Hepatitis B Screening and Vaccination Day

Thursday, June 12. Day 1 of the Hepatitis B screening and vaccination program at Nyanyano DA Government School. 

7:30 AM: I arrive on foot at Sweet Mother, a reputable food stall in Kasoa, to purchase lunch for the staff of the day. The one time I had been given lunch during a workday I was served rice, stew, and a hard boiled egg. I ordered six of these. "Eggs are finished" I was told. Chicken was the next least questionable option. "No no," said the woman (Sweet Mother?) "Chicken is finished." At 7:30 in the morning? Okay. "Cow meat!" she says, swirling a chunky vat of steaming brown. "Or fish." I glanced at the pile of dried fish stinking in a pile on the counter and dry heaved a little. The Ghanaian Hep B staff might have enjoyed cow meat or fish, but I was the one who had to sit with the smelly food in a taxi in traffic. I ordered rice, stew, and beans and hoped it would be an acceptable Ghanaian lunch.

8:15: Arrive at Nyanyano DA Government School with Claire, who started the project with me, and two new volunteers from our NGO who we have appointed to take over our project duties when we leave Ghana.

We greeted the headmaster and waited for our team to arrive. Mr. Tahir is the administrator of Justab Private Hospital and head of Alpha Al-Akeem, the organization that we are collaborating with to provide discounted screening services and vaccines. Tahir was to bring two nurses and a lab technician with him that day.

From the moment we set foot on the campus, we were swarmed with children. Teachers made minimal efforts to hold them back. We could barely walk to the headmaster's office through the crowd of jumping and screaming boys and girls. I felt like Beyonce.

8:25: Receive a phone call from Tahir saying that he is at the Station, just down the road from the school and will be there in a moment.

8:30: The program is set to start.

8:40: Call Tahir. Learn that the car his staff was traveling in had gotten stuck in mud. He had left to go rescue them.
9:00: Waiting.

9:10: Parents arrive for the optional pre-program parent education session

9:30: Waiting.

9:40: Panic. I confess angrily to Claire my frustration. She and I had been working day and night to execute this project. We raised over $3200 in one month. It felt like people didn't respect our efforts enough to be there on time. Rationally I knew the mud situation was completely unprecedented, but this wasn't the first time we had been left hanging like this and the feeling of disappointment in the moment was all too familiar.

9:40: Tahir arrives! We usher him into the classroom where parents have gathered. Tahir speaks in a combination of Twi and Fanti, two of the local dialects. We Obrunis sit cramped into the small old-fashioned desks and watch as he animatedly speaks then answers questions. 

I was thrilled that 10-15 parents had showed up. Based on what I have seen of the family dynamic and importance of work in Ghana, I had doubted any parents would give up work time to come to school to be educated about their child's health. The talk ended and the parents all rose to shake each of the Obrunis' hands, thanking us profusely. We thanked them for coming and began to set up the classroom, children crowded five deep around the doors and windows to watch us.

The screening began. We led in groups of ten children from class 4A. One at a time, they went to the front of the room and had a sample of blood drawn by the male nurse Atoo. Claire gave them all pep talks beforehand, warning them that the needle might pinch for a moment but that they had to be strong! The little boys were troopers, holding the cotton balls on their veins and flexing to proudly as they were led to another section of desks to wait for their results. A few girls cried, and we tried to go sit next to them and hold their hands if they looked nervous walking up to the nurse drawing the blood. 

(Photo credit Claire Boone)

(Photo credit Claire Boone)

The lab technician Nuzrat added the blood sample to a buffer and received results within a few minutes. We expected nearly all of the children to test negatively. The vaccine would be administered right there by the other male nurse King to the children with negative results. 

Unexpectedly, the second sample taken was reactive with the buffer solution, indicating a positive Hepatitis B screen. So was the fifth. By the time we had screened 25 children, we had five positive samples.

We continued with the pattern of taking ten children at a time, but our efforts to keep order were futile. There was not much technical work for the Obrunis to do so we focused on herding the children outside away from the screening classroom. 

Because of our limited funding we were only going to work with children in grade 4 that day. Our goal is to continue fundraising and promoting the project so that we can provide screening and vaccines for grades 5 and 6, and possibly the whole school some day. 

The day wore on, and around 2:00 the team broke for lunch. As I led Tahir, the nurses, and the lab tech to to the headmasters' office where the food from Sweet Mother was, I explained that I wasn't sure if they ate meat so I hoped rice and beans was an OK lunch. They didn't respond. I kept watch on the classroom while they ate. Afterwards, I asked if the food had been okay. I don't think they were impressed, and they made no effort to counter my assumption. Ouch.

After the food fail, we carried on for another few hours. By the end of it all, we had obtained the following results:

99 students screened
2 teachers screened
25 students absent
1 student opted out
91 vaccines administered
8 students tested positive

8 out of 99 our our sample group tested positive.Tahir was almost beside himself, he was so upset about the results. He had expected maybe one or two children to test positive. Eight, he said, was much too high. Especially for children. Our sample was almost precisely representative of Ghana's HBV morbidity rate of 8%.

The next step is to have a laboratory test the viral load of the positive samples. This test will tell how far the virus has progressed. If the viral load is within a certain limit in the acute stage, there is a chance the virus can be cleared from the body. But if the viral load is too high, then it has progressed too far to be cured and treatment will focus on symptom management and prevention of disease progression.

(Photo credit Claire Boone)

(Photo credit Claire Boone)

Of course, the parents of the positive children must be informed of the results.  We scheduled a date next week for Tahir and Claire to meet the teachers and parents. On that date they will also screen and vaccinate the children who were absent on Thursday.

Leaving Ghana will be bittersweet, but I will continue to work on this project from the States. I fly back to the US on Tuesday already, after spending 9 weeks in this country! I am excited to continue to move forward with this project though. 

Each vaccine requires three injections, so the follow-up for the group given vaccines on Thursday will be in one month. The third booster injection will be administered in September. As I mentioned before, we already have two volunteers who recently arrived in Ghana and will be here through August. They will take over the project when Claire and I leave (Claire is gone two weeks after me), and they will hand it off to incoming Public Health volunteers as they arrive. Claire and I will type up guidelines with all of the details  the successors need to know, and we will continue to manage the project remotely.

(Photo credit Claire Boone)

I'm not sure what I expected out of this volunteer opportunity. I think I envisioned myself doing background busywork for an already-established project. I never thought I would be designing and co-managing two screening projects (our tuberculosis screening was held two weeks ago, see previous blog posts). I am eternally grateful for being matched with Claire, a powerhouse of determination with the organization skills required to execute all that we did. I could not have asked for a more perfect partner-in-crime.

I had admittedly set the bar relatively average - not high, but not low - for the amount of a difference I could actually make during my internship. But our collaboration blew up the bar. I am really proud of what we accomplished and learned not to underestimate what I can accomplish by ignoring that silly bar and demanding results instead of hoping for them.

The One About Food

The Ghana Diet is pretty opposite of what I eat in the States. At home, I try (*key word) to eat mostly a balance of vegetables and proteins such as chicken or fish, tofu, dairy or eggs. (Of course, there are the inevitable junk food binges from time to time, and I won't pretend like I ever say no to chocolate chip cookies.) In Ghana, the diet is based on white rice, white bread, and potatoes. Plus sugar. And oil. There arent many protein options that are trustworthy in my opinion (its mainly questionable meat). Coming here for 10 weeks, I was in for a change.

Many Ghanaians eat heavy meals for breakfast, lunch, and/or dinner. I am usually on the go though and have smaller meals throughout the day, then a bigger one in the evening. 

Breakfast 

Breakfast for me here is either cereal and milk or fruit; the latter is sold on every road for crazy cheap. You can buy a huge mango, a papaya, or a pineapple for one cede (38 cents US) and the vendor will peel and cut it into a to-go bag for you right there. There are also bananas, plantains, apples, pears, oranges, watermelon... You name it. Yum. 

When my wonderful Grandma Eunice heard I was pining for some items from the US, she sent the best care package ever. After three weeks of uncertainty that it would make it overseas, the package finally arrived full of protein powder, Trader Joe's trail mix, and Starbucks instant coffee, among other treats that I usually tie into breakfast. Thank you Grandma!!!

Lunch 

Many restaurants, called "chop bars," offer meals of soups and stews for lunch. I usually opt for combinations of the snacks you can buy from street vendors though instead of big sit-down lunches. 

By around 11:00 vendors are in full force, carrying huge containers on their heads peddling a variety of foods. If I see something I haven't seen before, I generally buy it just to try once even if it looks undesirable. Most foods aren't more than one cede so if they're terrible, it's not a huge financial loss. The most common roadside foods include:

- Meat pies. Triangular pastries about the size of an open hand. Taste like Pillsbury biscuits. Apparently the meat is inside, but the one time I tried one I found only a tiny brown dot of sauce in the middle of the doughy biscuit. I guess that was meat? This was a one-time purchase.

- Egg pies. Similar to a meat pie, but with a hard boiled egg in the middle. I feel like sidewalk boiled eggs are a bad idea so this one I have not yet tried.

Egg pie vendor

- The "other" (awesome) egg pies: Face-sized pockets filled with a mixture of scrambled eggs and onions, deep fried. For some reason when I see the eggs cooked in front of me, even if in a vat of boiling oil, they seem more legitimate than hard boiled eggs that could have been cooked days ago. These egg pies are delicious but a definite heart attack waiting to happen.

- Corn: Either roasted on open coals or boiled in the husks. I hated both versions when I first tried them, as the roasted kind is very chewy and the boiled kind has no flavor. What good is corn on the cob without butter and salt, or chili and lime? But the roasted version grew on me, and the vendors will dunk it in salt water per request. The salt water is pretty unhygeinic if you think about it; I'm probably asking for a parasite. But I choose my battles here.

- Plantains: My obsession. Roasted over open coals like the corn, and you can buy little packets of groundnuts (peanuts) to eat with them. You break open the hot plantains length-wise and kind of jam the nuts in, and voila! Ghanaian version of banana and chunky peanut butter. The plantains alone are awesome as well. I usually have one each day as a between-meals snack.

- Variations on deep fried dough: Doughnuts. Nugget-shaped chips. Flat chips. Squiggly chips. The only ovens here are in conventional bakeries so most things are deep fried as an alternative to baked. Not particularly tasty, but also not bad.

- Groundnut candy: Peanut brittle. I sort of convinced myself its a healthy option. Nuts are good for you, right? 

- Ginger dough balls: These are chunks of ginger, groundnut paste, and sugar rolled into balls with the consistency of cookie dough. They are extremely strongly ginger-spiced. I love ginger and I can still only handle a little of this at a time. 

- Weird coconutty brittle cookies: I think they're meringue. No one else really likes these but I love them. I can only find them maybe once a week or so and have been known to chase the vendor from across busy intersections to stock up while I can.

Dinner 

Most big meals here consist of some form of starch (either banku, fuufuu, or kenke - to be explained) and a stew. Until Ghana, I pictured stew as potatoes, carrots, peas and beef in a heavy brown gravy. Ghanaian stews however are mostly tomato- and oil-based, with some onions and spices usually added. Okra stew is okra, tomato, and oil. Cabbage stew is cabbage, tomato, and oil. Egg stew is egg, tomato, and oil. You get the picture. 

Banku is fermented cassava and maize pounded into a dough and served in piping hot tennis ball-sized portions wrapped in plastic. Plain, it tastes like raw sourdough bread dough (or how I would imagine that to taste). I strangely really love banku, though most people merely tolerate it as a vehicle for whatever stew or dish it accompanies. 

Fuufuu is similar to banku, minus the sour taste. It is made from pounded cassava and plantain. When I tried it it was stickier than banku, which is really saying something because banku is a mess to try to eat.

Kenke is a little stiffer and is made from pounded maize, then wrapped in plantain leaves and steamed. It's grainier than banku or fuufuu and reminds me of the outside of an enchilada.

As you can imagine from the descriptions above, meals are heavy. And messy: Utensils are not usually utilized by Ghanaians. People eat with their hands, usually by using the starch (any of the three above, or perhaps boiled yams or if you're feeling really messy, rice) to scoop up portions of the accompanying stew or other dish. Its fun to try to eat this way, until you remember there is no running water anywhere and your hands are likely filthy despite the constant dousings of Purell. I opt for utensils, which are usually available for the Obrunis.


Tilapia and Banku 

This delicacy deserves its own in-depth explanation. 

Earlier I mentioned that I'm kind of a pseudo-vegetarian in Ghana, based on the questionable meats. My decision to go meatless was confirmed the day I went for a curious stroll through the market and unknowingly wandered into the butcher section. Huge slabs of raw cow, goat, chicken, and I-don't-even-want-to-know-what else were strewn across tables and market stalls, sizzling in the African sun and surrounded by vulturous flies. I decided at that point that I'd be ok sacrificing protein for two months. The chicken feet and giant snails roasting on sidewalk grills, along with the dried and deep-fried fetid fish being sold out of baskets on women's heads, also removed any desire I might have once had for meat.

Unfortunately, my cautious diet got boring quickly. One evening I worked late and decided to get dinner out in town instead of eating what was prepared at home that night. I passed a woman grilling fresh fish over a giant metal barrel filled with glowing coals. I was starving, and protein-deprived, and decided that since I had been sick to my stomach off and on regardless of what I ate for the past few weeks, I might as well give it a try. When in Africa...?

I was served a half of a giant tilapia marinated in magic and smothered in freshly chopped tomato, onion, and avocado, along with a tennis ball- sized packet of burning hot white Play-Doh wrapped in cellophane. 

The elderly lady who served me showed me how to pinch off chunks of the banku (not Play-Doh) and use it to pinch off bits of the fish and toppings. It. Was. Sensational. My mouth reveled in masochism as the homemade pepe (hot sauce) simultaneously sizzled my taste buds and demanded I consume more. 

Thank goodness the meal was served in the dark street, because there was no ladylike way to approach it. All too soon, I found myself staring down at a pile of fish bones. I felt like one of those cartoon cats that gobbles up a big fish and pulls the full skeleton out of its stomach. 

The next week, I brought back some of the other volunteers. We had a giant Obruni tilapia party to celebrate the birthday of one of the other volunteers. The elderly lady (Vic, I learned her name was) welcomed me with a hug and the broken "I have been waiting for you!" Her daughter and sous-chef Portia now hollers out to me in the street every day, asking if I'll be back for fish soon. Tilapia and banku is now a weekly tradition.

And, dear readers, I end this post with the following epic meal:

My lovely roommate Sara and I returned from a very late evening last weekend, starving. We raided the mostly-bare fridge and the care packages we had both recently received. It wasn't until after we'd chowed down that we realized the strangeness of all that was on the table, from both before our food frenzy and after. 

I spy with my little eye:

-Crackers (empty)

-Leftover cold spaghetti noodles

-Rat poison

-Mouse traps

-Chardonnay

-Nutella

-A mosquito coil

-Stale white bread

-Two mobile phones 

-Skittles

-Loose Ghanaian change

-Pepper spray

-Red Vines

... The wine had served us each a glass (by glass I mean mug) hours before. This was not an alcohol-fueled late-night meal. Just a desperate Ghanaian one.

Bon appetit!

CHF Public Health Ambassador Volunteer Opportunity

Finally got our volunteer opportunity posted on Idealist.org. For a chance to help out the Hepatits B Screening and Vaccination project I have been working on in a non-financial way, please check out: 

http://www.idealist.org/view/volop/wpTgsZx6KsCp/

Email me directly or at our program email, CHF.publichealth@gmail.com for more information. Thank you!

Ramblings.

In the past 8 weeks, I have collected countless observations that I have deemed somewhat unclassifiable for the sake of a blog post. They don't adhere to a theme or document a certain event. But to keep them from being forgotten in the depths of the iPad's memory, I figured I'd lay them out in a catch-all post.

I like lists. Who has time to read paragraphs anyways?

Things I miss from the US:

- Ice: It does not exist in Africa. And if it does, it's gone before you can sip the drink you drop it into.

- Ellenos Greek Yogurt: If you live in Seattle, go to Pike's Place Market and spend the $6 for a pint. Yes, I'm a yogurt snob, and you will be too once you've tried it. Dairy is essentially non-existent in Africa, minus shelf stable milk and cheese-product. (But those don't count. If it is safe at room temp, then I don't count it as dairy.) Ellenos is the food I'm most excited to get home to.

- Pedestrian right-of-way: Cars don't stop for pedestrians. Two other volunteers were in a taxi recently that struck a pregnant woman on the street because she didn't cross fast enough. Ghanaian drivers are not messing around.

- Parks: Kasoa is characterized by one long, filthy, dusty road. The sidewalks on either side are clouded with gas fumes and bustling street vendors (diesel-infused corn on the cob, anyone?). Trees are only present once you get back into dirt roads, and even then they are few and far between. I can't wait to be barefoot on grass or sand when I get back to Seattle. Gasworks, Greenlake, Golden Gardens: get excited.

- Baking. If you live within a 10 mile radius of me or do something even mildly niceish in the first few months when I'm home, expect some banana bread or a plate of cookies. Can't wait to get back to my favorite pastime.

Things I'll miss when I leave Ghana:

- Softball-sized avocados for 50 pesewa (14 cents US) each: Forget your $4, Whole Foods. I'm working on a strategy to smuggle a supply through Customs.

- Not wearing makeup. Ever.

- Going days without seeing my reflection: This is awesome, though it's always a shocker to catch a random reflective window when I'm not expecting it. I tend to not recognize myself, and usually look around for the disheveled, sunburned, wild-haired Obruni before realizing its me.

- Kids playing with a wheel on a stick. I don't know why this is so funny to me but I love it.

- The music. YouTube "Shatta Wale" and get excited about Ghanain dance music. Everyone here dances, all the time. There is always music playing and even better, no noise complaints. 



Situations: A few things have happened that have stuck with me in my time here. Again, they don't fit a pattern or belong in any other blog post. A few of my favorite random exchanges: 


Too Big

In my fist week in Ghana, before leaving for a 5-day trip to the coast:

Me: Is traveling safe? I'm afraid of being kidnapped.
Eric (NGO director): HAHAHAHAHAHA!
He falls over sideways, laughing for a solid 60 seconds.
Me: What? I don't get it .
Eric, wiping his eyes: You're too big to be kidnapped in Ghana!

(It's true: I rarely see anyone, man or woman, over about 5'9". I've got a good two inches on the average Ghanaian. Safe!)


The Name Game

Everyone in Ghana is given a nickname based on the day of the week on which they were born. There is a male and a female name for each day of the week. On my first day working at the clinic, the nurses asked which day I was born on. I had no idea, and was totally caught off-guard. Apparently that's something everyone knows here, and I wanted to fit in, so I quickly spat out "Tuesday!" My Ghanaian name became Abena, which a lot of the nurses and people I pass in town still call me (people here have a hard time saying "Emily" so when anyone asks my name, I usually say Abena). I fact-checked later that day, and learned that November 2, 1989 was actually a Thursday. My Ghanaian name should be Ama. Whoops. My little secret. 


Why aren't you running?

I run a few mornings each week before work. The humidity is debilitating even at 6:00 am, so my efforts are usually limited to about 30 minutes. One morning was especially muggy and hot and I slowed to a walk as I neared home. People always stare as I pass and sometimes call out, as I must look absolutely ridiculous to them. You don't see a lot of joggers in Africa.

On this particular morning a little girl yelled out. "Obruni! Obruni! Are you exercising?" I smiled and waved and continued walking. Children are usually content with small acknowledgement, but not this one. "Run, Obruni! Why aren't you running?"

I was taken aback, and ridiculously, my pride took a hit. I thought bitterly, "Well, little girl, because I just ran 3 miles and it's 90 degrees, so lay off!" She kept at it though, following me. "Run, Obruni, run! Exercise!"

I didn't know how to respond, other than to start running. She ran behind me, waving a stick, yelling "Run! Faster, Obruni, run!" until I turned up the dirt path to my house. Confused and exhausted, I collapsed onto a step, ashamed to have just fallen bully victim to a bossy African 8-year-old .  


How we really feel about your paintings

Vendors in Africa are overwhelming. Most of the touristy areas have tons of vendors selling basically all the same things: the same beaded bracelets, the same carved bowls, the same paintings in the same styles. All claiming to be original and hand-made, of course. They're nice to look at, but if you let your gaze linger on an item for more than a second, the seller is all over you like white on rice, shoving said items in your face and yelling about the good price.

My volunteer friend Claire was on a solo excursion in Osu, an artsy neighborhood in the capitol city Accra. A vendor not only called out to her, but started following her down the street with a painting of his, begging her to come into his stall and see his work. She tried to politely shrug him off but to no avail. After he had followed her for a few blocks, she turned to him and said, "You know what? I actually hate paintings."
Confused, the seller stopped. "You hate paintings?"
Claire: "Yes. I hate them. A lot."
The vendor considered. "Well what about bowls? I have bowls too."
Claire: "I hate bowls too. In fact, I really hate bowls."

While the man bewilderingly tried to piece together how someone could hate both paintings and bowls, Claire slipped away into the crowd. From now on, we all hate paintings. Works like a charm.


People: They don't each deserve a post, but at least a shout-out.

Koffe: The creeper Rasta who I've seen on 4 different occasions on three different beaches in Ghana. He looks like a mini Lil' Wayne, and is either slow on the uptake or embraces the Rasta tradition of marijuana all the time (definitely the latter). He never lets me walk away, always complaining I don't want to be his friend (I don't) and begging for my phone number (not happening). I first met Koffe in Busua Beach, which is a 6-hour trip away from where I live in Kasoa. The very next weekend he was at Kokobitre, the beach nearest Kasoa. Three weeks later, I heard the familiar "Emily!" in his slurred Ghanaian on a beach in Cape Coast, another 4 hours away from Kasoa. Once again at Kokobitre again a few weeks later... This guy seriously creeps me out. He's too stoned to be harmless and I'm a solid 8 inches taller than him, but still. I don't get it.

Pacques: Pacques is 2 and lives on the dirt road on the way to my house. He runs to me every single day, without fail, as I walk home. For weeks he yelled "Obruni! Obruni!" while I corrected him "Emily, Emily. Not Obruni." The first time he yelled "Emily" was the proudest moment ever. One day last week, he jumped out of the bucket he was being bathed in, suds and all, and flew at me while his mom and siblings cracked up on the porch. I always grab him and carry him back up the road with me while he wears my sunglasses and pokes at my white skin. I love this child. He has two older sisters, Vanessa and Monique, and cousins that live with him named Precious and Rhoda. Many of the children here are overwhelming with their yelling and taunting of the Obruni, but these are among the few that are great.

Clinton and Maria: Two more children who live near me. About 10 and 8 years old, respectively. They run a shop that sells crackers and laundry soap and little convenience items, and I don't think they go to school, since they are there all day. Every once in awhile the mother will be there too, but the kids mostly run the shop. Some days when I walk home they're dancing or playing games and I'll stop to play with them. The funniest thing in the world, apparently, is when I join their dance parties. "Dance, Emily, dance!" I don't have to be told twice... it's worth it to shake it a little and make a fool out of myself to see them rolling on the ground crying laughing at me. Always a mood lifter!

Joyce: An Obruni who moved to Ghana in the seventies and now lives as a local on Kokobitre Beach. Originally from Oakland, CA, Joyce traveled to Ghana to work with a project to save traditional Ghanaian music.  She has been here over 40 years now, and must be in her late sixties or early seventies. She walks around the beach in her bikini, selling handmade jewelery to tourists to support the music she came to save.

Abiba and Amalia: The two sisters who run the fruit stand near our office. I don't know which is which, and call them both by both names, and they both answer to both. I'm pretty sure they think all the white people are the same person too, so it all works out. They see me coming each day and begin peeling a papaya ("paw paw") for me, picking out a less-than-ripe one the way they know I like it.

Felicia: Runs a beauty shop next to Abiba and Amalia. She's super sassy and loves calling out to me while she has clients to show that she's friends with the white girl. She taught me to say "Nyame bwa, ochina" as I leave for the night, which translates to "If God permits, I'll see you tomorrow." It's always hilarious when I say it, even though it's been a daily routine for 8 weeks now.

Charles and Rosamund: The mother-son duo at the Forex money exchange in Kasoa. Charles is at least 6'5", skinny as a rail, and ambiguously aged anywhere between roughly 17 and 25. Rosamund is cheerful and motherly and constantly nags me to date her son. I don't give a straight "no" because I don't want her to cheat me on the exchange rate (she handles the transfer of US dollars to Ghana cedes). It's kind of weird. But they're both sweet, and the Forex is air-conditioned, so I don't mind making frequent trips to change my money there.

There have been plenty more noteworthy people and countless memorable events, but these are the ones that sprang to mind and seemed least likely to put you to sleep during this post. To be continued as more occur!