Tuesday, December 20, 2011
Tuesday, June 14, 2011
I have been given the great opportunity to present my research on maternal mortality in Ghana at the Global Health Council's annual conference in Washington DC. I'm so lucky to be in the midst of some of the greatest thinkers and influential leaders in the global health community. While I may be sleep deprived from third year med school clerkships, I'm fully prepared to be inspired and overwhelmed in the next few days! Follow me on Twitter (@EvaMLuo) for real-time updates on some of the latest ideas in the dynamic world of global health!
Monday, October 11, 2010
A Ghanaian Party in Michigan with the KNUST Exchange Students
It has been almost two months since my return from Ghana and my daily routine has completely changed. I'm no longer waking up with the sun at 6AM, walking into the bathroom with excitement as running water is usually flowing in the mornings, saturating my skin with bug spray, and then running downstairs to buy a bag of oats (oatmeal packaged in a plastic bag for easy eating) for breakfast before heading to the Kejetia tro-tro station to catch a tro-tro to a district hospital.
My days are arguably now much less exciting. The luxuries of hot water, 24/7 internet, and my car don't make up for the fact that I now spend most of my time rooted in one position in my apartment studying. With this dull routine to look forward to, it's not hard to imagine that my transition from Ghana back to the US was...traumatic.
On my first day back, I probably spent over half of the day just pacing around my apartment staring at my unpacked suitcases and trying to recalibrate my reality. How do these pieces of Ghana fit? I oscillated between bursts of meeting with med school friends to isolating myself in my room staring at pictures from Ghana while listening to "hiplife" music. However, whenever I was with friends, all I could talk about was Ghana. As one of them joked, I'd become the "official spokesperson for Ghana." But where are my Ghanaian friends? Where are my European IFMSA friends?
Slowly, the regularity of my class schedule forced me to readjust. Though, I found myself naturally gravitating towards anyone in my class who had ever been to Ghana. Just talking about our shared experiences of sitting in tro-tros, eating Fanyogo to stay cool, and taking malaria prophylaxis filled what felt like a gaping hole--a phantom limb, perhaps?
After just two weeks of navigating this awkward limbo of feeling like an exiled Ghanaian, I received the perfect remedy: Ghanaian exchange students from KNUST in Michigan! We met almost every weekend for about three weeks. While I'd like to say that I was showing them the best Michigan had to offer, as foreigner to Michigan myself, I was experiencing many things for the first time with the Ghanaian exchange students. We made jollof rice, red red, ate Chinese food, went raspberry picking, went to a Southern BBQ, watched movies together, played Cranium, and even did a little Ghanaian dancing.
After spending the last two months trying to redefine myself back in the US, I think I've realized that I've been forever changed. The ordinary little details in my life from the food I eat to the medicine I study all seem to bounce with an added rhythm and sparkle more vibrantly-- move with the Ghanaian spirit. I went to Ghana, became a little "Ghana Wild", and have brought it all back with me to the US. And I'm sure it'll keep my life interesting.
Thank you to my Ghanaian mentors: Dr. Kwabena Danso, Joseph Adomako, Dr. Henry Opare-Addo, and Kofi Gyan for this memorable summer opportunity. And thank you to all of the KNUST medical students (special shout-out to Ernest, Nelson, Cashito (Edwin), Mawusi, Prince, Mabs, Lydia, and Ron) for so warmly welcoming me and filling my summer with smiles and laughs. And a special thank you to Kwame, Yaa, Lily, Lenina, Deli, Space, Millicent, and Naomi for bringing Ghana to Michigan.
I will be updating the "Eva Ghana Wild" blog less frequently moving forward, but will continue to blog regularly at the IHI Open School Blog and the University of Michigan IHI Open School Blog. Please look for me there!
For those of you in Ann Arbor, the University of Michigan will be celebrating "50 Years of the Peace Corps" this week with a Ghana Symposium on Thursday. Come to the Union to check it out!
Thursday, August 12, 2010
Marriage proposals are timeless romantic vignettes that all girls, no matter where you fall on the romantic continuum, tell with a blushing smile. On my 68th day in Ghana, just two days before I had to reluctantly step onto a plane back to the US, I received my last ill-fated Ghanaian proposal.
I was briskly walking out of the Clinical Students’ Hostel on a mission to find a Ghana Black Stars Eissen soccer jersey that would fit me rather than swallow me whole in its size. The sun was particularly vicious that mid-afternoon, so I had my hair pulled into a messy bun and was unashamedly wearing my oversized sunglasses. I knew exactly where I had to go: the soccer jersey stand directly across from the National Cultural Center. It had rained the previous day, so the nice gentleman selling jerseys did not set up shop. This was my last night in Kumasi, so I was holding my breath that he’d be there sitting among his cornucopia of multi-colored jerseys.
Just as I a turned the corner to walk down a relatively steep road nearly tripping on my AADT yoga pants that I’ve neglected to hem, I see a brawny Ghanaian step out of his parked car. With over 60 days of Ghanaian experience, I knew that I had no choice but to spend at least 5 minutes making small talk with this gentleman since my path would pass right by his car. “εte sεn?” he says. “εyε” I reply, “How are you?”
After exchanging the ubiquitously used greetings, he wastes no time to ask where I’m from and where I’m going. It turns out that he is a lab technician who works at the teaching hospital. If I wasn’t in a rush to find my elusive soccer jersey, I probably would have slipped into what I’m sure the Ghanaians think is annoying when I ask unending questions—it would have been a golden opportunity to find out more about the lab facilities at the teaching hospital. As I was explaining that I was here in Ghana doing research, my new Ghanaian friend adeptly transitions into a Ghanaian suitor as he interjects comments and questions like, “I’ve seen you around the hospital”, “You must be as smart as you are pretty”, “Do you have a boyfriend?”, “Why don’t you have a boyfriend?", and “I like watching you.”
He then asked with a smile one of the most common questions I have received in Ghana, “Are you a Christian?” Religion does not play a very large role in my life, if at all. Consequently, I was not prepared for the religious fervor in Ghana. Nearly everyone in the southern half of Ghana is Christian, while the north is predominantly Muslim. Although I don’t subscribe to a particular religious faith, I sometimes believe that some sort of organic higher power exists--the spirits of my ancestors, Mother Earth, Father Time, I’m not sure what to call it and this ambiguity has never been a concern of mine. Because Christianity and Islam dominate the spirituality of the Ghanaians and few, if any, are non-religious heathens like myself, most Ghanaians don’t understand my stance on faith.
To truly immerse myself in Ghanaian culture, I’ve made an effort to understand religion in Ghana. During my stay here in Ghana, I have had the fortune and pleasure of attending several different Sunday church services with colleagues and on health fair trips with the medical students. Attending church in Ghana is an indescribable experience that I highly recommend to visitors. If you thought Southern Baptist church services were high energy, just wait till you walk into a church that can seat more people than a high school football stadium with large movie screens on all sides of the room projecting the word of God. Every church service I have attended has not only a church choir with record-label worthy leads, but also a complete band including guitar, bass, piano, and drums. I couldn’t help but stand up and clap my hands with the church in enthusiasm for the dramatic performances. What was more impressive than the musical spectacle was watching each and every church attendant’s public display of their deep personal relationship with their faith. The word passion came to mind as I watched people raise their hands in the air to praise God, squeeze their hands tightly to their chests as if trying to pour out their love directly from their hearts, and simply look up with their eyes closed enveloped in serenity.
My exposure to the Muslim population of Ghana has been limited to my few excursions to the north where I’ve seen the oldest mosque in West Africa at Larabanga and several other beautiful mosques dotting the roads. At sundown, around 6PM, it is not uncommon to see mosques and other community centers filled with people praying on oriental rugs. My flatmate, Shy, is Muslim and I think he has been warmly welcomed by the Muslim community here in Ghana.
Unlike some of the previous suitors, my answer of “no” to the question, “Are you a Christian?” did not deter him. The persistent Ghanaian lab technician then asked if I was Muslim. My confidence that our conversation would end with my answer of “no” was shattered when he laughed and said that it was not possible for me to be neither Christian nor Muslim. Time was ticking and the image of my jersey vendor packing up his shop flashed violently in my head like a pulsating aneurysm ready to rupture. It was time for me to whip out my impatient American attitude. Even though we have no established relationship, it was time for me to dump my Ghanaian suitor.
- “I’m sorry for cutting this conversation short, but I really need to go. You are a very nice guy, but today is my last night in Kumasi and I have a lot of things to do in town before the sun goes down…”
Usually, this statement is enough to prompt a retreat by the Ghanaian suitors…but not this one! Like an experienced Don Juan he explains that he does not believe that I am not religious because it is clear that God brought us together this afternoon, on my last night in Kumasi, to meet, to chat, and to fall in love. He argued that I could not leave because this act of God should be enough for me to believe. More importantly, how could I be so sure that he is not the one—my future husband and soul mate?
This silver-tongued Ghanaian suitor’s presumptuous flirting was really too much for me. If only circumstances were different: if we met in the US, if he was driving a slick convertible, or if he had a huge diamond ring and was ready to drop down on one knee, then maybe he’d be the one? No, under any circumstances within the realm of reality, some stranger I meet on the street for a brief conversation is not going to be “the one”. It took me a few milliseconds, but I thought of the perfect suave response that would give me the opportunity to leave him on the street and resume my jersey searching journey.
- “Then, don’t worry. If you are the one, then I’m sure God will find a way for us to see each other again. It was nice meeting you. Bye-bye!”
The end. My last Ghanaian marriage proposal. Will I miss these flattering street proposals from strangers when I’m back in the US? No, I don’t think so. Though hopefully the next time I decide to write about a marriage proposal, it will be of the sweet, romantic, and blushing variety.
NGO signs outside Nabisco Estate in Tamale
The most difficult facet of working in Ghana to grapple with has been negotiating the reality that Ghana is a developing country receiving "help" from an alphabet soup of NGOs, developed countries, and well-intentioned individuals. Whenever I travel to the district hospitals to collect data and interview management team members and front-line staff working in the various departments that keep the hospital running, I'm always greeted with this inexplicable eager attitude. Ghanaians are extremely hospitable and generous people, but I often wonder if the better than anticipated cooperation I have experienced would be different if my skin were darker.
One of the most common questions and comments I have received from my interactions with the district hospitals falls into a category I'd like to call, "What can you give me?" For example, when I tour the lab facilities of the hospitals to determine the types of services offered and gather a general impression of the quality of those services, the lab equipment that is broken or needs replacing are usually the first items I'm shown. At the end of these tours, the lab technicians almost always shyly say that their lab has so much potential if only they had X, Y, and Z and that they would appreciate and benefit greatly from anything I can offer to them. Unfortunately, my work in Ghana is primarily research. I am assessing the types of changes an OB/GYN can make at a district hospital and the potential these district hospitals have as teaching hospital sites. As a poor medical student wallowing in debt, I have nothing tangible to offer. So, my response to these comments is usually a smile, a joke about my medical school debt, and walking away from the situation wondering how many other obroni have toured the facilities before but with the promise of lab equipment to offer. In the end, I comfort myself with the thought that these lab technicians are mistaken. I’m here in Ghana to help at a level much higher than providing medical supplies. I’m here to do research and facilitate change.
The dark truth of my work didn’t occur to me until one of my interviews with a hospital administrator. At the end of the interview, he frankly pointed out that he was aware of and understood the benefits I’d receive from my time in Ghana. I would analyze the data collected and publish my findings. This would then contribute to furthering my career in health care. But, in the starkest of terms, what’s in it for them? What do these hospitals get in return for allowing me to freely wander around, stepping into the shoes of the management team and frontline staff? This conversation immediately triggered the loudest bells and whistles in my head—it was an exact parallel to an account of a conversation that Sudhir Venkatesh had chronicled in his book, Gang Leader for a Day, which describes his sociology research of crack-dealing gang-life in Chicago (highly recommend the book if you have not read it!).
In his book, Venkatesh was discovering the motivations and incentives for the members of this society to engage in drug dealing, prostitution, and other related behaviors. Everyone was hustling for a living. It then dawned on him that he was no different. Venkatesh was hustling the community, nabbing interviews and getting unprecedented access to account books and individual personal lives and to what end…for his own PhD work. My experience in Ghana is really no different. I can’t promise any immediate material benefits to the participating hospitals that have been instrumental to my work. I may be able to make some management and policy recommendations at the end, but I have little power in guaranteeing that my recommendations will change or at the least contribute to the continued regional and national level discussions on how to improve maternal mortality. As someone who enjoys the implementation portion of change, being stuck at the research end can sometimes feel like I’m walking through tar.
Health education workshop at Abono Primary School
My thoughts then moved onto to think about ways that I could sustainably contribute to the operations and improvement of the district hospitals and perhaps even make an impact on maternal mortality in Ghana (all of my travels take at least an hour, so I have plenty of time to think!). Even if I had the means, providing these hospitals with medical equipment or even a monetary donation is unsustainable and only feeds the willing acceptance of hand-outs and donations attitude that I have noticed across the entire country. While I applaud the attention that many NGOs give to developing countries, I think that most of their efforts are largely made in vain. How is it sustainable to ship doctors in for two weeks to perform surgeries within a community and then leave the community waiting for the next visit? Even a short visit I had made to a village elementary school with the IFMSA exchange students to teach healthy nutrition and dental habits could have been executed better to place a greater emphasis on the conceptual lessons learned rather than the toothbrushes and pens we handed out to the children. I can’t say this with certainty, but I do think the time we spent taking pictures with the children and school was comparable to the actual time we spent teaching the children how to brush their teeth and healthy eating habits.
There are three models of aid that I think satisfy the criteria of sustainability and positive impact. At a national level, I think China’s involvement in Ghana, while some say are efforts of colonization, qualifies. The Chinese government enters contracts with the Ghanaian government to bolster Ghana’s infrastructural development. Chinese companies then bring their expertise and equipment to Ghana while employing both Ghanaian and Chinese labor to build much needed transportation networks and other industrial essentials. This represents a knowledge and technology exchange in addition to the concrete infrastructural end products. At the very least, with better roads all of Ghana will attract more domestic and international commercial opportunities, furthering its development and improvement.
Project Fives Alive also qualifies as a sustainable model of aid. Project Officers identify Change Agents, who are local individuals charged with organizing and facilitating the health care improvement efforts in a specific locale. All of the quality improvement (QI) teams are also trained in the basics of quality improvement by attending a series of learning sessions, which empowers them to take on challenges and continuously make improvements. While Project Officers are there to encourage and motivate the teams, there is a clear exit strategy. Project Officers used to check in with the QI teams once a month and now only visit once every other month. Thus giving the QI teams the confidence and freedom to apply the knowledge and skills learned to make improvements on their own.
Although my research project will not yield immediate benefits to the participating hospitals, it is part of an important and sustainable partnership between the University of Michigan and Ghana’s Ministry of Health, Ghana Health Services, and teaching hospitals. Over 30 years ago, a novel postgraduate residency training program was created to address the low specialist retention rate and high maternal mortality rate. Since then, over 80 OB/GYN specialists have been trained and all but one have decided to stay in Ghana to practice. While the majority of the specialists are practicing in the big cities of Kumasi and Accra, a few are beginning to move out to work at the district hospitals—bringing expert knowledge and skills closer to the communities that are struggling with the safe delivery of babies. My research work focuses specifically on identifying the types of changes occurring at these district hospitals both in regards to the clinical treatment of obstetrics, gynecology, and emergency cases and the overall management of the hospitals. While I do have a considerable amount of analysis left to do, I can say that there have been significant positive changes. Since I have also been assessing the potential for district hospitals to become teaching sites for medical students and house officers (equivalent of US intern), this means that policies to move medical training closer to the areas of need are in the works. This academic-government partnership has been a very successful and sustainable effort that is only going to expand to further address maternal mortality concerns.
The gang leader Venkatesh followed, JT, allowed Venkatesh to follow him and document his work for years because he assumed that Venkatesh would one day write a book about him. Gang Leader for a Day isn’t a biography about JT and took years to be published. But now, it’s a popular book sitting on the bookshelves of many all around the world. So, while it may feel like I’m hustling now, I can say with confidence that we’re in it for the long haul. Positive change will happen. It just won’t take the form of a new electrophoresis machine, a skin graft procedure for one individual patient, or a toothbrush. It’ll be even better than that: a solid and sustainable system that allows Ghanaians to deliver quality health care to their people. I hope that is enough of a promise for now.
Wednesday, August 11, 2010
Since it is so easy for foreigners to attract attention to themselves in Ghana, I think it's essential to ensure that foreigners make a very positive impression. Ghanaians are generally very friendly so, getting a smile out of them is relatively easy and it's very difficult to make them angry. But, how do you really get on the good side of Ghanaians? Here are a few things that I've noticed that will make Ghanaians very excited:
- 1)Greeting people with Wo ho te sεn? (= how are you?) as you walk along the streets.
- 2)Wearing a Ghana Black Stars Jersey
- 3)Choosing to eat fufu and insisting on eating it with your hands
- 4)Wearing local clothing
- 5)And least expected of all: If you must tell people you are from the US, invoking President Obama in conversation.
All of these points demonstrate that you have embraced the local culture. Surprisingly, Obmama has become part of the local culture. Obama really made an indelible print here in Ghana when he visited. His face is on T-shirts, notebooks, key chains, and even biscuits. I didn't hear the current president of Ghana's name (President Mills) in conversation until maybe the middle of July? Obama love here in Ghana, is an unparalleled experience that exceeds the confidence Americans even feel about their own government. I guess "Yes we can" = "Go Ghana!"
Tuesday, August 10, 2010
Karni QI Team
In typical last-minute Eva fashion, two years ago, I decided to defer from medical school for a year to work at the Institute for Healthcare Improvement (IHI). IHI can be best described as a fast-paced social change organization that operates like a cross between a think tank and consulting firm that focuses on improving the delivery of health care through spreading systems redesign tools and interventions all around the world, including Ghana. As much as possible, IHI practices what it preaches. In addition to encouraging health care systems and health care professionals to employ the model of improvement to make the delivery of health care more efficient, reliable, and effective, all of IHI’s own work is continuously evaluated for improvement. After living and breathing quality improvement for a year, the transition to medical school, where the focus sometimes felt like mindless memorization of volumes of facts, was difficult.
My main motivation for coming to Ghana this summer to work on clinical quality and management research was to return to the field of quality improvement of health care. For the most part, my research has been very fulfilling as I have delved into answering the questions: what kinds of improvements can be made at the level of a district hospital to improve maternal health and how can those improvements be made? Since data is the backbone and currency of quality improvement, sometimes answering my objective questions has been frustrating because I continuously run into underdeveloped data and information systems. On the days that I felt particularly beat by data available to me, I’d wonder how IHI functions in Ghana.
Lambussie QI Meeting
IHI has three developing countries programs: Ghana, South Africa, and Malawi. In Ghana, Project Fives Alive, a partnership with the National Catholic Health Service (NCHS) and Ghana Health Service (GHS) is working towards reducing under five mortality through quality improvement. While I was working at IHI, the CEO, Don Berwick, made a short visit to Ghana and collected the most inspiring stories. Thanks to Nana Twum-Danso, Project Fives Alive director and Ernest Kanyoke, Project Fives Alive Project Officer, I had the opportunity to be inspired too.
Piina QI Team
Last week, I traveled to Wa in the upper west region of Ghana to join Project Fives Alive on two days of quality improvement (QI) meetings at various health centers and CHPS zones. It was a difficult journey up to Wa from Kumasi, but those troubles immediately melted away when I met Ernest. If it were possible to anthropomorphize quality improvement, Ernest would be the perfect model. He is brimming with energy and is whole-heartedly committed to quality improvement in his work and his everyday life. Upon arrival, when my hotel reservation was not processed correctly, Ernest immediately evaluated that this was due to a problem in hand-offs and he said he wished had time to help by first collecting data on how often this occurs. At the very least, seeing Ernest carry around a flip chart and colored markers conjured up feelings of comfort. IHI truly is flourishing in Ghana.
Lambussie Health Center
Because I arrived in Wa around 2:30AM and had to be up and ready for site visits at 7AM, Thursday’s meetings were tough. Immediately after Ernest’s more than deserved introduction of myself to the QI teams, I’d invariably fall asleep. I am still so ashamed that in response to the amazing work that these health centers are doing to reduce neonatal deaths, all I could give them was an inattentive, silent, sleeping Eva. Thankfully, even while sleeping, I think my brain was still alert and I gathered some truly remarkable accounts of the QI work being done by midlevel providers (midwives, community health nurses, and local support staff) to drastically improve the processes that can reduce neonatal mortality.
Samoa QI Team
For example, in Samoa, the two CHPS Zones have greatly improved their skilled delivery rate by making small changes to make delivering at a health center attractive for mothers. These changes include offering traditional porridge to the women after delivery. This small change does not just represent a inventive adaptation of traditional practices, but also sends the message that the health care staff cares about the well-being of the mother and that the health centers are welcome institutions. In Karni, the QI team discussed the progress of their intervention to reach out to women and develop a pregnancy plan to increase their skilled delivery rates, which are at a laudable 90+% and a very effective mosquito net distribution program that has reduced their rates of malaria admissions.
Karni QI Meeting
What impressed me the most was not the outstanding results and outcomes that these health centers can celebrate, but the dynamics of the QI meeting itself. The health center staff have no formal training in statistics, yet after just a few learning sessions, are very data driven. Midwives and community health nurses take turns contributing to and facilitating the QI meeting to discuss and evaluate the rates of first trimester registrants for prenatal care and improving postnatal care follow-up visits. During the meeting, their various registers (the raw data), are always open right in front of them and they reference the data throughout the meeting. The connection between data and the individual patient success narratives they are experiencing is strong and solid. I can’t say that even providers in the US have made this connection. The foundations of QI have been laid for these teams and with that, I believe that they can take on any health care delivery challenge.
Exuberant Ernest Working His Magic
All of this progress, however, could not have been possible without the skillful facilitation of the project officers. The project officers not only have a deep understanding of the individual process and quality measures and interventions that each health center is undertaking, but are also experts at managing relationships. Project Fives Alive is a partnership with the NCHS and GHS are extremely important agencies to work with for the success of its work. The project officer has mobilized and empowered all of the necessary stakeholders to participate in the shared goal of reducing under five mortality. A representative from the GHS district health office traveled with us and was present at every QI meeting. All levels of staff were asked to open their registers and discuss and interpret the data. And then together, the QI team would set aims and deadlines to meet before the next QI meeting. My own research experience has proven that this is no easy task. Building confidence and a positive attitude among the providers is on an entirely higher level. The hospitals that I visited were still struggling with just making sure all of the necessary stakeholders that would work together to improve maternal mortality were all available on the same day at the same time to just discuss maternal deaths. These project officers, like Ernest, have just the right combination of encouragement and persistence to have led the QI teams to where they are now.
Run-chart at Piina
The four sites that I visited were extremely resource deprived in comparison to the district hospitals that I have spent most of my time working with—most of the health centers do not have electricity! Yet, despite these resource challenges, look how far a statement like, “let’s take a look at the data” can go. The run charts and meeting minutes posted on the wall is really the only technology I saw that these facilities were using to achieve their results. It’s phenomenal. The next waves of the project are to expand and replicate the work being done in the northern regions to the rest of Ghana. This kind of exposure to QI has so much potential that I know whenever I have the opportunity to return to Ghana, the health care delivery system in Ghana will be positively unrecognizable.
The Fearless Issah
My site visits and time spent with the Project Fives Alive team was the perfect burst of inspiration that I needed as I begin to undertake my last small project before I have to return to Michigan. Perhaps it was Issah’s adroit driving skills that powered us through sometimes as much as 300km of dirt roads to reach these communities, but after just two days with Ernest (and his highly marketable energy if only extractable) and the community QI teams, I’m excited for my own project with the confidence that QI works successfully in resource-poor settings like Ghana. With more opportunities for these community teams to share, evaluate, and celebrate their work and even greater individual engagement with data, the results that Project Fives Alive will produce I think will exceed the already achieved success. Three cheers for Project Fives Alive!
Thank you again to Nana Twum-Danso and Ernest Kanyoke for this amazing opportunity to join you all for two days. I look forward to following Project Fives Alive as it continues to grow and spread.
For more information about IHI and Project Fives Alive, here are some relevant links:
Project Fives Alive Website
Fives Alive Project Description
On the Ground Account When IHI's Jane Visited Ghana