I rent a Toyota Camry from a ganef in Accra. I use the Yiddish pejorative here, because I have calculated that by the end of my stay in Ghana, I will have almost paid the book price of the car, but Danny the Ganef will still own it. And he insists that he is taking a bath on the car lease and that no one else in Ghana would be crazy enough to rent such a terrific car for $600 (US) per month. By the end of our stay in the country we will pay more than twice as much for this car as we pay for our rent, even though the car has no running water, gas stove, or ceiling fans. Oh, and by the way, she drinks only V-Power (the most expensive and hard-to-find gasoline in Ghana) and she eats only synthetic oil at $60 a gallon every 3000 miles. This, according to Danny, guarantees that she will never deposit us on the roadside in the jungle, hitchhiking to the middle of nowhere. Well, relatively speaking, Ghana is a small country, and there really is no such thing as the “middle of nowhere” here. So, I am determined to extract my money’s worth of life out of this pampered vehicle. I will drive this car as far north as possible and then to Accra again, to the Eastern Volta Region and the border with Cote d’Ivoire, and I will repeat these routes as often as possible, along with other exotic road trips, if I can figure out what they might be.
On December 8th, one day after the Ghanaian presidential election, Dr. GK arrived in Ghana on a whirlwind visit to grease the wheels of several upcoming UM – Ghana health projects and events. Part of his plan included a trip to Tamale, the largest city in the Northern part of the country, to make arrangements for a large group of UM students expected in May. They will undertake a healthcare-related survey. Dr. GK is managing the logistics of their visit and their studies. On his way, he stopped in Kumasi to do some university and personal business, and he accepted our invitation to stay with us at our house. Fortunately, Dr. GK considers the weather to be very pleasant at this time of year in Ghana, and he regards the water as warm. So, the absence of air conditioning and hot water at our house was not an inconvenience to him.
Dr. GK had proposed I should go along with him on this trip to meet some of the key people at the new medical school in Tamale and to acquaint them with the e-learning programs being produced in the South. I thought this was a great idea, because the school at Tamale is precisely the kind of institution that needs self-directed learning materials. The school admits 80 students to a class and has a shortage of full-time faculty. This trip was an opportunity to gauge the interest of a seriously-under resourced medical school and to find out what their principle concerns are. I thought Suzy should also come along, too, because we both needed a change of scenery. And because there was no way she was going to stay behind.
The plan was for the three of us to travel in the Camry, with Dr. GK at the wheel. We planned to be in the North for three nights, to return to Kumasi for an overnight stay, and then to continue to Accra for more work-related business, which I will describe later. This plan was in perfect alignment with my own project of turning over the car’s odometer at least once. This plan worked well for Kwame, too. On the day before the Presidential election, he drove to his hometown near Cape Coast with Father Q, a Jesuit architecture professor at KNUST, who comes from the same town. Both are registered to vote in this town, rather than in Kumasi, so Kwame was able to avoid paying the expense of a tro-tro by driving the priest in his Honda SUV. Kwame is Catholic and is completely devoted to this academic/priest. And Father Q calls on Kwame frequently to help with repairs of his ailing Honda. Kwame usually complies with a sense of urgency. I do not interfere; I consider this to be Kwame’s on-the-job self-directed education as a mechanic.
Oddly, Kwame is completely incapable of pronouncing “Fadda Q______’s” name intelligibly. Our interpretation of his references to the priest by name suggested that the family name was Irish, even though Father Q is a Fante. I have since learned that the father’s proper name is a Europeanization of a Fante one. However, since Kwame was my only reference on this matter, I freely mispronounced the Father’s name to his face on several occasions, until I was eventually set straight by an architecture student. Father Q is a gentle, diminuitive man. He never corrected my mispronunciation, but must have found my mimicry of Kwame’s utterances to be amusing. As an individual with a difficult name myself (my given first name is “Niels”), I know how tiring it can be to have people constantly telling you how to pronounce your name. And I suspect that Kwame is not the only Fante speaker who possesses this targeted speech defect.
Knowing that we would have another driver for the Northern trip (Dr. GK), we advised Kwame to stay with his family until further notice. So, he would be able to vote and to spend a continuous two-week leave with his wife, two small children, and the extended family, until Dr. GK was ready to leave the country. After the events that I will relate below, Kwame rejoined us in Kumasi ahead of schedule. According to Dr. GK, who spoke with him by phone, Kwame was getting “bored” in the village and wanted to be back in Kumasi, at the house, before we actually needed him. Apparently, he has learned to enjoy life in the “fast-lane” with the Englebergs and the exciting social life of Kotei New Extension.
Chilly Today and Hot Tamale
Kumasi is situated in the center of the Forest Region. Or it would be, if there was any forest left. Most of the land in this area has been cleared for agriculture. There are still many mature trees standing and dense bush around the plantain and cassava plantations. But it is only in designated reserves or in very remote regions that old forest growth can still be seen. As one travels north, through the city of Techiman, one enters a transition zone between the Forest and the Sahel. And by the time one passes Kintampo, which is about half the distance to Tamale, the terrain is Guinea savannah and grassland, where it is a long walk from one mature tree to the next. The vista is reminiscent of West Texas save for the familial clusters of cylindrical or square mud huts with thatched roofs instead of trailer homes (see photo gallery below). In many places, the grass is blackened by recent wild fires, and somewhere on the horizon, it is almost always possible to see a column of smoke rising from an active one. I am told that children sometimes set these fires deliberately to drive small game out of the bush – as a protein supplement. I cannot think of any other real benefit of the fires, and I recently read of the complete (and presumably unintentional) immolation of an entire mango orchard in the North by a wildfire, at a loss of an estimated 40,000 Ghana cedis. I doubt whether the children who set that one will be coming forward. In general, these regions are among the least affluent in Ghana, and the local problems typically involve a lack of access to the same assets that are missing in other Sahelian countries – water, energy, and human expertise. Food is available but limited in variety; calorie malnutrition does not appear to be a common problem. Superficially, the setting reminded Suzy of areas of Northern Cameroun that we knew 30 years ago. At an infrastructural level, there is clearly much more happening in Ghana – many paved highways, bridges instead of hand-pulled ferries, and rural electrification.
The people of the North are predominantly Muslim, not Christian. So, mosques outnumber churches, but not by many. More of the men cover their heads and wear the long shirt-robe commonly associated with Muslim males. Women tend to be more covered in their dress, but subtly and in indigenous African clothing. There were no burkas to be seen. In contrast, I saw two young women together on a motorcycle, sporting expensive streaked hair-dos, lots of jewelry, and short dresses. So, there is apparently a mixture of life-styles here and an atmosphere of tolerance, at least in the cities where Ghanaians from all regions of the country are mixed. Ghanaians I have asked tell me that they cannot always tell where an individual comes from. However, around Tamale, one occasionally sees a face that is clearly an expression of genes inherited from the Sahara. In addition, many northern people bear facial scarification that identifies their ethnic group of origin. The recent election results suggest that the people in and around Tamale are politically more like Democrats than Republicans, since they contributed heavily to the slim majority of the National Democratic Congress and the election of Atta Mills as President.
Tamale is very different from the cities in the South. It appears to be better planned (or at least planned), with a few broad boulevards, separate bicycle and pedestrian paths, extensive street lighting, and a brand new soccer stadium on the outskirts. The University for Developmental Studies (UDS) is also located on the outskirts of the city off the highway from the South. The medical school is contained in a single, new, three-story structure on the campus (see photo gallery below). I visited it at sunset when no students or faculty were present, and was afforded a brief tour by one of the guards. There is a large computer-internet facility that is intended to connect students with an electronic curriculum from Northern Europe. I do not know how well this works in practice, if it does work, but it clearly represents an attempt by the leadership of the school to leap-frog the usual teaching methods and to opt for a less faculty-intense method of instruction. I was also shown rooms that were designated for “small-group” sessions. So, I conclude that the pedagogical approach is to use self-directed learning where possible and to enrich the students’ experience through seminars and recitations.
I learned more about the school from this brief guided tour by the guard than from a meeting with the Dean, which was primarily intended for Dr. GK to discuss his upcoming program. I explained my projects to the Dean and to the younger faculty member who was also present at the meeting. Like most Ghanaian faculty that I talk to about e-learning, they expressed polite interest and mild enthusiasm, mixed with an unspoken body language that communicated, “I’ve heard all of this before – where’s the beef?” Regrettably, I did not have a completed project in hand to offer them at that time. But I will, soon. The young and outspoken faculty member present at the meeting with the Dean seemed most intrigued by my offer to assist them in generating materials. He asked for a copy of the Michigan M4 Medical Therapeutics Course, so I burned it onto a DVD for him. It will be interesting to see whether this stimulates any ideas of his own. He has my cell phone number.
The public hospital in Tamale is the teaching hospital for the medical school, but it is inadequate in size and staffing to accommodate the entire complement of medical students from UDS. So, the majority of the class is shipped off to Kumasi or Accra for their clinical training. I met the new Chief Executive of the hospital, a very bright, committed and enlightened man, with a desire to bring graduate training programs to the hospital and to expand its capacity. Speaking with him made me want to help.
We also paid our respects to the head of the Nursing School, whose office is in the isolated nursing classroom building, a short walk from the hospital. There were nursing students aplenty loitering about the building. To my surprise, the majority were young men. I was informed that there are increasingly more males going into nursing – an interesting trend that contrasts with the increasing prominence of women in the medical schools. There is a general recognition of the issue of gender equality in Ghana, even in politics. The leaders take pride in the fact that the newly-elected Speaker of the Parliament is a woman.
On the last day of our trip to the North, Dr. GK proposed that we visit the village of Larabanga, situated about an hour down the main road going south and about 50 kilometers down a secondary road going northwest. Dr. GK had developed a special relationship with this village of about 4,000 and was committed to building a health center there. Since the road to Larabanga is not conducive to the continued survival of the Camry, Dr. GK arranged for the Tamale Hospital to provide us with a truck designed for such ventures and to assign us a driver for the overnight excursion. We paid for the diesel fuel.
Excuse Me, Is This the Real Africa?
There is magic all over this continent. Sometimes it is not so obvious to foreigners; sometimes it is marketed as a tourist attraction. Sometimes, both. But anyone who doubts the power of magic and tradition in African village life should visit Larabanga. It is a village that treasures its history, however dubious the details may be. The artist and the shaman share in common the ability to make reality out of facsimiles. If one thinks of the village history as “mythology,” rather than simply as a fabrication, it takes on significant power.
Because of their “history,” the Larabangans regard themselves as special and unique people, distinct from the Gonja tribesman that surround them. I heard the story of the village from a friend of Dr. GK’s, named Ishmael. Ishmael is a community developer and village guide for the occasional tourist who wanders in. According to Ishmael, the village was founded by an Islamic trader who migrated to this part of Africa over 500 years ago from what is now Saudi Arabia. As evidence of the Founder’s origin, he offered the observation that the language spoken in Larabanga is subtly different than that spoken in neighboring Gonja villages. It includes many words from classical Arabic. For example, they use the Arabic words for numbers in common speech. So, I offered, “Like wahid, itnen, talata, arba’a. . .” showing off with what was left of my Chadian Arabic. “. . . Hamsa, saba, sita, tamane. . .” Ishmael continued the sequence, making certain that I got his point. Apparently, the name “Larabanga” itself implies the use of a foreign language in the local indigenous tongue.
After coming out on the losing side of a conflict between two local Gonja tribal groups, the Village Founder came upon an unusual, large flat rock in the bush. The rock, which is about 1 meter in diameter and is balanced on top of a smaller cylindrical rock, simulates the shape of a giant mushroom, or table, or altar, depending on your perspective. The Founder decided to recite his evening prayer beside this rock, and then – for reasons known only to him – he threw his spear (uphill) from that point with the intention of spending the night wherever it landed. Following the trajectory of the spear –which was east toward Mecca, based on my bearings — he recovered it at the top of a hill about half a kilometer away. He bedded down on that spot as he had planned, and that night, he dreamt of a mosque. When he awoke the next morning, the foundation of the dream mosque was already laid out beside him. So, he dutifully finished the building, and there it still stands today (see photo gallery). There is no historical documentation to support the villager’s claim that the mosque is the oldest building in Ghana, predating the Portuguese slave castle in Elmina built in 1421. Some non-residents claim that the mosque was built in the 1600s by the local imam, after he received an illuminated Koran delivered directly from heaven. The villagers acknowledge the presence of the heaven-sent Koran, which is still within the mosque, but refute the construction date. Unfortunately, visitors and historians are not allowed inside to view the Koran or the interior of the mosque. An external historical context for the mosque is that the 15th Century was the era of the spread of Islam into Sub-Saharan Africa; there are other ancient mosques in this part of Africa that date to that era. I have no personal opinion on the matter, having no knowledge of African history or architecture. However, having visited the mosque and the rock, I am amazed at the Founder’s physical strength. Throwing a spear uphill the distance that I walked between the two sites would challenge even today’s Gold Medalist in Javelin.
The “mystic rock” on the hillside is a site that has become sacred to the villagers, particularly in recent history. When the government built the road going west through Larabanga, the rock was in the way. It was moved several meters off the planned path of the road. However, the following morning the rock was found back in its original position. The rock was moved again, and it returned to its original location again. After a few repetitions of this process, the road commission gave up and engineered an “S” in the road to bypass the sacred position of the rock. And the villagers concluded that the rock was “mystic.”
When the Founder died some 500+ years ago, he was buried next to the mosque. A baobab tree has grown from his gravesite (see photo). Today, this tree is considered by the villagers to be the enduring embodiment of the Village Founder. To Larabangans, this is all oral history, not open to conjecture. If they have any doubts about how the “mystic rock” moved during the night, I detected no hint of it from any of the locals I met and spoke with, young or old.
How should one understand these stories? Does the “Truth” really matter? Do we care whether George Washington threw a silver dollar across the wide Potomac, or only the dribbly Rappahanock River? Is there documented evidence that he chopped down a cherry tree as a child? And as to the matter of a Koran delivered by angels, I remember hearing about less credible incidents from my childhood friends who attended St. Bernadette’s School rather than the secular public elementary school. The nuns told these kids fantastical (and non-canonical) stories of modern-day miracles and retribution for evil deeds, and my friends accepted them as authentic Articles of Faith.
The mosque is in the center of the oldest part of Larabanga. To see it, one must wind through a maze of mud-brick, flat-roofed houses, crossing front and backyards, eaves-dropping on ordinary domestic activities. As we passed by one house, we were introduced to one of the village chiefs, an elderly wizened man of no less than 80 years. He was sitting in the shade of his house, his back against the dried mud wall, enjoying a lunch of soybean cakes. (Could his diet account for his having reached this advanced age while living in Larabanga?) Naturally, he invited us (at least six of us, at this point) to sit and eat with him — a common, polite gesture in Ghana, but a totally impractical one given the circumstances.
This chief was one of two Larabanga chiefs. The other chief, equally advanced in years, lived in another part of town. Interestingly, the two parallel chiefs could never meet or even look at one another. If they did, one of them — the weaker of the two — would die. Neither one could be sure that he was the strongest. So, to say that they avoided each other “like the plague” is not an overstatement. And perhaps it is the strict avoidance of each other’s company, and not the soybean diet after all, that accounts for their longevity.
We came to Larabanga primarily to check into Dr. GK’s project there, so we were treated well. I have heard that overly aggressive young men in Larabanga, anxious to be tour guides, sometimes overwhelm tourists in an attempt to extract outrageous sums of money. Dr. GK says he doubts whether anyone in the town has as much as 10 cedis. The town is just emerging from a bartering economy and currently produces nothing for export. So there is no cash flow into the village, except what tourists spend. It is sad that a town that is so rich in culture is reduced to fleecing tourists on their way to the game park and sometimes to outright begging. But I suppose you see the same behavior in Paris. Only in Paris, they also steal.
One of the young men trailing along in our small entourage identified himself as the captain of the town’s soccer team. The local team plays matches with comparable teams from neighboring towns and villages. His plight was that he local team had no soccer ball to practice with, so Suzy and I bought them one from a local shop for 10 cedis. They were genuinely grateful about our donation to the team, given the remote likelihood that they would ever be able to raise 10 cedis for such an extravagance any other way. Suzy and I felt a sense of gratification, neither of us thought we had been fleeced. In fact, for reasons that remain unclear to me, the young people were more interested in exchanging e-mail addresses with us than shaking us down for money. I think the idea of having someone to contact in the outside world intrigues them. I doubt that we will ever hear from any of them, although we will probably come back to Larabanga at some point – to check on the progress of the soccer team. I also realized that these kids –and perhaps the adults also– have no notion of what we value. They may think that 10 cedis is like unwanted pocket lint to us. One young man watching me write an e-mail address with a gold Parker Sonnet pen announced (in good English), “I like your pen. Can I have it?” I was not about to give up my pen, but I know that a direct “no” is often interpreted in these parts as a personal rebuke. So, I explained that the pen was a gift from some of my students (true), and if they saw me without it they would be very disappointed that I gave it away (half-true). Interestingly, the young man understood this, was satisfied, and did not then ask me for my sunglasses.
Now, the Other Reality. . .
Dr. GK is a man who does not suffer injustice, particularly in the medical sphere of activity. Something about the hand that Larabanga was dealt by the National Health Service bothers him, and he is committed to correcting it.
Rather than being a beneficiary of the close proximity of the Mole National Park, Larabanga has been over shadowed by its existence. What is now the park land, was never productive or settled because of the abundance of tsetse flies and the high frequency of sleeping sickness. At some point in the remote past, it was concluded that the wild animals were a reservoir for the disease, so open season was declared on every species in the area. At that time, Larabangans and others hunted freely on these lands, but the high-protein feast ended officially when the park was created in 1971.
As the park became established, a small population of park employees and workers at the motel were induced to live on the grounds because of the promise of housing, a health station, and a school for their children, all of which they now enjoy. Perhaps of greater importance is the necessity for a proper tourist destination like a national park to have a first aid station to treat the occasional cut or scratch from an acacia bush, sunburn, or diarrhea episode suffered by the transient travelers. Tourists may decide not to visit the elephants and baboons and snakes in the wild Guinea savannah if they perceive that they are out of touch with anything resembling emergency health care. For these reasons, the National Health Service decided to locate a health center in the national park rather than in the nearest town, Larabanga, with the notion that the health center in the park would also serve the town as well as the park residents.
The health station is a small, free-standing, two-room structure staffed by a nurse. The station was closed on the Sunday afternoon when we visited, but I got a good look at the facility through the windows. It was equipped like the nurse’s office in any American high school.
So, to obtain even minimal health care, the people of Larabanga have a choice. They can either walk the 5 kilometers to see a nurse in the national park, or they can find some way to travel the 20 kilometers down the unpaved and rutted road to the regional hospital in Damongo. There is no transportation for this purpose. In a medical emergency, they are simply out-of-luck. Dr. KG is currently having an architect draw up plans for a health center in Larabanga, and the town has identified a large plot of land in a good location near water. There were stacks of homemade bricks at the site when we visited it. Dr. KG has already identified sources of support to build the center and to equip it. He is confident that the health service will staff it once it materializes. If he builds it, they will come.
We saw an example of being “out-of-luck” on our way back from the future health center site. A child of 3 years had been burned two days earlier by an overturned pot of water that was boiling over an open wood fire. She looked very uncomfortable, seated on the ground next to the front door of her house. Her mother used a piece of cloth to drape loosely over the burned areas of skin to keep the abundance of flies from landing on the open wounds. The child had not eaten anything since the burn incident 2 days ago and was drinking very little.
The family of the burned child was not enrolled in the National Health Insurance Scheme, which would have paid for reasonably comprehensive care in this situation. Access to this system is available to all Ghanaians at a very reasonable price, but the concept of health insurance is still misunderstood by less sophisticated people, and they do not understand the concept of spending the few cedis that they are able to accumulate without getting something tangible and immediate in return. In spite of her lack of insurance and funds, the mother carried her child to the nurse’s station in the park after this accident. Apparently convinced that the nature of the injury was beyond her expertise, or because there was no money changing hands, the nurse at the park health station wrote out a referral slip to the regional hospital in Damongo. No cleansing antiseptic, no bandages, no advice — other than “go to the regional hospital.”
The reality is that the child’s mother has two other small children, one older, and one younger and still on the breast. She has no money, no insurance, no transportation, no husband. She cannot go to Damongo without taking the other children with her. But this does not matter, because she has no way to get there, no way to feed herself or her children if she could get there, no money to pay for the care her child needs at the hospital, and no resources to get her family home again if all the rest of the dilemma is somehow solved. And here is the really sad part of this situation, and it is played out repeatedly all over Africa. The nurse knows all of this. When she hands the mother the referral slip, she knows that the child will never get to the hospital.
When I saw the burned child, she was slightly lethargic and tearless, although clearly uncomfortable. Her mucous membranes were dry, although she took occasional sips of water. The burned areas were mostly second degree, extending from one side of her face, down one side of her torso to the ipsilateral thigh. There may have been a few areas of third degree burn. It was difficult to tell. What blisters had formed were now open, and the burned areas highlighted a pink, macabre geography surrounded by a sea of intensely dark, intact skin. And there were lots of flies hovering over the landscape and enjoying the scenery. Clearly, this child needed attention – wound care, antibiotics, and rehydration at a minimum.
There was a great aunt living with the mother and two other children who spoke some Twi. With the burned child in the aunt’s arms, swaddled in colorful Ghanaian cotton cloth, we packed the great aunt into the back of our Toyota truck, supporting her and the child between Suzy and me, and we headed to Damongo.
Dr. GK knew the Chief Medical Officer in Damongo, and called him to come in to see the child. He arrived in about 15 minutes, ordering a technician to start a saline IV. This was deftly done with only a transient, weak note of resistance from the patient. The doctor was a charming fellow, apparently competent, and very reflective about the problems of delivering care to people in places like Larabanga. This situation was not new to him. He gave us an estimate of the cost of care, we agreed to cover it, and he admitted the child to the hospital. The great aunt was given a few cedis for food and transportation back to Larabanga after discharge. And we left. I am waiting for Dr. GK to tell me the damages.
The story has a happy ending, but it is a fairy tale. This child’s immediate problem was addressed, but at the same time, we reinforced the deus ex machina approach to emergency medical care in this community. Will anyone in Larabanga want health insurance after this experience? Clearly, all you have to do is to wait for an anonymous benefactor to show up.
What is really needed is a lot more and a lot less.
