanaian students were riding with us in the car one Sunday afternoon, and we noticed a man on the roadside of the urinating unabashedly.  One of the students remarked, somewhat apologetically, “ This is very African.  You will never change it.”

I am reminded of an episode in E. L. Doctorow’s historical novel, Ragtime, in which Sigmund Freud is visiting New York City and strolling the streets with several psychiatric luminaries of the era.  Freud felt the need to urinate but noted the complete lack of public facilities in 1900 New York.  Adler, Jung, and the rest of the crowd were forced to buy ice cream cones at a local parlor so that the Father of Modern Psychoanalysis could use the restroom there.  One assumes that those who lack the price of an ice cream cone would retreat to a dark alley in those days.  I suspect this remains a problem in modern-day Paris with the affiche, “ Defense d’uriner” on practically every bare wall in the city.  Occasionally, one sees, “Do not urinate here” signs in Kumasi.  But I think they are more common in Paris where public facilities are more readily available for a few sous.  So, Western civilization bans public urination, and Africans — or at least our African student friends– are embarrassed by it.  This set me thinking.  Is there any reason to change what the students agree could never be changed?

The primary concern is one of public health, the secondary concern is esthetic, and I add a third concern – gender equality.   From the public health standpoint, urine is not a particularly infectious body fluid.  From a bacterial perspective, it is sterile, but it may contain viruses, such as hepatitis B, cytomegalovirus, and others.  However, most of these viruses are not likely to survive in the environment in which indiscriminate urinators deposit them.  The one disease that is associated with indiscriminate urination is urinary schistosomiasis, and this disease is a problem for Sub-Saharan Africa and parts of the Middle East.  The disease is acquired when bathers enter waters where the parasite infects certain fresh-water snails.  The larval parasites that emerge from the snails can penetrate through intact human skin in about 30 seconds, circulate in the bloodstream and lungs, and eventually settle many weeks later as adult worms in the veins of the bladder.  The Egyptian or Sudanese child who bathes in certain areas of the Nile may develop bloody urine as a result of the worm eggs, produced by copulating pairs of male and female adult worms in the bladder veins, eroding their way through the bladder wall and into the urine.  This egg migration into the urine gives the parasite a chance to complete its life cycle if the urine is deposited in a river or stream infested by the host snail species.  In infected humans, this persistent egg production and migration, and the resulting inflammatory response, may result in urinary obstruction, recurrent infection, or even cancer later in life.  I cannot overstate the magnitude of this problem in the Nile Valley and in large regions of Sub-Saharan Africa.  And I should add that the intestinal form of the disease that requires indiscriminate defecation in the water to complete the cycle has even greater pathological consequences.  However, transmission of this parasite to the intermediate snail host is not likely to occur when one urinates into a drainage conduit, against a wall, or into the bush.  So, although indiscriminate urination (or defecation) into rivers and streams is definitely a bad idea in many areas, the practice in most non-aquatic habitats is innocuous from the standpoint of schistosomiasis.  Of course, indiscriminate defecation is a bad idea anywhere because of a whole host of other diseases, tropical and otherwise.

There is also the esthetic, or rather dysesthetic issue, and the potential for a foul “bouquet” that is probably the main concern of the French and African sign-writers.   But in the olfactory department, different cultures react differently.  In Africa, there is already a serious solid waste disposal problem that has left the populace, and the long-termers like Suzy and me, impervious to the rainbow of odors encountered in many quarters.  We regard it as part of the scenery and not as a personal insult.  Complaints from Ghanaians about rubbish and foul smells, particularly around the markets, appear from time-to-time in the newspapers and blogs, but this issue is not likely to become a major social priority in the immediate future.  There are many other more important concerns, and the esthetics can wait for more prosperous times or an impending election.

So, this leaves only my own issue, — gender inequality.  I have never seen a woman urinate in public in Ghana.  And I have witnessed this only once during the 2 _ years I spent in Chad and Cameroun, 30 years ago.  In this one instance, a woman carrying an overloaded basin on her head and a baby on her back, stopped, squatted slightly, and urinated on a dry sidewalk in Yaounde.  I think the need was urgent, and the problem of off-loading her head, unwrapping her baby, and finding a sequestered location was more than the poor woman could cope with.  A local man passed her in the opposite direction and indicated his disapproval with a “tsk, tsk.”  Would he have reacted the same way to a man urinating in the gutter?  I am doubtful.  I took in the scene and stored it in my memory to be retrieved 30 years later for this blog.

The unfairness of this double standard became crystal clear on the road from Accra to Kumasi, when Kwame and I were able to relieve our mounting discomfort on the roadside, and Suzy was forced to choose between waiting for the one and only bus stop on the route or risking an encounter with a snake or some gigantic jungle insect in the bush.  Suzy chose to wait (wisely, I think).  But I shared her discomfort with every pothole we hit on the highway.  The problem for women becomes even more urgent when traveling in the North of Ghana, where towns, public facilities, and even trees become scarce.

Water, water everywhere, and all the boards did shrink,
Water, water everywhere, and not a drop to drink. . .
– Samuel Taylor Coleridge

The town of Sevelugu, a few kilometers north of Tamale, is one of the last remaining hotbeds of guinea worm.  Here, the problem is not specifically one of human elimination into the drinking and bathing water (although I am sure that those activities also produce plenty of other morbidities in this population).  The problem with guinea worm is caused by the necessity for infected humans to have to walk into the water that they draw for drinking.

Sevelugu is a town of some 30,000 souls with no public water system.  It is not that the townspeople and the government haven’t tried to ameliorate this situation.  There is just no viable solution.  Previous attempts to drill for underground water have failed, because there is apparently no aquifer under the bedrock. The town is too far away from Tamale to extend piped water, and Tamale is a city that has its own water shortage problems to consider.  And finally, Sevelugu is in a relatively dry part of the country, so rainwater (a safe source for drinking if collected properly) is available only during certain months. The only reliable source of water, for all purposes, is a dammed-up waterway at the edge of town.  If you want to fill your bucket, you are going to have to go wading.  And this is the human behavior that the guinea worm has evolved to exploit over centuries of co-evolution with humans.

Like schistosomiasis, guinea worm finds an intermediate host in the water.  In this case, the water host is a tiny animal called a Cyclops that might be barely visible to myopic people under the age of forty.  Those of you who need reading glasses might as well consider this animal to be microscopic.  The Cyclops harbors the larvae of the guinea worm in infected waters, and the larva infect humans when they drink water with infected Cyclops’ in it.   The consequence of infection is that the larva may grow to a slender adult worm that may grow to several feet in length.  The worm usually orients itself tail-down in the lower extremity, but I have been told by an experienced guinea worm maven (Michael Humes, see below) that they can emerge from any part of the body.  For the sake of the worm, poking its tail through an ulcer that it creates on the lower leg or foot is advantageous, because this is the part of the body most likely to be submerged when the parasitized human goes to draw water.

Most peoples’ natural instinct when they see a worm emerging from a whole in their leg would be to pull it out.  But this would be the wrong thing to do.  The guinea worm is a hardy little beast, but it is not invincible, and if you pull too hard and break the worm, the consequences can be nasty.  Some people have a serious acute allergic reaction; others develop ugly infections.  So, the time-honored way of treating guinea worm, which has not fundamentally changed since Hippocrates, is to gradually withdraw the worm a few centimeters a day.  Traditionally, the worm is reeled up on a small stick during each of the daily attempts to advance it.  Eventually, it will come out without breaking, and the patient will be cured (unless he or she has other worms that require the same treatment).  Today, the treatment is essentially the same; the worm is reeled up onto a piece of rolled gauze and moistened with a dab of antibiotic ointment.

Some believe that the snakes that infested the Children of Israel in Exodus were actually guinea worms.  Why not?  We know that this disease has been present since the dawn of Humankind, and the treatment of it is probably one of the first truly effective medical therapies.  So, if the image of a worm (or snake) wrapped around a stick seems like a familiar one to you, check out the logo of your local medical society, and you might find it there.  Yes, the staff of Hermes, the Cadeuses, the striped barber pole of the House of Medicine, may actually have its origin in this ancient therapy!

In the photo gallery attached to this entry, there are pictures of a Ghanaian patient with guinea worm extending from his foot and another showing several patients receiving daily care for their infections at the Guinea Worm Treatment Centre in Tamale.  I am very grateful to my young colleague, Michael Humes of the Carter Foundation (also pictured in the gallery) for getting up early on a Saturday morning to take me to this facility.  I will have more to say about this extraordinary young person below.

In the gallery, I have also included a photograph I took a few years ago of ruined column at the Aesculapium in Pergammon (on the Aegean Coast of Turkey). The Aesculapium may have been the first hospital, and the logo on the column may be the earliest known use of the snake-on-a-stick motif in a medical context.

For an infectious diseases specialist like myself, closer to the end than the beginning of my career, seeing cases of guinea worm being treated in this traditional manner for the first (and probably the last) time was a peak experience.  Now I know how those NASA scientists felt when they saw the first image of the Martian landscape.  They already knew what there was to know about Mars.  They all had the spectrographic, topological, and climatologic data in hand, but they had never actually seen the planet’s surface until that moment.

So, why do I say that it may be the last time I see a guinea worm?  Well, because dedicated people like Michael Humes are going to make the disease extinct in the next few years.  Michael heads up the Carter initiative in Tamale, at the center of one of the largest remaining foci of guinea worm (the other is in Sudan).    The disease has been eradicated from many other African countries, the Middle East and South Asia.  Now, it seems likely that it will be eradicated within the next few years.   When this happens– and I am certain that it will—guinea worm will be the second disease made extinct by human efforts; the first being smallpox.  Polio will probably be the third.  Smallpox and polio were/will be eradicated, because these diseases are caused by viruses that infect only humans, and because we have effective vaccines.  The guinea worms that infect human do not infect animals, so we can think of it as an exclusively human disease also.  However, there is no vaccine against guinea worm.  So, how are Michael and his colleagues doing it?

Like the treatment of the disease, the elimination of guinea worm is an amazingly low-tech enterprise.  It simply requires a little knowledge and a lot of vigilance and persistence.  Public education is a critical factor.  The Carter workers identify people who have worms and transport them to Tamale for treatment.  The treatment facility provides wound care, a comfortable bed, ample food, and entertainment in the form of Ghanaian TV until all of the worms are out.   The patients do not seem to mind the inconvenience of a stay at the facility.  At the same time, the Carter people are also promoting the use of simple cloth filters for drinking water.  The filters do not remove bacteria or viruses (obviously), but they do filter Cyclops and so are effective in removing the risk of guinea worm from the drinking water.

Once there were hundreds of thousands of cases of guinea worm in this area.  When Michael came to Ghana, there were a few thousand a year.  This year, there will be about a hundred in the whole country.  Michael estimates that in about 3 years, there may be no further cases.  I don’t know when my next trip to the North of Ghana will be after this sabbatical is over, but it is quite possible that there will be no cases to be seen when I return.  For the next generation of infectious diseases physicians, this disease will be an historical curiosity.

Michael Humes has been in the guinea worm eradication business for quite awhile, chasing the disease to a final standoff in West Africa.  He worked on this project as a Peace Corps volunteer in Burkina Faso, then as a Carter Foundation worker in Mali, and for the past two-plus years in Northern Ghana. What a beginning for a career in international public health!  I tried to convey to Michael how important this experience is going to be for him in the future – how important involvement in the smallpox eradication effort was for the giants of public health in the generation that preceded mine.  At the end of this contract, he expects to return to the US to obtain a degree in Public Health.  He has applied to two high-echelon institutions with strong programs in international health, either of which would have to be seriously dysfunctional to let Michael get away.  I predict that he will be a star.

Lastly, and with some local pride, I have to report that Michael is a Wolverine and a Son of Ann Arbor.  His father, David Humes, is a renowned nephrologist working on perfecting the first biosynthetic kidney.  David was Chair of Internal Medicine at the University of Michigan while I was the Chief of Infectious Diseases.  I met Michael for the first time at his parent’s Anniversary Party several years ago.  David wanted us to meet because I also had been with the Peace Corps in Africa many years earlier, and he figured we both knew the secret handshake (which we do).  Would David have guessed then that Michael and I would meet next in Tamale?  It really is not so amazing.  I have learned that simply being an expatriate in Africa consigns one to an easily identifiable circle in which the members are unknowingly connected by many fewer than six degrees of separation.