Northern Re-exposure

During the past two weeks, my scholarly interests here received a significant boost, whereas my medical and social activities reached new levels of complexity.  Regarding the scholarly interests, three of my colleagues from the University of Michigan visited Ghana for the purpose of informing local faculty about open educational resources (OER) for health.  Separate workshops concerning OER policy and production were held in both Accra and Kumasi with the assistance of leaders of an organization called “OER Africa” who also flew in from Kenya and South Africa.  The entire effort was supported by the generosity of the Flora and William Hewlett Foundation, an organization with a passion for supporting and improving learning worldwide.  My role was to participate in the design and conduct of the “OER Production” workshops in both cities.

Approximately 20 university faculty and staff (i.e., from the University of Ghana in Accra and KNUST in Kumasi) were selected by the Provosts because of their interest in OER or their potential to contribute to Health OER production. There were representatives of the medicals schools, nursing schools, schools of public health, allied health schools, librarians, information technologists, and even — in the case of KNUST — faculty from the School of Art.

At the workshops, the participants heard about the concept of “open educational resources,” they received a practical introduction to international copyright concerns and how to avoid legal trouble using accessible materials from the internet for teaching, and they saw examples of electronic learning materials produced at the University of Michigan and in Ghana (by Ghanaian faculty members). We demonstrated methods for converting lectures to electronic resources, video production, and interactive learning programming. The enthusiasm for the concept was tremendous at both institutions, and if even half of the faculty members who indicated an interest in this process actually produce learning materials and make then openly available, our efforts in organizing and presenting the workshops will have been well rewarded. I can see, however, that this is going to create a lot of work for me.

Two of my colleagues from the U.S., Chris and Pieter stayed an extra week after the workshops to learn more about the local infrastructure and to cement some of the relationships that they established here. While in Kumasi, they both stayed with Suzy and me at our house. However, facing a three-day weekend in the middle of their final week with no opportunity to engage faculty, we opted for a mini-vacation.

We hired a car and driver, and Chris, Pieter, Suzy, and I headed north to look for elephants. I spite of the fact that I am dedicated to destroying Danny the Ganef’s car (see the blog entitled “Northern Exposure” for details about my car leasing arrangement), I was worried that the Toyota would not be able to make it down the 60km dirt road from the pavement to the Mole Game Park. And in spite of the substantial extra cost of hiring a 4 x 4, it proved necessary. The road was 60km of kidney-rattling washboard. And the alternate route (on return) was less of a shaking-up, but there were spots on the highway that were like crossing a dry riverbed. Had I brought the Toyota, it would have stayed there – forever.

We stayed two nights in the game park, allowing us to take both morning and evening hikes through the savannah, accompanied by a guide with a rifle, of course. Most of the animals really wanted nothing to do with us, although the elephant posing between Suzy and Chris in the picture below kicked up some dust when we passed a bit too close and threatened to charge. The guide cautioned us to back up and raised his weapon to fire a warning shot. Fortunately, this was unnecessary, since the elephant, seeing a small band of tourists fleeing into the bush, correctly calculated that effort involved in trampling one or more of us in the mid-afternoon heat would not be worth the potential payoff. We also saw two male antelopes fighting, no doubt over access to the women antelopes in the herd. And we saw several male humans at the Mole Motel pool drinking copious quantities of beer and sparring for the attention of human women from Great Britain and Canada in their herd. They my have been lost, though, thinking that they were on Spring Break in Fort Lauderdale instead of the Equatorial African Outback.

We also saw more baboons than you can shake a stick at — and I am referring to the actual lower primates at this point, not the Spring Break crowd. Considering the sharpness of the baboon canine teeth, I would not be inclined to shake a stick at one, even if threatened. One hotel guest was not of a like mind about this. She had a close encounter with a maladapted member of one of the local baboon troupes who was making periodic forays to the Motel swimming pool and attempting to steal whatever human belongings he could get his hands on. As he approached the table of the intrepid tourist lady, she snapped a towel at him, which is at least as provocative as shaking a stick in my view. The animal bared his teeth, hissed, and jabbed at the woman with his clawed hand. He probably outweighed her, and I thought he was going to tear her to pieces right there at the poolside. And he might have done, were he not acutely conscious of being outnumbered by sun-bathing humans armed with more towels and glass beer bottles. So, instead of standing his ground, he snatched a black plastic bag of something vaguely edible from the lady’s table and scampered away with it in a big hurry. He was later seen up in one of the trees enjoying the contents of the plastic bag and plotting his next sortie.

During that afternoon at the Park, we realized that were low on petrol (gasoline, to you Americans). The driver confirmed that the nearest station was in Damongo, a small town that we passed through about 20 miles down the road. Chris had noted a sign for an “internet café” on our way coming in through Damongo and was anxious to do some local infrastructure research. And Suzy was getting hungry for bananas. So, Chris and the driver headed out in the 4 x 4 to the internet café with petrol and banana money from Suzy. Everyone’s needs were being appeased. On return, Chris reported that the internet café was “just like in the States” except for the plywood décor, painfully slow connection speed, and the goats. He did buy bananas, but gave half of them away to group of children. And to my annoyance, the driver fed the rest of the bananas to a group of baboons at the Park Entrance on the way back. Chris said that he even backed up the car to make sure that all of the baboons got at least one. Ironically, Suzy did not get one.

Sunday Morning, we left the Park early, because we knew that there would be an obligatory stop in Larabanga. Dr. GK had alerted Ishmael, the local community development worker (see blog entry entitled, “Northern Exposure”), that I was in the area. And Ishmael had, in turn, called me several times during the weekend for reassurance that I would not leave the area without stopping in Larabanga. I assumed he had business for me to attend to, although he did not say so at the time.

Ishmael greeted us warmly and led us to a parking spot in the shade. Seeing that there were two new foreign visitors in the car, he led us to the mosque and gave the abridged version of the “History” to Chris and Pieter.

On the last visit, Dr. GK and I were presented with a little girl who had severe burns from an overturned pot of boiling water (see blog, “Northern Exposure” for details and reflections). Recognizing that she was receiving only well-meaning concern in the village, but no practical treatment, we transported her to the Damongo Hospital and guaranteed the cost of her treatment there. She survived and eventually spent more than two weeks as an inpatient. On our return visit, she appeared normal and was playing with the other children. I discretely examined the burns sites and noted depigmentation over the burned areas as well as a large area of insensate scarring over the left iliac crest where the burns had damaged the full thickness of her skin (3rd degree). In the U.S., she would likely have received a split thickness skin graft, but I am not sure that the results would have been appreciably better.

Her only problem now related to her poverty. She was being teased by the other children at the local school, because her family could not afford a school uniform. She lived with her mother and siblings who have no source of income, and her father is currently in prison. We solved the simple problem of the school uniform by purchasing the cloth in the appropriate colors and giving it to the mother to sew the uniform. The bigger social problem is being addressed in traditional ways that I have no wish to undermine.

Chris and Suzy pose with full-grown male elephant watching cautiously. The irony of Chris’s T-shirt was not overlooked.

The Park is vast when viewed from the escarpment on which the motel rests.

A green monkey, not a baboon — for the non-primatologists

Emotuo (or rice ball) with groundnut soup

After a 2-week hospitalization, the child resumed normal activities

chronic, bilateral leg ulcer below the knees. Is there a dx other than osteomyelitis?

I was not surprised to learn that there was another child with a medical problem that needed attention and was not getting it. Ishmael led me through the village to an enormous mango tree, under which a boy and his father were comfortably reclining. I was informed that the boy had painful open sores on both legs that interfered with walking and had kept him from attending school for the entire term. There were two skin lesions, one on each anterior leg, just below the tibial tuberosities. According to the child’s father, there was no antecedent trauma, and the ulcers developed spontaneously about 2½ years ago. When the dirty bandages were removed, the alleged chronicity of the ulcers appeared to be confirmed. The ulcers were large, well-establish sinus tracts, packed with a local herbal poultice, a granular concoction that was probably derived from an indigenous seed or root. The poultices were orange in color, having absorbed the drainage from the boy’s wounds. When the packing was removed by washing with water, it was clear that the ulcers track deep to soft bone (see photograph). In addition, there was firm, chronic swelling surrounding the ulcers, likely reflecting some reorganization and remodeling of the bone. Whatever might have caused these ulcers initially, the current condition was undoubtedly chronic osteomyelitis. How this pathological process began is a mystery to me, but I find the claim that there was no trauma to be questionable. Both ulcers developed at the same time in exactly the same location on both legs. Unless there was trauma, it is not clear how this otherwise might have occurred. (Any reader who has an alternate explanation is invited to propose it. Please.)

I showed this picture to my medical colleagues in Kumasi. Dr. PR, who is an expert in Buruli ulcer disease has a strong professional relationship with a local plastic surgeon who grafts large Buruli ulcers after they have been treated and cleared of mycobacteria. He suggested bringing the boy to Kumasi for surgical debridement, possible grafting and antibiotic therapy.  [N.B. Larabanga is too far north and too dry for Buruli ulcer to have been the initiating event.]

I was reluctant to ask this family to bring the child to Kumasi without some assurance that something beneficial can be done here. So, I had Dr. GK call his friend, the District Medical Director in Damongo, to arrange for the child to have x-rays of the legs. I reckoned that this would be useful to establish the extent of the bone involvement and to determine whether or not a thorough debridement of the dead bone will leave the child with something to stand on. There would be no point in bringing him to Kumasi if I cannot find a surgeon who is prepared to operate. I want a commitment and an OR date before I ask this family to bring the child here. Since this is a long-standing problem for which any sense of urgency is more emotional than practical, a delay in treatment is acceptable if it leads to a clearer and more thoughtful plan.

The necessary x-rays were taken last week, and the challenge now is figuring out how to get them delivered to Kumasi. I have contacted a medical colleague who lives in Tamale but travels regularly to Kumasi to visit his family here. I am hoping that Ishmael will be able to give the films to a tro-tro driver who will then give them to someone at the village where the dirt road to Larabanga and the Park meets the pavement. Then, my colleague from Tamale can pick them up when he passes the junction on his next trip to Kumasi – the Ghanaian equivalent of the Pony Express.

Apart from this unresolved issue, our Northern Reexposure was a successful venture. In Larabanga, I had an unexpected encounter with the captain of the local soccer team. When he recognized Suzy and I as the providers of the team’s soccer ball, we were greeted with gales of enthusiasm, high-fiving, and hugs. He and his teammates were proud to report that the Larabanga team had defeated Damongo 3-1 in a game over the previous weekend. Having a real soccer ball with which to practice may have been contributory to the victory. Or at least, I like to think so. The boys also found a sympathetic ear in Chris, who promised them uniforms. (We are still working on that one.) In spite of the pervasive atmosphere of goodwill, Chris evoked an explosion of rage from a market woman in Larabanga who caught him photographing her yams. To settle the matter, he was obliged to buy one at an inflated price. In the mind of the market lady, this act of contrition somehow removed the stigma from the other yams that his camera had captured. Peace was restored.  Then, Chris realized that he had no idea what to do with the yam. Yams are large and unwieldy, often the size of a Rugby ball or larger and definitely heavier. So, Chris bestowed it graciously on one of the local children to take home to her mother’s kitchen. In the final analysis, the child acquired a meal for her family, the market lady made a big profit from a single yam, and Chris got a picture of yams and the satisfaction of having managed through a weird cross-cultural encounter. A three-way, win-win-win situation!