238 days later

When we landed everyone was smiling, everyone was kind. After so many hours and an uncomfortable sleep most of the passengers were home and I was so much closer.

I love small airports without jet bridges in tropical places. I was grateful for the jet walkway in Frankfurt where they said it was twenty below, but the immediate welcome of the African air with all its subtle scents, and a view of green stretching out for miles was wonderful. I was slightly disappointed when the immigration officer looked at my 36 month visa and gave me 60 days but my high held and I made my way through customs to the taxi, determined to get to Clement as soon as possible.

The driver loaded my bags in the back and I slid into the passenger seat. It was 4:40pm. I asked him to take me to whichever bus station would likely still have buses leaving for Kumasi. When I told him that I was going to meet my husband after almost eight months of separation he smiled and enthusiastically promised he would make sure I boarded a bus. I was beaming and he was kind. There was plenty of traffic in Accra and we chatted easily as we waded through it.

I asked him how he felt about the new president (Atta Mills) who was elected last December and he said he hadn't noticed any changes. He said "Just give us education, food and health care and we will be satisfied. But," he said, "the hospitals are terrible. People really suffer there." He said when his wife was eight months pregnant she started bleeding and he rushed her to the hospital. She was losing blood quickly, soaking through her clothes and becoming dizzy. He was told to fill out paperwork for her admission. He said he thought he was going to lose her and as he spoke I heard in his voice and saw in his face the raw place that remained. No matter how he begged for a doctor to examine her, he was firmly told to finish the admission process first. He gripped the steering wheel and said he was entirely powerless. The doctors told him, "We do not kill people. If someone is going to die then they will die it is not up to us." It was over an hour before the doctors saw his wife but fortunately they did an emergent c-section and after an extended hospitalization of each they both survived and recovered completely. He said you are not treated well unless you can show that you can pay for everything. He said that he knows doctors in Ghana are better than other parts of Africa but he said he just prays that he and his family stay healthy. Just before we turned into the bus terminal he told me that his wife had lost a full-term baby during labor prior to the pregnancy with the hemorrhage. This must end.

I did not start the conversation about health care. I did not tell him that I am a midwife until he finished his story. The fact that these stories are ubiquitous and seem to find me everywhere communicates a message I can hardly ignore. I understand. I must do my piece. Persist. Joan Chittister says, "Persistence is the antidote to powerlessness." Persist despite all rational fears of failure and notions of inadequacy. My friendly taxi driver delivered me to the OA bus station, stayed until I had my ticket in hand, and departed with a warm hand shake.

I boarded a mostly empty bus and took my seat next to a middle aged woman. For the three hours it took the bus to fill I dozed and waited and day dreamed. Finally, at 2am I stepped down and after circling the bus a few times to locate my bags also found Clement and Ernest. Clement looked new and familiar and different and so good. When we reached home Ethel was awake and had warmed bathwater for me. In my over exhausted but joyful state I hesitated to test the solidity of the beautiful vivid dream. I was back at long last to my husband in our room with our bed under the mosquito net and the sounds of the night wafting through the open windows along with the breeze.

The next morning I was assured of the reality of my surroundings by a sore throat and fever. At least Clement was just as real too. I slept a lot and ate the food that Ethel placed in front of me when she woke me to eat, and I got better.

A couple days later I received a call from Muntali's brother. Muntali was the young teen I befriended last spring in the orthopedic ward who had his right arm amputated due to cancer. His brother called to say he had died in July. He had kept my phone number, which I had given Muntali on a slip of paper so long ago, and had been calling it periodically since July until he finally got through on December 21st. He said simply, "We gave him to God." I said, "I'm sorry" and "thank you" and that was it. I imagined my sweet Muntali with his long thin legs crossed flipping the newspaper and smiling brightly. I thought of his vibrancy and imagined the suffering he must have endured after I left. I thought of his family grieving him; he was the baby by many years. I thought of his brother holding that paper with my number and how through all their sorrow he thought of me – a stranger – and wanted to make sure I knew what happened to his little brother. I was equally saddened by the death of Muntali and awed by his brother's profound kindness calling me for months to let me know.

After I recovered Clement, Ernest, Ethel and I decided to take a trip to the Coast. Though I had more than my fill of travel, Clement, Ernest, and Ethel were eager to get out of Kumasi for a few days before classes resumed so we settled on Ghana Spirit, a small quaint spot on the beach. It was worth the nine hour journey by trotro and taxi. We spent four lazy days in the water, sun, and shade. Clement played soccer on the beach with boys from the neighboring village. Ernest joined the fishermen pulling in their nets. Ethel and I read and slept and we all took walks on the beach.

The day we returned I was rocked again by horrible nausea, stomach pain, and fever. Despite the smell of raw fish and a toddler's dirty diaper in the trotro, and an abundance of potholes, I managed to keep the contents of my stomach in my stomach. But, when I didn't feel better by 11pm Clement, Ethel, Ernest all accompanied me to the hospital for a malaria test. It was malaria. Malaria comes on fast and hard, and easily convinces you that you will never be well again but thankfully the anti-malarials usually start acting just as quickly. Ernest and Ethel definitely did not need to accompany us. I knew we would just spend a few hours waiting but they insisted and simply waited with us, and then shared my relief at the diagnosis. Even here I am flooded by gratitude for the love which surrounds me. So here I am, back in this place where life's exposed edges and its naked fragility always exist in symmetry with its beauty and depth.

After a long silence.

I am here. Tired but good. I'm in Texas and my sweet Clement is in Ghana. I have been here five months. I have two more months before returning to Clement and the Ghanaian heat. I am living with my parents and my brother, working as a nurse, putting away my dollars for another year of life half a world away.

Clement spent the summer in Malawi. He had clinicals to complete for school so we decided that if we couldn't be together the next best thing was for us each to go home. He spent six weeks working in a small district hospital and when we talked he shared his stories which exhausted me and melted my heart. Stories of a hopelessly understaffed hospital with meager resources, a pediatric ICU with patients but no staff, of children dying and pleading parents, of children healing and going home, of grateful happy laughing mothers. In comparison, my stories made me feel overindulged and underutilized.

A large part of me is home here. Being with my family, embraced by love and comfort and within steps of a pantry filled with food and a freezer with Blue Bell is wonderful. Challenges are more mundane and are faced in a familiar environment with my feet securely under me.

The remaining part of me yearns for that far away nonphysical home I have discovered, and the hope of a physical one. Here the hum of the air conditioner and electricity overpowers the calls of the birds in the morning and the insects at night. I miss watching the curtains dance in the breeze and shadow as I fall asleep and I miss waking up with the smell of the outdoors on my pillow. Periodically I twirl the ring on my finger to remind myself that Clement is real. We talk a few times a week. His laugh always sounds good in my ears. He writes that he is looking forward to the day when we will have a place of our own and live together indefinitely. Dreamy. I imagine again and again stepping off the bus in December and standing within reach of him at last. Then I imagine what will happen when our December holiday is over and he heads back to class. That vision is fuzzy and stressful. Will I be able to teach at the nursing school? Will I be able to get a visa that allows me to stay in the country for longer than a month? Will the money I am earning carry us through? How many years will we move across the planet closer and farther apart just to keep life going on in the direction of our dreams?


Time is passing quickly. Five months have flown by. I am working nights and sleeping days. The in between hours of insomnia I spend working on the nonprofit, writing, calling, feeling excited and hopeful then fearful, overwhelmed, and inadequate. The work is continuing and growing. It is so exhilarating to know that we have identified a real need and are working to meet it. I do not know of any other international organization that identifies high risk babies and moms at birth and follows them through their most vulnerable periods. I feel so much pride and gratitude, and I feel I am never doing enough. Mrs Namaleu, my friend the Malawian nurse who has taken this on as a job is phenomenal. She gives her whole self to the work and it is more than she can responably handle but she cannot set limits and I understand. If saying "no" means taking away hope we can only say "YES" and succeed or drown together. She is following over 80 infants, overseeing three feeding programs, and paying tuition for a handful of teens. We need money to hire more people to help, to buy a computer for her, to improve the programs. I am treading water and constantly stretching for a foothold or a hand.

The backdrop of life here is family. In this culture I suppose I should be at least a little embarrassed to live with my parents but I am not. I love meeting them at the breakfast table, my dad if I am up before the sun, my mom if I am not. I appreciate the wisdom of my father and the affection of my mother. I try not to be fearful as I watch them age in front of me. At times I feel a rush to hoard stories and memories. I want to cling and lay claim before they slip away. I am painfully aware of the blessings in my life and this pain is the heart of the challenge - how to feel gratitude without the anticipatory pain of future changes and losses.

A great irony of my life seems to be that at heart I am a homebody, a person who would happily live down the block or even share a house with my nuclear and extended family but I have followed a deeper compulsion to plant pieces of my heart around the world where they can never be fully reunited. And so I sit on my usual see-saw of worry and surrender, acceptance and self-blame. In the moments of balance I relax and give myself permission just to be here with all the love, frustration, and middle moments that entails.

This is the substance of my silence.

A lesson from Joby

Two months ago my beloved cousin Joby died suddenly, less than two weeks after coming to visit. We have old family video reels of my cousin on hands and knees "teaching" me to crawl as a baby. As a child he was my big brother who would never fail to make me laugh. As I grew he gradually became my peer. We lived on the East Coast at the same time and then on the West Coast at the same time. We spent holidays and long weekends together. He still made me laugh but he also confided in me and I in him. He was healthy and young. One moment he was eating with friends and the next moment he was gone.

I miss him.

In grieving and sharing grief with those he touched I realized how big his life was. Then I realized that though we live for each other we never belong to each other. It is at once overwhelmingly painful to realize this and breathtakingly beautiful to catch a glimpse of a life in its entirty, a life that you loved but whose scope and depth you never fully comprehended. How much better is or was it that that life was not yours, that it was so much larger than the size of your pocket or the expanse of your hopes for that person. I will never be ready to part with the people I love most deeply in my life but Joby is helping me gain some appreciation for a life well lived and the necessity of surrender.

. . . and God cut the thread

Check this Out!

This is the blog of my dear friend Stabliy Msiska. She is the charge nurse in the labor ward at Bottom hospital. A dear friend who is an obstetrician living in Norway set up an exchange program for Norwegian obstetricians and midwives to come to Malawi and Malawian midwives to go to Norway. Stabily is the first Malawian to go to Norway. She was not previously a world traveller. I think those of you who have been reading my blog will appreciate a glimpse into the reverse experience. http://www.stabilymsiskablogger.blogspot.com/

Yearning for Change

I finished my rotation, at last at Konfo Anokye Teaching Hospital. My Obstretrics and Gyenecology rotation was the final component. I had been looking forward to again being around birthing mothers and newborn babies but in the end I don’t think I can tolerate being witnessing this type of birth much longer.

I am yearning to work in an environment like Holy Family Birth Center. When I was young my mother would occasionally take us to Weslaco to visit a friend of hers who she met in Bolivia years earlier. As a child I did not place any importance on the words “birth center.” When Sister Janice and Sister Angela talked to my mom about their work I listened and let it go. For me it was simply a peaceful stopping point near the Gulf or on our way to Mexico with open flat land, goats and chickens, and many friendly women.

The summer after I qualified as a registered nurse, before my midwifery training, I went back with new eyes. I spent a couple weeks at the birth center volunteering (observing). Sister Angela founded the birth center in the early 80s to serve women who had nowhere else to go – poor uninsured women and illegal immigrant women. She not only gave them a place to deliver but provided excellent care throughout their pregnancy and postnatal period. The grounds include a small clinic, basic housing for the few staff midwives and volunteer nurses, a small chapel, space for chickens and goats, and five free standing suites for deliveries. Each birth suite contains a double bed, a rocking chair, a couple stools, a counter and sink, a bathroom and a small kitchen.

During my three weeks there I witnessed a handful of births. Each was beautiful, peaceful, personal. I loved the births but I also loved that an hour or so after delivery the midwife would wrap the baby’s body and wash his head under running warm water at the sink. The babies would never cry; they would close their eyes and move their heads in a rocking motion clearly enjoying the warm water and gentle massaging touch of the midwife. I loved that after the birth, when the woman was lying comfortably with her family and newborn in the double bed, the midwife or nurse would ask them what they would like to eat and then go to the kitchen and prepare the food herself. I loved that the nurses would visit the women in their homes or trailers for their postnatal checks. I loved that the quality of care given was what we generally believe accessible only to the wealthy but there was given compassionately and lovingly to the poor. And for the babies, their gentle welcome was an appropriate end to their difficult journey and a promise that the world is capable of offering comfort and love.

The births I have witnessed more frequently stand in dramatic contrast to those at Holy Family in Weslaco, Texas. Women are treated as though every cry of pain and every gesture of reaching out to touch a clinician is a personal affront to the nurses and doctors. I can’t understand the language here but I can certainly understand the tone and I do understand “mepakyew” which I hear the women say over and over to whoever yells at them. Mepakyew means please, or to be sorry, or to beg and the literal translation is “I lie at your feet.” No one rubs backs or holds hands; the only touch is the clinical touch. I watched a doctor give a woman a “gentle” slap on the thigh to tell her to spread her legs. I have seen few give a warning before beginning a vaginal exam or give an explanation afterwards. I have seen many give a harsh look or word if she cries during the exam or pulls away. I have seen newborn babies held without tenderness , picked up by two arms or just one, held by the back without supporting the head, placed on a sheet covering a cool metal table, suctioned vigorously so they gag again and again even if they come out pink and crying. I was horrified to see a few newborns scream as they were bathed in cold water (this was not at KATH and not done by nurses and I did inform the charge nurse that it was happening). On one hand after my couple days in the KATH labor ward I appreciated how much change occurred at Bottom during my three year stay, thanks I believe in great part to Dr. Meguid and a handful of motivated clinicians who were also eager to see change. On the other hand I feel so tired and sad. I cannot watch this anymore. I want to provide an alternative not just a hand to hold or a kind look to help make the inhumane treatment a little more bearable. It should not be born.

The morning of my second day in the labor ward at KATH I met Ama. Ama was struggling with a premature urge to push meaning that well before her cervix was completely dilated she desperately wanted to push her baby out. Usually this happens when the baby’s head is very low in the pelvis during early labor. The danger is that if she pushes against a partially closed cervix the cervix will swell, it will not dilate well and may become an obstruction or may tear, generally the mother tires early and her baby may show signs of excessive stress. During the contractions Ama would cry out and push, the vessels in her neck protruding as she strained. Periodically the nurses and doctors would yell at her from across the room and she would tearfully say over and over, “mepakyew”. I stayed with her. I rubbed her back and encouraged her to try different positions that might alleviate the urge. The urge was still strong but she cried out less while I was with her and every now and then she would look intensely into my eyes and say, “God bless you.” When her cervix was finally 9 centimeters I led her to the delivery bed and as she pushed I held pressure on her cervix and soon felt it slip over the baby’s head. I stood so that I blocked the nurse’s view of her perineum and no one yelled at her to push. She did an amazing job. She focused and pushed with each wave of contraction and released and relaxed complete when they passed. I encouraged her to continue following the rhythm of her body and the baby’s head crowned slowly. Luckily the resuscitare was occupied by another baby so I wrapped her newborn and placed him in her arms. She had no tear so I cleaned her and led her back to the bed then helped her breastfeed. The rest of the day anytime I looked in her direction she said, “God bless you. May God really bless you.” At one point she even tried to give me a handful of money. I received so many blessings from Ama that day. It felt great to help her but sadly what I did was nothing beyond basic care and her effusive gratitude was simply because the treatment she received before I stood next to her was really not care at all.

A few times during my three months at KATH while chatting with house officers (the equivalent of American first year interns) they asked me what I enjoyed about being a midwife and said that they really did not like O&G. Now I certainly understand why. If this is the sum total of your experience regarding birth - such an ugly side with only messiness, pain, yelling, and a policing attitude - it would be difficult to imagine beauty. There is a great potential for beauty. While I was on the labor ward, the house officers were often much more gentle than their seniors and I realized that the treatment of the women though most painful to the women themselves, also hurts all who stand by, slowly killing the voice that says quietly, “this is not right.”

Now that I have finished I am supposed to go to Accra to turn in my signed form from the hospital and pay another US$200 to register. I will actually be flying to the States on Sunday for a few months to work and be with family and since Clement will soon be heading to Malawi this is our last week together for some time. I am already dreading our separation. There is a Philippina nurse who became my friend during the rotations who will also be heading to Accra for the same purpose and she offered to take my papers so I could spend a few more days with Clement (and leave on Saturday instead of Thursday). I called the Nurses and Midwives Council to explain my situation and ask if she could hand mine in and whether I could sign the necessary papers on my return. The response I received was, “You need to set your priorities, everyone has husbands and children but if you want to practice as a nurse then you need to follow the rules here. . . Why can’t you come to Accra a day early to turn in your paperwork?!!. . . Maybe you should just stay at home with your husband if that is your priority rather than work as a nurse . . . “ She went on and on for a while chastising me for the effort I was creating for other people. Finally I interrupted and said, “I understand that everyone has husbands and children and that is why I thought you might understand. I am sorry that I am creating so much trouble for you. I am sorry I asked. Please forget it. I will come in person. Have a nice day.” Then I hung up on her. Then I cried (I am really too sensitive). Then I realized that I had just received a small taste of the attitude women in labor here face, which made me feel somehow better and worse.

African Mothers Health Initiative

Our work is going on and we are trying to apply for grants but in the meantime we are surviving hand-to-mouth. If you would like to find out about what we are doing or donate (any little bit helps), here are a couple links . . .

A radio interview I did that aired in March about our work in Malawi: http://www.worldvisionreport.org/Stories/Week-of-March-14-2009/Midwife-in-Malawi

Our website if you are interested in donating: www.africanmothers.org

Thank you for your donations, your encouragement and kind words, and your simple willingness to follow the stories here.

Nursing Rotations in Kumasi

I am now coming to the end of my general nursing rotation at KATH. Monday I will start Obstetrics and Gynecology and then I will be through. Everyday has brought its own stories here are some along the spectrum of good and bad.

A young teenager with cancer had his right arm amputated. He is one of the few boys in the men’s orthopedic ward. The ward is full of men with broken legs and arms from car accidents. They spend months in ward, waiting for bones and wounds to heal. He is the only oncology patient here. His wound is rank and large and he cries out each time I dab the gauze in an attempt to clean it. He forgives me the torture I inflict and afterwards we chat. When I leave the ward I still return to chat. I ask him about the wound, he says it no longer smells and the pain is decreasing. Every day he reads two newspapers. His brother brings them every morning. He lies in bed on his back, an ankle crossed over his knee and flips through the paper with his left hand. I ask him what interesting stories they contain and he tells me about a lion terrorizing a village. He says the paper included entries about the lion and the chief who fought him by hand for three consecutive days. He says the chief was working in the field when attacked, that he was badly injured and arrived at the hospital with wounds all over his body. He points to the picture of the chief lying in his hospital bed smiling, his left arm amputated and bandaged. He says the chief said he was grateful to have his arm amputated because the pain was too much. Then he flashes me his own beautiful smile.

A man tells me he would rather die than undergo a life saving surgery that would leave him impotent. He says he would surely become an alcoholic, saying that he would turn to alcohol unable to live haunted by the fear that his wife might be sleeping with another man. Instead he is willing to die and leave her with their three young children.

The day we change dressings in the orthopedic ward I change the dressing of a man with a bad avulsion injury and fracture with pins in his lower leg. The patients in the beds around him smile and tease him saying that he will sleep well because I changed his dressing. They all ask me to change their dressings the following day. When I arrive in the morning they greet me warmly and even those I haven’t said a word to all day smile and wave goodbye at the end of the day.

I spent three days in the burn unit. There were few patients but their burns were severe. There were three children: an infant disfigured by a fire, another infant who fell into a basin of boiling water, and a child who was splashed with boiling oil. There were two young women with acid burns, both had the acid thrown on them by jealous x-boyfriends. One cried silently throughout the day, the other hid her disfigured face from the patients around her.

In one ward there is an epileptic man, who while cooking had a seizure and fell into the fire. He sustained third degree burns over one arm and half his torso. By the time I arrive, he has been on the ward for a month. He sits quiet and motionless all day perched on the edge of a chair holding his neck and arms in stiff awkward positions which cause the least amount of pain. On the day his dressing is scheduled to be changed I ask the nurse about pre-medicating with pain medications before the dressing change but she says that patients here can tolerate pain better than where I come from. I suggest that perhaps they only tolerate it only because they are given no other option. He screams as they remove the layers of gauze. As they remove the dressings maggots fall on the floor. The nurses try to hide their disgust, some better than others. His wounds smell sweet and foul and the skin is rotting on his body. The nurses say to me, “Don’t worry the doctor will look at his wounds today and decide if he needs surgical debridement.” I leave the ward for lunch and return to find him in the middle of the floor twitching with rigors and people stepping over him. The nurse says his seizure began just after I left (just after his dressing change was complete). They say, “Don’t worry his doctor is here and will see him. I go and stand over him they ask me, “What do you want us to do? Carry him to his bed?” Feeling tears welling in my eyes I say, “Well?” and “How about a sedative to calm his twitching?” They watch me watching him and come to help me lift him on to his mattress. The doctor writes an order for a sedative. His doctor finishes rounding on the other patients , he does not look at the man still shaking on his mattress, he writes an order to use honey on his dressings, and leaves the ward. I ask the nurse whether the doctor will look at his wounds and she says, “Don’t worry he will come back tomorrow or Friday.” Later I see a nurse pocketing this patient’s medication. The next day I check his medication, the pills are still missing. The patient will be billed. He does not have insurance. The doctor does not return that day.

In the pediatric wards there is no room for the mothers to lie down. The mothers and a few fathers sit on wooden stools at the side of beds and during the night they just rest their heads on the mattresses to sleep. A parent must always be present so some parents spend months sitting on stools. Occasionally a small child is assigned alone to a twin sized bed (most beds have two children on them) so these parents can share the bed with their child at night.

A six year old boy comes in with a cough. From the x-ray it appears his has pleural effusion. He is sent to a regular pediatric ward, after a few days a chest tube is placed but little fluid is drained. The lung does not improve but the boy looks well, sitting on his bed tethered by the chest tube, talking, laughing, blowing balloons to exercise his lungs. Samples are taken from the drainage and sent to the lab to isolate the offending organism. The results are not returned or are lost, the infection does not respond to the antibiotics, during rounds the attending pediatrician says it is most likely tuberculosis. A test is done for tuberculosis but the results again do not make their way to his chart. TB meds are not started, instead they decide to open his chest. I leave him in the ward. Several days later I begin my rotation in the ICU. A critically ill boy lies unconscious on the first bed. After some time I recognize him. The surgeon says his lungs were filled with pus. No sample was sent to the lab. He never regained consciousness after the surgery. Three days later he dies. His mother brought him in with a cough, spent three months sitting next to him in the ward, and will leave with his inert body.

I come into the pediatric ward and move bed by bed through the room. Fifteen feet from the nurses desk I come to a severely malnourished young boy. His condition was very poor when he arrived, he is extremely wasted and his belly is hugely distended. He lies bundled in a blanket and his pregnant mother sits on the stool by his side. I look at his chest and see no movement. I listen to his chest and hear nothing. I touch his face, he is already cool; the life passed out some time before. I hear another mother behind me sighing, understanding - before his own mother - what has happened. I tell the nurses and the doctors. They briefly examine him but say nothing to the mother. I put my hand on her shoulder. She starts to cry but then stops herself. I take her into another room and ask a student nurse to interpret. We talk and then, after they remove the body, she lies on the floor in the quiet room. She must stay until the bill is paid.

In a quiet side ward with two beds there is a one year old girl with a disfiguring tumor on her face. She is small for her age and cannot walk. Her mother is attentive and loving. Whenever her mother steps into the hall she cries softly and says, “Ma.” She is on the ward for a month. Her mother smiles and plays and cuddles and sleeps with her. When her mother is not in the room she lets me hold her and she smells clean and sweet, she is a well loved baby. When her mother is in the room she screams at me in horror, my strange face and my white uniform worn by the monsters in her world. Her mom and I laugh together at her reaction and I leave after a moment. For over a month she waits for a biopsy of the tumor. I talk to the doctors and they express their frustration with the surgeons who keep rescheduling her biopsy. I notice her breathing worsening. The doctor says the tumor is probably beginning to occlude her airway. They begin chemotherapy without waiting for surgery. A few days later I arrive at the ward with a small pink teddy bear for her and find her bed empty. Her mother is sitting in the main ward with other mothers. At first I think she must be in surgery or moved to another part of the ward but she shakes her head and looks down. I take her to the empty ward and hug her, I give her a little money to contribute to the funeral and hand her the pink bear.

A three year old with cancer enters the ward emaciated and edematous. His skin is shiny and taught. His eyelids are so swollen he is unable to open his eyes more than slits. His mother speaks only a few English words. She greets me when I arrive. One day she shows me a picture of him as a healthy boy. She shows me a picture of his younger brother - a healthy baby staring at the camera - and says he died. She says the child’s father is also dead. She does not speak enough English to explain more. The boy looks terrible. He suffers. Then two days after chemotherapy is begun I see him looking beautiful, sitting up eating, all the swelling gone over night, long eyelashes framing big dark eyes.

A five year old boy with cancer had a biopsy and the site where the biopsy was done grew into a huge wound. He is admitted to the ward for daily dressing changes and antibiotics. His uncle stays with him and his father comes to see him daily. His mother has several other small children at home. She comes when she can. He never smiles, he moves slowly and speaks in a whisper. I walk in the room just after the nurses’ aides finish his dressing change. His father is not there. He cries softly and lifts his arms up to them. They giggle and leave the room. I take him in my arms and he snuggles into my neck. After a few minutes his uncle tries to take him from me but he refuses. He falls asleep with his head on my shoulder. I stand with him for a long while then sit on the bench in the hallway receiving comfort and feeling so much love for him.

Rain

The rain has come. Usually, conveniently, it rains in the evening or at night. Often moments after the rain starts the power goes out as though everyone should be silent and appreciate the down pour.

Waiting for Rain

In the States, the silver lining, the sunshine after a particularly heavy rain storm, is a symbol of hope but here the hope is rain itself. The heat seems to build in intensity until you feel the power of the sun wringing all moisture from your body and withering your skin with the smallest of its rays. Then at its climax the skies break open and release all the stolen water with the same intensity. The rains have not started in earnest yet this year but we have had a couple of storms and I have been caught in three of them. Warm, instantly drenching, restorative. Moments before the storm, the wind lifts the dust, coloring the sky a smoky red and carries ubiquitous plastic bags high over head. Then the drops fall and any one without shelter is soaked running home through warm rain and newly formed rivers. Today I’m waiting for the rain. The past few days have been hot. I try to avoid going outside and for my walks to and from the hospital I wear a hat, sun glasses, and a long sleeve shirt always arriving at my destination - even at 8 in the morning - dripping with sweat. In the hospital I don’t notice the heat much – distracted by tasks and conversations but I notice the patients without fevers sweating in their beds in sunny patches on the wards. In the afternoon on my way back to the trotro I often buy two sachets of water and drink the entire liter with little pause - my need for water more urgent than my need for air. When I arrive at home I head directly for shower, peel off the sweaty clothes off plastered to my skin and step into the flow cold water. During the weekends we sweat constantly in the house and avoid the bedroom in the middle of the day where the sun’s rays are most intense even through the curtains. The heat is debilitating. It steals away all motivation and shortens the slide into lethargy. On nights following days like these I am often asleep by eight o’clock. Now I am eagerly awaiting the wind which blows through the house before a storm, making the curtains puff like sails and then dance gracefully into the rooms from their rods. I am eager for the deafening sound of the rain on the roof. Mostly of all I am ready for the cool which follows and the clouds.

Home on Mango Rd

We have moved out of our dorm room into a real little house. Our Cameroonian friends, Ethel and Ernest, will move in with us next month. We live on Mango Road across the street from the University farm where they raise chickens, cows, and pigs. Clement met a cow and her calf outside our gate one morning. Our landlord lives next door with his wife, he is a very sweet man in his 70s who calls me Anna despite a few attempts to correct him. It’s a basic little house with cement floors and old deteriorating cabinets in the bedrooms and kitchen but it is freshly painted and filled with light. There are two good sized bedrooms and a third small study, three bathrooms, a common room, a small kitchen, and a covered patio. It feels like a palace compared to our room. The first few nights we spent here we found ourselves just hanging out in the bedroom and had to remind each other that there was more space for us past the bedroom door. It is sparsely furnished but that suits me just fine. We bought a bed and our landlord, Mr. Owusu lent us an old table, chairs, and a sofa set. Since we moved in I have been consumed by the task of turning the space into a home. I spent a weekend with Pamela sewing curtains on her sewing machine from 1912. She ended up doing most of the sewing on the first set of curtains but then Mrs. Owusu lent me her sewing machine (also hand powered and almost as old as Pamela’s) and I made pillows for the sofas and covers for the kitchen chairs, another set of curtains, and even a dress. We both feel more content here in the space and quiet. The closest evangelical church with loudspeakers is far enough away so that when they speak in tongues the sound is more like a large wasp flying outside the window and their all night prayer services do not wake us from sleep. [In general, the noise pollution from these churches is a real problem, several friends live so close that during services, which last up to eight hours, they must yell to communicate within their own homes. I suppose it adds a perk to power outages because when you lose your electricity they do too and off go their loudspeakers.] I hope we can live here for the remainder of our time in Ghana. Usually medical students live on this side of town for the first three years of their program and then move closer to the hospital for the last three years so it’s up to Clement and Ernest to find a way to commute. I am so happy with our home and can at last envision a life in Ghana for the next several years.

We are now ready for visitors if anyone is tempted to come.

What one can bear

For the past week I have been assigned to the Pediatric Emergency Unit. This is the ward where children with critical conditions are admitted and stabilized before they are sent to the regular pediatric wards. Most children spend only one or two nights in this ward. There are two rooms and a total of 16 beds. Three nurses cover each shift and a team of physicians round every eight hours, assessing the patients’ conditions and adjusting their treatment plans. There are three monitors for vital signs available and about five oxygen tanks. The number of eyes and amount of attention received by each patient is significantly higher than that in a regular ward. The most common cases included: severe malaria (cerebral malaria), sickle cell patients in aplastic crises, and diarrhea and vomiting resulting in severe dehydration. Thursday when I entered the ward my eyes were drawn immediately to a boy of about 10 years old. He dug his heels into the mattress and his body arched unnaturally. His hands gripped at his chest and his eyes were wide and fearful. His mother and father moved around his bed anxiously, one sitting then the other, then standing, both directing pleading gazes at the team of doctors then at their son.

Five days previously Samuel was playing on a merry-go-round and fell off onto something which cut deeply into the meat of his heal. His parents took him to their local hospital where someone stitched the deep wound with two layers of sutures, carefully bringing severed flesh together, stopping the bleeding, then calmed the boy and his family and sent the family on their way. They returned home satisfied but after a few days his muscles began to spasm. His parents rushed them to KATH in Kumasi when he cried from the pain of the spasms and his jaw froze shut.

Samuel had developed tetanus. Spores of the tetanus bacteria are ubiquitous in the soil and were introduced into his wound by whatever object cut his foot. The anaerobic environment of the sutured wound was the perfect environment for them to grow, so they multiplied in his foot and produced a potent neurotoxin. The toxin causes severe muscle spasms which are at times are strong enough to crush vertebrae and collapse the airway. The prevention, is simply a tetanus vaccination either as part of the routine immunization schedule and/or a booster immediately after injury. Once the muscle spasms begin recovery depends on the severity of the case, the age of the patient (in general children fare better than adults), access to tetanus immune globulin, and access to a ventilator which improves survival by ensuring that the airway remains open. Muscles spasms are precipitated by minimal stimuli – noise, light, even gentle touch – so patients should ideally convalesce in a dark quiet room. Mortality can be as high as 40 percent.

When the physician cut the sutures, Samuel’s wound gaped willingly as though his flesh was making an effort to physically push the toxins out of his body. Again and again Samuel would pull his mother’s hand to his chest and she would try to soothe him by gently tapping his arm, then his back would arch and he would cry through clenched teeth. The team of doctors passionately discussing his case feet from his bed at times were sensitive to the noise level they produced and at other times talked over each other and his cries.

Two small careless moments resulted in Samuel’s agony and a fierce battle for his life. Perhaps it was a broken bottle discarded carelessly. Perhaps it was metal from the merry-go-round unattended for years and left to decay. Certainly it was just a common item without power over life. The moment of power was most likely so casual and forgettable; a simple toss of the hand. If written in front of us as part of a screen play it would only take the tip of an eraser to cancel that moment from the possibility of existence. Then later another careless moment, perhaps the doctor who sutured Samuel had a long stressful day. Perhaps there were other urgent cases waiting. Samuel says he was not given an immunization. His parents did not know to ask for one. The doctor gave them his attention, addressed the messy problem in front of him, but a fraction of attention was missing - no vaccine, no instructions to seek the vaccine elsewhere (if it was unavailable at his facility).

At the end of my shift Samuel was calm, asleep. He had been given anti-tetanus toxoid and sedatives. All the other patients had been discharged from his room. It was a rare moment of quiet and peace in the PEU. His father’s face was calm, grateful, full of love for his son. In my limited Twi I told him I would see him ochena (tomorrow). He smiled and replied in Twi that they would be there with their son tomorrow.

Friday morning the nurses in PEU told me Samuel had been transferred to one of the pediatric wards as he was no longer considered an emergent case and they wanted to find him a quiet corner to recover. I walked up to the ward where Samuel had been sent. As I walked through the ward all the parents who had met me in the PEU came forward with smiles pulling me over to see their children. I walked through two rooms and saw many smiling faces but did not see Samuel. I asked the nurse sitting in the second room and she directed me to another ward. I walked through two other wards before I returned to the first room and asked the nurses. Hoping that he was recovering in one of the small quiet side rooms behind a closed door I asked the nurse about him. But, instead of leading me to a quiet room she told me he had died during the night.

I thought of his mother and father sitting by his side, taking turns holding his hands, placing their hands on his chest where he directed them to ease the pain. I thought of the nurse who, when I asked whether she had counseled the parents about the condition said “Yes, I told them everything will be all right.” I thought of the mother standing helpless over her son while he cried and his muscles spasmed looking pleadingly at the doctors talking nearby, not realizing that they were discussing his case and his treatment and were waiting for the medication to arrive from the pharmacy. Samuel was surrounded by love. He was raised in poverty but in the midst of deep love. His death at 10 was completely preventable. His death was completely devastating for his family and all but unnoticed by the rest of us.

After witnessing such unnecessary suffering and cheap death I often think about the platitude I have heard so many times but have grown to abhor, “You are only given in this life as much as you can bear.” What does this mean? Does this mean the poor are inherently stronger? That they can bear senseless death and early death easier than the rest of us? What measure of strength is used? Does this mean that tragedy will be heaped on your shoulders until just before you can no longer pull yourself to your feet in the morning or find the energy to eat? If this is the case then let me scream to the universe that I AM WEAK. And, WHO is it that gives us our burden? the “Universe” or God presumably. But to believe in such a way is to believe in a cruel God and to arm ourselves with religion to rationalize suffering is to reduce it to a talisman against our worst fears and a basis for maintenance of the status quo.

I believe in God but not a cruel God. I believe in a God who has united us all with life and the ability to love and who leaves it mostly to us to honor, respect, and cherish the life in us and around us. The poor are not stronger, or more saintly, or more sinful. The poor are less powerful. If there is anyone portioning our burdens it is us. And, if there is any burden to be born it can only be born as a community, as a global society, not as individuals. Perhaps together we can bear and transform these burdens but they will never be transformed as long as we turn away with gratitude and relief that it was not our child who died.

How many significant moments of our lives have their roots in the smallest action or gesture? Likewise, positive or negative, we will never know what ripples the majority of our words and actions effect. The doctor who sutured Samuels wound will never know that his carelessness resulted in Samuel’s death. And, I can never have my perfect self-contained life. So let us be conscious. Let us understand that all segments and divisions are of our own making. We are woven together by life itself.

The New Routine

Monday I attended what I sadly realized would be my last delivery for some time. It was fast and smooth, and moments after mother and baby were cuddling and feeding, staring contentedly into each other’s eyes. Last week I finally received word from the College of Nurse Midwives that I passed my nursing registration exam and was informed that I could now begin my hospital orientation. Unfortunately the orientation is for general nursing and so the 90 day period includes only a brief allocation to Obstetrics and Gynecology during which I’m not sure whether I will be permitted to attend deliveries. Orientation will finish in mid-April and then, having spent nine months without any income, it will be time for me to head to Texas in search of a well-paid short nursing contract which will keep us going here for another year. That means I will most likely not be attending deliveries again until the fall.

Nurses here still wear white dress uniforms and little white caps (as they do in all wards minus delivery in Malawi as well). I have been able to avoid this up to now by never asking about a dress code and just showing up in my American scrubs. However the letter from the Council explicitly mentioned that I must wear white and the Director of Nursing at KATH – the large teaching hospital where I will do my orientation – made sure I was aware of this. After a few hours worrying and then laughing at the idea of sending my midwifery classmates a picture of me in a white nursing dress, a little white cap, and Minnie Mouse shoes (as my aunt Joanna used to call them) I found a shop selling second hand white scrubs from Europe. I am the only nurse in the hospital wearing trousers but no one has complained so far.

Wednesday was my first day. I left the house at 6:30 and walked to the corner to catch a tro-tro. (After 7am the tro-tros are few and the hopeful passengers many and more aggressive than I can bear.) I don’t mind the 30 minute cross-town trip in a small minivan with 14 other people, I appreciate not having to drive, it is the other part of the commute which I find exhausting. The tro-tro stops on Roman Hill, named for the large Roman Catholic Cathedral perched on top, and from there I walk down the hill, across a corner of Kejetia Market, and up the opposite hill to the hospital. Someday I will have to video the walk. Even at 7am the streets are full, vendors who have already displayed their wares, shout prices to attract customers. Others quickly transform minimal wooden structures into colorful full shops. Permanent shops lining the road sell mattresses, or household items; their goods brought to the road side every morning and repacked every evening. In front of them sit the vendors, each with their little square of land. Women squat in front of large steaming pots selling foods I still can’t identify. Men stand next to tables of brightly packaged pirated copies of movies and CDs, irons and rice cookers, tables of cell phones, stacks of dvd players. At the bottom of the hill women sit beside their produce arranged in colorful heaps, tomatoes, carrots, onions, bell peppers, buckets of lettuce, yams, piles of smoked fish, dried shrip. One woman positioned just where I take my first turn straddles a large bushel of giant snails. Just about everything needed for daily life is available and everyone who has a spot returns to the same location daily.

Vendors sell soap, shampoo, beauty products, costume jewelry, used magazines and books, live chickens, cans of diet coke, vegetable seeds. Men stand at carts piled high with coconuts carving a hole for customers to drink their milk and then cutting them open with swift exact chops from their machetes. For a long stretch both sides of the road are filled with people selling used clothes, some heaped in piles, some displaying the best pieces on the walls of their stalls, some walking up and down with a pile over their shoulder. Along my walk I pass a minimum of three stations for roadside preaching. Each day at every station a different person yells into the microphone connected to enormous pair of speakers blasting his or her voice into the din. People selling CDs also amplify their music – I suppose the idea is to attract customers but it is deafening to anyone close enough to actually browse through their selection. Those who do not have their own corner of the market walk back and forth carrying their wares on their heads. Yesterday I saw a woman with purses hanging from her arms and piled stories high on her head. Men carry stacks of handkerchiefs, towels, used clothes, yogurt, chewing gum. Women carry sachets of water, trays of freshly baked bread, chocolate drinks in bags floating in plastic containers with bubbles of ice, bananas and peanuts, fried plantain chips, cheap plastic toys, women’s underwear, neat packages tied with banana leaves (the inside edible identifiable by the shape, circular, long and rectangular, or small and rectangular), pineapple, dried fish and fried yam.

Then there are people transporting packages. Carry-o girls with their white basins wait to carry items for you for a few cents. Wearing head scarves, and layers of mismatched bright prints, their eyes painted with charcoal, ethnic tattoos on their foreheads they are visible everywhere, some moving swiftly under enormous loads and others sitting or sleeping in the midst of chaos, their bodies draped over empty overturned basins. Wherever tro-tros stop men shout and frantically try to fill them with passerbys. Every day at some point along my walk a man stands in front of me or grabs my wrist pulling me towards his bus asking “where are you going?” but not waiting for a response. Every inch of space is colorful and full. The sound is overwhelming, talking, yelling, music, and endless honking. Cars move slowly, drivers keep their hands on their horns, and people weave through them, across the street and back like trails of ants.

Kejetia market is alluring and repulsive. Enormous piles of trash generated daily by the 10,000 venders and their customers rise along the road. I know the areas on my route where the stench rising from gutters is overpowering and go out of my way to avoid them. As I turn out of the market I pass the same woman in the morning always grinding pepper by hand in her clay pot. Across the street a speaker projects the shouting of an unseen man yelling tro-tro destinations. Every day I see the woman and hear the main in the same monotone shout, “Accra, Accra, Accra, Circle, Circle, Circle, Lelela, Lelela, Lelela . . .” A few paces from there I often meet the same street cleaner, a lone woman sweeping who smiles and says good morning. As I walk I have the sensation that I am again beginning the same day. On one hand it is the disquieting sense that there is no progress but on the other hand there is a sense of reassurance - that the worst has been survived previously and might be survived again if necessary - and a little hope that maybe today may be better.

As I walk up the road the market descends and I am soon overlooking a bus depot filled with hundreds of small buses of every make, year, model, and color imaginable. I continue up the street and approach what appears to be an enormous noisy swarm of birds flying in circles over a few acres of strange brown deformed trees and undeveloped land. But, as I get closer I can see that the birds are actually large bats and the strange brown branches are actually clusters of hanging bats. I walk up a back street filled with men weaving baskets and book stands then through the gate leading to the dorms for medical students and flats for doctors. There always seems to be a few chickens roaming freely followed by a cluster of fuzzy chicks.

When I reach the hospital I find a closet or an exam room where I change into my white scrubs and then find the room where I am supposed to report and introduce myself to the doctor. This week I spent two days in the outpatient pediatric triage room and two days in the adult triage room. All consultations are conducted in Twi, the most widely used local language of which I only understand a handful of words. Over the past few days all the doctors have willingly translated a summary of the patient’s complaint and involved me in their thinking process while making a diagnosis. Malaria accounted for a high percentage of the hospital visits. These cases are relatively straight forward a patient typically presents with chills, fever, and occasionally nausea, vomiting, diarrhea. Many times even if malaria is consider only a possible diagnosis the physician will prescribe the treatment because delayed treatment can be devastating and there are not enough resources to test everyone who comes in with such symptoms. While in pediatrics I saw a child come in and have a febrile seizure while in his mother’s arms. I saw two sisters with imperforate hymens. I was very impressed by the fact that the triage doctor just walked the mother with her young girls down the hall to see a specialist (in Malawi there are few physicians fewer specialists) and I was very impressed by the specialist who talked to the five year old, asking her her name, telling her what he would do and asking her permission – something else I have rarely seen. Back in the consultation room I saw several children with sickle cell anemia. Sickle cell anemia is much more common here than in Malawi. Children are currently tested at birth and at least in large cities there are regular clinics for positive children to help make sure their lives are as long and healthy as possible. The pediatrician I followed one morning said that sickle cell positive people in Ghana can live into their fifties but many patients die young and suffer greatly.

In the adult consulting room I saw many cases of malaria and many more of hypertension. Hypertensive patients came to refill medication which either they were not taking correctly or they were taking correctly but failed to control their blood pressure. I did not see a single well controlled hypertensive and many who came had blood pressures which classified them as severe. A few of these people were overweight but most of them were just middle-aged women (one of the male physicians said men would rarely their medicine, much less come for a refill, because of the side effect of impotence). One relatively fit looking young man perhaps in his early forties came for his medication refill, his limp and posture evidence of a previous stroke, and his blood pressure frightening at 170/110. There were a few elderly patients with bladder infections, an elderly woman with congestive heart failure, and a confused man with an infected laceration. Then there were the two men who pushed their relative through the door in his wheel chair, saying that three days previously their relative was normal and had complained of knee pain. I eyed the patient, suspicious of his immobility. He sat upright, eyes closed and his face relaxed. While the doctor conversed with the men I first thought he might have a psychiatric condition. Then I watched his chest for movement and saw nothing. The doctor checked his pupils with her pen light, felt for a pulse and then told the men that people from the mortuary would come and collect the body. The relative asked a few more questions of the doctor and when he left the room she said that he had no idea the man was dead until she mentioned the mortuary. He was a hypertensive and was only 48.

I miss birth already but I know I will see a lot during my six day weeks here and I hope that this experience will make me a better nurse in this setting.

High Life

Two doors down from us lives a famous Ghanaian folk musician. In front of his home, his wife runs a small shop which we often visit between our main shopping outings to restock on sugar, soap, and eggs. During the evenings Koo nimo sits out front on a wooden chair keeping her company and chatting with neighbors as they pass by. The first time I met him he casually asked me about where I was from and told me where he had lived and visited in the US. Always friendly and welcoming it was only over time, hearing from other Ghanaians, that I learned he is considered a living treasure here.

Originally trained as a chemist Koo Nimo worked and taught in the Biochemistry department at the University but in his other life he was known as a brilliant musician responsible for the creation of Ghanaian Palm Wine HighLife music. Through his career he taught courses on ethnomusicology, drumming, dance and guitar in Ghana and at well known Universities both in the States and Europe. He has also toured and performed worldwide. Now in his late 70s he is officially retired from his work at the University but stays busy teaching students from his home and regularly invites groups of foreign exchange students from all over the world to listen, learn, and participate in his passion. One evening as we stopped by to get some crackers he told Clement and me about a recent joyful experience of performing in a hospital and said that, as a way to give back to the community, he will begin performing regularly at hospitals and prisons.

A week ago I saw a bus load of obrunis heading to his house and then from my seat on our porch I listened to the drumming emanating from his compound for a couple hours. The next time I saw him at the shop I mentioned how I had enjoyed the drumming from afar and he invited me to another performance for the same group on Saturday. I woke Saturday morning filled with excitement and paced on our porch until I saw a few white faces walking towards Koo nimo’s home and then I hurried to follow them. They were four American friends of his and for them he played a few pieces on his acoustic guitar accompanied by two incredibly talented Ghanaian students. I sat nearby in a chair and let the beauty of the music wash over me and raise a smile gently to my lips.

Shortly after this group departed, the bus load of students arrived. They took their seats and Koo nimo introduced the musicians, their instruments, and his dancers. (I was slightly surprised to see his son who often mans the shop dressed in traditional Ashanti wear seated behind a drum.) A moment later drumming and dance animated the small courtyard. Drummers poured their bodies into their performance and guided the steps of the dancers across the floor. After several pieces, including a couple with the acoustic guitars and vocals, students were pulled from their seats for basic dance and drumming lessons. It was sweet to watch them initially struggle with the steps and gradually overcome their self-consciousness. Even those who never mastered the steps still clearly enjoyed moving their bodies with the drums. While I watched, Koo nimo leaned over to me and said he recommends everyone dances at least 20 minutes every day and believes dance is the natural cure for diabetes, hypertension, high cholesterol and so forth. Certainly even those who stepped up hesitantly with serious expressions soon beamed incontrollable smiles.

Clement and I reached home at the same time. It was a hot day and he had spent the morning hours with Ernest in town looking for a hard drive. Still weak from the malaria Clement collapsed on the bed while I danced around him talking a mile a minute, the joy literally bubbling out of me.

*** You can buy two CDs from Koo Nimo off amazon.com. I highly recommend Osabarima

Christmas and into the New Year

I find I must make a conscious effort to remember the approach of Christmas outside the US. In the States, whether Christian or not, you are made aware of the approaching holiday months before by decorations, lights, Christmas trees, music, and Santa Claus in stores and on street corners. It is easy to begin to associate the holiday with the fluff. In Kumasi I did not notice much change. There was the addition of people selling tinsel on street medians in town and the occasional American Christmas song broadcast from one of the many sidewalk sound systems, but not much more. I recognized just how deeply I have been programmed by American commercial Christmas when I felt a spontaneous flicker of excitement upon hearing “Oh, the weather outside is frightful . . . .” or “I’m dreaming of a white Christmas . . .” in the midst of town despite the ridiculous context where temperatures soared to 100F and everyone moved about with handkerchiefs in hand mopping their faces and drinking water from sachets.

Tuesday, December 23rd I went to the hospital. In the morning I did not notice any additional buzz but while in the labor ward it was at times difficult to auscultate the fetal heart because of the number of cars driving by outside with loudspeakers blasting. I’m not sure if was due to Christmas or the election run offs which were to be held on the 28th. When I left the hospital grounds it felt as though the population of the city had doubled. The nearby streets which cut through the market no longer accommodated cars and as I made my way to the minibus I found I had to be even more vigilant than usual to avoid physical collisions or being inadvertently pushed into gutters. During my third year in college in Rhode Island we had an incredible memorable blizzard (a new experience for a girl from Texas). I was wanted to visit a friend who lived two blocks from me in the evening, so I layered up and set out. The power was out and branches lay in the middle of the road. The snow reached my knees and continued to fall, obscuring everything. I leaned deeply into the wind and labored with every step. When I was just twenty feet from my dorm I began regretting my decision imagining that I could easily die just feet from warm dry shelter. Walking through the crowed market in Kumasi elicited the same feeling. I finally stepped into the minibus and slumped in my seat so happy to allow someone else to take it from there.

In this country where Churches are on every block and services often carry on through the night I expected Christmas to be a notable event. Christmas morning Clement and I woke up and prepared for church. I imagined the women lining the streets waiting for transportation dressed in outfits outshining their usual Sunday glamour. But, when we walked to the curb it looked more like a normal Thursday. The corner shop was open, and vendors were positioned in their usual spots already selling bananas and porridge to the regular crowd. Halfway through the mass the church was full. Mass was relatively simple and brief concluding again with a prayer for peaceful elections. In the evening Clement and I shared dinner with Pamela and Atta. I recently learned that there is an organization for expats married to Ghanaians. The group was formed years ago as a means for political advocacy during a time when foreign spouses were not granted residency and had to regularly fight to stay in the country. Members continue to meet but most are now in their 50s and above. I have met three women and two of their Ghanaian husbands; all are lovely people and are satiating my friend starved appetite. As it turns out Pamela and Atta live just a short walk from us in a simple house/art studio with a beautiful garden. They are the type of people I have long aspired to be - people living fully, but also simply and humbly, enjoying life and adding to its beauty. Pamela filled the table with the most delicious food I have tasted in months – curried prawns, grilled fish, spiced stir fried vegetables, homemade yogurt and chutneys, fruit cake, and miniature mince meat pies. Preparing such a meal is a feat anywhere but more so where ingredients are scarce and kitchen facilities are extremely basic. After filling ourselves beyond full Atta pulled out his computer and a pile of art magazines to show us some exhibitions, his own and a sample of inspirational others. Though it was only my second time with them and Clement’s first time meeting them, it felt incredibly comfortable to be in their presence. When yawns began spreading we said our goodbyes and as we walked home gleeful and grateful we were shocked to see it was already 11pm.

Saturday Clement and I left Kumasi with our friends Ethel and Ernest to visit the Coast. We are all foreigners in this country. We have all have had a difficult period of adjustment but we are ready to love this country and it is time to see more beyond our frequently traveled route in this city. My parents sent us some money for Christmas with explicit instructions that it should be used for travel. Without any income at the moment - just the hope of a 3-month nursing contract in Austin next summer - and the knowledge that AMHI in Malawi is still underfunded, I find it difficult to spend money on anything apart from the basic necessities so I was grateful for the condition placed on their gift. Our first stop was Cape Coast Castle – built by the Swedes in 1652, then transferred to the Danes then on to the Dutch and ultimately captured by the British in 1664. Elmina Castle which lies in a town just west of Cape Coast was built by the Portuguese in 1482, then captured by the Dutch who eventually sold it to the British in 1872. It is estimated that 30 million slaves passed through the dungeons of these two castles, many not surviving to even reach the slave ships, all who passed there experiencing, at minimum, the death of their former selves.

It is common knowledge that most religions have been used at various times to oppress and vindicate often violent ethnocentric marches across the faces of other cultures and people. To know this is one thing but to stand in a dungeon and then climb to the chapel situated directly above is jarring. The walls of the dungeons are made of thick stone and our guides informed us that the floor which appeared to be packed earth was in truth layers of excrement, blood, and vomit from those who occupied the space over hundreds of years. In some areas the original stone floors had been excavated six feet below. To imagine holding in your hands a tool for enlightenment and spiritual transformation and wielding it as a weapon of mass suffering and destruction is deeply disturbing. To stand in the light of today and measure the depth of blindness of others long gone is a powerful experience but also tempts us to quickly turn the page. We try to separate ourselves from such horrors by demonizing the offenders, placing everything we can between us - time, distance, defining factors inherent in them which led to such atrocities. However such atrocities are not unique to Christianity or Islam or any particular religion or race or ethnic group or political group. Unfortunately the ability to twist something good into an evil force is uniquely human. As long as we deny our shared humanity and our shared weaknesses, we allow that darkness a foothold in a corner of our selves.

Thank God that at least we no longer sanction such overt atrocities but our world is far from free of them and many times they are much closer to home than we would like to imagine. It seems the source of our blindness is our ego. Seemingly benign, our human ego is a disruptive force bent on its own survival. Why do we go to such great lengths to prove our righteousness? to justify our actions? to highlight the faults of others so we shine in comparison? All major world religions are founded on love, compassion, service, and forgiveness and in their purest form strive to unite but so often we struggle against these messages. There are few opportunities were can stand close to a monument of exceptional human failure and know that this particular chapter is closed. But, we should take more than comfort with us when we walk away. Let’s not forget that everything is a gradation of something else. The moment we begin to accept the alluring whispers that “we” are better than “they” is the moment we begin to fail.

With the castle walls looming over us we walked through the sand and shallows below, breathing in the space, collecting shells, and watching fishermen sail by. For a few days we toured the towns, and visited the corner of a nearby protected rainforest. In the evenings we sat by the ocean, shared meals, conversation and laughter, and watched the local boys perform acrobatics on the beach for their own amusement.

The December 7th elections went smoothly. In Ghana in order to be elected president a candidate must win a majority of votes (a minimum of 50% plus 1). With numerous parties and candidates running no single candidate was able to obtain that number of votes on the 7th so, a run-off between the two largest parties, NDC and NPP was scheduled for December 28th. Again people worried about peace as the party leaders each took turns vowing not to recognize a win by their competitor. On the 28th there were a few reports of problems – in one constituency 1,000 ballot papers were missing so no one in that area was allowed to vote; there was a story of a man who attempted to steal ballot boxes; and, a story of a reporter beaten after trying to record people stuffing ballot boxes. Yet, overall the elections went smoothly. While touring Cape Coast we listened to the regular updates as the votes were tallied on the 28th and 29th. The final count had NDC leading by 30,000 votes. The constituency which had not voted included a population of just over 30,000 and, though it was in a stronghold of NDC, NPP insisted that these people should vote before the results were announced. Nonetheless many NDC supporters began celebrating on the 29th. Meanwhile NPP supporters never imagined that NDC could win, and the NPP party leaders continued to make accusations of fraud and threatened to take legal action.

After the final votes were tallied John Atta Mills, the candidate for the opposition (NDC), was officially declared the president elect. Thankfully I have not heard any reports of violence. NDC supporters celebrated enthusiastically by painting their bodies the party colors - white, green, and red - and dancing in the streets. I’m sure the grumbling from NPP will continue for a while but at this point it seems Ghanaians have successfully experienced another peaceful transfer of power. As one Ghanaian noted, with each peaceful election the roots of Democracy grow stronger as does people’s confidence in their own power to effect change. Slowly people are beginning to understand that politicians should and can be held accountable for their actions. Atta Mills is not a new figure in Ghanaian politics however and whether his election will lead to any positive change for Ghanaians remains to be seen.

The morning before we headed back to Kumasi, I woke up early and moved outside to read the last few pages of my book. A short distance in front of me over thirty men and a handful of women pulled on the ends of a giant U-shaped net, coordinating their efforts by the deep chanting of one man “o – ei – he – yu . . . . o – ei – he – yu . . . .” A small boy stood between two men, the rope at their waist level was taut above his head. He grasped it with both hands and leaned with the men as they pulled. At the breaking point two men treaded water diving under the waves and tying the net into small sections as it was hauled in. The progress was slow. After twenty minutes the buoyed end of the net still floated freely over deep water. The adults strained and the chanting continued, harmonizing with the sounds of the waves and the calls of the birds. I returned to my book. When I looked again the net had been gathered on the beach and the women were emptying the sections into large aluminum basins. Once full, they overturned the basins on the beach revealing six or seven shimmering silver heaps. Women negotiated with the fishermen as the men coiled the net. A few hundred meters from the shore men dove from their wooden fishing boat and swam to land. On the beach, three men lassoed the net over their bodies and walked to their village in a line, the weight evident in their labored steps through the sand and the tension of their muscles. The women returned the fish to their basins, lifted the basins on their heads, and carried them away to begin their day of selling.

As we headed back to town and then on to Kumasi, we passed through a village and Clement pointed out an astonishingly small lamb. In front of a house where excited children shouted “obruni” as we passed, the lamb struggled to find his balance, legs splayed, his mother’s nose gently touching his side as if giving a word of loving encouragement. I saw a wet line of umbilical cord still dangling from his abdomen. These are images to savor; a holiday enjoyed thoroughly and joyfully concluded.

We arrived in Kumasi happy but exhausted, cleaned the heavy layer of dust left by the Hamatan from the room, ate a minimal dinner and fell into bed. The next morning Clement woke up with a fever and body pains – sure signs of malaria. I cooked some porridge, went to the pharmacy to buy some anti-malarials, washed three large loads of clothes by hand, prepared a simple dinner and then the day was finished. In the morning Clement seemed better though still weak so after a few hours I left to visit Pamela, check emails, and buy groceries. The time passed unchecked and it was dark when I returned. As I walked in the door Clement told me softly that he missed me and when I leaned down to him on the bed he hugged me as though I had been gone a lifetime, the heat from his body no less than that wafting from an open oven door. He said he was feeling terrible but had been even worse a couple hours before. I should have expected another exacerbation and was upset with myself as I imagined him suffering alone. He had recently taken another dose of medicine but the Tylenol did nothing to diminish the pain or quell his fever so, for the next few hours I traded damp towels between his body and the refrigerator. In this life here there is little room for comfort but so much space for gratitude. Life is always fragile and precarious but here it is a fact of which everyone is made perennially aware. I woke this morning and touched my lips gently to his arm so as not to wake him. The coolness of his skin sent a wave of joy through my entire being.