Friday, October 8, 2010

Apologies for Dropping Off the Face of the Earth

For anyone out there who is still checking my blog,

I would like to apologize for being silent for so long. I am, indeed, still in Ghana, and I do have more stories to tell, but both fortunately and unfortunately (depending on who you are), my life has become a lot busier as of late, and my blog has suffered as a result. In case you were wondering, here is a short jist of my life since the last blog (read: excuses for not blogging):

June - World Cup in SA for 2 weeks = AMAZING
July - Back in Ghana - work, studying for GMAT, grad school applications begin
August = Laptop and digital camera stolen (enter frowning emoticon here). Blog, GMAT, grad school prep take a big hit. PSGH gets first new grant in; work gets crazy.
September = Home to Chicago for a week, new laptop purchased, work is crazy.
October = Work is still crazy, GMAT, grad school.

So, there you have it. I am still here, but the blog has taken a back seat, as a function of other time commitments, thieves, and laziness.

I cannot guarantee that I will post another real blog before I leave, but I thought that I at least owed readers an explanation.

Friday, June 11, 2010

Coca Cola, Shakira, and Sun Screen

Seeing as though I leave for South Africa in about 30 hours, I bring you all this very special World Cup-themed posting. I’m not sure how many of you saw the official World Cup kickoff concert from Johannesburg yesterday (I think it was on ESPN2 in the US), but as it was simultaneously broadcasted on almost every TV station in Ghana, it proved quite unavoidable for me. The whole production was very entertaining for some obvious reasons, and even more entertaining for some less obvious ones. Allow me to explain.

“'This is not our World Cup,' explained Greg Fredericks, a senior manager for South Africa’s World Cup organizing committee. He noted the dominant role of FIFA, soccer’s Zurich-based world governing body. 'It is FIFA’s World Cup. We are just the organizers. We are the stage.'”

That is an excerpt taken from a two week-old NY Times article discussing some of the issues that have arisen in the run up to the first World Cup to be played on African soil. The main struggles stem from South Africa’s desire to make this tournament as “African” as possible, and the difficulties that FIFA and its billionaire corporate sponsors face in acquiescing to those wishes, like some gigantic yet tacit game of tug-of-war. This was first seen in public fora when FIFA discussed the possible banning of the vuvuzela horn – a much complained about and annoying-sounding plastic instrument that is a staple in all South African football crowds – from all matches. Eventually, Sepp Blatter, FIFA’s outspoken President, made the uncharacteristically correct decision* to allow them to stay. But in no place was this give-and-take more evident that on the stage last night.

When I first flipped on the TV, I was greeted by Alicia Keyes singing a song about New York: very appropriate. Then, after a set change about halfway through the show, the announcer came on the PA to declare: “It’s time for Africa! It’s time for Shakira!” If this blatant hypocrisy doesn’t make you laugh, then I can do nothing further for you, and you should probably just stop reading. These two sentences together perfectly underscore the backlash FIFA received after selecting both the Shakira cover “Waka Waka” (This Time for Africa) as the official 2010 World Cup anthem and the original line-up for the kickoff concert.

The NY Times article goes on to quote Oupa Lebogo, general secretary of the Creative Workers Union of South Africa, as saying “It’s like waking up in your house and finding people in your backyard saying ‘This is what we’re doing,’ without talking to the owner of the house.” The comparisons to international development are easier than breaking a sweat in Ghana. Luckily for everyone, the double helix of a typical South African looks something like this: cytosine—outspoken dissent—thymine—questioning authority—guanine, and all it took was the Union’s threat of hosting a rival concert in protest for FIFA to reconsider. When the final concert lineup was announced, more African acts had been added to complement the original Western-dominated one of Shakira, Black-Eyed Peas and John Legend, to name a few: crisis averted. But music has not been FIFA’s only misstep in South Africa.

Just a few weeks ago, ticket sales in South Africa (and the rest of Africa in general) were well under predicted estimates, and estimates for the rest of the continent had fallen by 77%. Many “experts” blamed the recession, the high cost of flights between African countries, and various other factors, but the true reason remained an enigma. In reality, the problem was with how FIFA had structured the system to obtain the tickets: online. Like many Western entities operating on the continent, FIFA remains completely oblivious to the on the ground realities of everyday Africans and failed to realize that prerequisites like computers, internet access, credit cards and bank accounts were barriers that made purchasing tickets out of reach for the majority of people. These same “experts” would probably use Swiss estimates to launch a brand new sun screen product in Africa, and then bewilderedly look at each other when only the rich white minority showed up to buy it. Once again, it wasn’t until irate fans called in to radio programs to complain that FIFA caught their drift. Originally, to buy tickets with cash one had to apply for them by submitting a written application at a bank: a procedure deemed too costly and complex. But all is not lost, as FIFA finally realized their error and began selling tickets over the counter on April 15th. According to the NY Times article, “Lines were so long that some likened them to those for South Africa’s first democratic election in 1994.”

Things are also looking better on the Shakira front, as well. As it turns out, her official World Cup song will end up being completely eclipsed by the one chosen by Coca Cola as their official World Cup song: “Wavin’ Flag” by Somalian-born K’naan. This was evidenced by the riveting performance he gave last night and the crowd’s reaction, which utterly upstaged the Columbian superstar. Sorry, Shakira. No one will argue that your hips don’t lie, but they’re just not African hips. Plus, it’s just a flat out better song with a can’t-get-out-of-your-head catch. And it’s that catch for which Coca Cola shelled out the big bucks. But that’s not the end of the story. Coke also paid K’naan to change many of the lyrics to take it from a dark song about his native Somalia and make it into a feel-good football celebration.

Example of original lyrics:

“So many wars, settling scores
Bringing us promises, leaving us poor
I heard them say, ‘love is the way’
‘Love is the answer,’ that’s what they say

But look how they treat us, make us believers
We fight their battles, then they deceive us
Try to control us, they couldn’t hold us
‘Cause we just move forward like Buffalo Soldiers

But we struggling, fighting to eat
And we wondering when we’ll be free
So we patiently wait for that fateful day
It’s not far away but for now we say”

Example of Coca Cola-friendly lyrics:

“Give me freedom, give me fire
Give me reason, take me higher
See the champions take the field now
Unify us, make us feel proud

In the streets our hands are lifting
As we lose our inhibitions
Celebration it surrounds us
Every nation all around us

Staying forever young
Singing songs underneath the sun
Let’s rejoice in the beautiful game
Then together celebrate the day
We all say”

These are the behind the scenes issues that made last night so entertaining, especially considering that K’naan sang the original lyrics on stage. I’m not sure Coke ok’d that. As I write these last lines, South Africa has just scored the opening goal of the 2010 World Cup on a fantastic upper 90 shot (that’s football speak for top corner of the net), and my coworkers, watching the game on the TV in the other room, just went crazy. There’s been so much talk about how important this milestone is for the continent of Africa, but I don’t think FIFA realizes just how big it truly is. Every African is rooting for every single African team. Yes, even Algeria, which is saying something. I can hear the non-stop vuvuzela horns eminating from the TV in the next room as all of Africa celebrates. Let the tug-of-war continue.

*A fun game to play is to google “Sepp Blatter, stupid comments” and see what comes up. It’s a wonder he still has a job. Enjoy.

Tuesday, June 1, 2010

My Snap of the Fingers, Blink of the Eyes Wish

In my short time here, I’ve spent a lot of it thinking about development in Ghana. Be it economic, political, or any other kind, development inherently moves at a snail’s pace. We would all like to be able to point to rapid and drastic progress being made in terms of weeks and months (especially when your funding comes and goes at the whim of politicians on election cycles), but the fact remains that development timelines are measured in years, and most large-scale progress is only visible when you take a step back and look at how far you’ve come over a longer period of time.

But midway through last month marked my six month semi-anniversary here, and I started asking myself: what if this wasn’t the case? What if I could snap my fingers or blink my eyes and something about Ghana would be instantaneously changed. If I had that power, what would my one thing be? (Normal people fantasize about fame or fortune or attractive celebrities, but these are the fantasies of those of us working in development. We don’t get out much.)

For the last few weeks, I’ve thought long and hard about what this one wish would be, and I think I’m finally at peace with my decision and ready to share it….drum roll please…..Sorry, you’re not gonna get it that easily. I think this would be best if done in a suspense-building countdown of my top three. Also, as an added teaser, none of my top three have anything to do with eradicating malaria! Crazy, I know, and also added intrigue. So, without further ado, here goes. If I had a proper three-wish-granting genie, these are what they would be:

#3 – Universal Primary Education (that is actually free)

This is pretty self explanatory. Health and education are the cornerstones of development, the two most important things, hands down. No one gets anywhere without them. Primary education in Ghana is supposed to be free for all, but this is not the case in practice. Not only is there a serious lack of teachers and other resources (as in most developing countries) preventing all children who want to go to school from having an adequately-staffed one, but also for those who do have a school to attend, it’s never actually free. I cannot tell you how many stories I’ve heard of students being sent home from school because their parents are unable to pay the $3 per month in school fees. This needs to change.

#2 – Universal Access to Information and Interventions to Promote Reproductive Health Rights

I almost didn’t include this one, because it involves changing cultural and societal norms of equating more children with higher status (and I tried to stay away from changing cultural and societal things), but this one is too important to ignore. Recent and future trends show declining population rates in developed countries and significantly increasing population growth rates in developing countries. This is almost exactly the opposite of what an ideal scenario would be and further exacerbates the development challenges faced by the world’s poorest nations.

I know this will not be a universally popular choice, as my small-but-loyal readership spans the political spectrum. But this is not really about personal views regarding condom use and abortion or the purpose of intercourse and when a human life truly begins. This is about individual freedom and math. If you want to talk about the sanctity of human life, I’d like to ask if there is anything sacred about a family that can barely feed two children having seven. I am constantly amazed by the young women sleeping on the curb who, without homes of any kind, still managed to find private places to have sex and produce the multiple children sleeping next to them, or the teenagers hawking goods in the middle of traffic, breathing in hour upon hour of automobile exhaust and fumes, with babies wrapped around their backs breathing in the same air.

And this is also related to wish #3, as statistics indisputably show a correlation between the level of education a person has and his/her number of children. But all of this stems from a lack of information about, and access to, modern contraceptive methods and family planning interventions. This wish is not advocating extreme measures like limiting family size in China. This wish is just meant to make all women and families AWARE of these options and able to access them if they CHOOSE to do so. That knowledge and ability can make all the difference.

And now, the moment you’ve all been waiting for: the number one spot.

#1 – The Miracle of Urban Planning and Maps

I wish that every street in Ghana had a name, that every home and business in Ghana had exact, differentiating street addresses, and that the government made use of such things for all administrative purposes, especially TAX COLLECTION. I know that after all that build up, this might seem like a boring one, but wow is it important (and mind-numbing to see that it remains undone). For the purposes of this blog, let's call this Map Ghana (MG).

Right now, I would estimate that less than 5% of the roads in Ghana have names, less than 5% of the people have home addresses, and less than 10% of the businesses have addresses. These figures are just estimates, but you get the idea. The reasons for this are cultural, so I am breaking my own rule again, but I would invoke the importance clause again. Ghanaians, I’ve been told, have never used road names, and never felt the need to; they are a 100% foreign import. If you ask a Ghanaian for directions, you better know your landmarks, because all anyone speaks of are signboards (billboards) and buildings. Even those few main roads that do have names are not widely known amongst most locals. As a general rule, Ghanaian knowledge of approximate distances, cardinal directions, and other map-related things leaves much to be desired. I was also publicly laughed at when I asked to buy a map of Accra in a bookstore.

Whenever I bring up MG in conversation, it seems to fall on deaf ears, and Ghanaians seem to be of the opinion that road names and addresses would never catch on. It is a foreign import that was never adopted by the native African tribes for centuries. To this, I would say that the same thing was probably said about Democracy, and that seemed to turn out ok for everyone here.

For everyday living, the efficiency gains of having a system of named streets and addresses are too numerous to count. However, these gains would pale in comparison to those that would be accrued to the government, and this is why it is number one on my list. Yes, the obvious winner would be the postal system (which is quite abysmal by Western standards). Currently, if someone wants to send me a package, I have to tell them to address it to our office (because my home is impossible to find), and because our office lacks a proper address, I have to tell people to write the neighborhood name, the closest named street, “near” a locally-known landmark, and the phone number of our office. Theoretically, the package goes to the national office, then the regional office, then to the smaller neighborhood office where they will either call you to come pick it up, or call you in the midst of delivery so that you can provide exact directions. The fastest I have received a package from the US is about a month after it was sent, and the slowest was two and a half.

While MG would be the biggest game-changer in the history of the Ghanaian postal system, the biggest winner in all of this would be the IRS. Yes, they have an IRS here too, and no, it does not do a good job. Think about the difficulties inherent in tax collection without the ability to systematically locate most of your country’s population or businesses. The vast majority of the private sector here is what we in development euphemistically refer to as the “informal sector” meaning the non tax-paying kiosk type shops and businesses that line almost every road in Ghana. And all the income generated from these and other businesses would be called the “under the table” non-taxable kind. All this is to say that the government is left high and dry trying to provide public services to the entire population (including a new National Health Insurance Scheme NHIS), which is just about bankrupt), when only a small fraction is actually paying taxes for them.

In my seventh grade social studies class, I remember learning that after the American Revolution, the new nation formed a weak government under what was called the Articles of Confederation. It was weak for several reasons, the most paramount of which was that it did not have the power to tax. For over a decade, this government struggled and ultimately collapsed, prompting the writing of the Constitution in 1789. While America seemed to learn its lesson early on, maybe we wouldn’t have if we had donors constantly subsidizing our lack of tax-generated revenue.

Like most countries, Ghana has a tumultuous history of raising and lowering taxes, and as with tax issues in any country, MG would be classified high risk/high reward. In recent history, Ghana implemented a highly-contentious value added tax (VAT) in 1995 to try to mitigate the lack of income, property, business and other taxes it should have been collecting. Akin to a sales tax, it was set at 17% and repealed shortly thereafter due to public protest. After an extensive public education campaign, it was reintroduced in 1998 at 10%. Two years later, the VAT was raised to 12% by those same politicians who railed against it while in the opposition party in 1998, but who had now taken over power by 2000. It still stands at 12% today, with a 2.5% NHIS tax on top of it. The problem is that Ghanaians really enjoy not paying taxes, and any measure that might be seen as a means to eventually create or raise taxes is not politically feasible. Last week, due to public outcry, the head government statistician had to come out publicly and say that the new census Ghana is trying to implement is not intended for tax purposes.

But MG would also be high reward, and should really be considered a prerequisite for any modern sovereign nation-state to effectively govern itself. (This is why people attain graduate degrees in urban planning and why Google Maps is so amazing.) The direct gains of administrative efficiency and tax generation are obvious, but it would also have myriad indirect effects of increasing accountability of government to its citizens (and vice versa) and spur much-needed consolidation in the informal sector (Everyone and their brother runs a kiosk shop selling oil and tomato paste to each other, but this would certainly change if everyone all of a sudden had to pay taxes to run their business.) just to name a few. The rewards are endless, and I can guarantee that Ghanaians will learn the names of roads and addresses if the government and the IRS lead the way. Ghana would then have money to finance family planning initiatives and universal primary education, where students could learn about maps! It’s so perfect that it brings a tear to my eye. These are the things I fantasize about.

Thursday, May 13, 2010

Theory and Reality Part 2: The AMFm*

It’s been a while since I’ve written a health-/work-related entry, so here goes. Watch out for the weeds!

One of the most important lessons I’ve learned in my first six months here is the huge gap between theory and reality in terms of donor-funded development programs. Policies and initiatives that are dreamed up in Washington and Geneva can seem magical on paper, and then when they are implemented in the developing countries they are meant to help, magical is just about the last adjective anyone would use to describe the outcome. For me, the Affordable Medicines Facility for Malaria (AMFm) epitomizes this phenomenon. Obviously, this difference between theory and reality can be said of many things in life (A big one that Westerners like to joke about is Communism.), but I feel a very acute sense of it with the AMFm.

I have touched on the AMFm in previous entries, but I’ll give a quick overview here now. The WHO-recommended (World Health Organization), most effective drugs to treat uncomplicated malaria are called artemisinin-based combination therapies (ACTs). ACTs are highly efficacious, fast-acting and prescribed in easy-to-follow dosages. The main problem with ACTs is their prohibitively high cost. The majority of Ghanaians continue to patronize private sector pharmacies and other drug-selling shops to treat malaria, and if you were to walk into a Ghanaian pharmacy right now, brand-name ACTs are about $7-$10 a dose: quite out of reach for the average person. Even the local generic ACTs are around $3-$6. Most price-sensitive patients opt for the older, cheaper treatments – chloroquine, sulphadoxine-pyrimethamine (SP), and artemisinin monotherapy – that retail for about $.50. Now, this scenario would be perfectly fine, except that, for a variety of reasons, these alternative treatments suck. The drug resistance profiles for chloroquine and SP are unacceptably high, making them highly ineffective treatments, and continuing to consume artemisinin monotherapies greatly increases the likelihood of resistance developing, thereby completely undermining efforts to expand access to ACTs. For these reasons, the WHO has explicitly advised all countries to stop using these older drugs and to switch to ACTs. In fact, many countries have already made their dispensation illegal, as does Ghana’s new malaria drug policy (which has yet to be disseminated and rolled out); however, despite these measures, the older treatments still remain widely available.

So, in come the donors. They looked at the situation described above and decided to create a pool of money that would subsidize the price of ACTs, so that the cost to the end user would decrease enough to rival those older, less-effective treatments. The idea is that by strategically injecting funding, the natural market forces of supply and demand could be used to not only increase access to the most effective treatments but also drive out those less-desirable drugs from the market. In a nutshell, this is the AMFm, and in theory, it is hard to argue that providing the highest quality ACTs for a fraction of what they used to cost is not a great concept. Indeed, when I first heard about this initiative as a wide-eyed research analyst just a few years ago, I thought it was fantastic use of donor funds.

Before I go any further, it should also be noted that where we are now is years in the making. The AMFm concept was first conceived in the 2004 Institute of Medicine (IOM) report titled “Saving Lives, Buying Time.” From there it was shopped around for a while before landing with a consulting firm called Dahlberg & Associates. Dahlberg fleshed out the concept to really analyze what the scope of a fund like this would be and how the internal mechanisms would work. After that, it was a matter of raising the money. Understandably, it took a while to find financial backing, but the AMFm was eventually taken on by The Global Fund to Fight AIDS, TB and Malaria. (Less the ten years old, the Global Fund is a multilateral agency that pools donor health funding for the three priority diseases. Eligible countries submit project-specific applications, and the Global Fund dispenses the money directly to the local Ministry of Health, which then allocates it accordingly.) A few years ago, an early version of the AMFm was successfully piloted in Uganda and Tanzania. Backed by about $225 million, it is now being expanded to about a dozen other countries, including Ghana, with plans to expand it all over the world if this larger pilot is successful.

So there we are. Now that I’ve given adequate background, we can get into where the problems arise, causing the rift between theory and reality. For simplicity sake, I will narrow things down to the two major issues: the prequalification problem and the margins problem.

The prequalification problem refers to the fact that all ACTs being subsidized with AMFm funding have to be prequalified by the WHO. WHO prequalification is a process that started back in 2001 to provide a level of international standardization for good manufacturing practices and high product quality for multilateral procurement agencies like UNICEF. When it began, its mandate was to give the nod to the highest quality drugs against HIV, malaria and TB. Since then, the list has expanded to include antivirals for influenza and reproductive health products as well. And after a decade, WHO prequalification is now THE standard used by bilateral agencies, governments, NGOs and other bulk purchasers of drugs for the developing world.

The problem is that no local manufacturers have attained WHO prequalification.

For donors (like the US government or the Global Fund) that give money directly to developing country governments for drug procurement, it is a good quality control measure to stipulate that the products must be on the WHO prequalification list. For developing country governments, especially those with a large local pharmaceutical manufacturing sector like Ghana , it is bittersweet when donor funding cannot also benefit your local industry (but rather helps its competition). And for the local manufacturers themselves, it is an onslaught in their fight for survival.

Right now, many of the ACTs in the private sector are supplied by Ghanaian manufacturers whose products have been registered by Ghana’s regulatory agency: the Food and Drugs Board (FDB). (When the national malaria policy was changed to ACTs in 2004, the government even encouraged Ghana’s local pharmaceutical companies to increase production to meet the demand.) While the FDB is considered to be one of the best and most stringent drug regulators in Africa, that is not good enough for the donors. (And possibly rightly so. The WHO recently conducted a study of the quality of antimalarials available in the African private sector, and the results were, in a word, dismal.) But attaining WHO prequalification is a costly, time intensive process that requires the sorts of investment and sunk costs that local manufacturers cannot afford. (The manufacturers with WHO-prequalified ACTs are pharma giants like Novartis (Swiss) and Sanofi-Aventis (French), along with some emerging market behemoths from India and China like Cipla.)

So, here comes the AMFm, which says that the market will soon be flooded with the highest quality ACTs in the world, at prices so low that local companies cannot compete. And they also cannot benefit from the subsidy, because they are not prequalified. It has been hard to get a straight answer from local companies regarding what percentage of their current portfolios ACTs contribute, but it is safe to say that if the AMFm is successful, that percentage will eventually be right around zero. I have been privy to many an impashioned speech from the president of PMAG (Pharmaceutical Manufacturers of Ghana) and others denouncing the AMFm as the end of local manufacturers as we know it. While this is certainly an exaggeration, large scale job losses resulting from weakened companies may not be. To quell these complaints, the response du jour from Global Fund officials is that “resources are being made available” for those companies with a serious interest in becoming WHO prequalified. Needless to say, the prequalification process takes years, and I have not yet heard of any companies asking to access said “resources.” In summary, local manufacturers are not happy in the least, and this is the prequalification problem.

To explain the margin problem, I have to explain a little more about the specifics of the AMFm and of the private sector pharmaceutical supply chain. For simplicity sake, let’s say that the private sector supply chain looks like this:

manufacturer --> importer --> wholesaler --> dispensary --> patient

and that at each arrow (besides the first one, since it’ll just be the manufacturer’s fixed price), a 50% markup is taken as profit for that actor in the chain. As an example, let’s say that the manufacturer sells the ACT to the importer at $2/dose. The importer tacks on a mark-up of 50% to that, and sells it to the wholesaler at $3/dose, making a profit of $1/dose. The wholesaler puts a 50% mark-up on the $3, selling it at $4.50 to the dispensary (e.g. pharmacy, clinic, hospital) and making a profit of $1.50/dose. The dispensary adds 50% onto that, selling it to the patient at $6.75/dose and making a $2.25/dose profit.

How the AMFm works is that the Global Fund has already negotiated with the prequalified manufacturers to bring the price of ACTs down to (an average of) $1/dose. Then, whenever the manufacturer receives a purchase order from an importer under the AMFm, the manufacturer will ok the order with the Global Fund, and the Global Fund will then co-pay (an average of) $.95/dose to the manufacturer. This co-payment is the subsidy from the $225 million pot-o-money. This means that the manufacturer then sells the ACT to the importer at (an average of) $.05/dose (instead of the $2 that it was before). The Global Fund makes all importers sign an agreement saying that they will play nice when it comes to mark-ups, and the idea is that even with all the mark-ups along the way in the supply chain, the final price to consumers of co-paid ACTs will be around the Global Fund’s target price of $.50/dose.

Now, you don’t have to have an MBA to realize that some of the private sector distributors might have a problem with this. When there is only a total of $.45 to be made from manufacturer to consumer, and the profit margin that used to be $1, $1.50, or $2.25 per dose is now down to $.15 or $.20 cents per dose, some people are going to start to question the financial feasibility for all stakeholders to participate. This is the margin problem.

In Ghana, The Global Fund’s plan, with the help of Ghana's Ministry of Health (MoH) has been to hold a series of “private sector” engagement meetings, where these issues are discussed to get private sector buy-in. I have been to more than a few of these, and while they are good in theory, the politics of all the big players and the dynamics of large group meetings mean that things devolve quickly and nothing of consequence is ever achieved. The Global Fund then looks to the MoH for support, but their requests often fall on deaf ears. See, like all things the Global Fund does, it was the MoH that submitted the application. Ostensibly, that means they were the ones who wanted the AMFm to come to Ghana in the first place. However, because of all of the resistance from the manufacturers and others in the private sector, the Ministry is often less than fully supportive in public forums, deciding to play innocent and let the blame fall elsewhere. (One goal that the international development community likes to talk a lot about is “country ownership” of programs. This means that the countries themselves throw their full support behind projects and willingly take responsibility for the success or failure of programs, instead of having them feel like this is the donor’s agenda and they are just along for the ride. Let’s just say that in terms of country ownership, Ghana's MoH would be getting a failing grade right now.) This was the song and dance we were all doing for the first 5 months I was here. But, luckily, the Global Fund’s portfolio manager for West Africa is keenly perceptive and decided to make a move.

His move was to call on the Clinton Foundation to set up several one-on-one meetings with the country’s biggest importers and wholesalers to better explain the initiative and to assuage any fears they had. Since the outset, the Clinton Foundation has been supporting the AMFm implementation, and with its unwritten policy of only hiring ex-management consultants, this was the perfect time for them to step up to the plate. There is only one full time Clinton Foundation employee in Ghana, and his entire job is private sector engagement for the AMFm. He immediately created a hypothetical pricing model in Excel and called me. See, the vast majority of private sector stakeholders in Ghana, be it manufacturers, importers, wholesalers, or distributors, are pharmacists. Pharmacists who belong to PSGH. So, I was able to rope Dennis in, and we were able to set up several one-on-one meetings for when the portfolio manager was flying in from Geneva.

So, two weeks ago, the 4 of us went around meeting with these guys individually, with laptop in hand to run through the numbers. Then we would have a discussion about how feasible they thought the whole thing was. This was private sector engagement. And this was probably the most useful thing I’ve been able to do since I arrived. It was understood and agreed that with the lower per-dose profit, the private sector distributors would have to up volumes a lot: anywhere from 4 to 20 times as many, depending on which actor in the supply chain you were. The good news is that most of the people we met with thought that these higher volumes could be achieved through the increased demand. (i.e. When a good that was $6.75 is suddenly $.50, a lot more people are going to buy it.) We assured them that the $.50 figure is an ideal target set by the Global Fund, but it is certainly not set in stone. This meant that in the short term, there was a lot more flexibility on margins, but that in the longer term, with ample competition, the price should approach the target. Some also discussed the appeal of the much lower cost of capital (amount of money needed to procure the ACTs), and everyone nodded their concurrence. We were able to get through to many of them, and a few have already started the process to become registered buyers with the Global Fund. The co-paid ACTs should start arriving in August, and there should be enough buy-in from importers and other private sector distributors to give Ghana a good shot at success.

When I first learned about the AMFm as a doe-eyed research analyst in Washington fresh out of college, I thought it was a fantastic idea. On the other side of the pond, all you hear about is how this will revolutionize malaria treatment by vastly increasing access to the most effective treatments. But you don’t hear about the local manufacturers who will have to lay off workers and might be run out of business. You don’t hear about the corrupt customs officials who will undoubtedly help leak these newly-affordable antimalarials across Africa’s notoriously porous borders.

Don’t get me wrong, I still think it’s a fantastic idea, but its development and implementation could be much better. Firstly, for an initiative that is SPECIFICALLY-INTENDED for the private sector, that engagement has been atrocious. Nothing substantial is ever achieved in large conference rooms. This is nothing new. (Need I remind everyone of the C5?) Inviting a handful of stakeholders and holding a few lunch meetings so that everyone can collect their per diem, while probably necessary, is not engagement; it is lip service. I hate to think about what AMFm adoption in Ghana might be if the Global Fund's portfolio manager was less perceptive, or if the Clinton Foundation was not involved, or if I was not acquainted with that sole Foundation employee, or if Dennis cared more about profit than public health. Secondly, how about consulting those parties that will be affected by a policy WHILE the policy is being developed so that they can provide input to better shape it, instead of just informing them that it is coming and there is nothing they can do about it? A novel idea, I know. The sad thing is that this can be said for almost all development programs. The AMFm was conceived in Washington, fleshed out in Washington, and funded in Geneva over a period of years before anyone in the local private sector, whose livelihood would be directly affected, was ever consulted. This model needs to change. (I know BTE was talking about the lack of country ownership when they penned their hit, “Desperately Wanting.”) Thirdly, I have not even mentioned the sustainability aspect of this initiative, for which there is no satisfying answer. The pilot phase will go for about 2 years, after which time the numbers will be analyzed and a decision will be made to either discontinue it, or to expand it possibly to all malarial countries worldwide. In the meantime, it is a big question mark. The local manufacturers will stop manufacturing, and the importers will cut ties with long-held business relationships. All the while, there are no guarantees of anything.

The AMFm is a great initiative with enormous potential, and I really hope it enjoys wide success. If it does, then I hope this pilot phase can teach us a lot about what needs to be improved for the next phase. If nothing else, then at least it has taught me the big difference between theory and reality. And I’ve already learned that I like dealing with reality a lot more than theory. Masters – 1, PhD – 0.

* Some names have been changed (or deleted) to protect the innocent. They asked me to do it. And, no, I am not kidding.

Tuesday, May 4, 2010

Jeremy and Lindsay Come to Visit!

I have tried really hard not to let this blog devolve into a typical travel blog (i.e. Hey, look at me in this crazy place doing this wacky stuff with these foreigners! Don’t you wish you could be me!). OK, maybe they’re not ALL that bad, but some of them surely are, and I’ve tried to take the high road by giving thought and reflection to all of my experiences. What I’m trying to say is that Jeremy and Lindsay were both awesome enough to visit me back in February/March, within weeks of each other, and while I’ve been avoiding writing this entry, I should probably take the time to acknowledge the fun (and some of it less fun), touristy stuff we did. Please keep in mind that they were completely separate visits, but while Jeremy and Lindsay were only here for 4 and 9 days respectively, and traveling around the country is a time-sucking affair, we stayed within about 150 miles of Accra, and I did many of the same things with both of them. (Also, it stopped letting me post picutres for this entry, so let me know if you'd like to see any more.)

Jeremy’s Visit:

Jeremy arrived at about 4am on a Friday night/Saturday morning, which was awesome for everyone. He came straight from an HIV/AIDS conference he had organized in Johannesburg, South Africa, and I could tell right away that he looked beat. Unfortunately, the first thing to ensure was a friendly altercation with a “chartered taxi” driver who wanted to charge us 17 cedis for a trip that I knew should be no more than 5. He explained that his price list was on a nice, laminated sheet of paper, so it must have been legitimate, and I responded by laughing in his face. I assured him that, despite the color of our skin, unfortunately for him, we were not saps. I explained that I was not a tourist, had been living there for 4 months now, knew how much things cost, and we eventually got into his cab when he agreed on the 5 cedi price. When we arrived at the hotel, the nighttime security guard was nice enough to let us sit down on some couches in the lobby and rest for a bit. Jeremy and I took the time to catch up a little: me discussing some of the projects I’d been working on and him venting about how he had not gotten a chance to eat, sleep or even leave the hotel during his conference over the past week. We did a little walking around Accra, watched the sunrise, grabbed some food and then returned back to the hotel for our homosexual ordeal with the reception staff. After that lovely experience, we crashed for several hours before going out that night to a few hotspots and, coincidently, witnessing the jovial gay men at the last bar, before turning in.

The next day we slept in, and I took Jeremy around Accra to some of my favorite spots. When the midday sun was unrelenting, we decided to hit up the mall and see Avatar (me for the second time, but Jeremy for the first). After that we grabbed Jeremy’s stuff from the hotel and took it back to my place. I introduced him to Dennis, Patricia and Desmond, and we tagged along on a quick drive they were making to Tema. Jeremy got to converse a little with everyone on the ride, and when we walked around Tema, Jeremy and I ate the first of many kebabs: a staple fast food around Accra. After a few hours, we bid everyone adieu and made our way back into the city for a fun night of 2-for-1 pizzas at a restaurant I frequent on Sunday nights for that exact deal.

The next morning we woke up around 10 and headed to the station to catch a bus to Cape Coast: a small fishing village and the capital of Ghana’s Central Region, which lies about 100 miles West of Accra. The town of Cape Coast itself sits on a hillside and is very quaint, but it is one of the top tourist destinations in the country because of the Cape Coast Castle and the Kakum National Park. The drive consisted of about 2.5 hours of increasingly tall trees and dense wilderness, and when we were let off in Cape Coast, Jeremy and I made our way to the stellar Mighty Victory Hotel, which thankfully gave us no trouble about two men wanting to share a room with two separate beds. It was about 3 pm when we dropped our stuff off, took quick showers, and made our way to the center of town to see the Castle.

view of Cape Coast from the Castle

Cape Coast Castle is enormous and impressive, with towering whitewashed walls staring down at visitors as they enter from inland. Once inside the gate, we followed a narrow corridor to the front desk where we were greeted by a smiling woman and asked to pay a fee, which I was more than happy to pay. You see, Accra actually has a pair of very historic Dutch-built forts (James Fort and Ussher Fort) smack in the middle of the city that are both well older than the United States of America, but there have been absolutely no efforts made at their upkeep and nothing done from a tourist perspective to make them appealing to visit. As they were both marked in my guide book, I went to visit them soon after I got here. Unfortunately, as I entered both, I was met by a single man sitting in a plastic chair who asked for money to “see” the fort. The fee was negotiable, there was no pamphlet, guided tour or gift shop. In fact, there was not a single other person within the confines of the fort: just weeds and ivy. I was not happy to pay this fee, because it was most likely just going right into the man’s pocket. On the other hand, Cape Coast Castle was a well-run tourist attraction, with all of the things mentioned above and more. It was about an hour until the next guided tour, so Jeremy and I were directed through the open-air, cannon-lined courtyard, to the Castle’s museum. The Museum was very nice, and it provided the perfect historical and cultural context to the World Heritage Site where we stood.

lots of cannonballs at the castle

interior courtyard of Cape Coast Castle

tunnel down to where the male slaves were held

Next was the guided tour, led by a very well-informed and affable Ghanaian guide, Andrew. There were about a dozen other people on our tour, about half locals and half foreigners, as Andrew took us all over the castle, explaining its history along the way. Originally built by the Swedes in the 1650s as a fort to protect their timber and gold trade, the fort traded hands several times (some by violent means, others more peacefully) between the Danes, Portuguese and Brits. It was the Brits who ended up with it at the end of the 17th century, when it was extensively rebuilt into the Castle we see today, specifically designed as a centerpiece for the Trans-Atlantic slave trade. In 1884, Cape Coast became the official capital of the British colony known at that time as the Gold Coast, with the governor residing in the top rooms of the Castle. Starting in the dank, dark dungeons where the slaves-to-be were held before boarding the ships headed for the Western hemisphere, and ending in the bright, airy governor’s quarters, it really was an unbelievable tour, in many senses.

By the time we were done, it was around 5:30, and Jeremy and I decided to hit up the beach-front restaurant next to the Castle for an early dinner. The food was delicious, and I was able to introduce Jeremy to my favorite Ghanaian dish called red-red: a combination of fried plantains and black-eyed peas served in a spicy tomato sauce. After dinner, we headed back to the hotel to veg out, because we had to be up early the next morning.

beach-front restaurant next to the Castle

The next morning we were up at 6:30 to have a quick breakfast in the hotel restaurant and catch a cab for the 45 minute drive to Kakum National Park. Our trusty guidebook said to be there when it opens at 8am to beat the crowd and for the best chance to see some wildlife. The drive was a straight shot, and when we got there at 7:45, the only other tourist there was a Swiss woman. Unfortunately, this meant that the first tour of the day was postponed until enough people showed up to make it worthwhile for the guides. That took until 4 German 20-somethings showed around 8:30, and then we set off.

The park covers over 350 square kilometers of tropical rainforest and is home to a rich bird and butterfly population as well as pygmy elephants, forest buffalo, meercats, and several species of monkeys, but it is the Canopy Walkway that really draws the tourists. Funded by USAID and built by 2 Canadians and a handful of Ghanaians over 6 months back in the 90s, the canopy walkway is exactly what it sounds like. Composed of cargo net, aluminum ladders, ropes and wooden panks, it is a combination of 7 bridges and 6 platforms suspended over 100 feet in the air above the rainforest floor. We were told it is the only one like it on the entire continent. I’m not the biggest fan of heights, so I wasn’t sure how I was going to like it, but it was pretty cool seeing the rainforest from the tree tops. In the middle of the walkway, camped at the third platform, was a group of 3 or 4 birdwatchers with cameras resembling bazookas excitedly exclaiming things like “That looks just like the one we saw in Bali!” from behind their enormous scopes. After we finished the canopy walkway, everyone stayed on for an hour-long nature walk. Unfortunately, we didn’t see any good mammals, but it was very nice. Our guide went from tree to tree informing us about them, explained some of the sounds we were hearing and talked about the history of the Kakum National Park. Even though the most exciting thing we saw was a colony of ants, it was very pleasant walking in the rainforest: all shade and no mosquitoes! The main disappointment was that the canopy walkway completely dominates the thinking in the park. But it is right on the edge, about a 15 minute hike from the camp, and even if you do the nature walk, you’re still only getting about 1/20 of the way in. Tourists want to see animals, and as of right now, there is no infrastructure to allow anyone to get further in to actually see the elephants and monkeys that call the Kakum National Park home. And they don’t allow anyone to wander around by themselves without a guide, a guide that you have to pay for by the hour.

shot of one bridge while standing on another

Jeremy on the canopy walkway

me striking a goofy pose on the canopy walkway

After the nature walk we made our way back to the camp for an early lunch, where I introduced Jeremy to Banku: a Ghanaian maize-based dough ball, typically served with tilapia (but we had with chicken). We had already checked out of the hotel, and had all of our stuff with us, so we hoped in a cab back to Cape Coast to catch us bus back towards Accra. Luck was on our side, because right when we got back to the bus station, there was a ¾ full coach bus ready to leave at any minute. Jeremy ran to the counter to buy tickets while I paid the cab and stalled the bus driver. It was perfect timing. 2 hours later and we were in Kokrobite: a small beach/fishing village about 20 miles West of Accra with fantastic beaches. Kokrobite has become a tourist hotspot in the last decade, because of its pristine beaches and its proximity to Accra. Ex-pats have also opened up a handful of beachfront hotels, which is a nice correlation. The one we chose was called Big Milly’s Backyard, a favorite spot for backpackers, which receives rave reviews on Big Milly’s was started by a British woman and her Ghanaian husband, and it is composed of about 2 dozen huts, right on the beach. It has a huge bar, a very good restaurant, a platform balcony with cushy chairs and couches to just sit in the shade and watch the water, and on weekends they have culture night (Ghanaian drumming and dancing) and reggae night with a live band. view of Big Milly's bar from Big Milly's restaurant

view of the beach from Big Milly's restaurant

We got off the bus around 2 or 3, sweating as always. We hopped in a cab to take us the last 3 or 4 miles to Big Milly’s, and we had one thing on our minds: the ocean. We got our room, changed quickly and were diving into waves within about 5 minutes. It was delightful. We lasted about 20 minutes before we decided to get some beers and just sit in the sand. After a few hours of beach and beer, Jeremy and I had some dinner at the beachfront restaurant: I had an entire barracuda and Jeremy a big bowl or creamy pasta carbonara. That night we met a handful of other expats staying at the hotel –a nice French couple around 30, a British student on his gap year and Swedish brother and half sister in their early twenties. The hotel next door was run by a Swedish man, and we learned that it was his birthday that day and there was to be a big party. We all walked over there around 9 o’clock, and the next 3 or 4 hours was filled with drum circles, drinking, birthday cake and very friendly rastas conversing about what life is all about. Also, the stars that night were the clearest and brightest I had ever seen them. It was pretty good time. The next morning we saw Carl at breakfast; Carl was the Swedish brother in the brother/half-sister duo. (His name was Carl and he worked for Carlsburg Brewery in Carlsberg, Sweden. You can’t make this stuff up.) He explained that his half-sister, Isabel, fell ill the night before and was actually in pretty bad shape. All the locals were sure it was malaria, but as Carl thankfully knew, the incubation period for malaria was at least a week, and since they had been in Ghana only 3 days, it was definitely NOT malaria. Unfortunately, Isabel was bad enough to necessitate them leaving shortly thereafter to go to a hospital. Checkout was at 12, so Jeremy and I spent a few more hours in the water, and then packed up our stuff and said Goodbye to Big Milly’s.

We made our way back to Accra (only about 30 minutes via tro-tro) and back to our same friendly hotel. Jeremy had one more day in town, which we spent going from one of my air-conditioned spots to another. We had to go back to my house to grab Jeremy’s bags, and before we knew it, Jeremy had to jet back to NYC.

Lindsay’s Visit:

Now, I don’t want to shortchange Lindsay in this blog posting, but it is already quite long, and like I said, we did a lot of the same things that I did with Jeremy. So, I will just highlight the things that we did differently. Lindsay was here for about twice as long as Jeremy, so we got to do a few more things. The first thing was to visit the Shai Hills Resource Reserve. The Shai Hills Reserve is a relatively small nature reserve outside Accra that covers approximately 50 square kilometers of savannah plains, and is home to baboons, kob antelope, and a huge bat cave, amongst other things. According to my guide book, it is by far the most accessible nature reserve from Accra, only about a 90 minute drive, and there are a few hotel options right around the reserve to accommodate tourists. It sounded perfect, so we did that first.

The tro-tro rides (we had to take one to another) getting there were interesting, and considering neither of us had any idea where we were going, you had to deem them a success. Friendly people pointed us in the right direction on more than one occasion, and we were lucky enough to spot the reserve from the car, prompting the second tro-tro to stop before speeding right by it (regardless of the fact that we repeated our destination multiple times to the driver and doorman). As with Kakum, the guidebook says that animal viewing is best in the early morning, or around dusk. When we got off the tro-tro at the Shai Hills gate, it was about 4pm, just in time for a nice dusk walk. That thought was killed almost immediately, though, when the rangers at the main camp told us that the park hours were from 6am to 5pm. So, resigned to visiting the reserve the following day, we trooped the mile down the road to the fabulous Shai Hills Resort Hotel.

When we got to the “Resort Hotel” it was fairly deserted, and it was about 20 minutes before someone showed up at the front desk to give us a room. The billboard advertising the hotel from the road mentioned a swimming pool, but when I asked about it, the woman behind the desk mumbled something about it being under construction, which was thoroughly disappointing. We ate dinner at the outdoor restaurant, which was actually pretty good, and in our subsequent wandering around the premises, we realized that a.) there was never any pool and would be a long time before there ever was one, and b.) that we were definitely the only ones staying at the hotel. Considering that we wanted to be up around 5:30am to be at the Reserve when it opened around 6, we just watched some TV and went to bed around 9pm that night. But as we were going to bed, we realized that the beds didn’t have sheets: just the fitted ones around the mattress. Lindsay and I went out to the front desk to ask for some, but once again, there was no one there. We walked around the hotel, but could find no one, so we finally went out to the gate and spoke to the security guard. The bow-and-arrow-yielding security guard (that’s right, he had a bow and arrow!) went to wake up the front desk woman who came out in her night robe and begrudgingly game us some sheets.

The next morning, we were up bright and early. We got to the main camp before the first ranger, so we actually had to wait about 20 minutes before we set out. Our ranger’s name was Michael. He was a nice enough guy, but for a park ranger who gives tours for a living for a non-negligible sum of money (the amount we paid at Shai Hills was more than the Cape Coast Castle and Kakum National Park Canopy Walk combined), he was not a talker. Michael explained that he was going to take us to the area where the baboons hung out in the morning, and then we would head North to the bat cave and maybe spot some antelope along the way. Lindsay and I said ok. Sure enough, we were only walking for about 10 minutes before we came upon the group of baboons. They were in the trees and on the ground, and it was by far the closest we had ever been to wild monkeys. After we took enough pictures, we turned around and headed back to the main camp. From there, we were going to catch tro-tro to the other gate at the North end of the Reserve, where the bat cave was. While we were waiting for a ride, the baboons had followed us out the main gate and were lounging in the middle of the road, causing traffic to stop and others to get out and also take pictures.

baboons in the trees

baboons in the road

We hitched a ride to the other gate after a little bit, and made our way into the main part of the reserve. It was getting hotter and hotter, and we could see a huge bluff in the distance. Michael walked very fast, and Lindsay and I struggled to keep up. We discovered that he stopped completely when he was talking, so we strategically asked him questions from time to time. The bluff was getting closer and closer with every step, and from about ½ a mile away, a strange howl rent the air. Michael pointed to a speck on the very top of the bluff, and said “They’ve spotted us.” He explained that it was a lookout for another, rival group of baboons, and he was warning the rest of his clan. After a little while longer, Michael stopped suddenly and pointed across the path into the the distance on the right, and said “Look….Kob.” They were really far away, but sure enough, on a distant hillside, was a group of spry antelope. We turned off the path to try to get a closer look, but they had seen us, too, and kept running further away.

Shai Hills savannah plains landscape, with big mountain bluff in background

We went back to the path and kept trudging along, having walked at least 4 miles by this point. Michael said the bat cave was not far, so we kept going. He explained that it was a very sacred temple for the Shai people who used to inhabit these lands before they were kicked out by the British when the area was made a reserve. Right when we got to where we were to turn off the trail to head ot the cave, a single antelope dashed across the path and into some thicket about 30 yards ahead of us. He was fast and we only glimpsed him for about 2 seconds before he disappeared again. Soon after that, we spotted a third, rival gang of baboons who were keeping a close watch on us from atop a rock ledge. We waved to them and continued on to the bat cave. We had to do a bit of rock climbing to get up to the cave, and you could smell the pungent aroma of guano well before the cave was in sight. The cave itself consisted of three or four huge slabs of rock wedged against each other, providing the perfect amount of darkness and air. You could peer in between a gap in two of the slabs to see the bats flying around madly, even though it was the middle of the day. They were squawking away and flying back and forth so crazily that it created somewhat of a wind tunnel. We didn’t stay long, for fear that some bats would fly out of the little gap in the rocks, so soon enough we were on our way back to the gate. When it was all said and done, we had probably walked about 10 miles over 4 hours, and we were extremely happy to get back to the hotel to shower and rest for a bit.

a very tired Lindsay and me towards the end of our Shai Hills trek

From there we went to Cape Coast and Kakum National Park, which was most of the same, except everything was more crowded: the Castle tour, the Canopy Walkway, etc. In fact, we kept seeing the same group of people at all of the different places, which made me feel even more like a tourist than we already were. One big difference was that we did the same hour long nature walk, except we took a different path this time, which included the biggest tree I have ever seen! From there we also went to Kokrobite, except Lindsay and I were able to spend two nights there, the first night at Big Milly’s and the second night at an actual hotel with A/C and a swimming pool! Lindsay on the canopy walkway

me in front of the biggest tree ever

Lindsay and me at Cape Coast Castle

Lindsay sporting an awesome face at Cape Coast Castle

The first night at Big Milly’s was one we would both care to forget. The water was not exactly running, so we had to crouch under a faucet to “shower”, and the power went out right as we were going to bed. The generator came on about 20 minutes later, starting the fan up again, but we were already quite sweaty by then. The generator would go off a few more times in the next few hours, but thankfully stayed on for most of the night. We made the snap decision to rearrange the furniture in the room, pushing the bed directly under the fan: it was the right decision.

After that, we decided to splurge on De Holiday Beach Hotel down the street, which had A/C, European-style rooms (instead of huts with thatched roofs) and a swimming pool, but luck was not with us. We got to the hotel around noon to find that their electricity was still off (even though Big Milly’s had come back on earlier in the morning), and their generator had also broken. We were even denied the ability to take a real shower, when they explained that the water pump is powered by the generator (something that is not even the case in rural villages). All we could do was sit/swim by the pool (at the Obama Terrace) and wait to see if the generator would be fixed. The pool was not the cleanest I had ever swam in, but the water felt nice. About 4 hours later, the generator was fixed, and we could take real showers! While Big Milly’s was at full capacity, we were the only ones at our hotel. But with A/C and a TV, we felt like royalty!
hilariously-titled "Obama Terrace" and swimming pool at De Holiday Beach Hotel

our fancy room at De Holiday Beach Hotel

I had also found out about an Italian restaurant down the street that was supposed to be good, and tonight was culture night at Big Milly’s, so were going to head back there after dinner to check that out. Started by an Italian man a few years ago, the Kokrobite Garden Restaurant was delicious. After a completely satisfying meal of bruschetta, pizza and pasta, we heard the drumming start from big Milly’s, so we headed down there. The next two hours was non-stop drumming and dancing from a Ghanaian cultural troupe of children and adults who performed at least a dozen dances, each individually introduced as coming from a particular tribe and/or region of Ghana and some of its West African neighbors. Everything about the show was impressive: the drumming, the choreography, the physical abilities of the dancers and more. People continued to pour in around the stage, and soon it seemed like the entire village came to enjoy the show along with us melanin-challenged tourists. It was exhausting watching all of the non-stop dancing (Even between songs, they never stopped for more than 30 seconds.), and Lindsay and I decided to grab a drink and leave for the quieter balcony to watch the waves. That night sleeping in A/C was glorious.

Ghanaian culture troupe: dancers in the foreground, drummers in the background

Heading back to Accra the next day was a laborious affair. A trip that should have been about 30 minutes was made into hours by an impromptu bulldozer I the middle of the road. The traffic jam was so bad that after about 20 minutes of literally not moving an inch, Lindsay and I decided to get out of the tro-tro and walk. It turned out to be the right decision, because after about a mile or so, we spotted the bulldozer. It was alternating between 5 minutes of work and 30 seconds of letting cars go by, offering no detour or alternative for motorists. So, we hopped in an empty bus just as they were being let through and probably saved us about an hour of sitting in traffic. There were three people in the bus: the driver, a silent man in the passenger seat and a very loquacious passenger, who took a liking to Lindsay and me. He explained how he really wanted to move to the U.S. and was asking Lindsay in particular how he could go about finding an American wife. I was able to point him to the U.S. embassy visa section and avoid that conversation for the most part. When it was time to get off, they wouldn’t even take a token payment, so we said goodbye to our new friends and continued on our way.

And it wasn’t long after, just like with Jeremy, that I was saying goodbye to Lindsay at the airport as well.

Thursday, April 22, 2010

A Tale of Two Ghanaians

It was the best of receptions; it was the worse of receptions.

On Sunday this past weekend, I was heading into Accra to a very nice 5-star hotel downtown where I happen to have snagged the wi-fi password, and have been known to camp out for hours enjoying the air conditioning and some of the fastest internet I have found in Accra. Door to door, the trip takes me anywhere from 45 to 90 minutes depending on traffic, with the first leg of my little journey being the 15 minute walk to the junction with the main road (Spintex Road) where I can hop on a tro-tro heading downtown. On this particular Sunday I had done laundry (by hand) earlier in the morning, and so, my trip into town was right smack in the middle of the day. Perhaps poor planning on my part, but the difference between dawn and noon is more like the difference between really hot and really really hot ; either way I am dripping with sweat 5 minutes after stepping outside.

So there I am walking down the familiar copper-red road, kicking up dirt dust with every step, the noonday sun relentlessly beating down on the back on my neck, sporting my trusty yellow backpack with laptop inside, when the brake lights engage on the back of a car that has just driven past, and it pulls over to the side of the road. I continue walking up alongside the car, as the driver leans over to roll down the passenger side window. He is a middle-aged Ghanaian man with a bald head and a kind face. I lean into the open window as he enquires “How far are you going?” “Just to the junction”, I reply. “Hop in.” he declares, “It’s too hot out to be walking long distances.” I respond with gratitude, as I open the door and take a seat. I have made that walk between the junction and my house at least a hundred times so far, and no one has ever pulled over to offer me a lift.

When we arrived at the junction, I said “This is great right here. I can catch tro-tro into Accra at this stop. Thanks so much.” To my surprise, he enquired once more “How far are you going?” to which I replied “Downtown Accra.” He said “So am I, so just stay in and we’ll go.” So, I did. On the 20 minute drive that ensued, I learned that his name was Andy, and that he lived right around the corner from me with his wife and three children (two of which were born in the U.S., and so, are U.S. citizens). He was in the “relocation business,” which, as he explained to me, was basically like a professional moving company that specialized in moving diplomats and aid workers between Ghana and their home countries. He was headed to the immigration office on business, which happened to be right around the corner from where I was headed. “How do you see Ghana?” is the standard question I am always asked, so I spoke of my work and my time so far, and we both agreed that, from a development perspective, Ghana is a very exciting place to be at the moment with lots of promise for itself and to be a leader in Africa as a whole. When he learned that I was American, he spoke of the U.S.-funded highway that is being built West of Accra that will do wonders for traffic, once completed.

All in all, it was a very pleasant trip, and Andy and I exchanged phone numbers outside the Ghana immigration office where he dropped me off. Having met a very nice man and been saved about an hour trek, I walked the rest of the way to the hotel in quite a good mood. Andy was the epitome of what I have come to know as the kindness of strangers in Ghana. But, as I was soon reminded, it is the kindness of MOST strangers. On the sidewalk just outside the hotel, I passed a tall, skinny, dreadlocked man who gave me a scathingly dirty look for no apparent reason. Even that could not damper my spirits; however, it did remind me of another, much less inviting Ghanaian I had encountered months earlier.

Towards the end of my first month here, Dennis and I found ourselves at the bank under another viciously hot midday sun. He was making a very large transfer of funds from another bank, and it was taking a while. Like most bank experiences so far, demand for services far outstripped supply, and the line was out the door. Not able to go inside and also unable to stay in the suffocatingly hot car, I decided to just sit on the shady curb next to the ATM. After a few minutes, dreadlocked man of slight build wearing sunglasses came up to use the ATM and started talking to me. At first it seemed friendly, but I soon realized that his intent was anything but. The short conversation went something like this:
“How are you doing?”
“I’m fine. And you?”
“ Good. So, what are you doing in Ghana?”
“I’m doing public health work with the Pharmaceutical Society of Ghana.”
“Working for pharmaceutical companies…that sounds about right.”
“No, not pharmaceutical companies. I work with pharmacists…Ghanaian pharmacists.”
“Where are you from anyways?”
“I’m from the U.S.”
“Oh, the United Snakes of America…that makes sense.”
“Listen, I am here working with a local Ghanaian NGO, with Ghanaian pharmacists doing public health work to try to make you and your fellow countrymen healthier. I don’t appreciate those United Snakes of America comments like that radio host uses.”
“Ha. Listen buddy. I think you should probably get out of Ghana.”

At this point he was finished using the ATM and turned to leave. But not before forming a gun with the thumb and index finger of one of his hands, pointing it at me and saying “BANG!” So, trying to be the mature one and take the high road, I just resorted to some good old sarcasm as he walked away: “Very nice to meet you too! Have a great day!”

The “United Snakes of America” phrase, I know, he had stolen from a very popular radio talk show host here in Ghana who calls himself “Blakk Rasta”. The show, which airs every day around lunch time, consists of about two hours in which the Blakk Rasta rants about the “white man” and the “imperialist devils from the West.” (Phrases in quotes taken verbatim from his script.) I have never heard him interview a guest or take callers; it’s always just him talking into the microphone. It’s a fantastic feeling to get into a packed tro-tro and hear his program on, only to smile broadly at the people around me. While it would be great if every single Ghanaian held a favorable view of Americans, like power outages and unrelenting humidity, I chalk it up to “all part of the experience” and try to learn something from it. And, indeed, in this case, there is much that can be learned.

I was first introduced to the Blakk Rasta when Charles had the radio tuned to his show as he drove Dennis and me to a meeting a few weeks after I arrived. Dennis explained that the show was very popular among all demographics, and that the Black Rasta was a college-educated man. The first segment of that particular show featured a history lesson of the life and death of Patrice Lumumba: a Congolese independence leader and the first legally-elected Prime Minister of post-colonial Republic of the Congo, who was arrested and killed with the likely support of the Belgian (and possibly U.S.) government(s). Like Ghana’s Kwame Nkrumah, he was a supporter of Pan-Africanism, and to the surprise of no one, the Black Rasta went on for about 15 minutes to lionize Lumumba as a martyr and demonize the West. The second segment was much less structured than the first, and he went on a tirade against the “IMFWorldBank” for another 15 minutes. The basic take-away was that the “IMFWorldBank” has more control over Ghana’s development than Ghana does, and that is a deplorable state of affairs. It was simultaneously a shot at the multilateral development agencies (and, by extension, all Western countries that donate to them) and the current administration in Ghana.

Now, there are a few interesting things about this broadcast on which to reflect:

1.) Blakk Rasta does make some good points. On Patrice Lumumba, yes, the U.S. and its allies did certainly play a role in the deposition and/or killing of some world leaders of sovereign nations, especially during the Cold War, when the Republic of Congo was getting aid from the Soviet Union. These actions are undoubtedly regrettable, and according to the CIA, they don’t do that sort of thing anymore. It is, however, a little much to canonize him, since he did very little that could be considered good for his country while in office. On the other hand, he did implement policies that precipitated a terrible civil war.

2.) The whole “United Snakes of America” phrase is hilarious when put into context. You see, in addition to being a radio show host and DJ, Blakk Rasta is also a reggae artist. His biggest hit single to date, is titled “Barack Obama”: a song he made supporting Obama in the run-up to the 2008 election. When Obama came to Ghana in July of 2009, Blakk Rasta was accorded much attention due to the song. He was interviewed by CNN, the BBC and other Western news outlets, in addition to having lunch and a photo op with the president: an experience he called the pinnacle of his life and career.

3.) His anger at the “IMFWorld Bank” is not completely unfounded, but needs to be much better informed. It is easy to rail at the two multilateral institutions, as they have dropped a lot of money here, with some questionable results. Development is a tricky field; not everything is a success story; and it is very easy to point the blame. That being said, they are completely different institutions with completely different mandates, so you undermine your credibility when you just say “IMFWorldBank.” As in: “The government needs to stop pandering to the IMFWorldBank and have a greater say in the projects that are being implemented.” To Blakk Rasta and many other Ghanaians, these institutions represent some sort of extended colonialism, and there is no difference between them. And he equates the government taking their assistance as being controlled by them and by their agenda. (The meeting Dennis and I were being driven to as we listened to the program was sponsored by the World Bank.)

While the overwhelming majority of Ghanaians I have encountered lean towards Andy’s view of the West, I am constantly reminded, through almost daily scowls I receive from passersby, of those on the other end of the spectrum like Blakk Rasta and the man at the ATM. And, after all the atrocities committed by the “white man” against Africans, I can’t say that I don’t see where they are coming from. (NB: Not all Rastafarians are vehemently anti-West. I participated in a fantastic moonlit drum circle on the beach followed by intense what-is-it-all-about conversations with some very friendly, thoughtful Rastas. I don’t want to paint a wrong picture.)

For me, it is interesting to note how much homage is paid to the views of Blakk Rasta, even by those who don’t agree with what he espouses. In an extreme light, he can be blindly anti-West regardless of the issue at hand and allow that bias to cloud his judgment, never capable of objectivity. However, in a moderate light, he can stand for not eating all that is fed to you without questioning it, for national pride, and for sovereignty, and I think that this is what Ghanaians across the political spectrum can relate to. Indeed, it is exactly this phenomenon that I have seen manifest in many of my work meetings here. Ghanaians, like any other nation of people, are proud, and one of the biggest lessons I have learned is that donors and other “development partners” (the catchphrase du jour) cannot underestimate this sentiment in their policies and interactions with their developing country colleagues. To do this (development) right, by building consensus, takes time, and local stakeholders must be involved in ALL stages of the process: from policy development to implementation. In one of my next blogs, I will discuss how ignoring these lessons might spell failure for a very exciting and promising initiative being piloted across Africa this year (including Ghana) in malaria control.

Ghanaians like Andy look at my skin, and think about the new road that U.S. dollars are helping to build. They want to talk to me and know what sort of work or study brings me to their country. Ghanaians like the man at the ATM look at my skin and they think about the killing of Patrice Lumumba and the development failures preached by the Blakk Rasta. They want to talk to me to tell me to leave their country. It is the best of receptions; it is the worst of receptions. You just have to take the good with the bad (add a few other clich├ęs), walk it off, and keep on going.

Tuesday, April 13, 2010

The Joy FM / PSGH Easter Soup Kitchen

This Easter Sunday was like none I’ve ever experienced. That’s because on this day every year, PSGH partners with Joy FM, Accra’s most popular radio station, and other organizations to put on the “Easter Soup Kitchen” (ESK) for the benefit of thousands of Accra’s poorest residents. In short, the ESK is a day of giving back, where anyone and everyone can come to get free medical care, clothes and a hot meal. It was a day I’ll never forget.

For me, the day started before dawn, when John and Jonas picked me up in the PSGH truck around quarter to 6, the flatbed already full of boxes of donated drugs and other medical supplies that we were transporting to the Children’s Park in downtown Accra, where the ESK was to take place. We arrived at the park about 20 minutes later to find dozens of volunteers already there, setting up the tables and chairs for the other stations. We quickly began unloading our boxes, so that John could go back to PSGH headquarters to get the second truck load of supplies.

truckload number one

That’s what PSGH brought to the table: the medical care. We had sent out letters about a month beforehand to pharmaceutical companies in Ghana, wholesellers, importers, and even the public sector medical stores asking for drug donations. The response we received was impressive, and over the next 4 weeks we were very busy picking up donations and taking stock of everything we received. That was basically my job, and I spent many days examining active ingredients and expiry dates, counting every single dose that we had and putting it into a nice little Excel spreadsheet. I would then repackage everything and slap a huge, easily-readable pink label on the box to make everything easier come Easter Sunday.

boxes of drugs in our office, each with a pretty pink label and my nice handwriting

As Jonas and I began sorting the boxes by drug type (analgesics, multivitamins, antihelminths (aka dewormers), antimalarials, etc.), we were soon joined by dozens more PSGH volunteers: doctors, pharmacists, pharmacy students, interns, and others who just wanted to help. The Joy FM people had finished constructing the DJ booth and stage and started up the music. When the first song out of the PA system hit my ears (Bob Marley’s “Redemption Song”), I knew it was going to be a good day. Not only was it an extremely appropriate choice on many levels, but it also happens to be my favorite Marley song!
setting up the DJ booth around 7:30 am

so much water!

The people were to start coming around 9, so we spent the next two hours sorting and opening boxes to make the distribution as smooth and quick as possible. We set up several long tables topped with boxes full of different tablets, syrups, creams and solutions. And when the tables could not hold any more supplies, we piled the rest of the boxes behind them, which I was in charge of. We had arranged it with Joy FM so that everyone came to our medical station first, before going on to the clothing and food stations. In the past, many people just came and grabbed food, skipping over our services, so this time they had to get a hand stamp in order to get the food. This was great, because it meant that we would be able to serve the maximum amount of people, but it also meant that it was going to be a madhouse! We had arranged it so that people would:

- first come to one of many registration desks, where a volunteer would write down their age and gender on a form;

- from there, they would move on to the doctor/pharmacist stations where trained health professionals would do a quick consultation, writing down their symptoms, diagnosis and prescription decision;

- finally, they would bring the form to one of the dozens of volunteers doing the dispensing, who would provide the treatment and dosage instructions, take the forms from them and give them a stamp.

And at 9am, that’s exactly what happened; people started pouring in (the vast majority being women and children), and within 30 minutes, everything was running at full tilt. It was a good thing that there were security guards on site to control the lines, because it would have been mayhem without them. The lines were soon over a hundred people long, and I spent the next several hours running around refilling stocks, answering questions from dispensers about what drugs we did or did not have (even though I had converted the spreadsheet into an easy to read list, sorted by drug type, giving doses and expiry dates, and printed out dozens of copies for everyone to use as reference) and finding the hard to find ones from the boxes. In addition to the main dispensing tables, we had set up independent stations for distribution of deworming tablets and oral rehydration solution, and everything seemed chaotic but, all things considered, was running as smoothly as we could have hoped for. (Later, we would do the final calculation and realize that we were treating over 400 people an hour!)

one of the diagnosing tables

one of the dispensing tables

yours truly doing some dispensing

one of the lines for our medical care station

Around 11, we had already run out of some of the creams, and it was clear that we would start running out of some of the syrups, multivitamins and paracetamol. With no signs of the lines lessening, we decided to make an emergency run back to the PSGH offices, where we had extra stocks of some of the drugs. The clothing station opened around 11:30, and then an hour or so later, it was announced that the food was ready to be served. With other places for people to go, our lines were finally becoming a little bit more manageable! Dennis arrived from church around then, and immediately jumped right in. All the volunteers even got free food around 2pm: a welcome respite!
people waiting patiently for clothes and food; security guard and huge pile of clothes at far right

By about 3pm, the last dregs of people were filtering in, and we were able to start packing up. It had been over 6 hours of mayhem, but with over 80 volunteers at our medical station alone (about 10 times the amount of volunteers as last year!), everyone agreed that it had been the most well organized ESK yet! PSGH will conduct another similar free health outreach day, in conjunction with its annual general meeting in August, so stay tuned. We learned a lot of good lessons this time around, so I expect things will be even better managed in the future. It was truly impressive to see the hundreds of volunteers giving up time on their precious weekend to help those less fortunate than themselves, and I was just happy to be a part of it!

See more pictures at the Joy FM website!