Of Input and Output

No one likes to talk about diarrhea. Except, of course, my father, a gastroenterologist, who would routinely take work calls at the dinner table and end up discussing stool samples and bowel movements of all kinds over the evening’s repast. But I digress…

On our way home from church last Wednesday night (yes, they attend Church on Wednesday, too), Pat, Dennis and I stop by a roadside market to pick up some food for dinner. At first glance, the market is just a few kiosk-type booths next to one another on the side of the road selling mostly fruits and fish (Accra is right on the coast, so everyone sells fish.). But once we park and get out of the car, I notice that these few booths are just the façade of about 5 times as many behind them. We begin to walk back about three or four booths deep before stopping in front of one whose countertop is crowded with glass cases of fish and shrimp, along with a huge pot full of shotput-sized balls of something wrapped in corn husks that gives off a plethora of steam when the woman behind the counter removes its top. We buy a good amount of the fish (fried tilapia, I would learn) and shrimp (also fried), together with 4 of the corn husk balls, and head back home.

“In Ghana,” Dennis explains to me as he pops a whole shrimp (shell, tail, legs and eyes, as well) in his mouth, “everything is eaten with your hands.” This meal happens to be very traditional Ghanaian fare: the shotput things are called “kenkey” – a sort of corn-based dough ball that is fermented for a few days to give it a bitter taste – served with seafood and hot chili sauce for dipping. Not only are utensils not required, but Ghanaians also eat ALL of the fish and shrimp: the eyes, tail and everything in between. I don’t think there are extensive catch-and-release laws in Ghana, so the fish are pretty small – at most a foot in length – making bones almost a nonissue.

So there I am struggling with fork and knife, removing head and tail, while Pat and Dennis are just putting it away at a very respectable clip, their only utensils the ones they were born with. When I comment on how I expected the chili sauce to be spicier, I learn that Pat does not like things too spicy, so she diluted her chili sauce (and mine) with tomato paste. I say that it is a very sweet gesture, but I do, in fact, like spicy things (Many of you know that I enjoy cooking and eating with a lot of spice: the more the better.). So, after some cajoling, they let me try some of Dennis’. It is definitely not for the faint of heart or weak of stomach, but nothing I can’t handle (I’m pretty tough, I know.). Dennis and Pat are continually surprised when I like Ghanaian food, but even more so when I reach for more of Dennis’ chili sauce.

Now I’m sorry to say this, but in the middle of the meal, I can’t help myself except to think about diarrhea. And not because I am walking a thin line with the chili sauce, which I might regret in the morning. Diarrheal diseases – a blanket term in the global health world for many food and water-borne microorganisms (shigella, rotavirus, cholera, enterotoxigenic E. coli, etc.) that cause it – are a very serious problem in developing countries, especially for children. And despite proven prevention and treatment interventions, diarrhea, together with malaria and malnutrition, remains one of the top 3 killers of children under 5 worldwide. For Westerners, it is called “Montezuma’s revenge” or traveler’s diarrhea; something only encountered on tropical vacations. But for children in the developing world, it too often leads to dehydration and death. In fact, this scenario might be spreading for older people as well; a new WHO report concluded that the OVER-5 mortality rate from diarrheal diseases might be 3 times as high as previously thought.

When I went to the travel clinic for my immunizations before leaving for Ghana, in addition to learning what it’s like to feel like a human pin cushion (5 shots in under 1 minute), the clinician delivered a kind-hearted lecture of the do’s and don’ts while abroad. For avoiding the food and water-borne illnesses, she cautioned: “Don’t eat the fruits or vegetables unless you can peel them. Don’t eat the meat unless it’s boiled or baked for the necessary amount of time. Only drink bottled water or water that has been boiled or treated. Don’t eat any of the spices. Don’t eat any of the rice, or other locally-harvested things. Definitely don’t eat any of the local food from the street vendors, and watch out for the food on the flight coming home.” Basically, don’t eat anything. Now, adherence to such pointers might be possible for week-long vacationers, but when you are going for a year, such advice becomes infeasible. And while I certainly try my best to adhere to these rules, I have already broken them several times over.

Back to the meal at hand (pun not intended). I am sitting there worried about eating with utensils that have been washed with tap water – water that had certainly not been boiled –, while Dennis and Pat are eating with hands that had, at best, been washed in the same water. Now, Dennis and Pat are very hygienic people who shower and wash their hands regularly, but the same cannot be said of all Ghanaians (or all Americans, for that matter), especially those in more rural areas without regular access to showers and hand soap. Like malaria, according to Dennis, the adult population becomes relatively immune to many of the food and water-borne disease-causing microorganisms. And after a time, he says, I might even be able to drink the tap water consequence free. This is all well and good for Dennis and Pat, but it’s a different case entirely for the toddler I witnessed being hand-fed by her mother only a few hours ago.

Now, I am not going to start telling Ghanaians to eat their Snickers bars with a fork and knife like George Costanza, but this proclivity for eating with hands is the sort of thing that makes one look quite differently at the motherly admonition to “Wash your hands!” It is the sort of thing that never occurred to me when researching diarrheal diseases from an office in Washington DC with instant hand sanitizer on my desk. It is the sort of learning from experience that makes me thankful for coming here.