HIV in Botswana: The Case for an Aggressive Approach

As I’ve mentioned here before, I’m in Botswana to work at a pediatric AIDS clinic. Work is going much more slowly than you might imagine. But I’ve spent much of the downtime of the past month learning more about just why what my corner of the clinic does, providing psychosocial support to teenagers, is so important.

First some background on HIV/AIDS in Botswana, which is the second hardest-hit country by the epidemic after Swaziland. Currently, about 17.6% of the population is infected with AIDS, though a decade ago nearly 40% of adults were infected. Compare this with the recent news that Kenya’s HIV prevalence has dropped from 7.2% to 5.6% in the last five years. I often find myself thinking about the peak years of the epidemic in much the same way I think about years of conflict or genocide in Uganda and Rwanda, with the societal impacts (particularly demographics and the long-term effects on the workforce, education system, family structures, etc.) playing out in ways that remind me greatly of post-conflict societies. HIV/AIDS isn’t just a medical problem, it’s a social and economic problem as well.

The government has been highly effective in curbing the devastating effects of the disease. In the early days of the epidemic, infection often resulted in death within a few years. Unity Dow and others talk of social life being overrun by funerals in 2004 and 2005 to the point that people couldn’t keep up, that traditions around burial and ceremony had to be adjusted to accommodate the surge. Life expectancy was under 40 years in the early 2000s; now it is 53. Thanks to the government’s work (in partnership with other organizations and companies) to end transmission of HIV by 2016, HIV testing is something you must now opt out of to avoid, anti-retroviral medications (ARVs) are widely available and covered by public healthcare, and prevention of mother-to-child transmission services (PMTCT) have caused a drastic drop in new cases in children (now only 4% of newborns get HIV from their mothers).

In fact, the government has been doing so well that people are starting to talk about redistributing funding. “These programs are great, but is it still the best allocation of limited resources?” Critical minds in development/aid work (always) want to know. Why pour more resources into eliminating transmission of HIV, an infection with which many people can live long, fulfilling lives, when there are other infectious diseases and rising levels of non-communicable diseases (NCDs) that kill lots of people and do not receive enough attention?

That is a question I likely would have posed before I got here. Not that it is a bad thing to try to stop HIV transmission, I would have hastened to ad, but hasn't there been so much progress over the last decade that we're reaching a point of diminishing marginal returns on investment? I still think there's a lot to be said for re-examining health spending priorities, but here is a non-exhaustive list of some of the points I'd now make in favor of continuing efforts on this front:

1. Children infected with HIV face a significantly higher likelihood of developmental delay than HIV-negative children. Those delays can, in some cases, cause them to slip through the cracks of Botswana’s education system. Not to mention the school they miss or work the adults miss to receive medical care. So not only has the previous generation’s working population been eroded, but also a portion of the current generation of youth is growing up unable to succeed academically or in the workforce.
   

   

   
   
2. Improving HIV/AIDS-related health systems strengthens more of the health network than just the HIV-related components, just as having HIV/AIDS makes you susceptible to a range of other health issues and often complicates treatment for other diseases (e.g. the rise of cancer in Botswana and other resource-poor countries is linked to HIV). The clinic I work in specifically targets HIV-positive children, but provides a broad range of services to them and their families. As fewer and fewer children are HIV-positive, I wonder whether the clinic will expand to adult HIV-positive patients or HIV-negative children. Overall, I expect the health infrastructure that has been put in place to combat the epidemic can be extended to cover more general health services.
   
   
3. Although life with HIV can be long and fulfilling, it’s not easy. Adhering to a strict daily drug regimen—taking your medicine at specific times of the day, with food—for the rest of your life is more difficult than it sounds, and non-adherence can allow the virus to develop resistance to your medications, which makes the disease more serious, for you and for society as a whole.
   
   

It’s this last point that’s most relevant to what I do. Following the implementation of PMTCT programs, the number of young children with HIV is diminishing and most infected youth are adolescents born pre-PMTCT (which was introduced in Botswana in 1999). And adolescents tend to have a hard time with adherence.

Adolescence is a difficult time for people anyways, with trying to prove yourself and establishing independence and rejecting authority and having insecurities and developing new relationships and being overexposed to narratives of what “normal” is—while still negotiating a sense of self to counter those narratives. Hyper-awareness of stigma and the opinions of others can tip the balance for adolescents grappling with issues of disclosure to their partners and others, of taking their medicine regularly when friends and dorm-mates are around, of wanting so badly to be “normal” that they play tricks with themselves (“maybe if I just don’t take my meds it will be like there’s nothing wrong”). These problems aren’t unique to HIV-positive youth.

I think there’s also a really interesting tension in adolescents between, on the one hand, the desire to live in the moment—with greater reward-seeking leading to greater risk-taking—and on the other hand, a growing appreciation of the idea of permanence, particularly among older adolescents. I think (though I’m no psychology expert!) it’s in late adolescence that people start to grasp what they can, and more importantly cannot, expect to change over the course of their lives and what it really means to have a medical condition that will be a part of them for the rest of their lives. And I imagine that can be a pretty scary, desperate place to be at times.

Last Saturday, over a hundred teenagers turned up to the clinic to hang out with other HIV-positive teens and do activities and hopefully learn something about how to have happy, healthy, fulfilling lives and (most importantly) to have a lot of fun. I’m responsible for planning these events every month, and it feels like a big task to shoulder—not because the logistics are difficult, but because I think about all the potentially dark things happening in their hearts and minds and wonder how to break through all that, to get them to healthy adulthood in day-long installations once per month.

Our co-facilitators for the day started off with some song and dance in the clinic lobby, coaxing the kids to mingle, then clap, then turn to their neighbors to say “you’re special”, then make some noise. I saw a girl of about fifteen roll her eyes at her friend. And somehow suddenly the entire room of 144 teenagers and volunteers was jumping and cheering and singing and waving their arms and bursting with impossible grins and in the deafening noise and exuberance, I swear you could feel the joy as a tangible force in the room. These kids were so full of life. I choked up; it was one of the most moving experiences I’ve had.

I don’t want these teenagers to get sick, don’t want them to feel they won’t be loved if they disclose their status, don’t want them to struggle with normality/identity/secrecy/insecurity any more than any other teenager does. And maybe they don’t, mostly – the small discussion group I joined talked about their biggest obstacles being stress over exams, just like any other teenager. But the facts are that adherence rates are significantly lower among adolescents and young adults than they should be.

I watch the teens elected to be leaders among their peers work magic bringing the teens together and taking responsibility to make sure things run smoothly, and I see kids turn up every Saturday for extra tutoring (and wait patiently for me to remember how to explain their basic chemistry problems), and I feel such fierce, affectionate admiration for them. They are what makes my being here worthwhile, and why I want to see what else Botswana can accomplish in HIV/AIDS prevention and treatment.

First impressions of Gaborone

Nearly four weeks into my stay in Botswana, I’m starting to feel like I’ve found my footing and am really getting settled. Unfamiliar pronunciations are starting to roll a bit more easily off the tongue, seemingly-identical intersections are becoming landmarks that help me build my mental map of Gaborone.

Work has been somewhat slow, but I am looking for projects to get involved in. When I’m not working, I’ve been filling my time with braais (barbeques), slowly improving my disastrous frisbee “skills”, camping, cooking and being cooked for—including a glorious eggs benedict breakfast and a Shabbat dinner, finding my way around the combi system, wine tasting at the aspirationally-named “yacht club”, reading, running, learning new boardgames, and, mostly, meeting a lot of fantastic people.

Just outside Gaborone

Botswana is dry. And, because it’s winter, surprisingly cold in the pale mornings. “Just wait ‘til the summer comes,” says every Motswana and long-term expat I’ve met. The sky stretches out blue and blue and blue without even the faintest thought of a cloud, and even the two days so far that have been overcast yielded no moisture. Gaborone is more of a sprawling town than a city, but it’s the largest in the country, so I’ll leave the condescending New Yorker behind for now. The deep pink light of sunset slanting through air thick with dust, the quietly imposing backdrop of Kgale hill rising at the southern edge of the city: these are moments of striking beauty that will stay with me. Botswana is often considered an African “miracle”—a stable, middle-income country with strong government investment in infrastructure, social services and population health. Indeed, I have to say I’ve been impressed.

I’m lucky to be living in a nice apartment provided by the clinic—primarily for American medical residents here to do month-long rotations at the clinic—in a neighborhood surrounded by embassies. So I know I can’t assume my experiences of reliable internet, electricity and running water are at all universal. A quick look at Old Naledi (a high-density, low-income neighborhood that was historically an illegal settlement) and villages just outside of Gaborone, neighborhoods that many of my teenagers call home, certainly makes that obvious.

Nevertheless, I’ve been impressed with the immaculately paved main roads, the relatively easy public transportation, the general quality of building construction, and the potable tap water, and I don’t think my impressions here are too overly biased by my living situation. Even an article critical of Gaborone’s planning, land allocation and development calls the city “extraordinary in African terms… a city lacking in mass poverty, extensive squatter settlements or recurrent civil strife: for all appearances, an orderly, affluent urban area.”

It seems to me that one of the most crucial differences between Accra and Gaborone is population density (about 9,600/km² and 1,500/km², respectively). I notice it in the different textures of daily life, the feel of the city as you walk down the street. Density is more concrete than just noise and bustle: it’s also the traffic that makes everything run late, the restaurants and small-scale businesses that can pop up and slowly grow in unexpected places, and (arguably) greater overlap of rich and poor. And, importantly, it’s the additional wear on infrastructure, including roads, water delivery and electricity grids. Brian Larkin points out that such “material structures produce immaterial forms of urbanism—the senses of excitement, danger, or stimulation that suffuse different spaces in the city and create the experience of what urbanism is.” I can think of numerous similarities between Gaborone and Accra, but ultimately the forms of urbanism in these cities are drastically different.

The simpler explanation for the differing material structures is that Botswana’s GDP per capita is over five times that of Ghana. But I suspect that Gaborone’s public services and infrastructure seem impressive because they endure less wear, and that the cloistering of low-income populations makes it that much easier to extol the prosperity of the rest of the city. These are density-related issues more than financial ones. It will be interesting to see if density rises significantly as the economy further develops and mortality declines (particularly HIV-related mortality), or if the city will rather sprawl.

Jane Jacobs (1961) writes that cities, and creativity and innovation within urban centers, flourish when there is sufficient density for street-level interactions between a diverse array of people. She would certainly prefer Accra to Gaborone, which was designed according to exactly the principles she most opposed. She would also, I think, prefer Old Naledi to Gaborone’s other, more sterile neighborhoods, much as I preferred Kariakoo to Sea Cliff Village in Dar es Salaam.

I imagine a future Gaborone with the same sparsely-populated center and ever more densely-packed neighborhoods around the periphery. Would those densely populated neighborhoods be pockets of collaborative innovation, or would the structural problems of poverty underlying the need for such close quarters staunch such creative vibrancy? A call for better education, health services, and investment in these neighborhoods….

Now that I’ve found my footing, I hope to venture further out of my privileged arena. I’m sure my thoughts on Gaborone’s neighborhoods, infrastructure and urbanism will develop—and probably change completely—as I get to know the city better and from different perspectives.

London Charm and the Colonial Legacy

I landed in London, over a week ago now, and felt an irrepressible grin take hold of my face. The reality of my latest journey having truly begun, after months of planning (nearly a full year since I began my application for this program), finally sank in as I walked through Heathrow. But that was only part of my excitement: I was in London.

I would never have expected to be so excited about visiting this city, but I guess over the last several years of reading the BBC, watching British tv shows, becoming increasingly familiar with the culture, and meeting many wonderful people who had claimed the city as home at one point or another, I’d worked up a subconscious curiosity about it. The U.K. is easily the country I know most about of those I’ve never visited. Without my realizing it, it’s been in the background of my mind as a sort of friendly “Other”, a reflection of my own country—or some sort of parallel universe. London and New York, the U.K. and the U.S. occupy similar spaces for most of the world, and yet there’s a distinct identity (primarily reinforced by them). Comparisons between the two places abound.

As I navigated my way to meet up with a friend, I walked into a place that had only existed in my mind. I paid for my ticket with POUNDS! I was on THE UNDERGROUND! It was charming and small! I emerged from the station and all of the buildings around me were stunning and I was in awe. Give me a few years in this place, I thought. Let me repeat: I had zero expectation of feeling this way. But I recognized my behavior. It was the same as someone from another country visiting the U.S. for the first time and seeing the iconic NYC sites and recognizing that, yes, this was the place in the movies and books and news. There’s something about being, in the flesh, in places that permeate our culture and our imaginations for years before we visit in person.

I was thinking about how the U.S. holds that position for many people around the world, and how it’s our cultural hegemony that engenders such widespread curiosity and desire to come to the U.S., not just hopes for prosperity (even if this is commonly expressed). On the other hand, I was also thinking about how different such a trip would be for someone coming from a developing country or the Global South. In my case, patriotic narratives and America’s global stature easily counterbalance British critiques of the U.S., but many others would have been told implicitly or explicitly that this other, more powerful country and culture was superior to theirs. The internet and other new technologies both challenge and reinforce this dynamic.

On that note, I thought of this beautiful letter on decolonial aesthesis from a Singaporean woman to her younger self about her experiences studying at Cambridge University. How many people would feel, in the face of Britain’s imposing cultural stature, as she did: “There’s not much culture [where I’m from]… There’s not much nature”? She writes, “[Colonialism] happens these days not by the strength of arms or the power of states, but by the captivation of the eyes, the training of the taste, by unwritten rules of thumb – that we all learn everywhere, without even knowing it.”

A recent map showing all the countries Britain has invaded reveals the global spread of its potential cultural influence. Source.

My entire time in London, I didn’t think for a moment about the fact that Botswana had been a colony of the U.K. That even if Botswana wasn’t itself Britain’s most lucrative colony, it was still part of a structure that gave the country wealth and power in the international arena, that had helped install British culture as a dominant aesthetic. Botswana had made London lovely, and I didn’t even notice it until I had landed in Gaborone.

When I left Ghana last year, I had a layover in Amsterdam, where I was also charmed by the beauty of a European city. I stopped into the Rijksmuseum and saw a portrait of a couple that had been based in Elmina, Ghana. The placard announced that they’d worked for the Dutch West India Company, which traded in gold and slaves from Ghana for nearly 300 years before the British took over. I remember the jolt of connecting the two sides of the same story, having seen the slave forts and trading posts owned by the Dutch in both Ghana and Benin. A recent AIAC post on Dutch denial/ignorance of their historical slavery practices notes that less than half of Dutch history textbooks in a recent study so much as mentioned slavery, and even in those, the emphasis was on hardships the Dutch colonists suffered, rather than those of the slaves. Walking through that museum less than a day after leaving Ghanaian soil, I was taken aback by the normalization of this terrible history and the narrow-minded focus on what the Dutch got out of this trade, the nostalgic pride in the Dutch empire at its peak. Ghanaians certainly hadn’t forgotten the price of that empire.

In Gaborone, I stood on my new balcony and looked out at the dusty scrub in the afternoon sun and crisp, dry air, wondering at the difference in my reaction to arriving here. I was excited, exhilarated and absurdly happy, to be sure, but the truth of it was I just didn’t know Botswana and its cultural references as I did the U.K., and that’s a sad fact. Normally the lure of exploring the unknown is a huge part of the joy of travel, but I’d sampled another style of encountering a foreign place the previous day and I couldn’t help but feel I was missing out. What would it have been like to feel in Gaborone that same sense of arrival in a mythical place?

Botswana challenges popular notions of “Africa” – including my own, based on previous travels. (This is not terribly surprising.) The airport lacked that smell of heat and fruit and human bodies that has greeted me in Uganda, Tanzania and Ghana. Sometimes I think I’m in Arizona. The city, like the rest of the country, is sparsely populated and the lack of traffic, the lack of bustle, the relative lack of streetside vendors throws me off a little. The clinic is, as my housemate said, “nicer than any clinic [she’s] seen in the U.S.” and the teens I work with would fit in at your typical American middle school. I live in a wealthy area, and have only been here a week, so my perception is drastically limited, but I like that I’m forced to re-evaluate perceptions of the continent I didn’t quite realize (still) I had.

I’ll end with a quotation from that letter preparing the Singaporean girl for life in a new culture.

Modernity is someone saying to you: look, we have made you better. And you believing it.

But the question is not how to retreat or how to prune yourself back to some pristine, native state. In fact, it is the opposite: how to recognize the narrowness of this so-called broadened mind – to realize that Europe is not the universe – and to take your sensing and knowing beyond those dominant ideas of the true, the good, and the beautiful. To move towards a pluri-verse that gives dignity to both the girl in the pajamas and the one in the little black dress – and yet to do so in a way that, unlike Western liberalism, is not naïve about either the ‘equality’ of the two, or about how we got from the one to the other.

I loved London, truly, but I don't want to lose sight of its context. And I look forward to wondering at all that makes Botswana magnificent.

 

Setting out on a new adventure

Welcome back to the latest incarnation of my blog, which I hope will be more active than the last. I write this from my new apartment in Gaborone, Botswana, where I will be living and working for the next year. Before we dive into Gaborone and my plans for the coming year, though, let me back up and explain why I’m here.

During my year in Ghana working with students trying to go to college in the U.S., I had a chance to finally dip my toes into something approaching “development work” in Africa—just what I always wanted. Over the course of the year, I had my share of disillusionment with the project (though I also came to see why the organization had chosen the strategies that it did), but there were a couple of things that I found particularly rewarding. I loved getting to know the students, through conversations and their essays and their aspirations for college. It was also a job that played to my strengths: I understand far more of the American college admissions process than your average African student, and I can comfortably say I wasn’t doing work that a local person who better understood the nuances of the local social, political and cultural context could have done better (more on this later).

So as I began to think about future directions, I knew I wanted to have a skill set that would make me valuable even as a foreigner, and that I’d like to work directly with people. On a recommendation and a whim, I checked out a public health master’s program, and realized it was exactly what I wanted. There’s something very concrete about working in medical fields, but I hope that there will also be room in public health for attention to the political and cultural influences/outcomes.

This year, I will be working with HIV-positive teenagers at a clinic in Botswana. Many of my roles and responsibilities will likely change over the course of the year, but generally my job will be to support the teenagers in building healthy, happy, productive lives.

I’m entering this new stage with a lot of questions in mind, mainly about how to do the best job possible. I’ve recently read Susan Wicklund’s This Common Secret: My Journey as an Abortion Doctor and Tracy Kidder’s Mountains Beyond Mountains. The first is the memoir of an abortion doctor working in Wisconsin, Minnesota and Montana, and the second is a biography of/love letter to Paul Farmer, the public health superstar physician who began Partners in Health.

At one point in the second book, Farmer is quoted as saying that “it’s not about a quest for personal efficacy” —that is, we should focus not on improving ourselves, but on improving the lives of others. Of course, true selflessness is impossible, since we gain something from helping others, even if it’s just a brief easing of moral discomfort, but the quotation struck me. If we’re focused on improving the lives of others, shouldn’t we make sure we are doing the best job of it as possible, and isn’t that a question of personal efficacy?

Kidder follows up with an explanation from one of Farmer’s colleagues, who says that the doctor represents a model of what should be done—proof that extremely difficult problems can and should be addressed—rather than a model for how it must be done. I think the same could be said of the abortion doctor. Focusing on trying to be Paul Farmer or Susan Wicklund is not important (and certainly there are many criticisms to be made of both). Nevertheless, they do both present a model for improving the lives of others, and share an intensity in their passion for caring wholly and specifically for the individual patients in front of them that I would like to carry with me as I begin this new job.

It’s really important to think about systemic problems and large-scale changes that need to be made (and, indeed, both doctors are engaged on this level as well), but without a focus on the individual, you perhaps risk allowing those systemic problems to overwhelm you. They might become an excuse not to act at all. Both doctors share concerns about the costs of losing sight of the individual, and Farmer in particular is presented as being afraid of allowing work on large-scale issues—like international advocacy on treatment procedures—to crowd out seemingly less impactful tasks, like day-long trips to see a single patient. At least as a starting point, I think it’s worthwhile to have a grounding in the personal and the specific from which to build a broader political awareness/advocacy agenda.

It will be hard, much harder than I’d like to admit, to fully relate to the patients I will work with and to consistently see through their eyes. I come from a vastly different cultural background, and from a position of both absolute and relative privilege: can I really hope to understand the perspectives of HIV-positive Motswana teenagers? I look forward to holding myself to the challenge of doing my absolute best to listen and learn from them, and to use what I learn to make whatever improvements for them possible.

This clinic is at the top of its field, and I know I have so much to learn from my experiences here. I hope that the lessons I learn will help me wherever and with whomever I end up working, but for now I would like to put thoughts of my own future aside to concentrate on the lives of these teenagers. Wish me luck!

Northern Ghana

View Northern Ghana Trip in a larger map

I woke up the morning of our big trip feeling poorly rested and anxious about the busy day ahead of me – I was already more than ready to escape. For every task crossed off my to-do list and every minute sitting in traffic to the rendez-vous point for our journey, my excitement grew. We drove to Kumasi on Wednesday night so we could squeeze as much into our trip as possible, and then left the next morning through horrific Kumasi traffic. Finally, we made it out and began zipping along the road towards the North. The sun-kissed thrill of speeding into new territory as Ghana flew by had me giddy with happiness.

The road we took followed a pathway of historical mosques (the guidebook points out that it is likely the road we were traveling on is the same as a much older Islamic trade route). We drove through increasingly Muslim areas, and saw more “modern” mosques alongside the old historical ones, including one that we drove past at 3pm, in time to hear the call to prayer belted out not through the speakers but just a man outside the door, facing the road. We stopped at Bole, the site of one historical mosque, and met some immigrants from Niger sitting on mats and apparently drinking tea in the shade of the mosque.



It’s amazing to me how different these old mosques are from any other mosque I’ve ever seen—as you can see from this picture. According to this site, the mosques are a mixture of “vernacular construction techniques” and the rules of mosque construction. The mosque had small doors, so one was crouching while entering and going up to the roof. From the roof we could see the whole village, including the modern mosque we had walked past to get to the historic one. I wish I’d asked what determines whether someone will use the historic one or the modern one.

After dinner at a local “spot,” we were soon flying through open, empty land again, the feel and smell of night in the air slipping through my fingers. But it was the sense of utter freedom that made my heart skip. It was too perfect to capture by camera. Suspended between the foreign and the familiar – the chirp of crickets and the smell of dry, grassy fields to remind me of summers at home, while open land marked by shrubs and sporadic trees reminded me of Nakivale and the way you would walk through flat lands of uniform composition – I was delighted.

We missed the turn to the hippo sanctuary where we’d planned to spend the night, and found ourselves in Wa, the main town of the Upper West region. There, we got directions from a bus driver, the gas station attendant, and a very friendly student, all of whom agreed that we should turn “at the stoplight.” We approached a sign pointing us to the town we were headed to and knew it was time to turn… only to discover that the “stoplight” was in fact a roundabout! (This experience was repeated later, when we were looking for the road to turn off the main road towards Mole National Park and were told repeatedly to turn at the “roundabout” – which was actually a T-junction…)

Suddenly we were sweeping through the dark, the world lit only by the bright full moon. We passed through remote villages, and onto completely deserted stretches of dirt road, as though we’d managed it: we’d slipped away from the world, thrown it away for the great expanse. Where does this mysterious urge in a city girl come from? To leave all behind and disappear into wilderness? The night, when we finally arrived at the hippo sanctuary, was a dream: bucket showers by the light of the full moon, my heightened sensations aptly identified as “the joy of simple pleasures” – surprising, that, how different a forced bucket shower in my grungy bathroom, next to a useless showerhead that will emit no water (either for lack of water or lack of electricity to pump the water), from this, calm and exquisite. Mattresses had been placed for us on the roof of a long clay building, with mosquito netting tied to chairs, and the soft moonlight a balm for tired, overfull eyes.



My bed in the morning light

We were up early the next morning, dew settled into our clothes, to the sun rising and a woman sweeping. I had a strong desire to luxuriate in the pale, cool softness of the dawn, but was dragged to the Black Volta river along the Burkina Faso border, by our chatty guide and our boatsman, who looked like he was about 13 and turned out to be 18. The water was still and flat – our guide’s claim that during the rainy season water would rush downstream and rise to the tops of trees was hard to believe. Our guide turned to my travel-mate:
“Martin, how many eyes do you have?”
“Umm… two?”
“And do you see hippos ahead?”
“No”
“Well me, I see hippos there”




Compared with dramatic scene by Murchison Falls in Uganda, of two hippos having sex next to their dead compatriot, these hippos were rather lackluster, but I suppose it’s better than having our boat torn to shreds by angry hippos. I liked the way they exhaled, pushing a spray of water out like a whale. We were allowed to set foot on the Burkina side of the border, as the border here was quite porous. Indeed, we saw one boat full of people heading across the river for a funeral, so it seems that ties between communities on either side are close. There was no checking of visas, just a wooden canoe ride back and forth over the calm water.





On the Burkina Faso side

Driving out of Wechiau, I was particularly intrigued by the unusual architecture of the clay houses. Having experienced our night on the roof, I began to see how much the roofs were used here. Women placed entire kitchens on their roofs, accessible by a small ladder formed from a tree trunk with wedges cut out. I wonder why they prefer being on the roof to the ground, or the shade of a tree. I would have loved to stay in that community longer, to understand better.




By the time we reached Mole National Park, we were so sick of driving and/or sitting in the car that we needed a full afternoon of poolside relaxation and observation of the exotic animals known as tourist Americanus and tourist Europus. The next morning we joined a group of Germans on a two-hour safari through the park, where we saw elephants bathing with trunks raised periscope-style and trying to clamber over each other, antelope-like kob scampering through the forest and defending their territories, baboons fraternizing with said kob, alligators, disarmingly and unexpectedly cute warthog babies copying their warthog father, and a sad-faced monkey with a bad leg. It turns out that I am pretty terrible at spotting animals from a moving vehicle, and spent a significant portion of the trip saying, “What? Where? I don’t see it!”




After breakfast and a last swim, we set off for Tamale, the main city of the North. The road out of Mole National Park is one traversed by obruni (white people) regularly, yet we felt as though we were the only ones, from the commotion we caused. The area rapidly became more and more poor as we drove, and suddenly we were in Northern Uganda – circular mud huts covered in pointed straw roofs, grouped together in villages in an increasingly arid savannah, with red dust to match my memories. I was struck by such unexpected déjà-vu my head spun, as I thought of practices and cultures spreading across vast distances over time.



A picture that could just as easily have been taken in Uganda as in Ghana.

As we drove further North, closer to Tamale, I felt I was seeing the Africa that I hadn’t even realized my subconscious used to imagine: vast, dry land raked by scraggly dead trees like sparse, bristly hair, open plains of straw-colored grasses and scattered trees, flat land stretching as far as the eye could see, with only small clusters of clay huts to break the expanse of ochre-colored dirt and sandy grass. As the land became increasingly arid, it eventually looked nothing like Northern Uganda and I had to forcibly abandon my comparisons in favor of simply looking and letting the Sahelian air wash over me.




Tamale itself is a small town that struck another chord in me – it felt so much like… somewhere. I remember thinking in Tanzania of the futility of trying to overlay experiences in one place and time with those from another, but the pull of an obscured memory, like a half-forgotten dream, is hard to resist. After watching the sun set behind Tamale’s biggest mosques, from a perfect people-watching balcony on the main road, we wandered into the lively night to walk through the town center, pointing out “mini-mosques” as we went. There seemed to be a mosque on nearly every corner, though often it would be just a small room with a diminutive minaret and a speaker for the call to prayer, or a shelter with prayer mats laid out. The streets were lined with striped plastic teapots, which I initially thought were for street-side tea-drinking (a major pastime in Mali, so I’ve heard). It turns out they actually held water so those preparing to pray could cleanse themselves as needed.




Tamale was also unbearably hot, we discovered the next day, as we were trying to explore further. I don’t think I’ve ever been so thirsty: the second you finished a water sachet, you were parched and in need of another. We wandered through a residential area in search of the leather-making area the guidebook recommended, though we received helpfully contradictory directions each time we asked for assistance. When we finally found it, it was disappointingly small and we were melting, so we turned back to hide from the sun and watch the football match. (Yes, I am actually starting to watch and even enjoy soccer…!) In truth, I think I like watching the passionate debates the game stirs more than the match itself, and the “sports bar” we found our way to did not disappoint in that regard. Even as the TV signal flickered in and out and electricity came and went, the ten or so Ghanaians we had joined shouted, gesticulated, drew on clichés, made absurd statements, joked, and put on such a stunning performance that we could only sit, like lumps on a bump, and watch in awe.

One of the most remarkable things about the North is the extent to which people speak English to each other. One of the men we met while escaping the heat explained the reasoning: there are so many different ethnic groups and local languages that English is the only commonality, the only way to be sure that everyone can understand you. But even those who do share another common language should speak English, he stressed, because of the strong importance of not making nearby people think that you are talking about them in a language they don’t understand. This consideration is notably lacking in Accra, where most everyone will happily speak in a local language understandable only to some.

We left Tamale early the next day, the cool air of dawn a welcome change from the stifling heat we’d faced the day before. We stopped for breakfast at the side of the road, where one woman was making omelet sandwiches and a few others were making bofrot, doughnut-like balls of dough. We waited for our food as we watched the women work in the hazy, fragrant early morning and the neighborhood stirred to life. It was beautiful, to be honest, this hidden, transient and completely ordinary moment.

As we drove, ever northwards, I saw more small towns awaken to begin their morning routines. I saw trails of children making their way to the water pump with jerry cans on their heads, roadside sellers set up their wares, and donkeys pulling their first loads of the day. We turned off the main road to go to Tongo village (ultimately the highlight of our trip!), and the terrain changed. Now we were driving through hills completely covered in boulders. I felt like our car had shrunk to the size of a termite and we were weaving among gravel. Architecture began to change, and suddenly it was like we were in another world.




Houses in Tongo were round, squat concrete structures with flat roofs, a combination of what we saw on the eastern side of the country and what we saw near Tamale, and they were joined together in a walled compound, but it wasn’t as simple as the ring of huts we’d seen elsewhere. Rather, each house was its own village, with circular common spaces joined by curving passageways. I suppose when you have 30 or more family members living together, each branch will want its own niche in the compound. Our tour-guide, the chief’s son, took us to the roof of the chief’s home (the only multi-story building in the area), and pointed to another family’s compound: they have a rule that they only build things in circles. Why? It’s tradition, you don’t need a “why,” silly.




Speaking of tradition, Tongo was the first place I’ve ever been where local traditional religions carry far more importance than any major world religion. The Tongo people have apparently always been isolated, slipping between two larger clans and holding out as a bastion of resistance against British colonizers who tried to move them from their sacred shrines. I suppose it’s not surprising then that they’ve avoided assimilation into the larger mainstream religions. Instead they worship at a shrine in the tallest nearby hill, where they sacrifice animals in order to avoid conflict – among themselves, with others, and among other people (even in Europe or the US). This abhorrence of violence is common in Ghana, though it strikes me as somewhat incongruous given the way people laud Yaa Asantewaa, the Asante queen who stood up to the British when the Asante men wanted to appease them.



A stand for sacrificing chickens

Eventually, we had to leave and set off on our long journey south, so that I could get back to Accra in time to teach a class. We drove up to Bolgatanga, known primarily as “Bolga,” for lunch, and turned back to Kumasi. As a proficient car sleeper, I don’t remember most of the trip that evening, other than one giant bump (fortunately we were able to get the punctured tire fixed very easily in Kumasi). The next morning, however, was glorious. It was the first time I was fully aware of how lush and jungle-like the southern part of Ghana is, having seen the arid North. We sped along alone on a newly constructed and very well-paved highway with small mountains ahead, the sun shining and the verdant greenery silhouetted against the morning haze. It was a perfect last breath of freedom before returning to work.

Ada Foah and the Plastic Bags

A couple weekends ago, I took a quick trip out of the city, thanks to my Ghana-savvy, car-owning friends, who generously let me tag along on their excursion to Ada Foah, where we stayed at a peaceful beach resort-cum-campsite. We were on the skinniest strip of beach at the Volta river estuary, ocean on one side and river on the other. It’s a beautiful place, reachable only by boat, perfect for relaxing with a good book on a hammock strung between palm trees.



Our accommodations were modest: a simple hut with a bed, mosquito net, chair, desk, lone bare lightbulb and the sandy beach for the floor. My hosts packed a picnic to last two days, and we (they) borrowed the hotel barbeque to cook dinner on the beach. It was peaceful, relaxing and simple enough to allow us to shield ourselves from the guilt of seeing small children working while we lounged. That is, until we saw the younger girl sucking the juice from the discarded rind while the older one deftly carved the pineapples and scolded her sister. Like many places in the developing world, the discrepancies between tourists and the local communities that partially rely on them are striking.



On the river side of the hotel, we breakfasted feet away from the calmly lapping water. On the ocean side, the sand stretched across vast expanses, reaching up to meet the sky and then sloping down to a sharp crest separating beach from ocean. It was so empty. At night, I felt utterly isolated sitting under the brilliant stars with creamy moonlit sand extending as far as I could see. After living in New York, you forget how empty parts of the world can be.



The moment I arrived, I was ready to dive in the ocean. I walked across the never-ending beach with barely contained excitement, until I peered over the sandy crest that held me above the water:



Trash. And more trash. Trash upon trash. The strip of plastic bags testing my desire to swim is the only thing to mar the stunning landscape. (Needless to say, the maze of plastic waste didn’t hold me back; it’s undeniable, however, that black plastic bags are not as pleasant to brush against in the water as seaweed.) A local teenager who appointed himself my tour guide told me that it was all from Accra, but I doubt the local community is exactly employing perfect waste management systems... I asked him why no one cleaned it, and he told me it was just because it was a weekend. I looked skeptically at the dense layer of plastic and pointed out that it looked like more than a weekend’s worth of trash. “Oh, well this part maybe the ocean will take it away.”



How long do you wait to see if the ocean is going to take away your trash before you start doing it yourself? We were charged a slight toll on our way to Ada, which we were assured would go towards cleaning the beach, but I have a hard time believing that my measly 3 cedis will really make a substantial dent in the fields of plastic. Of course, the trash problem isn’t limited to Ada: Accra’s reeking open gutters (into which you’re likely to see at least one man peeing every day—staring at the obruni the whole while) are also lined with drowning plastic wrappers and discarded juice boxes. I remember Gulu, Uganda, where there were heaps of garbage along the road, but where my host family barely bought anything with packaging that couldn’t be reused for years.



In Rwanda, plastic bags are outlawed. You actually get fined if you’re caught bringing a plastic bag into the country. It may sound like a small thing, but this is an incredible feat in the Ghanaian context. Here there is an obsession with plastic bags. You can’t buy anything without receiving at least one plastic bag, or “rubber”, and if (God forbid) the little shop should run out of the appropriate size of bag, the cashier will look at you apologetically and offer a bigger one to compensate. Often, your single purchase will be wrapped in not one but two bags, or each individual item will merit its own separate bag (all of which will go inside another, larger bag). The other main culprit is the ubiquitous water sachet, a cheap, popular alternative to water bottles. They are, in fact, quite handy, and my new housemate and I bought three huge packages of them to forestall our running water crisis: city water has been cut off to my neighborhood, and purchasing water to fill our tanks is a very short-term solution. Are they more wasteful than plastic water bottles? I don’t know, but their wrappers are everywhere, and because people drink them on the go, it’s considered perfectly acceptable to simply throw them on the ground or in the gutter when you’ve finished.



So how do you create incentives to eliminate the plastic bags? Surely the production of these things doesn’t turn such a huge profit that there could be a “plastic bag lobby,” right? And the Rwandan example demonstrates that the bags are far from necessary, despite their overuse. I suppose the American example is a more appropriate point of comparison, and even there it will be a long time before the last plastic bag is handed over a counter. But how can Ghana be encouraged to at least start the process? When will people look at the beautiful beaches of Ada and say not, “What a shame” or “It’s not fair that Accra’s trash comes here,” but rather, “We need to change our own lives and the way things run on a bigger scale”? I’ve heard of some projects that recycle bottles, but I’d be interested to learn of other programs to start dealing with this problem.

In the meantime, I enjoyed a small early birthday party on Saturday with my new housemate and Saleh, who made delicious Sudanese tea and bought me a lovely birthday cake at what is apparently the best bakery in Accra. I’m a lucky girl.

Where is 37? And other stories of being almost-there

One of my students submitted a draft of an as-yet rather directionless essay about getting directions in Ghana: the necessity of relying on others to navigate a world sans street signs and the likelihood that the instructions received will lead to the wrong place. The story this student told in the essay could have been any of the planned excursions I’ve made in the past couple of weeks, when I’ve set out to get to Point A and ended up at not-quite-Point A.

It started with a trip to the Accra Mall, which I had initially had no interest in going to, especially so soon after arriving in Ghana, but I figured it was probably the only place where I might find something to help with the 95% humidity rate in my bedroom and attendant mildew issues. Moving to Accra has been a very comfortable experience, in part because the social stratification between obrunis and locals is much less polarized than the mzungu-local divide in East Africa. Not only is the obruni population of Accra (especially the area where I live) pretty big, there are also a lot more wealthy Ghanaians than there were wealthy nationals in other countries I’ve been to. The market for places comparable to what I’m used to in the US is therefore fairly large, and a trip to the mall only emphasized that point.

Nevertheless, Accra is an African city, and that meant that after I’d finished my search of the expansive mall filled with hip Ghanaian teenagers and possibly the world’s highest cell-phone-per-capita rate, it was time to figure out the tro-tro system. Everyone had told me that 37 station was the main hub, and the point of connection between the mall and home. I had even gotten detailed instructions on where the first tro-tro would drop me and where the second would be waiting. How hard could it be? I sat on the tro-tro heading for 37 and waited for it to pull into a big station: that’s how I would know it was time to get off. Except we never did pull into a station, or not before I got a sneaking suspicion we’d passed 37 and saw a sign indicating that my neighborhood was to the left and the tro-tro’s final destination was ahead. I hopped off the tro-tro and walked to the left until I reached familiar ground. And so the mystical 37 eluded me.

On my way back, I walked through the edge of my neighborhood, as though I needed a reminder that I’m in Ghana, not America. While the main street of Osu is obruni-central, with roadside stalls clearly targeted at tourists and many of Accra’s most Western restaurants (including the gelateria I frequent and the newly opened KFC), this part is completely different. Poorly paved roads lined with cheaply constructed one-storey compounds and people selling Ghanaian food and daily necessities, and talking, laughing, singing, children running in and out of the compound yards… there is a palpable atmosphere of community, a sense that I’ve wandered into a neverending block party.

I began to get that feeling that people were staring at me, or that there was something going on that I didn’t understand. A woman tried to call my attention, but we shared no common language. Young teenagers ran up from behind. A steady stream of people moved in the same direction as me, as though something was pulling us forward. I assumed it was one of the Ghanaian funerals, where they set up a tent in the middle of an intersection for most of the day and hold a long open ceremony. An explosion goes off, the streets are more and more crowded, loud music ahead and why is everyone wearing yellow? I’ve walked into a political rally, perhaps? A company’s promotion? Why are people shooting fake guns in the air all around me? I duck down a side street to order a kebab with a disappointingly high intestine-to-meat ratio. It turns out I’d just wandered through a Ga festival celebrating agricultural successes and the end of a historical famine—something I wouldn’t have encountered mere blocks away in Obruni Land: maybe these worlds aren’t so integrated after all. Maybe I’m just stuck in my comfort zone.

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The following weekend I set out to walk to Makolo market, which seemed surprisingly small when I (thought I had) arrived. It was still fairly early on Sunday, as I’d escaped my apartment shortly after the neighboring church’s lengthy and enthusiastic service began. Nothing makes me miss living next to mosques in Dar es Salaam as much as that church’s terrible speakers and the speaking in tongues… especially on those rare nights, such as last night, when I can just make out the call to prayer from a distant mosque before Friday night service begins.

The entrance to the market was bustling, and the first stalls were filled with women selling cleaning supplies, cooking utensils, vegetables, groundnut paste, shoes, clothes and other essentials. But as I wandered further down the line, I saw empty stalls, stalls with laundry and other personal belongings, and stalls where people were sleeping and living. The farther I went, the less sure I was whether this was a commercial workplace or a residential community. I felt that I was intruding on a world I wasn’t supposed to see, the private underbelly of a usually public space.

After finding two bags to replace the one I’ve officially worn to shreds, and wandering through the parts of the market that were slowly stirring to life amid scattered debris left over from the week, I walked home, feeling quite pleased with myself for successfully exploring the famous Makolo market. It was only when I looked at a map to measure the length of my walk (over 6 miles) that I realized I hadn’t actually made it to Makolo market: I’d been in a station a mere block away from Makolo market! No wonder it seemed so small! And I’d been so close…

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Later that evening I decided to try my luck with the tro-tros again. Perhaps this time I would figure out where 37 was, finally. I smushed into the van headed for “Circle” (the center of Accra) with several laughing women with their children, all in their best traditional dresses. When I got off, I followed a woman into a shaded, enclosed market, winding along narrow lanes between stalls. Peering beyond the snaking pathways of busy stalls, I saw that the others were deserted: a lazy Sunday in the cool, quiet market. I emerged into brilliant sunlight, crowds of people trying to cross a busy street, more and more vendors, and an elevated footbridge crawling with busy commuters and the beggars and sellers hoping to win their patronage. It’s thrilling, vibrant, foreign.

When I thought I’d walked through most of the loosely connected center, sprawled messily across several traffic-stalled intersections, I set about trying to find another tro-tro to take me somewhere, anywhere.

Tro-tro mate: “Obruni! Hello! Where are you going?”
Me: “Um, I’m not sure”
Mate (with a look of concern for the lost obruni) “But where are you trying to get to?”
Me: “Oh, anywhere. I don’t really have a specific place in mind.”
Mate: “No, no, no, listen, white lady – what place are you going to?”

To be destination-less is a hard thing to explain to people trying to help you find your way. Especially when you’re trying hard not to laugh at your interlocutor’s consternation. Finally I jumped on a tro-tro, enjoying the adrenaline rush of having no clue where it was going. I piled off with the other passengers at Achimota station, where rows of mostly-empty tro-tros were lit by the golden light of the afternoon sun. Time to head home, I thought, or failing that to 37.

“How do I get to Osu?” I asked a nearby tro-tro mate.
“Ah hmm… you go take teyseyn car,” he gestured ahead. I hoped that “teyseyn” didn’t mean “taxi,” since I was determined to do this by tro-tro.
“How do I get to Osu?” I asked the next guy, a couple rows down.
“Osu? Take tesseh” (vague arm motion).
“Uh hmm, how about 37?”
He rolled his eyes, looked at me with pity and said “Ok, come with me, I go take you tayssen”
“Oh!! You mean thirty-seven!” I felt like an idiot.

I got on the tro-tro, where a passenger assured me I could finally get to this magical 37, and the mate continuously called out “Teyseyn! Teyseyn! Last stop teyseyn!” (which, I must admit, was starting to sound more and more like “thirty-seven” the more I listened). I was excited: this can’t go wrong.

Twenty minutes later, we reached a stop along a road and the passengers told me I’d arrived.

“This is 37?”
“Yes, yes, get off here.”

As the suspiciously still full tro-tro rushed on, someone leaned out to say, “Go there!” pointing ahead. I walked towards the entrance to something… a dusty clearing where some tro-tros were being washed and taxi drivers languished under a tree. Definitely not 37. I walked until I began to think I must be in the wrong place, and decide to seize the opportunity to ask for directions from two leering, bling-draped men who were clearly about to bother me for my number.

“Oh hmm… 37 station? That’s very far.” A glance between them and a slimy smile. “Would you like us to take you? We can take you.”

OH HELL NO. I’ve seen that movie before. Fortunately, a slow-walking group of older men and women passed and I launched myself into their group. Finally, I made it to 37.^[*] I took in the smells of gasoline, Ghanaian food and kelewele, the delicious spiced fried plantain chips, before locating my tro-tro back home.

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And so the adventures go: haltingly, with excitement, frustration, detours and helpful or less-than-helpful advice from others. Life, like Accra, has few signposts. Directionlessness can be difficult and seemingly unproductive, and it can be exhilarating but confusing to others. I’m stumbling through, clumsily, asking for directions but still not quite sure if I’ll make it there or almost-there. Either way, we try to see the wonder in whatever route we take.

^[*] If you’re wondering, like I was, why I was dropped a mile and a quarter away from where the 37-bound tro-tro claimed to be going and how I was ever supposed to have found it on my own, it turns out that I was supposed to wait where the tro-tro had dropped me to get another one that would go directly there. False advertising!