When the Power Goes Out

No one likes being woken up in the middle of the night. Whether it’s because of a loud noise, because nature’s calling, or because someone within earshot won’t stop snoring, a good night’s sleep is a coveted thing that people are willing to pay for (in the form of memory foam mattresses and pharmaceuticals). I have experienced all of these aforementioned phenomena many times, but in Ghana, the one I have come to dread most is not among them. Nope, it’s the power outage.

Why would a power outage interrupt your sleep, you might ask? Well let me tell you. The answer is simple: the fan stops working. Forget no TV, microwave, or electric water boiler. The worst thing about a power outage in Accra, by far, is that the fans stop working, and when this happens at night, forget it. In the middle of the night, the ambient temperature in Accra is around 80 degrees, and it is common knowledge in these parts that sleeping under a mosquito net adds a few degrees on top of that. Even sleeping on top of all my sheets, the ceiling fan is the only thing that keeps me from sweating. And I have come to realize that my body is fairly sensitive to temperature change, because I never cease to wake up just in time to look up and see the fan making its last glorious rounds. A motionless ceiling fan is the equivalent to the gavel dropping, as I am sentenced to another sleepless night.

my bed, covered by the mosquito net, and ceiling fan above

Now, most power outages so far have lasted anywhere from a few minutes to several hours. In these cases, I usually pass the time reading, playing games on my phone or, my personal favorite, showering: the only thing to do that does not involve sweating. However, over the Christmas break, we experienced a period of about 36 hours where 30 of them were blackout. In this case, drastic action had to be taken.

The power went out in the middle of the night, so by noon on the following day, it had been around 10 hours without power. Dennis, Patricia, Desmond and I came to two conclusions: we had to get out of the house, and soon, and the food in the refrigerator was in jeopardy of going bad. Coming to this conclusion, we did the only logical thing one could be expected to do in this situation: we had a binge eating session where we tried to consume all those foods most vulnerable to spoil, and then we went directly to the beach.

Going to the beach was a big deal. For one, Desmond is Ashanti: a very proud tribe from the center of Ghana. Not being near a large body of water, he never learned to swim, and is deathly afraid of the ocean. Dennis and Patricia do know how to swim, but do not seem too fond of it, and admit that they prefer swimming in pools. At this point, I had been in Accra over a month, and while we drive several miles on a road that hugs the shoreline on a weekly basis, I had not stepped foot on the beach.

We drove to a small cliff that overlooked a very nice beach, parked on the side of the road next to a few other cars, and made our way down the slope. The sand was unlike any I had ever walked on, with grains so fine that even after rinsing your hands off in the water, a few still resided in the lines of your palm. There were a few dozen people on the very spacious beach, so that it was not crowded at all. Boys playing soccer, two girls building sand castles, other children running and laughing in no particular direction while their parents chided them from blankets to slow down and remain farther from the water: everything was good. All thoughts of the power outage floated away, as I became thoroughly focused on enjoying the beach. We made camp a good 30 or 40 yards from the water, to make sure that Desmond was comfortable, and I put my towel down and made a bee-line for the water.

shot of the beach from atop the little cliff
people on the beach, some Accra hotels in the background

It was nice and warm, with some decent size whitecaps. Dennis and Patricia also chose to stay dry with Desmond, which seemed to be the general trend, as those on land vastly outnumbered those in the water. I immediately swam out past everyone else, and even though I was about 50 yards from the shore, the water was only up to my chest.

waves

For the next hour or so, I contented myself to play in the oncoming waves, jumping over some and diving under others. I returned to the blankets with well-pruned hands to dry off. Desmond and Patricia were returning from a walk, while Dennis decided to actually go in the water for a few minutes.

two little girls enjoying a day at the beach

When we finally made our way back to the car, the sun was about an hour from setting, and the sand was proving impossible to completely remove. We got back to the house to discover that the power was back on, and we promptly did a little dance, accompanied by some appropriate hooting and hollering. We were all riding high from our exciting day at the beach, and the prospect of being able to watch a movie seemed too good to be true.

In fact, it was. Not more than two hours later, the power went back off and stayed off for even longer than before. Oh well. Maybe we can make a habit of binge eating and swimming. But always waiting 30 minutes before going in the water, of course.

Edgar the Elephant in the Room and the C5

In the wake of the abject failure that was the Climate Change Summit in Copenhagen last month, I find myself observing my surroundings here in Ghana and wondering if any of the experts had observed Edgar, the big elephant in the room, while they were in Denmark.

Now, I am far from a climate change expert, when it comes to the intricacies of the negotiations. But, striving to be an informed citizen of Earth in the 21st century and watching week after week of the news coverage generated by the event, I like to think that I understand the key issues central to the debate. That being said, I welcome any and all corrections/additions/clarifications that would further enlighten myself and the good readers of this blog. From what I gather, developing countries don’t want to talk about any agreement that doesn’t involve maintaining the Kyoto Protocol. This is because the Kyoto Protocol – the old climate change agreement signed in 1997 in Kyoto, Japan – only applies to developed countries and doesn’t require any commitments or carbon abatement from developing nations. On the other side of the table are the developed countries, who won’t broach an agreement that doesn’t also rope in developing countries with legally binding requirements. Meanwhile, China continues to play both sides like a fiddle. Basically, there is a whole lot of finger pointing and no stepping up to the plate.

These are what I take to be the main points in the negotiation. I know (and hope) it is a lot more complicated than that, with some of the finer points being: what concessions to make legally binding, how to measure and enforce those commitments, etc. The summit gave lots of important people the opportunity to hear themselves talk, and after months and months of preparation, next to no progress was made. Leaders actually agreed not to let the mean global temperature rise by more than 2 degrees centigrade (about 3.6 degrees fahrenheit) from pre-industrial, which is about as asinine as agreeing that there should be 42% less wars over the next 67 years, while each country increases its military spending.

Meanwhile, Edgar the elephant was just hanging out, enjoying all of the free food and getting fatter. Edgar is the question of the capacity of developing countries to actually achieve any of the goals to which they might agree. This question was never addressed in a meaningful way. Instead, as they often do, rich countries tried to address it in the most superficial way possible: by creating a fund to throw more money at the problem. This time, they called it a fund to “help developing countries cope with the effects of climate change.” While negotiators remained fixated on who should be bound by what concessions, no one seemed to be talking about HOW developing countries would actually be able to achieve any of these said concessions. For me, having witnessed the C5© – Copenhagen Climate Change Convention Catastrophe (C5 is copywrited and comes with YMCA-style hand gestures to refer to it) – unfold from a developing country, Edgar remains the most important unaddressed issue of this entire debate.

Many of the proven interventions to mitigate and prevent climate change, like in health, involve behavior change of entire populations. And more than anything, these interventions require the political will for large-scale investments to increase public awareness hammered home over years and years. This is not a silver bullet vaccine that donors can just throw money at to buy more doses. This is condom usage. Think about how long tree huggers have been preaching about recycling in the western world. Meanwhile, the concept of recycling in Ghana is more of a myth. In many respects related to individual behaviors affecting climate change, the developing world is decades behind.

A few illustrations from a little over two months here:

- In my first week, I asked Patricia if we recycled; she just laughed. We have to pay a private waste management company to pick up our trash. That public service is almost non-existent. Most people just burn their trash in piles on the side of the road. Trash is everywhere, and Accra makes Manhattan look like Chicago (In case you missed it, that was a ZING to all you New Yorkers.).

- The first time I traveled downtown, I bought a bag of water to hydrate. (Purified water is sold in 500ml plastic bags here for about 4 cents: a really good deal. You bite off a tiny corner of the bag, tilt and squeeze.) I spent the next 7 hours looking for a trash can for the empty bag. I never found one.

- I’ve been to half a dozen conferences so far, some with over 100 participants, where they hand out an average of 20 sheets of paper per day per attendant. Not once have I encountered double-sided printing.

- The combination of terrible roads and an ever-increasing population is not a good equation for traffic in Accra. An even more important variable is car quality. Let’s just say that the average car here is a lemon, and the idea of having any sort of emissions standards in laughable. Sitting in Accra traffic with everyone’s clunker humming away and looking at the fumes slowly rising into the sky is downright depressing. I have yet to see a hybrid car. Not even the donor SUVs.

A typical vehicle on the road, spewing fumes into the air

- I saw on the local news the other day that some rural areas are running out of trees for firewood with which to cook. They interviewed one woman who had a gas stove in her house, but refused to use it in favor of burning wood. When asked why, she said because she was scared that turning it on would cause her house to explode.

- Last week I received a call from Ghana Immigration Services where they were processing my visa extension forms. They needed some more documents for my application, so I asked if I could send them in an email. “No, you need to print them out and bring them in person.” was the answer from the other end. “It takes over an hour for me to get there, so I’ll have to come tomorrow”, I said. “Are you sure there is no way I can email them to you? I have the forms on my computer, so I can get them to you right now.” “No, you need to bring hard copies.” “Do they need to be originals?” “No, photocopies are fine.” “Then why can’t I just send them to you? It’ll save me a trip, be quicker, and you can print them out there.” “No. You must bring them.” Accepting defeat, I gave up. Charles and I successfully sat in more traffic the next day, adding the completely unnecessary trip to our carbon footprint.

While these anecdotes can be amusing and comical to westerners, the serious impact they have on the world is no less real. Many of the aforementioned tidbits illustrate the behavioral nature of culturally-ingrained actions requiring change. But it is precisely these changes that take the most time. Trying to look on the brighter side, I can see several opportunities for policy initiatives. How about a government-run trash pick-up program that would create jobs while simultaneously cleaning up the country? Not every solution needs to be rocket science.

trash-filled drainage system lining a major road in Accra. Much-needed during the rainy season, these channels line most streets in Accra, and every one of them is riddled with garbage.

close-up of the same above

Outlining a climate change agreement is a means to an end, not the end in itself. Making an agreement for the agreement’s sake helps no one, especially one where developing countries have extremely limited capacity to achieve the goals set forth. The main question is not which countries or what levels, but rather HOW. Meanwhile, the U.S., China and others continue to act like children on the playground at recess after someone just fell off the slide and hurt themselves. The problem is that it’s the Planet that’s down for the count, and there is not a teacher around to regulate and figure out what happened. But that doesn’t stop the children from finger pointing. And that doesn’t help anyone notice Edgar the big elephant happily playing on the see-saw.

Dr. Alex Dodoo

So, I have been consciously avoiding talking about my work in Ghana and instead discussing everyday experiences about the people and the place that highlight cultural similarities and differences which I think people will find more interesting. I have mainly been doing this because who wants to read about what other people do at work? Honestly. I have also been doing this, because it would force me to use and explain A LOT of acronyms. And I hate acronyms. However, it seems like you are a fickle bunch; what used to entertain no longer does, and you want to know what I'm actually doing with my days. So, I thought I would ease into the work stuff with an introduction of my boss, Alex Dodoo, and a quick gist of what I’m doing. We can get into the weeds of global health and development in Ghana in later posts.

Alex is a pretty awesome guy, in most senses of the word. A pharmacist by training, he holds a PhD in Pharmacology from Kings College in the UK. And now, by his early 40s (I think), he is simultaneously: a lecturer at the University of Ghana Medical School and Korle Bu Teaching Hospital, the president of the Pharmaceutical Society of Ghana, the chairman of the Food and Drugs Board (Ghana’s FDA), and has just been the first African elected president of the International Society of Pharmacovigilance, amongst other things. Very articulate with a commanding presence, Alex can often be seen and heard on TV and radio programs here, informing the public on all things pharmacy and representing some of the many organizations to which he belongs.


poor quality picture of Alex from a google image search

In addition to his professional accolades, he is also one of the nicest guys you will ever meet. Knowing that I’m new in town and living with a pastor (because he's the one who made the arrangements), he has gone out of his way to invite me to parties and get-togethers with his closest friends and family: most of which have been great fun. I don’t want to get him in trouble, but let’s just say that he works VERY hard but is also intimately knowledgeable about how to have a good time.


Alex on our TV via a morning talk-show, discussing the H1N1 virus

I first met Alex through my previous job at the Center for Global Development, where he was a member of the working group we convened for a project on the immensely complex topic of drug resistance. A pharmacist with a passion for pharmacovigilance*, he was a great contributor to the work during my time there. Then, when I decided that I had done enough policy research in DC and wanted to get out into the field, he was one of the first ones I spoke to. And here I am.

I am working with the Pharmaceutical Society of Ghana (PSGH): a professional association consisting of every single registered pharmacist in the country. In developing countries where doctors are few and waiting rooms at hospitals are never-ending, pharmacists have a much greater role in the provision of health services than we think of them in the US. For better or worse, pharmacists are often the first health workers patients see, especially for certain common disease types like diarrhea and malaria, so they often have clinician duties on top of their drug dispensing ones.

a bow-tie clad Alex relaxing with friends at a party to which he invited me

In addition to representing all Ghanaian pharmacists in public and private sector matters, over the years, the PSGH has also run several public health projects: Hepatitis B vaccination campaigns, bed net distributions, public information programs on TV and radio, etc. PSGH’s mandate also includes running yearly mandatory continuing professional development (CPD) training modules to keep all members up to snuff on the latest developments in the profession. Put generally, my job with PSGH is to help them develop, fund and implement more of these public health projects and CPD trainings. I probably have the most experience in malaria, and since it is by far the number one disease in the country on most lists, Alex is very happy with me focusing on that. Put simply, he wants me to bring home the bacon in the form of donor funding. It’s the first explicitly results-based job I’ve ever had, so we’ll see how it goes. So far so good.

But that’s that, enough work talk for today and definitely enough acronyms.


*Pharmacovigilance (PV) is defined by WHO as “the science and activities relating to the detection, assessment, understanding and prevention of adverse effects or any other possible drug‐related problems.” Such problems might include drug interactions, off‐label uses, and the presence of substandard or counterfeit products on the market, as well as reported lack of efficacy. In practice, it is mainly two-fold: monitoring patients’ relationships with the drugs they consume and surveillance of pharmaceutical quality of those products on the shelves.

All Dennis Wants for Christmas...

is a goat. Seriously, he never came right out and asked for one, but for the couple weeks leading up to Christmas, he was laying the hints down pretty thick. “Oh, how nice it would be to have a goat over the holidays!” “We usually get a goat for Christmas, but I’m not sure if we’ll be able to this year.”

random goats on the side of the road: as common as as the grass they eat

After hearing these subtle pleas for a few weeks, I got the hint. And even though I have gotten to know Dennis and Patricia fairly well in the month and a half I have lived with them, I still had absolutely no idea what to get them in exchange for all their kindness and generosity. The goat was a win-win for everyone involved…except the goat. Plus, it would mean that I would get to share in all the stews and kabobs Patricia would make from it.

So, about a week before Christmas, after another one of Dennis’ hints, I asked him how much a goat was. His answer: maybe 70 or 80 cedis ($50-$60). Then, I told him my plan: we’d go 50-50 on it. He thought about it for a minute, and then a big smile came across his face, and he said “Alright!” He was in good spirits for the next few days, shopping around for the best deal. He called some friends in more rural places to see how much they were selling for up there (Accra is on the southern coast, so when I refer to rural places in Ghana, I will probably use “up there.”) and contemplate transportation logistics, and we went around to a few of the sellers in town. It seemed many Ghanaians also had the same goat idea, and we quickly found out that there was a holiday premium on our furry, horned friends. But all that meant was that we would have to pay a little bit more or sacrifice a little on size.

A few days before Christmas, Dennis came home and declared that he had found our goat from one of the sellers down the road and that he and I would be going to pick it up the next day. So, the day came, and we went.

****EXCLAIMER****It gets a little gross after this****EXCLAIMER***

As we drove to the place, Dennis explained to me that we had to pay an extra 10 cedis for them to do the dirty work (killing, burning the hair off, disemboweling, etc.). He said that, according to the pre-arranged time for us to pick it up (noon) it should all be done by now (2:30), and we could just grab it and go. But, Ghana being Ghana, of course it was not done yet. We pulled over and parked on the side of the road about 30 yards before a roundabout (rotary) whose center was being used as a makeshift pen, with 3 or 4 guys guarding/herding the dozen or so goats. Dennis explained that yesterday, when he came buy there were about 3 dozen left: apparently they were quick sellers.

Goats of many sizes, shapes and colors in the center of the rotary, guarded but some guys

We crossed the road to the shack right before the rotary, which was where the dirty work was being done. In front of the shack was a dead goat, skinned and de-furred, lying in an empty bucket. From inside the shack, the din of loud, ominous chopping rent the air for all around. The guy from inside saw us approaching and came outside to meet us. He was a huge man in height and girth, probably about 6’5, wearing a sleeveless shirt drenched in sweat. Large burn scars running up the length of his right arm from shoulder to wrist. He explained that he was running a little late, but that he would start the disemboweling process now, motioning to the goat in the bucket. GREAT!

Luckily, there was an empty bench nearby for Dennis and me to have a front-row view (slight sarcasm). For the sake of time and sick stomachs, I will not describe the process in detail, but rather only use a few key words and let you know that I do have pictures, so, if you’re interested, inquire within:

saw, head, off, slit, intestines, innards, wash, drain, wash, drain, chop, chop, chop

We left half an hour later as Dennis happily carried a black bag full of what had become of our goat. His step was so airy that you would have never guessed that the bag was about 50 pounds. When we got home, Dennis got right down to the business of chopping it into even smaller pieces. Everyone was very pleased with the proceedings, and I had seen enough dead goat to last me a lifetime, so I left the kitchen. At the writing of this, I can say that Patricia has certainly put the sacrificed animal to the good use of very tasty stews, meat pies and more. All in all, it was one of my more successful Christmas gifts, if rather unconventional.

Dennis happily chopping up the goat in the kitchen

The Tema Market

A few weeks ago, I was in desperate need of some vegetables and spices, so Dennis said we could get both at the Tema market for a lot cheaper than you can find in a grocery store. I said sounds good. I’m not really sure what I was expecting the Tema market to be, but it turned out to be quite the adventure.

We came upon a narrow street lined with booths, cars parked on both sides, so that only pedestrian traffic could pass. Behind the booths was a very high cement wall, large enough to not be able to see what lay behind. Dennis pulled up behind a car on the right-hand side of the street and said “We’re here. Let’s go.” The first thing I saw was a large cage filled live chickens, and Dennis informed me that for 10 cedis (like $7), they would kill one, de-feather and dress it for you. He said that for 12 cedis you could get a “free range” one, motioning to the group of chickens running around on the side of the road. Next to the cage was a van parked so that the rear opened up onto the street, its back doors open wide with a few guys sitting in the back, legs dangling. When we got close enough to the van see what was inside, it was eggs: hundreds of eggs in cartons stacked the height of it. We kept walking along to see several booths of vendors of all kinds: clothing, food, cosmetics, etc. We came across a vegetable seller, and Dennis let me look at some tomatoes and onions for a few seconds, before saying “Let’s keep going.” I looked up and down the street, as well as the adjacent booth-lined street and asked “How much more is there?” Dennis just laughed and said “You’ll see.”

When we got to the end of the street we were on, we hung a right onto a street even more populated with booths and people. The high wall ran along this street as well. The further we walked the more dense everything became. I could see up ahead that everyone was filtering through a gate on the right that led into the space behind the wall, and when we got there, my jaw definitely dropped. What I thought was the market was the bare outskirts, and the true market lay in every inch of the plaza enclosed by the high walls, where hundreds of booths manned by haggling vendors were pressed together to allow no more room between them than was needed to walk. I though immediately of two things: my good friend (who shall remain nameless) that is diagnosed with ADD (true ADD, not a function of the over-prescribing, drugged-up society we live in today), who would have loved every second of all the activity, vibrant colors and noises of the market, and a favorite childhood movie called “Bed Knobs and Broomsticks” in which Angela Lansbury sings a song called “Portobello Road” about a street in London where you can buy “anything and everything a chap can unload.” The Tema market was a lot brighter and less dusty than the road protrayed in the movie, but I can’t really help the linkages made by my mind sometimes. I also couldn’t really decide what to look at and in what order: a basket full of shimmering blue crabs or a table covered with giant African snails bigger than your fist (a delicacy, according to Dennis). We approached the most colorful table in sight which boasted a rainbow assortment of tiny bags of spices. I bought some garlic, curry (good curry that actually has some zing, not the weak stuff you find in America and have to resort to the paste) and chili, but was denied cumin and basil (partly because Dennis didn’t know the Twi translation and partly because they actually might not grow those here and I have to settle for imports).

shot of the market right at the entrance...booths as far as the eye can see.

shot of it a little further in. You can see plantains and yams on the front table.

giant African snails...DE-licious.

We actually didn’t stay long to peruse. Being the guys that we were, our shopping entailed knowing exactly what we needed to get, getting those things, and then leaving; we were not hampered by a second X chromosome, which necessitates window shopping. I would go on to buy some tomatoes, onions and peppers, along with a dozen eggs from the dudes in the van and a whole smoked mackerel. Making our way back to the gate to leave, Dennis and I were stopped by a shady guy carrying a basket full of what turned out to be blister packs of medicines. As politely as possible, Dennis told him that he was a registered pharmacist, what he was doing was illegal, and that if he ever saw him again, he would call the police. (I’ll leave the health schpiel out of this entry, but you do not want to get me started about antibiotic resistance. Needless to say, that was not cool, and it brought my nice little trip to the market back down to reality very quickly.)

platter full of smoked mackerel. I chose the most delicious one.

When we got back to the car, I opened the trunk to deposit my spices, veggies, eggs and fish, and I looked over at the chicken coop close by. As much as I wanted a chicken to be slaughtered all because of my appetite, I couldn’t bring myself to do it. Maybe next time, I told Dennis, because I really want to come back as much as possible. The market is only open on weekends, and I could probably come back every Saturday until I leave and not see everything there is to see in there. That night I de-scaled and de-boned the mackerel all by myself and made a deliciously spicy fish curry…with a little garlic: BAM!

A Night Out on Oxford Street

In a previous entry, I delved into my lack of both a social life so far in Accra, as well as interactions with other obrofo (white people). As I had also mentioned, I was invited to dinner a little bit ago on Oxford Street (the ex-pat/aid worker area) with two (white) guys around my age working for the Clinton Foundation, one of whom I had met at a conference. So, I would like to take this opportunity to tell you a little about that night.

Allan, the guy who invited me, and I had actually communicated previously (via phone and email), when I was exploring my options for working abroad. I still had no idea what he looked like, let alone that he was in Accra. So, to say that I was surprised (or that it is a small world) when we met in person, is an understatement. Allan was to meet a colleague for dinner on Saturday night at 7pm, at a sushi restaurant called Monsoon on Oxford Street, and he asked me if I’d like to join. I tried not to be too excited when I said sure, but the prospect of having a social engagement for the first time in a long time, let alone with two other white guys close to my age, was a nice feeling. It was like a guys night out.

That was the extent of my knowledge about dinner. According to my trusty Ghana/Accra tourist book and pull-out map, Oxford Street was the center of a very happenin’ upscale neighborhood called Osu with some of the best shopping, restaurants and night life in the city. I was also able to see that the street was about 1 mile long, located in the southeastern part of the downtown area. As the crow flies, it looked to be about 10km (6 miles) from where we lived northeast of downtown, but in terms of navigable roads, it was more like 15 (9.5 miles). So, I needed to consult with Dennis about my transportation game plan.

He told me that from where we lived, and how cabbies’ rates worked, it would be cheaper to take three group cabs from where we lived: the first one straight west to a high-traffic spot, the second one straight south into the city to another popular junction, and then the third one to my destination. He explained that with cabs, you have two options: group and individual. The color of my skin being what it is, he said cabs would automatically assume I wanted an individual ride, so I had to insist it was group. Group meant that they would pick up other passengers on the way, and it would be a fraction of the price. As I was completely deferring to him on this one, I said group cabs were fine with me and agreed to do whatever he thought was best.

So, at 5pm on Saturday night (I was giving myself plenty of time for a worst-case/ getting lost scenario), armed with map and camera, Dennis drives me to the main drag where I would catch the cab. Right when we get there, one of those “private “vans I previously mentioned (It is a conversion van that seats about 16 comfortably and commonly squeezes in 20. Run by a driver and a door guy/cash man, they run specific routes to fill the gap for the lack of public transportation, and are a very big private transportation enterprise in Accra.) skreeches to the curb, and several things happen at once: Dennis shoots me a quick glance, says that it will be a lot cheaper than a group cab and I can take the same 3-stop route we mapped out, I shrug my shoulders to tacitly say “Sure, what the heck”, he negotiates the fair (75 pesues = 55 cents) and the door guy gently shoves me into the front row of seats behind the driver and next to woman cradling an infant.

a typical private van

It becomes immediately clear that this is a very smoothly-run operation. The driver is the most aggressive on the road, swerving in and out of traffic, on and off the actual road, while the cash man hangs out the door yelling the final destination of the van for those on the side of the road who might want to get in. Sometimes the door is closed and the cash guy hangs out the open window, but most of the time he keeps it open for ease of exit and entry. At each stop, he gently pushes some on and some off, continuously haggling fares with multiple potential riders, never forgetting to yell the van’s destination (Accra Mall) less than 100 times a minute. When the van pulls away from a particularly busy stop, he closes the door and turns his attention to the riders inside, snapping and pointing to collect the agreed-upon fare and dole out the correct change. It is a well-oiled machine, to say the least.

As the day turns to night, the traffic into the city gets worse, and the exhaust from all the vehicles that floats in through the windows causes many to cough. The heat, however, makes closing them a non-option. Halfway to the mall, the baby next to me starts screaming, and the woman quickly pulls out her bosom to feed. Baby stops crying. No big deal. I exit at the mall with many others and have to cross a highway of sorts to get to where I want to catch another van going south. After waiting for a lull in the speeding cars, I am able to cross and another van pulls up in no time. “How much to Sankara?” “40.” “30.” “Fine.” It seems silly to be haggling over paying 35 cents or 25 cents, but for Ghanaians it would be silly not to. Plus, it is fun and gets people smiling.

This time I am in the back row, next to two police officers with AK-47s. Thankfully it is not as crowded, and then guns are able to have their own seat. At this point I am into unknown territory, and I continuously steal furtive glances at my map, which I have folded many time to make as small as possible. Hospital should be coming up on the right…there it is…good, not lost yet. I get out at my next stop, look at my watch (5:45) and my map: Oxford Street looks to be only about ½ a mile away. Pretty happy with myself that I just paid about 75 cents to go about 10 miles in 45 minutes, I start walking. About halfway to the top of Oxford Street, I see a big white building across the street on the left, and notice the sign “UN Headquarters”. I never really stopped to think about why this area had become the pale-skinned haunting grounds, but then the fog lifts and it all makes sense.

UN Headquarters in Accra

At the top of Oxford Street, I see two big groups of signs for some of the things I can expect to find. The sun has completely set, as I turn the corner. In a word, the street is busy. It’s one lane each way, with a good amount of traffic. Vendors of purses and soccer jerseys and food hug the road, backlit by the neon signs from the buildings behind them. Bank, restaurant, clothing store, bank, restaurant, bar, bank, clothing store, bar: I am seeing a pattern. It is very clear that this is the North Michigan Avenue, the Georgetown (M Street), the Newberry Street of Accra. After about 5 minutes of walking and getting heckled by salesmen, I come across the huge neon blue letters of Monsoon. Next to it is a sign declaring: “Now Open: Sushi, Pan-Asian, Seafood and Steak.” I call Allen to let him know that I am quite early. He has some “conference calls with Vancouver” to take care of, so I tell him no big deal, I can certainly entertain myself for an hour. He says “You gotta at least go to Frankie’s, and I’ll see you at 7.” Having no clue what Frankie’s is, I agree.

maybe 1/3 of the signs at the top of Oxford Street

Wrangler store on Oxford Street....supposedly "The Authentic Western Jeans"

A little further on, I see exactly what Frankie’s is: an oasis is the desert. A bakery and Gelateria. People sit on stools and chairs on the outdoor patio, licking and crunching and biting happily. Cool air conditioning blasts me in the face, as I open the door and try my best to close my jaw. Glass display cases boast shelves of sugar coated pastries on top of loaves of fluffy and crusty breads, reminding me of Paris. And then of course there is the gelato, bringing back memories of Italy. I might have shed tears, I’m not sure. Dinner is in less than an hour, but this is GELATO! I don’t even look at the price before ordering two scoops (espresso and cookies n’ cream). It could have been $20, and I would have paid gladly. It happens to be 3 cedis (about $2.25), and it is delicious. Not Rome delicious, but North End of Boston delicious. I deliriously walk outside with cup and spoon in hand. The heat melts it quickly, so I am forced to inhale it, as I actually tend to do with desserts anyways.

croissants, muffins and other European-influenced pastries

GELATO!

I still have about 30 minutes to kill, and knowing that the Chelsea vs. Man City game is on, I find a little bar to grab a Ghanaian Guinness and watch. (Guinness has a brewery in Ghana, where it manufacturers a beer called “Guinness Foreign Extra”. More alcoholic than the regular stout (over 7%), it looks and tastes like a regular Guinness on first impression, but the finish is a lot more hoppy and bitter than the smooth stout you find in the US. It is a great combination and VERY good.) The beer is a little more than $1 (dangerous), and I go outside to where a dozen guys sit on plastic chairs surrounding a TV. The score is 1-1, as the second half is just starting. I talk soccer with some of the guys, and sip on my beer. In general, most Ghanaians love Chelsea, because their countryman and most-famous Ghanaian soccer star in the world, Michael Essien, plays for them. So, 10 minutes after I sit down, when the star of Man(chester) City – Argentenian Carlos Tevez – scores a fantastic goal on a free kick from 30 yards out he puts UNDER the wall and inside the far post to take a 2-1 lead, they are not too happy. I stay as long as I can, but am forced to leave for dinner in the 70th minute.

random shot of Oxford Street

As I walk into Monsoon, I get a call from Allen that he is running late, but that his friend, Isaac, should be there. I spot a 20-something guy at the bar, with a Katrina Relief t-shirt on and ask him if he is Isaac. He is, and we get to talking. He works for the Clinton Foundation at their West African HQ in Lome, the capital of neighboring Togo. He is here only for the night, catching a flight out for the US in the morning. We order drinks and get to talking. He is from Belmont, Massachusetts, a stone’s throw from Tufts, went to Brown and starting volunteering for the Foundation after college. Allen shows up and we get a table.

The place is a swanky rooftop, very big with several bars, big bay windows overlooking the street, arched doorways and a very Mediterranean feel, like something you would find in Casablanca. Non-Africans of all kinds are everywhere, and I am a little overwhelmed. Moustached, pot-bellied Middle-Eastern business types stereotypically smoke cigars at a table with their much younger, skinnier female counterparts. At the next table, a group of overdressed girls sit, and Allen makes a comment about regretting not wearing his glasses. Couples are everywhere.

Allen, an Accenture-trained business consultant type from Vancouver says that it’s the best sushi he’s found in Africa, and being from Vancouver makes his somewhat of an expert. One look at the menu tells me I am going to spend more tonight than I did all last week. With a decidedly why-not attitude, I join them in ordering bowls of noodles and sides of sushi, as we discuss our common experiences. Allen’s craziest stories come from time he spent in Nigeria, and Isaac talks about life in francophone Lome, with a Togolese girlfriend he has acquired. I find it surprisingly refreshing and fun to share stories, commiserating about African frustrations and acknowledging African virtues. Dinner takes quite a while, but time goes quickly. The noodles I could make better myself, but the sushi is truly good. Before we know it, it is 9:30 and we are asking for the check. Allen has to go back to his place to do some work, but Isaac and I decide to go to a bar for bit.

We hop in a cab to an ex-pat bar Allen tells us he has heard is good, but after deciding to not pay the 15 cedi ($10-12) cover charge, we end up back where we started. Isaac asks me if I like to smoke hookah. “If been known to from time to time” I say. He says his hotel is a few doors down from Monsoon, and there is a good hookah bar in the lobby. “Let’s do it” says I, so we do. (Sorry mom and dad, but I didn’t inhale). It turns out to be quite fun, and we chat some more, unsuccessfully playing the college “Do you know…” name game, as we smoke apple-flavored shisha. Before I know it, it is going on midnight, and I have a lot longer to travel. Wishing Isaac a safe flight and exchanging contact info for when he is back in town, I bid him adieux.

This entry has been long enough, so I will wrap it up. Needless to say, the vans do not run that late at night, so I have to spend 10x as much money to get home as I did to get there. As I lay down to sleep, I feel quite satisfied with the night: gelato, Guinness, sushi, hookah, and new friends. I can’t have nights like that all the time, as I had spent a non-negligible fraction of my monthly budget in one night, but every once in a while, it’s fun to let loose.

Throwing Coke Bottles at BRICS

When you work in the global health field long enough, specifically when you work with groups that advocate for increased “resources” (dollar dollar bills) for R&D (research and development) for new products (drugs, vaccines, and diagnostics) targeting “diseases of the developing world” (mostly HIV, Tuberculosis, and malaria) long enough, and you attend enough meetings and conferences around Washington, DC to last a lifetime, you will undoubtedly hear about the Coca Cola Syndrome. The Coca Cola Syndrome, when discussed in this context, refers to the fact that the Coca Cola Company has MUCH better supply chain management than pretty much any resource-poor country’s health system this world over. What this means is that you can go to the most remote, rural villages in the world and find people drinking Coke, but we are utterly unable to get the health care products most needed by those same people into their hands. This subject is almost always broached by someone opposed to giving the R&D folks more money: someone who then advocates that the money would be better spent strengthening the supply chain on the ground and enabling the products that we already have to reach the people who need them. If the naysayer feels exceptionally clever, he/she might even tell another little anecdote about warehouses full of medicines and vaccines that have wasted away and become useless over months and even years of neglect: more victims of the African or Asian or Latin American sun. But this entry is not intended to weigh the merits of the new products vs. supply chain debate; the truth is that both things are greatly needed. No, I would like to get back to the ever-present Coke.

one of thousands of roadside shops always stocked with Coca Cola

Many of you have asked me what the food is like. I have detailed a few dishes in previous entries, but if I had to describe Ghanaian food in one word, it would be “unhealthy.” For breakfast every morning we have what’s called “Hausa Cocoa”. It’s a delicious porridge-like drink made from ground millet and spices originally from Nigeria, which has now become engrained in Ghanaian culture as well; but that’s not what is unhealthy. It is served with fist-sized fried doughnut balls and other smaller fried morsels made from chickpeas. Dennis reminds me that the chickpea ones do have nutritional value, and I remind him that they are also fried and oily enough to lube his car. Lunch is usually something small like soup with rice balls or one of the many corn-based dough balls native to Ghana. The two main soups are a peanut-based one and a palm oil-based one. Both are very tasty, but I constantly remember Dennis, as we ate palm oil soup on my very first day in Ghana, telling me “Delicious…but VERY high in cholesterol.” Also, the vast majority of carbs I have encountered so far are the bad ones: white rice and white bread predominate healthier alternatives. The favored proteins for dinner are fish and goat meat. These are not too bad, but the fish is usually fried. Healthier bean-based dishes can be found if you do some searching, but it’s much more common to find fried fish and fried plantains. A late-night snack, which I have fallen prey to many times, is the plantain chips. Very similar to potato chips, they are made from plantains, a banana-like fruit, and the chips are sweet, salty, crispy and delicious…but definitely not good for you. So, what does all this mean?

fried doughnut balls and chickpea patties: breakfast of champions

In my first week, we visited a woman from Dennis’ church whose husband had just passed away from heart disease. In a country where the male life expectancy is under 60, he was under 50. When we pulled up to the house, she, along with several family members and friends, was sitting on the porch in all black observing what I took to be the Ghanaian version of what the Jews call Sitting Shiva: a week-long mourning ritual. Except that the Ghanaian version, I would learn, can last anywhere from one week to several months, depending on circumstances, and we would visit this woman 3 more times over the next week or so. I also learned that the man had well-documented high blood pressure and had been given medication for it from his doctor: medication he did not take. Dennis said that this is very common with hypertension medication in Ghana. It’s not that people are leery of or don’t understand Western medicine, but it is cultural. He explained that the symptoms are not overt, and because they cannot be felt on a daily basis, people just don’t take the pills. In my first 3 weeks, Dennis attended these observances for 2 other people as well, both of whom died from different chronic conditions (stroke and diabetes).

My Ghanaian experience is a microcosm of current global trends in disease burden shifting away from infectious diseases and towards chronic ones. And nowhere is this happening faster than in low and middle-income developing countries all over the world, where over 80% of the world’s population resides. As economies develop and individuals become better off financially, this expanding middle class is able to use the extra disposable income on red meat, cigarettes and sugary drinks. Add onto that the simultaneous demographic trend of rapid urbanization, where the masses moving from rural areas into cities find both everything they need in a smaller radius and the need to walk around and exercise less necessary. In fact, chronic disease experts agree that diet, along with tobacco use and lack of exercise are the three main factors driving this global trend.

sign at a hospital I recently visited

In 2003, employees at Goldman Sachs came up with a clever acronym for the largest, fastest-growing, developing economies in the world: BRICs. BRICs stands for Brazil, Russia, India and China (sometimes the S can represent South Africa), and together, they will completely redistribute the world’s power and financial balance sheet in the foreseeable future. They are also leading the pack for the changing disease burden. While Wall Street and the rest of the private sector is busy setting up offices in Durban, Bangalore and Sao Paulo, angling for this emerging middle class to provide their future revenues, the citizens of these countries are acutely experiencing some of the less-desired effects of this “development.” In 2000, none of these countries ranked in the top 5 global economies, in terms of GDP. By 2050, all 4 BRIC countries are projected to be in the top 6. In Russia, wages TRIPLED from 2001 to 2006. Income is projected to TRIPLE in India from 2005 to 2025.

But these huge economic gains are not being translated into reciprocal health benefits. From 2005 to 2030, life expectancy is only projected to increase, on average, by less than 5 years in BRIC countries (about 2-3 months per year). According to the WHO, three of the top 4 causes of death worldwide – cardiovascular disease (CVD), cancer and chronic respiratory diseases – are associated with chronic conditions. These three, together with diabetes, accounted for 60% of worldwide deaths in 2005, with more than three quarters of them occurring in developing countries. From 2005 to 2030, India, Latin America and Sub-Saharan Africa are projected to experience double digit increases in CVD burden. Over the same time span, the BRIC countries may experience a 3.29% compound annual growth rate in diabetes incidence. Similar projections can be found for cancer, respiratory disease and other chronic conditions, and this entry could go on and on.

Concession stand filled with doughnuts, meat pies and other deep fried things in the lobby of the SAME HOSPITAL

My former boss at the Center for Global Development, Rachel Nugent, is a population economist and an expert in this topic, so I was fortunate enough to be somewhat prepared. However, as I am finding out over and over again, it is a completely different animal when you experience it first-hand. Going to the mourning observance for someone who died from a very preventable and treatable condition is one thing. Consciously trying to exercise and eat healthy foods and finding it very difficult to do either is another. But Americans can rest assured that while we continue to lead the world in obesity, thousands more decide to join our ranks every day. I’ll keep fighting the good fight, but in the meantime, our fridge is never without Coke, and the plantain chips are delicious.

close-up of some plantain chips

Happy Holidays

The holiday season is upon us, and I thought it appropriate to give you all an early present. These have been a long time coming, but here are pictures of some of the people and things I've been blabbering about. Enjoy.

Desmond, talking to his little sister after Chruch. Desmond refused to pose for a picture. So, I took it upon myself to take one of him by surprise. This is the best I did. I have many of him turning away at the last second.

Charles, the fun-loving ladies' man and PSGH's crazy driver

Some color-coded girls walking to school in the morning

Patricia

People carrying goods on their heads, selling them in the middle of the road

The Upside of No Social Life

My next entry will probably be about chronic diseases, so I wanted this one to be a little more light- hearted.


I will be the first to admit that I don’t have much of a social life here in Accra, yet. The apartment and office are near one another, on the outskirts of the city, quite far away from both the night life and where the white people hang out (an area called Oxford Street). The only public transportation available is in crowded (“private”) vans or personal taxis, and I don’t really have a desire to do either just yet. So far, I drive to and from work and home with Dennis, and I pretty much do what he does. As he is a pastor, who also has a full-time job, it’s safe to say that he doesn’t exactly party like a rock star. Dennis, Patricia and I spend our nights eating dinner, watching TV (mostly soccer) or DVDs, and getting to bed at a decent hour, as Dennis and I leave for work at 7:30 every morning. But I’m definitely not complaining…it’s really not that bad.

Dinner has markedly improved over the last two weeks. We went to “the market” over the weekend (another blog entry for sure), so I now have a good stock of food and spices and have gotten into the swing of cooking for myself. Sometimes I’ll try what Dennis and Pat are having, and it’s usually pretty good and always interesting. They are getting to know what I do and don’t like, so the bad surprises (intestines, liver, etc.) are fewer and farther between.

As for TV, that’s a different story. We get about 7 or 8 channels, and when we get home from work, the line-up has become pretty predictable. 3 of them are news channels. The SABC (South Africa Broadcast Company) is pretty high-quality and focuses mainly on African headlines. Then there is PressTV: a very high-quality broadcast that is actually based in Tehran. Sometimes they like to portray the US and its allies in a not so great light (as with the IAEA sanctions against Iran recently), but more often than not, I find it to be fairly objective and very good (ie: Sean Hannity and Keith Olbermann could learn a thing or two). Finally, there is local Ghanaian news; it’s pretty budget, but I find the topics very interesting. Lately, they have been discussing the new budget proposed by government and what Ghana should do with its forecasted oil revenues (definitely a future blog entry). Once you get passed the news, there is one channel that always seems to be broadcasting a terribly-dubbed Spanish soap opera. Another channel usually always has a soccer or rugby game on (often it’s from the Dutch, Scottish, Russian or another lesser league). The “American channel,” as I call it, which I suppose I am to find solace in, seems to alternate between reruns of Oprah, America’s Next Top Model, and CSI Las Vegas. And those of you who know I feel about these shows know that, in my humble opinion, this station might as well be static. The programs on the other few stations are a wildcard of televangelists, Ghanaian shows, science-y shows and the featured soccer matches (always the English Premier League) and featured movies (they have a weird thing for Eddie Murphy movies here).

As I said in a previous blog, Dennis and Desmond enjoy movies, and we have many DVDs. We don’t see Desmond much during the week, as he lives in Tema, but he comes over to spend the night on weekends, and that’s when we do the movie watching. Pirated DVDs from China are the norm here, where anywhere from 9 to 90 movies are contained on one disk, and we have many. Ostensibly, they all have themes – Harrison Ford movies, epic war movies, Wild West movies – and Dennis and Desmond seem to favor the action-packed ones.

The lack of a social life has also given me ample time to read. I’ve already finished one book – a fantastic read about microfinance and international development entitled “The Blue Sweater” by Jacqueline Novogratz, founder and CEO of the Acumen Fund (thanks Mrs. G. for the gift) – and started on another: “Selected Stories of O. Henry.” In times like this, I like to read the “classics” that have yet evaded me. When I studied abroad in Spain, I read “The Catcher in the Rye, “Lord of the Flies,” and many others. (No, I did not have to read them in high school.) However, I don’t think that I’m quite ready for the Kafka or Sun Tzu that I brought with me. And, when it comes time to applying for grad school, I imagine that will take up a significant amount of my time as well.

Another good thing is that I’m not spending much money these days. A penny saved is a penny earned, so it’s almost like I have a salary! An old coworker and friend of mine has been consulting for the World Bank for the last two months in the Tanzanian capital of Dar es Salaam, and she has had a very different experience thus far. Like most ex-pat aid workers, she socializes mainly with others of her kind (aka: white people). They lounge in expensive rented villas; spend money on gym memberships, massages and gasoline for their cars; and go out dancing and drinking ‘til all hours. If you don’t believe me, please read her blog. As she is a professional writer, I will admit that it is much better than this one. But I am glad I am not doing things that way, if only for the reason that the money I saved would last me about half as long as I’d like it to. Also, I don’t think she would argue that I am probably having more of an “authentic” experience living and working with only native Ghanaians. Last week I had my first conversation in 2 weeks with a white person: a missionary’s wife from “central Pennsylvania” who approached me after overhearing me talking to Dennis at the grocery store.

Like I said, I’m not complaining about being a loser, but there is a light at the end of the tunnel. I fully expect to procure a bike soon, to make myself more mobile. And, as of this writing, I doubled my “conversations with white people” tally this past week, bringing the grand total to 3. One of them, an analyst with the Clinton Foundation that I met at a Global Fund conference on Wednesday, invited me to a (sushi) dinner with him and some of his friends this weekend. He lives on Oxford Street, so yes, they have a sushi restaurant for the rich white people that coalesce around that part of town. I’m a little apprehensive about being one of the “obrofo” (the Twi word for white people, plural; “obroni” is the singular) patronizing a sushi restaurant on Oxford Street, so we’ll see how it goes. But at least I have something to do on a Saturday night.

Ghanaian Efficiency Strikes Back

I would like to apologize for the recent decline in new updates. It's not because I have not been writing them. On the contrary, I have not had internet at my work for this past week to enable me to post them.

I wrote this entry before my office lost internet for the week, so the irony of this entry being about Ghanaian efficiency is certainly not lost on me...but it's still a good story.


I love efficiency of all kinds. Whether it’s small-scale (plotting out the errands you need to do on a Saturday morning in order to travel the shortest distance) or large-scale (re-orienting the divisions of your business to open internal lines of communication that did not previously exist), the economist in me (yes, it was one of my majors in college) really enjoys it. Now, I realize that my work experience thus far tallies more than a few non-profits, not exactly representing private sector, profit-driven efficiency at its best, but I have worked with several MBAs and PhD economists, and it doesn’t stop me from liking it!

A few of my previous posts have described how inefficient things can be here, or in any developing country, when compared to the “Western World.” So, I wanted to share a nice little anecdote regarding something that was MUCH easier and faster to do here than it would have been in the latter. And it all starts with me being an idiot.

As I mentioned when I got off the plane, Dennis drives a nice silver VW sedan that he takes good care of. The model is called a “Bora,” which hasn’t made it to the US, but it is very much like a Jetta or Passat. When I arrived, the rear, driver’s-side door had the child lock engaged, not enabling the passenger to open it from the inside. As that is the only back seat with a seatbelt, I usually sit there (with Dennis driving and Patricia sitting shotgun), and it has proved to be very annoying. After a while, I asked Dennis why it was engaged, and he said no reason. He didn’t even know how it had happened, but he would like it to be disengaged as well. Upon hearing that, I took matters into my own hands: a big mistake.

Dennis' VW Bora

Last Sunday, Patricia and I were waiting for Dennis in the parking lot after church, and I thought it was a perfect time to put my mechanical engineering skills to use. What mechanical engineering skills, you say? Well, that is a very appropriate question, because I have none. But that didn’t stop me from opening the door and playing around with the lock mechanism, trying to undo the child lock. I rotated the hinge on the inside of the door, and then tried to close it. The only problem was that now it wouldn’t close. I tried to undo what I had done, and the door was having none of it. I had completely broken the door’s lock. I told Dennis what I’d done, and he said we would take a look at it when we got home. We had to drive home with me holding the door as closed as it could get from the handle on the inside. Whenever we would go over a bump or make a sharp right turn, the door would open slightly, and I would close it quickly. It was ridiculous, and I felt terrible.

When we got home, I told Dennis I would pay for the repairs, as we examined the bad door and the other good ones. We saw why it wouldn’t close and what needed to be done, but the hinge would not rotate back into its original position. We played with the automatic keyless remote, the automatic lock inside the driver’s door, and the manual lock on the door itself. I even got a few screwdrivers and a wrench I brought with me to make our trials seem more official, but nothing was working. As Dennis looked at the other rear door (passenger’s-side), he began playing with it, and before I could stop him, he had done the exact same thing to that one. So now, both rear doors would not close. Luckily, it was Sunday, we weren’t going anywhere before work the next day, and Dennis said that his good car shop was on the way. Knowing all too well how much fixing a German car can cost, I fell asleep thinking the worst.

When Dennis and I drove to work in the morning, I had to be in the ridiculous position of the middle rear seat, with both arms extended holding each door closed from the inside. As we pulled up to the Dennis’ “good car guys,” the shop consisted of an air pump, dozens of tires stacked in piles of different heights, tools strewn about seemingly at random on the ground, and a few cars outside in various states of rundown. There was no building, but rather a covered dugout of sorts where 4 men in their late teens or early twenties sat chatting on a triangle of benches. As we pulled up, one of the men pivoted off of his bench and walked over to us, as Dennis got out to meet him. Needless to say, I did not think we would have any luck here.

The best shot I could get of the car "shop" from my passenger seat

Dennis and the man spoke is rapid Twi, as I remained in the rear middle seat looking over at them. The man opened the rear passenger-side door, examined the lock, and began playing with the door handle. After 10 seconds, he called over to one of his partner, who brought him a screwdriver, and in another 10 seconds, he had fixed the first door. He opened it and closed it to make sure, and then went around to the driver’s side and fixed the other one in no time. A feeling of combined relief, stupidity and awe came over me. The man walked away, as Dennis handed him 2 Cedis (less than $2) as a thank you.

The rest of the way to work, I couldn’t stop telling Dennis how cool that was. They had fixed both doors in under 30 seconds, and we payed less than $1 per door. In the US, I assured him, if you took a VW to the dealer to fix the same problem, they would tell you it would be ready in a few hours minimum and then charge you at least $50 for the labor alone. He just laughed.

PS: I am happy to say that when we were fidgeting with the two doors, trying to fix them, I figured out how to actually disengage the child lock. So, it all worked out in the end, and now I can ride with a seat belt and open the door for myself when we stop!

The Good with the Bad

On this Thanksgiving Day, I am thankful for the times like this, when the power is on and the internet is working. It provides me the opportunity to be online, to post blogs like this, and to Skype with my mom, Gordy and Ashley, as I just did. In America, most people would not count these as some of their blessings, but in Africa, they certainly are.

Not only is internet availability a privilege for few, but this week alone we have experienced daily power outages, some lasting 20 minutes, others a few hours. While I am told that they never happen with this frequency, the fact remains that they are. During these outages, all lights go off (obviously), but it also affects the air conditioning (a pretty big deal) and the internet, due to the fact that the router is now off. In addition, all desktops are now off, and despite the advertisements, my laptop, which is now forced to run on battery power, doesn’t have more than an hour or so of juice left. That email I was about to send will have to wait.

For all intents and purposes, office life comes to a halt. Yes, there is always reading to be done, and I have already made a habit of downloading PDF reports when I can (to read in such an eventuality), but the rapidly rising temperature makes it almost unbearable in the office. We do have a back-up generator, but it takes about 15 minutes to get going, and we wait at least that long to see if this outage will be a short one. On a related note, a former CGD colleague of mine, Vijaya Ramachandran, has researched and written extensively about power outages in the developing world (specifically focusing on Nigeria and India) and the detriment they have to a thriving private sector. The statistics related to the losses in $ faced by businesses due to these outages is large, to say the least.

Our trusty 200-pound generator

Now I know that I have been writing about diseases, power outages and other sour subjects, but I want to put it all in perspective, and end on a high note so that everyone can have a happy Thanksgiving. As I often do, I will relay some quick reflections of two very promising things I saw one afternoon driving around town with Charles. The first has to do with a street vendor of a different sort. Rather than selling food, phone cards or razor blades, he is selling newspapers. Not only is he selling newspapers, but he is selling a variety of newspapers, from across the political spectrum. These papers are not government-controlled propaganda; but rather, they are very reputable publications, many critical of the current government, and they represent the very essence of what it means to have freedom of the press.

Front cover a popular newspaper called the "Daily Graphic"

The other one has to do with a billboard. No, this is not one about HIV. This promising billboard is one for an opposition candidate running for president: a remnant of last year’s VERY heated presidential election (internationally certified to be free and fair) that had to be decided in a run-off. It represents the strength of democracy in Ghana. Democracy is so well-rooted in society, that earlier this year, President Obama came specifically to Ghana to congratulate its citizens on their successful and peaceful transition of power and emphasize how Ghana is a “beacon of hope” for the rest of the African continent.

The election billboard

Just like reliable internet and being able to live and work without daily power outages, a free press and strong democracy are things most Americans take for granted. Most will not consciously be thankful for them on this day. But in the developing world, these advances cannot be underappreciated. So remember, Ghana may have its fair share of problems, but at least it’s not Somalia.

Now have a very happy Thanksgiving and pour some gravy and/or cranberry sauce out for a guy who will go without this year.

Like Two Cars Trying to Cross a One-Lane Bridge

Every day I learn more and more about the cultural dynamics at play in Ghanaian society. Some of them I almost expected, like the fact that women are expected to do all of the cooking and cleaning and domestic work, while the men are expected to have the paying job. Others have caught me completely off guard. For example, I just learned that going out to eat has a negative connotation here. Since groceries can be very expensive, eating out is often a more affordable option; however, as Dennis explained to me this morning, it is often seen as the option of last resort when the woman of the household is not capable of cooking the requisite meal for her family. “Pat would never allow it!” he said. I told him that in the U.S. it is almost exactly the opposite: cooking is generally cheaper and eating out is often considered a treat.

Another thing that I expected to see was the large adoption of Western technologies. It is quite ignorant to think that Africans want to be just like us, and that the goal of international development should be to make it so. However, cell phones and the internet are examples of transformative technologies that have completely changed the way we live and work, making it possible to communicate and interact in ways unforeseen only a generation ago. Most Africans feel the same way, and, seeing the greater efficiency and enhanced connectivity made possible in their personal and professional lives with many Western technologies, they have welcomed them with open arms. Without a doubt, the most advertised item in Accra is the cell phone, and I saw an Apple store on my first day. This is all the more reason why I was completely dumbfounded to witness the vast inefficiencies in the workplace stemming from the lack of use of these technologies.



It happened during another eventful day of driving around Accra with Charles. This time we were accompanied by Dennis, who had to go to some government ministries to personally enquire about the status of approved funding (which was now owed to us), as well as knock on a few other doors to get certain things moving. He wanted me to come to better understand the “politics of Ghana” and the organizations, associations and ministries with whom I would be working.

We arrived at the first government ministry office, where Dennis was following up on some emails and phone messages he had previously sent, from which he had not heard back. When we opened the door to the office, four desks piled high with files sat in a very cramped room full of about a dozen people – one person behind each desk and the other eight or so mulling about doing nothing in particular. Dennis found the person he was looking for and spoke to him for about 2 minutes. There was a lot of nodding, and then Dennis turned to leave, motioning for Charles and me to follow. I asked if everything was ok, and he said, “Yes, we will get our money now.” We then went to two or three other offices where the same thing happened. Even though it had taken us hours to get everywhere in the traffic, we never stayed at one place for more than 5-10 minutes.



As we left the third stop where this same scenario has unfolded, I said “I don’t get it. Why did we need to come all this way, when a phone call or an email would have sufficed?” Dennis and Charles just laughed. They said that the previous phone calls and emails served mainly to broach the subject, and many times they are not returned, let alone in a timely manner. More often than not, in order for things to actually get done, an in-person visit is required. During this visit, the emails and phone messages that have been sent to the person are discussed, where the individual will confirm their receipt and that they intend to follow through on whatever it is. If these messages are not sent before the in-person visit, the person will just say that they have no idea what you are talking about.

“But that’s so inefficient, especially when it takes us so long to drive here.”

They laugh even harder. “That’s Ghana” they say, which reminds me of “It is what it is,” a favorite phrase of my best friend, Jeremy, who stole it from his father. It’s a phrase which is simultaneously both profound and inane and can be said of anything under the sun. “You’re right, it is very frustrating. It was not this way in Germany” says Dennis, who got his masters degree in Berlin and has also studied in Norway.

In DC, the government is the butt of many jokes and the cause of much frustration regarding bureaucracy, red tape and inefficiencies. I’m not sure if this phenomenon is exclusive to the government here, but as of right now, my diagnosis is that this need for a face-to-face interaction may be cultural (More investigation to be done, so stay tuned). I was prepared, as many told me before leaving, for life to move at a slower pace here, but this lack of use of readily-available technologies is certainly surprising. An economist would term this "higher transaction costs" - the cost of making a transaction - and higher costs are always a bad thing in economics.

This conflict between “Westernization” (for lack of a better term) and the preservation of native cultural norms reminds me of something else that happened last week that may be serve as a nice metaphor. Perhaps it is not an appropriate metaphor at all, but I thinks it’s a good story in it’s own right, so here goes:

As Dennis, Pat and I were headed to Church last week for Pat’s women’s bible study (Dennis and I would run some errands during it), we came to a stop in front of a one-lane wooden bridge over a little brook. A steady stream of cars were coming over it from the opposite direction, and we were first in line to go over as soon as it let up. The only problem was it wasn’t letting up. I asked Dennis if there was a traffic cop* on the other end who would stop the cars at some point, and he just laughed. After 5 minutes, and prompted by honks from the line that had formed behind us, Dennis decided to take matters into his own hands. At an opportune moment, he turned into the traffic and began to cross the bridge. Inevitably, about a quarter of the way across, we found ourselves nose to nose with a car from the other side. A standoff ensued for a good 30 seconds before the other car put it into reverse to let our side have its turn to cross.

*Say what you will about traffic cops (I will readily admit to despising them, as they invariably prove themselves to be utterly worthless 96% of the time), but in this instance, we could have used one in Tema, Ghana.

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.