Papayas and Plantains

Thursday I headed back to the labor ward at Maternal and Child Health Hospital (MCHH). A week had passed since my return from Accra but I still felt like hiding in our room from the possibility of more disappointments, but after a week I forced myself out. I forced myself to walk to the bus stop, to board, and then to make my way through the noisy crowded market. I reminded myself that the best moments so far in this city have all happened at MCHH. I reminded myself that there I can be useful - which is what I miss most here - and so I kept walking until I made it through the doors of the maternity ward.

Everyone greeted me warmly. I put on my scrubs and found the midwife on duty delivering a woman with twins. Three other women labored in the adjoining room. I started my rounds with Twumwaa, a 22 year old laboring with her first baby. At first Twumwaa’s face tensed with fear and pain during her contractions but with my hand on her back and a few encouraging words she relaxed visibly. From her I moved to Kate. This was also Kate's first baby and every now and then her body shook and she snapped her fingers as a contraction rolled through her. I stayed with her a while, my fingers lightly on her belly. She was still in early labor and her baby was doing well. Finally there was Rita who was not in labor but had come because her water had broken the day before and she needed antibiotics. As I waited for the night midwife to give me her report I stayed with them, chatting with Twumwaa and rubbing backs. Twumwaa showed me a few wedding pictures on her phone. She told me about her husband and her family. Her sister Porsha had delivered a boy two weeks previously at MCHH and was in the next room waiting for a sickling test. Twumwaa’s mother also came in and out, bringing porridge and water, both happy and anxious.

After a while the midwife told me that none of the women had been examined. By that point Kate’s contractions had picked up and I heard the baby’s heart rate slow after each one (either a sign of distress or approaching delivery). Unfortunately when I examined her she was only one centimeter dilated so we transferred her to KATH, the large teaching hospital up the hill. When I returned to MCHH I sat with Twumwaa, chatted, listened to her baby and periodically listened to Rita’s baby. I would have loved to stay and attend Twuwaa’s birth but I did not like the idea of making my way through Kejetia (the sprawling open market) after dark. So around 3:30 I said goodbye.

The next morning I found Twumwaa smiling ear to ear next to a little baby boy. When I asked her what time she delivered she said, “You told me I would deliver at 6 and I delivered at 6.” Her mother had been with her (or rather outside the delivery room when she delivered) and now greeted me warmly with a big smile and a huge bag of papayas and green plantains.

In the labor room I found Rita now visibly uncomfortable with contractions. I examined her. Her baby was breech, she had no fever but the baby’s heart was racing, and her cervix was only dilated five centimeters. This was Rita’s third delivery. I could not fully grasp the details but Rita said her second delivery was difficult and that the baby had died on his first day of life. Having witnessed too many tragic endings to similar stories I prepped Rita, took her phone number and transferred her to KATH. Each time I came in and out of the postpartum room Twumwaa’s family greeted me with warm smiles. I was not even present for the delivery but their joy at having a healthy newborn overflowed on to my shoulders. When they left that morning, Twumwaa’s mother said they wanted me to come to their home soon and she reminded me to put the papayas and plantains where I would not forget them.

A few hours later after transferring a third patient to KATH, I found Kate post c-section lying besides a sweet baby girl but found Rita still lying on the bed where we had left her. When I put the fetoscope to her belly I heard the same racing heart beat but now with the ominous addition of decelerations after each contractions. I found the nurse on duty and asked her what was happening. She said the doctors would be back soon and with smiles I begged her to take special care of Rita. I kept Rita in thoughts and prayers all day then steeling myself for the worst called her that night. Her voice was joyful, she said that she had delivered vaginally, and that the baby was now okay. Filled with gratitude and relief Clement and I sat down to our meal of black-eyed peas and plantains.

Power Hunger

People are getting ready for the elections this Sunday, 7 December 2008. At 4am someone blew a horn for a good 20 minutes while walking up and down the street. Then at 6am someone within our building turned their stereo up to share their gospel music with the world at full volume. It’s Saturday. On Wednesday I was in Accra and what should have been a maximum of an hour long minibus ride took three hours due to a huge political rally. For weeks now large chartered buses have been cruising the city, packed with people dressed in their party’s colors, leaning out widows, shouting, cheering, waving, blowing horns. This is the third democratic election since Rawlings, the military president, left power in 2001. Rawlings took power in 1982 and his military rule lasted until 1991. That year a new constitution was approved, multi-party elections were held and Rawlings was elected President. He held the presidency for two consecutive terms then in 2000, John Atta Mills (Rawlings’ Vice President) ran against John Kufuor. John Kufour won the elections and his rise to presidency marked the first peaceful transfer of power. In 2004 President Kufour won the re-election but now at the completion of his second term he must step down. Kufour’s party, the NPP has nominated Nana Akufo-Adda while, for the third consecutive election, NDC has nominated John Atta Mills. Ghanaians who remember the Rawlings era as the too recent past - with its human rights abuses, the disappearances, the stripping and beating of women in the streets - say never again. But, Atta Mills has been building up his constituency among the youth whose memories do not include such difficult times who argue that he became involved with Rawlings after the infamous era of human rights abuses so he should not be blamed for those incidents. Everyone is concerned about peace.

I am not worried about violence in this area. I feel no hostile energy in the city, in fact pleas for peace are ubiquitous. Coverage of the recent US elections were followed by local commentary on take home lessons for Ghana and the peaceful transfer of power. Last Sunday mass concluded with a prayer for peaceful elections and the church bulletin included a two page write up on the purpose of democratic elections. Most people I have spoken with say Ghanaians have experienced too much to resort to violence. I am not worried, but my thoughts do occasionally revisit a scene from a video presentation at a local museum. In the opening scene the camera panned a large crowd of men surrounding the Ashanti king all chanting and hoisting guns over their heads, while in a monotone voice the narrator said, “The Ashanti are a peace-loving people. They are always ready to defend themselves” . . . an interesting twist of logic.

Malawi will also hold elections next year. Since their dictator or “President for life” Kamuzu Banda, who ruled for 30 years, they have had three elections. Muluzi ruled for ten years (two terms) enriching himself greatly while infrastructure deteriorated and the people starved. Then in 2004 president Bingu waMutarika was elected. President Bingu lacks Muluzi’s charisma but many praise his efforts to cut down on corruption the physical development of Lilongwe has been significant over the past 4 years. President Bingu will run again but Muluzi is trying to elbow his way back into power (despite the fact that the Constitution limits any individual to two terms). Another likely contender is John Tembo, Banda‘s former Vice President. It seems in many countries African politicians never step down they just reinvent themselves. I have heard many Africans from different countries complain that political stagnation at the top is one of the greatest factors negatively affecting development. Clement says simply, “It is time to put this power hunger to rest.”

Struggling to Register as a Midwife

I just returned from taking the nursing exam in Accra. Only a few questions covered the material I studied but still, it was not a difficult exam, and for once in my life I did not feel compelled to score well. I am quite sure I passed and that will be enough. It was however, a frustrating experience. I learned at the exam that if I want to be registered as a midwife in Ghana, after the results are out for this exam and after I complete three months of full-time unpaid “orientation” at a teaching hospital, I must submit another application, pay another fee take another exam and do another three months of orientation in order to be registered as a midwife. Since I will be in the US in June - working for money so we can eat - I won’t be able to take the midwifery exam until next December, which means I will not be registered as a midwife here until mid-2010!! This kind of ridiculous bureaucracy is what bring me to the point of wanting to pack my bags. It is not the struggles of daily life or even the tragic and stressful experiences in the hospital, but the nonsense roadblocks set up to prevent people from actually being useful in the areas where they are most needed.

We were 20 foreign-trained nurses taking the exams to become registered in Ghana. Most of those in the room were Ghanaians who had trained in the UK or US and were returning home for a period to work and help their country. During the break between the exams, nurses traded story after story of how the Nurses and Midwives Council made every step of the process difficult. Several nurses had started the application process two years previously. While in Accra I also heard stories from another nurse returning to the public sector after leaving the field years previously to raise a family. She was required to complete six months unpaid orientation in the public sector, in a town two-hours from where she lives (she rented house and paid for transportation without an income). Since completing that phase she has spent the last three months waiting for an interview so she can begin work. Another nurse who was trying simply to transfer back from the private sector to the public sector was also made to work a six months unpaid orientation. Somehow a punitive mentality seems to be obscuring the vision of what is required to create a better health system. Ghana, like most of Africa, suffers from a severe nursing shortage. While it is necessary to monitor the caliber of nurses coming into the system it should be possible to streamline the process for the benefit of nurses and more importantly for the benefit of those receiving health care at public facilities.

African Mother Health Initiative Visits

When I left Malawi I left the seedling projects I had been working on in the hands of my good friend Beatrice Namaleu, a nurse with 28 years experience in maternal and child health care. With minimal funds and no additional support other than sporadic phone calls and emails she has been visiting and supporting 19 infants, overseeing the feeding program which feeds about 50 children three times a week, and paying school fees for 10 adolescents. We have no office and no support staff. We have a small local Board of Directors, Beatrice, and one hand-me-down computer donated by a friend. The nurses in the newborn nursery at Bottom keep a log of the babies whose mother die during childbirth and others who need follow-up visits at home. These nurses teach the guardians how to prepare formula for the baby and contact Beatrice so that she can arrange continuing home visits. Since Bottom is the referral maternity hospital for the Central Region of Malawi at times women come from great distances to deliver there. Without a vehicle Beatrice makes her way to the babies via minibus (privately owned minivans used for public transportation into which 15 passengers are squeezed) and bicycle taxies. While I was in Malawi, I accompanied Beatrice on her visits using these types of transportation to experience the work as she does day to day.

Our first visit was to Chikumbutso, one of the first babies I started following. Her mother died after giving birth at Bottom in February 2006. We boarded a minibus in town waited for it to fill, rode about 40minutes out to the town nearest Chiku’s village then hired two bicycle taxies to take us the remaining 15 kilometers. At certain trading areas off the main cross country roads and in small towns where minibuses are few, men with bicycle taxies gather in large groups waiting for passengers. They earn their living carrying people and cargo (e.g. 100kgs of maize or fertilizer, firewood, charcoal, goats, pigs, chickens, etc) around on their cheap single gear bicycles made in China. Those who generally transport people add padding to transform the bicycle rack into a fairly comfortable passenger seat.

I had traveled the road to Chiku’s village many times previously but always by car. It was a new and pleasant experience to ride through the farmland and neighboring villages on the back of a bicycle. As we neared the village I heard my name shouted by children before the bikes came to a stop. Chiku’s brother and cousins, her aunts, and grandfather came to meet us. Chiku, always suspicious of strangers looked at me with the same sour expression she had been giving me since she was an infant. I kept my hands off but laughed with joy. Seeing her now on the cusp of her third birthday and hearing her talk quietly to her brother filled my heart. She climbed onto her grandfather’s lap keeping us under observation as we chatted with the adults. As we mounted the bicycles again Chiku’s grandfather told Mrs. Namaleu to tell Clement to take good care of me and expressed his gratitude saying that the family would have never managed to keep her alive without our support.

From Chiku’s village we boarded the bicycles again and headed to see David. This was my first time meeting David but Mrs. Namaleu had been visiting him for several months. David lives with his grandmother. He is 11 months old. His mother was diagnosed with post-partum psychosis and shortly after his birth she was institutionalized in a hospital five hours South of the family‘s home. Within a few weeks the mental hospital contacted the family to report her sudden death. David’s grandmother said her daughter was not sick physically when she was taken away so the family was surprised by her unexplained death but when the body arrived they saw that she was covered in bruises.

At this point David is small for his age and his grandmother requires a significant amount of assistance in providing his care. When we arrived we found the grandmother home alone she led us inside her mud brick home with its dilapidated thatch roof and spread a tattered grass mass for us on the floor. She then collected David from a relative and told us he had just eaten but from his voracious sucking on his fist and inconsolable tears we decided that if he had eaten he was not full. Beatrice set to work, starting a fire in the center of three stones in the single room, preparing milk and then teaching the family how to prepare nutritious porridge for David with readily available local food: maize, soy, peanuts, and vegetables. As we left we decided that Mrs. Namaleu will increase her visits to monitor David, observe his care, and provide assistance as best she can. By the time we reached the small town in-between Chiku and David’s villages evening was setting in so we boarded a minibus headed back to town and then home.

I spent the first weekend with Clement’s dad, brother, best friend Fatsani, and grandmother in Mangochi. His grandmother made tobwa (a drink made from maize and millet), they prepared nkwani (pumpkin leaves - my favorite Malawian vegetable) and Clement’s dad paid too much money to buy me an illegal fish head (the lake is closed from November to January to allow fish to spawn but people continue to fish illegally) which I guiltily shared with William (Clement‘s 19 year-old brother). William accompanied me to the village to make the rounds to all the aunts and uncles but we found most of the adults missing. November marks the beginning of the rains and the time for planting. Malawian’s staple crop is maize which is not indigenous, it requires fertilizer to grow well. Most Malawians grow their own maize, even those living in town, and every year the government subsidizes fertilizer by providing coupons for distribution to the poorest in each village. Fertilizer is relatively inexpensive with a coupon but without a coupon villagers must often sell their livestock in order to raise enough money to buy a few bags. This year the government is providing significantly fewer coupons. I am not sure about the politics involved but people are very worried about how this will impact maize production. While we waited for the adults to return from lines in a nearby village, William and I hung out with children, walked to the lake and shared stories. Everything was over too quickly and moments after I arrived I was back at the bus station saying goodbye to Clement’s dad.

The next week was filled with more visits and a spontaneous trip to the border of Mozambique. A set of triplets were born at Bottom in August and a few weeks later the nurses in the nursery contacted Mrs. Namaleu to follow them up in their home. The mother was alive and well but the babies did not seem to be growing well. Mrs. Namaleu began visiting them in a village outside Mitundu (involving another 40 minibus ride and then a 30 minute bike ride). Thursday morning, Mrs. Namaleu phoned the village chief (the only person with a cell phone living near the triplets) to ask whether the woman and her triplets were home. He told us to come and that we would find them. When we arrived in the village we were greeted by the maternal grandmother of the babies who informed us that her daughter had taken the babies to Mozambique the previous week to follow her husband. I never fully understood why the husband left - one story was that he went to find work another was that he married a second wife - whatever the reason his wife decided despite the pleading of her family to load her belongings and three infants on a bicycle and follow him.

Mozambique shares three quarters of Malawi’s borders; on a map Mozambique appears to be in the process of swallowing Malawi. There are sections of the main road running South from Lilongwe where just meters to one side of the road is actually Mozambique. So, when the grandmother told us that the village in Mozambique where her daughter was living was not far, Mrs. Namaleu and I believed her. She explained the route to the bicyclists and they agreed saying, “We can make it there and back in good time.” It was 10am. As we just started off the man whose was carrying me pointed to some distant blue mountains, said the village was on the other side and that it would take us about four hours to get there. Malawians are notorious for their underestimation of time and distance so hearing that was enough for me to call the whole thing off but the moment I started questioning and told Mrs. Namaleu both of the cyclists began insisting that it would take only three hours. Mrs. Namaleu became convinced and I decided to accept the adventure. I tried to send a text message to Ruth telling her that I might not be home until Friday but there was no signal.

I could not show on a map the route we traveled, we did not approach any roads, instead we weaved our way through villages, farmland, and a forest reserve, climbing and descending rolling hills until we finally began to ascend the mountain once blue in the distance. I chatted with Braveson as we traveled amazed by his strength and endurance. We shared bread and stopped in a village to refill my water bottle at a borehole. Adults who caught sight of my face under my wide brimmed hat stopped in their tracks shocked by the sight. Children pointed and screamed with delight. As we ascended the mountain Mrs. Namaleu and I got off the bikes frequently to walk beside them. Mrs. Namaleu and her cyclist often lagged behind and at various points we debated whether we would be able to make it to our destination. Each time we decided to continue. Finally after four hours we arrived at the border which consisted of a small adobe compound with one desk manned by a Mozambican solider. He charged us each 100MK (about US$0.80), to stamp a piece of notebook paper and add his ostentatious signature. The solider spoke Chichewa and Portuguese only, so with my rusty Portuguese I asked him how far we had ahead of us. He and his friends laughed at the idea that we would be able to travel to the village and back in one day. A man on a motorbike came up behind us and said he would carry me to the village and back for a fee. He said it was not very far but when I asked how many minutes on the motorbike and he said one and a half hours I knew our journey had ended there at the border. If I had been able to contact Ruth, and if Mrs. Namaleu could have called her daughters I would have felt comfortable to continue but it was not right to worry them unnecessarily. We debated a while longer about how to get the formula to the family but finally decided that we would have to carry it back. (Mrs Namaleu felt that if we entrusted it to a stranger it was more likely that they would sell it than deliver it.)

I was disappointed about our failed adventure but more worried about the condition of the triplets. I could not imagine how the mother made the journey alone with her babies on the back of a bicycle. I wondered who was helping her care from them in Mozambique. Our return trip was faster - a mere three and a half hours. It was just as beautiful but cooler. Braveson and I lightheartedly agreed on four problems which contributed to our failed quest: (1) the village chief telling us to come; (2) our late start; (3) Braveson’s underestimation of the time; and (4) his colleague’s slow pace. Braveson was particularly keen on problems two and four. Mrs. Namaleu is a bit heavier than I am but when I suggested that this might be why his colleague was constantly lagging behind, Braveson refused to accept this reasoning. He said that at times they carry 100kgs of maize and even a 70kg person is much easier to carry than 100kgs of maize. In my opinion, cycling for 7 and 1/2 hours even with only a 50kg load is an amazing feat.

By the time we reached Mitundu the sun had set and the last minibus heading to Lilongwe had already departed. Luckily we were able to hitch a ride in the back of a covered pick-up. Once in town we boarded a minibus and then Ruth collected me from a gas station near her home. We did not accomplish what we had set out to do but the family would hear about our adventure and meet us at Bottom the following week. We would find the triplets hungry but alive and well. That night my sense disappointment was eclipsed by a greater feeling of being alive, the newly laid memories of a beautiful day, the smell of the air in my clothes, and pleasure of a shower, and the joy of lying down to rest.

The following day was my 33^rd birthday. I treated myself to a haircut and pedicure, had tea with a friend, received a birthday call from Clement and then from my parents. I had lunch with the Namaleus which evolved into a spontaneous dance party, then had dinner with Lisa, met 9-month old George and chatted until midnight. I am somewhere I never imagined I would be but this journey with all its unexpected twists has also brought so much unanticipated joy. This is what I must remind myself of during the moments when I crave something else or when I simply crave a life path with fewer curves and better visibility of the road ahead.

The following weekend I visited Clement’s mother and stepfather in their village in Salima. William had spent the week with them. I was happy to see him again and grateful for his help with communication. Village life is full of physical labor but as a visitor I always find my time in the village to be a peaceful retreat. We spent the afternoon sitting on a mat greeting neighbors. Now and then I noticed neighbors bringing plates of food to the house, flour, nsima, mangoes. I have seen this each time I have visited and I asked William whether they do this because his step-dad is the chief or because he has visitors. William said that the people there share what they have with each other and it is something he has not seen in other villages.

Clement’s mom prepared a chicken and offered me more than I could eat. Then William and I visited the farm with James, his step-dad, to see the dry earth tilled in neat expectant rows. I took a bucket bath in their newly built adobe shower then as the sun set we ate small sweet mangoes until my skin felt tight over my belly. Inside the house, the temperature was stifling but outside was cool and fresh. William said he had been trying to convince them to sleep outside all week and so when I mentioned sleeping outside he made sure his mom heard. She prepared two grass mats on the sandy ground, covered each with a few layers of blankets and cloths and then we all laid down under the stars. The night was crisp and peaceful, the silence broken occasionally by sounds in the distance of people talking or laughing, or dogs barking. Sometime around 1am a few rain drops began to fall and though I would have happily continued to sleep under the dripping sky, we moved inside. The rain never fell that night.

Early the next morning Clement’s mom woke to fetch water. Apparently the village borehole has been broken for three months so now she must walk to a nearby stream to collect water. I jumped up and offered to help but everyone laughed and told me to go back to sleep. When she returned the skies opened and we sat inside drinking tea watching the downpour. They told me that every time I come, I bring the rain.

A few hours later William and I left. I wanted to see the lake near the village so William directed my driving. He had biked to the lake during the week with Felix (their young half-brother). Felix told him initially that the lake was nearby and then from his seat on the back of Williams bike - each time William felt discouraged or tired - Felix would say that they were almost there. The lake was 18 kilometers from the village. We laughed over our similar experiences of “almost there.” William is quiet and sweet and has a good sense of humor. It was lovely to spend time with him, trade a few stories and laughs. When we returned to Lilongwe, I took him to the bus station and hugged goodbye.

The rest of my time in Malawi, flew by. The days were filled with visits and the evenings with friends. Every night I slept soundly and every morning I was surprised by the hasty arrival of sunshine. Every day carried joy and the familiar enigmatic feeling of overwhelming love. The feeling would come while looking at Chikumbutso and her little sour face, or sitting with Nayopa family drinking Sobo and laughing, or holding Catherine (Ireen’s baby girl who was born around our wedding time last year) and kissing the top of her sweet smelling head, or riding through the country on the back of a bicycle, or watching Pamela gently and lovingly tend to her three surviving quadruplets, twins and three other children. In those moments I felt I would do anything to sustain the feeling of such a perfect inebriation. I think when you see someone struggling through life but living with incredibly love the natural response is an urge to drop everything and become a part of that force.

The only difficult part of being in Malawi was being separated from Clement and not being able to talk apart from a few minutes every couple of days. Still, my departure day arrived too soon. I packed my suitcase like an African - a few clothes, toiletries, etc. then ofa (maize flour), millet flour, kapenta (small dried fish from Lake Malawi), Nali (Malawian hot sauce), Malawi tea, chocolate and Belgian chocolate, and a bottle of Champaign (the chocolate and Champaign were gifts from a Belgian friend just returning from home). Thankfully no one at any of the airports requested to look through my bag.

When leaving Ghana I thought that on my return I would stay in Accra several days until completing my nursing exam but when the plane touched down the first thing I wanted was to get back to Clement. As I stepped outside I could feel my pores opening in the heat and a weight or maybe a familiar sadness settle over me. I found a taxi, boarded a bus to Kumasi, and after five bumpy hours I stepped down into light of Clement’s handsome smile. I left so much behind in Malawi but here with this man there is also comfort, love, and hope.

The Roof of Malawi

Malawi was lovely. It was wonderful to be back. Even before I actually stepped off the plane a Malawian nurse on-board recognized me and said, “Welcome Home.” Mrs. Namaleu greeted me outside the baggage claim and escorted me to my friend Ruth’s home - a Swiss nurse working at the American Embassy. In comparison to Kumasi, Lilongwe looked so tidy. In the months since our departure there had been notable development - new buildings, new traffic lights, freshly paved roads. Though people complained of the heat I felt comfortable, my shirt remained dry against my skin and I could feel a breeze on my face. It felt so good to be with friends, to hear the sounds of birds and bugs rather than radios and conversations as I fell asleep and woke up, it felt so good to be with friends, and it felt great to be useful again.

I did find a small dose of shock waiting for me as I was confronted again by the grip of HIV on the country. In Ghana the HIV rate is reported to be around 4% (while in Malawi it is 14%) but even with the hundreds of women I have seen for prenatal care in Ghana I noted that only one of them tested positive. Perhaps I am less aware of the effect of HIV in Ghana because I still have few friends. In In Kumasi, the heart of the Ashanti region, funerals are celebrated grandly and just moving within my limited radius I see about one funeral a week (I am not suggesting that these funerals are all HIV related). All the guests dress in black, large tents are erected - sometimes blocking off a section of road, people dance, and the drumming and music can be heard from great distances. Evenso, in Malawi quiet funerals marked only by a couple branches laid down on the road in front of the house and crowds of men and women sitting outside, the funerals seem much more visible. All my Malawian friends told me about relatives who had died, about siblings who had tested positive, and about co-workers who had died since I left. During my three short weeks in Malawi someone who had helped with my wedding died and a key figure at the hospital died.

In Malawi HIV touches everyone. After each death, children are redistributed to surviving relatives and over time the burden on certain families becomes crushing. As in much of Africa, orphanages in Malawi are rare. When parents die relatives or even villages take on the responsibility of caring for the children. Many times this works well for the children - as they live within a loving familiar environment but other times jealousy, resentment, or poverty work to their detriment.

As we moved around visiting the babies and families we are supporting through our non-profit, African Mothers Health Initiative Mrs. Namaleu often said, “Mutu umodzi susenza denga” One head cannot hold up the roof. She said this in relation to the work she had been doing - as she is our only employee and has been going to great lengths to keep things moving. She would say this in gratitude for my visit and in gratitude for the linkages with others we began to establish but I could not help but apply this to the situation of Malawi in general. Because of HIV the number of heads holding up the roof is decreasing and the remaining people are struggling under a crushing weight.

This is illustrated dramatically by the story of a woman living near Mrs. Msumba the TBA in Kauma. As she was on her way to visit Mrs. Msumba a few months ago Mrs. Namaleu noticed a large group of women gathered around a neighbor’s home. Gradually she made her way to the center of their circle and there she found a toddler with severe Kwashiorkor (a disease of malnutrition, manifested by - generalized swelling, peeling skin, loss of pigment of hair, and areas of the skin which are either hyper or hypopigmented). After inquiring, Mrs. Namaleu learned that the child’s guardian was his grandmother. The grandmother had had 15 children but 12 of them had died in adulthood leaving their children in her care. She was married to a man who was not the father of any of her children but he was a good man and was trying to support them all on his salary as a night watchman. Often they did not have food in the house for days at a time so the grandmother decided to get work at the nearby rose farm. Unfortunately while she was working, spending long hours away from home and from her youngest grandson, his condition deteriorated. After a month of working six days a week and still not having received the measly salary of 1,500MK (about US$10), she returned home. The day Mrs. Namaleu came to their home, hope had disappeared and the women gathered were literally waiting for the child to die.

Without hesitating, Mrs. Namaleu took the grandmother and the child to the malnutrition ward, admitted them, visited them regularly, oversaw his care, and in time the child made a full recovery. However once he was discharged home and stopped receiving the enriched peanut butter based supplement from the hospital he immediately began deteriorating. Again the grandmother took him to the hospital and again he was restarted on the food supplement. At the time of our visit the baby looked very healthy but he was still receiving the supplement and the family worried what they would do once he was again discharged from the program. The grandmother, her husband, and their nine dependents live in a small mud brick home on the outskirts of Lilongwe. We are looking for funds to help support this family. We would like to provide them with what they will need to begin a vegetable garden as well as supplements for the youngest children in the household.

Ruth told me of another friend, an educated middle class Malawian - who has built bunk beds throughout his home to accommodate nieces and nephews, orphaned by HIV. This man who by the standards of most Malawians “made it” is now struggling to stave off poverty. The great tragedy is that these stories are not uncommon and they are becoming increasingly common. How can the weight be redistributed?

Obama

On November 4th I was on my way to Malawi. It was time to go and check on the projects I left behind and after a few difficult months in limbo, I was more than ready for a reunion friends and family there. Unfortunately Clement was in the midst of exams so he will stay in Kumasi. I promised to return with edibles and stories. In order to register as a nurse in Ghana I must take an exam. The exam is only offered in June and December and when I bought my ticket they did not yet have a set date in December. After I bought my ticket they set the date for December 3^rd, so in the end Clement and I could have traveled together.

I spent the night of the 4th in Accra with friends. Thoughts of the US election consumed me but even late in the evening, coverage of the US elections was minimal. Though the pre-US-election frenzy was not equal to that in the States, for months Africa had been emotionally participating in the US campaign process. Streets vendors sold homemade pamphlets on Obama and his family and people every where discussed what Obama’s election would mean for the continent and whether it was truly possible. The night of the 4th I only lightly skimmed the surface of sleep then around 4am I heard someone switch on TV. Relieved, I jumped out of bed and rushed to a chair in the den. We heard McCain’s speech and then moments later Obama‘s acceptance speech. A friend called and said people were dancing in the streets in New Hampshire. My cousin in New York wrote an email saying people on his block were chanting, “Si, se puede.” As I began my journey, to the airport in Accra then to Nairobi then to Lilongwe, every television along the way was tuned to the coverage of the US election results. People kept asking if I was an American, if I voted, and if I voted for Obama. Each yes was met with cheers and handshakes. I don’t remember ever feeling this way. I guess for the first time I was beginning to believe in the American dream; recognizing with awe and pride the reality of dramatic peaceful transformation of a country in the span of a single lifetime. My mother, my aunts and uncles lived under Jim Crow, my older cousin desegregated their high schools, and now we have a black president. Hope and change don’t sound like mere slogans but forces that have been working their way up to the surface and are beginning to bubble.

Light

Today I delivered my first baby here in Ghana. I began in the prenatal ward in the midst of well oiled prenatal care. The nurses started the day panicked because two colleagues had called in sick so their solution was to pick up the pace. The conveyor belt flew at full speed and a nurse stood in the door like a coach on the side-line, waving the women towards the finish line shouting, “fast, fast, FAST.” Women obliged, handing off charts while setting down purses, and lifting skirts as they climbed onto the exam table. Each woman lay down, belly exposed, arms stiffly at her sides, her mind absent, eyes fixed on the same corner of the ceiling. I enjoyed pulling them back to Earth, by saying “Good morning,” we would both smile as though we were breaking all the rules and I would watch her muscles relax.

After a few hours of that I was called to do the prenatal ultrasounds. Dr. Annie usually does them but it is just one of her many responsibilities and I enjoy doing them so she has passed it on to me. I feel comfortable with my scans but I would love to take an actual class, know I have a lot to learn. I was taught through oral tradition - receiving hands on instructions then refining tips (some tips contradicting others) from various clinicians, most of whom had learned in the same way. Just as I was moving towards the door a midwife from the labor ward entered, said something to Doris in Twi and threw in the word, “breech.” I asked her, “Is there a breech delivery?” She said yes, asked whether I knew how to conduct a breech delivery and then led me hurriedly away towards the labor ward.

Mary was straining when I walked through the door and I could already see a little corner of a tiny pink bottom emerging from between her legs. The midwife who was there stepped aside and set up the resuscitare - which I soon learned consists of one old ambu bag and a non functioning oxygen machine. Mary was amazing, she smiled at me between her contractions and within ten minutes her little girl's head emerged and I lay the baby on her belly. It was so wonderful to be there that I laughed as I dried her baby, congratulated Mary, and thanked the nurses. I rushed back to the scanning room to find 26 women waiting for me but as soon as I finished the scans I returned to Mary and her baby. Mary looked happy and fresh lying beside her little girl nestled in blankets. This is the beautiful lightness of life.

Ennui Again

As our sentence in limbo extends indefinitely out before us I feel frustrated by inactivity; I feel passion and energy and life bubbling inside, I am ready to do something but life is holding me still keeping blinders over my eyes. I suppose the notion that any life could be overflowing, that moment after moment would be charged with emotion, that incredible joy would be waiting to be discovered out there, is childish. We distill out the salient moments and find that each life holds an amazing story, we hear or read the stories of others and become inspired by 100 words or an autobiography but in the living there are so many more moments of waiting, of expectation, of reflection, of questioning . . . Is this the right path? Perhaps these are the moments when we truly become who we are rather than a laundry list of what we have done.

Clinic Days

Today I woke up happy and excited to go to the hospital again. I need a salary but I would happily go every day without one. The thought occurs that at this moment it is a privilege to be there, perhaps when it becomes an obligation the attraction is ever so slightly diminished. I should remember it is always a privilege.

Even though I’m just in the prenatal clinic I love it. The nurses have welcomed me and they make me laugh silently as they vacillate between gushing over patients and admonishing them harshly and loudly. A young girl came over from the labor ward to tell the charge nurse, Doris that she had delivered. Moments before Doris was frowning deeply and whole-heartedly criticizing a woman for something or other but at the sight of the girl she transformed with light. Proudly she announced to me and then to the rest of the clinic that this was our patient, and then with her arm around the girl, she rushed off to see the newborn. The loud harsh tones still make me uncomfortable (it was the same in Malawi) but I recognize that this is part of the concept of parenting here. All older women are called Auntie or Mama, they are supposed to be treated with respect, and in return older women may treat any young person as they would their own child. In the West few would tolerate a stranger’s reproach of their child and we would just as rarely trust a stranger to care for our child even in the performance of a simple mundane task. The other day a familiar scene struck me in a new way, I watched a woman board the minibus and leave her two year old on the ground behind her as she stepped in. Without a glance back or a word she knew the man opening the door would pick up her child and hand him to her once she was seated, which is exactly what he did. Trust preceded the event and its existence was so deeply understood that it was never even acknowledged. It was beautiful to witness an implicit trust in humanity, and I think particularly on such a small scale. If I can’t trust a stranger to hand my child to me, how can I trust a stranger to care for his community? Or to raise his own children to be compassionate global citizens? Or to conserve natural resources? Or to care for the environment? These are our ideals and they require enormous levels of trust and faith but when it comes to a very small test of trust we so often fail. (I still would not want someone to yell at my child and definitely not slap them - even lightly - but it is useful to consider what we gain and what we lose in each perspective.)

As I spend more time at MCHH I am noticing many small positive differences between this hospital and Bottom. First, all women submit urine and stool samples at the initial prenatal visit to test for both bladder infections and parasites. And it seems that many, though asymptomatic have positive results for which they receive treatment. Also, women are indeed asked quite directly on every visit, whether they have any complaints. The nurses who ask the women about their complaints and offer treatment are aware of the need for privacy (as I was told to sit closer to a woman on account of needing to protect her privacy) but even with the attempt to talk in low voices and distance the client from others waiting by two or three feet, it is obvious that others follow the conversations with interest. In general, despite the strains on the system, when a woman needs a second ultrasound or another lab test or treatment for a yeast infection she is able to get it. Hopefully this will not change despite the increasing numbers. Doris told me that before the announcement of free prenatal care they would see 80 to 100 women every day, now the numbers range from 150 to 300. Finally, though the women are poor, there are more well-nourished women here than among those who come to Bottom. Every day I see quite a few American sized bellies and though I do see many Hbs of 9 (12 to 14 is normal), I don’t see many below that. These differences are really quite small but I imagine that they are in part responsible for the lower maternal mortality rates.

Dr. Annie is sweet, she is always grateful for my presence, the nurses greet me warmly and ask after Clement each morning, and the women smile and trust my hands on their bellies. I enjoy being there, listening and observing. Many of the women have come from rural areas to the city to work. Their bodies are decorated with information I do not understand. Many have scars around their belly buttons transforming a growing pregnancy into a starburst, some have a simple tattoo in the center of their forehead something like two “S”s hanging on each other. Others have hands hennaed, and feet decorated with black paint, others use dark thick charcoal under their eyes. Diversity is beautiful and intriguing.

Water

Ernest told me yesterday that there is no central water supply in Kumasi, no water treatment plant. Homes and buildings all pump water from the ground. This is pretty incredible for a city of 1.5 million. It makes sense why the water so often goes off but I’ll have to check out the facts. Our water has now been off for going on four days. The problem is not the source but the pump. There is plenty of water we just have to go down stairs and carry it up in buckets, but the water is not the same water we usually have running through the tap. On the second day of no running water I met the landlord downstairs and he showed us where we could fill buckets from a large tank. He helped us fill our buckets and I eyed the suspiciously murky water but carried it up. We have separate water for drinking and cooking but we still need water for bathing and flushing the toilet and washing our hands and . . . washing our plates. Now I have giardia. I have had it so many times before that I instantly recognized its undesirable presence. I know as soon as I can get meds from a pharmacy I will improve but it’s Sunday so this means one more day of nausea and running back and forth to the toilet. I think I also now need a doting relative to help fatten me up. Those pounds gained bite by bite with Blue Bell ice cream in Texas are now just a memory. Ghana why are you being so difficult?

Clement just came up with a bucket of water (I finished off the rest with all my toilet flushing) and says that now the tank is dry. We are completely out of water both dirty and clean. This is not a personal torture, this is not a personal torture, this is not a personal torture . . . .

Health Care for Women of the World

In the national newspaper today there was an article specifically about the health care crisis brought on by the National Health Insurance Scheme (NHIS). NHIS was introduced last year with the goal of providing affordable health care to the population at large. A nominal fee is charged at the time of enrollment but then, once enrolled, services are essentially free. The government is supposed to reimburse hospitals for the actual cost. The recently established policy of free antenatal and delivery care goes a step beyond NHIS. According to the article, within just one year of instituting NHIS, the government already owes hospitals millions of Cedis (US$1.00 = 1.14 Cedis) and as a result many public health centers are on the verge of collapse. The article also stated that the government expects hospitals to cover much of their operating expenses but at the same time has created a system in which hospitals do not generate income. Effectively one problem has been traded for another, a great percentage of the population were unable to access health care and now they have been granted access but the care available is rapidly deteriorating.

Today was my second day in the Prenatal clinic at MCH. The process is very similar to that at Bottom with some slight improvements. Women arrive in the morning and pass through a series of stations - history taking, blood pressure, weight, belly checks, dipping urine for protein and glucose, and treatment (here there are a couple extra stations). All women have labs drawn twice during the pregnancy, all women are tested for HIV (done confidentially by specially trained counselors), and all receive one ultrasound during the pregnancy. Within the prenatal care clinic, the only space with relative privacy is reserved for the belly checks, the rest of the stations are located within the large open waiting area. There is a constant flow of women around the room, which is maintained by the staff and it seems that unless a woman is very determined to mention an issue to a nurse, it might be overlooked. The clinic continues until the flow stops. Today that was around 11:30am (it was teen clinic so there were not as many women) but apparently on Fridays and Mondays clinic closes around 4pm). I have been in the belly check station. I was happy to see that measurements are made with a measuring tape. If women have an accurate date of delivery (based on either their last menstrual period LMP or dating by ultrasound) the uterine measurements should correspond fairly closely with the gestational age. If the measurement is off by more than 3cm in either direction then we would refer the woman for further investigation (e.g. if the gestational age is 24 weeks the measurement from the pubic symphasis to the fundus should be between 22 and 26cm). But ironically, even with possibility of calculating an accurate date of delivery, gestation is measure by hand. So, for example, if the top of the uterus reaches her belly button the nurse will say she is 20 weeks and then perhaps on her body the measurement from her pubic symphasis to that point is only 16cm. This method severely limits the value of obtaining a specific measurement. I have also already been told that the women do not know their LMPs. I was told this at Bottom too but I found that if you ask a woman and give her a few seconds to think about it she can usually come up with an exact date. I had the same result here with one woman, we’ll see how it goes.

Most women who come to MCH are quite poor, many of them work as vendors in the nearby Ketejia market. Dr. Annie said that because they would rather save the little money they earn they will not eat for the entire day, until they return home. Around town one of the most common items to sell is water (water and handkerchiefs since everyone is constantly sweating). Women buy a satchel containing 30 individual water bags (500ml each) for 1 Cedi and sell - eventually one by one, walking back and forth between traffic with a basket of water their heads, competing with each other for customers - for a grand total of 1.50. Will 50 pesewas even purchase enough food to replenish the lost calories? Due to the poor diet, as in Malawi, anemia in pregnancy is a common problem. Yet, even with severe anemia by US standards women are transfused rarely. Dr. Annie says that the blood is supposed to be free but if you get the free blood it means unscreened blood, to obtain screened blood each pint costs at least 15 Cedis (you if transfuse a child and use less than one pint, the price is still 15 Cedis).

I am not surprised by the conditions. The summer between nursing school and midwifery I went to Bolivia and spent and few weeks in a public maternity hospital there La Maternidad. I wanted to see what birth was like for poor women of the world. There I was shocked. A midwife mentor in the US set me up to observe at a clinic in Santa Cruz that she herself had helped establish. The clinic was immaculate, well stocked, and the staff were welcoming but the births were few. So, after hearing about the public hospital with 50 births a day I decided to go there. I walked into La Maternidad wearing scrubs, bearing a letter of introduction from another physician, and carrying my nursing school ID, and asked if I could observe. I was given permission. La Maternidad is a large teaching hospital with many staff and numerous medical students.

At that point I had already seen many births in the US but birth was very different in La Maternidad. As I witnessed my first birth there I felt myself start to lose consciousness several times and each time I had to either sit on the floor rush to the hall. For a few hours afterwards I doubted whether or not I had chosen the right profession until I realized that the trigger was not the birth but the violence. When the laboring women arrived in the hospital they were examined in a room with four exam beds. The women could not see each other as screens were set up between beds but from the desk in the center of the room where groups of 10 or more students and staff often gathered, you had full view of all exposed women. If someone determined that the woman was in active labor she would be sent to the labor room, which consisted of about eight beds pushed against the wall, no screens, no privacy. Women were made to undress and lie or sit on the beds. In the event that there were more than eight laboring women their shared beds.

Once a woman was fully dilated and read to push she was made to crawl off the bed onto a gurney which would be pushed hurriedly across the hospital to the delivery room. Once in the delivery room she crawled from the gurney onto a delivery table, her legs were tied into stirrups with pieces of IV tubing and then staff yelled at her to push. All women delivering for the first time received episiotomies as well as many second time mothers. If the woman was not pushing to the liking of the person sitting between her legs, they might yell insults, slap her legs, or a nurse would stand on a stool besides her and apply fundal pressure with her forearm by jumping into the woman’s abdomen as the woman pushed. As soon as the baby was out it was whisked away to lie under a heating lamp in the next room and await a pediatric exam, which was sometimes a very long time wait. No one told the woman anything about the baby. Once when a mother asked whether she had had a boy or a girl the doctor quipped, “They always want to know the gender as though nothing else matters.” That hospital was a nightmare.

I did meet a couple physicians and students who were kind to the women and understood my sense of horror but they were in the minority. Women were shouted at when they cried while their poorly anesthetized perineums were sutured. I had one physician call me away from the bedside of one young woman in the labor room who was terrified of the pain and the nearing delivery to tell me that I should not touch the patient or stand too close because, “These women are dirty and you never know what you might catch.” I remember another woman who had four previous deliveries which were all conducted at home. She was a poor indigenous woman who was now coming for her first hospital delivery with her fifth pregnancy (probably as advised by a traditional birth attendant who was trained to refer all grand-multips to the hospital). The physician asked then who had conducted the previous deliveries when the woman responded that it was her husband the physician laughed sarcastically to a colleague, “Oh is he a physician too?” It took all my restraint not to punch her. Who would want to deliver in such an environment regardless of risk? Another day I found a teenage girl left alone to miscarry her fetus of about 20 weeks. There was only one sink at the end of the hall which separated the delivery rooms from the post-miscarriage care ward. Rosa was lying on a bed in stirrups crying, “mi bebe, mi bebe” with a small inert body half exposed between her legs. Anyone washing their hands had a full view. I went in to sit by her. If I had had any midwifery training I would have completed the delivery and sat with her but I had not so I just sat with her and talked with her while she waited there with her baby between her legs and nurses next to her, separated by a curtain, ate their lunch, laughing and chatting completely deaf to her cries. At one point a student walked over after taking in the view from the sink and yelled at Rosa, “Did you do this to yourself?” I gently asked her to leave and then I closed the door. I had reserved 6 weeks to spend observing but I barely made it through three. I will never forget those women.

When I returned to San Francisco I began asking the Latina women who had previously delivered in either Central America or Mexico about those deliveries. Their stories were depressingly similar. At least with regards to the humanity shown laboring women, Bottom is leaps and bounds above La Maternidad, and MCH seems to be a little better staffed and stocked than Bottom. But in general they all fall way below acceptable. If we consider that these are not three individual cases but examples of hundreds of thousands of similar facilities, what do we do? Do we just get overwhelmed and close our eyes? Do we critique and blame? Do we stand and hand hold within a crumbling system? Do we build up a collage of private clinics? It seems something more fundamental must change to really transform these places. All these places are health care facilities which cater to the poor; certainly no woman with a choice would choose to deliver in such a place (unless granted some control over the situation, like hand picking her midwife and physician). Our attitude towards the powerless and the poor must change. If we considered the poor and powerless our equals these places would not exist. Evidently many physicians at La Maternidad despised the poor indigenous women with outright passion but what do I share with those physicians? What judgments do I hold about the homeless on the streets of San Francisco? Why do I quicken my pace when I pass the man sitting in a heap dressed in rags black with filth? What do I fear? What could be different if I address my own fears? Is not the existence of La Maternidad, Bottom, MCH, and countless others proof enough that globally we believe the poor are dispensable? That our commitment to international aid is superficial or politically motivated? Why are governments and leaders who prioritize the well-being of their citizens over the strength of political alliances demonized? What do we fear? What could be different if we address our fears?

Beauty

Ethel, the Cameroonian wife of one of Clement’s friends is on vacation from class at the moment and we have been spending a good amount of time together. She makes me laugh. Her biggest complaint with Ghana is the food (the lack of her familiar foods and the high cost) and apart from earning her degree, growing fat is her biggest priority (she has quite a ways to go). I tried to encourage her by saying that she will probably gain a good amount of weight when she is pregnant but she just shook her head and said, “There’s not enough food.” Apparently in Cameroon for the first three months after the baby is born the new mother stays in the house, eats, and does nothing other than nurse the baby. According to Ethel when she emerges she is nice and fat her own fat now, not just weight from carrying the baby. I promised to play the role of her doting relative when the time comes and fatten her up to the best of my ability.

Back to Birth

When we returned from the States we found new neighbors living in the room next door, a physician and her two daughters. About a month ago they found a house and moved out but yesterday they came by for a visit. Dr. Annie Opoku is from Madagascar but attended medical school in the Ukraine, there she met and married her Ghanaian husband and she has been living here in Ghana now for more than 20 years. Yesterday I learned that she is the medical superintendent of the Maternal and Child Health public hospital here in Kumasi. When she asked what I am doing and I told her that I am still waiting, she offered that I come and volunteer at the hospital a couple days each week. She said she does not mind if I am not officially registered and I will find plenty to do, though no pay. I am so excited. I thought it would be mid-2009 before I again assisted a mother bring her baby into the world. I will go for the first time tomorrow.

Her description of the hospital began with a litany of problems: the high nurse to patient ratio, the high rate of HIV (6.9%), and general lack of resources, etc. Unsurprisingly, Ghana and Malawi seem to share the same set of problems though health indicators speak to some difference in severity. From the way she was talking it seems this hospital is quite small, they only conduct 100 deliveries per month (as compared with Bottom’s 1,000) and they refer their complicated cases out. It was not clear to me whether they even have the capability of doing c-sections. Dr. Opoku did say they do not have a vacuum extractor. (That will top my mental list of necessary donations.)

This past July the government started offering free prenatal and delivery care in an effort to decrease the maternal mortality rate which is over 800 per 100,000 (astoundingly high compared to the US’s rate of 7 but much better than Malawi’s rate of 1,800). This idea sounds wonderful in theory but Dr. Opoku says that it is devastating the health sector. The system is not set up to cope with the numbers of new patients flooding the hospitals nor has the government established a way to efficiently reimburse the hospitals for the increased operating expenses. Hopefully these problems will be addressed relatively quickly (the policy has only been in effect for two months). However if they are not addressed soon and limited resources are consumed and not replaced, the care women receive at public facilities will be no improvement over no care at all. This seems to be another example of how emphasis on numbers, elevates them to the position of an independent goal and obscures the actual desired outcome. The World Health Organization collects statistics on the percentage of births attended by skilled birth attendants, the percentage of women receiving prenatal care, and the percentage of deliveries conducted in hospitals. The assumption is that the higher these figures, the lower the maternal mortality/morbidity and infant mortality/morbidity rates. (As a midwife I know that in all settings whether here or in the US, hospital births are not inherently safer births.) These numbers also provide a clear marker for comparison between countries. Because of this new policy Ghana will soon be able to boast an increase in all these figures but is this increase significant when women will labor in hospital beds alone because there are too few nurses to adequately monitor the laboring women? Or if laboratory tests or medication are unavailable for those who need them because they cannot be stocked regularly? I will see.

At the moment I am just excited to be around birth again. There is nothing that compares to it. One of my favorite experiences is the moment when a baby quiets after his first few cries to attentively take in his world. We exchange awestruck expressions, me at this new person, so complete unique and beautiful and he, I imagine, at the strange beauty of this place. The expression is always something like a tourist gazing at the ceiling of St. Peter’s Basilica. Wide eyes experience color and light for the first time, the quality of sound, the perception of his body and its movement are all different. But there is no fear. Being held securely, warmly, and then the presence of his mother are enough. She too is now completely transformed in his perception but he recognizes her and trusts her without needing to know what trust entails. I am so privileged to bear witness to these moments again and again, to be reminded that there is great beauty here in what we so quickly come to call mundane, and to learn again that miracles happen every day.

Accepting Happiness

I still don’t have many friends. Clement supplies me with my necessary quota of hugs but despite the lack of friends my harvest of smiles and friendly waves has never been more bountiful. This morning as I walked along the road a boy about three and his older sister yelled “oblonie” ecstatically to me. When I turned and waved he let out a squeal and started running towards me as though I was his favorite aunt. I laughed as his mom sternly called him back. Children are the most effusive in their expressions of warmth but even adults along the street, in the bus, or in the market will quickly and easily return a smile.

As an American accustomed to the anonymity of city life in the US it took a while to adjust to the constant attention - little voices shouting “mzungu” or “oblonie.” When we first returned to Ghana I met a Dutch woman walking along the road in the same direction. We joined paths and chatted as we walked. The usual chorus of children shouting “oblonie” greeted us along the way and when I turned to wave she asked, “You still wave?” I have definitely had my moments when I tired of the word, “mzungu” and thought in my head, “yes, I’m an mzungu, what’s the big deal?” But when she asked, I realized with new clarity how absurd it would be to consider any other response. She said, “Sometimes I just want to be invisible.” Certainly I have shared the feeling but it is comical to think that anyone other than someone who looks African would ever be invisible here, walking with your head down does not change that. All the children want is a smile and a wave. It makes them happy and it makes me really happy to see how such a little gesture can give someone such great joy. So maybe I’m feeling down or thinking deeply about something and on a certain level I want to stay in that pensive spot but why not rise out of that and harvest the joy?

Day by Day

Thank you for your responses to the last post, I have received several good ideas which we will pursue.

Life continues with its difficulties. Last week Clement and I both came down with malaria. It was the first time for me and an interesting experience that I do not hope to repeat. In the morning I felt tired by noon my body was mildly aching and by five I had a splitting headache, chills, and a fever of 102. I started taking anti-malarials right away (we always carry a couple doses with us) and by morning I was feeling 80% better. I went out and bought a treated mosquito bednet and hung it the next day. Clement’s symptoms started a day after mine and hung on a little longer but we are now both fully recovered and are enjoying mosquito free nights under the net. Then for the cherry on top, my computer crashed. My dad says that several friends have left his company feeling better about their day-to-day problems after inquiring about us and hearing some of ours. I suppose even knowing that is reassuring, at least some good is coming out of all of this.

The high of the week was seeing a little girl about two years old in the market with a calculator pressed against her ear wobbling in circles in the midst of the market chaos yelling “Hello? Hello? Hello?”

I also met with Abigail Kyei. She is the Ghanaian midwife I originally met in Malawi. She was working and living there for three years but just recently returned to Ghana and is actually opening a nursing college next door to our hostel. She is one of those people who lifts your spirits just by sitting with you and looking in your eyes. She listened with compassion to my worries, offered some assistance, and reminded me - once again - that she and her husband know what it is like to live in a foreign country and that they will always do what they can for us. A burden lifted. We are not alone.

Malawi Updates and a Request

The assistance to mothers, the feeding program, the school fees, the assistance to families caring for newborn orphans continues in Malawi. I never anticipated starting this handful of little projects but they naturally sprouted from working in the hospital and certainly when I left I could not drop them. I could not find a pre-existing organization in whose hands I could place them and though the activities are few and assist a relatively small group of people they do help. So, last June I organized a board of directors and filed the paperwork in the US to set up African Mothers Health Initiative (AMHI). Finally this June we received our 501C3 (legal non-profit status) letter of determination from the IRS. www.africanmothers.org

Before leaving Malawi, with the help of my dear friend Beatrice Namaleu – a Malawian nurse with 28 years experience in maternal and child health – I set up a sister organization (and board) in Malawi to carry out the activities called Chimwemwe mu’Bereki or Joyful Motherhood. Beatrice retired from the government in December and is now heading Chimwemwe mu’bereki. Beatrice is the only employee and at the moment she is working out of her one bedroom house (where she lives with five of her six daughters, her husband, and nephew). She has no car and travels through town and surrounding villages by a combination of minibuses, bicycle taxis, and walking. She keeps the nursery at Bottom stocked with formula for those babes whose mothers die or who cannot breastfeed, she coordinates with the nurses there and visits the babies at home; she oversees the feeding program working with Thoko and Melai who volunteer to run it from their homes three times a week; and she distribute tuition to about 10 teens and keeps tabs on their progress by visiting their schools and talking with their teachers. The wonderful piece is that the vast majority of money – everything except Beatrice’s salary and a little money for phone, fax, copies, etc – goes directly to the projects. But, for one person it is a big job without much support.

The fundamental idea is to provide quality care and assistance to the individuals enrolled in the project. We want the children to survive childhood, we want to assist women and families move from devastation to joy, we want to focus on stories rather than numbers. I want the money to go to Malawi, I want to support Malawians caring for these projects, I want any employee to have what they need to make it possible to enjoy this work and do it creatively while always prioritizing our clients.

Just limiting ourselves to the few projects we currently have, there is still a lot that needs to be done to ensure that roots set deep. This coming year in Malawi we want to rent land to for a garden which will be cultivated and used by the feeding program, we also want to increase the number of meals provided and work on making sure the children are growing well (kids are weighed and measured monthly), and we would like to create opportunities for the women who volunteer cooking and cleaning to organize a small business; for the newborns we want to improve our monitoring system and make sure that resources are enough to provide intensive support during the first year; and for the adolescents we want to continue assistance for those excelling and find vocational programs for those struggling.

We need people who are interested in becoming involved in the US or at least from somewhere regularly accessible via email. We are looking both for volunteer assistance as well as more formal affiliation. AMHI activities are focused on fundraising and project support. Up to this point, everything has been funded by donations from friends, family, and blog readers, which is wonderful and amazing but we do go through periods of financial drought. I am not a manager, I am not a fundraiser, but I am trying to develop a few new skills and stay on task. Please, if you have resources, ideas, a few hours a month to donate let me know, I have open ears. joanne_jorissen@yahoo.com

Kumasi

Clement and I are back in Ghana and as we wait - life again paused by the great force of bureaucracy – I have to remind myself occasionally that this is not a torture designed especially for us. Clement’s classes resumed today but after visiting administrative offices daily for weeks he is still not registered. I spoke with the Nurses and Midwives Council when we arrived and was told that in order to register I must take an exam in December and then after the results are out, I will have to do an orientation of several months before I can practice as a midwife. And so we wait. At present the water has been turned off for five hours and the power has been off for three days. I just finished my daily excavation in the fridge, tossing half of our remaining vegetables and washing out the mold that appeared over night.

Thich Nhat Hanh says happiness is accessible right now. Presumably that means without running water, without electricity, and without a job. Love exists and can flourish without those things. At times metaphor of a prison comes to mind but I consciously exchange it for the image of a cocoon. I am in a cocoon awaiting metamorphosis. I realize the world will remain the same but I’m encouraging and waiting for something within me or my life to shift so that the world will be available to me in a new way. Inside the cocoon I have little but still much beyond the basic necessities; I have my husband, food, some books, often water, a few movies, and then of course the true source of both my torture and joy – my own spinning mind. I have my freedom and when the entropic forces begin climaxing I can step out.

From the balcony at dusk, the world invites me to quite my mind. Immense sky, supporting thick purple cumulus clouds, is lit by tendrils of pink, the ends of the sun’s rays inviting night to bloom as they follow their mistress below the horizon. The calls of a few dozen birds reach my ears from different distances and directions. A choir warms up for an all night prayer service and from somewhere beyond their church, the adhan begins, “Allah Akhbar” calling Muslims to prayer. Just in front of the gate a woman walks by, flip flops tapping the Earth, her baby on her back, a small package on her head, her young son trailing a few steps behind with a package on his shoulder. Downstairs on the pavement my neighbor is out of sight but I can hear her grinding pepper – the sound of a clay pot rolling on the ground - and smell the faint aroma from her cooking. On the other side of the fence men chat while they pound fufu – the methodical deep thumping a familiar sound - one man raises and pounds the giant pestle, the other squats at the mortar dexterously turning the yam and plantain in between the thumps. Enormous leaves of banana trees cast even larger shadows in the dimming light. A few televisions and radios talk unintelligibly and a car door closes is in the distance. Our individual dramas diminish to a handful of colorful stories set against the enormity of the universe; the proximity and pulse of life is reassurance.

Lettuce

Last week I unexpectedly found myself hopping through a large field of lettuce. Jumping from bed to bed trying to avoid both the tender leaves and the rivulets of algae and mud. I started off from home going nowhere but somewhere new needing space to ventilate my thoughts. The main roads are paved but all the roads with in the residential area where we live are dirt, some better, others quickly degenerating into narrow bumpy footpaths. From the balcony of our hostel the area at night is filled with lights, buildings seem almost to touch but between them and often in the center of those sitting unfinished there are banana and papaya trees, maize stalks and apparently a couple acres of lettuce. At the time I felt foolish, imagining dozens of unseen eyes fixed on the silly foreign woman hopping through lettuce and mud rather than taking the “obvious” path, which I’m sure ran somewhere nearby. The experience gave me what I needed, it brought my mind down to my feet and then to the bright blue sky.

Home in Texas

I'm home in Texas. The air-conditioner says it's 75 degrees inside. The plastic thermometer with the red hummingbird stuck on the window says it's 87 degrees outside. Clement is asleep in the other room. Mom is downstairs organizing papers, moving them from one pile to another to the trash, fighting and losing to their fiercely swift reproductive rate.

About two weeks after arriving in Ghana, Clement was told that he would have to wait until August to resume classes. For a couple days the dean of the medical school said he might be able to continue this term but in the end he was told, "Sorry, come back in August." Since I had not yet started working we decided to try to come to Texas. My cousin Jon's wedding was scheduled for April 5th in Austin and I desperately wanted to attend. We booked the first available visa interview which was over a month away (March 26th) and bought - as we were told by the travel agent and believed after trying four different agencies - the last two seats on any flight heading to the US after March 26th and before April 5th. Then we waited and sweat.

Every day Clement walked to campus and entered the human pin ball game of trying to obtain a letter addressed to the consular at the US Embassy saying that he was enrolled in the fall term. The dean referred him to the registrar, the registrar told him to return tomorrow and then tomorrow and then tomorrow and then finally told him to go to the international student section. At the international student section they did not have the correct letterhead he was told, “Come back tomorrow” for about a week. Then once the letterhead arrived they told him he needed a letter from the registrar addressed to the student section. The registrar said it wasn’t her responsibility to write the letter; finally a secretary from the dean’s office copied a letter from his file which had already been sent to the student section. The man in the student section was satisfied with the copy but then asked if Clement had paid the fee associated with the letter they would write. Once the fee was paid – involving of course visiting another office and waiting in another line – the man at the student’s section told him he needed a passport picture. When I very calmly (much more calmly than I wanted to) reminded the man that Clement had been visiting the same office daily for weeks and suggested that it might be a good idea to explain on the first visit what is needed, the man became indignant, told me not to tell him how to do his job and with a mix of passion and anger said that his job is to help students – at least we agreed on that point. Finally, five minutes after the University officially closed, the day before we had to leave for Accra, Clement was handed the letter.

In Accra we stayed with a cousin of Peter and Abigail Kyei – friends from Kumasi. Having never met us she welcomed us hugs, cooked for us, and refused all help. In Kumasi we had been frustrated by the weekly unannounced interruption of our water supply but in her neighborhood we learned that for at least the past 15 years, water has only flowed through the taps on Wednesdays. For the rest of the week people buy water and fill tanks behind or above their homes. Without intending to do so, I have become very good at bathing with surprisingly small volumes of water. It seems to me that in the US our wealth as a nation buffers us from so many “coming” hardships due to global warming and population growth that have already arrived in many countries. After a few more days of waiting, on March 27th Clement was given a ten year tourist visa and on March 28th we arrived tired but happy in Austin to the loving hugs of my parents, a cool night, a quiet drive home on a wide highway, a hot shower, and clean soft sheets - I don’t remember ever feeling so grateful.

I am eager to work. I miss birth. I miss feeling useful. I'm driving Clement slightly crazy by asking him 1,000 times a day "What do you want to do now?" Still, it is wonderful to be here. I adore my parents. They are generous, wise, kind, and aging. I love my family. My cousin’s wedding was beautiful, the love professed deeply rooted, and my heart skipped an entire measure of beats from the excitement of surprising my paternal aunts, and uncle, and cousins who flew down from Michigan.

Two weeks later we also spent a weekend with my mom’s family in Houston and Raywood. Raywood is a small farm town in East Texas where the vast majority of residents are direct relatives of my mother’s. Once Clement assessed the place he leaned in close and said with a smile, “You never told me that you have a home village.” We started our visit with an entertaining tour of the cemetery, learning which deceased married couples were first cousins, hearing the story of two who hid under an overturned wagon to wait out a storm and then emerged alive and pregnant, we learned who was an infamous womanizer, who died from tuberculosis, who died from syphilis, and who died in childbirth. We ate a big lunch then concluded our visit by dancing Zydeco with my mom’s cousins in someone’s den. I let the joy flood every cell - sitting with Clement, watching my mom laugh out loud with her cousins, then turn around after each song to pull someone else to the dance floor. She was radiant and our time together is rare and precious.

The future as usual is uncertain, Clement and I will live 4 months of our first year of marriage with my parents, hopefully I will find a per diem nursing job while we are here, then we will return to Ghana August 1st, leaving all the trappings of middle class America behind. When I consider the future I feel the responsibility weigh on me as the sole provider for a new family. I wonder if my career as a part-time volunteer will be enough. I still refuse to spend any more than a fraction of a second considering job possibilities that would be more lucrative than midwifery.

Suffering and Joy

If we grow up in a secure household in America we learn – and may come to believe – that everyone has the right to pursue happiness. Although we are not told this explicitly, in America, in our consumerist culture, this most certainly means a right to the external pursuit of happiness. It is highly debatable whether in actuality all Americans share this right but I won’t get into that. The thought that captivates me is the simple idea of being free to pursue happiness. It is beautiful. Happiness as a sustained state of being in the world – as opposed to on a remote tropical island in a four star facility but rather in life around people, with all the pain, despair, and suffering that involves – must be an internal state. This pursuit of internal happiness is truly open to everyone but the path towards its achievement is far more difficult. I am beginning to think that the only people who achieve internal happiness are highly evolved spiritual beings. For the rest of us here on this planet, so distant from God, we are left mostly to our own devices to increase our compassion, learn grace, and find joy. Our relationships with ourselves are often tragically flawed not to mention our relationships with each other. We create pain, witness pain, experience loss, and misplace priorities. Living in Malawi and working in the labor ward there over the past few years has had a profound impact on my spirit. I am still unsure of how to characterize this impact; at the moment perhaps I can say it has left me with a greater sense of surrender. I have seen much inequality and cruelty; I have gained no understanding its purpose. We might grandly hypothesize that spiritual evolution requires suffering but when so much suffering is merely a degradation of life, the conclusion that most readily arises is that we as a global community are responsible for its unnecessary existence. I am exhausted, I feel a desire to rest but an inability to turn away. Certainly, I have deepened my respect for those who walk through life with their eyes open and radiate joy. I wrote before that I want to find more joy in life and I am renewing that intention.