If this is your first visit to my blog, you’re welcome to read this post, but it might make more sense to start at the beginning (bottom of this page), with the “We’re in Ghana!” post and work your way forward chronologically.  At the very bottom of each post is a set of two black boxes with white arrows; if you click the left-facing one it will take you to the ‘next post’, and eventually you’ll arrive here.

Before we left for Ghana I spent a good deal of time researching, reading about Ghana, interviewing others who had spent time living there, in hopes of avoiding major pitfalls and social faux pas.  One anthropologist I interviewed gave me a lot of good insight, despite the fact that her own two-year experience living (and working as an anthropologist) in Ghana had effectively ended her desire to remain in her chosen field.  She returned to the United States from Ghana with a masters in anthropology, and when I met her she was working as a waitress.  Reviewing my notes from the two-hour interview I conducted with her in March of 2010, the first thing she said was “their first question will be, ‘what did you bring us?’”  It was this expectation that Westerners are there to ’save’ them, to give them things, that was off-putting to her.  She told me of a school project in her village:

A farmer had donated some of his land so that a school could be built by UNICEF.  Something went wrong during the construction of the school, possibly with local contractors, and UNICEF pulled out of the project with it halfway finished.  The villagers could have banded together to finish the school, but their expectation was that some other NGO would come in and do it.  No other NGOs were interested, because then they would have to share credit for the school with UNICEF.  So the half finished school sat, perennially half finished, covering previously useful farm land.

In a way, her experiences helped to immunize us against some of the damage and perceptions created by Western tourists, aid workers, and “voluntourists”.  Where she had gone to Ghana as perhaps a slightly-too-naive masters student, we went as amateur ethnographers who were aware of this and other unfortunate phenomena.  Much has been written about the aid culture, perhaps most notably by William Easterly, Linda Polman, and Robert Chambers.  What is most sad is that in a paradigm where Africans are supposed to benefit from the benevolence of others, it is the Africans who are most victimized, while the ‘benevolent’ generally get to feel good about the charity in which they have engaged, never knowing that schools are left half-built (amongst other injustices), and those they “helped” might actually be worse off for the “help” they received.

I am a person of privilege.  By virtue of the nation of my birth, I am rich.  By virtue of the color of my skin, certain benefits nearly the world over are conferred to me.  By virtue of the education I have been fortunate enough to receive, I am in a position to make a difference for others.  It seems to me that the moral question of the remainder of my life has a clear answer.  If my goal is to serve others, I can think of none more deserving than the poor, than those with the least access to education, to healthcare, to the basic fruits of science and technology.  Whether my service will ultimately be to those in my own country, or to those in Ghana, Nigeria, or elsewhere, it is more clear to me today than ever that nothing is more important to me than working to undo these structural injustices.

It can be difficult, at times, for any of us to have the necessary empathy for others.  As someone for whom empathy comes easily, I find myself forgetting that empathy may sometimes be absent for some.  In Nigeria, traveling with a [Nigerian] nurse-midwife, seeing children who were dying of malnutrition, we were all outraged.  The direction of our outrage differed, however.  The nurse found herself upset with the parents — upset that they had forgone vaccination of their children (which was free at the local clinic), upset that they had sometimes failed to seek treatment when their children fell ill, upset that some of them simply left their child’s survival “in the hands of god.”  This was upsetting to me too, but I did not, and do not, direct the bulk of my outrage to these parents.  The parents are nearly as much the victims of structural injustice as their children.

For me, I think, it was easier to see that parents may not understand the benefits of vaccination.  That they may not trust the health workers who offer vaccinations.  And that in an area where one in five children will die before its first birthday, and where the average family will have more than five children (and thus experience, almost inevitably, child death), it is easy for me to see how parents may become fatigued — that parents may come to feel as though anything they do is nearly ineffectual, that life or death is solely the will of god.

It was, I think, easier for me to see this, than for our Nigerian nurse.  I had presumed the nurse would have an even more lenient viewpoint than I, and I was surprised to find that was not the case.  She, being a Nigerian, is much closer to the situation than I, and more likely to impose her own worldview on those we encountered.  I understood going into this that there was almost no way any Nigerian villager would share my worldview, and this allowed me to be more open to seeing their own.  What it taught me is that I must work to have more patience, more empathy, for those in the United States.  In the months since, I have found myself, on occasion, about to pass silent judgment on someone in my own country, and found the need to pause and remember that the closer one is to a situation the harder it may be to find empathy for those who are victims of that situation.

I spent much time driving to remote areas with this nurse, discussing the nature of humanity, and my viewpoint at the time was that most, in fact virtually all humans, will act in a way they feel to be rational.  For instance, [virtually] no parent wants to harm her child.  So the question is, if harm does come to a child, what went wrong?  If we can accept the premise that humans generally act in a way they feel to be rational, then why did the situation that led to harm feel rational to that parent?  Why, for instance, might not vaccinating your child feel rational?  Or why might not seeking treatment for your sick child feel rational?  The more I want to condemn someone for failure, the more I must work to first ask myself this question and to be open to empathy.

Another thing we found was, as you might expect, very different attitudes toward healthcare in Africa than in the United States. In Ghana, we encountered a much more collectivist viewpoint than exists in the United States.  I cannot imagine mass immunization days taking place in the US, and even if they did, what I certainly cannot imagine is doctors grabbing lone children off the street and immunizing them without parental involvement — yet this is commonplace in Ghana.  In this regard, I found Ghanaians to have much more trust of their government and of the public health system than [the typically individualistic] Americans.

Some of the drawbacks of emergency care seemed on par with America.  The cost could run into days’ worth of wages, and much of this must be paid up front.  Many people circumnavigate the doctor’s office or hospital by simply visiting a local chemist (pharmacist).  This is a situation about which I have experienced much ambivalence.  The chemists are quick to push antimalarials and deworming medications, two classes of drugs that are no-doubt widely needed in Ghana.  At the same time, I found some chemists to have little medical knowledge at all (or even English fluency), and they are undoubtedly pushing drugs which may be inappropriate for many patients.  Anyone with a fever or headache will get malaria treatment.  For many this will probably be the correct course — for some it will not.  A doctor would be more able to make that diagnosis, but many of those who visit a chemist are unable to afford a doctor.

In Nigeria we found many, many measles patients who had first seen a chemist for treatment and ended up with either Tylenol or antimalarials (before finally going to the hospital when those did not alleviate the problem).  So I don’t know what the answer to the chemists is; they do harm, but they also do much good for a large segment of the population that otherwise would have no access to medical care.  My ultimate answer, is of course, to make the fruits of public and social health available to all as a human right, but this will not come soon or easily.

In general, in Ghana, large stores do not exist.  In fact, there are really very few ‘walk in’ types of stores.  If a store has a roof, it’s generally either a container shop (made from a corrugated steel shipping container), or maybe a small concrete shop or a plywood ‘booth’.  Much of the commerce in the country takes place on street corners and out of small booths.  In the capital city, Accra, there is a mall, frequented by whites and by affluent Ghanaians, and in the mall there are a couple of dozen Western-style shops.  The Accra Mall reminds me of a low- or mid-level mall you might find in a random medium-to-large sized American city.  With the exception of the mall, though, there is really no sort of organized aisle-based Western-style commerce.

One of the first things to strike me is how alien most Ghanaians would find the United States.  How simply overwhelmed I was when entering a grocery store again for the first time.  Rows and rows and rows of well stocked, nicely lit, neatly organized products.  I do not think, even with an hour of time, could I explain to the average Ghanaian what a Costco or Wal-Mart Supercenter looks like.  I mean, I am sure they could grasp the idea of a giant building full of products, but really I don’t think they could understand it.  It was these unnoticed differences that stuck me most, I think, when returning.  You can buy apples here, and you can buy apples in Ghana, but the experience is very different.  For all of the potential pitfalls in Ghana’s way of doing things (lack of health codes, or at least enforcement thereof, etc), I have a lot of preference for Ghana’s way — 99% of the time when we bought something, we were supporting an individual person or family from our neighborhood, rather than a faceless multinational corporation.

I also think our difference levels of infrastructure and have benefits and drawbacks.  Americans feel very entitled.  If your electricity shuts off, you’re likely to call the electric company right away.  If your Internet stops working for a few days, same deal.  If you turn on the faucet and no water comes out, again, someone is going to hear about it.  In Ghana, these are simply things people accept as a way of life.  On one hand this is unfortunate, as it felt to me that it breeds a certain amount of permissiveness when it comes to infrastructure failing — how much urgency is there to get the water working again if no one is going to call and complain.  If you’re a high-level manager at the water company and some client walks in and wants to pay you $1,000 to divert half of the city’s water to his project for the day, well, you’d be tempted to take that money, knowing you could probably get away with it.

On the other hand, our obsessive expectations about things working, always and instantly, must create a certain amount of stress in our lives.  Comedian Louis CK tells a joke about a friend complaining that airplane seats don’t recline far enough, and Louis has to angrily remind him that he’s in a magical metal tube flying through the sky at hundreds of miles per hour — the message is that he should just shut up and be happy for what he has.  In the same way, I think Ghanaians are very good at this.  They take the good with the bad.  They shrug when the water or electricity doesn’t work, and move on with their lives.  Americans are more likely, I think, to bottle this sort of thing up, or take it out on others.  Either way, we must carry a certain amount of allostatic load that Ghanaians simply do not.  So the next time your cellphone can’t get reception for you to load a YouTube video, just remember: it’ll work again soon.  I found that Ghanaians had developed admirable social modalities for dealing with the various stresses and unpredictable elements of daily life; most Americans could learn a thing or three from the average Ghanaian.

Maybe the most significant thing I learned from my experiences in Ghana and Nigeria, was that inequality didn’t present exactly the way I thought it would.  In global health we use indicators much of the time.  Indicators are great little tools, they are things you can measure, and through inference they can tell you much about a society.  But it’s important to know what indicators to measure.  Indicators like infant mortality, per capita income, and so forth, are common and time-tested.  The age at which the average person will die (life expectancy) is another very commonly used indicator.  Countries with robust public health tend to have very good stats — places like Sweden, Iceland, Canada, Japan, all have very good infant mortality, life expectancy, and so on.  To some extent income is a factor here, but only to a certain level: once your country is “rich”, the overall public health strategy will matter a lot more than whether an average person makes $25,000 or $45,000.  This is evidenced by the fact that the United States has one of the highest incomes in the world, but ranks very poorly when compared against other OECD nations that have lower income levels (but better overall public health measures).

Ghana and Nigeria are interesting examples because they are similar when we look at certain indicators.  I had studied a lot about Ghana before leaving on our trip, but didn’t know much specifically about Nigeria (beyond my general background knowledge).  Partly this was because we knew at the beginning of the trip that we would be going somewhere with a measles outbreak, but not where, exactly, that would be.  It might have been Zambia (which was at the tail end of a huge outbreak at the time), Nigeria, or a couple of other places.  Within Ghana I spent some time looking at Nigeria’s indicators once we knew that’s where we’d be going, and indeed they did look similar to me.  (See image above.)

Before all of this, I’d studied global health both informally and in a college classroom environment, having taken two 400-level global health courses that were heavily indicator-based.  I considered myself pretty sharp when it came to indicators.  If you’d told me how much money the average person in a country earns, I’d have guessed I’d have a good shot at divining the top three causes of death, proportion of population under 15, and so on.  What I hadn’t really realized is how much ‘averaging’ can skew the real picture on the ground.

A year later when I think back to what I learned in West Africa, to what will never leave me, the most striking thing I learned is that any statement made about a population cannot be viewed without context to the stratification within that population.  I feel now pretty strongly that poverty is not as important as relative poverty.  Allow me to try to explain what I mean by this. When viewed on paper, Ghana and Nigeria have about the same levels of income per average person — that is, the average person on the street that you’d pass probably earns about $1800, maybe $2000 per year (according to the World Bank).

When we arrived in Nigeria, I was surprised to see that it was significantly more developed than Ghana.  Lots of little clues almost right away led me to realize there were way more persons of wealth and privilege there.  The freeway overpasses and general construction looked way more ’solid’ than in Ghana.  I saw more expensive cars in traffic (and more cars in general).  What didn’t immediately occur to me, but soon would, was that for every person who makes, say, $20k per year, in order for Nigeria to keep its $2k average income that means nineteen or so people have to make around $1000 instead of the “$2000″ that the ‘average’ income would suggest.  Or to say it another way, the income averages out to $2k per person, but the spread from poor to rich is greater in Nigeria than in Ghana.  It is this stratification that is really critical.

The first night we were in Nigeria we stayed in Abuja, the capital city.  Our contact at UNICEF, who was one of the nicest and most helpful people I’ve ever met, got us a bargain-basement UN price at a local hotel.  Our room, comparable to something in the U.S. that you might find at a Motel 8, was $200 per night.  With discount it dropped to about $100.  WOW.  Needless to say, after months of trying to live on $8-10 per day (for food and lodging), this was a shock.  We’d actually only come into the country with about $500 in cash.

After we moved on from Abuja to Kaduna, the UNICEF office there again had more supremely helpful employees, one of whom drove us in his own car to the cheapest hostel any of them could think of.  It was a Catholic guesthouse, and our room was $40 per night.  We had electricity and water for a handful of hours each day.  This room was comparable to the guesthouses we’d stayed at in Ghana, except those had typically been $8-10.

So where am I going with all of this hotel rambling?  Right away in Nigeria I noticed the prices of things seemed to be at least three times whatever they were in Ghana.  Sachet of water?  Three times.  Guesthouse room?  Four times.  Now, many of the things that we purchased were marketed towards those with money, so the price inflation for staples (rice, casava, etc) might be less marked, but my overall point is this: as your society has more and more wealthy folks, those folks are prepared and able to pay more for goods and services.  Prices go up.  Those who are not wealthy are less able to afford goods and services.

The link I give above goes to per capita income expressed in PPP dollars — purchasing power parity.  This indicator is supposed to take into account things like the cost of bread, clean water, and so on, to get at the real income of the average person.  If you are living on a dollar per day, it really doesn’t matter if your neighbor drives a Mercedes or not, a dollar isn’t going to cut it.  But, if you are living on $6 per day, whether a bag of rice is $3 or $9 is going to make a big difference in whether you can eat or not.  And whether your neighbors with the luxury cars and disposable incomes are buying rice might inflate the price from $3 to $9.  Absolute poverty is important, but so too is relative poverty.  To give another example, $12 per hour might be an okay wage in Iowa; in San Francisco it will be much more difficult to live on such a wage.  The wider the stratification of income within a society, the greater the problems for those on the wrong side of the fault lines.  Ironically, the PPP chart actually shows Nigeria as having more purchasing power — this was not my experience.

Purchasing power wasn’t a concept that was really foreign to me before Nigeria, or even Ghana.  What it took was seeing the concept in application in Nigeria to make me realize the power and tragedy of averaging. That is really what I learned in Nigeria.  Here was a country with more development than Ghana, yet also more suffering.  My initial impressions had been how developed they were compared to Ghana, but once I got to the north, especially to rural villages, I saw many things I would never have seen in Ghana.  I saw children malnourished and blinded from measles complications — something that essentially doesn’t happen anymore in Ghana.

I had known coming to Nigeria that infant mortality in the north of the country could approach 200.  In Ghana the average is around 50 (compared to Nigeria’s average of 80).  To me, fifty infants out of 1000 dying before their first birthday is unacceptable.  Eighty is even less so, and 200 is a tragedy of nearly inconceivable proportions.  What I learned, almost right away, is that averaging hide these outer bounds, these more marginalized populations.  For every Nigerian whose child is delivered in a hospital and has a lowered risk, there is another Nigerian, probably a teen, delivering her baby alone or without trained assistance, scared and unsure of what to do, at great risk for infant death, maternal death, fistula, and so on.

I came back to the US and with my revelation: inequality is what matters!  We need an indicator for this!  Income, life expectancy, infant mortality, none of these are truly useful unless we can use some other indicator to get at their spread, at the levels of inequality.  What I quickly found out was that for income this indicator already exists.  The most commonly used indicator for income inequality is the Gini Index.  The higher the Gini score, the more inequality.

And when I thought about it, this sort of made sense.  Poverty is a problem, I am not denying that.  But might inequality be a bigger problem?  Might we often be meaning “inequality” when we talk about the ills of “poverty”?  Cuba is poor, yet the people of Cuba do not die as if they are poor.  They live longer than their counterparts in the United States, they have better infant mortality, and they spend around $200 per year (per person) on medical care, compared to over $7,000 for us in the United States.  Cuba has very low income inequality; most people are marginally poor, and there are essentially no extremely poor or extremely wealthy.  What I began to realize that is from a public health perspective, once you are not starving to death, once you have your so-called ‘plate of basic needs’, income inequality is a much bigger factor.

The United States doesn’t have very good infant mortality for a rich nation, but I started to wonder, what effect might averaging have on this.  I mean, the U.S. isn’t good to begin with, when we look at the average, but what about when we look at the outliers … how can we tease out communities that are at exceptional risk and see how they deviate from the overall population?  If our average is around 7/1000, what is the real number for those who are part of marginalized groups?  For African Americans, for instance, infant mortality is about double the national average.  What might life expectancy be for the “average” white American compared to, say, someone living on the reservation in Pine Ridge South Dakota?

For a little experiment, let’s look at low birthweight newborns.  This is a good indicator because I suspect most everyone reading this will be familiar with how dangerous it is to be a low birthweight baby — this is part of the reason that smoking during pregnancy is so harmful, because it’s closely associated with lowered birthweight.  Low birthweight officially means 5.5lbs or less.  The U.S. overall average is 8.3% of newborns, which is the highest it’s been in 40 years.  This is not a great number, but hidden in that average is an even worse number.  What about when we stratify this information by race?  Blacks have double the prevalence of whites!  In fact, our African American low birthweight stats are so bad that if we use that number alone and compare it to other countries, blacks in America have a higher proportion of low birthweight newborns than many low income African countries: Rwanda, Ghana, Uganda, Tanzania, and so on.  (See Prof. Vernellia Randall’s presentation at 6:46.)  This is what averaging hides.

So many American health professionals volunteer to abroad to try to help impoverished countries increase their health outcomes, but what we find if we tease apart some of the statistics is that black health in the United States might actually be worse than in many African countries, when looking at certain indicators.  Perhaps those professionals should stay and volunteer domestically, if they feel that those who are at the most risk deserve the most help?  Obviously the answer is complicated and multifactorial; I don’t mean to oversimplify, but simply to show that the answer is not cut-and-dried: the health status of some communities in rich countries might be worse than the average status in some poor countries.  This realization reframed how I thought about health in America.  I knew that we had marginalized sub-populations, but I hadn’t fully considered the extent of their marginalization.

In the early part of 2011 I attended an academic forum on population health, and had a chance to pose my questions to a senior lecturer from the School of Public Health at UW.  We talked about infant mortality disparities for black Americans versus white Americans, and I asked how we can tease this sort of thing apart and really get a broad view of the health statuses and disparities within the United States, since averaging hides so much of this.

He explained that it was difficult, and as we talked some more about this concept he invited me to audit his Population Health graduate class.  In the Spring of 2011 I did just that.  It was a very informative experience — he and another physician named Paul Farmer have both had a significant influence on my ways of thinking, and I wrestle daily to continue to assimilate all of the information and ideas they’ve both put out there.  I have been incredibly fortunate to be able to not only attend this class, but to pose many questions in the hopes of wrapping my head around the very abstruse problem that is the determinants of health.  In the last year I’ve read countless books on inequality, and still have many dozens left to go.  My understanding of the human condition is by no means near complete, but I feel a much more educated and extrospective person now than I did 18 months ago, and I have West Africa to thank.

I don’t yet have the answer on how we can reliably get a broad view of marginalized communities within a population.  It is difficult, to say the least.  One promising approach is to use economic inequality (the Gini Index) as a predictor of poor outcomes.  There are several physicians and epidemiologists who have done pioneering work in this realm, and it’s really quite fascinating.  Richard Wilkinson wrote a fabulous book on this topic, and recently gave a short TED talk that does a great job of summarizing his findings, everyone really should watch it.

I was already interested in the social and structural determinants of health before I got involved in this measles project.  Going to Ghana, and then Nigeria, I already knew this was my primary interest — why for instance a child might get measles in Nigeria, but not in the US.  It took traveling to Nigeria for me to realize that it’s not just the health disparities between populations that matter, but the health disparities within populations.  These disparities amount to life and death in a very real way for literally a billion or more people.

I learned that you cannot generalize about countries, populations, even communities.  Within any group there will be those who do well, and those who do poorly.  Just because two African nations have the same average income does not mean those nations are the same, or that one public health approach will work well within the other.  Our goal should be to alleviate both disease and its causes, whether in the United States or in Nigeria, and to innovate effective and culturally sensitive ways of doing so.

When we started this project, we decided to name our non-profit Change For a Billion in the hopes of being advocates for structural change for the world’s poorest, if even just making available a twenty-six cent vaccine.  Before my experiences in Africa I could quote various authors and knew a lot of statistics and figures, but now I have some tiny idea of the significance of those figures — how vitally important it is that we all work together to eradicate the structural harm that immiserates so many innocent people.

You may have heard something about the controversy surrounding MMR (measles, mumps, rubella) vaccinations and a possible link to autism.  This story came to prominence after a 1998 article appeared in The Lancet (a prestigious medical journal in Britain).  In the time since then the article has been retracted by the journal, and the doctor involved in authoring it has lost his license.  Now that some of the details of his license revocation have become public it is now clear that his study wasn’t just bad science, but outright fraud.  “Normal” test results were falsified, three (of the 12 total) children in the study didn’t have autism at all, and the [now: former] doctor who authored the study stood to financially gain from its findings.  You can read about those and other aspects of the fraud at the Telegraph.  In short, the link is completely unfounded, and every credibly subsequent study that has controlled for MMR vaccination while looking for a link to autism has found that no link exists.

In 1996 the worst recorded epidemic of meningitis hit Nigeria, with more than 100,000 recorded cases.  Measles and cholera outbreaks soon followed.  Amidst all of this, Pfizer flew in a teams of doctors to test an experimental drug called Trovan.  The Guardian has a pretty good write-up on what occurred, and the descriptions of Kano State are dead accurate.  Another article goes into detail on the Ministry of Health granting the exemption for the drug to be used (the special assistant in the MoH making this request without knowing what the drug was used for), and Pfizer making campaign contributions to officials in the Kano State a week after the trial was approved.  As if surreptitiously testing an experimental drug (meant for Europe and America) on sick children in Africa wasn’t bad enough, it seems that when families tried to sue Pfizer, the company reacted by blackmailing the Nigerian Attorney General.  A Wikileaks cable has revealed “Pfizer had hired investigators to uncover corruption links to federal attorney general Michael Aondoakaa to expose him and put pressure on him to drop the federal cases,” and the $6BN suit against Pfizer was withdrawn by the attorney general, in return for a $75M settlement, with $35M going to the families of the children who died.

On a brighter note, Ghana has had nine months without transmission of Guinea Worm; three years without transmission are required for Guinea Worm to be certified eliminated.  Ghana is one of only four countries where Guinea Worm hasn’t been eliminated.  Among parasites this is one of the most painful, and we’re very excited for Ghana’s progress — down from 242 cases in 2009.

Here’s a new study confirming what we already knew, that giving Vitamin A to children precipitates a drastic lessening of mortality.  The study found a 24% reduction in mortality from “any cause.”  What’s interesting is that a senior reviewer of the study is quoted as saying that Vit A is actually reducing the incidence of measles, not just the mortality.  So that is great news!  Currently WHO/UNICEF measles vaccination programs (like the ones we filmed in Ghana and Nigeria) give Vit A capsules in addition to vaccination.

The government of Japan is known for supporting humanitarian aid, and has just given a $10M grant to Nigeria to combat vaccine preventable diseases.In other Nigeria news, here’s a sad article about goldmining killing kids in the north.

A sad article from the ICRC talking about child mortality from measles and other preventable causes in Afghanistan.

Lastly, here’s an interesting article from the New York Times that details the progress of Gates Foundation grants.  Amongst the grant recipients was Dr. Sievers inhalable measles vaccine, which we’ve covered here previously.

Today her driver had overslept, so she drove us herself.  This gave me a chance to sit in the front with her, which made for more optimal conversation.  Normally she sits in the front and we in the back, so we don’t converse as deeply as today.  The 90 minute (or more?) drive to Ikara afforded a lot of time for us to discuss our Nigerian and American cultures and their similarities and differences.  America and Nigeria are large from both a geographic and population standpoint, so I think the two have more commonalities than most people might realize.

We saw several cold stores today, and it is interesting to see how they scale downward in size as we approach smaller cities and villages, but they are all mostly the same: freezers; generator(s); lots of handmade posters on the wall with catchment maps, population data, focal person cellular phone numbers, and so forth.

The village we’d heard had an outbreak was a small (by Nigerian standards) place called Sia Sia (also spelled Saya Saya).  We made an appearance at the community gathering area, met the focal/ward person for the area, and he set off to show us the cases he knew about, we saw families with five or six children who all had just recovered or are now recovering from measles.  Most of these cases were fairly straight forward and there weren’t major complications other than anemia or some minor malnutrition.  The very first case we saw though, I wasn’t allowed to enter because I am male (something about Muslim tradition that I didn’t quite grasp the intracacies of but was willing to accept), was a girl of two who was extremely malnourished.  The mother was flippant about her condition, ascribing her fate to the “hands of God.”  This is hard enough to hear for a normal meales case, but a lot harder when a plump, nearly obese mother sits in front of you ignoring her skeleton of a child.  I wasn’t present for this, but reviewed the footage Miranda shot, and am pretty horrified.  We both spent some time talking with Amina trying to figure out what we could do — giving money to the mother for medical treatment (which is free here anyway), Amina was certain, would only be pocketed by the mother.  Short of bringing a nurse with PlumpyNut directly to the house, there’s little we could do, and even if we could somehow do that (nevermind it takes weeks to fully recuperate a malnourished child), that wouldn’t much protect the child from the next time she is on the precipice of death and her mother decides to let fate or God decide.

I am sad to say, but it’s possible the child will die, and there is little we can do.  Amina is going to return to try to make further interventions for the child, but it may be too little, too late.

One of the last cases we saw was a little more promising, but still heartbreaking.  The mother had heard we were in the village and sought us out.  Again, there is a free clinic she can go to that is not far, but at least she made some effort, even if only to see us.  She hadn’t taken her child to the clinic because the father is away and she needs his consent.  It was explained to me that this ‘father consenting for any treatment’ is semi-official — I get the sense that if she was empowered and demanded treatment for the child she would get it, but there may be reprecussions later from the father for disobedience on her part.

The child was maybe a year-and-a-half old, bleeding from the nose and mouth, with both eyes stuck shut and literally crying puss.  The rasp of the child crying was closer to stridor* than normal crying.  This is a child that will almost certainly be blind if she doesn’t receive immediate treatment, and even with immediate treatment it may already be too late.  This is the first time in my life I have even conceived of, let alone seen first hand, tears of puss.

There was another village not too far away having an outbreak as well, but after seeing dozens of cases in Sia Sia in just a short period Amina felt it would be more-of-the-same to go to the second village, and we should focus on doing what we could for the first with the limited time we had.

We spent about an hour meeting with the chief of the village, imploring him to do whatever he could to motivate the members of the community to avail themselves of the clinic.  After suggestions from his council and from us and Amina it was settled that he would speak to the village members and that Amina would come on her own time with other nurses to give informational seminars, and that a few other avenues of educating and pursuading the members of the village would be pursued (trying to get the local clinic to do outreach, etc).

After the meeting with the chief, we tracked down the immunization teams of the area and Amina inspected their paperwork to see how many children they’d jabbed today … one team had done only 27, which is probably about the same number of cases we saw in less than an hour of just going to a few houses.  The other team had fared better, and Amina lauded of their efforts.

Today is, for me, a perfect example of where more funding is needed, although it’s not needed in the most straight forward way — which is to say that this village already has access to free nurse-staffed-clinic care for under-fives and free drugs for most conditions, as well as free immunizations, so the funding isn’t for drugs or nurses, but for more outreach, for education and trust-building within the community (which may also include hiring better nurses or other clinic staff).  Likewise, an ounce of prevention is worth a pound of cure — whatever the cost of trying to save this child’s eyesight, or nourish the other case we saw, it is certainly more than the twenty-six cents of a measles vaccine.

Having a free clinic means nothing is the community won’t use it.  We saw this in Rigasa and again today in Sia Sia.  Having community health volunteers works well for Ghana (something this village wasn’t doing), and in general involving the community in the quality of their treatments is a way of giving ownership over their own outcomes.  When the poorest people of Nigeria will go to a pharmacist and pay money rather than go to a free clinic, you know that something in this picture needs fixing.

I am by no means an expert at this, but I look at Partners In Health (Zanmi Lasante) and their successes in Haiti by involving members of the community in outreach and education, and I would wager this model could be nicely imported to Nigeria.  In the same way Voodoo can sometimes be seemingly at odds with medical science, so too can religious leaders in Nigeria … and in the case of Voodoo, it’s integration of the community and an open-minded approach that doesn’t denigrate religious beliefs that has led to ZL being so successful in Haiti.  If local religious leaders and community elders were brought on board, and if a couple of community volunteers were designated and given training to do early interventions by way of referrals and patient followup I suspect the prevalence of vaccination and incidence of morbidity in Sia Sia would both take turns for the better.

As it was, we were on the ground and surveilling measles cases better than the actual officer assigned to this area.  We made a point later not only for Amina to apprise the district surveillance officer (who was about 10 minutes away, and is a doctor) of this situation, but to show him photographs of the two worst cases, and try to draw his interest.  He glanced at one photo for a second and then went back to his work.  I am not blaming him for their outcome, but of anyone he is in the best position to make an intervention on their behalf: he’s a doctor, he is working and living in the area, and it’s his job to respond to this outbreak; yet from what I have seen he will probably do nothing.  Amina is going to do what she can, both officially and on her own.

When we apprised him we had seen a couple dozen cases, he simply remarked to indicate this jived with the 20 or so he’d had reported to him.  If someone were to go door to door within Sia Sia, I suspect they would find many multiples of that number — but no one will go door too door, because no one has the time, no one is being paid to, and no one cares enough to do so.

When we left the Cold Store, one of the health workers there said he hoped we had a “meaningful trip” in Nigeria, and I think that is the best way to characterize what I have seen.  I have experienced things that have saddened and angered me, and things that have filled me with hope for the future.  If anything, my experience here has been meaningful.

I have more to write, more to say, but at this point I think I still need to process everything I’ve seen.  I hadn’t even come close to really forming concrete conclusions about all of the things we saw in Ghana, and now we’re in the north of Nigeria having so many strikingly dissimilar yet thought-provoking experiences.  The last three months of my life have been quite meaningful, but I think it will take me some time yet to fully process and synthesize all of that meaning.

*Stridor is a labored breathing condition children can develop for various reasons.  It is characterized by a rasp or high pitch when breathing and intercostal retraction.  You can find some videos of it on YouTube I suspect, but I warn you it may be disturbing to watch (although it’s more disturbing to see than it is necessarily damaging to the child).

She texted when she was on her way, and despite Miranda’s desire not to, we snuck out for ten minutes of quick Internet access while waiting.  This allowed me time to post my backdated blog entries, and rapidly check my e-mail (but not really reply to anything).

Amena ‘picked us’ and we headed to do some quick errands with her before Zaria.  The drive to Zaria was picturesque, again in the “great American plains” sort of way; grasslands peppered with boulders and the occasional tiny mountain.  After so many months of jungle-covered rolling hills in Ghana even the smallest bit of topography seems striking.

Zaria has a feeling of being old, steeped in tradition.  The original part of the city is still walled off, it’s probably older than a millenium, although I have no idea as to its exact age.  We drove through streets choked with robed pedestrians, passing temples and narrow alleyways, barely another car in site.  Eventually we found the Zaria Cold Store and were invited inside to see freezers full of fresh vaccines, power courtesy of a large petrol generator in a cinderblock building adjacent to the Store.

Amena dropped us with her contact in Zaria and we left for the Health Department, to do the official notification of our visit before we could find measles cases.  The head of the dept informed us there were no cases at his clinics today but we could check the General Hospital, which reports to the state government and not him.

At the GH we found a handful of cases, mostly with pnuemonia and/or malnourishment.  Measles damage usually comes as a complication of the synergy between measles and other issues, often vitamin A deficiency.  There were two cases with eye complications; measles is the leading cause of blindness in the developing world.  The last case we saw, which was the second with eye complications, will likely result in permanent blindness.  The mother sat sullenly, quietly answering our questions and then lingering in silence as I thanked her in Hausa for speaking with us and letting us film her child.

It was especially hard to encounter that last case — any admitted measles cases at a hospital will mean severe complications, but most of the children we were seeing would make a full recovery after nourishment and drugs.  Here in this case was a kid who would probably never see again, and all of these complications for lack of a nickel’s worth of vitamin A.   This is the exact reason we’re making this film: the world must work harder to reach more children and make these simple, inexpensive, and effective interventions.

Back at the Zaria Cold Store a coworker of Amena’s told us of an outbreak of measles going on in his LGA (Local Government Area) so we’re going to head over there early tomorrow for the first day of Child Health Week to observe vaccinators and health workers.  At the hospitals and clinics it’s hard to get a sense of the scope of the outbreak because the only cases we see are the ones admitted for inpatient treatment (a small percentage) or the outpatient cases that have literally just arrived.  Hopefully tomorrow will hold some door-to-door possibilities to get a sense of the scope of things on the ground.

We drove the hour back to Kaduna, Amena bought us some Fan Ice (what passes for ice cream in West Africa), and dropped us at our hotel.  Miranda promptly passed out, and I’m knee deep in backing up footage, as always … 14 minutes left on tonight’s transfer and then I can sleep for a few hours before we do it all again.

We headed to dinner at a restaurant just up the street from our hotel.  We arrived to find it running on generator power — it seems Kaduna fairs no better than Abuja for electrical grid consistency.  The place was called Tropical Eatery and basically was like something you’d find in a food court of an American mall: rice, meat, and side dishes scooped out of steel tins by employees in an assembly line fashion and served to you on a tray.  We had a lot of difficulties conveying our vegetarianism, and finally just went with the logic that the rice LOOKED vegetarian (and came with meat afterwards, so probably wasn’t flavored with meat).  I had fried rice with plantaines, and after not eating all day it was quite satisfying.  This is the first time we’ve seen any African “fast food” outside of the Accra Mall … normally in Ghana it will take 90 to 120 minutes to get your order, no matter what it is (even if it’s a sandwich).

Back at our hotel we did some charging of electronics and fell asleep.  We awoke a few hours later to prayer call blaring from a nearby mosque.  The A/C wasn’t running, the fan was off too, and the batteries we’d plugged in were no longer charging.  So much for paying 50% extra for a room with A/C (although if we’d had a choice we’d have gone for non-A/C, but what’s the point of the extra cost if the power is always off?).

We caught a taxi in the morning for 500N (slightly too much), and got lost on the way to UNICEF because our driver didn’t know how to get there (despite initially saying he did).  The taxi drivers we’ve had in Kaduna have been much less fluent in English (as well as our servers at the restaurant last night).  This is the first of several observations I’ve made as to the indicators of wealth, education, and health in Abuja versus elsewhere in Nigeria.

After arriving at UNICEF we met with the Health Specialist, the WHO Health Consultant (who would be our guide today), and the Nigerian-MoH-attached consultant in charge of SIAs.  The meeting was very productive and I think we learned a lot as well as became quite aware that UNICEF Kaduna was not only happy to facilitate this portion of our project, but really understood what we were trying to show.

The UNICEF Health Specialist, Dr. Amina, made a very good point about people seeing news on satellite TV regarding the “huge cholera epidemic” in Nigeria (the largest in 20 years) this year, and calling her to convey concern.  In the story she was telling, they called around the time of 300 deaths having been recorded, and she made the point that although every life is important, in a country of 150 million 300 deaths is not that many — far fewer people were calling her concerned about child malaria deaths here despite the fact that there were orders of magnitude more in the same time period.  I’ve heard other public health officials make this sort of point before: that sensationalism easily captures the imagination, so we become concerned about bird or swine flu whilst millions silently die from tuberculosis every year.

We set out with the Health Consultant, Amena, planning a visit the Cold Store Warehouse as first on our list.  We met the doctors running the Cold Store, and saw a plethora of freezers holding various vaccines: meningitis, measles, polio, and so on.  Robed men were offloading vaccines from freezers to portable coolers and then into vans, with the vans were speeding off to whatever destination.  We also saw the adjacent store house where they keep the syringes, cotton wool, finger dye, and so forth.  The entire facility was running on generator power.

Next we set off to the MoH, to meet with the chairman of the State Action Committee on Immunization, to apprise him of our comings and goings within his state and to ask him some basic questions about health indicators in Kaduna state.  He was quite happy to see us (he remarked how he’d already met Melinda Gates and wanted to know if she shared her first name with Miranda — we pointed out the slight difference) and was not only happy to answer questions but also to call the local OPD and arrange for us to see the measles outbreak cases they had today.  We asked our questions, mostly about local attitudes toward immunization, and then departed for the OPD.

At the hospital OPD we found two active measles cases that had been severe enough to admit to the wards; normally measles cases here are simply treated and sent away.  The first child was recovering well, and had caught the measles a week or two ago from a cousin who later died of it, which was heartbreaking to hear.  None of the measles cases we saw today had been immunized properly — Kaduna State has just 21% coverage for applicable vaccines (nearby Jigawa State has 0%, however).  In contrast, Cape Coast has about 85% coverage for measles.

As we saw more measles cases, several themes recurred.  Either parents didn’t care to immunize their children or had heard something bad about the vaccines, and either way once the child fell ill, rather than a doctor visit they went to a pharmacist for cheaper treatment.  The pharmacists either treat for malaria (based on fever), or simply give acetametophin.  This lack of proper diagnosis and treatment leads to complications, and the children often end up in the hospital with severe issues.

We saw a third child at the OPD, who was maybe two-years-old, and had now recovered from the measles but was taken ill with complications.  The nurse referred to these complications as “emphyzema” but I think was being confused with adema, because he was covered with a generalized swelling — his eyelids looked like he had black eyes, his abdomen was swollen, and so on.  I hesitate to post a photo here because his condition was so graphic.  We saw the child naked and his scrotum was extremely swollen, probably the size of a large orange.  Another child we saw who was now recovering has prolapsed his rectum from the severity of his diarrhea.

The final measles case we saw at the OPD was a woman from Rigasa, one of the most ‘non-compliant’* neighborhoods in Kaduna, where there is still belief in the rumors that the vaccines are tainted.  There is a government clinic in Rigasa that offers both free treatment of under-5 children and free drugs, so we set out to find the clinic.

This would prove more difficult than previously imagined and we stopped several times to get conflicting directions.  Partially this is because Rigasa is very large and the clinic has a catchment area that is challenging for it to handle, but also because the people here don’t use the clinic, so they don’t know where it is.  When we eventually found the clinic there were more measles patients there, they see an average of one or two a day, all for outpatient treatment (so they have no idea as to the outcome of the child).

Amena talked to the nurse running the clinic, to find out why they weren’t reaching the surrounding neighborhood.  Partly it’s poverty, and partly ignorance about vaccines, but also partly people just don’t know they are there, or the clinic is understaffed and women who come with their children leave unserviced because of long lines.  They gave recent examples of husbands who won’t let their wives come to the clinic to vaccinate their kids because of religious beliefs, or because of plain obstinance.

We asked the two measles cases we saw there, in depth, why one hadn’t vaccinated her child and why the other hadn’t sought treatment for hers after the child fell ill.  The two answers we received: one had refused to vaccinate her child when health workers came to her house because of rumors she’d heard about the safety of the vaccine; the other had gone to a chemist rather than the clinic because of cost issues.  It is hard to be anything but frustrated with these answers.  Not frustrated with the women, but frustrated with the structure of society that would create a situation for these answers to exist and seem valid.

In the case of the latter I found myself most upset as the neighborhood already has a free clinic, with free drugs — a monumentally rare thing, and thus the impediment for this woman treating her child wasn’t actually the cost at all, but that she just didn’t know the clinic existed.  It wasn’t until a neighbor whose child had also had measles told her about where to go for free treatment that she came to the clinic.

We went to see community leaders afterwards, to try and urge them to work with the clinic to do outreach to the neighborhood, to let them know that these services exist, are safe, and best of all are free.  The leaders agreed with us about the importance of social mobilization, although it is hard to say whether we were just getting lip service … time will tell.

At the community center we met an American from Atlanta, Yolanda, who works for the CDC and is here consulting for UNICEF/WHO.  We agreed to go to dinner with her, and afterwards she took us to a pricey but nice French restaurant (although I had pizza and Miranda spaghetti, so you be the judge on the origin of the cuisine).  It’s Thanksgiving though, so a bit of splurging is in order I suppose, and it was nice to chat with another American about our experiences here.  We also managed to transfer to a cheaper hotel room (saving over 2000N per night), so that covered much of the dinner cost.  Our new hotel room doesn’t have A/C or the other electrical amenities, but given the nearly constant lack of electricity here anyway I don’t think it’s a big loss!  Paula at UNICEF in Abuja told us of employees of hers who have so little (read: no) electrical service at their homes that they have to charge their cell phones at work.  The power at the restaurant kicked off once or twice while we were there.  Edison once proclaimed (in the late 1800s) that we would make electricity to cheap that only the rich would burn candles — perhaps that day will come, but in West Africa it is not yet here.

We’re back in the hotel room now, it’s 9 o’clock and I’m copying footage and getting ready to call my parents.  I’m glad we brought a netbook (low power usage) with a six-cell battery (6-8hr life), so that the absence of electricity doesn’t throw too many grenades into my digital workflow for our footage and photos.  The lack of Internet access for us in Nigeria (my cellular modem won’t work here) does mean that I’ll have to backdate these posts and flood them all in at once, however, so I hope you all are ready to do a lot of reading, haha.  More to come soon.
*non-compliant is a dirty little term that implies a failure on the part of the patient.  Paul Farmer writes extensively about this, but often (at least in his view, and dare I say mine) non-compliance is really an indication that the structure of the system is designed to exclude certain patients and thus force non-compliance.  So in this sense I use non-compliant to easily convey that Rigasa has a low prevalence of vaccination and a low turnout on Child Health Days (and acceptance of vaccination workers’ efforts), but not to cast aspersions on the people of Rigasa.  Where ‘non-compliance’ feels an apt term, I think it is often best to look first at the system’s structure and attitudes of its practitioners, and only last at the patients to find the failure in delivery of care.  In this case I think it means more must be done to ensure people know of the clinic and its benefits, and more must be done to educate people in Rigasa as to the safety of its services and medicines and to win their trust; for people who have been marginalized and abused by the system for generations, trust is bound to be a difficult thing to garner.

So in order to travel to Abuja we had to check all of our clothing and toiletries and other “expendable” items, and carry onto the plane the film gear.  They only allow 5KG of carryons, so that was a bit dicey.  Luckily there wasn’t much attention paid, and the 20KG of gear we carried on went unnoticed.  Partially this is because we broke the gear down into its smallest possible configuration and put some of the less than essential stuff in the check bags.  The broken down configuration makes it much easier to carry, but impossible to use in any timely sort of manner.  I saw plenty of things in Lagos and Abuja I’d have wanted to shoot, but didn’t have the twenty or thirty minutes required to break out all the gear and put it together.

After getting the gear sorted and mostly back together we packed up to checkout and meet Mr. Abubakar.  On checkout we asked for the remainder of our deposit back — we’d been told to pay 20,000 Naira ($140) and we would receive nearly 7,000 on checkout as a refunded deposit.  The problem was now that when we went to checkout, we were asked to pay nearly another 7,000 Naira.  The employee at the desk in the morning knew nothing of our discount and took our “balance” to mean we owed that amount.  We explained our situation and he argued with us some, insisting he must have a letter from UNICEF.  I don’t want to get further into it, except to say it took another 30 minutes to check out, and even that was possible only thanks to the continued hard work of UNICEF (and the annoying love of Nigerians for paperwork).  We were paid all but ten Naira (7 cents) of what we were owed, and left with our contact for the bus station.

One our way to the bus station we saw an errant taxi blatantly run a red light, nearly getting t-boned.  And by ‘red light’ I mean ‘police officer with gloves directing traffic.’  The bus station it turns out was actually a “trotro station,” and we soon found a tro to Kaduna.  The tro itself was about a 7 on the one-to-ten scale, which is fine enough by my tastes, and in fairness I didn’t see any broken down trotros on the way to Kaduna, but did see two broken down buses, so maybe taking a trotro was the right move.  The driver’s maneuvering was entirely reasonable as well.

We paid 2100 Naira, about 21GHC (14USD) for the two of us.  This is about 2-3x what a similar trip would cost in Ghana, further reinforcing my perception that things here are more expensive.

As the trotro found its way to the freeway we cut through a junkyard-slash-place-people-fix-vehicles and I saw a man siphoning gasoline by mouth from the tank of a broken taxi.  This is the first time I’ve seen someone spitting gasoline outside of an action movie.

It took about 45 minutes to get out of Abuja and into the country, although of the three hour trip there was really only at most an hour where we were truly in the country.  Even after getting out of Abuja there was another half hour of roadside stands and little clusters of homes alongside the road.  Once we finally did stop seeing villages, the grasslands with sporadic trees reminded me a lot of Texas.

Soon we were seeing the hustle and bustle of the outskirts of Kaduna, something that was familiar to me from my many trips into Accra.  A good half hour before you hit what I would call “Accra” you start seeing lots of urban activity.  This periphery isn’t anywhere I’d want to live, thanks to its distance from the central services of the major city (embassies, hospitals, etc), but still has all of the major necessities of life (markets, vendors, chop bars, and so on).  Kaduna would prove to be no different.

Our tro eventually emptied out until it was just us.  The driver dropped us at another (much smaller) tro-station called “Kowoo” or something along those lines.  He found us a taxi and we hopped in, off to UNICEF.  We asked the taxi for the fare rate, and he replied “one-five.”  Not knowing where we were going (having never been to Kaduna), we had no idea if this was fair or not.  It turns out he had little more idea than us where UNICEF was other, as he had to stop and ask some people alongside the road.  Eventually we arrived and I think it probably should have been more like 500N instead of 1500N, but I suppose that is not so bad in the scheme of things.

We met with Rabiu, the Communications Officer for UNICEF in Kaduna.  It took a little while for him to arrive because this is the beginning of the Child Health Week in Nigeria, and he is of course quite busy.  On Paula’s reccommendation we asked to see the Zonal Warehouse, where UNICEF supplies are stored for emergencies and also during the period between procurement (on behalf of Nigeria) and delivery (to the Nigerian state governments).  Rabiu arranged for a car and we were off to the warehouse as the sun began to fade.

At the warehouse, which was maybe 15 minutes away, we got a tour from the manager and saw lots of rows of boxes of various things: midwifery kits, borehole pipes, rehydration salts, vitamin A capsules, and so on.  No measles vaccines at the moment, though.

From Kaduna it’s looking like we’ll head to Zaria, a smaller city of “only one million” (did I mention Nigeria is the most populous nation in Africa?), to film the Child Health Week ‘flagoff’ (I prefer the term ‘kickoff’ but here they say flagoff).  This is assuming it takes place — we have word that it may or may not (the flagoff, not the CHW).  From Zaria there are some smaller areas/towns/villages (again, given Nigerian scale I am hesitant to commit to a noun) just a bit more distance to film in.

Tomorrow we will meet with the UNICEF Health Consultant here and then we should know a lot more about where the specific measles cases are taking place now so that we can go find them.

As I write this it’s 7:30pm and we just finished at UNICEF.  We’re going to catch a ride from Rabiu to a local hotel that is inexpensive.  There was a brief pow-wow of UNICEF people all consulting (mostly in Hausa) as to where would be good to take us.  According to Rabiu Nigeria doesn’t have guesthouses (low cost lodging) in the way that Ghana does.  He thinks there’s a 6,000N ($40) hotel that should work nearby, although some other staffers suggested a 3,000N hotel slightly across town that might also work.  He’s graciously offered us a ride (nice to save on taxi fare) as he drives home tonight.

We also have yet to eat today, other than a “donut” purchased from the cafe in the lobby of our hotel.  We considered doing their continental buffet, but it was $30USD per person, which is roughly ten times what we normally spend on meals at restaurants in Ghana, so we weren’t too keen.  Ater we find accommodations we’ll see how hard it is to track down some suitable food; there’s always our protein bar strategic reserves that can be tapped into if necessary.

As the bus left Cape Coast I had a brief moment of finality.  Finality because the Cape portion of our filming was over — whatever we needed to shoot, we’d have better done it already –and also a bit of sadness because I don’t know when, if ever again, I’ll see Cape Coast and my many new friends.

In Accra we headed to the Rising Phoenix, the 26-to-30 GHC per night guesthouse I had previously said less than great things about (the first time we stayed we got a room with no electrical outlets, despite it being the most expensive place we’d stayed in Ghana).  We’ve stayed there subsequently, mostly because we know how to get there, it’s central in Accra, and our stays keep improving (for instance, I haven’t been covered in wet paint recently).  They also have a vegetarian cafe, if one desires a “bean burger” and fries.  Last time we stayed, the owner, Phoenix, even gave us a ride to the STC station near Kaneshie, which was awful cool of him.  So we’d called to ask if we could store our non-Nigeria baggage there whilst in Nigeria, and then stay for a night when we return (before flying to the US).  Phoenix not only said yes, but said he’d store our 4 bags for free, which was again, awful cool of him.  So we dropped our bags at the Phoenix and then headed to do some errands.

The full list of errands is too much to recount, but basically we handled little things we needed to do before leaving, and the only accounts on which we were unsuccessful were in buying new cheap sunglasses at the market (I left mine at the Red Cross in Cape Coast by accident), and in finding a Nigeria guidebook.  We wanted the guidebook because it happens our Lagos flight would include an overnight layover before we’d fly to Abuja, and due to our checked bags we wouldn’t be able to stay in the airport (also it turns out our Abuja flight as at a different airport!).  A guidebook would have some idea of cheap accommodations we could taxi to … hopefully.

After failing to find any guidebooks anywhere (Miranda actually got laughed at when she inquired at the bookshop at the Accra mall — I guess people don’t vacation in Nigeria), we started to get a bit desperate.  I read the Lagos lodging section of the Bradt guide online (on googlebooks) but their minimum priced place was like $150 USD, which is about ten times what we prefer to spend.  I messaged a couple on CouchSurfing (a site on which we have met many cool people when hosting in Seattle, and on which we met Dom in Cape Coast, who is now one of our best friends).  I messaged a friend on Facebook (who lives in Nigeria) as well, in case the CS couple in Lagos couldn’t come through.

My friend promptly called us and said not only would he host us for the night, but he insisted on picking us up and then driving us back to the airport (4 hours later).  And, sure enough, once our plane landed and we cleared customs, there was our friend (and my fellow Citizen Ambassador) Toye.

Leaving the airport Miranda and I successfully fended off a “I-push-your-cart-and-then-ask-you-for-money” airport employee, and I had a moment of satisfaction at now being immune to at least the major pitfalls of Africa, so perhaps Nigeria wouldn’t be so scary.  As we made the long walk to Toye’s car we met a security gaurd who asked for a bribe (in a roundabout manner I’d read about on Wikitravels) and it was interesting to see Toye say “maybe next time, my friend,” which is exactly the method we’ve been using on people who ask us for things we cannot provide to them.

The streets of Lagos were quiet and dark as we sped along the highway.  It was nearing midnight, and it turns out it was about to be Toye’s birthday, which speaks even more highly of his Nigerian hospitality.  We ate some oranges he brought us and sat in his apartment asking him about Lagos and his experiences here.  His power goes out several times per day, apparently because Lagos sens its power to the federal grid (by law) to be redistributed amongst Nigeria.

We headed to sleep, and a mere three hours later were back up again to head to the domestic airport (which is a 1500 Naira –$10USD– cab ride from the int’l airport, so apparently when we fly back to Accra we should be ok).

Landing in Abuja I immediately had the feeling that we were in a very different place.  Lagos, even at night, had reminded me a lot of a slightly-more-dangerous Accra … lots of barred windows, potholed roads, trotro (although they call them something else), crazy driving, and so forth.  We did see streetsigns in Lagos, though, one thing we would never see in Ghana.

Abuja is in the north of Nigeria, which is a very different place from the south.  Speaking in general terms the south is more Christian, and oil rich (and also much more violent thanks to the oil).  The north is either halfway or entire Muslim, depending on where you are.  Abuja is the capital city, so it’s more on the halfway side, although I have seen several giant mosques and no Christian churches at all.

The airport was tiny, and the luggage conveyor belt terminated at a wall; in most airports if you miss your bags they will “come around again” indefinitely for another pass, but in Abuja if you miss your bags they hit a wall and fall onto the floor in a haphazard pile.  I collected our bags, fended off several “let me help you with that” people who would undoubtedly want compensation afterwards, and Miranda and I paid for a shuttle.  Toye had warned us a cab to the city would be 4000 (or more) Naira, which is like $30-40USD, so we took a shuttle for 800N each (around $5-6).

In front of the airport there was, surprisingly, no mad rush of taxi drivers vying for our business; just a few top-up credit sellers and maybe some gum or something small for sale.  I didn’t even see anyone with anything balanced on their head.  Were we still in Africa?

On the drive into Abuja I saw why the cab ride costs so much: the airport really isn’t in Abuja at all.  It’s certainly the nearest airport to Abuja, but maybe only because no one has built another in the region.  The drive into Abuja took at least an hour, with about half of it marred by crazy traffic.  The traffic itself was similar to anything you’d see in LA or Chicago, except there were dozens of desperate drivers in the median and on the shoulder, trying frantically to bypass the jam on the road.

With the drier climate, prevelance of Islam, relative calmness of the airport, and crazy driving (although this exists in the south too), Abuja to me has a much more Egyptian feel to me.  Abuja has a lot more visible infrastructure than Accra — most of the construction projects I see in Accra look scary, with homemade concrete and not a right angle to be found, but Abuja has the feel of proper construction (to me this is an indication that industry in Abuja has “money”).  Abuja also has a lot better English speakers than Ghana.  So far we have yet to have a cab driver misunderstand anything we’ve said.   One even admonished me to buckle up!  (After three months of riding in vehicles without seatbelts, it’s become habit not to even try to buckle in taxis.)  The roads are smooth and populated with myriad expensive vehicles.  The shoulders of the roads have virtually no one walking on them.  In general Abuja does not feel like West Africa to me.
The north of Nigeria is supposed to be quite impoverished, so it’s interesting to see so many signs of education and wealth in Abuja.  The prices of things are on par with the US (and in fact rent for a western style apartment would rival or exceed NY city).  Our UNICEF contact refers to Abuja as an anomaly.  Paul Farmer writes a lot about steep grades of inequality, and the problems they create, and I have a feeling we’re about to see the bottom of that grade.

We spent the late morning getting up to speed at UNICEF, and then the early afternoon running errands thanks to a lot of help from Paula at UNICEF (who took us to the money changers, a UNICEF lunch where I had pretty decent spaghetti, and then worked her butt off to find us a hotel room).

We stayed the night in Abuja in the cheapest hotel we (er, Paula) could find that had rooms available.  The only rooms they had were about halfway up the scale of prices, but with the UNICEF discount it worked out to around $80USD.  This is roughly four times as much as we’ve paid for lodging anywhere in Africa, and had Paula not been working so hard to take care of us (and find us a room), I would have passed.  That said, we could afford $80 for one night, it would be rude to say no after her hard work, and it gave us a bit of a chance to see how the ‘other half’ in Africa lives.  Maybe that should say ‘other one percent’?  I took my first hot shower since we left the United States, watched a few minutes of BBC News, and then we left to handle more business.
Two days ago we’d been standing next to the Gulf of Guinea, meters from a village of mud and thatch huts, watching a local fisherman, use just a hand-line bated with crawfish to catch small stingrays, pluck them from the ocean, cut their stingers out, and leave them in the sand to die while he worked to catch more.  He spoke no English, but happily showed us his catch as he de-hooked it.

Forty-eight hours later we’re in Abuja, where it’s hotter but less humid, surrounded by men in three piece suits and linen gowns.
We tried to find some dinner but the restaurant didn’t open until seven.  We met in the vacant lounge with a former teacher of Toye’s, who gave us a potential contact in Kaduna and went out of his way offering to drop us at the bus station in the morning.  As we were talking in the lounge the power kicked on and off several times.

Earlier in the day, as we’d been driving around Abuja, Paula had remaked how the entire cluster of UN buildings is on generator power 24/7.  The majority of Abuja has no power.  Whether a given place is wired for power is not the question, because effectively there is no power.  Most hotels are on generator, along with other buildings that the wealthy congregate at.  A handful of intersections have working streetlights because they, too, are on generator.  The rest are either tenuously negotiated by drivers in some sort of informal stop-and-go system, or during the day some of the major ones have police officers in the middle to direct them with hand signals.

We had to get moving on our Nigerian visas, and like it or not, this would mean some trips to Accra to the Nigerian High Commission.  We are headed to Nigeria for the last week of the month (hopefully) to work with UNICEF and see some of the measles outbreak that is going on there (and child health interventions taking place to try and stanch it — this year’s outbreak is tenfold larger than last year’s).  To do that we’d need a visa to come back into Ghana for our plane flight home (Nigeria reportedly won’t grant your visa to there without proof you can leave), and then various other documents to apply for our Nigerian visa.

Miranda took a day last week and went to Accra while I filmed in Cape, but the trip itself was a failure, mostly due to the slowness and/or ineptitude of the Ghana Immigration Service.  Without recounting the entire trip, let me just point out a period where Miranda was told to “wait right here” for an official’s boss to come; Miranda sat for an hour, no one came, and when she finally inquired she was told “My boss came and I looked for you and didn’t see you.”  This, I suppose, is the nature of government services in many, many places, so in a way we aren’t surprised.  That said, it’s still annoying.  In the end we were told the visa we need can be obtained at the airport when we travel back to Accra and that GIS won’t issue it now (without a 14 day turnaround).

The Nigerian High Commission, unlike GIS, can do visa turnaround same day or two days.  Official they do it in 2 days, although we saw several people get theirs same day.  So there’s one plus.  We got to Accra around 11am, after waking up at 5am to take the STC bus there.  We spent the entire day (without having eaten, whoops) until after 5pm sitting inside the Nigerian High Commission.

Unfortunately they do not allow electronics inside the High Commission premises, so there were several trips back outside the gates to make phone calls to procure more paperwork, then heading back in to wait, only to discover an hour later that it was not right, or had not come, and that the hour of intervening time could have been thirty seconds instead had we had our phones or laptop so our UNICEF contact could have reached us (or visa versa).  In the end the correct documents were submitted, we were told to pay $260, and to come Thursday for our visas.

We asked for a passport retention slip, or some receipt, and were told “don’t worry, I know you,” by the front desk receptionist.  So hopefully we show up Thursday and all is well, since they have a few hundred of our dollars and both of our passports.

We got breakfast/lunch/dinner all in one meal, and then headed to Kaneshi (I am sure I am spelling this wrong, but regardless of its spelling it is the hubbub-filled neighborhood in southern Accra where the trotro and Metro Mass buses queue for passengers).  Our taxi ride to Kaneshi was the best ride we’ve had in our time in Ghana; the driver spoke really good English, and as a result we we able to converse on some topics that we had yet to mention to taxi drivers.

The level of English fluency in Ghana varies widely, from older people or those more at the socioeconomic fringes who may not speak any English at all, to those who have had more formal (usually private school) education and are as fluent as any Briton.  Virtually all taxi drivers can speak English in the sense that you can tell them where you need to go, and negotiate a price — although see previous posts of mine about the redenomination of money and how this causes issues with conceptializing numbers, “one five” might be $15, or it might be $1.5 — but possibly little else.  With those who speak better English, we will often ask Fante/Twi words, or make the usual taxicab small talk.  On rare occasions we find a driver who speaks really great English, and we can ask for his insights into various things.

With this driver we discussed whether there are any female taxi drivers (there is one in Accra he personally knows, but she drives a very particular route).  We talked about the gender bias in occupation of street sellers in Accra (e.g. women always sell oranges, men always sell cassava and Fan Milk, boys/girls/women sell water sachets, and so on) and his interpretations as to why each occupation has its particular preferred gender.  The conversation wandered to many other topics, and in general it was really great; the trip was worth the price just for the ethnographic insight into life in Accra.

We found a “four bus” or whatever they call them here (I am fuzzy on the name, we have heard it only twice), which is the same sort of bus we rode to Kakum in — it’s not a full sized 80-person bus, but it’s not a trotro either, it’s a sort of Chinese-made diesel bus that seats around 22.  We waited about ten minutes and then the bus was off.

Unfortunately there was still road construction going on (Miranda’s trip back last week took 7 hours instead of 3.5) and we spent 2 hours in traffic just to get out of Accra (keep in mind Kaneshi is at the border at the outskirts of urban Accra).  After having slept only a few hours the night before, and now finding myself crammed into a small Chinese bus (I have yet to ride in a bus in Ghana where my knees weren’t pressed well into the seat in front of me) and crawling through traffic in stiffling heat, I meandered in and our of consciousness.  I became fully conscious when we stopped after 2 hours to let everyone urinate at the edge of the road, right after we’d passed the construction.

Traffic opened up and our driver tried to make up for lost time.  I’d already agreed with Miranda that we wouldn’t make trotro trips after dark, given the poor state of repair they are usually in, the risky maneuvers their drivers undertake, and the fact that RTAs (Road Traffic Accidents) are the 7th or 8th leading cause of death in Ghana.  Our hope was that since the fourbus was an actual bus (albeit a smaller one), that the driver would be less risky (although this still doesn’t stop another vehicle from passing on a double line and hitting you head on)

Unfortunately our hopeful logic would prove to be incorrect.  Our driver did everything he could to make up for lost time, or maybe he just likes to swerve, pass illegally, and fail to slow for speedbumps.  At the most ridiculous point we were illegally passing a vehicle that was illegally passing another vehicle, making for three-lanes-of-vehicles on a two-lane road.  I probably should have known when our trip commenced with a group prayer — that is, the driver paused just before we set out, to say a prayer in Twi as the entire bus collectively bowed heads — that the trip was going to be interesting.

We eventually got back into Cape Coast, caught a 2GHC taxi home, and passed out immediately upon entering our room.

The intervening 2 days have been spent trying to wrap things up here, basically doing our own “mop up” of shots we aren’t quite happy with or little things we haven’t yet had time to film.  Another two visits to Akatekyiwa, getting some shots of fisherman on the beach, and so forth.  We interviewed Kennedy’s uncle in depth, which should make for good cinema as he has had an interesting life, and seems to have the most “wise” perspective of anyone I’ve met in Ghana.  We spent some more time slacklining with kids in Akatekyiwa (at their request), as well as a few adults.

So basically we’ve been mopping up, and saying our goodbyes.  This is basically it — in a couple of days we’ll be in Nigeria, and then scarcely a week after that we’ll be back in the States.  Cape Coast has really come to feel like home, and it seems almost cruel that just when we are really getting to know people, really feeling like this is where we belong, that we must leave.  Everyone we have grown close to asks when we will be back, and I feel tormented that I don’t have a good answer and must simply say, “hopefully soon.”  A year ago I certainly wouldn’t have guessed I’d be in Ghana right now, and knowing this I can also see there is no way to know when I’ll next be here.  So when I’m saying goodbye to someone we’ve come to care about, it is especially hard to do so, knowing that this might be the last time I ever see him or her.

We said goodbye (for the second time) to Kennedy tonight, and it was hard.  He told us how much we’ve meant to him, and how we’ve inspired him, and we tried to tell him how special of a person he is, and how we can see that he has much to share with the world.  We were helping him to get an e-mail address (using our netbook), so that we can keep in touch, and hopefully send him some information on furthering his studies, and as I was helping him to setup his gmail I felt extra proud of him; as we were traversing the various registration questions it was obvious how few of them applied to him (and many other Ghanaians).  Security questions asking what your car’s registration tag is, or what street you grew up on (how many people here own cars?  and how many streets have names?  or for that matter, how many village homes are on streets?).  That Google’s registration process so poorly fits his life experience I think is representative of how valuable that experience can be in informing his worldview.  Kennedy truly knows how the majority of people in the world live, and by extension he is that much closer to understanding what is important to them, and how their lives could be improved.

We gave him Miranda’s copy of Mountains Beyond Mountains, and I hope he can take it to heart, that he can see Western education as a tool for bringing a better life to those who need it most.  Too many educated persons in poor countries fall pray to brain drain, and yet too many more never have the chance to become educated at all.  I hope Kennedy can somehow thread the needle: to gain a valuable education, whether in the US, in Ghana, or simply from books and experience, and use it to help his countrymen.  It is clear to us he has the desire to do much in life, but is precluded by the predicaments of structure that limit so many in poor countries.

Miranda and I are having a goodbye dinner of Pizza at the nearby gas station (only in Ghana would the best food we’ve had so far be served at a gas station restaurant) as it thunders outside.  Lightning knocked out the power here a few minutes ago, but the various conversations in the room hardly skipped a beat as the entire restuarant chatted in the dark.  In an hour or so we’ll be back home, packing before a few hours of sleep and a hopefully quick but productive trip to Accra tomorrow.

We’re off to Accra to meet with the Red Cross, WHO, Nigerian High Commission, and hopefully be back in Cape by nightfall (with Nigerian visas in hand).  The plan is to shoot more stuff in Cape on Friday (saying goodbye to Elizabeth and the girls we’ve been living with), and then off to Accra to fly to Lagos (and then Lagos to Abuja).  I fear I’ll be too busy to post much over the next few days, so mentioning what we’re planning is maybe the next best thing.

In the photo at right Miranda and I are posing on a hill overlooking Akatekyiwa.

I don’t recall that I wrote about the huge storm that came through here, friday night, but it was terrific indeed.  It came on with no warning and in a matter of a few minutes Cape Coast (or at least my bedroom in the Siwdu neighborhood at the edge of Cape) was enmeshed in thunder and lightning.  In thirty seconds my bedroom dropped at least ten degrees ferenheit as the wind blew directly into it, covering my netbook screen with mist.  Our porch accumulated easily 2″ of standing water, and this is considering the porch is well above the level of the yard and the street.

In Cape we have seen some pretty torrential rain, and some good lightning, but this was truly awesome.  I now understand why so many of the gutters are six or eight feet wide and five or more feet deep.

At about five in the morning today a slightly less intense storm rolled through, and we were worried our football practice might be canceled.  Almost all of the kids came, though, and played happily in the mud.  Tony had a lot of passionate things to say about Ghana’s sense of community and helping one’s fellow human, partly bolstered by the fact that his American visa application was just denied (without much cause, if you ask me).

I feel very bad, talking to a guy who puts his own time and money into coaching kids, to acquiring gear and supplies for them, into traveling and developing his own skills so he can better teach them, when he tells me his one-week visit to a soccer training seminar in the US is blocked by my own country’s conservative visa policies.  I don’t even know what to say, other than to tell him that I understand, having seen my own brother and his wife (who is not a citizen) battle with the challenges of immigration.

Here is a guy who has maybe three or four thousand dollars saved up, who has traveled in europe, who has a college degree, who well understands the paradigm of soccer/football — that his prospects for employment in the states (especially if he stayed illegally in violation of his visa) would be very minimal, and his savings would last a month or two at best, or that he could live for years in Ghana on that same money, foster youth and develop their talent, and simultaneously improve his own career prospects here (where he can work legally, and where football is very, very popular).  Why with his education, savings, sponsoring organization in the States, US immigration would consider him too much a risk is beyond me, and I was at a loss to give him the answer he was looking for.

I don’t want to preach here, there are many different views on immigration, and I am not qualified to say what is most valid, I can only say what I have seen, and in this case I have seen someone who simply wanted to visit to learn and further his own skills, who will have slightly less experience to the children of Cape Coast now, thanks to the conservative nature of US immigration policy.  This makes me sad.

The cell network here has been out all day, probably from a lightning strike (around 6am it killed the power).  I can still get on the Internet, although I cannot say why (since my Internet service is cellular), but I am happy enough for that.  We have to travel to Accra tomorrow to apply for our Nigerian visas, and we are doing it on a very tight timeline … if they are not granted the first time around (Nigeria is known for loving paperwork, and for rejecting the first time if your paperwork is insufficient) we will not have enough time to reapply before our flight.  Miranda is confident, which I guess should make me feel better, since she is very good with logistics, but I still have my doubts.

Maybe half of the kids had some football gear (shoes, pads), and the other half played in sandals and without shin pads.  One kid was bleeding at the end from a blow to the shin (and not having pads).  We both felt for Tony and his struggle to get them gear, something even as simple as balls for them to kick … all of the different age brackets he coaches have to share the same couple of balls (each ball is 70 GHC, basically a month’s wage for many), which unsurprisingly are showing a lot of wear.

This bike will mean a lot to Kennedy, as far as doing health stuff, as coming to the clinic is a 10km journey.  That said, I perennially feel bad about America’s castoff culture, sending our shitty bikes with bad brakes and flat tires off to West Africa, to rust a bit in a container and then be distributed.  I am glad the bikes were donated to the clinic, and glad Kennedy got one, but also a bit sad that something in better shape couldn’t have found its way into the donation bin.

Kennedy has been warming up to us more and more every time we visit, but also it’s pretty apparent that he wants to escape the village.  He’s spent his life in a rural village and hasn’t had the opportunities that many in rich countries have.  He says to us that he wants to come and study in the States, and asks me how this is possible, and I don’t even know how to phrase it so that he can understand.  He speaks English well, so words aren’t the problem, but rather the massive disparity between the “American” world and his world.

I explained to him that my plane ticket here cost two thousand Cedi, and he had to convert that to old Cedi to make sure he was imagining the right number.  When the idea of $1,400 is mind blowing to him, how am I to explain that even if he could somehow magically get a visa to the US, and even if he could gain entry to a university, he’d be looking at $10,000 (or more) per year in living expenses, and $10,000 (or more) per year in tuition and related expenses.  That’s about 30,000 Ghana Cedi, a number that would boggle many Ghanaian minds — they have a spinoff of the show Who Wants To Be A Millionaire, except here it’s called Who Wants To Be Rich, and instead of a million dollar top prize, it’s 50,000 GHC.  The average person here makes less than 1,000 GHC per year, so the cost of a US college education is essentially a lifetime’s worth of wage.

So yesterday I hung out at the clinic, chatted with Kennedy for an hour or two, and otherwise observed the goings on.  Also managed to interview Elizabeth a bit, which nicely ticks off some of the boxes on our shot list.

Today was also a productive day.  We started off at 6am sharp, meeting up with one of the “characters” from our documentary (an early-20s guy who was working on the measles campaign, and has also founded his own NGO that does free medical clinics in rural villages).  We caught a ride with him and the clinic volunteers (7 of us crammed into a Renault that ought to seat 5) and headed most of the way to Accra.

We ended up in a village a few miles off the Accra-Takoradi highway, and began setting up big tents to do the exams, dispensation, and referrals within.  They were kind enough to provide Miranda and me each with a shirt from their NGO so we could fit in, which was lovely.  Quite a few people showed up, and the volunteer who had organized this (who grew up in the village) thanked us as our white skin makes all the kids shout “Obruni” and then the bulk of the village comes to see what is going on; so basically we make for a very effective way of getting the word out about the free clinic, hah.

After a few hours baking in the sun we left the clinic early to go film at the deaf school in Cape.  It took us a couple of hours to get back, as we were quite a ways from Cape and had to take (a few) trotro to get here.

The deaf school turned 40, so they were having a large celebration open to all, and since we’ve been filming there for several weeks, we were excited to come.  I must say, for me, the deaf school has been one of the highlights of the trip.  We’ve gotten pretty close with a young kid named Evans, who is a student at the school.  He and I have our communication blocks as I don’t sign nearly as well as Miranda, but he is constantly teaching me new signs, and I feel that if I could just hangout with him for a few months I could be rather fluent.

The celebration was interesting, although I don’t want to spoil the highlights as they will appear in the film.  I met lots of really friendly DHH (deaf/hard-of-hearing) folks, and eventually we made our way over to my favorite little slackline spot on campus, and setup the slackline.  This was Evans second time setting it up with my assistance and he did pretty well.  On the way to the slack spot he bought us some oranges and eggs, which was really nice of him, and something I sensed he wanted to do for us, so I was happy to oblige (by eating three oranges!).

They eat oranges really oddly (from my perspective) here, by the way, but almost exactly the way the word “orange” is signed (by holding your half-open fist to your mouth and squeezing it shut), which lends some context to the sign, I guess.

We had a fun slack session, with lots of newcomers, and Evans is getting pretty good after just a few sessions.  Everyone loves the slackline, as usual, and it was really great at the end of the session to sign to him that the line was a gift for him from us — I gave him my personal/favorite line, which I guess means I’ll be buying a new one eventually.  I thanked him and did my best (considering my lack of ASL schooling and that I had a camera on one hand) to say that we were both glad that we have him as a friend.  He signed something back to me that I didn’t catch, but am going to assume is “I feel the same.”

After the deaf school we walked to Moree (there was a crazy traffic jam and it was quicker to walk the 2.5km than to taxi/tro) to meet up with Dom to interview him, but due to the failing light and my desire for a cold beverage we just found ourselves at the gas station bar by the police barrier instead.  I had an Alvaro, a really tasty malted (non-alcoholic) pear beverage (that I think I have blogged about before, when we found the pineapple version), and Dom did his best to get the bartender to find a cold ‘proper’ beer for him.

I’ll try to add some more photos (of Evans on the slackline, etc) tomorrow.  For the moment I am exhausted and have to be up early (although not as much so as today) tomorrow morning to shoot some more stuff with Coach Tony.  I’ll continue to try to think of a good answer to give Kennedy.

He is obviously resourceful and sharp, so my temptation is to tell him to go the route I have gone — when you want to know something, figure it out yourself, or read about it … but given the dearth of libraries and bookstores here, I’m not sanguine that “just read a lot” is a very practical answer.  So I continue to think of a good answer for him; I think the practical, if not good, answer is to try to study here (something that is still subjectively quite expensive).

It’s also very sad to me that the proportion of people who have cellphones here is certainly higher than the number who have access to safe drinking water.  When I think about the priorities that we (members of Western culture) foist onto Africa, it’s really upsetting.  I can think of several dozen cellphone and cellphone-unlocking shops I have seen around Cape, at least a few hundred cellphone-credit vendors on various street corners, yet only one single 200sq ft bookshop (and no library) in Cape.  Books, cellphones, clean drinking water, American Idol — I’ll let you guess which two of these four are in high demand here.