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.