Suffering on Lost Island

This region in which we were working in Ghana is all that it looks – lush, verdant, cooler than the city, and peaceful.  We refer to it as the island from Lost. To me it seems a much more pleasant lifestyle to live in poverty in this rural area than in Accra.  There is space and cleanliness; sanitation is separated from homes.  There is solid shelter, even if it is made out of mud.  It is actually pretty cool how the villages are laid out, with a single path leading into the forest, emerging in a freshly swept clearing with a home, leading to another path, and more clearings.

I was surprised at first when people here said “we are suffering” because it seems such a pleasant life compared to that of the urban poor.  But then I remembered that people here have a high burden of disease and little access to health care. There is no electricity, cell phone service, clean water, or plumbing.  They work very hard from a young age, doing the physical labor of farming and carrying many kilograms over many miles to trade their goods.  They have only a few, tattered items of clothing for their children to wear.

While suffering is all relative in a country like Ghana, their perspective reminded me of the importance of meeting certain basic human needs – really human rights – like clean water and sanitation.  I often found myself thinking back to elementary school, where I learned that all humans need food, water, and shelter to survive.  Back then I thought of it in the context of something just like Lost, about people who ended up on an abandoned island or in a dense wood alone and would need to resourcefully find food, water, and shelter in order to make it out alive.  At the time I had no awareness that there were whole countries where the majority of people don’t have proper food, water, and shelter.  Even now, with this reality fresh in my mind, it is hard to comprehend – and daunting to think of where to begin trying to create change.

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How are you I’m fine

Ghana comes with its own fan club for any obroni (white person).  Children above a certain age are just thrilled to see these natural wonders and to practice their English.  The two lines that every single Ghanaian child knows are “How are you?” and “I’m fine.”  Sometimes it comes out all at once “How are you I’m fine” and sometimes it comes out separately, as an enthusiastic question or response.  They’re never great, or good, or ok, or happy, or so-so, or not so good.  They are fine.  Of course, all that I know how to say in Krobo, the language spoken in the region where the study is taking place, is something along the lines of “Kinge keh?” and “Inge saminya” (phonetic, in an error-prone way); or, “how are you?” and “I’m fine.”

Children above a certain age are also eager to pose for the photographs that obronis inevitably take and tend to squeal with delight and make fun of one another when they see the screen of a digital camera.

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Children below a certain age tend to look from my face, to their mom’s face, to my face… and then burst into tears, no matter how harmless I attempt to appear.  Less exciting.

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Street scenes

Below are some videos capturing the different environments we’ve experienced lately.  The first is a video of the sidewalk outside of Makola Market.  The second video is a scene from our drive from the rural community of Dzamam, where we are distributing bed nets, back to the town of Asesewa.  It is the first leg of a journey that involves four vehicles and four hours to get back to Accra.

The trip typically takes place in a very old, very rusty car such as the one pictured below. Cars only go by on this single road out into the rural area about once an hour;  people pile in them when they get the chance, cramming into the trunk or even propped on the front hood.   Given that it already takes me a few minutes to regain my balance after being tossed around inside the car during this journey, I have not ventured to its outside.

Vehicle

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A clinic in rural Ghana

We have selected a site in Ghana’s Eastern Region for our bed net distribution.  We are working about a 30 minute drive from a town called Asesewa.  The photos below are from a clinic serving 8000 people in the region with 5 staff, none of whom are physicians.  A midwife used to perform deliveries there, but she moved.  Now the people from this community give birth in the company of a traditional birth attendant or go to the hospital in Asesewa.  It is the only hospital serving about 90,000 people and it has just one doctor.

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The next big thing

Seat belts!  So I mentioned in an earlier post that I was happy the American ambassador plugged the public health message to wear our seat belts three times in the five minutes that we met him.  I think of him every time that we are in taxis or tro-tros and, more often than not, the seat belts have been secured in a manner preventing their use. Often the seats of taxis have been taken out and reinstalled with the seat belts secured under and behind them.  Sometimes tro-tros actually have belts that are strapped and buckled – around the back of the seat.  Other times they have removed parts of the belt. As reinvigorated as I am each time I see the remains of car accidents with the distinctive head prints on the front windshields, my efforts to free the belts have mostly been rewarded only with broken nails.

Removed seat belt buckle

Removed seat belt buckle

Unused seat belts

While data is a term used loosely and that on causes of death varies quite a bit – the World Health organization lists 11% of deaths as caused by malaria; the Ghana Health Service lists 44% of deaths as caused by malaria – the lists all include traffic accidents among the top ten causes of death and estimate that they account for between 3-6% of all deaths.  In a country where infectious diseases, maternal mortality, malnutrition, and a lack of improved sanitation exact a high toll, road safety may not seem like a high priority.

But the US Highway Administration estimates that using seat belts results in about 50% fewer deaths and 40% fewer serious injuries.  Deaths from road accidents plummeted after the United States enacted legislation requiring people to wear seat belts.  As long as they are already built into cars and as long as there are frequent police stops here in Ghana (where bribes are sometimes collected), I think that requiring people to wear seat belts here would be a relatively straight forward public health measure to implement.  If seat belts are as effective here as the highway administration estimates they are in the United States, that could prevent 1.5-3% of the deaths that occur in Ghana, or save between 110,000 and 220,000 lives each year.

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Good morning

The house where we’re staying in Accra is next to a pre-school.   We awaken to cool beats and squeals of delight on the many mornings when drummers perform there.

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Don’t Suarez it!

Matt and I just got back from a National Malaria Control Program (NMCP) meeting. The second such four hour long affair that TAMTAM has attended, the meeting excited me. The meeting consisted of 25 people from the NMCP itself, USAID, and partner NGOs; a very strong group setting out with the ambitious goal of achieving universal insecticide-treated net coverage in Ghana and making good progress toward this goal. It was heartening that we were two of the three people in the room who are not from Ghana. It was also nice to feel like the study we are doing this summer will inform their work.

So, what are we doing this summer? We had a vague idea of what we might do before we arrived; of course, all that changed once we got here.

We will be conducting our study on both registration for bed net distributions and the actual distributions. During registration, community health volunteers survey the number of people, sleeping spaces, and existing effective bed nets in compounds. While this may seem straightforward enough, the devil is where he so often resides – in the details. For instance, many people here live in compounds, which we’ve so far seen range between 4 and 36 people. Sometimes a compound means multiple families live in different rooms of the same building; sometimes a compound means multiple wives and their children live in different rooms of the same building; sometimes a compound means all manner of extended family living in different rooms of the same building. When you are registering people, do you register them by home or by compound? Who should pick up the bed nets during the distribution? Does the veranda count as a sleeping space if people sleep there when it is hot?

We will follow the WHO guidelines of distributing one net per two people (rounding up for odd numbers) up to the number of sleeping spaces, minus the number of existing viable nets. I must mention that this formula is henceforth known as the Constance formula, for she is responsible for developing it at the very meeting we attended this morning. And herein lies the source of this post’s title: “Don’t Suarez it!” As in, don’t take something that’s not yours! (BOO Suarez!) At least he provided a good laugh at the NMCP meeting, though I’d prefer he not have batted Ghana’s ball out of the goal. BOO Suarez!!

Our study is on whether or not offering soap as an incentive for effective bed nets will increase reporting of effective bed nets. This will be an important topic for the NMCP as they undertake campaigns in regions with 30-40% net ownership. With limited funds for nets, they want the nets that they have to go to people who do not already sleep under good nets.

The second phase we are studying is bed net distribution, which you can imagine has as many caveats as registration. One such caveat is whether to do a door-to-door distribution or a point distribution. While this would be an excellent topic to investigate, we are limited to a few thousand nets and the ability to randomly assign people, not whole villages, to different treatments. We will be doing a point distribution, in which people come to one point in the community to pick up their own nets. We will be randomly assigning each compound in which people live not to receive hang-up of their nets, to receive hang-up by community-health workers after 3 days, to receive hang-up by community-health workers after 7 days, or to receive hang-up by community-health workers after 14 days.

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