A Generational Traveling Sandwich

On my right - Deck. An adorable 19 year old Dutch boy embarking on a life-altering 6-month solo journey through East and Southern Africa and Asia. Dressed in typically stylish Euro fashion of well-fitting jeans, grey hoody, grey striped scarf and gorgeous Asics kicks (soon to be browned by Africa's rich earth) and with a mop of curly hair and endearing slight stutter, Deck shares with me his excitement over his first trip to Africa and beyond before returning to Amsterdam to start at the University. During our stop over from Amsterdam to Dar es Salaam in Kilimanjaro airport to let off passengers (90% of the flight) coming for safaris and Mt Kilimanjaro climbs, Deck is a child on Christmas morning - straining his eyes as he looks out the airplane window at the airport terminal ("There are only two other planes here!") and, like a child unwrapping the corner of a Christmas gift to get a peek at what is to come, confesses that he wants desperately to get off the plane just to see his first real glimpse of AFRICA.

On my left - Sidell. Barely 5-feet tall with a Nike hooded sweatshirt and shoes maybe size 4, she'll be turning 80 next month. Originally from New York and now residing in North Carolina, Sidell, who takes a wheel chair to and from the airplane but still able to shuffle around on her own, is disembarking at Kilimanjaro to begin a 3-week safari tour. She says she does a big trip like this every couple of years. Her favorite trip so far was two years ago when she did a tour of Fiji. I assume she is a widow, though I never ask her if she has children or what work she may have done.

I am flying to Tanzania in a generational sandwich that I can't help but compare to the new Jim Carrey's A Christmas Carol preview I keep seeing at the theatre: Deck is the (adorable, male version of) ghost of Drew's travel past, I am the (very much alive, thank you) present traveling Drew, and Sidell is the ghost (also very much alive) of an amazing travel future yet to come.

Deck reminds me so much of my own experience in terms of the sheer excitement and glee of beginning a long solo journey at a time of rapid personal growth, knowing it will be life changing but having no idea of how and to what extent. He infects me with the excitement of arriving in a new place, and his blind energy and youthful naivety remind me that I am long past the age of 19, and while I have lost some of the naivete, I have not yet gained the jaded perspective of travel that seems to infect people who travel for work (this being my first work travel).

Sidell is everything I hope to be at the age (almost) of 80: of good mind and body; able to do things for myself but not afraid to ask someone to help open the darn plastic cutlery pouch; reading mystery novels; and traveling the world fearlessly. I always feel that I should grasp every opportunity to travel I can, since I cannot guarantee it in the future. It would be the most comforting and satisfying psychic reading ever if a Madame Crystal were to tell me I'd be traveling well into my 70's.

Today's generational sandwich has left me fully invigorated - wanting to travel more than ever (even though I am right now!) and greatly looking forward to the next 6 days in Tanzania.

Welcome to Drew's Clues

Welcome! You’ve found yourself on Drew’s newly compiled and revamped blog. I realized that if I continue to create new blogs for every trip I take you and I will never be able to keep track of where I am and what I am doing. So this will be an ongoing blog, resembling the state of our river systems in today’s global climate: sometimes a gushing forth of muddy musings, sometimes a stream of consciousness, sometimes a mere trickle of traveling trials and tribulations, and on occasion, a drought due to being sequestered in my cubicle in Atlanta. It also has on it the original blogs from my research in Ghana on maternal death and disability at a large hospital in Kumasi, Ghana over the summer of 2008 as a Minority Health in Research and Training fellow.

This blog is a combination of public health geek statistics and inquiry acquired during my master’s in Public Health at the University of Michigan, Ann Arbor, and my continuation in public health as an ASPH/CDC Allen Rosenfeld Global Health Fellow. This blog also contains much more personal reflections on the nature of travel (often as a solo female), and experiencing the world.

Drew's Clues represents my continuing quest to better understand myself by understanding the global world I inhabit. Each time I travel I find myself clued into something new and bigger than myself - be it the state of maternal health in Ghana or the religious heterogeneity in Tunisia. I truly believe there is no better way to understand who we are and the synergies that exist between our lives and the lives of men, women and children around the world - especially in terms of public health - than to travel.

GHANA

What exactly is Drew Doing in Ghana?
Maternal death represents the greatest disparity between developed and developing countries. Almost all maternal deaths (95%) occur in Africa and. In her lifetime, a woman in sub-Saharan Africa faces a 1 in 16 risk of dying during pregnancy or childbirth as compared to a 1 in 2800 risk in countries such as the U.S. Ghana, an estimated 56% of mothers give birth without the assistance of a skilled birth attendant and 214 women die for every 100,000 women who give birth – compared to 8 per 100,000 in developed countries such as the U.S. Additionally, the life time risk of a woman dying while pregnant or giving birth is 1 in 35 in Ghana. Okay, enough with the grad school statistics, but they are important in giving an idea of why I am going to Ghana and the importance of this research.

I’m going to Ghana! I’ve been trying to get to Africa for what feels like my whole life. And I couldn’t be more excited to be going to Ghana to research my passion – global reproductive health. I’ll be spending ten weeks collecting data at Komfo Anokye Teaching Hospital in Kumasi– the second largest city in Ghana – with four other students from the University of Michigan, Ann Arbor. This is my summer internship for my master's degree in public health. We will be recording all of the women who come to the hospital to give birth. But what we are really interested in is the women who come in with serious labor complications. We will conduct interviews with these women to try and identify what may have led to the seriousness of the complications. For instance, some women who live outside of Kumasi may have had to walk 10-20 kilometers to reach our hospital after they went into labor. Our goal is to collect enough interviews to create a picture of the main risk factors that lead to labor complications at this hospital, so that a prevention program can be created to reduce the number of maternal deaths and disability associated with pregnancy and labor in Ghana.

After my ten weeks in Ghana, I will fly to Cairo for a ten day traveling adventure. I had wanted to go visit Tanzania or Kenya, but it is incredibly expensive to fly even within Africa. But I got a great deal on a flight to Egypt, and am thrilled to see the Pyramids, the Sphinx, and possibly float down the Nile.

Africa, I've waited a long time to see you. Ready or not, here I come!

It's Ghanarific: Sweaty bills and mysterious rice baggies

I have arrived. Accra - the capital of Ghana - a sprawling, lush, bustling city during the rainy season. I have spent the past two nights at a hostel at the University of Ghana, and the days exploring the campus and touring Accra. The weather here brings back memories of Jamaica during it's rainy season - hot hot, humid humid, hot - with occasional heavy showers (though it hasn't actually rained yet). We're talking over 100 degrees Fahrenheit each day and 80-90% humidity. But I actually don't mind (except for my secret money belt fanny pack which holds in some rather unpleasant heat and moisture in my groinal area, making me feel quite sorry for the poor Ghanaian who must take my warm, moist Cedi (Ghanaian money)).

I head up to Kumasi today on a bus with the other U of M students. Besides the four of us who will be conducting research regarding maternal obstetric complications in the hospital, we have been joined by another U of M group of students (undergrads) who are also studying maternal mortality on a four week program and who will be staying with host families. So it has been interesting touring Ghana with such a big group. And by interesting I mean uncomfortable. I have found - through my study abroad program in Jamaica and to a lesser extent in Korea - that it is always better to be a traveler or tourist by myself or with one other person. Groups of obvious tourist/travelers, especially in countries where there are few white people, are such an eye sore, and draw so much (often unwanted) attention, making me feel quite uncomfortable. I much prefer to be on my own, where I can interact with locals better.

However, despite my previous experience being on my own in other countries, I must always start out a newbie, getting a feel for the culture and learning how to go about simple tasks such as getting lunch. For instance, yesterday when we were dropped off on the main busy street to find ourselves lunch and look around, I was DETERMINED not to eat at Papaye, the "Burger King/ McDonald's"-esque fast food chain that all the other students made a beeline for. For I, having traveled around the world and being oh-so-knowledgeable, was going to order street food like the locals and the ex-pats who live here. So I found a popular street stall (always go for a popular one so you know that it at least sits well with the locals) and attempted to order the one dish I knew called Jolof rice (rice cooked in a tomato-based soup). Of course, they were out, and I ended up with a plastic baggy full of plain rice with a mysterious brown sauce. I had no idea if I was supposed to eat it with my hands or if there were utensils around, because all of the locals ordered and took their baggies with them. So I paid and walked away, pretending I knew exactly what I had just gotten and how I should properly consume it (turns out they eat it with their hand, which I'm glad I didn't given how filthy mine were).....and made a beeline for Papaye, for an expensive but delicious grilled fish and Jolof rice...WITH utensils, thank you very much.

And so it goes as I slowly get a feel for my new surroundings, adapting to the heat and constant sweat, and the new food and ways to consume it. West Africa is vibrant and alive, and I am excited to go to Kumasi where I will spend the remainder of my time (besides weekend excursions), exploring the largest open air market in West Africa, the food (I had Bunku last night- a large ball of play dough-like mashed cassava that you pinch off with your hand and dip in sauce- not so great) the countryside, the people, the language (Twi is the main spoken language after English in the Ashanti region where I'll be staying) and the culture.

Akwaaba - Welcome- to Ghana

Hospital Hel(l)thcare and Detective Drew's Data

The past two days my research team and I have been familiarizing ourselves at the Komfo Anoke Teaching Hospital here in Kumasi where we will be conducting our research the next ten weeks. The maternity wards where we will be spending our time are grossly different from those in the States or other developed countries. Our hospital delivers 40-50 babies each day, and the antenatal (before they give birth) and postnatal (after they give birth) wards are overflowing to the point that they often have two women per bed - the overflow rest on sheet-less mats on the floor. There is absolutely no privacy for these women, as people such as ourselves walk through the aisle and the hustle and bustle of the nurses and medical teams ebbs and flows somehow despite the ever-diminishing floor space. This is how it is, unless you have the privilege of affording the "VIP" labor ward that offers curtains, clean sheets, and a private delivery room.

In the delivery room, up to 10 women in their first stage of labor (before their cervix has dilated enough to begin delivery) wait in a tiny room with a bench, using buckets to relieve themselves as they wait to reach full dilation, at which point they will be transferred to one of eight side-by-side delivery beds where they will give birth without the assistance of any medication or drugs. As is cultural custom, they are urged by the nurses to refrain from making noise or screaming during delivery.

This is one of the top two hospitals in Ghana. Yet it remains understaffed, understocked with essential life-saving medical supplies, overburdened, and overcrowded. These are just a few of the reasons why my research task is so difficult and important: trying to locate all of the necessary information about each woman who comes in to deliver, and conduct interviews with those who have severe or life-threatening complications during delivery, is an exercise in detective work when patient records regularly go missing, women are transferred without notice to different wards, and the nurses are too overburdened to fully record all of the important information for each patient.
For instance, each of the three delivery wards (the regular, overcrowded one, the VIP one, and the surgical one) have an A&D book- Admission and Dispatch - that tracks each woman while she is there. They each have a delivery book as well that records information about the actual birth. There are also the individual patient records. And finally, the anesthesiologist in the surgery ward has his or her own book. Now, imagine a woman who is admitted to the regular ward and is having labor contractions. She is registered in the A&D book for that ward. One day later, it becomes apparent that she has pregnancy-induced diabetes and needs special care. So she is transferred to the "black room" - the ward for pregnant women with complications. So she is signed out of the first book and into the new ward's book. Then her family manages to come up with some quick cash to get her into the VIP ward for the best care. Now she has been signed out of the second ward, and has been admitted to the new VIP ward and is in its book. But then the doctors detect fetal distress and decide they need to perform an emergency c-section right away. So she goes down to the surgical ward (called the theater) and is recorded in that book, and has the emergency c-section and is recorded in the anesthesiologist's book, before being returned to the VIP ward with her new baby. So now, she has been admitted into three wards, discharged from two, and her delivery was officially recorded in the third (surgical ward). She is additionally in the anesthesiologist’s book, and has her own personal chart.

So the next day, when I come in and see there was a woman who had a complication and I go to try to find her, I must track her through each ward and book to find all of the information. This is especially complicated because not all of the proper information was recorded in each of the books. Rather, each of the books captures some of her information, and it is possible that even when combined they fail to capture the full picture of what happened, so I need to find her chart, only it has gone missing....and once I find all of that information, I still need to interview her. Now you begin to get the picture of what we are up against.....

There are many additional logistics to be covered before we can begin our research - most importantly the fact that we are still awaiting the final approval of the IRB ( the Institutional Review Board that must clear us for our research). It also includes securing interpreters for the interviews and finding an appropriate place that ensures privacy during the interview, practicing the interviews and the data entry, and meeting all of the appropriate contacts, nurses and doctors we will be working with.

PHEW! Needless to say the last couple of days have been intriguing, exciting and exhausting. I'm incredibly excited to begin the research, to continue picking up the local language (Twi), to learn how to get around using the tro-tros (the mini-vans that act as public transportation) and to finally have a place to stay. Our first place in Kumasi on Sunday night consisted of four cement walls, two bunk beds, and THAT"S IT - unless of course you count the bed bugs...two of the students who were less-than-thrilled opted to sleep on chairs for the night (LOL). So last night and tonight we are "living in luxury" at a very nice guest house our research director has been staying at while we wait for our next place to stay to be ready. We will move tomorrow to the medical students' guest house located right behind the hospital. But after two weeks we will move one more time to the newer quarters of the med student lodging where most of the international medical students are housed (it is currently full as school does not get out until the end of this month).

Such is the current state of affairs here in Kumasi, Ghana.
Detective Drew, signing off.

Musings on what this research is really all about.

One of the most difficult aspects of working here at the Komfo Anokye Teaching Hospital is witnessing the horrible conditions under which the doctors and nurses must work to ensure the health of laboring women and their infants, and the squalid conditions under which women give birth. It is not seeing a woman give birth on the floor of the ward, or the lack of sanitary instruments, or even hearing of the woman who died the previous night after she delivered a still born baby. Rather, what makes bearing witness to such events so trying for me is learning to deal with seeing such daily happenings, without becoming numb to their significance in the broader global context of countries that have versus countries that desperately need. As my directer of this research Dr. Anderson pointedly remarked before he headed back to the States this past weekend, "Don't forget the significance and implications of what you see here. When you see two women to a bed, or hold the maternal death registry in your hands and feel its weight, don't ever forget that it should not be this way - that this is unacceptable." And yet, how does one allow oneself to feel so indignant at what one sees, when day after day one witnesses it and it becomes "normal." It is an intense exercise in emotional and intellectual compatibility.

Today was a glimpse for me of what lies in store for me as I work here. This week we are piloting our research, practicing collecting data and interviewing patients before we officially begin next Monday. When we made our way down the stairs from the 5th floor labor ward for the "VIP" women to the first floor where the delivery ward and "dark room" (the room housing all post-delivery complications) are, we were greeted with a loud, rather chaotic scene. On the tiny landing between the stairs, the elevator and the entrance to the delivery ward were about 20 men and women milling about. The elevator door was open - but there was no elevator. Men were shouting loudly up and down the shaft, below the elevator was stuck due to power failure with a laboring patient inside. Meanwhile, just inside the doors to the delivery room, people were peering through the windows to the floor. Inside is a very small waiting room where women who have begun labor but are not yet fully enough dilated to be brought to the delivery table wait. And as we arrived and walked up to see what they were looking at, I saw a woman lying, slumped against the doors, giving birth on the cement floor. It was over in seconds, there were two nurses there, one of which quickly cut the umbilical cord and carried the baby to the delivery room. The other one attended the new mother, and pulled her to her feet about 2 minutes later to walk to the recovery room. The woman was naked, covered in blood, and watched by over ten pairs of eyes through the door. We waited around a few minutes to see if we'd be able to get inside the doors to find our data books, but upon seeing the large amount of blood on the floor left to be cleaned up, we decided it was time for lunch.

Later today I told one of my medical resident friends what we had seen, and he laughed gravely and said that it was very common for women to give birth on that floor, and that the elevator ride was never a sure thing.

Last night, a woman died after giving birth. Two students here from University of Michigan to observe the wards saw three infants pass away today, all from asphyxiation - a cause of death that would never happen in the States where every newborn has access to assisted breathing machines.

As I left the hospital this afternoon, I noted the 30+ women sitting and lying under the tree in front of the main hospital entrance. these are the women who have no friends or relatives in Kumasi with who to stay with as they wait for their family members to be seen for their various illnesses.

Witnessing today's events and knowing that they are in no way unusual makes me evermore sure that my research matters. The death of these women and newborns will not be forgotten - through our careful recordings of their delivery, determination, and sometimes death, our research will contribute to the reduction of obstetric complications in this and other hospitals in Ghana.

Ghanaian Soccer Fans: Testosterone and Stinky Pits

Soccer - or "football" as it is called in every other place in the world besides the States - is the national pastime here in Ghana. On our first full day here in Kumasi, we were walking to find a bank to exchange money. Everyone on the street had their radios turned to a station with a man talking so fast I thought it was an auctioneer. All of a sudden, the entire city erupted in a roar of victory, completely stunning me and the rest of the researchers. Kumasi had just beaten Accra- their arch enemies - in the Ghana premier league championships. We soon found out the game had been here in Kumasi, for shortly after as we driving back to our hostel we encountered thousands of fans running wildly in the streets, waving their shirts frantically, honking horns, and jumping up and down as they poured out of the stadium. This was my first introduction to the extent to which Ghanaians live and breathe football.

My second introduction occurred last night. It turns out that Ghanaians are nearly as passionate about the European leagues as they are about their Ghanaian ones. The talk of Ghana the past couple of days has centered around last night's match between Manchester United and Chelsea as they faced off in Moscow for the Champions League final. Since we arrived here, we have met and made friends with a number of medical students who will be coming to the University of Michigan this fall to do 6 weeks of rounds at our hospital. The guys made us promise to join them for the match at the medical school hostel, located close to our own hostel.

Now, in the States, I picture the TV viewing of championship matches as a time for eating drinking, and swearing at the TV. You know - chips and salsa, beer, pretzels, cheese, popcorn, swearing at the TV...unfortunately we found out that in Ghana they replace food and drink with sweat and B.O., although they still retain the foul language. We arrived to find ourselves in a small, stuffy dark room with approximately 60 guys and no women save us. The air was the most awful smell of testosterone, sweat (it is soo hot here, and I'm guessing few if any of the guys managed a shower between hospital rounds and the game...eeew!) and hoooribble B.O. We were packed into the room, and I thought I'd pass out from the lack of fresh air - thank god I didn't have any food I was hoping to eat!

I was cheering for Chelsea, but they were playing lousy and Man U wasn't looking much better. When each team scored, guys would jump up, tear off their shirts, run around the perimeter of the room and then jump over all the couches and chairs where everyone was sitting, screaming and pounding their chests and body-checking the guys cheering for the opposing team. By the time the game finished its double OT and went into shoot-out, I pretty much didn't care anymore who won or lost- I just wanted to shower! And of course, just as the first round of shootouts ended and Chelsea stepped up to take the first sudden death kick, one of the excited fans kicked out the electricity cord and the TV went off - by the time it came back on, Chelsea had missed and Man U were the victors.

The Man U fans screamed as they ran out of the room, the scent of testosterone trailing behind them and into the street. Meanwhile, I couldn't even count on both hands the number of Chelsea fans I saw crying, including our med school friends.

Needless to say, I don't think us girls will choose to watch the next big game at their hostel, our own has a much bigger screen and an OUTDOOR LOUNGE WITH PLENTY OF FRESH AIR. Oh, and beer, too.

The game reminded me of being in Seoul at the town hall square with 60,ooo other S. Korea fans watching the World Cup, only of course it was outside, and their was food drinks, and yes - plenty of swearing.

Nurse-Midwives: A Hazardous Occupation

Incentives, Pay and Brain Drain in the Health Care System. During my data collection rounds the other day, I happened to take a break in the nurse’s lounge with my translator Auntie Lydia and the head nurse for the labor ward, Auntie Mercy (we call everyone here auntie, uncle, sister etc). Auntie Lydia is one of our two translators, and is currently on leave from the labor ward here as a nurse-midwife. Auntie Mary, our other translator, just recently retired from her position here as head nurse-midwife of the antenatal ward. However, both of them have been working here on and off to help with the shortage of nurse midwives. As we sat, Auntie Lydia and I listened to Auntie Mercy tell of her difficulties in desperately trying to hire two more full-time midwives for the delivery ward. Currently, Komfo Anokye Teaching Hospital (KATH, where we work) is experiencing extreme shortages of staff, most notably among the nurse-midwives, who contribute far more throughout the maternal wards than the doctors. Many of the nurse-midwives have been taking double shifts to assist their coworkers when short of staff. Many of the newly-trained nurse-midwives being trained here leave immediately for district hospitals because the work load is lighter and the work incentives are better (KATH is famous for overworking and underpaying its staff). Lydia and Mercy talk about this new generation of nurses as being more concerned about making money and less about caring for their fellow Ghanaian sisters than the older generation of nurse-midwives. Lydia and Mercy refer to these younger nurses as the “computer generation” – one trained for money and new technology, and less for quality patient care. They explain that the older generation of nurse-midwives are very close friends, and so are willing to work double shifts to help each other when they are overburdened. In the past, nurse-midwives (okay, I’m shortening them to NM, this is getting tiring) were trained solely in the maternity ward. Today, NM-in-training spend three years doing rounds that include other departments in the hospital, including oncology, pediatrics, and even psychology. Mercy and Lydia think it is beneficial to have a more well-rounded NM, unfortunately it also means having to wait longer for potential new workers. Where as KATH doesn’t provide any work incentives such as reimbursement for the cost of transportation or providing free meals, district hospitals usually do – accounting for the majority of new NMs wanting to work there. While both are government run, District hospitals have much more financial discretion because they employ so few workers, and are therefore able to provide meals and money for transportation, as well as a yearly bonus. For instance, according to Mercy, last year one of the nearby district hospitals gave each worker a bonus of 35 cedi, while here at KATH each received just 8 cedi (one cedi is approx. $1.01). Brain drain to other African countries, especially South Africa, is extensive. However, with the recent riots in S. Africa over international workers and the deaths of 7 Ghanaians and the burning and pillaging of many of their shops, Mercy and Lydia, are hopeful their Ghanaian workers will return. They note that Ghana is a stable, peaceful country relative to other African countries, and they can’t understand why their fellow Ghanaians leave to work elsewhere- even if the pay is better. They believe that Ghanaians can plan out and budget their earnings and should live according to their means and not what fancy accessories they see others having. “Occupational Hazards”: Putting oneself in danger to help others. As Kumasi expands, many nurses are living farther away from KATH – some as much as 40 km away. And for these women, many of them must walk 1-2 km from their homes to the nearest tro-tro stop (Ghana’s form of public transportation - small mini vans that pack in 20 people). If they work in the morning at 7am, they must leave up to 3 hours ahead of time, and add an hour if it is raining. These long distances and the transportation hubs involved put these women at a much greater risk of being attacked, and such dangers are considered “occupational hazards” by Lydia and Mercy. The attacks usually involve robbing for phones (which use SIM cards and so are easy to immediately sell off) and money, but have become increasingly violent to include rape and murder. Two days ago, the TV reported on a pregnant nurse-midwife who was returning home at night from her shift at the main teaching hospital in Accra when she was attacked with a machete while waiting for the tro-tro, killing her and her unborn child. Mercy and Lydia argue that in the old days, it was the district hospitals in and near the mining towns that were the most dangerous to work at. Now, they assert that all hospitals are somewhat dangerous to work at, including KATH. They believe this change began in 1983 when the Nigerian government decided they were too many foreign workers, and deported them all (including 10 million Ghanaians of every profession) back to their home countries. This massive influx of returning Ghanaians fostered high unemployment, housing crunches, and massive burdens on the health care system, all of which led to an increase in violent crime. Since 2001, KATH has been transporting a number of its staff on new hospital-owned buses. This has reduced the chance of these workers being attacked. However, there are not enough of these buses for all of the staff, and they do not run during the night, when many of the doctors and nurse midwives begin or end their shifts. Mercy and Lydia argue that providing more buses for transport along with providing accommodation close to the hospital for doctors, nurses and their families would greatly reduce attacks and would increase the retention of workers, ultimately reducing brain drain.

Soccer Insanity: Mosh Pits, Pick-Pockets and GOOOOOALS!!!

So I have been greatly anticipating today's Ghana versus Libya Word Cup qualifying match here in Kumasi. It has been apparent from the moment I landed on Ghanaian soil that people here live and breathe soccer ("football"). And after this evening's match, I think I can say that the football fans here are more passionate about the game than the players themselves.

This weekend, the four other students here on my program (two who are doing research on sickle cell genes in Accra and two doing research in Aburi on native herbs that have been used for centuries in obstetrics here to induce uterine contractions during labor or slow post-partum hemorrhage) have come to Kumasi to visit. We arrived at the football stadium two hours before the game began, and had some late lunch. Kofi, our Ghanaian liaison here (without who we'd still be sleeping in the cement jail cell) warned us we'd better get inside before all the seats were gone.

We made our way around the stadium to the side we had tickets for. When we approached the entrance - two turn styles about 8 feet apart going thorough a huge concrete wall - we were met with utter football fan chaos: about 150 crazy fans fighting in a massive mosh pit to get through the turn styles. I mean, there was absolutely NO line whatsoever, just a sea of sweaty fans screaming, pushing and cajoling each other. When someone would finally get up the turn style, they would try and get their friends up there too, and people were elbowing each other even when they got to the turn style, using any body parts the could to push people back.

As we joined the craze, we noticed a young man getting yelled at and slapped in the face by a couple of other young men. I was able to get the gist of the argument, which was that the guy had been pick-pocketing and had been caught. I yelled to the other seven girls to hold tightly onto their purses and not to keep anything in their pockets. As we slowly got shoved, pushed and elbowed towards the turn style, I started having fun with it- what else could I do? I pushed back, stuck my butt out so the guy trying to push past me got stuck, jabbed a couple of men in the ribs, felt myself get actually lifted up off the ground and moved forward by the surge of the crowd. The other girls weren't finding as much sport in it as I was: their hair was being pulled, their necklaces torn off, groped (it pays in such circumstances to be tall as I am...) - one of the girls actually started punching the guys around her. A football fan and I caught each other's eye and he saw my wry smile and the other girls getting upset and yelled to me "football is everything to us fans, welcome to Ghanaian football!"

I managed to make it to the turn style before most of the girls by perfecting the skills of knowing when to push back and when to let myself be carried by the crowd. I was laughing and high-fiving the girls who made it through before me, and shook hands with the football fan I'd spoken with on "the other side." The whole thing took about 15 of the sweatiest, exhilarating minutes of my life, and I found it hilarious. Until I realized I'd forgotten to take my own advice and had left my phone in my front pocket. Gone. I'd even felt hands in my pocket in the mass of limbs, but had thought to myself that I had nothing in them.

But the rush of it all made it impossible for me to be upset - especially because I knew to be thankful that it wasn't my wallet, passport or credit cards (like in Barcelona). The last time I'd had my phone stolen was in Kingston, when I had been in a similarly crowded scenario in the back of a route taxi.

We all finally made it in and found seats. The game was amazing: thousands of excited fans, the Black Stars of Ghana scoring three magnificent goals against Libya, and an incredible sunset as a backdrop.

Football here truly is a sport for all - for the players on the field, and the fans jostling to get a chance to watch. Todays' experience reminds me of the absolute passion of the fans I experienced in S. Korea during the World Cup. It is such a shame that those of us who grew up playing and adoring soccer in the States never got to experience soccer with such nationalistic religiosity. It's worth a cell phone any day.

Data Collection Hazards: Fountains of Labor Waters

Yesterday was my lucky day. I had been waiting impatiently to witness births here at the hospital, but had yet to really have a chance beyond glimpses from afar when the woman gave birth on the floor, or peeking into the labor ward when trying to get a hold of the elusive delivery book. But yesterday, the nurse-midwife in charge had me copy the data from the book at the nurse's desk right in front of the two birthing tables (usually they give me the books and I take them to the waiting room where the women in first stage labor are waiting to reach second stage- this is where the "floor births" take place).

As it was Monday, we were having to collect data on every delivery from Friday, Saturday and Sunday, which ended up amounting to 117. Needless to say, I spent a good 3+ hours in that delivery room copying the delivery information onto my data sheet (which is then taken back to our work room where we upload it into our computer databases).

And during this time, I witnessed 8 births. Births in the labor ward - I can assure you - are nothing like ones back home (although truthfully I've never witnessed one in the States). Besides the occasional "floor deliveries" in the first stage labor waiting room, the labor ward boasts of 8 beds with mostly naked women in various stages of 2nd stage labor, some naked, others half clothed. Some screaming, some moaning, and some snapping their fingers (a sign of pain). Meanwhile, doctors, nurses, med students, and occasional research teams such as mine are wandering through. Although there are curtains hanging from the ceiling in front of each bed, they have remained tied up. When a woman must relieve herself, she does so in her "hot bucket", a small plastic pail with lid that the women must provide themselves to urinate and defecate in. They simply get off the bed and squat over the pail between the beds.

In the adjoining room is the delivery room with its two labor tables and newborn assessment area in the corner. Across from these is the nurse desk where they write down the delivery information in the patient files and record them in the delivery book. It is also the resting place for the nurse-assistants, nurse-midwives, and any other helpers or researchers such as myself - all approximately 3 feet from the table where the laboring woman is lying with her legs spread.

The deliveries were fascinating: the women are not given any drugs - no epidurals or easy ways out like we have - and yet most women remain incredibly in control, although there is of course a number of women who make plenty of noise. Part of the reason they are often so quiet is that it is a Ghanaian belief that a woman should be quiet during birth to prove her maternal strength. And part of it is that the nurses often yell and sometimes even hit women who choose to scream or cry out.

From my sitting point three feet from expanding vaginas I was able to watch (amid writing names, dates, times) the nurse-midwife as she aided the baby's head to first emerge, then checked with her finger to make sure the cord was not wrapped around the baby's neck, then watch carefully for the shoulders to rotate before pushing the head down and freeing the shoulder as the rest of the grey body quickly followed.

Birth number four was interesting from the beginning. The young woman was put in the stirrups, and after about 5 minutes her contraction slowed, and then seemed to cease altogether. Now normally, the woman is in and out of the stirrups in 10 minutes by the time they get her in there (because there are only two delivery tables they can't afford to put women in them until they are literally delivering, because there are so many more waiting). But this young woman (about my age) had been on the table for about ten minutes making no sounds. I was hardly surprised, therefore, when the nurses gave her an IV drip with oxytocin, which is a drug used to induce uterine contractions to progress the labor development.

The nurses, nurse assistants, nursing students, janitors, and myself were all looking on intrigued, asking about the treatment and how long it would take to kick in etc. Within two minutes, the woman began groaning and fidgeting, and I suddenly saw her stomach contract down as if the baby was about to burst out....when suddenly her waters broke, shooting a HUGE projectile stream three feet out, and directly onto three of the nursing student’s laps. I was mostly spared - it only got on my shoes. We were all pretty shocked, as none of us had realized her waters hadn't yet broken.

But this was only the beginning. As the time between contractions became closer, it was apparent that the baby's head was not going to fit through the small vaginal opening. The nurse-midwife made the decision for an episiotomy, and using a small razor blade, told the woman to push and cut the perineum little by little with each push so that the woman would not feel the cuts through the other pain.

The baby's head soon followed, and was delivered shortly after. It didn't take long for the placenta to follow. The nurse took the pail where the blood had dripped into and poured it into a large measuring cup - 800 ml of blood, she announced. This is quite a lot, given that most women we record average 150-250 ml of blood loss. Anything over 600 ml is a potential case for a blood transfusion.

I then watched a different nurse suture her episiotomy closed, and as awful as a comparison it was, I could only think about how similar the technique seemed to the stitches I received from my skiing accident a few years back...

I thought I might have had to interview this woman today if she ended up indeed having a blood transfusion, but luckily she never showed up today on our list of complications. I was grateful for the opportunity to see how hard the nurse-midwives work to safely deliver babies as easily as possible for the laboring mothers. I was in total awe of this young woman's strength and courage - of every woman's - to sacrifice her body in order to bring a new being into this world. And I was relieved for having a lap free of her labor waters.

Pentacost, Pastors and Palava Sauce

As an agnostic undecided in what exactly I do or do not believe in, I have always been intrigued by religion, and happy to join in on religious events/festivals of my friends in the States or around the world. During my time in Jamaica, I would go every weekend with Mummy (my host mother) to her tiny church in the mountains. As a Seventh Day Adventist, her church brethren and sistren spent much of their time being “taken by the spirit,” which I found quite intriguing and a little bit disturbing. I always managed to dodge the weekly attempt by the pastor to convert me by singing for the church members one of the religious songs I had burned in my memory from years of choir. I suppose Easter in the Philippines last year would have to take the cake for the most insane and extreme of my religious spectating, where I watched the town drunkard allow himself to be nailed to a giant cross and paraded though the town as Jesus (which he apparently does every year on condition that the town will feed his alcohol addiction for the coming year). Today I had another wonderful opportunity to witness a religious celebration. Auntie Lydia, one of our two wonderful translators and a still-practicing nurse-midwife, invited us all to attend her church’s Pentecost celebration. I am still a bit foggy as to exactly how it works, but I think the gist is that she is Pentecostal, and therefore attends church on Saturdays, but because today marked the Pentecost – the time when Jesus rose to heaven 50 days after his death – there was an all-day festival today (Sunday) as well. We arrived around 10:45 and it was clear the sermon had been going on for a while. The “assembly hall” is typical for third world countries- a bare cement structure with no walls (it’s waay to hot for them) and plenty of wooden benches and plastic chairs to sit on. We sat down and I managed to pay attention to the pastor for the next 45 minutes, despite not understanding anything he said as it was in the local Twi language (with the exception of “Amen!”). But then the uniquely Ghanaian sermon turned to something I’ve been trying to escape – American religious doctrine. An American preacher with a very strong southern drawl appearing to be about 90 years old stood up to present the key sermon. He tried to convince the church that the idea of all its members being “taken by the spirit” is “hogwash.” His incomprehensible stories about Kansas in the 1800’s were lost not only on all the church members, but those of us Americans in the audience, and felt like they dragged on as many hours as he is old. The only thing that kept my attention was that a church member had to translate everything he said from English to Twi. And somehow his Americanisms didn’t quite make it in the translations (“It’s hogwash that any person can be taken by the spirit.”) This was indeed the case, as Auntie Lydia leaned over and explained that the reason the members kept laughing was that the translator was prefacing most of his translations with “Now I don’t really have any idea what he saying, but it’s something like…”). I was beyond thrilled when he finished the hour sermon and it was time for lunch. The next hour and a half was probably the best time I’ve had here in Ghana. We spent it playing with the approximately 100 children ages 2-12, taking photos together, playing clapping games, and hanging out. Auntie Lydia served us a delicious lunch of one of our favorite traditional Ghanaian foods – Ampesi, which is boiled yams and green plantains with Palava sauce (a spinach sauté with garden egg, which resembles a small zucchini). After our wonderful time with the kids, we went back into the church for the singing and dancing portion of the festival. I swear, their songs last an average of 40 minutes. That’s forty minutes of dancing and swaying and yelling and parading in front of the congregation and then throwing some money in the pot and then dancing again. I thought I was going to pass out form the heat and sweat. But it was very entertaining and far better than the morning half for sure. During this loud and crazed hour, I noticed the floor covered with sleeping toddlers, which were placed on top of blankets on the floor by their mothers. I can’t imagine how tired they must have been to sleep through all the singing, stomping and clapping. It was actually sad to leave. Everyone – especially Auntie Lydia – was so generous and inviting, and the kids were such a joy to be with after the last few weeks of intensity at the hospital. However, after the praying session I was ready to go: the four pastors took us into a back room and we stood in a circle as the four of them prayed out loud all at once, sometimes yelling out suddenly as if about to be taken by spirits (while they were praying for me, I was praying that they wouldn’t start speaking in tongues). It actually made me really nervous to be shouted at in prayers by these four men, and I certainly did not feel more relaxed afterwards. But it was a very heartfelt gesture nonetheless – although they failed, once again, to convert this pagan. I find religion to be fascinating, absurd, and dangerous. Its ability to simultaneously instill love and hate between people has always filled me with awe. I have been fortunate in my life to have only directly experienced religion in a positive and inclusive light through the people I know and meet.

Connecting the Dots: Slavery and Identity

Three weekends ago my group traveled down to Cape Coast, a beautiful coastal region of Ghana west of Accra. This area boasts gorgeous postcard-perfect scenes of palm trees lining the ocean beach and women carry bowls of pineapple on their heads for sale. It also represents the heart of the West African slave trade in the 16th and 17th centuries. I have not managed a post on this trip until now because it is difficult to put into words – as is obvious to me as I sit and try to write it now. The importance of the Cape Coast Region lies in its position as the main link between the maritime trade routes of the European powers and the terrestrial trade routes through the Western Horn of Africa. Through the 1700’s, Cape Coast economy was most consumed by its role as the heart of the slave trade – up until its abolishment in 1807 by the British parliament. Most of the slaves were captured in modern-day Nigeria, Mali and Burkina Faso, but also included many other West African countries. Of the forty-something European castles/forts that line the coast of West Africa that were at some point used for the trade and shipment of slaves, 31 of them are found along Ghana’s shores. Our first stop was in a small town called Assin Manso, an hour from Cape Coast. This used to be the most important stop along the slave trade routes. As the exhausted, dirty captives made their way towards Ghana’s coast from the interior of West Africa, this spot on the banks of the Ndonkor Nsuo (Slave River) was where the slaves were made to bathe before being rubbed down with palm oil to make them look healthy, then sold to slave traders before making their final trek to the dungeons of St. George’s and Cape Coast castles, where they awaited the ships bound for the new world. Our next stop was at Elmina. St. George’s castle in the fishing village of Elmina represents the oldest remaining colonial building in sub-Saharan Africa, having been built by the Portuguese in 1482. Our tour took us through the male and female slave holding cells, in which 200 hundred years of feces and urine combined to raise the ground 3 and half feet from the original stone floor. It was horrible to stand in the dank dungeons which lack light and air, and imagine the terror and anguish felt by so many people. Indeed, we could actually see it, as fingernail clawings were still very distinguishable on the floor and walls. We also saw the secret trap door that took the female slave of the general’s choice up to his private quarters where he would rape her, and on the way down she would be made available to anyone who wanted “sloppy seconds.” The most intense part for me was the “door of no return,” which apparently all such slave castles had. This door opens from the final dungeon out of the castle wall to the ocean, where small boats would ferry the captives to the giant ships waiting further out in the water. This door thus represents the end of Africa and the beginning of a long and arduous trip in which only one in four slaves would survive. It was intense to gaze out of that passage, facing towards America and all of the struggle it held in store. After Elmina we went and did a tour of the Cape Coast Castle, a similar but even larger castle compared to St. George’s. It is reputed to be one of the largest slave-holding sites in the world during the colonial era. At any given time, the Cape Coast Castle held as many as 1500 slaves awaiting shipment to the “new world.” The castle has beautiful white-washed walls and boasts a stunning scenic view of the coast, making it all the more haunting as we descended into the claustrophobic dungeons. It was disturbing to see how similar it was built to the St. George castle in terms of the way it housed the slaves and the tunnel passageway to the door of no return. One of the most interesting parts of these tours was observing how the context of race in the past and present was handled by the tour guides. The castles actually offer race-segregated tours (that we never actually did), which I think is an important option. One of our tour guides took the opportunity to stop our tour group and announce that he realized that those of us who are white did not directly contribute to the slave trade (awkward), while our other tour guide made a more subtle acknowledgment of the race and power equation by explaining how even before the Europeans came, Africans would enslave other Africans as trophies of war (I however find this to be an entirely off-based comparison). In any case, it was clear that all of us Americans were trying to grasp slavery and our identity within it from a different angle than that we are familiar with: looking outside of America in.As I watched my African-American friends grapple with the truth that most of them will never actually know which country their ancestors originated from, I couldn't help but think about the basic human need for belonging and identity. Is it enough to know where you were born, and where your parents were born and possibly your grandparents? America is unique in that with the exception of Native Americans, a great number of us do not know exactly where we come from when we try to go back to the continents on which our ancestors left - by force or through the hope of a better life. When I lived in South Korea, most everyone had detailed family trees that went back hundreds and hundreds of years. Traditions are formed upon the basic knowledge of where one came from in the course of history. In comparison, I find myself a bit lost from time to time in America, as I have not attached myself to a certain religion with which to belong, nor do I feel I have a particularly strong link to my ancestors who came to America as far back as the 1600's. But I have been raised to search for such identity within myself, which I believe is one of the reasons why travel has become such an important part of my life. It is through the experiencing of other cultures, religions, traditions and history that I can gain understanding of my identity as a person - as someone trying to understand themselves through the world around them.

The Labor Ward: Life, Death and Plenty to Ponder

Last Wednesday was another day collecting data from the labor ward. The labor ward is simultaneously coveted and avoided by our team members. It is coveted because you get to witness births as you copy the deliveries entered in the book. And it is usually followed by avoiding having to go there the next day because it takes so long to enter the 30+ recorded deliveries into our database. I really enjoy the labor ward. I have been thinking a lot this year about going on to an accelerated nursing degree program after I finish my MPH, or at least becoming a certified doula. So getting the chance to see the midwives at work is really special. When I entered the delivery area, I immediately noticed that both women occupying the two delivery beds had a baby’s head already sticking fully out. Soon after I sat down behind the desk, the midwife closest to me delivered the rest of the baby. But the midwife with the other woman seemed to be taking her time and not really paying attention to the woman before, who was lying back quietly. I kept worrying the baby would pop out while she was looking away. But then the midwife left the woman, and I kept glancing up the next couple of minutes, looking at the scrunched up face protruding from the vagina. Finally it dawned on me that this other baby was probably an IUD – inter-uterine death. I asked and it was confirmed. Apparently, when a baby dies inside the womb, the woman’s body fails to properly expel it through contractions. Furthermore, babies actually assist in getting themselves out by squirming and rotating. So if a baby had died in utero, in is very difficult for it to be delivered. Finally after about 15 minutes, the midwife came and spent the five minutes very forcefully pulling and yanking out the baby. It looked so painful. The poor baby’s body was already macerated- caving in on itself- which meant it must have been dead for a week or so. The mother never cried, held the baby on her stomach as the midwife cleaned it off. She allowed no signs of mourning. This is one of the things we often muse about at this hospital: does the lack of emotion we witness among women as they watch their babies die – or the women in the beds and on the floor next to them die – have more to do with an emotional blunting they use to guard against the anguish of death, or the sad fact that nurses yell and hit them anytime they cry or scream out, telling them they are disturbing the other patients? The former is something that has already set in for me. I am witnessing or recording at least one death each week, yet I have yet to cry or feel any extreme emotion other than an empty sadness. It should not be this way. Maternal and infant death should not seem so normal, especially in one of the best hospitals in Ghana. The next delivery came with its own double – twins! I was asking the midwife questions about what she looks for when she examines the placenta, when a women came waddling in crying out. The nurses yelled at her and smacked her arm as her water broke all over the floor (apparently they yell at the women for pushing too early and not holding back), and she barely made it up onto the table before the baby’s head popped out. The nurse barely had time to put on gloves before catching the newborn. I thought the excitement was all over until 2 minutes later I glanced up in time to see another baby slide out. They were both beautiful, health little girls. It seemed to be the week of twins and doubles- the two side by side births, the twins I saw born, plus two more women we interviewed who had twins. We also had two women die in one day from obstetric complications. But then today the spell was broken as we ran into triplets! A woman who had suffered from ante-partum hemorrhage had delivered three, healthy girls vaginally! Auntie Mary said I should try for the same so I could get it all over in one pregnancy. I told her it was triple the pain. She told me that no, giving birth was just like when you accidentally bite your tongue… Being here at this hospital, I am constantly witnessing an intricate dance between Life and Death. I keep trying to find a pattern in it, but it is sort of like a Celtic knot. One minute I am witnessing a still birth, the next minute I have the privilege of bringing one of the women I interviewed her baby whom she had yet to see after she recovered from eclampsia. Here in Ghana, so much of life and death is left to chance, to fate, to God, to witchcraft. There is little room left for western medicine.

Travelling in Ghana on Friday the 13th: B Prepared

We decided to spend this past weekend in Aburi where two of our research members are analyzing traditional herbs used to induce uterine contractions to stop hemorrhaging in women who are about to or have just given birth. Aburi is famous in Ghana for its botanical gardens which were planted back in the mid-1800’s by the English colonists. Interestingly, I found out that Aburi, due to its location on a hill/mountain side, was one of the few places where colonists did not succumb to malaria as there used to be no mosquitoes (this has begun to change as travel has increased and with the effects of global warming).

BUSES Anyway, we opted to take Friday off of work as the bus ride is more or less an all day affair. On Thursday, it dawned on us that Friday was the 13th. Ooooooooooh. We woke up early Friday morning, and as we were having breakfast it began to pour rain in torrential cascades. We hopped into a taxi and arrived at the STC bus station. I decided to buy a newspaper as we waited to board. As I turned away and looked at the front page, I saw that the giant front page picture was of vehicular carnage – with the caption “21 Die in Two STC Bus Crashes!” The crashes were pretty bad, but we were slightly reassured by them both having occurred late at night when it was dark. While the girls fretted over the crashes in the paper, I made my way to the little snack shop for a soy milk. Somehow I managed to lose my boarding ticket in the process and spent the next 15 minutes searching high and low among the cockroaches and dirty feet to no avail. Luckily, it only cost a dollar to get a ticket reprinted, and off we went. The bus we boarded was a standard large travel bus, only it was very run down with the seats starting to break and stuffing pouring out, and the curtains stained and a nasty dirty floor. But we settled in as best we could. As we were pulling out of the station, two of the girls prayed for a safe journey on Friday the 13th. They should have prayed for that AND a bus with no bugs.

BUGS One of the girls spotted the first cockroach about an hour into the ride, coming out of the crack where the seat meets the back of the chair. As the girls are deathly afraid of cockroaches and pretty much every creature that moves, they quickly stuffed the crack with our “STC Bus Crash” newspaper. Shortly after, the bus stopped for lunch. I ate my PB&J and put the bag in the front seat. The other passengers got back on and started munching away at their fried yam chips and pork kabobs. And then it began….a steady stream of cockroaches pouring out of the seats, ceiling, curtains, and worst of all – my purse (EEWWW! It must have been because the sandwich was in there)! Now normally I am extremely annoyed from having to sleep with the lights on every time my roommate sees a cockroach, but even I was freaking out. And to make matters worse, as the cockroaches descended on us in an increasing frenzy, our bus was stuck in the insane Accra traffic – so close and yet so far away from the bus station. So there we were, cockroaches streaming out of the sandwich bag I’d put in the seat net of me, the other three girls standing out of their seats the last hour (one of them cried at one point when a cockroach was on her lap) and a bus that was not moving. Needless to say, we were beyond thrilled to jump off the bus, although that itchy feeling of bugs crawling on us took a while to subside. Our fortune turned when we arrived at the bus station and a medical resident friend of ours was there (he had done a short residency at U of M this past fall and we’d met him then and now worked with him at the hospital). He’d just finished a clinic on maternal and child health, and was so generous as to give us a ride. Of course, the awful traffic from a Friday afternoon persisted, and it took a while to get to Aburi – but no complaints! We were in an air conditioned SUV cockroach-free. We arrived at Aburi in the botanical gardens where our guest house was, exhausted and dreaming of a clean, good night’s sleep. Wrong! We were given the keys to our rooms, located across the hall from each other and accessed from an outdoor hallway, illuminated by a giant fluorescent light. Unfortunately for us, it had just rained heavily, and apparently it was just the right conditions for a frenzied hatching, mating and dying festival by what looked to be small cockroaches with huge wings. Now, I am not kidding when I say that we were both laughing and crying at this point. The hallway was filled with thousands of the flying bugs, attracted to each other and the light above our doors. And our keys were of the old kind that are impossible to correctly insert to unlock the door. So we would take a deep breath, run into the sea of flying fornication, and attempt to unlock the door while yelling and jumping up and down as the bugs descended. On the floor were massive writhing orgies of them. It took a good five minutes of this before we finally got the doors open. And of course the bugs had been crawling into our filthy rooms under the door, so there were about fifty in each room. To add insult, as the bugs mated they lost their wings, so there were thousands of wings lying around, and little bugs running around gasping for their last breaths. It was…disgusting, even for me. Sleep did not come peacefully that night my friends. BOTANICAL GARDENS We were supposed to begin a bike tour at 9am, but as usual things were running on Ghanaian time, so we took a walk around the botanical gardens. The gardens were so relaxing, and we had the quaintest breakfast on an outdoor pavilion overlooking the forest canopy. Breathing fresh, cool air was something none of us had experienced in 5 weeks. The gardens are absolutely stunning: giant palm trees majestically lining the main entrance to the gardens and our guest house, massive mahogany and other trees stretching over 300 feet high, hundreds of different species of flowering trees and bushes with benches under them…and an old helicopter. What? This amazing old helicopter had crashed into the gardens back in the 60’s and was still in its spot. I had a great time climbing around in it and taking a couple of pictures.

BICYCLES Saturday turned out to be the best day I’ve had here in Ghana. I hadn’t realized how much I’d been missing exercise, and how good it felt to get out and break a sweat not caused simply by the scorching sun. It was a cloudy day, and we had signed up for a 12km biking tour of the surrounding area. Now it didn’t sound too taxing or long. But we were in for something else. Our bikes had all at one point been nice mountain bikes, with front and rear shocks and suspension. But now, the brakes felt pretty shady and the tires not quite centered. We rode off, all ten of us girls and two guides, through the town of Aburi. As it is situated on a beautiful mountainous ridge, our first 10 minutes were cruising down hill as we wound through the town. It actually felt dangerous and I went very slowly. For one thing, it wa a pretty sharp descent and the brakes didn’t feel so hot. But mostly, it was on account of there being a large funeral celebration in town, which took up all of the street with chairs, dancing, singing and hundreds of guests – which we were working hard to avoid. As I was bringing up the rear, I could see that some of the girls were pretty out of practice of riding and I was afraid they’d crash into a mourner ( I myself was having flashbacks of a crash I had trying to take a steep turn riding downhill in Jamaica…).Of course, as soon as we got to the bottom of the valley between two ridges we had to ride back up. I suddenly found myself at the front as I pedalled hard to the top. It felt so good to be breathing fresh air and working my lungs in a beautiful location. Once we reached the top of the road and recovered our breath, our guide turned us off the gravel road and onto a 1.5 foot wide trail heading straight down the ridge through the amazing array of agricultural crops. I’ve never been mountain biking as off road as this: careening down this steep narrow path full of rocks and roots, corners and streams. We often had to get off and walk the bikes as the path was too steep and rocky! But it was amazing. We got to stop and eat one of my favorite sweets: sucking on the sweet white pulp encasing cocoa beans. And we saw every crop in Ghana, from yams and cassava to bananas and plantains to mangoes and papaya to cocoa and calabash gourds. I was enjoying myself so much and felt so full of life (something that the hospital has been sucking out of us all) that I began to sing random songs. I know that if I start to sing it means I’m in a really happy place, because it usually only happens when I’m riding my horse in Montana. Aburi was the best break from the dusty hot monotony of Kumasi and the stealthy cloud of despair and resignation that cloaks us in the hospital. And although we were surrounded by bugs, at least we couldn’t see them.

Breathing Desp(air)

The past two days have been the hardest for me so far here at Komfo Anokye Teaching Hospital. Since I arrived, I have heard the nurses, midwives and doctors say that many of the women die here because they lack insurance or money to pay for simple life-saving procedures. Some days I come to work and see a woman in the “dark room” (where the pre-eclampsia and eclampsia women are) and see a woman with her eyes rolled back, gasping for breath. And the next morning she would be gone, having passed away. I have also arrived on the ward to watch as the mortuary workers have come and collected these same women. But it has always remained impersonal – abstract and hollow. The imposing smell of death, despair and despondency engulfs me, sneaks up amid the silence where crying and grieving ought to fill the air. It’s as if, at the end of the day I leave the hospital feeling exhausted and empty without really knowing why exactly, despite what I see. This detached state of being was shattered on Tuesday for me. It was my day to interview, and I was interviewing a woman my same age that had come here with severe ante-partum haemorrhaging. She described how she began bleeding heavily at midnight. She immediately set off walking for the nearest maternity home/midwife about 2 miles away while her husband frantically went around the rural village trying to secure a car. She had to stop on the way more times than she can recall to catch her breath, and each time she did, she would bleed profusely on the road. Her husband caught up with her on foot when she was almost at the maternity home- I took a full hour of walking, resting and bleeding before she arrived. Once there, the midwife referred her here, and drove her here immediately. But she arrived at 2:30 am, and had to wait another 6 hours to get a caesarean section, at which point two still born twins were delivered. The story was heartbreaking and made me so angry at all of the delay- to have to walk an hour! While she was telling her story, a woman walked by who I’d been introduced to three days previously – she had just lost her baby and was wandering aimlessly through the hospital. Throughout this entire interview, we were constantly interrupted by a woman in a bed across from us (there is no way to get the privacy we should have for these interviews in this hospital when women sleep two-to-a-bed). She was sitting cross-legged in her bed, moaning, screaming, gagging and coughing. She seemed incoherent, one minute talking to herself or singing, the next minute screaming out for the doctor or nurse- all of whom just stared at her and ignored her. It was so disturbing for me, especially amidst the despair of the story I was collecting. I asked about this patient, and found out that she had renal failure. She had come to deliver, and had a stillbirth. She was discharged, but our hospital has a policy that if you have no insurance and are unable to pay the bill, the hospital essentially holds you hostage until your family pays it (so for instance there is a woman with her now month-old son who has been here since she delivered, waiting for her husband to come up with the necessary money). And during this time, her kidneys began to fail. The doctors weren’t going to put her on dialysis because she hadn’t even paid for her delivery. But a med student begged and was able to get them to front four dialysis sessions for her, after which she had greatly improved (although was still not totally cleared of the toxins in her blood). Meanwhile, the government’s “social welfare” officers had gone to her home and assessed somehow that her family should be able to pay for ¼ of the bill. However, her family couldn’t even come up with that. So by the time I saw her on Tuesday, her kidneys had degenerated so badly that she was severely edematous – her whole body swollen from all the fluid in her tissues – and more disturbing was that the poisonous toxins building in her blood due to the kidney failure was making her delirious as the blood poisoned her brain. Thus the current situation in which I saw her. She kept yelling out to the nurses, who were laughing and told me that she wanted to drink bleach…she wanted to die. Their laughter was both incredulous and pained, as they stood helplessly as they watched her fade. Meanwhile the women in beds around her tried to tune out her screams…. I felt so claustrophobic then – as if I was in an asylum where women were sent to die – and suddenly the full weight of the stale air dropped on me and I wanted to run out as fast as I could, my heart in my throat. Unfortunately, I had to finish my interviews and data entry. On Wednesday I prepared myself to hear her or see her when I returned in the morning. But her bed was empty. She has died around midnight. I was not ready for her to pass so quickly – for the full force of injustice to pass so swiftly – and to witness the ward continue as if nothing had happened. I could sense her soul in the air, and it was then I think I decided that the stale, heavy, opaque-tasting air may well be made up of all the grieving souls who have died in this ward without any of their family by their side – without ANYONE by their side. And maybe this is the cause of the indescribable weight I feel in these halls. While I am confident that the research I am doing will have some sort of impact on the state of maternal mortality in Ghana, it is painful to watch helplessly as so many women die who might have been saved if born in a different country.

“Now don’t forget to wash your hands….”

So yesterday I went as usual to the Friday morning meeting where the medical students and house residents gather for a summary of the ward statistics for the past four days. But this time there was a power point set up instead. The man was a representative of the “sanitarization committee” at the hospital, composed of representatives from each general area within the hospital. And he was here to remind the doctors and medical students to wash there hands – among other things. The first half of the presentation was basic, 2nd grade information about the importance of hand washing and the types of soap/antiseptic available. After going through this embarrassingly basic reminder, he went on to say that “Now we have barriers at our hospital to hand-washing…there is a lack of accessible sinks, running water and soap, and there was overcrowding and understaffing on the wards. But nonetheless, “be sure to wash your hands after you touch ANYTHING!” Next he went on to introduce the new color-coding scheme for waste, involving three different colored trash bags to distinguish between pharmaceutical waste, sanitary waste such as bloodied pads, and general garbage that would be “found in an office.” He then explained that there would be one of each for the ward – a ward containing 15 doctors, 30 nursing staff, and up to 60 patients in a ward. The idea that there would be only one set of these color-coded trash bins per ward was ridiculous. The third part of his talk was to introduce new needle-cutters that would be given to each ward. They were nifty little contraptions really – a small plastic box with a hole in the top in which you placed the syringe after using it and you press the box which causes a razor blade to close the hole, cutting the needle and dropping it into the box for safe keeping. Of course, there were to be all of two per ward…. A nurse then got up and they handed out the boxes to all of the med students and residents present along with sterile syringes to practice cutting it with the box. While it wasn’t difficult, it was important that the syringe was plunged all of the way before cutting it, or the remaining liquid would spray out. Additionally, it was important to make sure the syringe was pushed firmly into the hole so that the razor blade cut the rubber part of the syringe and not the needle itself. It would only take once for that to happen to cause the razor blade to dull and become ineffective at cutting any more syringes. Nurse: “By the way, it is important to show and teach all of your many colleagues who can’t be present right now how to use them correctly so liquid doesn’t squirt out and the razor blade doesn’t break or become dull….we haven’t got extras….” After the demonstration, the rep opened the floor to questions/comments. The first was from a house resident suggesting that they put more than two needle-cutters on a ward, seeing how it would cause staff to wander around with the needle in hand looking for an available box – or alternatively wasting time waiting for one to be available before treating a patient. The man agreed that it would be better to have more, but explained they simply couldn’t afford more. The next comment was by a medical student recounting how a British med student (one of my friends) had told him that the British were phasing out long-sleeve white coats because studies had shown that the cuffs pick up a large number of pathogens from the patients and medical instruments. Additionally, they had mandated the removal of ties, or sticking them under the shirt, for the same reasons. The rep, in a truly Ghanaian fashion, responded by talking in circles about how there are two sides to evidence and research always had mixed findings…and the hospital couldn’t afford to buy all new short-sleeve white coats (never mind they could simply roll-up their sleeves!)…and besides it took nearly a year just to get the idea of color-coded trash bags to actually happen today. He finished by suggesting that the student write a letter to his committee and they would look it over. The final comment was from the back – one of the chief house officers: “Please, every day we are in surgery doing caesarean sections, and we only have short gloves to wear. We only are allowed to use the long gloves (past the elbow halfway to the shoulder) if the patient is known to be HIV positive. But we have many patients who have not been tested for anything, and are therefore potentially even more of a risk. And everyday we are splattered with blood the length of our arms and it is very dangerous and worrisome…can we please have long gloves for all of our surgeries…we need to protect ourselves and not just our patients.” The rep was sympathetic and admitted it was very important for the doctors to be protected, but explained that as of now there was not the money for the expensive long gloves, and that he should write a letter to the committee… I was incensed, appalled, frustrated and angry after the presentation. How could he open the floor to suggestions and comments and then shoot them all down with a “write us a letter and we’ll think about it”? Not to mention his round-about bull responses to very important, valid questions and suggestions. But I suppose it isn’t really his fault – if there’s no money there’s no money. And it is also Ghanaian fashion to do everything veeeeery slowly without any concern – even when it comes to trying to save someone’s life. So maybe in a year they will get around to applying for funds to provide surgeons with long-gloves… As I waited with those same house residents for our rounds to start, I asked one of them if he felt frustrated for being told to wash his hands and then told that there is no soap or water to do so, and to use the new trash bags and needle-cutters despite the fact that there aren’t enough, and he shot down the evidence for rolling-up sleeves, and that their request for long-gloves was shot down. He laughed (which always frustrates me- they laugh about death, about the lack of resources etc.. which I recognize as a coping mechanism but still bothers me) and said that yes it was very frustrating, but that that is how it has always been. Nothing happens fast, if at all. One of the major things that shocks the British and us about being at the hospital is how slow everything moves: A woman will go into an eclamptic fit and the nurses will just watch her seizing and then stroll over to give her an injection; a women will come crawling to the delivery bed with the baby’s head already out and the midwife will yell at her for pushing and then saunter over to put on gloves just in time to catch the baby. And it is clear that this is a major contributor to the rate of mortality. It makes me want to yell at the doctor’s and nurses to DO SOMETHING. But after witnessing the woman with no insurance who died of renal failure, and the inability for the doctors to even secure surgical gloves, I recognize that the slow, apathetic responses of the health care staff are coping mechanism for their lack of support by the hospital in terms of necessary supplies, patient insurance, and the feeling of inevitability of death. It makes one want to wash her/his hands…of it all.

Maternity Homes in the Kumasi Area

A week ago Tuesday I had the fortune to accompany two of my UM research friends on their facility assessments in Kumasi. Brooke and Tina are second-year med school students at UM, and arrived here with our fifth research team member three weeks after I did to begin their facility assessments. They are conducting research related to ours, by going to all of the district and private hospitals in Ghana that refer their women to our Hospital (KATH) for pregnancy complications. Specifically, they are looking at the extent to which these hospitals are seeing women with pre-eclampsia and eclampsia, and what medications, if any, they are giving them before referring them to our hospital. They also check to see what kind of drugs they have present, the types of tests and procedures they can do, how many health care staff they have and of what type, and the working condition of the equipment. They finished the referral hospitals, and this week began going to maternity homes that refer women to KATH. Maternity homes are privately-operated, usually small clinics that offer any where from just a few services such as antenatal care (ANC) and standard vaginal delivery (SVD), to an extensive array of services including prevention of maternal to child transmission of HIV (PMTCT), voluntary counseling and testing (VCT) for HIV and other STIs, circumcision, ANC, nutritional counseling, family planning etc. We managed to visit 6 maternity homes in as many hours on Tuesday. It was striking to see the variety of maternity homes in terms of patient capacity, services offered, equipment available (and actually working), overall cleanliness and amount of good lighting. Most of the smaller ones we visited saw very few pregnant women each year, and delivered maybe just five babies in that time. Why would a midwife choose to open such a small maternity home that sees so few patients each year, and how does she manage to stay in business if she is receiving so little money? I don’t have to look farther than our hospital to understand the first question: at KATH the midwives work double shifts, have a head midwife to report to, witness numerous deaths of their patients, and are paid very little for their physical and emotional contributions. Like anyone who dreams of opening their own business, the prospect of being one’s own boss is enticing, and as I can imagine, so too is the knowledge that one won’t have to be around so much death and suffering (because they immediately refer any women with pregnancy complications to our hospital). However, the monetary factor is far more complex and I’m trying to get a better grasp of how it works. Three years ago the government of Ghana implemented a National Insurance Scheme, in which all health care facilities had to register with the government and pay a fee in order to be eligible to receive the insurance funds from their patients. And of course all Ghanaians were eligible for insurance, provided they could pay the “small” fee. Now if the individual hospital/maternity home/private clinic does not register with the NIS, they are ineligible to receive the insurance money for the care they give their patients, and thus their patients leave to find health care facilities that will accept the insurance so they don’t have to pay out-of-pocket. Now this all began three years ago, and there still remain a large number of health care facilities that are. But even for those who do register, the government is often months behind in paying the facility the insurance money owed, so that the health care workers end up paying out of pocket for medicine for their patients. Hence a number of the maternity homes hadn’t actually delivered any women in the past couple of months to even the past year, and had provided antenatal care to only a handful. As for the question of how such a place can remain open…I have no idea. Except that if the center is only employing one person besides the midwife who opened it, her costs would be pretty low beyond the rent. What really struck me was that every midwife we interviewed said she immediately refers patients with any obstetric complication – eclampsia, haemorrhage, obstructed labor etc – to KATH where we work. Komfo Anokye Teaching Hospital where I work is incredibly overcrowded, with patients we’ve interviewed often waiting overnight for care. Furthermore, it is also considered by many in Kumasi to be the “last stop” in care: if you are referred to KATH, you are probably going to die. And the doctors/midwives are always complaining about two intertwined factors affecting their work: 1) referral hospitals and maternity homes refer patients as soon as they see a problem because they are unwilling to have a patient die at their hands rather than give them very basic medical treatment (at least for pre-eclampsia and eclampsia) that could prevent them from needing referral; 2) Alternatively, many of the health centers’ hold on to their patients until their condition worsens, so that by the time they finally do refer them to KATH they often do die. These two factors are really difficult to overcome simultaneously, which is really how they must be approached. Timing in obstetric complications really is everything. For instance, a woman with high blood pressure who is immediately referred to KATH from a maternity home may arrive at our hospital only to wait outside overnight, and during that time develop pre-eclampsia and then have a seizure…whereas if she had been kept at the maternity home and given basic BP medications to see if her condition would improve, she would have gotten much better care without delay. Conversely, if for instance a woman is not progressing through labor and she is kept at a maternity home while they wait and see, her obstructed labor may cause internal bleeding and her uterus to rupture, whereas if she had been referred to KATH she would have been given a c-section before that could happen. Thus KATH where we work is overcrowded with patients who either could have been treated elsewhere, or who have been referred too late and often do not survive. Any intervention must tackle both of these problems, either by organizing education workshops for midwives of maternity homes or going out to each facility. Most of the maternity homes Brooke and Tina have gone to do in fact have magnesium sulphate to control pre-eclampsia, but have not used it and instead referred straight to KATH. And for those that don’t, a greater effort needs to be made to equip health centers with such life-saving drugs. It is often a fine line between whether a patient should be given care and wait to be referred unless absolutely necessary, or to err on the “safe side” by referring to KATH where the overcrowded conditions may not allow for the best of care and patients not in serious condition take up valuable space.

The Midwives in Our Lives: Much love to Auntie Lydia and Auntie Mary

Today is the last day of work. I simply can’t believe it. The past three months have absolutely flown by, filled with wonder, excitement, generosity, courage and struggle. Just last Monday Ember (the med student in our group, an amazing girl who got her master’s in public health at Emory University) and I received IRB permission to being a second study on nurse-midwives here at Komfo Anokye. Through our conversations with our own two interpreter midwives we had come to learn of some major themes: the struggle to provide adequate care to their patients despite extreme over-crowding, lack of equipment, and understaffing of midwives due to the brain drain as the younger ones “leave for greener pastures.” Along with covering a number of other topics, we’ve so far conducted 6 interviews and hope to reach at last ten in the next two days before we leave. I am soo thankful for doing this second study: listening to the stories of these midwives – many nearing or already hitting retirement – has been a much needed inspiration here when sometimes the weight of the intensity of the hospital can feel so overwhelming. The real inspiration for this study has come from the time we have had getting to know our two amazing, brilliant, compassionate midwife-interpreters for our project, Auntie Mary and Auntie Lydia. They have been so patient in answering our endless questions about pregnancy and caring for and delivering their patients. Most of all, they represent the spirit of midwifery to an extent that has made me seriously consider the profession. Auntie Mary recently retired from Komfo Anokye where she was the head midwife-in-charge for the antenatal ward. However, she has continued to supplement her income by working night shifts at a maternity ward. So she comes to our hospital to interpret for us from about 10 am to 2-3 pm, and then goes home to sleep before working from 8pm to 8am at the maternity ward. Auntie Lydia – at 65 years of age – is still working at Komfo Anokye on the official ward (“VIP ward) where she follows her patients from antenatal, through delivery and then postnatal care. She comes to work for us the same time as Auntie Mary (around 10am), and then begins her shift from 2pm to about 8pm or later. Every day these women come to work with more energy than I can muster at less than half their age, ready to assist their patients as best they can under the conditions they are given. When asked about how they handle the lack of proper compensation for their time and effort, they – and all the midwives we interview – insist that to be a midwife is to dedicate oneself to one’s country and the women who make it. They truly love their profession, and despite the endless hours would do nothing else and would not change their choice to stay in Ghana for anything. It seems this point of view has largely been lost (according to them) on the younger generation, who concern themselves first with making the income they want to allow them to buy the material objects they feel are necessary to live well, and adjust their job location accordingly. I wonder if this is the same with my generation in the states. It certainly is true that my age group and those below me are concerned with being able to provide themselves with the material goods and comforts that our parents have and more. Being from the states, this has les to do with looking for jobs out of our country and more to do with the type of job one chooses. For instance, it is clear with the major lack of incoming professional teachers and nurses in the States that money comes first over a civic duty for our country. Sometimes I worry that my choice to focus on health behavior and health education in my master’s program is a mistake, since it is in many respects like an international social worker degree, that to say, one that does not exactly bring with it a substantial income. And sometimes – rarely but sometimes – I question my choice of this path. But after listening to the stories of these courageous midwives here, I am reinvigorated with a passion for striving to provide every woman and newborn with a safe passage through pregnancy and birth. I am so inspired to do more, to not just be able to recite statistics on maternal health and authors recommending how to scale up the health care system, but actually have the knowledge of how to help a woman deliver safely and with dignity. The midwives in our lives – often over-looked and under-appreciated – are an inspirational force in the maternal health community and deserve the utmost respect for the love they show for their work and their patients. Thank you Auntie Lydia and Auntie Mary, and everyone else for reminding me of why I chose to become involved with maternal health, and how each one of us does in fact have the potential to change the lives of mothers and in doing so – the world.

On my Way to Egypt: A Sad Goodbye and a New Adventure

I am leaving tomorrow night (Friday) for Cairo, where I will catch a bus over to Dahab on the Sinai Peninsula for 10 days of scuba diving and sight-seeing.

It is always weird to say goodbye for me when I have been living/traveling in another country: I cannot say for sure I will not come back, and always hope I will. When I travel, I know that I will eventually leave the incredible friends I meet, and while it doesn't make me hold back from creating lasting friendships, it does make me appreciate the ability to connect with people across the world, and know that immeasurable friendships and experiences are stronger than measurable distances.

I've learned far more from this experience than i anticipated, and am looking forward to the process of uncovering the myriad ways in which my time here has influenced me as a person and in terms of my perspective on maternal health. Much love to Ghana and all of my friends here! I'll post lots of pictures as soon as I get to a place with stable, high-speed Internet.

Now, onto Egypt, where I promise to continue blogging on my undersea, camel, Cairo, and Mt. Sinai adventures.

EGYPT

EGYPT

A Day in Dahab
Ahhhhh. This morning I woke up at 6am to do some sunrise yoga on top of the cafe next to my "camp" (guest house). Afterwards I changed while my friend We'il who works at Dolphin Camp made me Egyptian pancakes with bananas and honey and I drank Bedouin tea. Then I was off for an hour horseback ride along the beach to a gorgeous lagoon, racing the guide Mohammed (My mare was named Madonna - fitting isn't it?).

After the morning ride I had to jump into my bikini to make it in time for my morning scuba dive at a place called Blue Hole. To get there, we take a jeep along a winding, dirt road between the red desert mountains and the blue-green Red Sea waters, passing through two security checkpoints (which I found out have been set up throughout Egypt by the government as a means of employing some of the numerous unemployed men). Along the way I stopped counting at 450 the camels in huge groups ly8ing down, some standing, others in a long line walking - all ready and waiting for the massive 100+ tourist groups coming from the Ritzy Sharm-El-Sheik Resort area an hour south of Dahab.

By 11am I was descending straight down through a jagged coral hole to the vast "blue hole." At 35 meters deep (110ft) I suddenly felt giddy and realized I was saying "Wheee!" to myself as I rolled in horizontal 360 degree turns...when I realized I was narced from the depth (nothing like a little oxygen deprivation and utter weightlessness to really enjoy oneself). On the coral we spotted a huge (2 foot diameter head) octopus who was madly flashing from white to black to blue-gray in an attempt to hide from us. Unfortunately out dive had to end about 15 minutes short (only 32 minutes long) soon after as a man with me was unable to equalize his ears, and 34e had to make an emergency ascent. Nonetheless, it was a great dive, made all the more so by the fact that it was given to me for free due to the shorted time and emergency ascent, Woot!. (However, I must admit that I find both the coral and the fish here extremely lacking when compared to all of my dives in Thailand and the Philippines - I didn't realized how spoiled I had been starting in those locations).

I decided to break from an afternoon dive and instead spent the afternoon sunning and swimming, eating Greek salad, drinking a pineapple-orange lassi, and smoking apple sheesha as I read a book.

Tonight there are parties at the two clubs, so I'll be dancing the night away and playing some pool with new friends I've made from Quebec and London, as well as my dive masters.

As you can imagine, for most of the people I've met here, a day in Dahab quickly becomes a week and then months with such a relaxed atmosphere, great food, gorgeous beach and generous locals.

What else: The cats! Everywhere else I have traveled in the world mangy, homeless dogs are the norm. But here the place is crawling with gorgeous Egyptian cats - tall, long-legged with long pointy ears. (There are definitely a fair share of dogs as well). Both the cats and dogs are well-cared for compared to everywhere else I've been, and if you are not an animal lover - or at least capable of accepting five cats at your feet under the dinner table - then maybe Egypt is not for you.

So far everyone has been very kind and helpful here, especially when I was making my way via buses from Cairo here. The men love to try and woo you into their restaurants and shops, but it has yet to ever make me feel uncomfortable in the way it did in Jamaica and other places I've been.

The scenery is absolutely spectacular. From the Peninsula, I look across the channel to the desert mountains of Saudi Arabia, and at night the lone city over there sparkles while the crescent moon rises above it. Behind the ocean front on the back side of the hotels, camps, shops and restaurants of Dahab lie stunning jagged desert mountains. the beach front is filled with large huts and giant parasols housing restaurants and cafes with sleep-inducing floor cushions surrounding a low table. Evenings are spent enjoying the desert breeze over tea and sheesha and good company, before heading to one of the clubs for some dancing or pool.

Apparently this is not the high season for tourists here in Dahab - that comes next month when the weather cools down a bit. But the mix here is good : single travelers such as myself, European and Egyptian families with their children, ex-pats working the diving schools, and amorous couples. It's truly one of those places with something for everyone.

So far Dahab has been a much needed "detox" for me after Kumasi as a place to really lie back and allow my thoughts to wander and coalesce over the past three months in Ghana. I already miss it a great deal - both the country itself and the people I became so close with. And my mind is constantly whirring over the data we collected and how I can use it to best improve maternal mortality in Ghana and elsewhere. I find myself constantly starting to speak Twi instead of Arabic or English. And I already miss red red and palava sauce.

Travel always reminds me that life is so good, makes me realize how fortunate I am, and challenges me to constantly broaden my world view and become a better person.

Camels and Commandments

I am EXHAUSTED. But in a very good way. The past three days have been filled with nonstop scorching hot adventure.
It began with a two-day camel/scuba dive trek. Myself and six others took a jeep ten km to a diving outpost where our scuba tanks, gear, food etc was loaded onto 6 camels, and finally ourselves, for a two hour trek to Abu Galum, a small Bedouin village comprised of maybe 20 huts. Apparently, this is what Dahab used to look like 20 years ago before it began its rapid expansion into tourism. The 4km trek on camel was beautiful, with the ocean to my right and the desert mountains to my left. Have you ever heard a camel before? They constantly are making throaty gurgling sounds have way between a meaty burp and serious indigestion. But they have really funny personalities and like to kiss on the lips.

One thing I love about the jeep/truck rides out to diving locations is the Egyptian form of free public transportation. At any time that a vehicle slows down to go over a speed bump or to take a turn, a number of small children or adults run after the vehicle and climb aboard for a free lift, simply yelling at the driver when they want to get off. So we had two adorable young boys sitting in our jeep on the way to the starting point of our trek.

Once at our destination, we tried to forget about our sore butts by immediately suiting up for our first dive. The dives here were the best so far in Egypt, with lots of lion and scorpion fish, stone fish, a green turtle, and pristine corals. After our first dive we were treated to our first of many filling traditional Bedouin meals: for breakfast we had foul ( a mashed bean dip), the essential diced cucumber and tomato in cow's cheese, more slices of cucumber and tomatoes, with pita bread to wrap it all in. It was very delicious. After a quick break for digestion we had our second dive, then ate lunch : fresh fish caught right outside our hut, with long-grain rice, a potato and vegetables stew, and diced tomatoes and cucumbers. The Bedouin tradition of providing far more food than can possibly be consumed was well observed. Each meal is followed with Bedouin tea, a delicious tea almost ruined by the heaps of sugar poured in.

Afterwards we attempted to nap as the midday heat reached 115 degrees. We read, played cards, ran into the sun for quick dips in the ocean. Dinner was fresh fish, the traditional Egyptian coushery (imagine a spaghetti-ohs type ensemble of short spaghetti, tomato sauce, and a few spices), vegetables, and honey melon for dessert.

In the evening we played Frisbee on the beach with the Bedouin children, before settling down to watch the incredible desert night sky. There are few times in my life where I've witnessed as many stars as I did that night, and a fair number of shooting stars too. Unfortunately, the desert heat lasted all through the night and my sleep on the sand was less than restful. Nonetheless, it truly felt magical to look out over the Sinai Straight, with the stars above and the outline of the Saudi Arabian mountains across the channel.

Yesterday morning we went on a morning dive, then had another wonderful breakfast. I was unable to go on the second dive because I was planning to climb Mt. Sinai that night and as a rule a person should not climb a mountain or fly within 12 hours of one dive or 24 hours of two dives. So I attempted again to nap despite the waving heat and pesky flies who for some reason really wanted to go up my nostrils.

We made it back to Dahab around 5pm, exhausted and content from amazing diving, food, tranquility and adventure. I probably should have slept but instead took care of postcards, banking, gifts etc. My tour was leaving at 11pm to start the drive to Mt. Sinai.

I thought I'd be able to catch a few zzzzz's on the "bus" there, which turned out to be the same type of van as used in Ghana and everywhere else I've traveled for public transportation where they cram in as many people as possible. Sleep remained elusive and we arrived at the base of Mt. Sinai at 1:45am.

We were given a Bedouin tour guide and started off. While some tours had provided the guests with flashlights, our group had mostly forgot with the exception of the two overly prepared Germans who looked as if they had brought all possible gear for spelunking. So the entirety of our climb was in partial to complete darkness, and it is a wonder that more people don’t fall and get injured on the slippery sandy rock path.

We first passed St. Katherine's Monastery, which actually looked stunning with its lights illuminating the gardens. It really appeared as a beacon of light and safety, and made me think of Monty Python's Search for the Holy Grail when they come upon the Castle in the rain with all the half-naked women in it....

On the way up we had to navigate not only the 500+ people also making the trek, but a whole host of camels carrying the lazy and "less fit" people up the mountain, while simultaneously dodging camels coming down the mountain to carry up the next round. Nonetheless, it felt wonderful to be out finally exercising, and again with the brilliant starry sky.

After 2 hours of climbing, we reached the second half of the pilgrimage, the 750 rocky and uneven steps to the summit. By this time everyone is tired, and can't see, and people are slipping and stopping in the middle of the narrow path...tons of fun. But I made it to the top with about an hour to spare before sunrise.

Sunrise on Mt. Sinai was truly incredibly beautiful, as it bathed the surrounding rocky desert mountains in a red light. And as soon as the sun was fully risen, 500+ began the trek back down. At first I was pretty worried, as I was so tired I was literally falling asleep while climbing down the rocky steps! I chose to take the 3750 Steps of Repentance (laid my a monk as a form of penance) down, rather than the path we took up, to get a different view. Whereas the other path wound around and up Mt. Sinai in a spiral, this path went straight down a gully in the side of Mt. Sinai and had some beautiful arches carved into the path.

Back down at the bottom, it was time for a quick tour of St. Katherine's Monastery and a glimpse at the Burning Bush, before heading back to our van.

I am now safely and exhaustedly back in Dahab, where I am planning my bus to Cairo tomorrow. It is hard to leave this town, but I am excited for the sights of Cairo and the chance to compare its supposed worst traffic ever with that I've seen in Bangkok. Apparently, there are 32 million people in Cairo during the day, and just 24million at night, representing the 8MILLION PEOPLE who commute each day to work in Cairo! Now that's insane...

Now I am off the follow the only commandment I knowingly received while on Mt. Sinai: "Thou shalt take a long nap."

My last Day of Travel: Seeing Everything in Cairo in ONE DAY....

I finally arrived in Cairo after pulling myself out of the quicksand of Dahab, giving me exactly one full day in the tourist treasure of Cairo.
I began this morning at 7:30am with the Great Pyramids of Giza. They truly define awesome. I got haggled into a camel ride by a man named Sallah and his camel Mickey Mouse, which ended up being a blast as he was all about helping me get my requisite jumping photos in front of the Sphinx and the Pyramid. And in the end he had Mickey Mouse lie down and I stood on him for a bunch of rather amusing photos.

After eating my breakfast I’d taken from my hostel consisting of hotdog buns and fig jam, I caught a taxi to Khan-al-Khalili, the famous Cairo market. I wandered through the Islamic quarter where the locals buy their undergarments, spices, toiletries etc., and continued into the tourist quarter full of Egyptian purses, jewelry and shoes. I sat at a famous little alley cafe that has been open supposedly for 200 years while I sipped mint tea and smelled the wafting aroma of apple sheesha being smoked by local men and people-watched. I made a stop at a traditional pasteries, fruits and nuts store and bought some delicious Persian yellow raisins and amazing peanuts coated with honey and sesame seeds, before catching a third taxi to the Egyptian Museum.

Entering the Egyptian Museum is like finding the door to an immense mansion attic full of someone's life treasures: the museum is covered with sarcophagi, vessels, mummies, jewelry and a million other things, many of which are left uncovered/unprotected and look like they were simply dropped off by the movers and never properly put away. My favorites were the animal mummification room, the Royal Mummy room which houses the best preserved mummies in the world from the Valley of the Kings and all other famous locations in Egypt, and the King Toot ankh amoon (my Egyptian friend's spelling) wing which houses the most famous death mask, largest sarcophagi, most extensive jewelry etc - all for a king who ruled for just nine years!

Next I decided to wander around the downtown area, since my hostel is only a ten minute walk from the Egyptian Museum and the main downtown streets of Tarir Haab and El Nile are so close and full of the latest Egyptian fashion. I wandered and window shopeed, and stopped for a refreshing lemon juice, and wandered some more...before finally returning to the hostel for a much needed shower.

There are a million things I did not see today, least of all the Citadel, Islamic Cairo, and the Saqqara step pyramid. But this provides me with yet another great excuse to return. Tonight my plan is to see a Sufi dance and to go on a sunset falluqua (traditional Nile sailboat) ride on the Nile, since I wasn't able to do a 2-3 day Nile river trip.

It is so hard to believe my time traveling is up. I feel that for me, life is most in perspective when I am traveling. And I feel uncomfortable not knowing when the next time is that I will leave the States again - although I know it will likely be less than 6 months (fingers crossed). While I am not ready to be done traveling, I am very excited to be back home in the most beautiful location off all the travels I have ever done: my hometown of Missoula, Montana. I have been dreaming of sitting on my back porch, gazing out at my mom's incredible flower garden while sipping on Sangria that my dad and I make. And I am equally excited to begin my last year in my master's program so I can begin compiling the qualitative and quantitative data from my three months in Ghana, and hopefully get the findings published before I graduate.

I feel at a loss of eloquent words to summarize my experiences, thoughts and emotions over the past 100 days. Suffice it to say I am thankful for the amazing experiences I have had and everything I have learned, and I hope that it will all contribute to some small change for the better as I continue my work in public health.

Money, not Tears
Ugh. And so it goes. I missed my flight today. That's what I get for diligently checking the flight status beforehand. So my flight was delayed from 12:30pm to 2pm, and when I saw that online I decided to just stay here at the hostel a bit longer. I arrived at the airport at 11:30am and was promptly told that the gate for my flight was closed...despite the flight delay they had processed it at the original time. So there I was, and they refused to let me on even though the flight wasn't leaving for 2.5 more hours! They must have already given my seat away.

So for the first time in months I began crying, and I'm never the type of girl able to turn on the water show when she wants something. But even my beautiful tears of sorrow failed to sway the hunch-backed Delta man from getting me on the plane.

Because Delta only offers one flight to NYC a day, and no other flights in North America, the flight was booked until the 10th. So I could either wait another five days and sight see some more, or pay $233 for the emergency seat tomorrow.

Flight delays on your way home are one of those events that so gleefully mess with your emotions. Even yesterday, if I knew I had the option to extend another five days I would have jumped at it. But today, having psyched myself up for "finally going home" it was such a blow - "not just a later flight today but in five more days?!!" So I took the option of paying to fly home tomorrow. Either way I'd have spent the same amount of money.

When I finally arrived back at my hostel (via an hour and a half taxi ride through the ghettos of Cairo when it should normally takes 30 minutes) I told one of the hostel workers what had happened. I told him I had cried and still I wasn't able to get on and now was going to pay for a flight tomorrow. He asked me incredulously, "You mean you didn't try and pay the man to get you in?!"

Another lesson learned in Cairo: money not tears my friend, money not tears. I should have known bribery was the best option....silly American.

In any case, I now have one more day/night to eat my favorite Ta'mayya (falafel) and rice pudding while inhaling the black Cairo air. Life is still good.