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.

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 tripadvisor.com. 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.