More babies and obrunie beach adventures!

Keesha and I spent 2 more days observing in the hospital after my last post. Thursday we returned to the labor ward for the third time. It was packed as always with women ready to pop. I can’t say I really felt any less overwhelmed or helpless the third time! Soon after arriving the power went out-- the staff carried on without missing a bit. It happened again several times throughout our day, leading me to realize why the surgery sweets had large windows. C-section in the dark anyone? The power outages weren’t too surprising, our hostel has them frequently too, but what I couldn’t get over was the water outage. The water went out for the entire day! The doctors were scrubbing in for surgery using buckets of water kept on hand for outages. None of us could wash our hands or flush the toilet… and there definitely isn’t any hand sanitizer to be found. I think partially because of the power outages affecting the wash, the ward had also run out of scrub caps for us to wear in the surgery theatre. Have no fear, the resourceful Ghanaians had a backup plan for this too. The nurses took the paper wrapping from used sterilized instrument packages and wrapped them around our heads like a bandanas. When I fumbled trying to fasten mine, she laughed, and said “you’ve never done this before?! Don’t you know how to make a hat?” Silly me, eh?

With our puffy baby blue paper hats, we settled in for more surprises in the obstetric theatre. We saw two more c-sections, neither of which went smoothly. One of the women was a bit overweight, and the anesthesiologist couldn’t get the spinal anesthesia in… there was a lot of laughing and talking, and blaming the woman for not staying still enough… I really felt quite uncomfortable. Everyone was feeling rushed, as the other theatre had broken equipment and was out of commission, backing up the line for c-sections even further. So, after 10 minutes of failed attempts, they intubated this woman for her c-section. They proceeded to intubate the next patient too, when her spinal wasn’t completely effective. I’m really unsure of how this type of thing is handled in the US, but regardless of the choice to intubate, I felt like there was a huge lack of communication and respect for the women. I can’t say, without knowing Twi, but I really don’t think the women knew they were being intubated, and I know they weren’t consulted about the risks or options.

Struggling to take in all the challenges of the ward, Kogo, one of the residents, shared his thoughts. Kogo stood out as one of the most compassionate of the medical team—he is really great with the women, pulls curtains to protect privacy, and talks to them more than I’ve seen anyone else do. He said when his residency is done he wants to get out of Accra and go to the states. When I asked why he said that this- indicating the ward- isn’t the practice he wants to do. I probed for more detail, and he said, this wasn’t the way medicine was supposed to be practiced, there were too many women, too few resources, too many compromises in quality. This is the not the type of medicine he wanted to be affiliated with. He wants a better outcome and circumstances for his patients. It’s a catch-22. I completely agree with what he’s saying, but at the same time his services are needed so badly here. These women need help! He sees the task of caring for these women, and the overwhelming odds stacked against him in his attempts. If you came to work day after day set up for failure and hardship, would you want to stay? How do you keep those with the skills that you need, when they feel like they are eternally constricted by their surroundings and resources? As much as I wish he wanted to stay and work to improve the situation, hypocritically if I was in his situation, as horrible as I feel admitting it, I might be just as tempted to leave. The task of working toward improving the situation is so much bigger than the problem of space and resources in one ward—the multitude projects needed to ban together is overwhelming the public health campaigns, infrastructure improvement, education, sanitation, family planning, funding—and on and on.

This is not to say that Korle-Bu is bad. The hospital offers invaluable services to a huge number of people in Greater Accra. The teaching hospital is improving steadily and has a number of collaborating institutions. It is my understanding that obstetric residencies here are relatively recent, and since implementing residencies here in Ghana the majority of OB/GYNs trained here have stayed here, whereas when they used to go overseas for residency, they rarely returned.

Our final day of observing was spent in the antenatal clinic on the ground floor of the maternity block, just below the labor ward. (Power at the hostel just went out again…) At first glance the place looked like a mad house. At 8 AM when we arrived, there were rows and rows of pregnant women sitting on benches waiting to be seen, with a handful of nurses and women roaming to and fro. If I had to guess I’d say that in the wide hallway that serves as the main corridor for the clinic, there were 150 women, all hot and pregnant. Dr. Adanu introduced us to one of the nurses, and asked her to show us the ropes, and then he headed off for the day. I think we really lucked out having him as a mentor—not only is he supportive of the work we’ll be doing in Akwatia, but he is incredibly accommodating, and clearly an influential figure around the hospital. Cheryl, our mentor from U of M, tells us he’s being groomed to be the Dean of the Medical School. Fancy!

The nurses and midwives of the antenatal clinic were amazing. They had organizing the chaos down to an exact science. Women came into the clinic and were directed to the first nursing station behind a curtain, where, if they were visiting for the first time for this particular pregnancy they were given a Ghana pregnancy booklet, which would stay with them throughout the pregnancy as their pregnancy record. The first nurse filled out the basic information with them, asked background medical history, and covered one or two of the ten or so topics in the ‘education’ section of the booklet, checking them off as she went. The nurse explained that by the time the woman goes to deliver all of the educational sections are supposed to be checked off. She said they ask women to come at least 6 times for antenatal care—ideal once every two weeks until 28 weeks and then once a week after that! I can’t imagine! Visiting the clinic is a four or five hour affair on a good day!
From station 1 women are sent to sit in the section waiting for station 2 where their height and weight are recorded in their book. Then they head to station 3 in groups for HIV counseling. We sat in on a few sessions, run by an inspirational midwife. She was so passionate, so talented at engaging the women, making them as comfortable as possible, and doing her best to make sure the vital information about transmission got across. After the group discussion, each woman did a rapid HIV test. The test involved a glucose-check type finger stick drawing a drop of blood which was placed on a small plastic one-use instrument. A drop of developer was added and in 10-20 minutes you had your results. Results were given by the midwife one-on-one with the women. We were privileged to sit in on a few of these sessions as well. The educator would tell them they were negative (all that we saw were) and then would ask what the women were going to do to maintain their negative status. The women would mumble and blush and laugh and consistently said “I will take care of myself”, the midwife would chuckle and ask for more detail. Though the women knew exactly what she was getting at they were painfully shy and couldn’t even start to say anything about sex or protection. How could anyone possible negotiate for protection or talk about monogamy when they can’t even mention the subject matter! The shyness was consistent and strong, woman after woman blushed and squirmed, knowing exactly what the nurse wanted them to say, but feeling far too shy to say the words or broach the topic! They were all pregnant! Obviously they’ve had sex! Their reactions to the topic in a supportive setting, alone with a compassionate woman, were shocking. The nurse told us afterwards that day after day this is what she experiences. She encouraged the women to bring their partners in to be tested (for free). She said many can’t convince them to come and get tested and are trained to not bring up the subject anyway—so instead she would suggest that the women just tell the men “the doctor wants to see you” just to get them in the door.

One of the tests we saw was unfortunately positive. Ghana has relatively low rates of HIV compared to other African countries. But, unfortunately, we were told that virtually none of the women who test positive go to the HIV clinic for follow up help after being counseled to do so… again, a result of denial and stigma. The midwife told us that last year 106 of the women they saw for antenatal care were positive. Shockingly, at least too me, was that of those women, 80 of their partners were coerced into coming in, but only ONE of those men tested positive, suggesting that the majority of these women got HIV from a previous partner or via another method. I guess that really speaks to how much easier the disease is to transmit male-to the male’s partner.

Anyway, back to the clinic flow. After counseling women go to station 4 where they pee in a cup which is immediately stick tested from protein and glucose (to test for pre-eclampsia and diabetes), the results of which are recording in their book. At station 5 blood pressures are recorded. And finally as station six they see a doctor. The examining rooms were something like 9 by 6’ and included a metal stretcher (no pad), a card table, and four plastic chairs. Two doctors worked with two patients in a room at a time. The women sat back to back in two of the chairs, next to the table where the doctors sat facing each other adjacent to the women. They looked through the nurses’ charting, asked a few questions, and then had the women jump up on the stretcher to have their belly measured and the fetal heart beat checked. Sometimes they would write for an ultrasound or prescribe some meds. The patient would then leave and the next patient would file in to fill their seat. An amazing, efficient, ‘herding’ method, that I’d venture to say is a fairly ingenious way to manage the limited resources. The nurses we met in the clinic were inspirational: skilled and compassionate educators who connected with every woman, no matter how shy or quiet they were—I left feeling really good about what these care providers were able to do with a bare minimum of resources. If they can accomplish this much on the ground floor, maybe there is hope for the labor ward!

After a positive clinic experience, a tasty pile of fried rice for lunch, and my first skypable internet connection (courtesy of sneaking into the doctors library and hacking our way onto the internet…)—we called it a day and wrapped up our week of observing at Korle-Bu. (Power just came back on!)

Despite the fact that Kofi (our go-to guy) is back in the States at the moment, the Michigan group (MHIRT students + 3 SPHers) decided to reconvene in Accra Saturday morning to head out on a weekend adventure. There are beaches near downtown Accra, but we’d heard rumors of some fabulous beaches a little further off the beaten path where we might be able to escape some of the hustle and bustle of the city. Having never ridden a tro-tro before, we headed out with vague directions. The plan was to meet up (some of the other students are now stationed outside Accra) at Kenashie market. Getting there wasn’t hard. Almost all of the tro-tros that pass by the ‘hole in the wall’ that leads to our hostel yell “Kenash! Kenash!”-- indicating their destination. We flagged one down and piled in, smushing ourselves in a van with a dozen or more other people packed like sardines in the back of a speeding death-box, that swerved to avoid pedestrians, pot holes, and oncoming cars, and honked at every passerby to ask “do you want a ride” until ‘capacity’ was reached… we survived! For 20 cents, we were dropped wide-eyed at Kenashie. As far as the eye could see the streets were packed with vendors, hawkers, shops, street food, taxis, busses, bolts of fabric, cans of nails and pins and bolts, cell phones, donut balls, soccer jerseys, piles of socks, clocks, toothpaste, fried fish, piles of mismatched sandals, coconuts, and anything else you could possibly dream up. If you could find it in the maize, you could buy it. The area of the market we stood in was only half the craziness, two pedestrian bridges about a half mile apart, connected the side of the market we were on to a continued expanse of craziness on the other side of the four lane thoroughfare. Miraculously, in the madness, after a handful of phone calls and bad directions, we connected with our group. A happy reunion of our little eight person Ghanaian family!

Within minutes, Alex and Nick’s aptly named friend, Wisdom, had us on a tro-tro headed to Kokrobite. Alex and Nick are working in a lab in Monpong 45 minutes from Korle-Bu. Wisdom is a young guy who does IT in the lab. He has taken them under his wing—teaching them to cook some Ghanaian food, playing soccer with them, and now, insisting on accompanying all of us to Kokrobite, just to make sure we didn’t get lost! The eight of us, plus Wisdom, filled the better part of a tro-tro, and headed North out of the city, before cutting west to the coast. For 70 cents, after a 40 minute ride, we were watching waves wash the sands of the African coast. We pulled off the main road onto a windy dirt road that took us hairly up a dirt, pot-hole ridden lane, over a steep hill for the overloaded bus, and then down the coastal plain, through roadside villages to the ocean. In the hills we could see larger houses, mostly grey cement block buildings, some finished, many half built or crumbling. Along the roadside little arrows indicated various beaches and food stops. Roadside stands spotted the drive, interspersed with garbage, beautiful views of the beach, shanties, children, and a smattering of goats.

We were dropped at a dirt road junction, 30 yards from the water, shaded by palm trees ripe with coconuts, and sided by a few cement buildings with lodging, and a sign that read “Big Millie’s Backyard” pointing down the lane that ran parallel to the ocean. Our plan had been to get to the beach and then find a spot to stay for the night. With Wisdom’s help we secured a few rooms at the “Dream Hotel”, breaking the bank at 13 cedi a person for the night. If we had explored further we could have probably stayed in a less touristy type place (though as far as we could tell there wasn’t really anyone else staying at our hotel…), but for our first outing, we were content with this place… plus we all just wanted to hit the beach!

The hotel was actually made up of outbuildings painted pink, reminiscent of Spanish styles, hidden in a garden behind the entrance. Each villa contained a few rooms, each outfitted with three single beds, a toilet (which sometimes flushed and had no seat), a shower, and a fan! As with all beds we’ve encountered in Ghana, there is a fitted sheet covering the mattress and a pillow—but no other sheets—not that you would want them in the heat! We were more than pleased with the place. Outside the rooms there were monkeys in the trees! At first glance we were stoked… before realizing that the monkeys were shackled to the trees, clearly on display for the visitors. It was later pointed out that none of the monkeys made noise and had probably had their vocal cords cut. I contemplated cutting them free… but decided that probably wouldn’t end well for me or the monkeys.

The sun was high, the beach was gorgeous, and with the ocean breeze we experienced comfortable temperatures for the first time since arriving. We staked out a spot, not a challenge on the spacious sands. A little further east 30 or so people played in the water, at the beach front of a hotel with trinket stands that sprawled onto the sand. We settled between a row of hardy wood fishing canoe-like boats and a little wood hut with rasta-men and the more than occasional smell of pot in the air. The beach was heavenly. Within minutes Nick and Alex had drummed up an intense game of beach soccer with the rasfa-dudes. We laid out towels and spent the afternoon lounging, playing in the bathwater ocean waves, and watching the action on the beach. I couldn’t help but cave to the lour of the water, and delinquently removed my cast, and was helped to the shore where I happily sat in the waves. Water therapy?! 

Two guys and a young boy practiced an acrobatic routine nearby for hours—doing flips in the sand, standing on each other’s heads, whirling around with impressive balance preparing for a performance that evening. A group of nine or ten year old boys chased around after soccer balls and ended up stark naked running on the beach, kicking the ball and flipping into the water, surfing on old water jugs, and having far too much fun. A few chickens wandered on an off the beach at their leisure. Occasionally women would walk by with drinks or snacks balanced on their heads—unlike the men, they don’t solicit their sales (so much more pleasant!). They sold me my first ‘bag water’ which was intensely chemical flavored, to a degree that keesha’s crystal light powder couldn’t mask—unpleasant enough to dump out despite being thirsty. A pair of jewelry makers stationed themselves behind us, and we sat for a while sorting through their necklaces and bracelets of glass and stone hand painted beads. Once the soccer game wrapped up there was a fairly constant stream of rasta-dudes coming over to chat us up—asking about my leg, and telling us to come back later to hang out. The majority of Ghanaian men are so forward… “Hi, what’s your name? You have eyes as beautiful as the sea. You come later? We hang out!” Ummm no. Did you really think that line was going to work for you?!

At one point a scruffy little puppy, no more than 6 weeks old wandered onto the beach. He had patchy black fur, and clearly was in serious need of a mom and a vet, but he was playful as could be. He came loping clumsily across the sand, and I couldn’t help but pick him up! (I promise I washed well after and didn’t bring him anywhere near my face). He was sooo friendly. When I put him down and walk away he came running after me, jumping on me when I laid back down. He then joined a little boy playing near the bead lady. The boy totted him around and fed him parts of his donut ball snack. At one point he wandered over to the rasta men, and one of them picked him up by the ears and carried him whimpering back to the edge of the hotel… maybe that’s his dad? Poor puppy! There is a completely different mentality towards animals here—from the puppy, to the goats we’ve seen dragged on the street, to the monkeys tied to the trees. Sad.

After beaching it up, and pricing out the two close-by food options (annnd the power is out again) we chose to eat at our hotel. We seem to be fairly slow learners. We sat down starving, ignoring the fact that nothing happens fast here, particularly food. I’m fairly sure that when we order in most cases the cook then goes and starts the meal—I mean it makes sense, they can’t have a whole bunch of premade food kickin’ around. Plus, we were the lone diners at the outdoor hotel patio, in sight of the beach… table lit with my headlight. About an hour after ordering, and then gorging on dinner, but walked over to “Big Millie’s Backyard” where the place was hopping with a number of “Obrunies” (The word for “white people”). Their accents sounded Australia, South African, and American accents—obviously a tourist spot for 20 or so lucky folks. A word that sounds like o-bee-bee-nay means black person—Alex has taken to responding with o-bee-bee-nay when little kids point at him surprised and yell oooobrunie! Apparently the shock is double when he responds in Twi!

At Millie’s I had my first African beer: “Star” ‘Ghana’s favourite beer!’ according to the bottle. It tastes like America’s favorite beer, Budwiser. We sat under an outdoor bar with a grass roof. Christmas lights illuminated signs hanging from the roof with prices “per tot” (shot?). (Power is back) The local gin was 50 peswaes a ‘tot’… thankfully none of us wanted to try it. We hear it’s seriously potent and sometimes dangerous stuff. It was a chill night—we each had one beer, and sat chatting in a big circle tiki hut within ear shot of the ocean under a blanket of the first stars we’ve seen since arriving (first clear night). By 10PM we all moseyed the 100 yards back to the hotel to collapse into bed . Now that is my idea of a night out!

I spent Sunday morning reading on the beach, and was out early enough to see the fisherman paddle their bulky wooden boat through the surf on their return from the morning catch. It took seven men to get the boat up on the beach. These guys had the routine down. They placed a large tube under the front of the boat, grabbed the sides and together rolled the boat forward over the tube, repeating this process until the boat was in the proper place. Then they hauled out there nets. I sat a few feet away and watched them sort through enough crabs and crawfish to fill a laundry sack!

We capped off the stay with “Obrunie Breakfast” at Big Millie’s where we happily had omelets, crepes and coffee (!!!) for a few cedis each. Here, traditional breakfast food is the same as traditional lunch and dinner food—lots of rice, platans, chicken, and spice—so it was a treat to get breakfast food and coffee! We expertly tro-troed it back to Accra, and for less than a cedi fifty were back in the urban sprawl. An all around successful first outing and a wonderful weekend break!

Sending tropical rays to all of you.

Much love!