Life Lesson . . . Don't ride a bike barefoot!

I remember that growing up my parents had the rule that we always had to wear shoes when riding our bikes.  I assumed it was because the ridges on the pedals would hurt your feet if your rode barefoot.  Today, this poor 7 year old and I both learned why it is important to ride a bike with shoes on.  She was a passenger on the back of her brother's bike and her foot found its way into the bicycle spokes.



The girl is missing her entire big toe and part of her second toe.  The third toe is missing skin, but the bone is all intact.

Using bone rongeurs to cut off the ends of the exposed bones so that I could close her skin over the ends of the bone.

The father pulled this out of his pocket.  It is the child's big toe . . . he looked very sad when I told him I would not be able to reattach the toe.  He would not throw it away though, he is going to bring it home and bury it in the house.  I guess it is a superstition, that if a person lives and you have discarded a part of the person without a proper burial of the part then the person can die.  

Local Cuisine

At the top is rice balls in groundnut soup, the
bottom is TZ in okra soup

Ghanaian cuisine is mostly organized around a starchy staple food such as rice, cassava, yam, or maize.  Depending on where you are located in the country the starch will be prepared in different ways, making a variety of different dishes, such as fufu, kenkey, banku, rice balls, TZ.  Here in the Northern Region, where I live, they primarily eat TZ (pronounced T-zert) and rice balls.  These starch variations will all be served with some kind of soup, which is made from fish or some kind of other meat (goat, beef, chicken, guinea fowl, or pork).  Here in the Northern region groundnut soup (basically a peanuts soup) and okra soup is most common.  They will place the rice balls or TZ in one of those two soups and then give you a little side of beef. 

I actually like most of the food here in Ghana with the exception of TZ.  TZ actually does not really have a taste.  It is the texture that gets me.  It is extremely slimy and makes me feel like I am eating boogers.  Here in Nalerigu we go to the local “chop bar,” which is called Free Bar, to have local cuisine.  My favorite is rice balls and groundnut stew.  

Sharing a meal of fufu in okra soupwith Asubonteng (right)
 and his twin, Seth.  They are from Kumasi (south of the
 country) where fufu is primarily eaten.  Fufu is basically a
gooey ball of pounded cassava root or yam. 
 

When you sit down to eat the first thing you do is wash your right hand.  The left hand is considered dirty and should never be used.  In fact, they will not even use the left hand to take something from someone, always the right.  You don’t even use your left hand to wash your right like we do, that is just contaminating your right hand again.  (A child was in my office one day and I gave her a pencil after her visit and she took it with her left hand.  Her mother gave her a love pat on the back of her left hand and made the child give me the pencil back.  Then we tried again, this time the child received the pencil in her right hand and all was well.)  After you wash your right hand it is time to eat.  You scope part of the TZ or rice ball into your hand, roll it around into a ball, and dip it into the soup.  That is the worst part.  The soup is so hot and I always go away with burnt fingers.  I think the Ghanaians are used to the heat because it does not seem to faze them.  The challenge then is to get this mushy soupy mess into your mouth without dripping soup everywhere.  I always end up with soup running down my arm and making a huge mess.  My friend, Asubonteng, has told me it is because I was never taught the proper why to eat with my hands.  He said he remembers when he was a child his mother teaching him and correcting him when he was eating wrong, just like we would correct our kids if they are using a fork incorrectly.  He has given me a few pointers and I am getting a bit better!  The trickiest part is finishing the soup with your fingers.  I can’t do it at all, but Ghanaians, cup their first three fingers, scoop up the soup and then kinda wip the soup into their mouths, turning their hands upside down as they do it.  I am always amazed that they do not drip or fling soup everywhere.  I choose to finish my soup cereal style, drinking the rest of the bowel. 

Eating fufu with Asubonteng.  I find fufu is very heavy on my stomach and I can not eat much before I am full.  You can notice that Asubonteng has already finished his portion!  All of the starch foods they eat could be compared in a way to how we eat mashed potatoes.  I had a funny conversation with Asubonteng once about the differences.  He has had mashed potatoes when he shared Thanksgiving dinner with us and he can not believe that we eat it.  He hated the texture and said it had no taste.  I think fufu and TZ are the most tasteless things in the world and how he wants to eat fufu every day is beyond me. 

 Eating TZ, with my neighbor T Welch at Free Bar in Nalerigu.  TZ is made most commonly from pounded maize.

 

 This is one of my favorite meals served by the cooks at the BMC.  It is fried rice, Ghanaian style.  It has chicken, green peppers, and onions added. 

 

Behind rice balls and groundnut soup, Jollof rice is my second favorite dish.  It is a spicy dish comprised of rice cooked in tomato sauce.  It occasionally has pasta noodles and meet mixed into the rice.  It is served with meat, fish, or chicken.  Here I had it with cabbage salad (lettuce is rare in Ghana so we cabbage salads instead) and kabobs.

Red red is my third favorite dish here in Ghana.  It is a spicy bean stew made with black eye peas and is usually served with fried plantain, cassava root, or rice.  It gets its name from the palm oil that tints the stew an orange color.  It is greasy goodness.

Eating fried plantain with groundnuts on the go in Kumasi.

 

Banku can be seen in the top right hand corner of this picture.  It is made from fermented maize meal and is served with a tomato based relish that you dip the banku into (below the fish on the plate).  Banku is surprisingly sweet tasting.  It is mostly found served in the south of Ghana.  This banku was served with the best tilapia I have ever had.  Tilapia is also very common in the south of the country.

 

Traditional Homes



Traditional homes in the North of Ghana are made of mud with thatched roofs.  They are more like a family compound with many circular rooms around a large courtyard.  I have found recently that the rainy season is hard on their homes, often washing away walls, etc.  During the dry season when there is no farming, the men will spend their time repairing the damage the rains created. 

I have found that actually where people live is a complicated subject.  I guess families in general are a complicated subject here in Ghana.  They do not live in nuclear family units like we are familiar with (although young and educated Ghanaians are more often living this way).  Here are some of my observations: 

1)      Children usually are with their mothers.  If a child is in school often they have to travel to another city to be educated so they will live in dorms or with some “relative” (this term is used very loosely here often it simply means someone from the same tribe) that lives in that city, or will even rent a room and live with strangers. 

 

2)      Husbands and wives don’t always live together.  Many times they are separated by work restraints, but also wives in the villages will sometimes live still in her mother’s house.  Polygamy is also practiced here, especially those that are Muslim.  Husbands will have their wives in many different homes, sometimes even in different cities, and the husbands will travel between the wives. 

 

3)      Polygamy makes trying to figure out who is related difficult and also the fact that they consider everyone of a same generation in a family a brother or sister . . . even though it might actually be a cousin or half sibling.  So if someone says another person is their brother you have to ask, “same mother, same father?” Often the answer is no it is my father’s brother’s son or same father different mother.  If someone says another is an aunt or uncle you also have to question, because anyone that is a generation older from the same tribe would be an aunt or uncle.  They will also say someone is their “junior father” or “senior father.”  That means the person is their father’s younger brother or father’s older brother. 

 

4)      Having children here in Ghana is extremely important because it is your insurance policy that someone will take care of you in your old age.  Most elderly Ghanaians live with a son, although this can be tribe dependent. 

 

5)      It is not unusual for families to rent space in their compounds for extra income.  Usually it will be a single mother and her children that will rent the space.   

 

6)      For the most part every compound has some combination of generations living there.  In the villages, the grandmothers are important figures for staying home and carrying for the kids as the adults go out a farm.  So it is usually a grandparent, parents (mom, dad, or both), and a gaggle of kids living all together.

 

Another interesting thing about Ghanaians is that they do not trust banks and have an interesting relationship with money and savings.  All of the cultural practices around money in West Africa is a whole topic in of itself, but one thing they do is invest in property and building materials instead of a savings account.  If there is any money left over at the end of the day a family will put the money towards building a modern “block” house, which is basically a house built of concrete blocks.  If someone has money saved and a tribe member asks to borrow money they are culturally obligated to give them the money up and they might never see it again, therefore they put the money into something literally concrete.  It might take up to ten years to complete a structure this way.  This practice is apparent as you walk around town an see dozens of half built homes and shops.

Case of the Week: Condyloma

Since the beginning of July the BMC has been blessed with the addition of an OB/GYN to our staff, Dr. Lynn Coppola.  I was probably the happiest of everyone to see her arrival because I had been trudging through taking care of obstetrical patients for the past 7 months.  I am glad that the women of Northern Ghana finally have an expert at the BMC.  Below is an interesting case that she has seen and managed at the BMC.

By: Dr. Lynn Coppola

The first week I was here, an approximately 30 year-old lady came to our outpatient department complaining of a foul-smelling vaginal discharge.  Both of her labia were covered with condyloma, and the odor was indeed foul.  The condyloma had been first documented in the hospital chart almost 3 years ago, at which time a midwife had questioned whether or not vaginal delivery would be advisable.

The patient was now requesting surgical management.  Because I wasn’t totally sure what to do, I gave her some antibiotics and requested an HIV test.   I also took a biopsy.  A week later, she came back.  The odor was better, and the HIV test was negative . . . but she was still requesting surgical management.  Still uncertain whether or not excision was a good idea, I asked her to wait one more week until a urogynecologist with years of Nigerian OBGYN experience would be visiting. 

She came back again to see Dr. Norman, and he said something like “I’m not sure what the right thing to do is, but we can’t just leave her like this.”  So . . . we did a bilateral vulvectomy.  I have seen her weekly since that time, and she is very happy.  The anterior part of the wound separated a bit, but she is keeping the area very clean.  She asked permission to wait two weeks until her next appointment because we are now in the rainy season, and the river she has to cross reaches to her waist.  She doesn't like to get the river water on her wound.

I am still waiting for the biopsy result.

Case of the Week

The patient in the picture is a gravida 9, para 8 (pregnant 9 times, has delivered 8 times) woman from a “far,far village” who came in complaining of a cough.  After talking with her a little, it seemed like she really came to our hospital because her last six babies have died during childbirth.  She says all but one of her stillborn children have delivered breech.  She knows they have been alive at the beginning of labor because she can feel the legs kicking.  Then the feet come out and she struggles for prolonged periods of time to deliver the rest of the body.  She stated that she could feel the feet stop kicking while she is “waiting long” for the head to deliver.  She has never delivered in a hospital before. 

The patient was asked to unwrap the layers of cloth she was wearing around her waist so that an ultrasound could be performed and an amazing site was seen!  She has a large abdominal hernia with a fascial defect probably 10-12cm wide.  The working theory is that her uterus tilts forward into her hernia sac, resulting in fetal malpresentation and possibly even fetal head entrapment in the hernia.  Now, she is only 24 weeks along by ultrasound.  A plan was made for her to return to her village for the next month.  Then she will come back to Nalerigu to deliver at our hospital.  We pray that all will go well.

It is quite amazing to me where the scrubs in the hospital come from.  Today I pulled out a shirt from St. Louis University.  I had to take a picture in honor of my dad, who went to medical school and residency there and for many years was a faculty member.  I know he would have been happy if one of his girls had followed in his footsteps, but wearing this scrub top in Nalerigu will have to do.  I have also come across a scrub top from Akron General Medical Center, but in solidarity with Akron City Hospital (where I trained and is rivals with General) I put that one back on the shelf!

Defiantly Not Irish Dancing!

I was invited to dance by one of Asubonteng’s relatives during his grandmother’s funeral.  I felt like I could not refuse, Asubonteng told me it was a requirement at a funeral, and I figured I could make a fool of myself because I would never see any of those people again.  After I was finished, Asubonteng told me he had never danced at a funeral in his life and he thought it was hilarious I did and of course videoed it.  Over the last few weeks has enjoyed showing the video to everyone at the hospital, including the administrator, so I figured I would go ahead and share it with you.

The women in the red cloth with the red necklaces that joined me dancing are Ausbonteng’s mother and Aunts.  At the end of the video, the man that comes and touches my forehead and who is dressed more ornately than everyone else is the local fetish priest.  Although I felt like those were the longest three minutes of my life, I know that the family really appreciated that I was willing to get up and try. 

Case of the Week: Anthrax

I admitted the patient above to the hospital; not because I actually had a clue about what was wrong with him, but because I knew what was happening to him was NOT right.  He told me the swelling in his neck had happened over a few days and I was worried if it continued to swell he would obstruct his airway.  I thought it was strange that so much swelling happened over a few days and could not place the rash that he had overlying the swelling.  I asked Dr. Hewitt to take a look at the patient in the ward because I did not know what to do with him and he remark without blinking, “Oh, this is just cutaneous anthrax.”

 

If you remember, anthrax was launched into the US news in 2001 with a death from inhaled anthrax from a deliberately contaminated letter.  Over a few months, there were 13 cases of cutaneous anthrax and 11 cases of inhalation anthrax all associated with exposure to contaminated mail.  This spread fear of bioterrorism across the nation (including into the head of a young curly haired family member, who will remain unnamed, who saved a letter in a plastic bag for weeks that had some “powder” she insisted fell out when she opened it, thinking the Frontenac police should investigate it for anthrax).

Well, here in Ghana we have naturally occurring anthrax which is a disease of sheep, cattle, horses, goats, and swine.  Bacillus anthracis is a gram positive spore forming aerobic rod.  The spores are the infectious form of the organism.  It is spread to humans through contact with contaminated animals, animal products, hides, or soil by inoculation of broken skin or by inhalation of aerosolized spores, rarely by ingestion of the spores.  The result is cutaneous, inhalational, or gastrointestinal anthrax.

Cutaneous anthrax occurs within two weeks after exposure to spores.  The lesion initially looks like an erythematous papule that then vesiculates and ulcerates.  It undergoes necrosis and eventually turns to a purple / black eschar.  This lesion is typically painless.  The most impressive aspect is the surrounding area of edema.  Patients may have fever, malaise, headache, nausea, and vomiting.  Infection is usually self-limited in most cases, but hematogenous spread with sepsis or meningitis may occur.  The infection can be treated with penicillin, however, in many places resistance to PCN has formed so it is currently recommended to treat with ciprofloxacin for two weeks.  Cutaneous anthrax is the least worrisome of the potential forms of infection and recovery is excellent, however with inhalational or gastrointestinal anthrax there is up to an 85% mortality rate.

In questioning this patient further, he had killed a sheep a week before his symptoms started.  He was started on antibiotics and did very well.  I will defiantly never forget what this infection looks like and next time I see it I am planning on nonchalantly saying, “Oh, this is just cutaneous anthrax.”