Day 14: January 11, 2010

Today we returned to Nkonya to conduct my Community Project group’s intervention: HIV/AIDS Prevention Education. We had slightly over 50 participants from age 12 to 18. There were a few in the male group who were even a little older than 18 (early 20s) but we let them participate regardless.
Our program was designed to target adolescents from age 12 to 15 years of age, because we had identified the highest risk group for HIV infection being those aged 15 to 24 years old. We wanted to be able to educate the younger population, so when they reached the higher risk age groups they would be better prepared to protect themselves from HIV infection. Our original goal was to conduct this program in Kpando, but when we arrived we learned that HIV (while a problem in Kpando) was an even larger concern in Nkonya. The area is very poor and has minimal access to healthcare; there is a maternal clinic in the village, but the nearest full service clinic and hospitals are located in Kpando over 30 minutes away by car. Given the poverty in the area, education above a primary level is not common in the village, and many girls leave town for bigger cities (such as Accra) to make money for their families as prostitutes. Once they become sick, commonly infected with HIV, they return home.
I believe that our program was really successful in this setting. The participants were all voluntary and eager to learn about the topic. Our pretest indicated a huge need for further education. Many participants were unclear on what HIV even was, how it would impact their health, and even more had a very poor understanding of how HIV was transmitted. We handed out index cards so that individuals could submit questions they had about HIV, sex, etc. and because this activity gave the person anonymity we got numerous questions on each card. I worked with the female group, but when we regrouped later in the day to review how each group did I found that all of the questions the adolescents asked were intriguing:

-If I have sex with an HIV infected girl and she does not orgasm, can I get HIV?
-If I wear two condoms, am I better protected against HIV?
-Can I get HIV from a mosquito bite?
-If someone with HIV cooks for me, can I get HIV?
-Can I get HIV from deep kissing?
-If I am a student and I have sex, am I still at risk of getting HIV?
-Where does a condom go, how do I use it?
-Can a boy use a condom more than once if you do it more than once with him?

We reviewed all these questions at the end of the program, and I know that at least the girls were 100% when we conducted our post-test with them. They had a hard time choosing their favorite part, and did not offer us any cool feedback when we informed them that we were just trying to improve the program for the next group. I felt really, really good about what we did today. The girls were waiting to get their soda and biscuits during the break we provided to ask me individual questions. We had 5 immediate volunteers when I completed a condom demonstration and opened up the floor for others to try.
The only negative part of the day, for me, was HIV testing that was conducted following our education session. First off, I think those 15 to 25 should have been prioritized for testing because they are at greater risk of being infected, but the testing was opened up first to participants in our group. My other problem was that those being tested were being told that we had a test “for diseases of the blood” that they could participant in if they chose. The NSWB members were instructed not to tell people we were conducting HIV testing. Our guides and advisors at Africed said people will not willingly go for HIV testing in this area, and many areas of Ghana, because of the huge stigma surrounding HIV. That is why they said we needed to keep what we were testing for a secret.
I am a firm believer in patients’ rights. I think women have the right to choose whether or not they want to terminate a pregnancy, I think a patient’s end of life decisions should be respected (DNR or Full Code, etc.) and I firmly believe that informed consent should be given before someone is subjected to any kind of invasive procedure or test. I chose to opt out of the testing, because those being tested did not know we were looking for HIV or not. Also, at the end, if they were negative we were simply to tell them that they were “free from any diseases we tested for today.” That is misleading and, especially given the language barriers we have encountered here, can confuse people into believing they are healthy when they are merely HIV negative. They could still have some other STI, or malaria, or TB, etc. But, now that a “white nurse” has told them they are disease free they may think they are free and clear.
The argument made for testing was this: HIV antiretrovirals are available to those who are HIV+ even if they don’t have money. People are refusing to find out their status by getting tested. There is huge stigma surrounding HIV, and people would rather be ignorant than have their “life be over” when friends and family and coworkers learn that they are HIV+. In the meantime, the spread of HIV continues and is a huge problem in the area. It was a greater good for a greater number. Positive members would be counseled by local healthcare workers trained to deal with this kind of life changing news.
I can see both sides of the argument, but that was my ethical dilemma of the day, and I am glad I chose not to participate. At the end, when everyone turned out negative I reminded those gathered that just because they tested negative today for a disease didn’t mean their actions tomorrow couldn’t cause them to be sick. I also reiterated that we did not test them for every disease out there, so if they had a rash or a fever or some other symptom of illness they still needed to report to a clinic or hospital to be evaluated. I hope everyone there heard that part of the message.

Day 15: January 12, 2010

Today we went to Anfoega to donate to Anfoega Catholic Hospital. Lt. Holly, who met us at immigration at the beginning of our trip, is receiving a special honor in this village. They wish, in the “near future” to make him a paramount chief (or maybe it was one below this, I don’t fully understand the chief structure here.) He thought it would be nice for us to see the area, and we were delighted to see him again and thank him for being our Knight in Shining Armor when we first arrived, tired and nervous, two weeks prior. Before we arrived in Anfoega we were under the impression that we would be conducting our HIV education program again. After learning that the hospital was Catholic however, this plan was axed since condom use is promoted by our program and that is not in line with Catholic ideology.
We received an extensive tour of the hospital, which was the cleanest I’ve seen since we arrived in Ghana. However, they are lacking vital resources which is a problem we’ve encountered throughout the region.
-The hospital is located about an hour from Kpando, but that is the only ambulance they have access to.
-There is no anesthesia machine in their “theatre” or operating room, so surgery, including c-sections, are conducted under conscious sedation!
-There is no blood bank refrigerator, so the hospital does not have blood banked for an emergency
-The lab had to conduct all its blood work without the assistance of a machine (that means manual counts on CBCs, etc under a microscope!) until a week before our arrival, when the new doctor (only doctor) at the hospital made sure a machine was purchased.

I give so much credit to the healthcare providers here in Ghana. They are asked to do so very much, with so little. I want to make it clear that some of the poor practice we have witnessed (not utilizing alcohol swabs before starting IVs) is not the fault of the nurse but the system (not having alcohol swabs.)
In Anfoega, specifically, Dr. Alex Ackon has done incredible work. He has been stationed here for only 6 months and he has revamped their Pharmacy system, begun updating the Laboratory, ensured a more cleanly environment, and is working hard to get an X-Ray machine and updating the OR. He came from a teaching hospital in Accra, and is amazed with how little this area has. Yet, he is hopeful that they will get help and make the hospital (which takes cares of 10 surrounding villages) is better equipped to provide safe and effective patient care.

Day 16: January 13, 2010 National Nurse’s Conference

Today we hosted the first (annual) National Nurse’s Conference at Chances Conference Center in Ho (the capital of the Volta Region.) There were approximately 35 nurses from the Volta Region (HoHoe, Kpando, Ho, etc.) in attendance. Some we recognized (Edith, a midwife from Marquat; Peter, the surgical ward RN; Sister Magdeline, the CNO from Marquat; Senna, an RN from the Kpando clinic) and many were new faces. Funding for this educational day came from Sigma Theta Tau, Valerie King’s parish, Maura Norton and Valerie King’s own wallets, and was co-hosted by Africed (the organization our guides work for, though I am not sure if they assisted in its financing.)
The day started off bumpy. Our bus arrived at quarter of 9 when we were up and waiting outside Cedes Guest House for its arrival at 7am. The conference was scheduled to begin at 9am, and we had an hour and a half drive ahead of us. Luckily, Zanele and Allison had gone ahead with Nicholas (the representative from the Ministry of Education we had been working with) and Mawuli (one of our escorts who works for Africed.) When we arrived, embarrassingly late, Allison was completing her talk on Pediatric Rehydration Therapy. Then we were informed that some important politicians were arriving with the media, so we had to put the conference on hold until they arrived. Politics is very big in Ghana. It is my impression that many groups and organizations have seized on the opportunity to promote themselves when we go places to conduct our interventions. When the important Ministry people arrived, they stayed long enough to make speeches for the media and then left; they didn’t stay to see a single lecture. This sort of behavior frustrates me, but I will never understand politics (even in America.) From here on in, I think the conference went well. I think next year’s group should view the Second Annual National Nurse’s Conference as an incredibly important intervention. Continuing education for nurses in Ghana is practically non-existent and it is certainly not mandated like it is in the United States. The nurses gathered together today came from far away and were very eager to hear us speak, to ask questions, to participate in their learning. Topics that were covered included (I don’t have their official titles):
Pediatric Rehydration Therapy-Allison Geissert
Hypertension Diagnosis/Prevention/Treatment-Elizabeth Long
Stroke Prevention Education-Jody Roper and Lauren O’Keefe
Diabetes-Valerie King (she is a very engaging speaker for anyone who has her for Community Project this Spring!)
Congestive Heart Failure Definition/Treatment/Pharmacology-Renee Glennon and Stephanie Whippen
Breast Self-Exam-Zanele Denaro

At the conclusion of the lecture portion of the program we opened the floor up for more questions, and then every nurse was called forward to receive a BP Cuff (we had 18) or Stethoscope (35) and all were provided with a marker, highlighter, pen, and t-shirt we had made for the conference. The BP cuffs went first which is not surprising, given that oftentimes a clinic only has one (and it’s mercury.) Everyone was very grateful and excited about continuing this tradition next year, but with even more participants.

Peki
After the conference we began the ride to Peki (Mawuli’s hometown.) We were greeted with an elaborate, traditional welcoming ceremony. I have never experienced anything like it. When we arrived, the area was packed with people of all ages- there was some drumming and dancing already underway. As we got off the bus, children swarmed around us. They cheered and jumped and shrieked in delight whenever we took a picture; everyone wanted the opportunity to see their “photo.”
We joined the dancing briefly and then were seated under a canopy of palm tree branches/leaves. Across the dance floor (an open dirt patch) sat the chief and his linguist as well as male elders of the community. All of them had robes of various African clothes wrapped around their waists and thrown over their left shoulder. To the chief’s left sat the Queen Mother, her linguist, and drummers.
Our guides spopke to the chief on our behalf and presented him with a gift of Schnapps. They explained our mission in Ghana. The chief received the Schnapps, which symbolized him receiving us and recognizing our mission as good and our relationship to the community as friendly. After a time, the chief and some of the elders approached to let us know we were welcome, and then entertainment was provided in our honor.
First a group of 12 you
ng people danced and sang for us (in their native tongue, Ewe.) The group had boys and girls of varying ages; they had cloth wrapped around their middle fingers that they twirled and utilized as they danced to an upbeat, hip swaying, rythym. Then young boys took their turns performing. Their routines involved sticks that were cut to look like small swords or spears. They made menacing faces; puffed out their cheeks, rolled their eyes upward until only the whites were visible, and bared their teeth. They spun and crawled and ran around, interacting with the entire circle of people; at times grabbing at or leaping toward the small children on the outer rim. Their “dance” incorporated defensive and aggressive moves, and seemed to be inspired by battle/swordplay/fighting.
Next up was a group of women in matching skirts and tops who sang a few songs; the first in their own language and then some religious (Christian) ones in English. The last piece of entertainment involved the Queen Mother and her linguist dancing around the circle. They pulled NSWB members forward to join them. It felt like she was showing us to the people. Those who were pulled from the safety of the canopy were: Whip (Stephanie), Myself (the Queen Mother told me I was “very good”), the Mamas (Val and Maura), as well as Jocelyn and Zanele. I’ve got pictures. They aren’t as good as some others, as the dust and sand kicking up during the dancing came out as spots when our cameras would flash.
The entire affair was quite an event to witness. After all the entertainment concluded, our formal acceptance into the community began. The chief called each member forward and gave them their African names and two bracelets made of long strands of some kind of dried grass cinched by two traditional painted clay beads. These bracelets, we were told, represented our membership into the community as children of the Chief and Queen Mother (the word Royal was thrown around too.) Our African name is our first name, the day of the week we were born (in Ewe), and then our last name. Mine is Jody “Akousa” Roper, because I was born on a Sunday (my mom will have to correct me if I’m wrong.)
Maura Norton (being the eldest) received an even greater honor during the ceremony. She was crowned as a Queen Mama; as the community views her as “Mama” to our group. She received more beaded bracelets, a crown of woven/braided cloth, and special sandals. She sat on a stool beside the true Queen Mother, wrapped in a robe of Kenti cloth for the rest of the evening.
The dance floor was opened up to all participants at this time; so we danced. The welcoming session concluded with our group being offered palm wine, which was shared around our circle in a gourd bowl; you drink and then pour a small amount on the ground (I believe for your ancestors.) I have a phobia about sharing drinks, so I hung back a bit with the little girls I’d been dancing with and was passed over in the dark. I was told the drink was warm and bitter.
We loaded back on the bus, exhausted. We’d all been up since 6am and the ceremony had lasted three hours. There was one more stop to make; Mawuli’s uncle’s house. On the well lit front porch a brand new bottle of chilled palm wine was opened for us. Many gourds were offered around our circle. I received a fresh “glass.” It was fizzy and cool and delicious; though my tastes may have been influenced by the fact that I’d danced and sweat and been without drink for over three hours. It was a very unique flavor though, so I can’t think of anything to compare it with at the moment.