A Ghanaian Funeral

A quick note of apology for taking so long to post something new. Jeremy visited, then Lindsay visited, then work got busy. I know excuses are lame, and I was thinking of you guys the whole time....it'll never happen again.

I was informed last month that Charles’ mother, Dora Poku, passed away, and that he would be out of the office for much of the next few weeks planning the funeral with his family members in his home town: a small village in the Brong Ahafo region of central Ghana, about 7 hours drive Northwest of Accra. After a week, a date had been set, and a noticeable buzz of anticipation filled the office with each passing day. The anticipation was a foreign sensation for me, as a funeral in the America is not usually looked forward to. Also, it usually happens less than a week after the death, so there really isn’t a whole lot of time. But in Ghana, it is another ballgame. Funerals are scheduled weeks and often months ahead of time, so that all family members and friends have ample heads up to travel back for it.

poster outside our office notifying people of the upcoming funeral

About a week before the event, we had a little meeting to decide who would/could/wanted to go, how we would get there, and what an appropriate gift would be for the family (It is customary in Ghana to give money as a gift for the bereaved family.). I definitely wanted to go, both to support Charles and to experience a Ghanaian funeral, and so did Dennis, John, Jonas, and Vivian, our executive assistant. It was decided that we would be taking a big coach bus, and that everyone in the office would chip in some cash for the family, with another monetary gift also coming from PSGH itself. A typical Ghanaian funeral spans an entire weekend, so the five of us left on Friday night after work.

The main “bus station” in Accra is basically a huge parking lot across the street from the much smaller government-run bus transportation hub. It is filled with hundreds of buses and vans of various sizes crammed in, in what seems like no particular order. These informal buses supplement and now completely dwarf the insufficient fleet of public transportation options. When we turned into the main entrance to the “station” we were met by dozens of men yelling at us, asking where we were going and steering us in the right direction: their right direction not necessarily being our right direction. But, for the most part, they were extremely helpful, and like many things in Ghana, something that seems to be lawless chaos turns out to have its own very clear order, if not completely observable at first sight. Vehicles going to particular areas around Ghana all congregate in certain areas of the lot on a first come first serve basis. Nothing leaves at a pre-arranged time, but rather when it is full, allowing the next vehicle in line to begin taking on passengers. So, the tickets Jonas bought for us earlier in the day said 8:30pm, but really, it could be any time before or after that, depending on the demand.

We got there around 8 to find our big coach bus about 1/3 full, which meant that we would need about 50 more people before we could shove off and would most likely be leaving well after 8:30. In the meantime, the mobile hawkers selling food and others goods from baskets carried on their heads were in full force at our windows. By the time we ended up leaving around 9:15, I could have purchased a used book, a toothbrush, ice cream, a bandana and so much more. Around 9 we were treated to a full 10-minute sales pitch from a medicine salesman who actually boarded the bus. I was sitting next to John, our accountant, who provided the color commentary for me. He said “It’s quite sad, but watch how many people buy his products when he is done talking.” And John was right. When the salesman went around to collect the fruits of his labor, at least a dozen people bought something.

our trusty red coach bus

When we finally pushed off, I thought we were done with the hawkers hissing and banging on windows and could enjoy several hours of hassle-free peace. But it was not so. As soon as we started moving, a woman in the front row stood up and began addressing the rest of the bus. I didn’t really need John’s translation (but enjoyed it anyways) to know that she was preaching the gospel. John told me that this was very common. She would probably go on for at least half an hour, and then collect whatever money the passengers gave her before getting off and boarding another bus heading back to the station to do it all again. It wasn’t so much the unsolicited preaching that surprised me, but it was the passenger’s reaction to it that really hammered home the whole Christianity in Ghana thing for me. Whereas my reaction to having more religion shoved in my face was to get extremely annoyed and contemplate heckling, everyone around me seemed to really enjoy her presence. They would sing along to the hymns and songs she led, follow perfectly in the call-and-response portions and repeat obedient “Amens” when appropriate. Religion in the parts of America where I have lived really only pokes its head out around holidays (e.g. Easter and Christmas Catholics and High Holidays and Passover Jews) and takes a back seat at most other times in the year. But here in Ghana, religion is everything. It is intertwined with every single facet of life, and it is because of god that everything happens and it is with god that all things are possible. I can’t really stress that enough.

The bus ride was fairly uneventful, where they showed Mel Gibson’s extremely violent “Apocalypto” followed by a new Ghanaian movie called “Chelsea.” Most Ghanaian movies are fairly unwatchable, where the production quality provides ample opportunity to play a game out of searching for the background lights, microphones and wires that should not have made it into the shot, but did. 95% of them are about a love triangle, and in this regard, “Chelsea” was no different. However, the quality was much higher than usual, and the main character of Chelsea, center of the love triangle, was gorgeous, by all standards, which made it much more watchable. (I would later learn that she once dated Ghanaian soccer superstar Michael Essien…obviously.)

The bus dropped us off in Mim, the town next to Charles’ hometown of Bediako, at about 4am, just in time to hear the first Muslim call to prayer over the town’s PA. (Around 10-15% of Ghanaians are Muslim, with much higher concentrations the further north you go.) We caught a lucky tro-tro to go the last 10 minutes, where we were met by a smiling Charles and his brother. Despite the hour, loud African pop music could be heard over the town. As Charles and his brother showed us to the one-room house where we would be staying, we walked by hundreds of plastic chairs arranged in neat rows, as Dennis turned to me and excitedly exclaimed “This will be a great funeral.” The house’s one room sported a big bed and two full couches. We all entered the one room, got settled onto the couches, and then Charles and his brother stood up to face their guests. Charles spoke in Twi, so I was pretty lost, but Dennis provided translation. He explained that it is a formality that needs to be performed the hosts ask the guests why they have come. Dennis responded that we have come to mourn with our good friend and co-worker over the loss of his mother. We then presented the monetary gift from the 5 of us and were instructed to present the other gift, on behalf of PSGH, at the ceremony tomorrow afternoon. With the formalities out of the way, Dennis, Jonas and I stayed there to sleep, while Charles took John and Vivian to other quarters.

A few hours later we were awoken by Charles, telling us that the ceremony would begin around 8am. We took turns taking a bucket shower, my first, (Bediako lacks running water), and then I followed Dennis’ lead by wearing a black suit, feeling slightly vindicated for bringing one with me to Ghana. As we followed Charles’ through the streets of his boyhood town, Bediako by daylight seemed very cozy. Small wooden houses and mud-bricked huts lined the narrow red-dirt roads. We came upon the same lines of plastic chairs which we had walked by the night before, but this time they were all full, whose occupants faced the entrance to what was a walled courtyard. Inside the courtyard, many more rows of plastic chairs lined the walls, all facing inward towards a closed tent. As we entered the courtyard, it was customary to shake hands with everyone already seated. This would turn out to be at least a hundred people, most of who looked at me like I was not unlike an alien. I tried to return their gazes with a strong handshake, eye contact and a solemn nod of my head. There was a microphone wielding MC whose job it was to announce the current arrivals to everyone already seated. This helped somewhat, as they explained that we were Charles’ co-workers who had traveled from Accra. We then took our seats along the back wall of the courtyard (with a nice booklet on each chair), and the next half hour or so was spent receiving others (more handshakes). Most attendants wore black, with all family members wearing shirts and dresses of a color-coordinated orange-patterned fabric, and most spent this time crying. After a while, the family members folded up one side of the tent to reveal the body lying on bed with the casket behind. Everyone then formed a line to circle the body and pay their last respects. This lasted another half hour or so, and it was a little after 9 when we departed back to the house.

I learned that it would be another couple hours before the next part of the ceremony: the church service. At the house, we ate a late breakfast of eggs and bread and then slept a little bit more. At about 11:30, we were again woken up by Charles to go to the service. Charles led us to the intersection of the two main roads at the center of town. The hundreds of plastic chairs had been rearranged in four big groups under tents all facing the main tent in the intersection, under which was the casket, flanked by the family members and the reverend. What followed was the church service, which consisted of the normal choruses, scripture readings and sermon, but which also included a nice biography and then three tributes: from Dora’s generation of family, from her children and then from her church. All of these could be easily followed along in the booklets we received earlier. There was a lot less crying, and a lot more reflection on life and death in this part of the ceremony, and I was amazed at the turnout. There were easily over 300 people there; pretty much the entire town came to a halt so that everyone could pay their respects to their fallen village member. I was personally befriended by a group of children who would not leave my side for the entire service. John got a kick out of it, and kept stealthily snapping off photos, reminding me that there was a good chance that I was the first white person they had ever seen in person.

When the service was completed around 1, everyone got up and walked up a short hill with the casket to the graveyard for the burial. This was actually the shortest part of the whole thing, and only took about 20 minutes. After that, Charles said that it was time for lunch, and he led us to another house, where we were served fufu with light soup and grasscutter meat. Let me do some translating. Fufu is a spongy dough ball of sorts usually made from pounded cassava and always served in soup. Light soup is the standard fare, and just means a tomato-based slightly spicy broth. Grasscutter is the name of a type of bushmeat, a local delicacy from an animal that looks like sort of like a porcupine (but, according to Wikipedia, with the much less appetizing name of a "greater cane rat"). All in all, it was pretty tasty, and we ate in the nice, airy house, drinking fanta and watching another Ghanaian love triangle movie.

throng of people heading up the hill to the burial site

fufu in light soup with grasscutter meat...yum.

After about an hour, we went back to the sleeping house to rest a little bit more before the last bit, which was the formal presentation of gifts to the family. We vegged out and napped a little bit until about 4, when we got dressed (this time without our suit coats!) and followed the sound of the drumming to a street that had again, been lined with the plastic chairs and tents. (At this point, everywhere I walked, I was being followed by little children, yelling “obroni!”, and coming up to me to shake hands or high-five. At one point, a little boy just came up alongside me, put his hand in mine, and walked with me indefinitely. This went on for about 5 minutes, until his mother came and grabbed him apologetically.) On one side of the street, there was a troupe of about 5 or 6 drummers beating away non-stop. There were traditional drums held with your knees and played with hands, stand alone drums played with straight sticks and then a very cool drum in the center which was played with sticks bent at a 90 degree angle. Directly across from the drummers was the family tent, where they all sat, some still dressed in orange and others in regal, flowing red fabrics. They sat behind a wooden folding table atop of which was a glass display case into which all of the gifts were being deposited. Again, the MC was there to announce the arrivals, as well as the gifts, and again, we did a big round of hand-shaking, stopping to give Charles a big hug, before taking our seats.

drummers

I spent the next hour or so, shaking a lot of hands and watching the drummers, as they played for what seemed like twenty minutes at a time. It was very clear that we had now moved from sadness to reflection to celebration, and those crying eyes were replaced with bright, cheerful ones above wide, laughing smiles. Along with the drummers came a lot of dancing, and I successfully parried several attempts from people trying to pull me up to dance. Before we knew it, it was 6 o’clock, time for us to make it back to the neighboring town of Mim to catch the bus back to Accra. As the five of us crammed into a taxi, Charles and his brother approached carrying huge burlap bags filled with yams, cassava and plantains (about 20 pounds for each of us!). They were gifts from the family to show appreciation for us coming all the way to Bediako and for our generous gifts.

It turned out to be the exact same bus that we had taken coming there, so we were again treated to “Apocalypto” and “Chelsea”. We had to stop over in Ghana’s second biggest city, Kumasi, to pick up more passengers, and another sneaky woman came on to subject us to another hour of unsolicited preaching. This time it didn’t seem as bad as before, perhaps because I was very glad to have had the opportunity to experience a Ghanaian funeral. I was able to tune out the preacher and reflect on the past day. So much of international development has to do with quantifiable variables like income, school attendance, and disease prevalence. And while it is of the utmost importance to measure and quantify these things, there are many other variables like the importance of community, ceremony and family that are much more difficult to quantify, but that Ghana and many other developing countries have in spades. All I know is that if that many people show up to my funeral, I’ve done something right.

The Price of Ignorance: Homosexuality in Ghana

My best friend, Jeremy, and I were trying to check into the Hotel, and we were arguing with the management about the price. I have become somewhat of a haggling expert in my handful of months here, but this was a different kind of negotiation entirely.

“The price on that board says 35 (cedis) for a single and 55 or a double. We would like a double, so we are offering to pay the listed price of 55 per night.”
“Yes, but if it’s two men staying in the same room, then you must pay 65.”
“Listen, I know how negotiations work here. We could haggle to pay well less than the listed price up there, but we’re not even doing that. We will pay exactly what it says for a double room.”
“If my boss came and saw two men in the same room only paying 55, I would be in trouble.”

Jeremy had just flown in from an HIV/AIDS conference he had helped organize in Johannesburg (South Africa) to visit me for a few days. I had reserved a room for the two of us for two nights, since I lived pretty far from the center of town. We had “big” plans to go out at night, so it was much more convenient for me to just stay at the hotel with him. I had put up some of my colleagues at this hotel over New Years, so I knew the two women behind the counter, and they were very friendly in my past encounter. The hotel is by far the best deal for the price, in a very good location. In the cab ride over from the airport, Jeremy had confessed that he hadn’t eaten or slept in over a week in the run-up to and during the conference he had planned. Knowing Jeremy, I knew that this was an exaggeration, but only a slight one. He looked very beat, we had just watched the sun rise, and both of us needed to crash for a bit.

“Where does it say that two men must pay more? All it says is 35 for a single and 55 or double.”
“I cannot give it to you for 55. I’m sorry, but I cannot. I would be in trouble.”
“Listen, I think I know what’s going on here. Scotty and I were roommates at university. We’ve slept in the same room many times. It is normal in the U.S. You said that the bed could be separated into two smaller single beds, right? Can you do that? Would it help if we went out, picked up some girls and brought them back to the room with us?

Jeremy was successful in getting a little chuckle out of them after that one. He has always been good at that kind of thing, defusing tense situations. The main manager looked down at her intertwined hands resting on the blank countertop behind which she was all but pontificating. This “conversation” had been going on for several minutes now, and no one was budging. Finally, she started to look visibly distraught.

“Would it be easier for you if we just left?” Without looking up, she slightly nodded her head.
“OK then, we’ll go. Thanks for your time.”

We weren’t exactly mobile, as Jeremy had a few bags from his flight, and we had taken a cab here from the airport. But I knew of two other hotels within a chip shot of this one, so we slung the bags over our shoulders and made our way out the door and down the street.

“I know we’re essentially arguing about less than $10, but it’s the principle of the thing. We’ll try these two other hotels over here and see what happens.”
“Yeah man, I agree. That was pretty messed up.”
“I mean, maybe I should have foreseen this problem, but I’m not sure how I could have. My colleagues, who were a male and a female, had stayed together in a single room for less than 35 (cedis). Now they are saying that we have to pay more than 55 because we both have penises. Come to think of it, I can’t remember seeing any outwardly gay people since I’ve been here.”

But our luck only got worse from there. When we asked about vacancies at the first hotel, the guy looked suspiciously from me to Jeremy and then tersely spat “No rooms available.” We left without another word. At the second hotel, one of the employees was showing us up the stairs to a double room, when he stopped, turned, and said “It is just one of you staying here, yes?” “No, we will both be staying in the room.” we countered. “Two men in the same room is not allowed.” he said as he motioned for us to turn around and walk back down the stairs.

Standing in the early morning light outside the last hotel in the area that had rejected us, I looked from Jeremy to the bags and asked “So, what do you want to do?” “I don’t know, man, this is getting a little ridiculous.” Yeah. Again, sorry I did not foresee this.” I looked back at the first hotel. “You know me, man. I really don’t want to have to go back there with my tail between my legs, but I think it’s our best option at this point.” Jeremy agreed, and we made our way back there. When we entered the lobby, our friends were sitting on the couches there.

“Alright, alright, you win. We’ll pay the 65.” I said casually in an effort to foster a more congenial atmosphere this time around. I was successful, as they both broke into uproarious laughter.
“HAHAHA. What happened?”
“Well, there were no openings across the street, and then they said it was not allowed next door.”
“We told you it was not allowed.”

We almost got into it again, as I could not help myself but explain that they had never come out and say it was not allowed, rather that all we had to do was pay some extra money. There was a big difference. Anyways, that side note was able to be skirted and for the rest of our stay were acted like old friends with an inside joke.

That night, I took Jeremy out around town to various ex-pat hangouts in Accra, and it so happened that at one of them, we saw a group of flamboyant gay men singing and dancing and having a good time: the first gays I could remember seeing in Ghana. In most of the American cities with which I’m most familiar – DC, Chicago, New York – there are entire neighborhoods that are known to be LGBT havens and seeing gays and lesbians in your everyday experience is nothing to write home about. But their absence in Accra was something that had gone completely unnoticed by me for months, so that when I finally thought about it, it made a lot of sense. It was one of those great coincidences in life that we came across them that same day, but it is not a coincidence at all that they were there and not somewhere else.

Homosexuality is illegal in Ghana. Under Ghanaian law, it is considered “unnatural carnal knowledge” and lumped in with beastiality as a misdemeanor or first-degree felony, depending on the consent of the partner. The Constitution of Ghana guarantees the protection of all human rights for Ghanaian citizens “whatever his race, place of origin, political opinion, color, religion, creed or gender”, but does not mention sexuality. What results is that gays in Ghana constantly live in fear. In this deeply religious nation, homosexuality is considered and evil act that is not naturally “African.” Many view it as an export from the Europe and the Americas, and gays are put on the same level as thieves and pedophiles. Certain churches have been known to conduct exorcisms to remove the evil homosexual spirits from those afflicted with this disease. Gays are also correlated with poverty here, since many of them are disowned by family members and thrown out on the streets at a young age. If a gay man were to report an assault to the police, he (the victim) is just as likely to be thrown in jail as his assailants.

As more and more states and territories in the U.S. recognize gay marriage (way to be DC!), across the pond gays are still considered criminals in the eyes of the law. In September of 2006, an LGBT conference that was to take place in Ghana was banned by the government with an official statement from then Minister of Information: "Ghanaians are unique people whose culture, morality and heritage totally abhor homosexual and lesbian practices and indeed any other form of unnatural sexual acts." Even human rights officials have admitted that Ghana is “not ready” to recognize gay rights.

And by no means is this just a Ghanaian issue. Jeremy was quick to remind me that he had flown in from South Africa instead of Uganda, where his HIV/AIDS conference was originally supposed to be held. It had been moved from Uganda as a show of protest of their pending anti-gay legislation, which was recently condemned by a bipartisan U.S. Senate committee. The legislation would expand penalties (including the death penalty) for homosexuality and require Ugandan citizens to report information about homosexuality to the police or face imprisonment. No, this is a most-of-Africa-except-South-Africa-issue.

That is why it is not a coincidence that Jeremy and I saw the group of gay men that night at the ex-pat bar (rather than a Ghanaian hang out). It is probably one of the only places in Accra that they feel comfortable being themselves. After a lifetime of being in the closet and pretending to be something they are not, who can blame them for singing and dancing and turning the volume up to 11? Even the BBC covered this topic in a 2007 article entitled, “Ghana’s Secret Gay Community.”

I have been quick to compliment Ghana on its strong democracy, free press and other liberty-promoting institutions, but this was a nice reminder that it still has a long way to go. In fact, the world still has a long way to go. I am reminded of a talk show I saw (blanking on which one), where the guest, “Family Guy” creator Seth Macfarlane, said of the gay marriage issue (paraphrasing): “Everyone who has ever been on the side of denying equal rights to fellow human beings has been shown to be on the wrong side of history. This can be said for civil rights, women’s suffrage, and gay marriage is no different. History will show that they are wrong.” Whatever your thoughts may be on his crass, crude, controversial TV show, I thought this to be extremely profound and true. I hope it is just a matter of time. But even if it is, we really need to speed things up, because we continue to pay the price for every second that is lost, both literally and figuratively.

And Now For Something Completely Different...

Let me begin this post by saying that it has absolutely nothing to do with Ghana, Africa, global health, international development, or anything else I have tended to write about. What it does have everything to do with, however, is movies. Those of you who know me best know that my love of movies (and very opinioned personality) would not allow me to have a blog and not share my views about the nominees (and those not nominated) come Oscar season. Allow me to opine, because I can guarantee I will make predictions you won’t find anywhere else!

A few issues before we get started:
First, for time’s sake, I will not discuss every single category, lest the music start playing me off the stage before I’m through. Second, in order to follow along, I would recommend opening another window/tab and going to (http://www.imdb.com/features/rto/2010/oscars). This would allow me to not have to say who is nominated in every category, and we can all still be on the same page. Third, I will admit to not having seen every movie nominated. However, even being in Africa these last 3-4 months, I have been able to see a majority of those 10 nominated for best picture, so I still feel relatively ok offering up my semi-educated thoughts. Fourth, I will go in somewhat of an order of least important to most important (Sorry to all you make-up artists, but you’re not as important as the director). Fifth, for some of the awards, I name the movie instead of the person nominated. I do this for simplicity and clarity sake. Good? Great. Let’s begin:

Best Animated Feature Film
Who Should Win: Up
Who Will Win: Up
This is a foregone conclusion. I’m really sorry to all the other movies nominated, but if you really were hoping for an Oscar, maybe you should have talked with the people at Pixar first and realized that they were making perhaps the greatest animated movie of all time before releasing your movie in the same awards cycle. Maybe you could have held onto it until next year, like the Weinsteins tried (unsuccessfully) to do with The Road this year, or maybe you could have rushed it out last year to try to battle WALL-E and Kung Fu Panda, but no one will be victorious against Up.

Best Visual Effects
Who Should Win: Star Trek
Who Will Win: Avatar
I’m really just mad that Star Trek was not included in the expanded category of best picture nominees this year, so I plan to include it as my “Who Should Win” opinion for every award it is up for. In reality, I don’t see any movies beating Avatar for the visual effects-type awards.

Best Sound Editing/Sound Mixing
Who Should Win: Star Trek
Who Will Win: Avatar
For the record, these are two completely different categories that I have combined because the nominees are largely the same and the winners most likely will be as well. For explanation, please see above. While I have indicated Avatar as the likely winner here, another strong possibility is The Hurt Locker. All I remember during that movie is being on the edge of my seat the entire time, and I’m sure the sound had something to do with that. It has been a critical darling so far, so I would not count it out to snag some of these types of awards.

Best Original Song
I have not seen any of these movies or heard any of these songs, so I don’t feel educated enough to wager any guesses. I will note that perennial Oscar nominee Randy Newman continues to not go away, as he will try, like Meryl Streep, to improve his dismal wins-to-nominations ratio (currently 1-for-16). Best of luck, Randy.

Best Original Score
Who Should Win: Sherlock Holmes
Who Will Win: Up
While I’ve seen 4 of these 5 nominees, I can really only remember the light, playful score from Sherlock Holmes. I think it should also win, because it was an extremely well-acted and entertaining movie that only has this one nomination to show for it. That being said, I just have a feeling that Up will go away with this one.

Best Makeup
Who Should Win: Star Trek
Who Will Win: The Young Victoria
If you’ve been reading this post, then this additional nod to Star Trek is obvious. However, whether it’s Helen Mirren or Cate Blanchett, Queen Elizabeth or Queen Victoria, the Academy seems to have a love affair with these British monarchs, and I predict that affair to continue this year.

Best Costume Design
Again, I have not seen any of these movies, so this category is pretty dead to me, and I will not offer any predictions. I will note that it would be a pretty hilarious smack in the face if the Coco Chanel movie did not win. I would kind of like to see The Imaginarium of Dr. Parnassus win this one, as indirect homage to Heath Ledger. It was his last film (which he didn’t even get to finish).

Best Art Direction
Who Should Win: Avatar
Who Will Win: Nine
Avatar was simultaneously the most expensive movie ever made and the highest grossing movie ever made, and a great production designer has a lot to do with that (along with inflated 3-D ticket prices, of course). However, the Academy loves musicals for this category, having awarded it to Moulin Rouge, Chicago and Sweeney Todd in recent years, so look for Nine to take this one.

Best Editing
Who Should Win: The Hurt Locker
Who Will Win: The Hurt Locker
I spent this entire movie with my heart racing on the edge of my seat, thanks to the effectiveness of the quick, jarring cuts.

Best Cinematography
Who Should Win: Avatar
Who Will Win: Avatar
Did you see Avatar? That movie was awesome and larger-than-life in every sense of the word/phrase and that means cinematography. It will follow its older brother, Titanic, onto the podium.

Best Adapted Screenplay
Who Should Win: In the Loop
Who Will Win: Up in the Air
In the loop was one of the smartest, funniest movies I have seen in a long time. Anyone who likes dry, British humor; works in/with the government; hates acronyms, or has laughed out at seeing those t-shirts that say “Trust Me, I’m a Policy Analyst” should see In the Loop immediately. Like Star Trek, it’s another one that I am both surprised and mad for it being left off the Best Picture list. This is its only nomination, so I gotta go for it. That being said, with the Diablo Cody win for Juno in 2007, I feel that the Academy is turning a new leaf towards hip, modern screenplays. Juno’s director, Jason Reitman, who penned Up in the Air, certainly knows this, as he has his two of the main characters “sexting” on their blackberries. If it’s not Up in the Air, then it will probably be Precious, as the full title makes it blatantly obvious that is was adapted from a novel.

(As a quick side-note: my raspberry award for the worst adapted screenplay of the year (ie: the best books turned into the worst screenplays) would go to Harry Potter and the Half-Blood Prince with The Road close behind.)

Best Original Screenplay
Who Should Win: Any of them
Who Will Win: Quentin Tarantino, Inglorious Basterds
Honestly, I can see any of these writers going away with the prize, and they would all be deserving of it. (I have not seen The Messenger.) Obviously, you know how much I love Up, but animated films have always come up short in this category. I loved the Coen brothers retelling of the biblical story of Job behind A Simple Man, and could discuss the enigmatic ending at length, but it doesn’t seem like their year. The Hurt Locker has a good chance to go away with this, however much I disagree with the main message of the movie, but I really think that Tarantino will take home his second Oscar in this category for his multilingual, other film-loving, historically-revisionist script.

Best Director
Who Should Win: Kathryn Bigelow, The Hurt Locker
Who Will Win: James Cameron, Avatar
As is usually the case, the best director category is an exciting race. This year’s nominees provide the possibility of the first female winner, the first black winner, the first director win for Tarantino, the first win for one of the best young filmmakers of this generation (Jason Reitman), or a reprisal of James Cameron’s “I’m the king of the world!” speech from 1997. Unfortunately, I think this latter event is the most likely. While I think Reitman, Tarantino and Daniels are in the just-happy-to-be-nominated category, the once-married pair of Bigelow and Cameron have the best shot here. As much as I would love for the director of Point Break to go on to win the Academy Award for directing later in life, I don’t think she has what it takes to stop the Avatar train.

Best Supporting Actress
Of these movies, I have only seen Up in the Air, so, once again, I don’t feel entirely comfortable making predictions. However, two of the five nominees do come from that movie, so I will say that Anna Kendrick was better than Vera Farminga. Part of it was her character’s ability to show much more range, but part of it was that she completely nailed the overly-ambitious recent college grad who ostensibly has it all together but is very fragile and naive under the surface. That being said, I have heard very good things about Monique’s performance and really like Maggie Gyllenhall, so if either of them win, it’ll be fine with me. I really just don’t want Penelope Cruz to win. She just won this same award last year for a movie that no one saw, and I have always thought she was overrated.

Best Supporting Actor
Who Should Win: Christoph Waltz, Inglorious Basterds
Who Will Win: Christopher Plummer, The Last Station
I will preface this by saying that Waltz’s is the only performance I have seen in this category, but just based on that, he should win the award. I think Brad Pitt is a great actor, but in the hero vs. villain repartee of Inglorious Basterds, Waltz shows Pitt how it’s actually done. However, I think the academy will favor Plummer, the deserved (accent on the last syllable), venerable veteran, as a nod to his lifetime achievement more than just to this role. Stanley Tucci is a favorite character actor of mine, but I think he, Damon and Harrelson will also fall short.

Best Actress:
I have not seen any of these films, so I’m really just going off of the buzz I’ve heard and personal preference. I really hope that Meryl Streep doesn’t win solely for the fact that she is Meryl Streep. Possibly the best actress ever, I think she has been nominated and unsuccessful for better roles in better movies. I’ve heard really good things about the two newcomers, and Helen Mirren seems to be in the running more often than not recently, but all the buzz seems to be about Sandra Bullock. For the actress who won me over with The Net way back when, maybe this is her year.

Best Actor
Who Should Win: Not Sure
Who Will Win: Jeff Bridges, Crazy Heart
Again, I’ve only seen Clooney and Renner in this category, and neither really wowed me. I keep wanting George Clooney to show more range of emotion in his roles, but he continually disappoints in that regard. He’s already shown me range of character with great turns in movies like O Brother, Where Art Though; Syriana; Burn After Reading; and Michael Clayton, but not range of emotion. Basically, I want to see him cry…believably. There is a scene towards the end of Up in the Air where he almost sheds a tear, but then he becomes Cool Hand George again. Renner turns in a great performance as the lead in The Hurt Locker, but I came out of the movie more impressed with the direction and cinematography than with the acting. I think this one is really between Colin Firth and Jeff Bridges, the latter of whom seems to have a slight edge right now.

Best Picture
Who Else Should Have Been Nominated: Star Trek, In the Loop, 500 Days of Summer
Who Should Win (in my non-realistic, time-traveling utopia): The Dark Knight
Who Should Win (for real): Up
Who Will Win: Avatar
Like I said, these are predictions you will find nowhere else. Where do I begin? This year is the first year in decades where there have been more than five best picture nominees. Ostensibly, the Academy decided to double the number to increase ratings of the Oscar night production, to increase revenue for more movies during the Oscar push season, and to generally make the awards more enjoyable for the average Joe by including more movies Joe has actually seen (including maybe an outstanding comedy, sci-fi, or horror flick, etc.).

However, industry insiders are calling this doubling “The Dark Knight Rule,” because everyone knows that the Academy is trying to repair the damage it did by not including that movie in last year’s best picture nominations. In no small way is The Dark Knight responsible for movies like The Blind Side, District 9 and Inglorious Basterds being in the top category this year and earning them hundreds of millions of dollars more due to the cache that recognition brings. Now, obviously, The Dark Knight cannot win anything this year, as it came out last year, but in my humble opinion, all of those movies in the “we’re just happy to be here” camp should campaign for The Dark Knight to win instead of futile campaigns for their own movies.

Some common question I heard fellow audience members asking each other last year as they left the theatre after seeing The Dark Knight*:
1.) Was that movie simultaneously an amazing action-packed thriller and a mind-numbingly deep drama that asked intensely moral and ethical questions about true human nature, good vs. evil and vigilante justice?
2.) Did I just witness the best reinvention of an already iconic movie character in history (a thing so difficult to do that one of the best movie actors of our time, Johnny Depp, failed miserably to do the same with Willy Wonka); a reimagining that was so good as to make the previous incarnation (done by an academy award-winning actor himself) looking like child’s play?
3.) Did that movie have five different Academy Award winners/nominees in it?
4.) Did Christopher Nolan just flip over a semi truck in one take and make almost that entire movie sans CGI? (Kinda makes Toby Maguire flying around on the green screen also seem like child’s play)

If you were wondering, the answer to all of these questions is a resounding: Yes. Put simply, I’ll settle for Sid whatever his name is, the president of the Academy of Motion Picture Arts and Sciences, to admit how dumb they were last year when he makes his little speech this time around and mention The Dark Knight by name. OK, I’m done with my little rant. Now onto the real nominees, in order of least to most likely to win:

10.) The Blind Side: I have not seen this movie, and I have heard great things about it, but come on. I know it has the power to reduce grown men to tears (men who shall remain nameless), but I imagine it to be a lot like Remember the Titan: a great movie that addressed some of the same racial issues through football, but not really in the best picture discussion. All of the rich, old white guys in the Academy love movies where white people come in to save their minority neighbors (see: Precious), but they are certainly in the “just happy to be here” camp.
9.) District 9: Again, I have not seen this, but I’ve heard really good things. I’m sure it is great, and I know it also poses a lot of ethical questions about civil/human rights through the sci-fi lens of an alien refugee camp in South Africa, but if this was any other year in the last 50, we would not be having this conversation. See: The Dark Knight Rule
8.) Inglorious Basterds: I really enjoyed this movie; but again, we wouldn’t be having this conversation if the nominees were five. If you could give the award for the best single scene in a film, I don’t know if there’s a better one than the opening floor boards scene in this movie. Unfortunately, the rest of the movie is down-hill from there and devolves into Tarantino’s typical gratuitous violence minced in with him showing everyone how much he knows about French and German film. The suspense in the pub scene was also great, but a movie needs more than two good scenes to be a best picture.
7.) Precious: Please see: The Blind Side. I’m sure this is an emotionally-gripping movie with great acting, but I can’t get past how Hollywood continually portrays white people saving their heathen minority neighbors. Do incest, child abuse and poverty not occur in white households? It’s interesting that African-Americans are at the helm of this movie, but choose to continue this trend. Try asking an educated black person what they thought of it. But again, this movie was never made for blacks; it’s for the old white guys in the Academy. That being said, it’s not gonna win. Sorry.
6.) A Serious Man: I really enjoyed this movie as well, but it’s just not going to win. If not for this nod and the writing one, you would think the Coen brothers took this year off. Their most Jewish movie to date, this film was made for that small niche population (Jews), and maybe I liked it for that exact reason (I know that why the Academy did). It is another movie that poses (but does not answer) many deep philosophical questions and intertwines them with religion in this modern day pseudo-retelling of the biblical story of Job. The acting was subtle but great (surprised Michael Stuhlbarg did not get the best actor nod), but again, this would probably not have made the top 5.
5.) An Education: Here’s where we start to crack the top 5 that probably would have made the cut sans The Dark Knight Rule. I have not seen this movie yet, but I’ve heard the acting is phenomenal, especially by the young leading lady, Carey Mulligan. It seems to have everything the Academy loves in its best picture nominees: great acting and smaller, art-housy type films whose characters learn meaningful life lessons through European culture and history (See: The Reader). Probably not going to win, but a typical, strong nominee.
4.) Up In The Air: This was a great movie with a quick, smart script and solid performances from everyone. (Quick note to Jason Reitman: please don’t stop casting JK Simmons in all of your movies, because he steals the show with every scene he’s in (See: Thank You For Smoking and Juno).) This time around, Geroge Clooney is the one doing both the mentoring and being the mentee. The characters are able to learn what’s most important in life through their co-workers, family and lovers. Reitman turns in another highly satisfying film, with a reasonable shot at the top prize.
3.) The Hurt Locker: From the opening scene, director Kathryn Bigelow proves that she is a master of gritty, intensely suspenseful, heart-pounding sequences. This movie comes up for air less than Blackhawk Down, and that’s saying something. Intertwined with the action, she is trying to get at the motives behind her main character’s seeming death wish: a conclusion that she almost wants to extrapolate for all IED bomb technicians in Iraq and one that I find overly simplistic and most probably false. I also just read an article about how unrealistic the entire plot is. That being said, it is one of the most engaging films in years and critics love it, so I’d say it’s got a solid chance.
2.) Up: What more can I say about Up except that I think its Pixar’s best film to date. If you ever doubted Pixar (e.g. no one will like a movie about a rat in a kitchen, no one will like a movie about a non-speaking robot where the first word of dialogue does not come in until the second half of the movie, no one will like a movie whose main characters are a fat kid and grouchy old man, etc.), please stop it. The opening sequence about the husband and wife and showing the passage of time with the tie tying montage…filmmaking doesn’t get better than that. And the scene where the old man chooses to throw out all of his furniture and stuff that is literally weighing him down in order to get the house afloat again is simply perfect. It is a timeless classic for every age group and it would be very fitting for Up to win the top prize in the first year of the expanded category.
1.) Avatar: What more is there to say about Avatar? It is an awesome, larger-than-life film that reminded people of the magical possibilities of the movie-going experience. It has everything Hollywood loves: an evil corporation, a great love story, god is nature Pan-theism (see: Every Disney movie ever), and lots of action all rolled into one. All you can say is that James Cameron knows what he’s doing. But it also has another layer, if at times too thinly-veiled, about extractive industries, colonialism, international development and terrorism that was also not lost on me (especially seeing it in Africa). These issues are as important today as they were when Cameron started writing Avatar in the 70’s. (He put it away, because the technology did not exist at the time for him to make the movie how he wanted to. After Lord of the Rings, Cameron decided that the technology was finally there and took it off the shelf.) It is a movie that expands the frontiers of movie-making, and it will win best picture for the same reasons Titanic did over a decade ago. (Did I mention that the female lead, Zoe Saldana, was probably cast in the role because of how kick-ass she was in Star Trek? Honestly, I’m not even a big Trekkie, but that movie was badass.)

*slight dramatization

Battleship: West Africa

These days are not the greatest for West African nations. Every day it seems like one more of Ghana’s neighbors falls victim to another political fiasco, torpedoed by the powers that be. It makes me understand and appreciate a nation like Ghana even more, which really does seem to rise above the fray and stand out as a beacon of democracy for the rest of the region.

I suppose this recent bout of turmoil started with Nigeria: the most populous African nation, and less than 300 miles East of Ghana. At the end of November 2009, the Nigerian president, Umaru Yar’Adua, conspicuously disappeared. At first it was sort of like, “Hey, has anyone seen the President?” The Nigerian government was silent and the media became restless. For a few days it was sort of a running joke over here, like those old advertising campaigns: “It’s 10pm, do you know where your president is?” or, like the dairy farmers asked: “Got president?” But after a while it became clear, like when a parent discovers that their teenager is not at the friend’s house who was supposed to be having a sleep-over, that something was going on. The game was up, and the silent treatment would no longer work.

As it happened, the government revealed that President Yar’Adua was receiving medical treatment for a heart condition in Saudi Arabia, but the extent of the condition was still kept very close to the vest. As his departure lengthened from weeks to months, rumors of his impending demise and the “power vacuum” in Nigeria strengthened. Compounding the problem, the strongest militant/rebel group, the Movement for the Emancipation of the Niger Delta (MEND), ended its 3 month cease-fire with threats of all-out assault on the oil and gas industry. After more than two months away, the president finally made the formal transfer of power to the vice president, Goodluck Jonathan (I can’t make this stuff up), mitigating the “power vacuum.” President Yar’Adua flew back to Nigeria earlier this week, and surprise surprise, the vice president isn’t so keen on relinquishing his new powers.

Meanwhile, the president of Ghana’s next door neighbor to the West, Ivory Coast, has deemed it necessary to dissolve the country’s parliament and electoral commission, after accusing the latter of fraud. Elected in 2000 for a 5-year term, Ivorian President Laurent Gbagbo has now postponed elections for the sixth time. The latest issue is over the electoral commission trying to add some 400,000 names to the definitive electoral role. In the last month, presidential supporters have been trying to use the courts to remove thousands from the electoral role, whom they deem to be foreigners, and this latest move is no different. According to president Gbagbo, these people are foreigners, and this amounts to fraud. According to the opposition party, these people are from ethnic groups in the north of the country who are unlikely to support Gbagbo. In 2002, the rebel group, New Forces, seized power in the north of the country and formed a power sharing government with Gbagbo, which has been in power ever since. Ex-rebel leader and current Prime Minister, Guillame Soro, has been asked to form a new government. New elections have not been scheduled yet.

If East and West weren’t enough, just last week, Ghana’s neighbor to the North (and East), Niger, experienced a coup when a military junta kidnapped the president and seized power. To the junta’s credit, they say all they want to do is oust a tyrant and hold elections, and they have done nothing to make anyone believe otherwise. To the African Union (AU), however, a coup is still a coup, and they have suspended Niger and threatened sanctions. An article in The Economist on this development points out that despite the AU’s harsh denunciation of the coup, the body has done very little to address the worrying trend of African heads of state abolishing term limits, which Niger’s president Mamadou Tandja did at the end of last year, following in the footsteps of nations like Uganda, Algeria, Chad and Cameroon. It is a major factor that led to the coup in the first place, and a reason why the majority of people in Niger seem to be in favor of it. As a member of ECOWAS (the Economic Community of West African States) stated, paraphrasing JFK: "When you make peaceful change impossible, you make violent change inevitable."

For Ghana, its political problems are almost laughably small in comparison. In fact, I did laugh out loud when watching news coverage of the most recent episode. The quick version of the story goes like this: The house of one of Ghana’s ex-presidents, J.J. Rawlings, burned down. All I will say here is that Ghanaians of all political leanings seem to have a soft spot for this guy (who is “very charismatic” according to Dennis), and his story of multiple coups and democracy in Ghana is really very interesting. But anyways, his house burned down and the public was pretty distraught, calling for the current administration in power (Rawling’s own party, the National Democratic Congress (NDC)) to help him and his family in some way. Meanwhile, a member of the opposition New Patriotic Party (NPP), Mr. Nana Darkwa, went on radio and said that he had evidence that Rawlings had burned his house down himself, inferring that he would capitalize on the insurance and the help the current administration would surely provide. The guy was then arrested and thrown in prison, on what charges, I am not sure. The NPP was obviously furious, and the news coverage I laughed at was showing the NPP members, noses in the air, holding a walk-out of a parliamentary session in protest. I could only be reminded of the trial scene in “Animal House,” and was just disappointed that the NPP members weren’t also humming the national anthem as they departed.

Now, I know that this is not all that funny, and regardless of his so-called evidence (which turned out to be bogus), it is a serious case of freedom of speech and individual liberties, but I can’t really help the connections my mind makes sometimes. Ghana’s democracy is still very nascent, relatively, and they are learning that you can’t just throw someone in jail because he/she said something derogatory about your friend on the radio. I’m not a lawyer, but I’m pretty sure a lawsuit has to filed with legitimate charges brought forth against the accused (in this case maybe slander or defamation), and a free and fair trial has to be held before you can throw someone in jail. In this vein, you’ll be happy to know that Mr. Darkwa has since been released on bail, and the charges will most likely be dropped…baby steps.

Like I said, Ghana is learning, but its democratic institutions seem to be strong, and its problems are laughably small compared to some of its aforementioned neighbors. I know that to compare the political troubles of West African states to a game of battleship is to trivialize them. But again, I can’t really help the connections my mind makes, and recently, it sort of feels that way. Our fellow ships are being torpedoed all around us, and we’ve cleverly hidden our vessel along the bottom row of the board. Who will be the next victim and how long will we remain unscathed? These are the unanswerable questions being discussed at the water cooler, while everyone crosses their fingers that the next number called isn’t ours.

Lunch of Champions

I have already told you about my typical Ghanaian breakfast (Hausa Cocoa and Kose). Since then, I have also established my lunch option of choice: grilled plantain and fried yam. There are two women who set up shop next to each other on the roadside about ½ a mile from our office and cook them both for the lunch rush: one specializes in grilling the plantain over a charcoal grill and sells it with little bags of peanuts (called groundnuts here), while the other fries the yams in a big vat of vegetable oil and sells it with red or black pepper sauce for dipping. The latter also fries whole tilapia, but I stick with the yams. As I am a very good repeat customer, coming back anywhere from 2-4 times a week, and surely the only white person who tries to greet them in their native tongue, they always have big smiles and waves for me when they see me coming up the road on my midday stroll.

There isn’t really a standard time when the food is ready, so sometimes I get there and they are just getting going. The grilled plantain is pretty standard. Very similar to banana, she simply peels the fruit and then just throws it on the open-face grill. I watch eagerly, her hands jetting in and out of the heat as she turns the plantain with nimble fingers. When they are good and done (brown and crispy on the outside, hot and soft on the inside), she stacks them in a pile on a corner of the grill away from the most intense heat but still staying warm. I select two good ones just in time to hear the sizzle as the first of the yams are thrust into a large vat of oil on the ground about 10 yards away. As the yam slices settle at the bottom of the basin, I watch the translucent surface bubbling over with intense escaping heat and can’t help but think of Harry Potter (never far from my thoughts). It reminds me of a cauldron in Snape’s dungeon during Potions lessons. It’s not long before the yams are being fished out of the oil with a long black spatula, ready to take their place next to the tilapia in a glass display case on top of the wooden table that faces the road and the customers.

my two lunch-time buddies, grilling plantains at front

yams frying in the vat of oil

I should say that yams in Africa are quite different than what we know as yams – the orange-fleshed sweet potato – in the U.S. The best way that I can describe African yam is to say that it is almost identical to yuca, a dish native to Latin America, which you may have encountered at Caribbean or South American restaurants in the U.S. (There is a Cuban restaurant in Arlington, VA I used to frequent that serves yuca with a terrifically spicy green sauce.) Like yuca, the fleshy, edible part of an African yam is much denser and starchier than potatoes. A full yam is large and tubular, usually over two feet in length and weighing about 10 pounds. Its skin is much rougher than a potato, almost more like tree bark. African yam is almost always prepared by peeling off the skin and cutting it into smaller pieces to be boiled or fried. The end result of the fried yams is that they resemble very large steak fries. Dip them in spicy black pepper sauce and pair them with plantain hot off the grill and you’ve got a nice little lunch. Not only are the yams and plantain delicious, but they are really cheap, too. I can get more than I can (or should) eat for the equivalent of about $1.

table-top glass case with fried yams top left and fried tilapia top right

a typical road-side produce stand: unripe plantains front left, ripe plantains right, yams center left and bananas far left

I have discovered that if I want to eat and live like a Ghanaian, then it is generally very affordable to do so. On the other hand, the second that I have “Western” cravings that require addressing, I better be ready to pay for it, because everything is imported. American/European food is usually at least twice as expensive as it should be, while toiletries can simply be laughably expensive. Last week, I went into a western shop to see how much my shampoo (Head and Shoulders) costs in Ghana. I walked back to the hair care section and found my shampoo in the middle of the shelf next to other standard fare. If you just took a snapshot of the products on the shelf, you could have been anywhere in America, but as soon as you look under those products to see the price labels, you realize that you are definitely not. For a standard bottle (not like a huge Costco bulk size), it was about $15. I just laughed audibly, thought about asking one of the workers if anyone actually buys this stuff for this price, thought better of it, and walked out the door. Luckily I have some people visiting me in the coming weeks who will be kind enough to indulge me a shopping list!

PS: If anyone was wondering, Everton just got through beating Chelsea and Manchester United (the two top teams in the league) in back-to-back matches. It's more of less the equivalent of sweeping the Yankees and Red Sox in back to back series. On top of that, Landon Donovan is tearing it up, especially considering that many of the defenders he's played against in recent weeks are first stringers for the English national team that he and Team USA will face in the first game of the World Cup. Everton have not lost a league match in months, as they continue their climb up the ranks of the Premier league. Since I declared my fandom, the have gone from 11th place to 8th. And the fans love Donovan; unfortunately, it seems like he will be headed back to the LA Galaxy when his loan is over, but many are saying that he will be signed permanently next year.

Theory and Reality: A Natural Experiment

Yes, another blog about malaria…deal with it. ***DISCLAIMER***This entry became longer than intended, so please know that going in. There is, however, a story involved, so hopefully it won’t seem as long as it is.

In my previous Malaria 101 posting, I spoke of how Ghana’s new “Strategic Plan for Malaria Control” calls for moving from a presumptive clinical diagnosis to a diagnosis based on laboratory testing or rapid diagnostic test (RDT). In theory, this has tremendous potential to reduce costs for patients and the overall health system; to decrease the likelihood of drug resistance emerging, thereby preserving the efficacy of artemisinin-base combination therapies (ACTs); and to improve the health outcomes for the public by treating patients for the disease that is actually ailing them. That is in theory; in practice (aka: in reality) is another story entirely. To illustrate this, I will detail a natural experiment I was lucky enough to conduct some weeks ago. But first, a little bit more explanation of the malaria diagnostic situation.

When ACTs first came on the scene 5-10 years ago, the malaria community was so happy that there was a highly efficacious, well-tolerated alternative to chloroquine and SP (the two antimalarials in wide use at the time, to which plasmodium falciparum had developed high resistance profiles in several countries), that it’s number one priority became increasing access to ACTs as quickly as possible. In this regard, many countries (including Ghana) made ACTs available over the counter, instead of needing a prescription, and the WHO recommended clinical diagnosis in high burden areas, especially for children under 5. So basically, for the last 5-10 years, if you felt feverish or sick in Ghana, you could pop into your local pharmacy or licensed chemical seller shop*, they could take a look at you, declare that in their opinion it seemed likely that you had malaria, give you a regimen of ACT, transaction completed and you were out the door: not much different than buying advil. But ACTs are not advil. Ibuprofen (advil) fights inflammation. ACTs are anti-infectives that fight living microbes that put up a fight because they don’t want to die. The other issue is price, and the main catch with ACTs is that they are significantly more expensive than chloroquine and SP. Many people can only afford these alternatives, which are actively discouraged by the government but still widely available in the private sector. Alternatively, if a person demands ACT but cannot afford a full regimen, irresponsible drug dispensers have been known to provide less-than-complete doses.

Fast forward to 2010 where several developments have caused the global malaria community and Ghana’s Ministry of Health (MoH) to rethink their treatment strategy. First, there is a growing body of evidence that malaria is being significantly over-diagnosed and, consequently, ACTs over-prescribed. In Ghana, those numbers look something like this: around 90% of patients presenting with fever at both public and private sector health facilities were diagnosed with malaria, whereas the percentage of those febrile patients that actually had malaria (confirmed through laboratory tests) was more around 50%. This is alarming not only because of the vast, unnecessary use of ACTs and other antimalarials, but also because so many sick people are not being treated for the illnesses they have. Second, the first documented cases of resistance to ACTs have been documented along the Thai-Cambodian border. This is troubling both because that is the same hotspot where chloroquine resistance first appeared in the 1950s (before spreading to the rest of the world) and because there is no new antimalarial drug in the pipeline to replace ACTs if they significantly lose efficacy. Third, there is promising evidence of reduced malaria transmission rates in some countries (including Ghana). While this is a very exciting development, it also means that the over-diagnosis that stems from equating all fevers with malaria is even more pronounced. The fourth and final development is the emergence of RDTs on the scene. RDTs for malaria are pretty awesome; they are very easy to administer (a little finger prick, a drop of buffer and voila), they are quick (results in 15 minutes), they are relatively affordable (less than $1) and they are very accurate** (sensitivity and specificity in the high 90th percentiles).

So, faced with these 4 developments, some pioneering countries have decided to change their treatment guidelines. But, as is so often the case, the difference between theory on paper and realities in practice may be massive. The MoH has not rolled this new program out yet, but a little natural experiment I was able to conduct highlights some of the practical issues it might be facing in the private sector. And the story goes like this:

I should first say that one of my number one priorities upon landing in Accra was to secure some RDTs for myself. It took me about a week, but I was eventually able to procure some from the MoH. I had to buy an entire box (30 tests), but like a good boy scout, I was prepared. I kept them under my bed at home.

One day at work, John, PSGH’s good-natured accountant and Jonas, its hard-working on-site handyman, declared that they weren’t feeling very well, and both thought (or in their own words, knew) that they had malaria. Jonas was feverish and achy all over. John, while not feverish, was also achy and had a badly sore throat with bitterness in the back of his mouth: a symptom, he said, that was unique to his bouts of malaria. Rosslyn, PSGH’s head of public health (and a pharmacist like Dennis), immediately took a slip of paper and began writing down some ACTs she recommended, so that Jonas could run out and buy them. Sensing the opportunity, I jumped in and asked if we couldn’t first use RDTs to make sure that they actually had malaria. For a split second you could hear a pin drop, but then they all decided to humor me. I offered to go home with Charles (PSGH's driver) immediately and grab them, but it was already late in the day and John and Jonas both decided that they were fine waiting until first thing in the morning. I felt bad, like I was the reason for them not being treated today, like I was the white man rationing the medication for the Africans. John, always quick with a sarcastic barb, grinned and said, “We will take the test, but I fear we are wasting them, since I have no doubt that it is malaria.” Jonas nodded his agreement. Again, I offered to go home to grab the tests, so we could do them now, but John, seeing the anxiety on my face and sensing the tension, put his arm around my shoulder and said “No worries. Tomorrow, we will see.”

John, PSGH's sly, slick-dressed accountant

Jonas, PSGH's always-smiling handman, with his typical headphones

Tomorrow came quickly, and I was sure to bring the box of RDTs to the office. Jonas was already hard at work when Dennis and I arrived, but we decided to wait for John to do the test. Waiting anxiously for John’s arrival, I opened the box to look through its contents. It was filled with lots of little, individual packages neatly arranged in a space-saving manner. The box contained: single-use sterilized lancets (miniature plastic swords), single-use alcohol swabs, single-use pipettes, the bottle of buffer and the test cards. While it was a little confusing staring at all those little packages, when John arrived, Rosslyn took over - she had actually attended a MoH training session to learn how to correctly administer it – and it was pretty logical. You wipe the tip of the index finger with the alcohol swap, do a little finger prick with the lancet, get a few drops of blood with the pipette, drop two or three into one of the little basins on the card, squeeze two drops of the buffer into the other, and wait 15 minutes for results.

box of malaria RDTs and contents, from left: test card and pipette, buffer, alcohol swap, and sterilized lancet

We administered the tests in Rosslyn’s office, which I currently share with her. Jonas excitedly granted his finger to Rosslyn and watched the proceedings. John, on the other hand, had a decidedly all-knowing air about him, as if this was a meaningless perfunctory task which would only confirm what he had known all along. The “patients” left the room for the interim, as I snuck furtive glances at their test cards on Rosslyn’s desk. RDT results are displayed with 2 clearly-defined lines that would either appear or not on the face of the card. If the “control” line appeared, it meant that you had conducted the test correctly; if it did not, you had to do it over. If the other line appeared, a case of malaria was confirmed. Pretty simple: two lines = yes, one line = no. After a few minutes, the control lines on both of the tests appeared (good), and Rosslyn and I waited anxiously (I saw her sneaking glances, too) for the others. 15 minutes passed, 20 minutes passed, for good measure, we waited a full 30 minutes, but no second line appeared on either test.

RDT card showing negative result, on left are the two basins where the buffer and blood are dropped

When Rosslyn left her office to break the (good) news to them, their immediate response was to question the quality and validity of the test: “Are you sure this thing works?!?” “I’m sure I have it!” Rosslyn successfully parried those concerns by assuring them that the RDT is very accurate and a false negative is extremely rare. The next question, which Rosslyn so eloquently posed to me upon re-entering her office, was more troubling: “OK, now what?” In theory, the answer to the “OK, now what?” question is that the person should now go to the hospital for more tests to determine the identity of the bug that is actually ailing him/her. But I don’t have to reiterate what is wrong with theory. In reality, John had already started taking SP the day before, and Jonas did not want to wait in line at the hospital for more tests, so he did nothing and ended up feeling better in a few days. From a public health standpoint, this little 2-person experiment can provide a lot of insight into challenges facing this new diagnostic policy, especially in the private sector:

1) The public’s perception of what is and is not malaria is incorrect. This might be the consequence of too much of a good thing, where donors, government ministries, NGOs and others have put so much stress on combating malaria that the general public perceives the problem to be worse than it is. Every Ghanaian has grown up knowing and fearing malaria since birth, so when in doubt, they err on the side of malaria. It’s a common sense approach that anyone would do, but it is a real problem that is both very tough to fix and getting bigger, as malaria transmission rates go down.

2) Getting patients and practitioners to use and trust the validity of the RDTs will be a big hurdle. This was evidenced by John and Jonas’ initial reaction to their test results. In the public sector, this is not so much of an issue, but when patients have to actually pay for the RDT with their hard-earned money (instead of just finding a shop that will give them antimalarials without taking an RDT), this is a major challenge. There is also a growing body of evidence showing pharmacists and others dispensing anti-malarials anyways, even in the presence of a negative RDT result. It is not just patients who need to work on their trust issues.

3) Issue 2 in compounded by the profit motive of practitioners. As we know all too well in America, when healthcare is provided by parties with a profit motive, the incentives affecting behavior do not always align with those actions necessary for optimal individual or public health outcomes. Pharmacists in Ghana make good money dispensing anti-malarial drugs. This new policy calls for testing all possible malaria patients with an RDT, and that a good chunk of them (who they would have dispensed anti-malarial drugs to in the past) will come back negative. A negative result will mean that you can either give them something OTC (most likely with a lot smaller profit margin than an ACT) or tell them to go to a hospital for more tests (no further monies coming into your shop). How likely is it that pharmacists and other, less-trained dispensers will turn sick patients away because they need to have more tests done? How likely is it that the patient will actually go wait at the hospital for those tests, when the reason they came into the pharmacy in the first place might have been to avoid those same lines?

4) What did John and Jonas do? John chose to incorrectly self-medicate, while Jonas chose to do nothing. Leaving alone the fact that John managed to procure an antimalarial (SP) which is not supposed to be available anymore outside public hospital (and only used for pregnant women), how likely is it that patients with a negative RDT result will self-medicate, or go from shop to shop until they find one that will give an anti-malarial without conducting an RDT first? The policy is only as strong as its weakest link. And Jonas did nothing. Whether because he did not want to miss work, did not want to wait at the public hospital, could not afford a private clinic, or any other one of myriad reasons, is this outcome any better than anti-malarial over-prescription?

5) This entry is becoming much too long, so the final lesson that can be learned from my little experiment is that laboratory capacity will become even more important when this policy is rolled-out. Two RDTs = two negative results = two more patients that should then go get further testing done. The number of trained laboratory technicians capable of conducting the requisite amount of tests is already much too low in all developing countries. Microscopy takes time, culturing samples takes time, and these health workers are already spread too thinly. Some tests take days or weeks for results: days or weeks in which the patient is still sick. If we really expect patients to obediently wait it out, the MoH should couple this policy roll-out with adequate increased investments in laboratory capacity. Is that happening? All signs on the ground point to no.

So what is my part in all this? I’m trying to secure funding for PSGH to go all over the country and run training programs for all of its member pharmacists in this new policy prior to roll-out. I think that’s enough malaria talk for today. We’re really getting into the weeds on some of this stuff, and I know you’re all very excited! My next couple extries won't be malaria-related at all, so I'll give you all a break for a bit, I promise!

* In Ghana, licensed chemical sellers are able to dispense only over the counter products (including anti-malarials). They are not trained pharmacists and, so, cannot dispense prescription drugs, but they outnumber pharmacists almost 10 to 1.

** There are dozens of malaria RDTs currently marketed worldwide, all with variable quality. Thankfully, the WHO and others partners have begun conducting lot tests to determine the quality of each. The brand I procured from the MoH received very high marks for quality from the WHO lot tests.

Football and More Football

For those of you who were worried about my ability to watch the Super Bowl this past weekend, fear not; I was successful in finding a place. There is a local sports bar called Champs, which is a favorite among expats for its nightly specials (Tuesday is ½ price kebobs, Wednesday is wing night, Thursday is trivia, Friday is karaoke, Saturday is an all-you-can drink special, Sunday is movie night, etc.), its plethora of flat screen TVs, and its satellite subscriptions showing any sporting event around the world that you would ever want to see. You can see why it is slowly becoming my go-to spot. The first night I hung out there was actually on New Year’s Eve, and I haven’t looked back. Champs happily stayed open until 3am to cater for all the rowdy Americans wanting to see the big game, myself amongst them.

sign outside Champs

the back of the Champs menu outlining the daily specials

In other football news, you will all be happy to know that I have decided to become a full-fledged supporter of the English Premier League team Everton. (That's a soccer team; or, as the rest of the world calls it: football.) I spent the first few months here just happily enjoying all the games (matches) allegiance-free, but something was definitely missing. It was really easy for me to tease Dennis when his team, Chelsea, lost, or to give Desmond a hard time when his team, Manchester United, did. But they couldn’t give it back to me, because I did not support a team. This situation was pretty unfair to them. And since I have already resigned myself to probably not being able to watch a single White Sox game all season, it was also necessary for me to find another team to root for.

And so, I had the task of picking a team. For those of you who don’t know, there are 20 teams in the English Premier League. Every season, the bottom 2 or 3 teams get relegated to the second division for the next season, while the top 2 or 3 teams in the second division get bumped up into the Premiership. I didn’t go through a long process like ESPN writer Bill Simmons did when he picked a team (Tottenham Hotspur) to support back in 2006, but I had already watched enough games to know which teams were fun to watch. While Simmons based his pick on things like the owner, jersey color, and team nickname, my criteria were a little less defined. I had already narrowed it down to half a dozen potential teams back in December, and then Everton announced that they were picking up USA captain Landon Donovan on loan from the LA Galaxy. Everton was already in my top six, because I liked the coach, fans (a lot like White Sox fans), style of play and general vibe I got from their club. Not to mention their goalie, Tim Howard, is also the starting goalie on the USA national team. (For some reason, all the Premiership teams with Americans on them had made my cut.) When Donovan came in January, I anxiously watched his first few games to see how he would fit in, and he delivered in a big way. What sealed the deal for me is that their center midfielder is this tall, lanky Belgian guy named Fellaini who sports the biggest afro I have ever seen. And so it is, that I am now an Everton fan.

This is how I roll now.

The reason I mention my Everton fandom here is because I was headed to Champs on Saturday to both watch their match against archrivals Liverpool and see if they would be showing the Super Bowl the next day. While Everton unfortunately lost their game, I learned that not only would they be staying open late to show the Super Bowl, but also that Sunday night is movie night and they would be showing (a bootlegged copy of) “Up in the Air,” a movie that I really wanted to see.

When Sunday night rolled around, I made my way over to Champs for the Super Bowl and what was my first of probably many movie nights there. Sitting in fairly comfy booths with all the lights off, we watched George Clooney, projected on a good sized screen, as he fired hundreds of employees he did not employ for the next two hours. Watching a movie in a sports bar, I have to say, was quite interesting.

3 quick pros and cons:

pros:
1.) the movie was free
2.) no commercials beforehand
3.) the movie was free

cons:
1.) a few times some guys playing pool in the back room would yell and you would miss lines
2.) no previews
3.) no popcorn

Either way, the movie was pretty entertaining, and when the lights came back on, it was game time.

About an hour before kickoff, the place was filling up, and I could no longer have the booth to myself. Fortunately, a very nice couple from Atlanta sat next to me. The woman, Ashowa, had grown up in Ghana, but been in the US for most of her life and was back visiting her mother for a few weeks. About that same time, a half-dozen teenage-looking kids (I swear one girl looked like she was 13, but they were probably in some sort study abroad or exchange program.) rolled in and took the table right in front of the projection screen. Another of their group was a skinny blonde girl with a pony tail wearing a Drew Brees jersey. She quickly made sure that everyone in the bar knew she was from NOLA and led the first of about 4 dozen WHO DAT chants. I was pulling for the Saints because of two good college friends who are from NOLA and love their Saints, but honestly, this girl was so annoying (and completely wasted even before The Who stepped on stage) that I almost changed allegiances. But then I remembered Dave and Chelsey and continued rooting for the Saints.

projection screen and other TVs; loud blonde girl on the right

Ashowa, her husband and I endured the endless pregame babble from the Chris Berman, Mike Ditka and the other monkeys who never fail to look like blind people helped them in their wardrobe selections. They finally gave their picks for who was going to win, but astonishingly, none of these “experts” predicted a double-digit Saints victory or for the Colts to score less than 20 points….and Robert Meachem certainly did not have a big game, as one of them boldly stated. After the completely unnecessary God Bless America (was Rupert Murdock running the show?), it was time for the National Anthem, the coin toss and kickoff!

another view of the great Champs ambiance

All in all, it was more than I could have asked for. I got to watch the Super Bowl live at a really fun bar and have a comfy place to sit in front of several big TVs, not to mention that is was a really good game and my team won. The main/only drawback to my Ghanaian Super Bowl experience was the lack of commercials: something I look forward to almost as much as the game itself. The bar got the game on a direct ESPN feed, so all we had for 4 hours were commercials about ESPN 360 and ESPN Deportes. And the only "This is Sports Center” commercial (which are consistently hilarious) aired was the one where Drew Brees is driving a big Mardi Gras float and can’t get it through the main gates at ESPN, which we saw no less than 12 times.

When the game was finally over, the rowdy, now-drunk, blond girl led her last WHO DAT cheer and almost fell backward into the projection screen after an overly-enthusiastic jump. Looking at my watch, I saw that it was past 3am. I bid adieu to the nice couple from Atlanta and followed the crowd outside. I flagged down a cab, and quickly made my way home, where I was able to sleep almost a full 3.5 hours before my 6:59 alarm reminded me that it was Monday morning: time for work.

More Than You Ever Wanted to Know About Malaria

As promised, here is another work-related blog. I have tried to keep the acronyms to a minimum but found it very difficult. The good news for me is that my work life is starting to get interesting. The bad news for all of you is that my upcoming blogs will invariably have a lot more to do with malaria (control) and a lot less to do with goats and beaches. But seriously, some of this stuff is really interesting (at least to me), and I will try my best to convey it in a way that you will also, hopefully, find it more than soporific. Now, the readership of this blog certainly has varying levels of knowledge about malaria. In an effort to get everyone on the same page, I will do a general overview of the disease and the main interventions currently in use to control it. Once that is taken care of, I can get into the interesting stuff in future entries and keep the explanations to a minimum. For those of you know all of this stuff, bear with me.

Malaria is an infectious parasitic disease endemic to most tropical and sub-tropical countries in the Americas, Asia and Africa. In humans, it is caused by 5 species of a parasite of the genus Plasmodium – falciparum, vivax, ovale, malariae and knowlesi – with falciparum by far the most deadly, as well as the predominant species in sub-Saharan Africa. The parasite is transmitted to humans via a mosquito bite, specifically the female Anopheles mosquito. Once inside humans, the parasites migrate to the liver and begin multiplying inside liver cells. After an incubation period, usually 6-15 days, these cells rupture and the parasites escape into the blood stream and infect red blood cells: killing those and infecting new ones. The most common clinical symptoms of malaria include sustained fever, shivering chills, joint and muscle pain, headache, vomiting, fatigue and dry cough. Severe malaria cases can lead to coma and death. Less common is a malarial infection of the brain, known as cerebral malaria, which can cause permanent cognitive impairments and brain damage, with children being much more vulnerable.

Annually, there are believed to be between 300-500 million cases of malaria each year, killing between 1 and 3 million people: 90% of these deaths occurring in sub-Saharan Africa and the vast majority killing children under 5. Adults die much less often from the disease, especially in endemic areas with "stable malaria" transmission, which I explained in a previous blog. (The large range of disease burden estimates is inherent in high-transmission, resource-poor countries with many constraints to adequate diagnosis. This will be discussed further in future entries, so stay tuned. I know you’re on the edge of your seat.) Malaria is the number one cause of death of children in Africa, and among adults, the lost productivity due to illness is estimated to be 1.3% of GDP. In some high-burden areas, it is estimated that malaria consumes up to ¼ of all household income.

Currently, there are 4 main interventions used to prevent and treat malaria in endemic areas. The first is using insecticide-treated bed nets (referred to as ITNs, LLINs, or other acronyms) to prevent the mosquitoes from biting humans, thereby preventing the transmission of the disease. The rationale behind this is that the Anopheles mosquito likes to bite at night. So, if people can cover their sleeping areas, this can prevent transmission. The current nets last 5 years; after that the insecticide wears off, and they become less effective. Many countries give nets out to pregnant women and children (the most vulnerable population) in the public sector hospitals and clinics for free. Prices vary greatly in the private sector, but in Ghana, you can pick one up in a pharmacy for about $7-$10. Bed nets have been shown to be an extremely cost-effective intervention, and they are now a major part of most national malaria control programs. There are also some NGOs and charities specializing in bed nets that you might have heard of across the pond, most notably Nothing But Nets, which partners with the NBA, and Malaria No More, which runs a very successful program with American Idol called "Idol Gives Back."

The second intervention is called Indoor Residual Spraying (IRS), and it involves going door to door to spray the inside walls of residences with insecticide (yes, sometimes even DDT). The rationale here is that the Anopheles mosquito, in addition to liking to bite at night, also prefers to hang out on the inside walls of homes. If we can make it so that they die every time they land on the wall, then that is one less malaria-carrying mosquito. The IRS only has a 6 month duration and can be fairly expensive, but it has still been shown to be another very cost-effective prevention intervention.

The third tried and true intervention is called Intermittent Preventative Therapy (IPT) during pregnancy. This is where pregnant women are able to take a drug during pregnancy to protect themselves and prevent mother-to-child transmission of malaria. In Ghana, the drug used is called sulfadoxine-pyrimethamine (SP, for short), and is, ideally, given 3 times at different intervals during the 9 month gestation. As children and pregnant women are the most vulnerable populations for malaria infection, this makes inherent sense and has been shown to be very effective.

The final intervention, and the one that I am most involved with in my current capacity, is increasing access to the most effective drugs available: artemisinin-based combination therapies (ACTs). Artemisinin is a drug derived from the plant Artemisia annua, or Chinese wormwood, whose antimalarial properties have been known to Chinese traditional herbalists for centuries. In the last 5-10 years, using ACTs has become the WHO (World Health Organization)-recommended treatment for uncomplicated malaria in all endemic countries due to their high efficacy and tolerability. Unacceptable levels of drug resistance have developed to all of the previous first-line antimalarial treatments, including chloroquine, SP, and artemisinin monotherapy, but using artemisinin in combination (as with ACTs) helps prevent the emergence of resistance, since 2 different drugs with 2 different mechanisms of action are attacking the parasite at once. The challenge with increasing access to ACTs is two-fold: first, over half of all malaria cases are treated in the private sector (mostly in pharmacies and community drug seller shops), and second, the natural extraction of artemisinin is costly, which means that ACTs are quite a bit more expensive than the aforementioned alternatives and out of reach for most people. A lot of this taking place in the private sector means less government control, and in resource-poor developing countries, this means that even though effective treatments are on the shelves, much less effective ones are often given (or a fraction of a regimen of ACT is given), which continues to drive drug resistance.

(Worth mentioning here is an exciting donor-funded project being piloted in 9 countries (including Ghana) called the Affordable Medicines Facility – malaria (AMFm), which will highly subsidize the purchase price of ACTs, hopefully making them as cheap as, if not cheaper than, all other alternatives for the end-user. Much more on this to come in future blogs.)

These challenges are also compounded by the difficulties of adequately diagnosing malaria, where the vast majority of diagnoses (especially in the private sector) are presumptive and symptomatic (euphemistically called clinical diagnosis) rather than confirmed with laboratory tests. This practice is actually recommended by WHO in most high-burden countries, especially for children under 5. However, as the main symptom of malaria is fever, it has becoming common practice to equate all fevers with malaria and treat accordingly. And, not surprisingly, more and more studies have concluded that there is vast over-diagnosis of malaria and over-prescription of antimalarials happening. Combined with this growing evidence base of over-diagnosis, studies showing decreasing transmission rates in some countries (thanks to the interventions above), as well as the development of accurate rapid diagnostic tests (RDTs), have made it feasible to take action in some countries. And Ghana is one of those countries. The 2009 Strategic Plan from Ghana’s National Malaria Control Program (NMCP) calls for moving from clinical diagnosis to laboratory or RDT-confirmed diagnosis. While this is an exciting paradigm shift, indeed, it is one thing to have it on paper, and another thing entirely to roll it out in practice (especially in the private sector).

So there you have it: Malaria 101 brought to you by Scott(y). Don’t say I never gave you anything. As you can see, there are several cost-effective proven interventions in the arsenal, which makes malaria control a very dynamic field to be in. However, challenges remain, especially in relation to leveraging the full potential of the private sector (“leveraging” is business speak for “using to the fullest”), which is why working with pharmacists is an exciting place to be. There will be much more on malaria to come, and you have been adequately warned, so try to contain your enthusiasm. And, to answer your question: no, there is not a vaccine (yet). The farthest one along in the pipeline is British pharmaceutical giant GlaxoSmithKline’s (GSK) RTS,S candidate. It is in phase III clinical trials, but it is at least 3 years away and will most likely only be partially effective (30-60%).

I know that I used the word gestation is this post, so I hope it wasn't too much like a science lesson. And I apologize about the lack of pictures. I’m tired of acronyms, aren’t you?