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THE STATE OF GLOBAL HEALTH

Akwaaba! I am welcome!

The author shares a dish of fish and rice at a refugee camp in Ghana.

by Valda Boyd Ford

The call for prayer echoes in the background, but it is not the reason I am already awake at 5 a.m. Nor are the crowing roosters and overburdened trucks thundering along the main road contributors to my wakefulness. The day has not yet dawned in Ghana but my day has begun. You see, the temperature has begun to rise in the wee hours of the morning and that, along with the fact that there is no movement of the ceiling fan and therefore no breeze, is the reason that the sandman has left the vicinity.

Maybe I can get another 30 minutes if I will myself to be cool. Maybe not! I now hear another rhythmic sound from outside my window. This is different from the Islamic call to Allah I know so well from my time spent in Saudi Arabia. I struggle to determine if I am hearing English or an African language and then realize that some words are English, and some are Twi or another common local language. They are now chanting in English, and “hallelujah” is a key word. Hallelujah—God grant us peace. Hallelujah—God grant us peace. The words move from a rhythmic chant to the gloriously rich and unmistakable sound of African a cappella harmony. It is so beautiful I forget about the heat for the duration of the singing.

After being uplifted through song, I give up on returning to the elusive REM sleep I crave and begin my morning ablutions. Even before I move, a fine patina of perspiration is evident on my arms. Within two minutes of moving around, the patina becomes a layer of sweat and, within five minutes, I am reaching for the ever-present towel to catch the downpour. Today I am using the blue-and-white kitchen towel that was given to me by Sussie, the guesthouse manager. I’m hoping it will be more effective in absorbing perspiration than the terry cloth hand towel I brought from home.

I start my cleansing and cooling ritual with the bucket of water and cup that I left in the “shower.” It is not a good idea to assume that the shower will work, owing to the regular depletion of water by four Western women at the guesthouse. Even though the large black tanks are filled twice weekly (or more), there is no way to tell when the tank is nearly empty. The system is to wait until the tank yields no more precious water and call for the water truck. This morning, the shower is working, so I take advantage of the opportunity to have a shampoo, although I am too tall for the distressingly low-pressure showerhead. I finish by using the plastic cup to draw water from the bucket. After replenishing the water in the bucket, I move slowly to convince my body that it is no longer hot. After finishing my shower, I move slowly, trying to convince my body it is no longer hot.

I dress in the dark. Some days the electrical current is working, and I can see what I am doing but, more frequently, I try to find my way in the semidarkness with a flashlight. I drink from one of the many bags of water I keep in the room, always conscious of my proximity to a Western toilet.

By now the morning is filled with the sounds of people moving around (not my fellow volunteers) and a series of announcements via loudspeakers. Today there is a plea for help in locating a family member, a job announcement for a history teacher, and a listing of camp activities, most of which relate to repatriation issues and the UN Refugee Agency, officially known as the United Nations High Commissioner for Refugees (UNHCR). After determining that the announcements are not specifically for my attention, I leave my room for the relative coolness of the Internet café.

The technicians at the café greet me with “Good morning, Madam” and “How was your night?” They no longer marvel that I am the first, and frequently the only, customer at 6 a.m. The short walk has induced another downpour of sweat, and my friends at the café turn on the fans and blessed air conditioning just for me. I am left alone to surf the Web, check e-mail, or work on training-of-trainers curriculum on eye health and visual-versus-learning deficits for teachers in the Buduburam school system. Today, I have a wonderful collection of Web sites provided by Theresa Hartman of the McGoogan Library at the University of Nebraska Medical Center, and I take an hour to select basic concepts appropriate for the teachers. By now, others are coming to the café who do not welcome air conditioning, so it’s back to the guesthouse to meet my colleagues and plan for the challenges of the day.

“Obolo obroni!” Over the course of my life, I have been called many things and have managed to keep my head up by remembering that “sticks and stones may break my bones, but words will never hurt me.” It took me a moment, however, to absorb the full impact of the toddler-delivered pejorative I was blasted with today. Imagine being an African-American woman walking through a refugee camp with Africans from Liberia, Sierra Leone and the Ivory Coast and having the children call me “obolo obroni.” For those of you who do not speak Tre, the main Ghanaian dialect, obolo means fat and obroni means white woman. So, put that together and you get “fat white woman!” As you might imagine, I was sure he meant PHAT, as in Pretty Hot and Tempting! I am still pondering the circumstances that would have me be called white. Of course, I do realize that, even with my melanin mechanisms working at full blast, I am still “lighter” than the average person around here. On our team, there are two bona fide white women here: one blond and blue-eyed and of Croatian heritage, the other with a very fair complexion consistent with her Scotch-Irish heritage. Both, it seems, are less “unique” to these children than my little old self. Well, “little” is quite an exaggeration, but walking in 90-plus degrees every day for at least 45 minutes has, literally, melted away a few pounds. Still, understanding the extreme poverty of the majority of people in the camp, my plus-size frame and my stature are on the far right of the curve. The adult people around me had various responses to the unadulterated words of the toddler: shock, dismay, nervous laughing or just plain belly-laughing. Those who were doing the serious guffawing were quick to tell me, “In Ghana, the one who gets three meals a day is the rich man (woman).” I think I feel better but I’m not too sure. At the end of the day, I felt better because my proprietress said, “You are reducing, so I will get the tailor.” Hallelujah! Vanity—thy name is still woman, or more precisely, Valda. — by Valda Boyd Ford

As we walk to the clinic, we wonder where we will be located. On the first day, we planned how best to set up the room and mark the floors with tape to make visual acuity assessments, only to find on Day 2 that we could not get in the room we spent so much time organizing. Newly arrived Ivory Coast refugees were sleeping on the “clinic” floor.

There are at least 10 patients waiting today, hoping to be first in line and fearful that we will leave or that our supplies will be “finished,” as they say, before they receive help. A local volunteer has assumed the powerful responsibility of controlling “the list” and thereby controlling access to the clinic. I am no expert but I would take odds that he was the poster child for hyperactive states. I am resigned to certain irregularities (from my perspective), but we have a conversation, again, about the nuances of “the list.”

Today, I am helping with registration. On other days, I might help with visual acuity screening using the illiterate “E” chart or do physical eye assessment using a penlight and ophthalmoscope. The process is always interesting and challenging. Many people are looking for someone—anyone—to actually listen to what they have to say, so history taking may include much more than a chronology of the eye condition or injury. Far too often, the eye problem began with traumatic injuries during escape from the war zone or inability to afford eye drops or surgery because all material possessions had to be left behind.

I serve as clerk and triage nurse and, more often than not, first patient educator. It is sometimes difficult to teach about eye health when the conditions—social and environmental—are so daunting. While egg yolks, paw paw (a local fruit) and carrots are excellent sources of vitamin A, many say they cannot afford to buy eggs and carrots. Luckily, paw paw grows wild around the camp, so we encourage them to eat the fruit whenever it is in season.

Each day, we find one or two people who have operable cataracts. We find even more who have congenital or traumatic cataracts and eye ulcers that cannot be corrected. I am learning to recognize those conditions that cannot be helped by anything less than divine intervention, but it still pulls at my heart when the miracles of modern medicine at our disposal offer no respite.

I am also in charge of matching eyeglasses to prescriptions, some of which are 12 years old. If I ask patients to go to a Ghanaian hospital or clinic for a new prescription, most cannot afford the fee of 45,000 cedis (about $5). So my next challenge is to find glasses that might fit using the Ford technique (that would be guessing mostly). Amazingly, and probably with divine intervention, I have been able to find about 80 percent of the prescriptions needed.

This is a very long way from the organized, antiseptic, regulated world I know back in Nebraska. There are times when the unbearable heat, lack of running water and indeterminate variety of bugs and spiders seem too much to bear. But then there is the smile of a little boy, blind in one eye, who is happy because “auntie” is telling him a story or holding his hand … and there is the teenage volunteer who offers me part of her food, even though it may be her only meal of the day ... and there is the joy and peace that come from receiving so much more than I can ever give that makes me know that I am akwaaba, I am welcome, I am at home. RNL

Valda Boyd Ford, RN, MPH, MS, is director of community and multicultural affairs, Community Partnership, at the University of Nebraska Medical Center in Omaha.

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