As a man 60 years, I am inclined to get up in the middle of the night one or more times as a matter of routine.  But I am not used to being awakened in the early morning hours by commotion.  This has happened only 4 times since we moved into our house in Kumasi.  The first episode was due to the Man of God preaching in the streets (in Twi) at about 4 am.   I have written about this episode in a previous blog entry.  I was also awakened one night by Joseph, knocking on my bedroom door.  He rousted Suzy and I from our bed to inform us that Kwame was suffering with severe throat and neck pain and was unable to sleep — and he apparently did not want anyone else to sleep either.  So, we administered some analgesics and warm saltwater gargles.  I started an antibiotic the following morning and took him to see an ENT specialist at Komfo Anokye Hospital who diagnosed a peritonsillar abscess and recommended antibiotics and peroxide gargles.  The problem resolved itself slowly over the next few days and has not recurred since.  And Kwame is now back to eating whole crabs, with their shells.

The two other episodes were more problematic.  During December, Suzy and I were awakened by a few salvoes of what we later learned was gunfire.  Joseph initially thought that this was the work of the police who periodically patrol the neighborhood and fire weapons to let any would-be criminals know that they are around.  This explanation never sounded plausible to me, and in fact, it proved not to be so.  Last month, we learned from a neighborhood “security” meeting that the incident was due to one of our neighbors discharging his own rifle.  Apparently, a night-watchman stationed on a roof at the head of the Kotei New Site Road spotted some “intruders” entering the neighborhood with guns during the early morning hours.  He immediately phoned the neighbor with the rifle, who then came outside and began firing his weapon into the air, letting the armed intruders know that they could expect lethal resistance.  This was apparently an effective intervention, since the intruders had second thoughts and left the area, according to the night-watchman.

The confirmed explanation for this event actually seemed less credible than the previous explanation.  And it is a bit more unsettling to consider the possibility that armed robbers have already focused their attention on our little neighborhood.  It makes one wonder if the razor wire over our wall and bars on our windows are a sufficient deterrent.  At dinner last Sunday evening, my Department Head informed us that he has electrified razor wire and four guard dogs at his house.  And he walks a different dog every morning for his own good health but also to let any onlookers know how many dogs he has.

So, in this background of acute paranoia, Suzy and I lay mesmerized last night after being awakened by a crash at 2:30am that came either from inside the house or nearby, outside.  We waited for another sound that might indicate what was happening, but there were no whispering voices or stealthy footsteps, no doors creaking open, no groans from the inept burglar having fallen over the wall onto our potted tomato and garden egg plants.  After 10 or so minutes of active listening and surveying the compound through our bedroom windows, Suzy decided to venture out of the bedroom, ever ready for a fight.  I quickly dressed and followed her.  The living and dining rooms were intact.  Turning on the lights elicited no response.  But when Suzy opened the door to the back hallway, the cause of the crash became clear.  The floor was littered with faux ceiling tiles and wooden splinters.  One strip of faux tile was hanging from the lighting fixture, and the electrical wiring, attic beams, and corrugated roofing were all exposed through a gaping hole in the ceiling (see photos below).

There were some rotting and sagging pieces of wood protruding from the hole, and I was concerned that the rest of the ceiling might soon yield to gravity as well.  So, I roused Joseph, who knows all the secrets of our house.  He had heard the crash but assumed that it came from somewhere else and went back to sleep.  He was astonished to see the hole in the ceiling, but he also quickly identified the cause. Termites, not burglars, had brought the ceiling down.

It seems that the falling ceiling also had a history of which we were unaware.  Joseph explained everything as we sawed off a heavy bamboo pole to support what was left of the sagging infrastructure.  Apparently, at some time in the mythical past, the hallway ceiling was of plaster, like the rest of the house.  But large chunks were periodically raining on the occupants.  So, the landlord instructed Joseph and friends to put up an alternate ceiling of faux tiles.  Joseph recalls that when they replaced the cross-beams to which the tiles are nailed, they ran out of wood at the end of the hallway nearest to our bedroom.  So, the original wood, old and untreated for termites was left in place, and the new ceiling tiles were nailed to it.  These supporting beams were now broken or crumbling.  Joseph reassured us that the rest of the ceiling was supported by relatively new wood.  Moreover, the beams supporting the roof were fully intact and had been treated against termites.  So, we only have to be concerned about the ceiling falling on us, not the roof.

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.

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!

(I apologize to those who have followed this blog and have noted my prolonged absence from the blogosphere recently.  The hiatus in my reports from Ghana is a function of how busy I have become with work, and not a lack of interest in recording experiences or impressions.  I will try to catch up.  In fact, I have several “stories” in mind that I wish to document for Americans who hope to understand this country and its culture better.  They trust that I am getting it right, and I hope I am.  A few Ghanaian friends and colleagues have dropped in on this blog recently, and I hope they will keep me honest.  Particularly in light of this current entry, since politics – like religion — is a controversial subject everywhere.)

My friends in the U.S. inform me that the news – the only news they hear from Ghana — relates to the recent election here.  As usually happens in reporting current events on this continent, the news is reduced to oversimplifications and sweeping generalizations so that we who do not care to understand the subtleties can digest it with our Corn Flakes.  By all accounts in the U.S. press, the election was a watershed event for Africa.  A modern African country has now had two peaceful transfers of power to an opposition party dictated by the ballot box rather than by the rifle barrel.  Indeed, this is what happened here this December and January.  And this is good news for Ghana – the positive publicity, I mean.  Maybe an American investor will feel confident enough to build a factory here and to employ some of the willing, cheap labor.  Perhaps a stable African country can take off economically the same way China and India have done.

Of course, the reality is a bit more complicated.  The election was hotly contested, because the Presidency was up for grabs.  The sitting President had completed his limit of two 4-year terms.  His political party, the National Patriotic Party (NPP), fielded a strong candidate to succeed him and to continue their wealth-building programs.  Most knowledgeable people with whom I have discussed local politics compare the goals of the NPP to our Republican Party.  Their intentions are similar insofar as is possible in a country that lacks many of the fundamentals, such as food, housing, education, and healthcare for much of the population.  So unlike our Republicans, the NPP leaders cannot direct all of their efforts into the proliferation of more millionnaires.  In addition, they can claim credit for installing a few social programs that have been substantial successes, e.g., national health insurance.

Several political parties challenged the status quo in this election, including the National Democratic Congress (NDC), which peacefully handed over power to the current regime eight years ago.  The NDC nominated Atta Mills, a University of Ghana Law Professor and a previous two-time loser, as its candidate.  This was done at the insistence of the NDC party chairman and founder, former President and Flight Lieutenant John Jerry Rawlings, who is typically either beloved or despised depending one’s socioeconomic status and one’s geographic and ethnic identity.  Rawlings’ stronghold is the Eastern  (Volta) Region of the country, named for the large man-made lake and river of the same name.  The lake is the source of most of the country’s hydroelectric power, and the Volta Region is populated predominantly by people of Ewe ethnicity.  Atta Mills is not a member of this ethnic group, and his Vice-Presidential choice is from the Northern Region, which is predominantly Muslim.  Accordingly, the NDC has a social democratic philosophy and a reasonably credible policy of bridging ethnic divides.

There were a slew of other partisan hopefuls in the first-run of the election on December 7th, but none was able to attract more than 2% of the vote, and the real contest boiled down to a run-off between the NPP and NDC held on December 28th.

The NPP stronghold is the Ashanti Region, where most of the residents are of the Asante ethnicity and owe allegiance to the traditional leader, the Asantehene (Asante King).  The NPP has also fielded Vice Presidential candidates from the North in the past and in the current election, but their track record suggests that this seat at the political table has not translated into any significant benefit for the Northern Region.  As a result, the only regions of the country that produced a majority for the NPP in the election were the Ashanti Region and neighboring Brong-Ahafo Region, where the majority of the people are Asantes.  However, since these regions voted overwhelmingly for the NPP, and since there are large populations of this ethnicity and related ethnicities that share common Akan-based languages elsewhere in Ghana, the popular vote was extremely close.  The NPP presidential candidate, Nana Akufo-Addo, failed to win a majority in the December 7th election by only a few tenths of a percent.  So paradoxically, the minor parties that failed to attract any significant voter turnout themselves played a decisive role in the outcome of the election.  Moreover, the NDC won a majority of the parliamentary seats, indicating its wide geographic popularity – an omen for the run-off election.

The run-off election between NPP and NDC was held on December 28th.  Again, the margin between the parties was razor-thin.  The Electoral Commissioner, a man who appears to have the patience of Job and the wisdom of Solomon, delayed the announcement of the results for several days in order to allow one small electoral constituency in Brong-Ahafo that had failed to receive ballots on December 28th to vote, to address claims of electoral shenanigans from both sides, and to permit the angry crowd of NDC voters assembled on the streets around the Electoral Commission in Accra to tire and eventually to disperse.  The final result was an extremely narrow victory for the NDC and a peaceful exchange of power.  But there remains some doubt in the public mind about the validity of the results.  Several partisan radio stations and newspapers nourished this doubt by circulating stories about election day irregularities in either the stronghold Ashanti or Volta Regions, most of which later turned out to be apocryphal.  Nevertheless, NPP voters remain as doubtful about the bonafide vote count as American Democrats were about the 2000 Bush-Gore contest results.  Just as our Supreme Court seems to have decided the 2000 U.S. Election, the Electoral Commission played a critical role in Ghana by certifying the valid votes.  As a result, many Ghanaians view the election as an affirmation of the national will to continue the peaceful transition of power, rather as a demonstration of a successful democratic election.

One of my Ghanaian friends remarked that both sides cheated in the elections and that the NPP lost the election because they did not cheat sufficiently in the first round.  Another observed that the change of regime, whether earned or not, is itself a victory for democratic principles, since it serves notice to politicians that they will not be able to maintain their seats on the basis of party machine politics or ethnic identity alone.  They will have to earn the confidence and the votes of the populace if they intend to remain in power.  Most agree that the freedoms of uninhibited journalism and speech acquired with the transition from autocracy have become so ingrained in Ghanaian society that no elected regime will ever be able to reverse this progress.  Ghanaians are free to be openly critical of anything in this society, and some are not timid about exercising this right, albeit in a polite way.  And although most acknowledge that such a close election in another African country might have sparked a civil war, post-election violence in Ghana (whatever the electoral outcome) was never likely to be significant.  This general perception did not stop the local media from an “ambulance chasing” style of reporting on Election Day.  This is the way some of the coverage appeared to me:

ANCHOR: We go now to Field Correspondent Kwaku Ofosu at the _______ polling station where we have heard there has been some trouble reported.  Kwaku, what is happening there at ________?

KWAKU: There has been a disturbance here, and the police have taken one man into custody.  [footage of one obviously-intoxicated man being led away by a policeman].  We do not currently have his name or know what he is being charged with. However, the police have restored order here, and polling has resumed at this station.

ANCHOR: I see.  (pause)  I have just received a report of some violence at the _____ school polling station.  Kwabena Osei is standing by at the scene.  Kwabena, can you hear me?

KWABENA:  Loud and clear.

ANCHOR: What is happening at your location at the _______ school polling station?

KWABENA:  Well, there are long lines of voters here waiting to cast their ballots.  The turnout has been much greater than anticipated, and there appears to be insufficient election officials on hand to process all of the voters.

ANCHOR: . . . and this has caused some disturbances?

KWABENA: None that I have seen.  Voters are waiting patiently for their chance to cast their ballots.

ANCHOR: (muttered) Well, thank God for that!

It is not surprising that there was no recipient selected for a prestigious annual Ghanaian journalism award last year.  Ghanaian telejournalists seem to have had an idea of the story they wanted to report, but reality did not comply with their pre-concepts.

There probably was an authentic risk of trouble when the relatively small NDC protest crowd assembled in Accra outside the Election Commission, but this also came to nothing in the end.  This was the only worrisome occurrence of which I was aware during the election, and the police were on site in force the whole time.  They would have promptly handled any violence that erupted there, and I doubt that it would have spread.  Regarding the potential for serious electoral violence here, one of my friends remarked, “Ghanaians are not prepared to die for politicians.”

Up to now, President Mills has projected the image of a fair and just leader, an aged sage with nothing personal to gain from the presidency.  He seems to be a man of vision in spite of the fact that his eyesight is failing, and the television cameras revealed the text of his speech was printed in an oversized font, 5-7 lines per page.  The budget that he presented to the Parliament yesterday (March 5th) reflects the NDC Manifesto and the campaign promises that he made during the election.  Today (March 6th), his speech at the Independence Day ceremonies in Accra emphasized his commitment to fairness and to prosecution of government corruption wherever it occurs.  In contradistinction to these stated principles, some zealots in his administration have been taking actions that could be considered vindictive against members of the former regime.  The most recent example was the impounding of Nana Akufo-Addo’s car while the former presidential candidate was temporarily overseas.  The car turned out to be a privately-owned vehicle and not government property as was alleged.  Mill’s Independence Day speech specifically disavowed using governmental power to settle political scores as a strategy of his administration.  So, we will see whether this gentle and grandfatherly leader also finds “corruption” among his own partisans as well as the opposition.

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.

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.

What you understand about time, or fruit, or fruit flies all depends on whether you understand the various meaning of the word, “like.”  It is the ambiguity in the statement and the uncertainty about which meaning is intended that evokes the double-take among native English speakers when they read Groucho Marx’s argument.  Imagine the confusion of a non-native speaker.

I suspect that I have fallen victim to these kind of misinterpretations on more than one occasion in Ghana.  This happens frequently in the half-English, half-Twi communications I have with the Extended Family.  Any level of understanding is a kind of success, even if there was no communication at all.  Unfortunately, there is no way to verify if the intended message is getting through.

One recent example. . . In this blog, I recently commented on the identity of the word, “nkruma,” (meaning “okras”) and the name of the first president of Ghana (“Kwame Nkrumah”).  This realization came up one day in our kitchen, when Suzy, Agatha, Kwame, and I were discussing the impending trip to the market in Kotei.  Agatha volunteered that “okru” was one okra, or okra in general.  But if you wish to enumerate okra, you would refer to two, three, or more “nkruma.”  Suzy immediately made the connection with the First President, and the African heads nodded when they saw the light bulbs appear over our heads.  We were sure that we had discovered a cultural pearl, like learning that an English person named “Fletcher” likely had an ancestor that manufactured arrows — the kind that fly like time.  We were wrong.

Our mistake became apparent when we actually met someone named “Nkrumah.”  Andrew Nkrumah is a member of Suzy’s religious group.  When we were introduced to him at the Baha’i center, and Suzy heard his name, she immediately acknowledged her understanding of its meaning.  But wait!  That is not correct.  Okras are “nkruma;” Andrew’s family name is “Nkrumah.”  Two completely different utterances, Gringos.  For okras, there is an upward inflection on the last syllable of the word.  The name “Nkrumah” has flat intonation.  Very different.  Hmm.

Is that the final word on the matter?  Or, am I missing subtle shades of meaning; the kind that humorists and third-grade joke-tellers depend upon.  Are the pronunciations of the words so different that native speakers do not even notice the similarity.  If so, why did Kwame and Agatha nod approvingly when we demonstrated our ignorance?  Is it that they simply enjoy witnessing our complete lack of a clue?  Could it be that Andrew has been plagued all his life by school chums enjoying the alternate pronunciation of his last name?  Could it be the equivalent of a family name like “Butz,” or “Lipschitz,” or “Fokker.”  I do not know, but I am going to have to take the issue to a more knowledgeable authority.

Then there are the verbal exchanges that defy interpretation altogether.  What follows is the gist of a conversation that I had with Kwame a few days ago while he was driving me to work at the medical school.   This conversation occurred a few days before the election (which is now taking place as I compose this entry).  Kwame has gone to his hometown near Cape Coast to vote in the election, so he is not here to verify whether he understood the meaning of our conversation.

I noted that the rain had not damaged the recently graded road into our neighborhood – “The road is good” (in Twi), followed by the more complicated concept about the grading in English.
Kwame acknowledged his assent.
I said, “It seems to be raining a lot for the Dry Season.  Is this normal?”
“Cape Coast not like here — Kumasi is forest region – different — but rain is more now — last years, since Kufuor.”  (He is of course referring to the sitting, two-term President of Ghana and leader of the National Patriotic Party (NPP) who will be replaced in the election.)
“It rains more since Kufuor became President?” I asked.
“Yes.”
“Do you think it rains more because Kufuor is President?” I asked jokingly.
“Yes.”
“So you think Kufuor controls the weather?”
“Yes.”
There was a long pause while I considered this response.  So, I took a different tack.
“Have you decided who you will vote for in the election?”
[without hesitation] “NPP.”
“So, you like more rain?”
“Yes.”

Is it possible that Kwame is a single-issue voter in the national election, and his issue is more rain?  Or, was this conversation just a strange series of misunderstandings?  I am not sure.  Sometimes he expresses acknowledgment when I know that he has not understood.  Alternatively, Kwame has demonstrated magical thinking more than once.  He is educated at just above the elementary level, so fluid mechanics and meteorology may not be his strong suits.  Again, I will need guidance to understand this interaction, or I will have to learn the local language better.

Gyinyase – my kind of town

There is a small village (small suburb) situated on the paved road between Kotei and Atonsu (larger suburbs) that I habitually pass through on my preferred, circuitous auto route to the medical school.  It is the preferred route because I like passing through Gyinyase (“Jin-ya’-si”).  It is clearly part of the Kumasi Metropolitan Area, but it could be a stand-alone village in any part of Ghana.  The Kotei-Atonsu road becomes “main street” in Gyinyase, and there are a few speed bumps at one end to let you know that you have arrived in an area of human concentration.  Once in the center of Gyinyasi, the houses that front on the road are small cinder-block and corrugated roof structures that are closely spaced to one another and the roadside.  Yet, there is room for petty traders to erect stalls, to sell vegetables, cellular telephone credit, and Ghanaian fast food of all varieties. I have it on excellent authority that the stall with the handpainted “Kenkey Special” sign is the place in town to buy kenkey (steamed, fermented cornmush wrapped in leaves).  At the heart of Gyinyase, there is an open square lined with modest shops, all facing a grassless soccer pitch with goals at either end.  The square slopes gently downward toward the road, for drainage purposes, creating a distinct advantage for the soccer team aiming at the roadside goal.

Suzy and I went to dinner to celebrate my 60th birthday a few nights ago.  I usually drive the car on such occasions, because neither of us likes the idea of having Kwame waiting for us in the car while we dine.   And we know he is not an adventurous eater, preferring kenkey to many of the foods that we prepare for ourselves at home.

I am not enthusiastic about driving here, but I have a license, and I can manage to be almost as aggressive as the taxis and tro-tros when called upon.  But driving here is intense and requires maximum attention, particularly at night.  To me, it is more like playing a video game than it is like driving in Ann Arbor.  You have to steer clear of potholes to avoid breaking an axle and slow down for speed bumps to avoid losing your muffler.  You must adjust to taxis passing at inappropriate and unexpected moments.  You must watch for pedestrians who cross haphazardly and who seem to be required by some unwritten law to dress in all black clothes at night.   Chickens, goats, and zebu cattle appear as random obstacles.   And finally, nearly all of the roads in urban Ghana are bounded on either side by 3-foot deep concrete open drainage conduits that serve as leg traps for unwary tourists on foot, and force local pedestrians to walk between the cars and the open drain.  For cars engaged in the driving-video-game, they serve the same purpose as the gutters of bowling alleys; once you’re in, you lose your turn.  Game over.  It will take several stout men to get your car back on the road.

Needless to say, I am very careful driving through Gyinyase, especially at night.  And I have pulled over to the drainage conduit on many occasions to allow an overly-anxious taxi to pass at speeds that defy reason.  Pedestrians are not well-respected here, and they know it.  Parents keep their children close when they are near the roadside.  Hand-holding is the rule.

The night of my Birthday dinner, there were big doings in Gyinyase.  The square was lit up and abuzz with activity related to the 3-day Crusade for Christ.  Rows of blue and red, plastic chairs, mostly occupied with supplicants, were set up facing a make-shift stage next to the south soccer goal.  An electric band was entertaining the crowd with amplified, high-intensity music that one rarely associates with religious events, but which was undoubtedly devotional in content nonetheless.  I was tempted to stop and check it out up-close, but I reasoned that the Crusade would require some face time and more than a few cedis, so I yielded to my hunger and yen for Indian food and passed up the local festivities.

Dinner at a fine Indian restaurant 3-4 miles northwest of Gyinyase was superb, but expensive.  I had red wine for the first time in 2 months – a bottle of very decent Cabernet from Australia for only 14 cedis.  The maitre d’ who served the wine was a tall, slender, and stunningly attractive young woman wearing a vest and trousers and sporting an explosion of tressed and gold-tipped hair on her head.  In a very brief conversation after paying the bill, we learned that she was also a resident of Gyinyase and was unaware of the big doings there that very night.  I assumed that she would miss the Crusade altogether because of the hours of her job.

On the way back through Gyinyase, the band was gone, and the clergy had inherited the stage.  There was a white-suited personality with a hand-mic preaching to the believers, backed by women in choir robes and a life-size cut-out of Jesus mounted behind and above the stage.  Again, I was tempted to stop, but I needed to attend to the reflux that was already surging upward after the Indian Birthday dinner and half a bottle of cabernet.

At the intersection of the Kotei-Atonsu road and the unfinished road to the medical school, about halfway between my neighborhood and Gyinyase, there is now a tall radio antenna.  We had watched this structure being erected during the past several weeks, by men tethered to and hanging from the sides of the rising tower, securing sections upward by hoisting them from the ground, in the absence of a building crane.  Now, the tower is complete, and the imperiled workmen have moved on to another project.  But the tower is now the tallest object for miles in all directions.  It is clearly visible from anywhere in Gyinyase.  So, proceeding east down “main street” before it curves rightward outside of town, the tower appears to rise from the middle of the road ahead.  I like to think of it as the Eiffel Tower of Gyinyase, a notion that Kwame finds amusing, even after I explained the reference.

The day before Kwame left for his village, he drove Suzy and I back from the campus and through Gyinyase.  We stopped to buy fresh eggs and groundnuts from one of the petty traders on the roadside.  Kwame parked on the right roadside, inches from the drainage conduit and only a few yards from the north soccer goal.  I waited in the car, watching the dismantling of the Crusade.  The chairs were mostly stacked at this point, the 2-D Jesus had left, but the loudspeakers were still operational and were being used to broadcast cheerful, rhythmic music.  An overweight, middle-aged woman in a Ghanaian print dress with matching headcloth, danced across the road in front of our parked car.  It was a momentary and involuntary act, and she resumed her matronly demeanor when she stepped over the drainage conduit and onto the square.

I realized that I had witnessed, or more correctly passed-by, the cultural life of Gyinyase.  And it is probably the same in all of the neighborhoods of Kumasi.  We have found little evidence of theater, concerts, public lectures, or the like here.  There is nightlife, which consists of drinking and dancing to tympanum-busting music in bars, and there are occasional events related to the tribal past, at the Asante Cultural Center and the Asantehene’s Palace, no more sustaining than watching Changing of the Guard at Buckingham Palace more than once.  The cultural life of this city centers on the churches (Sundays) and on funerals (Saturdays).

Dead people get first-class treatment here.  It is not unusual for family members to finance billboards proclaiming the passing of a loved one with a photograph and a message – “gone too soon” one says.  The funerals are not dour events.  They are celebratory. The attendees typically put on traditional dress in black or red, and they attend a lively, loud event with music, devotion, and socializing, and of course, a burial.  Funerals are much like the 3-day Crusade for Christ focused on the deceased and condensed into an afternoon.  Responding to my questions about the cultural opportunities in Kumasi, a colleague at the University pointed out the church-funeral axis of activity to me.  He commented to me, somewhat derisively, “The Asantes like to play with their dead.”  Clearly, he yearns for the nightlife of Accra and Europe.

Honestly, I do not share his yearning.  I am busy with my work and with writing entries for this blog.  I am finding wonder in very simple things here.  On my last trip driving through downtown Gyinyase with Kwame at the wheel, I broke into song. . .

“My-y-y-y kind of town. . . Gyinyase is my-y-y-y-y kind of town. . .”

[Kwame erupted with laughter.]

“. . . my-y-y-y kind of people, too-o-o. . . people who-o-o, smile at you . . .”

[Did he know this song, or was he just laughing to hear the obruni singing?]

“. . . (modulating up one whole step) and e-e-e-each time I roam, Gyinyase is. . .”

[Who cares if he knows Sinatra, he’s laughing.]

“. . . calling me home. . .”

Suzy and I came to Ghana with fairly limited and lightweight wardrobes. Our past experience in Africa taught us that clothes were not difficult to find or to make here, so paying excess baggage fees to bring along another cocktail dress or sports jacket seemed absurd.

Like many other African countries, Ghana has a lively textile industry, which produces cloth based on both traditional and modern designs for local distribution. A colleague at the University informed me that the idea of Casual Fridays, popular in the West, took hold here as a way to encourage citizens to wear Ghanaian styles and to support the local textile industry. For men, this generally means tropical-style shirts, worn outside the pants. Or, for the more traditional-minded, the shirt-robe to the knees with airy pants made of the same material. For women, the local outfit is generally a two-piece affair, with a top that ends at or slightly below the waist and a long, form-fitting skirt, either tubular or flaring from the knees down. The materials are multicolored repeating patterns, some resembling the patterns on “kente” cloth, a complicated traditional weave that is far too heavy and too expensive to fashion ordinary clothes.

Suzy and Agatha made a trip to the Central Market where Suzy bought 6 yards of two cloth styles to make into two dresses. Agatha has a sewing machine and has offered to make curtains for us in the past when that issue came up briefly. And now, she was offering to make the dresses. She had a collection of posters showing women in a variety of African dress styles from which Suzy could select. Suzy was more than happy to let her try.

Agatha took a few key measurements and then started to cut the cloth. For the next few mornings, we awakened to the sound of the hand-operated sewing machine from China, ka-chun-ka-chun-ka-chun-ka-chun. Suzy was surprised to find that Agatha had sewed together all of the pieces with straight, permanent seams before she had Suzy try on the first dress. This proved to be a mistake. The fit was not good, and this was obvious. The top looked like a sack, and Suzy could not squeeze into the skirt either by stepping in or by the over-the-head approach. So, seams were removed, and Agatha tried to fix things. We showed her other clothes of similar design that Suzy already had and which fit well. She was able to let out the skirt. The bodice was improved by adding another seam, but below that point, it looks as though Suzy has an inner tube around her waist.

Suzy will not wear the dress as it currently fits – at least not out of the house. She and I have discussed at length how we can approach this problem with Agatha without shattering her confidence. Should Suzy tell her the dress looks fine but never wear it? Should she have Agatha try to make additional alterations that may irreversibly make things worse? Or, should she accept the dress as is, then surreptitiously take it to a professional tailor to see what can be done to remediate the problem? Suzy has not decided what to do, and the second dress has already been cut and is being assembled. Here is an opportunity for the readers of this blog to influence ongoing events. Please vote your advice in the comments.

The dress-making problem has two possible causes. First, we may have expected too much from Agatha, who is, after all, not a professional dressmaker. Second, Agatha proceeded to make a dress for a Ghanaian physique (perhaps her own) with a few modification to take Suzy’s vital statistics into account. Then, she appeared with a finished product without making any attempt to customize it to Suzy’s physical appearance. Her approach was earnest and well-intended, but it was not thoughtful and did not take all of the variables involved in a custom fit into account.

So, why am I going on about dressmaking in this medical education/travel blog? I will explain by relating an experience that I had in a clinical setting in Ghana.

A 72 year old man complained of pain at the site of previous surgery six months earlier. He had undergone an operation to repair a hiatal hernia with mobilization of the herniated transverse colon back into the abdominal cavity. Now, he had discomfort under the surgical scar. He also complained of swelling of his ankles each evening and constipation. At the time of the surgery, the patient was found to be hypertensive and was placed on two-drug regimen with lisinopril and nifedipine. These were his only medications.

At the time of the visit, the patient was still mildly hypertensive. The abdomen was unremarkable. There was minimal tenderness associated with the more rostral portion of his mid-epigastric scar.

I commented that calcium channel blockers, like nifedipine, are not considered optimal agents for Americans of African descent and that they are a frequent cause of constipation, particularly in the elderly. I assumed that the physician that I was observing would solve the pain problem and take the opportunity to optimize the antihypertensive therapy. I thought about the possible causes of pain in this situation and considered the possibility that the surgery may have failed or that he had a recurrence of esophagitis that accompanied his original complaints before the surgery. Or, did he have adhesions that might be responsible for intermittent pain and constipation?

What happen next surprised me. The patient was given a prescription for an oral NSAID and a laxative. There was no change made to the antihypertensive regimen.

Medicine is an art as well as a science, so there is usually more than one solution to any given problem.  However, from my perspective, symptomatic treatment was prescribed without considering the possible underlying causes of the patient’s complaint.  The doctor’s prescription was the most direct response to the patient’s complaint, but not necessarily the best one.  In this case, one might be concerned about using a medication (NSAID) that can cause gastric irritation or bleeding in a patient whose primary complaint is epigastric pain, and although constipation may be a routine problem of the sedentery elderly, it could also be a sign of something more in an individual who had recently undergone abdominal surgery and who takes medications that may affect gastrointestinal motility.  Of course, we are in Ghana not New York City, and the clinical resources available to sort out this patient’s problems are not vast.  This patient could not be referred for gastroscopy, because there are no certified endoscopists here.  If there were, they would likely be preoccupied with more urgent problems.  And who would pay for the procedure?  Still, I am forced to ask myself whether the limitation of diagnostic and therapeutic options here has created a sense of comfort with empiric and symptomatic treatment as the default approach.  Have physicians who are as intelligent and well-trained as their US counterparts abandoned the art of diagnosis?

During the past week, I met with a colleague from the Department of Internal Medicine in Kumasi, Dr. JZ.   Dr. JZ and I have been working on a project together that will instruct students in the interpretation of certain laboratory tests. He has been enthusiastic about the materials that we are developing and impressed with what can be done. He has a long-term interest in creating a Clinical Skills Center in which this type of programming would be useful. Currently, Dr. JZ is also involved in the Open Educational Resources activities of our joint grant with medical schools in Ghana and English-speaking medical schools in South Africa. He had just returned from a visit to Michigan to discuss some of the objectives and aims of this grant, and he returned to Ghana with a fervor that I had not seen previously.

Dr. JZ was educated in medicine abroad and completed training in a medical subspecialty at Columbia University. So, he knows how medicine is practiced both in the US and in Ghana. Dr. JZ believes that Ghanaian physicians are not being taught how to synthesize all of the available clinical data when making therapeutic decisions, a practice that is fundamental to American medicine. He complains that Ghanaian students and practicing physicians tend to focus on a single sign or symptom and to make snap clinical decisions based on that limited information, as in the case I described above. Another classic example is the assumption that all fevers are related to malaria. In fact, a great many are indeed associated with malaria, but this assumption not only overlooks a broad range of disorders that also cause fever, it results in a massive overestimate of the impact of malaria as well as unnecessary treatment. One physician in Accra has reported that 75% of all patients who come to his clinic have malaria!

Dr. JZ wants to create and to assemble teaching materials that will force his students to put together information from various sources to solve clinical problems. Interactive, case-based e-learning materials would provide a superb platform for this goal. He is jumping ahead in the process that I had envisioned here and wants to arrange for the two of us to meet with a leader at UST in Computer Science to identify impending graduates who might be interested in learning how to develop electronic medical course materials. He sees me as a mentor for both himself and for a local computer science student so that we can create a capacity on site to continue the kinds of projects that I have started. I am, of course, enthusiastic about his approach, but a bit nervous also, since we have not yet deployed even one small example of an e-learning project here. We do not know yet what the problems and the acceptance will be. However, with Dr. JZ taking the initiative, I am much less concerned about those issues. He will be in a better position to deal with any problems than I would be.

Regrettably, I will not have the time or the expertise to generate e-learning materials concerning dressmaking. I will leave that problem to my successor.

Thanks to two charming acquaintances from the University of Utah–thank you Ruth and Rosey—and our sons in Ann Arbor, the police reports from the Washtenaw County Sheriff’s Office finally arrived in Kumasi.  For those readers of this blog who are thinking of mailing me a Care Package, note that the FedEx Envelope containing the police reports took one whole week to get here at a cost of $118.00.

I was naturally interested to see which felonies I had committed, so I checked out the reports as soon as they arrived.  But no surprises, neither Suzy nor I had any record with the Sheriff’s Department.  However, the report goes on to say that their records may not be complete.  So, if “To Whom It May Concern” wants more information about either of us, they should contact the State Police Department in Lansing!  Great!  Then, they can check with the FBI, Interpol, and Homeland Security to confirm that we are not international terrorists.  Why did the Sheriff’s Department have to create doubt in this report!??  Don’t they realize that I am dealing with African bureaucrats?  I thought I made the purpose of this report clear in my expensively “notarized” letter.  What crime of international interest could I have possibly committed that would be unknown to the police in my own jurisdiction?  Could my visa here be held up because I might have an unpaid parking ticket from Alpena?  [I don’t, by the way.]   But the police reports were on official letterhead, with a notarial stamp, and several signatures. Perhaps that will be sufficient, and no one will actually read them.

Suzy has a travel guide to Ghana that claims that it is much easier to get a visa extension in Kumasi than in Accra.  That sounded good.  So, instead of returning to Accra and the College of Physicians & Surgeons for the necessary letter requesting my extension to one year, I will ask the Provost here for a letter.  He is a charming man, very supportive of my interests, and very helpful.  It seemed more appropriate to approach him, since I am officially a Visiting Professor here, and I am living in Kumasi now.  I drafted a letter, the Provost reviewed it, had it printed on his letterhead, and signed it.  Since time was running short on our current visa – 10 more days, Suzy and I headed immediately downtown to Immigration, which we were told was “across from the Central Post Office.”  [An aside: street addresses do not mean much here.  Most people do not know the names of streets.  Neighborhood names are well-known reference points, and for greater resolution, you must relate the destination to a specific structure.  And then you ask someone.  So, the “address” of Internet Ghana is “behind the Adum Shell Station.”  The location of our house has an official designation with a section and plot number that is mentioned in the lease, but no one could possibly find me with that information.  If I say, “Turn at the red and white ‘pole’ between Gyinyase and Kotei, then ask where the obruni lives” you will have no trouble locating me.]  The Kumasi Immigration Office was indeed across from the Central Post Office, only behind another government building that was directly across the street.  We only had to ask two people to find it.

The Immigration people in Kumasi were indeed very pleasant and much more accessible than their counterparts in Accra.  Unfortunately, they have limited authority (perhaps that explains their accessibility).  This was the plan that the very pleasant immigration officer suggested: we should renew our visas now for two more months (40 cedis for each passport).  Then, when that visa runs out, we should come back for another two-month extension for another 80 cedis.  Then, when those visas expire, we leave the country.  There is no visa that allows us to stay for more than six months.  We need a residency permit to stay longer, and that can only be issued in Accra.  After further clarification, a very nice senior officer was willing to call Accra to see what could be done for us, and he mentioned the name and phone number of Mrs. H, an authority in Accra who could approve such a transaction.  I wrote it down on the back of the police reports.

Since I was not ultimately interested in paying 160 cedis to become an illegal immigrant in 4 months, I decided to lay the problem before the Provost again.  How do they deal with this?  Shouldn’t the University have faced a similar situation in the past? I still don’t know.  The answer may be “no.”  However, when I related the details of my encounter with the two immigration officers and mentioned the name of the authority figure in Accra, the Provost immediately responded, “I know Mrs. H. personally.  She is the Head of the whole operation there.  I will call her.”  And he did, while I watched and listened in total wonderment from the other side of his desk.

So, we revised the addressee of the Provost’s letter, and Suzy and I set out for Accra early the next morning.  Not wishing our plight to be out of Ms. H.’s mind for too long, we went directly to Immigration after our arrival that afternoon.  We never actually met with Mrs. H. in person, but her secretary was very helpful.  For the first time, we got a complete account of what was required for a residency permit, and we had most of the necessary documents already.  She did not seem to be perturbed by the wishy-washy police reports.  Maybe she did not read them, and this will come back to haunt us later.  But she did point out a potential inconsistency in the Provost’s letter that asked for a “visa extension” rather than a “residency permit.”  However, I think I convinced her that an academic surgeon like the Provost could not also be expected to be well-versed in Ghanaian Immigration Law.  He had asked for an extension for one year, and it was up to the Immigration Service to decide how that should be done.  She bought that explanation – at least for now.  But the one additional requirement that we could not dance around, apart from the 400 cedis in cash, was the required medical reports from a Ghanaian physician.

Okay.  So now, we were finally playing in my ballpark.  This was something that I might be able to facilitate on my own.  And I was not disappointed when I called my colleague, Dr. EA, at Korle-Bu, who was both generous and accommodating with his time.  He did a screening physical for Suzy and me.  We had blood counts done in the Polyclinic Lab – results in one hour– and he waived the chest x-rays when I told him that we had negative PPDs before leaving the US.  After two hours, we left Korle-Bu with medical reports, sealed and stamped.  My eternal gratitude goes to Dr. EA for this unscheduled attention.

Mrs. H’s secretary was floored when we returned that same morning with the medical reports and an obscene bundle of currency.  I do not think she believed we could do it before the weekend.  But she looked through the documents again, found everything to be in order, and had another officer escort me to main hall where the hoi polloi wait for their visa accommodations (or not).  There, the packet was handed to a young lady who, after 45 minutes or so, handed me a bill, directed me to the cashier, and provided me with a receipt for our passports.  I was told to return on or after the 14th of December (one month) to reclaim them.  So, will this be it?  Will this be my last trip to Ghana Immigration?  Or will there be some additional, last minute hurdle to jump over?  Will it be the Provost’s request for an extension rather than a residency permit?  Or the indecisive police report?  Or the absence of  a chest x-ray report?  Stay tuned.  I’ll know next month.

Oh, by the way, in case you think that 400 cedis for two residency permits is in some manner excessive, I will relate to you what was told to me by a Ghanaian friend, Elizabeth A, in Accra who has applied five times for a visa to visit the United States.  Elizabeth has a house, a car, and a good job in Accra. For the sum of $135 a significant proportion of her monthly salary, she was permitted to fill out an application and talk to a consular official behind a bullet-proof glass window.  Her application was rejected five times, and she is simply out of pocket for $675.  She bought nothing but the privilege of visiting the Embassy/Prison.  This confirms my impression, also based on my painful experience in the London U.S. Embassy trying to get Suzy into the U.S. after we had been married and living together for 1 ½ years (long story for another blog).  My impression is that immigration officials from all countries, and particularly the U.S., are in the employ of Satan.  I would rather do business with the Sopranos.

So, that is the latest Immigration story.  And the trip to Accra was not a total loss, either.  I saw the Rector of College, I met with Dr. EA (who was delighted with the parts of our co-development project that I had sent him), I met with my senior pathology colleague and mapped out the cases for the Pathology Review, and I saw Dr. AR and set a date for videotaping of a hysterectomy.  December 17th corresponds nicely with my return to Accra to pick up the passports (or not).  I gave Dr. AR a copy of what I had started on the hysterectomy program based on his cases.  He is now already talking about collaborating on another e-learning project for teaching Caesarian section.  Is this idea catching on?

So, the unexpected, unplanned trip to Accra turned out to be a success on several levels.  But it was not a pleasant three days for Kwame, our driver.  And that is what I really want to focus on in this entry.

Keeping in mind that what I am next about to relate has traveled through space and time and across the Language Barrier, this is what I understand about Kwame’s life before the Englebergs.  Kwame identifies himself as a farmer, from a small town that is now a suburb of the city of Cape Coast, about 2 hours west of Accra.  Like many Ghanaians, he has also had a makeshift auto maintenance business that he ran from his house in the village, which is conveniently located on a major road.  His wife and two small children live in that house now, and he sees them once a month – an arrangement that he feels quite contented with.  His older child, a daughter, goes to a primary school that costs the family 25 cedis a month in fees.  His younger son, the toddler, currently stays at home with his wife.  But he will also eventually require school fees.

The childrens’ school fees and the demands of modern life have required Kwame to engage in the cash economy.  He has been a private chaffeur and a tro-tro driver, and his wife earns some cash in the village as a hairdresser.  I do not know what the state of his farm is or who is taking care of it now. He has many primary relatives in the village, and they seem to support his family in his absence, up to a point.

He had mentioned more than once that his wife had not been feeling well recently.  As best as I could understand, her legs were “weak” and she was occasionally dizzy.  This may have been a single complaint.  I am not sure.  But I knew that this illness was stressing him out.  In fact, he had also been complaining of intermittent chest pain, but I checked this out, and it was clearly musculoskeletal in nature.  Suzy seems to think he has had chest pain problems since he climbed a cocoanut tree some time ago, found a snake at the top, and jumped.  Could be.

Halfway between Kumasi and Accra, he received a phone call from his brother informing him that his wife had been taken to the local hospital and had undergone tests and treatments.  She was still in the hospital, and the cost of care (not being enrolled in the National Health Insurance Scheme) was now at “600,000 cedis.”  Now, before assuming that his poor wife had undergone an emergency heart transplant, understand that the “Ghana cedi” only replaced the “cedi” about a year ago.  One Ghana cedi is 10,000 “old cedis,” but many citizens still use the old scale and have a difficult time converting to the new currency.  Initially, Kwame told me that his wife’s bill was “6 Ghana cedis.”  I was skeptical, knowing that his English was not much better than my Twi, and his math was slightly less adept than mine.  In fact, the correct conversion is “60 Ghana cedis,” which would not buy a Band-Aid at the University of Michigan Hospital, but seems to buy comprehensive care in Cape Coast.  Nevertheless, this is a fat chunk of change for Kwame on the local scale of relative values, and I could tell that he was deeply concerned both about the health of his wife, the maintenance of his children while she was in the hospital, and his finances.

When we arrived at Linda D’or, a favorite bus stop, restaurant, and snack bar on the Kumasi-Accra road, Kwame was in a very agitated state.  He didn’t want to eat; he didn’t want to drink, he didn’t even want to use the fine toilet facilities (for only 10 pesewas).  So, we agreed on a plan.  After we arrived in Accra and made our first stop at Immigration, Kwame would drive us first to the bank to get money, then to the tro-tro station in Accra, where we would supply him with 80 cedis.  He would take a tro-tro to his village and see to his wife and children’s problems.  He would return only when he felt everything was in order.  If he returned Friday night, he would drive us back to Kumasi on Saturday morning.  If matters were more entangled, he would stay as long as needed, and meet us in Kumasi when he could.  The latter course would require me to drive the Kumasi road, something that I looked upon as an adventure but with some trepidation.  I had learned some valuable lessons on our trips thus far.  Kwasi has a “Mean Streets” sensibility on the road, and he knows when to stop when signaled from the roadside and when to pass by without braking.

I also wanted to know in more detail about his wife’s illness.  He was fairly convinced, perhaps by his brother, that someone had gotten a hold of some of the wife’s hair clippings — remember she is a hairdresser — and was using them to perform “juju” on her.  Suzy, who is a devout Baha’i and decries superstitions of all kinds, promptly informed him that there is NO “Juju.”   But I do not think he was convinced.  She advised him to see his parish priest to get some perspective (Kwame is a Catholic and member of his church choir).  I thought this was good advice whether the local priest exploits the “Juju” idea or not.

I suggested that he obtain and bring to me receipts for the items that she was charged for in the hospital.  In that way, I could figure out what the doctors there were doing and maybe have a better idea of what was wrong with her.  I assured him that, if his wife did not get better, we would bring her to Komfo Anokye Hospital in Kumasi and have the University doctors see her there.

Thankfully, things turned out well.  Kwame returned on Friday night.  His wife was better.  He paid the hospital bills and gave the rest of the money to his “sister” who is looking after the children in his wife’s absence.  I know that he did not want me to drive myself to Kumasi, but I also feel certain that he was comfortable with the way things were left in his village.

He did bring back the hospital receipts for me to look at: 20 cedis for “admit to the hospital”, 10 cedis for “medicine”, 10 cedis for “laboratory tests”, 20 cedis for “scan.”  So . . . completely useless.  But as long as she was better, I was not going to press the issue any further.  I might learn more than I want to know or need to know at this point.

Kwame also returned with a box of oil filters and a new air filter for the car that we are leasing.  He apparently did not spend any of the money we gave him to purchase these items, and it was not apparent to me who paid for them, if anyone.  He claims that he just “had them.”  Perhaps it was his way of paying us back in kind.  I have not told him so, but I have no intention of deducting this 80 cedis from his salary at the end of the month as I have other cash advances he has asked for previously.

This entire experience brings up an interesting and touchy subject. Based on the local economy, Kwame, Joseph, and Agatha are well-compensated.  To what extent are Suzy and I responsible for the people who provide personal services to us, and what obligation do we have to their families?

I received some guidance on this from the Department Head I work with at KNUST.  We were discussing neighborhoods, and I commented that all of the houses in my neighborhood, completed and half-built, were enormous.  Nobody was building a bungalow for two, or even a four-bedroom house.  The Department Head pointed out the houses were often constructed with separate “apartment” areas internally to accommodate extended families under the same roof.  This was particularly true of Asante families in which kinship obligations take an interesting, oblique turn.  When an Asante King dies, his son does not inherit the throne.  His nephew does.  Nephews and nieces, aunts and uncles, are very important in this culture.  Uncles may be expected to provide material and educational support to their nieces and nephews, even sometimes to the exclusion of their own children, who are hopefully someone else’s nephews or nieces.  A family that can afford to build a house may design it to accommodate nephews and nieces as well as children.  This is the tradition.  But it is changing, the Department Head informed me, as Ghanaians are becoming more Westernized and more focused on the nuclear family.  His own wife and high-school age children are living abroad, where they have access to the best schools, and return home only for holidays and the summer break.  So, the Department Head, an already accomplished academic, lives alone with his caretaker, and spends his evenings working on another advanced degree.

All of the houses in my neighborhood, whether finished or not, are occupied.  If it has a roof, people are living in it.  And here is how this happens: future homeowners here do not buy their homes; there is no widely available mortgage system to permit this.  So, those with means buy land and build a house.  They invest in the construction as their fortunes allow, and thus, the process of building a home is expected to take several years.  During that time, it is customary to have someone living in the house, keeping an eye on the property and protecting the building materials from petty thieves.  The Department Head said it took 7-8 years to build his current home.  The man who is his caretaker now and currently lives in the “boy’s quarters” on his property, approached him early in the building process and asked if he could live in the unfinished property.  When the house was completed, he was hired as the caretaker, although this is not necessarily the rule.  Sometimes when houses are completed, the temporary residents are asked to make other arrangements, and they become temporary residents in some other unfinished house.

Fairly affluent and living alone in a large house, I can see how the Department Head could become very dependent on his caretaker and the caretaker’s family.  They provide the Department Head with real security in his dwelling.  And the Caretaker is certainly dependent on the Department Head.  Were he not so employed, what else could he do?  And the Department Head is generous with him.  School fees are paid, and emergencies are managed.  At Christmas, there is a bonus, so that there are some comforts as well as necessities.

Mutual dependency.  It seems to be the African way.  It is what prevents this impoverished continent from imploding.  The three people in our employ are loyal and dependable.  Although we like to consider ourselves self-actualized, we need them.  I have resolved to make sure that are all enrolled in the National Health Insurance Scheme, that their children’s school fees are paid, and that they get an extra salary by the 15th of December.

Note:
To regular readers of this blog (if there are any), I apologize for the lack of images lately.  My snapshot camera is dead, and my video camera is now also acting up and creating grey bands across the images when I try to play them back.  I must resort to my computer webcam to take pictures.  Here are three new ones, unrelated to today’s entry.  The images show cocoa trees with pods growing on the sides of them.  A friend of Suzy’s is showing us where chocolate comes from.  He is holding two halves of a cocoa pod that he cracked open.  Inside are seeds separated by a sticky white, wet substance that is sweet to taste.  The seeds themselves, the source of cocoa, are very bitter to bite into, but there is a subtle taste of chocolate there also.  Normally, the seeds are fermented and then dried before shipping out to make chocolate.  The last picture has nothing to do with cocoa.  It is a portrait of a student from KNUST that just came out nicely. To me, this picture may say more about Africa than anything I have written.

Ghanaians have African names, like Kwame or Kofi, that are vaguely familiar to most Americans, or they may have European — usually biblical — names.  Often, they have both and use one or the other depending on the situation.  There are seven common male names and seven common female names, one for each day of the week.  And yes, this name is determined by the weekday of your birth.   So, the first President of Ghana, Kwame Nkrumah, was born on a Saturday.  My driver, Kwame, was also born on Saturday, as was I.  Had I been born here instead of Mississippi, I would also be Kwame.  I have not yet watched enough television in Ghana to know whether the local writers have yet recognized the comic potential of this tradition.  I personally know a man named Kofi (Friday) who has four brothers who were all born on Friday and are therefore all, also named Kofi.  There is a tradition to deal with this confusing circumstance also.  Everyone with sameday siblings gets a number to go with their name as an added identifier.  The five Friday brothers I mentioned have one sister.  To me, this sounds like a pilot for a weekly 30-minute TV program, “My Five Kofis.”  Shakespeare’s “Comedy of Errors” meets “The Brady Bunch” meets “Roots.”  Mistaken and switched identities, misunderstandings abounding – “Oh, when you said ‘give the yams to Kofi,’ I thought you meant Kofi 2.  But I gave them to Kofi 4, and he ate them!  What a silly mistake I have made!”  The episodes would write themselves.

And sometimes, as generations pass, the numerical suffixes may also become names.  Sometimes they are eventually used as the equivalent of a family name.   I personally know a man who introduces himself as “en-syen” (six), and I also know an “an-wah-tchree” (eight).  And the number four, which is pronounced  “eh-nine” in the Akan languages (including Twi) is spelled Annan.  So our former UN Secretary General was born on Friday and was himself a number four, or else one of his ancestors was.

Lest I leave the impression that I have the naming protocols all worked out, let me hasten to add that all Ghanaian names are not numbers or days of the week.  The cultures here are much more complicated than that.  There are a lot of common family names in Ghana the significance of which remain a mystery to me.  One of them, however, I learned in the kitchen, while Agatha was preparing an okra stew to be eaten with Banku (corn and cassava stiff porridge).  An okra pod, or okra in general, is “oh-kru”.  But more than one okra pod are “nkrumah.”  And so I am back again to the First President of Ghana, another political figure whose family name conjures up food.  Move over Claude Pepper, Felix Frankfurter, and Bob Dole!

I have eaten the standard Ghanaian foods served in several chop bars and restaurants in both Kumasi and Accra, and I have concluded that either Agatha is an exceptionally good cook, or you cannot get the equivalent of home cooking, or better, in a restaurant.  Recently she offered to prepare her Ghanaian repertoire for Suzy and me.  How could we possibly decline such an offer? It is a win-win situation; we get great food, and she makes enough to feed Joseph and Kwame and some to take home also.  On days when Agatha cooks, she and Suzy walk to the neighborhood marketplace in Kotei together or drive to the Kejetia Open Market in downtown Kumasi to purchase the needed ingredients.  Then they return to the kitchen where Suzy and I get to observe the magic happening.  It is essential, Agatha believes, to get down on the floor to have the proper leverage to crush the peppers in a mortar and pestle.  Okra must be grated into fine pieces before it is added to the stew.  And banku must be stirred over a charcoal fire outside (not a gas stove) using a 4-foot long spatula, until it is sturdy enough to wrap in plastic bags for individual servings or to be refrigerated.

Meals for ordinary working Africans are not recreational events as they are for us.  Traditionally, when one sits down to eat, the object is not necessarily to savor the subtlety of the sauces or to appreciate the virtuosity of the chef.  Instead, the primary goal is to turn an empty stomach into a full one with ingredients that will endure through the day and the night.  This was true in Chad and Cameroun when Suzy and I lived there 30 years ago, and it is true to some extent in Ghana today.  Africans eat to power their bodies when they are hungry, not as we do, to satisfy a craving.  As a result, Kwame and Joseph, who are both in their 40s, are as buff as any Santa Monica lifeguard.  And I cannot imagine that either has any idea what it means to be on a diet.  This is part of the reason why Ghanaians are such attractive people.  They are, with few exceptions, lean.

Thirty years ago in Central Africa, most people were eating the same food every day.  In each location, there was a preferred starch, which was pounded into flour and then boiled as a porridge until it assumed a semisolid state.  It was then shaped into a large lump from which smaller lumps could be teased away with the fingers, dipped into a lubricant sauce (usually well-peppered) and swallowed.  When the preferred starch was unavailable or unobtainable, then one switched to the next acceptable foodstuff.  But the meal is the starch.  You eat “millet,” or you eat “manioc,” or “yam,” or “corn.”  If there is a chunk of goatmeat in the sauce, that is a bonus, but it is basically part of the lubricant.

I find that Ghanaian food is more varied and creative than what I have just described. Whether it is a consequence of the passage of time or a product of a more wordly culture, I do not know.  The basic meal is similar to those that I have already described.  The starch occupies the main plate with a sauce on the side (as with banku), or it is placed in the center of a bowl of “soup” (as with fufu).  And the porridges are mixtures of foods – corn mixed with cassava, or boiled cassava and boiled plantain pounded together after cooking (i.e., fufu).   And although eating this food is a quick path to alimentary completeness, one also experiences a certain intimacy with the dish when you get to shape the starchy pudding with the fingers, dip and scoop up the peppery sauce, and swallow the bolus with a minimum of mastication.  You can taste and smell it for certain, but you can also touch it and handle it — an experience that you cannot even begin to approximate with a meatloaf and gravy (at least in the better American homes).   I cannot even imagine what it would be like to eat fufu without using the hand.  It is designed to go from the hand to the stomach in one continuous sweep, and it would be anathema taken in any other way — as inappropriate as using a knife and fork to eat an ice cream cone.

Agatha pays more attention to the flavor of the food than I would have expected.  She uses Maggi shrimp cubes for certain purposes and Royco shrimp cubes for others.  She seasons dishes with unexpected spices, like freshly grated nutmeg, tumeric, and curry.  And she buys only a certain genre of red palm oil.  Perhaps there is an culinary evolution in progress.  People in Ghana do not have to eat just anything, and their preferences and tastes are cultivated.  There are several Ghanaian dishes that do not necessarily involve the hands – Red-red (spicy red beans with plantains fried in red palm oil on the side) and Joloff rice (cooked in a sauce with tomatoes, onions, peppers, and various mysterious flavorings).  Both are usually accompanied by some protein source – chicken, fish, etc.  Tonight, Agatha is serving up Joloff rice, and I am expecting another revelation.  And I am imaging Agatha, who speaks maybe a half-dozen words of English and has never left Ghana, as a successful restauranteur in Ann Arbor.  I know people there who would line up to eat at her establishment.  “Sorry, it a Saturday night, and we don’t have anything available until 10:45, but you are welcome to sit at the bar and drink some fresh cocoanut water.”

Although there is more appreciation of the sensory aspects of eating than I have seen elsewhere in Africa, there is also something else of a more insidious nature happening here as well.  It comes with the growth of the middle class, flattening of the population (to use Thomas Friedman’s term), and globalization of the economy. Chinese food, pizza, burgers, and the usual dreck that we eat in the Civilized North are now here to stay.  And what a surprise!  Ghanaians are now expressing concern about obesity, and every year, the hospital has more diabetic patients to cope with.  Fortunately, for reasons that I do not understand, tobacco has not established a beachhead here.  No one smokes.  In fact, the thought of puffing away on a Romeo & Juliet Churchill, a past-time that I found exceedingly pleasant in the privacy of my hot-tub at home, seems nauseating here when I consider that for the price of one fine cigar, a family of six could eat for a week.

I do not wish to leave the impression that either the Julia Child or the Ronald McDonald philosophy is taking hold here.  While there is no starvation, many people are living hand-to-mouth in the figurative, rather than the literal, sense.  They are living on a diet of their preferred starch staple made at home or bought from the market, and it is not sophisticated, but it is cheap.  And thankfully, the World Financial Crisis is unlikely to impact the availability or price of these comestibles produced from backyard gardens or subsistence farms.  I see cassava and plantains growing like weeds everywhere, and thankfully, they will be here even after Wall Street collapses.

Yesterday was Election Day in the United States.  My vote was cast two weeks ago on a write-in ballot at the Embassy in Accra.  I have no idea if it was counted, but I was pleased with the outcome in any case.  This morning, I lectured the medical students again for two hours.  There was a lot of interest in my reaction, and I realized that the students knew much more about what had happened in the previous 24 hours than I did.  They have radios and TVs.  I do not.  Early this morning, the internet was jammed, so I learned the outcome of the election when I heard a snippet of the victory speech, eavesdropping on my next-door neighbor’s radio (only a few meters from my bathroom window).  I then received two congratulatory text messages on my cell phone – one from a student and one from a colleague.  I had given them both Obama campaign buttons.

I am old enough to remember the national mood surrounding the election of John Kennedy in 1960, and this is reminiscent.  I do not know whether to expect another Camelot – probably not – but tonight I was finally able to download Obama’s victory speech from ABC News, and for me, it had the inspirational value and impact of a Kennedy speech.  Whatever one may think about the man as a politician, there is little doubt about his ability to keep an international audience enrapt.

An interesting note: if you pronounce the President-Elect’s name as “Oh-beh-ma” with an upward inflection on the second syllable, it means “he will give” in Twi.  I wonder if this coincidence has influenced the man’s popularity here.

The School of Medical Sciences (SMS)

I have mentioned the KNUST Medical School frequently in this blog.  Below are a few pictures that I took with Goggle Earth and with my computer’s video camera.  (My snapshot camera is FUBAR, so I have to resort to extremes to obtain any images at all.)  As seen from a satellite, the medical school consists of a series of parallel, long rectangular buildings separated by well-tended lawns and connected by a perpendicular breezeway.  Some students hang out in the library, but the breezeway is also a popular place for study groups to meet before and after classes (see photo).  My office is in the last building in the back, so the view from the window in my lab-office reminds me where I am.  There is a rooster back there who can be annoying.

The entire medical school is on a single floor, unlike one of the College of Science buildings next door (see photo).  This morning before beginning my lectures, I blurted out “smile!” and took a picture of the class with the computer.  Looking at the result, I realized for the first time that women have occupied all of the seats in the front of the class.  I do not know the significance of this uneven distribution of genders, but I will ask.

The last two pictures in this collection of photos are satellite images showing our house in Kotei New Site and a zoomed-out view showing the relationship of the house to the University.  Downtown Kumasi is several miles to the left.  The thin blue line (added by me and not visible from orbit) traces the circuitous route that I follow to get to work in the car.  The thin red line shows a route that is unpaved, but finished except for a short gap in the middle that forms a dirt path through high grass and over a tiny stream.  When it is finished, my trip to work will be a moderate walk, instead of a car ride.  I have been down to the stream to investigate and found that I could easily use this route now.  However, I have been advised by more than one colleague not to do this.  They fear that muggers might watch my commuting behavior for a few days and then lay in wait for me to snatch my laptop or the 10 cedis in my pocket.  This is a serious disadvantage of being advantaged, and it is a potential problem even if you happen to be an advantaged Ghanaian.  But if you are an “obruni” like me, everyone knows you are carrying something of value.  Fortunately, 99.9% of Ghanaians are honest, God-fearing people.  I take advice like this seriously even though I have never had a moment of discomfort here with anyone.

Driving home this evening, as we crawled over the potholes on the dirt road that leads to the house, we were passed by a car going in the other direction.  The driver of the vehicle, a complete stranger, saw me in passenger seat of my car and called over through his open window, “O-bama!”  A statement of solidarity.

A Note to Self About Lunch

N.B. Even if you are hungry, don’t do it.  There is no such thing as a light lunch here.  I saw that the faculty order from the SMS Canteen or the local chop bar at mid-day and eat in their offices.  So last week, I thought I would do the same.  I gave Peter, the departmental go-fer, 2 cedis, and he returned with a platter of food that could feed a family of four—a large pile of Jollof Rice, spaghetti with meat sauce, a quarter chicken, mixed vegetables, and a salad with dressing.

When you are served food here, you eat it.  It is disrespectful to throw it away.  And anyway, there are no trash cans.  Of course, I draw the line at lettuce.  The lettuce was sent back, but I consumed the rest, and promptly went into an afternoon hyperlipemic lull for the next 3 hours while I digested the red palm oil.  Truthfully, it was delicious as well as filling.  But I don’t know how the locals stay awake.  Maybe they don’t.

I asked the Department Head about this daily engorgement.  His response was, “This is the standard.”  So, I remained cautious about ordering lunch here– until today.  Today, I thought I would try again and try to set some limits.  This time I stressed to Peter that I was interested in a small lunch.  He informed me that fufu was on the menu.  Would that do?  Yes, it would because I like fufu, but I already know from experience that fufu (a sticky paste made of cassava and plantains and submerged in a soup) is a deadly mid-day meal from the sleep-inducing, heavy-lump-in-the-epigastrium perspective.  So, I said, “Sure, but please, just half a portion.  Just for one cedi.”  Then I gave him 2 cedis so that he would also bring a bottle of water.

Ten minutes later, my lunch arrived.  The fufu was finished, I was told.  So, acting on his own initiative, Peter ordered Jollof Rice for me instead.  But it was 2 cedis, and it was served with a shish-kebab, vegetables, noodles, and a salad, all on a plate the size of a satellite dish.  Oh, yeah.  And I owed him 20 pesewas (20 cents) more for the water.  And yet another afternoon sacrificed to lunch.  This has to stop.

Porcupines, Professionals, and Jeremiah of Kotei

Joseph, our caretaker, has a TV back in his room.  Some evenings, he and Kwame gather back there to watch European soccer matches.  I know this because the noise they make during the match carries all over the neighborhood.

Last Saturday, I tried listening to one of the internet radio feeds from the Michigan Football game.  I do miss those Saturday outings, even though this year is turning out to be a good one to be in absentia.  Well, the internet bandwidth could not support the gravitas of a Michigan football game, so I was forced to follow along on the ESPN Gamecast, a play-by-play process that has all of the excitement of waiting for water to boil and none of the fun.  I did not make any noise, and Michigan lost to boot.

So, the next day, I felt a primordial need to fill the sports vacuum with something.  I remembered having passed by the stadium in Kumasi, and I had heard in Accra that professional soccer games were played on Sundays.  So, knowing that Joseph was a fan, I asked whether there would be a soccer match in town.  In fact, that very day, the local team, Kumasi Asante Kotoko was to play a “cup final” against the Dansoman Liberty Professionals (one of the teams from Accra).  Tickets, I was told, were two, three, and four cedis – quite a bargain for my pocketbook, but a large chunk of change for someone drawing the salary that we pay Joseph.  So, knowing that both Joseph and Kwame were soccerheads, I asked them if they wanted to go with Suzy and me (my treat) to see the match.  Well, of course they wanted to go.  Joseph would arrange for someone to watch over the house, and the four of us should depart at 2:30 to get there in time for the customary 3:30 kick-off.

As usual, there was plenty of traffic approaching the stadium on the Kumasi-Accra Road, and it took us about half an hour to get there.  Nevertheless, when we arrived at the stadium at around 3:00pm, the parking lots were empty.  And when we bought our tickets and entered the stands, I was surprised to find the 45,000 seat facility was nearly empty.

Three cedis allowed us to enter between the endlines on the sunny side of the stadium, and to gaze across the field at the elite, who for a premium price were sitting under the shade of the press box.  We found excellent seats on our side of the field on what would have been the 40 yardline at Michigan Stadium, and we waited for something to happen.

The Jumbotron was replaying highlights of British League games, between which an announcer was hyping the local game in Twi.  It was getting hot in the sun, so we bought an Asante Kotoko official team umbrella from a hawker to create some shade where we sat.  I figured that the umbrella would serve double duty, because there was already a major downpour in progress and plainly visible over Central Kumasi, a few miles behind the elite spectators.  The umbrella had the team logo on it with the team motto, “Kum apem a, apem beba.”  Central to the team logo is a porcupine-like creature, the kotoko.  So, the team name could theoretically be translated as, “Asante porcupines.”  Of course, all of the players are not ethnically Asante any more than the players for Notre Dame Football are all Irish.  But the Asante are the predominant ethnic group in Kumasi, and the current Asante King lives here, so Asante Porcupines seems appropriate, political correctness aside.

I had already heard the origin of the team motto from Dr. GK before I left Ann Arbor.  As he related the story, at some indefinite time in the past, an Asante King sent a thousand (“apem”) of his people to live in an unsettled area between his tribe and another.  This did not sit well with the leader of the neighboring tribe.  In fact, he was so upset that he ordered that all of the settlers be slaughtered, except one.  The one survivor was to be sent back to the Asante King to report on the havoc.  After listening the survivor’s account, the Asante King instructed him to go back to  the neighboring chief to be killed also and to bring the message, “Kum apem a, apem beba” (“[you] kill a thousand, and a thousand will come”).  A firm statement of toughness and tenacity, expressing a bravado that puts to shame Schwartzenegger’s “I’ll be back!” or Eastwood’s “Go ahead. Make my day!”

While roasting in the sun myself, I expressed an interest in what appeared to be peanuts wrapped in neat plastic bundles on the head of a lady stadium hawker.  The stranger sitting next to Suzy informed me that these were “tiger nuts,” not peanuts at all, some other genre of local nosheray with a hard crust and a sweet “milk” in the center.  So naturally, I had to try some of those.  The stranger interceded with the hawker on my behalf and purchased a packet.  Up close, tiger nuts look hard, black, and shriveled, not really a nut at all but more like a seed that grows on a tree or bush.  When chewed, there is a dampness in the interior with a pleasant, if not sweet, taste.  I gave some to the stranger and also distributed some to Suzy, Joseph and Kwame.  Kwame insisted that they were to be chewed to a pulp and then spit out, but the stranger affirmed that they could be safely eaten.  Later, back at SMS, I asked Peter if he thought it was okay to eat tiger nuts.  He said that some people prefer to spit out the pulp, because the local folklore is that eating the pulp produces erections.  Peter is no fool; he doubted the veracity of this common belief.  And I ate quite a few and did not experience a Viagra effect.  So, for the sake of public hygiene, I decided to eat them all.  I needed the dietary fiber anyway.

I assumed when the clock hit 4:00pm and there were no soccer players to be seen, that starting late at Ghanaian soccer matches was de rigeur.  However, I was wrong again.  They were not late.  We were early.  To highlight the importance of this particular match, the “cup final” was scheduled to start at 5:00pm and to be played under the lights.  No one had informed Joseph about this.

Eventually, the stadium did fill up to about 1/2 to 2/3 capacity.  There were probably 25,000 in attendance; 24,998 Ghanaians and 2 others (Suzy and I).  The players arrived in busses and went through their warm-up routines on the field.  They were as skilled as one would expect professional athletes to be.  I watched two Kotoko players 10 yards apart passing the ball back and forth without touching the ground and using only their feet, chest, and heads.  This is probably a routine exercise for a professional soccer player, but quite impressive to a novice soccer spectator like me.

The game began without raising the flag or playing the Ghana national anthem.  Kwame pointed out that it was not an international game; both teams were from Ghana.  So what was the point of a gratuitous show of patriotism?  Makes sense.

Once the action started, the game looked like any professional soccer game I have ever seen.  Kotoko seemed to dominate the entire first half with numerous shots on goal but no points.   Liberty scored an opportunistic goal about half-way through the second half, and Kotoko just could not answer in spite of multiple scoring opportunities.  They lost 1-0.   Kwame had a two-part explanation for this: 1) the woman who was the main referee was not up to the task of officiating a game of this importance; and 2) the coach of Liberty was a “bad” man (i.e., he made use of voodoo to win games).  I had a much simpler explanation: Liberty scored and Kotoko did not.

The comportment of the fans was about the same as one would expect at Michigan Stadium.   There was a concentration of Liberty fans sitting together at about the 20 yard line to our left.  They brought their own quasi-band with them, and they were loud and celebratory, but I didn’t see any trouble.  There were other Liberty fans mixed in with the Kotoko fans.  There was a fellow two rows behind us who started an argument and threatened fisticuffs with an opposing fan, but the clearer heads held him back and most of the rest of the crowd told him to sit down, which he eventually did.  When Liberty scored in the second half, a middle-aged man dressed in Muslim-style clothing, went into a personal celebration that involved jumping up and down in the aisles – a harmless form of regression also often witnessed in Michigan Stadium.

After the whistle, getting out of the stadium was not as easy as getting in.  There was no crowd control.  So, it was something of a lesser miracle that the four of us were able to get to the car without being run down by exiting vehicles, and perhaps an even greater miracle that we were able to drive to the main road again without running someone else down with our car.  Kwame is a professional Ghanaian driver and therefore not particularly sensitive to pedestrian rights.

We got home at about 9:00pm.  We were weary, but we all agreed that it was a successful and entertaining afternoon and evening, which I thought ended when we went to sleep.  Not so.  At about 5:00am, we were awakened by the voice of a man in the street, speaking loudly and lyrically in Twi.  I could not understand what he was saying, but it sounded like a supplication.  Earlier in the day, I had heard a minor domestic squabble across the street.  I imagined that the man was locked out of the house and was pleading with his wife to let him in.  The monologue went on for about 15 minutes and then ended abruptly.  I went back to sleep.

The next morning, we asked Joseph if he had heard the nocturnal visitor.  He had.  It was not the resolution (or attempted resolution) of a domestic argument as I had thought.  It was a man preaching to the neighborhood; spreading God’s Good News, at 5:00am.  Apparently, this is not an uncommon event here in Ghana, where religiosity is never inappropriate, anywhere, anytime, and where every neighborhood has its Jeremiah.  Now that I know what this was about, I am looking forward to his return. . . but not too often.