In the next few days, our group;the CSI Advanced Team, consisting of five doctors, five nurses, and four support staff will screen the hundreds of young Ghanaian patients waiting (hoping, praying) for surgery. The Main Team - six more doctors and nurses will arrive several days later, as surgery begins.

What do we hope to do in twelve short days? First of all, to change some young lives. Kumasi is Ghana's second biggest city, home to over a million people, has a long and illustrious history as the capital of the Ashanti Empire. A rich cultural life has existed here for centuries. However, like any city in the developing world, there is great poverty. A large proportion of Kumasi's inhabitants live a precarious existence in makeshift shantytowns. They have no health insurance, and if their children are born with a disfiguring craniofacial deformity, such as cleft lip or palate, they are not automatically taken care of, as they would be in this country. The parents must somehow scrape together the money to pay not only the doctor's fees, but the cost of a hospital stay. This amount is often beyond their reach.

Cleft lip and palate surgery can create dramatic results in a short amount of time. A child can transform from an outcast, hidden away within a family, into a child able to speak, eat, and (best of all) smile normally, and blend in with peers. This surgery can give a child in a developing country a chance at normal health, marriage, a job - things that otherwise might be out of reach.
We on the CSI Team also hope to forge bonds between the visitors and the hosts. We will learn by being there. The people who are hosting us at Okomfo Anokye Teaching Hospital, and kindly opening up their facility to us, will learn from our visit. We will swap knowledge, both medical and cultural, learn a little bit more tolerance. Perhaps we will convince a few more people that most Americans mean well in the world. Perhaps we will create bonds that last beyond our stay, into the future.

Some thoughts on the way, as to why some of us come here to work:

"To reconnect to the ideals of my youth."

"To give back to a world that has been good to me."

"To learn and serve. I am really here to learn, honestly. Medicine is practiced differently all over the world. In the US, we rely heavily on machines. I can't wait to see how things work here."

"I want to help children, no matter where they are. That is the wonderful thing about being a nurse; you can help people directly, and see the results of your care."

Next stop, Kumasi!

Dr. Peter Donkor spoke to us of the tragedy of the appearance of a cleft lip in a Ghanaian baby, the embarrassment and horror that accompanies it. Some parents, in their shame, fill the bathtub, hold a cloth over the baby's face, and smother the child. Others that live have a lifetime of stares and shunning.

Some parents, however, are brave. They nurture their children as best they can. And they came to us today, from hours away, over 115 children! Some were babies, some older children, even in their teens, still bearing the blemish of cleft lip. There are many, many that we can help. Tomorrow we will screen again, then Monday surgery will start.

Africa is impossible to describe! So different, so alive. Two snapshots: The elegant, brilliantly swathed, swaying figure of a woman walking over red clay with a 5-gallon pail of water on her head. And the twilight sky filled with a stream of robin-sized fruit bats, flying home to rest.

One note: it is a thrill to see the two Ghanaian members of our team return to this city, where they have both spent a good deal of time. Dr. Kofi Boahene, a facial plastics surgeon training with Drs. Peter Hilger and James Sidman (both of whom are here), went to boarding school here. He was instrumental in setting up this trip, and has been both guide and interpreter. Without him, we would never have come. And Felicia Addae, one of our operating room nurses, actually trained in the hospital we are visiting, 14 years ago!

One last snapshot: an artisan in a small village we visited yesterday, squatting over a vat of tar-like liquid. He boils a certain root for hours, strains it, and then uses it to make the vibrant printed cloth that Ghana is famous for. We watched him expertly score the fabric with a five-tined fork, then use a hand-carved stamp to decorate the open spaces. Other villagers sat in a circle, observing the master at work.

Cleft palate can run in families, and today brought two separate cases of siblings with cleft. Augustine and Kwasi Owusu--a sweet 8-yr-old boy and his baby brother--both had surgeries today. Another family, the Achichiaas, were not as fortunate. They traveled 220 miles from a distant village with their two children. Their 3-yr-old, Ernestina, qualified for surgery, even though she was a bit malnourished. But her baby brother was not healthy enough for surgery, and must return home with his cleft lip. The team must always put the health of the child first in its surgical decisions, even though it means passing up some chances to make a difference.

One note: the quality of camaraderie on a trip like this is unlike anything I've ever experienced. There is an intense focus on one goal (safely helping as many children as possible) that supersedes anything else, and that can only be accomplished working together. Everyone pitches in, no matter what the job, whether it is locating an important piece of equipment or cleaning up after snacks. Humor is rampant. Half the joy of the experience (besides dealing with these amazing children) is sharing the wry, unexpected stories of the day--and ribbing each other over new-found quirks.

The hard things? Finding ways around hospital conditions that we would consider substandard in the U.S. Dealing with cultural differences that might baffle us at first. Seeing the poverty, the haphazard way many hang onto a livelihood. And breathing in the taxi exhaust on the congested ride back to our hotel each evening!

Snapshot: seeing little Abibate Samadu (whose cleft lip was repaired yesterday) in her green dress and gold earrings, walk proudly into the pre-op room with her smiling mom.

Most rural children have never seen a jigsaw puzzle, and neither have their parents. I gave one puzzle to a couple of fathers (many children have come with both parents), thinking they might pass the time doing it. After much discussion, they sorted the pieces into like-shaped piles, but couldn't figure out the next step. I found the corners for them and showed them how to line
up the edges, and after that they went like gangbusters. One pulled me over with a delighted smile to show me the completed puzzle.

On the other end of the spectrum was a sophisticated father whose son and I were playing a Concentration-like card game. As we played, he read the directions so thoroughly that he pointed out I had the rules wrong! Fittingly, his son beat me soundly.

All the children I've met, even the tiny ones, are very adept with balls. They throw and catch incredibly well, and love to play stacking and building games. Soccer (or "football" as they call it) is the biggest sport in Ghana, and the Kumasi Kotoko Club is one of the country's best teams.

Today in the hospital, we had another full day of surgery, and many happy families from Monday's and Tuesday's surgeries were discharged to return to their homes. Komfo Anoyke Hospital general surgeons consulted with our surgeons about a patient with a terrible gunshot wound that had damaged his jaw, and had a productive discussion about treatment. Tonight the hospital is holding a symposium in which CSI team members (both doctors and nurses) will present information that will help sustain this cleft initiative.

The hospital and community at large has been extremely supportive in all aspects of our visit. They advertised well beforehand on radio, TV, and posters so that many patients came for screening. There have been follow-up articles in the newspapers. And schools and churches have spread the word as well. This strong community involvement has strengthened hope for improved health care in this region, and also increased chances that the CSI team might return here on future missions.

Snapshot for today: A group of public school children, dressed in the universal uniform of brown pants or skirts and pale orange shirts, walking along the sidewalk next to our taxi this morning. Our white faces caught their attention, and we were moving so slowly that they kept up with us for almost a block, running, waving and laughing.

The most glamorous occurrence today was an extraordinary visit to the Ashanti
King (called the Ashantene)! The Ashanti Empire was formed centuries ago and is now the spiritual and cultural center of Ghana, with Kumasi as its capital. While Ghana is now officially a democracy, the Ashantene (much like the British queen) is a wealthy and extremely influential leader. Dr. Peter Donkor, our Ghanaian host, arranged the visit, which is almost unheard of for a foreign delegation. A delegation of seven team leaders went to the palace, where they were ushered in to see the king, who was dressed in a ceremonial "Enyintomah" robe, wrapped about his body and draped over one shoulder. Surrounded constantly by his retinue, the Ashantene does not actually speak to the public. Instead, he addressed Friday's remarks to his linguist, who then spoke to an interpreter, who spoke to us. He thanked our team for helping his subjects, praised our Ghanaian medical hosts, and asked us (in fact, told us it was our duty) to return again. The team was with him for little over a half hour, but it marked a significant moment in our mission. The event was especially thrilling for Dr. Kofi Boahene, who is originally from Ghana.

The other high point of the day was a party we hosted in the Children's Ward, a vast room that houses over a hundred patients (including ours). As I climbed the dark concrete stairs to the ward, I heard musical voices echoing down the stair. The scene as I arrived was electrifying: a huge room, filled with over a hundred children, practically dancing in their beds! Nurses, mothers, and siblings stood swaying, clapping, and singing to a popular Ghanaian folk song. A cart wheeled back and forth, distributing candy, doughnuts, and balloons to each child. Curtains at the huge open windows billowed in the breeze. The mood was irresistible; before I left, I had blown bubbles for each child, shouted the words to the song, and joined an impromptu nurses' conga line. It was a moment of joy and unity that I will never forget.

Yesterday was also a full day. There was intense debate as we considered the case of Ana Missbel, who had been scheduled for surgery but was discovered, in a routine pre-op examination, to have a heart murmur. Ana was already underweight, with a low hemoglobin (a vital part of the blood for healing), and would have been considered high-risk in the States--definitely not a candidate for surgery. The mother was distraught when she heard that surgery might not be performed. There was the grim possibility that the baby might be smothered if her lip were not fixed. Thus a terrible dilemma: the operation might save the baby from harm, but might kill her in the process. After weighing all factors, team leaders (including Dr. Donkor) decided the risks were too high for surgery. Fortunately Dr. Donkor stepped in and pledged to follow the Ana's progress, counsel the family, and perform the surgery when she was stronger.

I was lucky enough to ride yesterday with Jim Amaral, Development coordinator, and Sue Baysden ("Auntie Sue"), our Logistics queen, on their daily errands. All week Jim and Sue have been meeting with community leaders, and procuring whatever items we need. Yesterday it was about a hundred AA batteries, to power portable OR monitors, head-lights, etc. Our faithful taxi driver "P"--who later invited the three of us to his home and brought his mother some chocolate--drove to a trio of roadside stands, where he proceeded to negotiate a deal with several of his cronies while we waited in the steamy taxi, gawked at by curious passersby who rarely see a white face. Ten minutes later, after much discussion and gesticulation, he produced a box of Duracells. Auntie Sue then stealthily pulled out her huge wad of cedis (the local currency; the exchange rate is 1 dollar to 10,000 cedis!) and sealed the deal. Most small commerce is transacted in a similar way here in cash, with small vendors, using hot and heavy bargaining.

From there, we went to one of Kumasi's state-subsidized orphanages. Jim hoped to establish a connection with the director and find some U.S. sponsors. The orphanage buildings were rudimentary but adequate, boasting spacious grounds, large shade trees, and a large (if rundown) playground. And the children?
They obviously hungered for hugs, but were bright-eyed and laughing. At first they peeped around the doorways curiously. Then we became like three walking magnets. As we strolled about the grounds, kids hurled their big-eyed, bare-footed bodies at our legs and laps. One young girl with burn scars over much of her face and hands claimed me for the entire visit, while Jim and Sue competed for the most-kids-in-one-lap award. We delivered our box of toys, infant formula and medical supplies, and pried ourselves away, stopping to pat the good-natured orphanage dog.

I will close now, before the power goes out again! This mission has been an amazing experience. As I said when I started, Africa is impossible to describe. You must come visit yourself--or perhaps make it possible for others to visit. If we can raise enough funding, CSI fervently hopes to return to Ghana in 2005 for another chance to learn and heal. Please help us send another team to support these remarkable people.

Our final 48 hours were packed. Saturday night we invited Ghanaian medical counterparts to the Rex Mar Hotel (where we were staying) for a farewell dinner. The whole gang was there, from surgeons to OR techs. We loved seeing the normally hospital-blue-garbed nurses dressed up in their finery. There is no question that Ghanaian women know how to dress. No subtle black or ecru for them. They were resplendent and our own Felicia Addae joined them in a traditional dress & head scarf that looked fabulous!

There were several speeches, but the most moving was from Nora, head surgical nurse, a tower of strength and graciousness. She poured out her own gratitude and that of the patients, who asked her over and over to thank us.I would wake up every morning and see my baby girl, and cry and cry, one parent told her. Now my daughter has a future. I am so, so happy, my heart is full, Nora said to us,that we are here together, black and white, working toward a common good.

Next morning, after packing up, we headed on a roundabout route to Accra, where we would catch a late-evening flight to London. Our first stop was the village of Bonware, home to the famous hand-loomed Kente cloth. In a dim barn-like building filled with looms, we watched a weaver's deft fingers zip back and forth, producing thin strips of brilliant, intricate designs that are sown together to form Kente cloth. Coached by team member Kofi Boahene (whatever they say, offer half, until you meet in the middle), we bargained our way to scarves and bedspreads.

After a few hours more of driving, we reached the picturesque coastal city of Cape Coast, which was central to Africa's slave trade. We toured Cape Coast Castle, a fortress built on the wave-pounded rocks of the Atlantic ocean by the British as a final clearing house for slaves. In these grim, dank, claustrophobic walls, hundreds of people were kept for weeks in their own filth, before being shipped all over the world. We saw the "Door of No Return" through which they were marched down gangplanks to waiting boats.

And then--after we hurried through a somber lunch to keep to schedule--the bus wouldn't start. Kofi frantically negotiated with several mechanics who materialized and came to our aid. We were all glad to hear the rumble of the bus engine and even endure three tense hours of washboard dirt road (Ghana's version of road construction) to reach the Accra Aiport.

Here are some final thoughts on our voyage, gathered from team members on the long hours of homeward-bound travel.

HIGH POINTS OF THE TRIP:
The people--the comraderie, both amongst ourselves and with Ghanaian team members.
The gratitude of the patients and their families.
The many successful surgical outcomes, and knowing what a difference we have made in their lives.
Watching the older cleft lip patients [we operated on some young adults who had had cleft lips their entire lives] see themselves in the mirror for the first time after surgery.
Flying paper airplanes with an 8-year-old boy who'd never seen one before.

LOW POINTS OF THE TRIP:
Rest stop bathrooms.
The heat. It's unrelenting, energy-sapping.
The smog-filled air. And those children have to breath it every day. You should see what I suctioned out of their lungs.
Seeing the poverty. They have so little, not even real diapers for their babies.
Having to explain to some parents that even though the child originally qualified for surgery, we now have to turn them away. [Our pediatrician, Dr. Peter Melchert, diagnosed malaria in several children. We were able to treat them for malaria, but they were too sick to undergo surgery.]

And a final, moving high point, related by Rowie Hansberger, Ward Nurse: A mother told me that when she kissed her daughter after the surgery, her daughter for the first time was able to kiss back.

That just about sums it up from this end. Over and out from Kumasi.