International Exchange

The University of Michigan Medical School and most medical schools all around the US are missing out. By virtue of being an American Born Chinese, I have been directly and indirectly involved in international exchange for as long as I can remember. Many of my travels to countries around the world were a result of international exchange or cultural immersion programs and with the start of medical school, I knew that was an area of my life that would diminish drastically. But, being in Ghana has taught me that international exchange and travel is definitely still possible.

While staying at the Clinical Students’ Hostel in Kumasi, I have had the pleasure of meeting and getting to know several international medical students visiting Ghana for about a month on elective rotations in internal medicine, surgery, emergency medicine, and OB/GYN. Since nearly all of international travel at Michigan is sponsored and organized through relationships established by the University of Michigan Medical School and faculty, I assumed that all of the international students were here as a result of similar relationships. It turns out that I was wrong.

The International Federation of Medical Students’ Association (IFMSA) is a collection of medical students’ associations all around the world with 97 member nations from 89 countries encompassing 1.2 million medical students. Its activities include medical student bilateral exchanges, conferences, collaborative projects, and workshops. Projects include medical outreach and health education initiatives and others that provide medical equipment and medical education supplies to developing countries. The largest conference is the annual General Assembly. This year, the General Assembly is in Montreal and students from all around the world are currently traveling to attend this meeting.

The most unique programming that IFMSA provides is probably the bilateral exchange program. Through IFMSA more than 11,000 medical students annually have the opportunity to experience the practice of medicine in a health system different from their own country. Medical schools from the member nations develop contracts with each other: for every medical student from country A that comes to visit country B, a country B equivalent medical student visits country A. Since debt seems to be a general concern for all medical students globally, the bilateral exchange is a very cost effective way to engage in international learning. As a believer that cultural sensitivity cuts across all industries and fields, especially as global travel becomes easier and easier, I think these exchanges are playing a key role in developing a truly international physician workforce with a strong grasp of comparative health systems and the global delivery of health care. We all live in different countries, but despite these superficial differences, we all face very similar health care challenges: how to deliver quality health care to all.



In a more immediate time frame, having the IFMSA exchange students around has added greatly to the international flavor of my stay in Ghana. The best example I can think of is this international potluck dinner we had last Thursday. Each student was asked to make an international dish that best represents them. In a previous food post I had griped about the lack of the proper ingredients to make Chinese food, but after combing through the city of Kumasi, I was able to find all of the ingredients I needed to make Chinese pan-fried dumplings and guacamole (not meant to be eaten together). If I can make dumplings with just a small hot plate at my disposal, anything is possible in Ghana.



The dinner was a truly international affair. The Ghanaians made kelewele (spiced fried plantain bits), yam balls (fried yam balls with meat inside), and asaana (purple maize and pineapple drink). The Spaniards made Spanish omelets, sangria, and this light tomato sauce to be eaten with cured meats (various forms of jamon) and bread. Shy made samosas and chicken tikka. The Austrians brought chocolate and marzipan truffles. Mathias, although Swiss, represented Italy with some spaghetti. Dimitri made a yogurt based dish and brought in some delicious feta cheese on top of fresh tomatoes. The tables were packed with food. I’m happy to report that my dumplings (while I intended to make pork dumplings, I was given beef. Very unconventional…but still tasted good, haha) and guacamole were hits: no leftovers! We then danced the night away to Ghanaian, Greek and American music.



For unknown reasons, the US is a member of IFMSA, but very few exchanges occur between the US and other countries. If your medical school offers IFMSA exchanges, I’d highly recommend participating. I’m definitely going to look into this back at the University of Michigan!

Ponding

I have never been more thankful for a winter birthday than today. Every dorm, school, university, whatever locale has its own birthday traditions. All of them seem to mix a bit of humiliation and pain with fun. For most young people, their friends will take them out and get them drunk. Humiliation: losing all inhibition and doing the craziest things. Pain: nursing a hangover the next morning and piecing the fuzzy memories of what you did the previous night back together. Fun: your friends enjoy watching and egging you on in your drunken madness. In Jones College, my sister’s residential house at Rice University, you are thrown into a fountain on your birthday. Humiliation and pain: being thrown into a fountain and getting soaked against your will. Fun: your friends enjoy your reaction.

Here at KNUST, the tradition is that you are “ponded” on your birthday. Let’s break the word down. A pond is a body of water and to pound means to hit or to beat. So, what is “ponding”? On your birthday, your friends publicly clobber you with buckets of water for thirty minutes! Humiliation and pain: being pummeled with water. Fun: throwing water on your friend and watching his reaction.

Without any mercy, your friends slap the water on you from all directions: left, right, from above and below. If you try to run away or hide, your friends will drench your bed with water. The only way to avoid a ponding on your birthday is to be away from school.

Today was my friend Edwin’s birthday and he made the most unfortunate decision not to go home for his birthday. At 11:30PM, his friends began to troll the hallways of the dorm. They lurked around his room and called each other periodically to see if anyone had seen any sign of him. His faithful roommate did his best to hide his whereabouts. I admittedly am a guilty accomplice to his capture. I called to ask where he was and even though he gave me false information, his response tipped off his friends and he was found. Poor Edwin was dragged out into the courtyard and the ponding commenced. You would think that in Ghana, since water can be such a scarce resource it is possible that ponding can be avoided or at the very least a ponding session would never last thirty minutes because you’d run out of water. Unfortunately, in the middle of the courtyard is a large polytank, a water reserve that can hold hundreds of gallons of water. Once captured, ponding is unavoidable.

At the end, Edwin was not only soaking wet, but you could see welts on his back like he had just been whipped! I can only think of one piece of hope that can help you withstand the pain of being ponded: everyone will eventually get his turn. So, if you can avoid it, try not to celebrate your birthday in Ghana, or it will be a wet one!

Cape Coast

Even though I get to travel and see different parts of Ghana almost every day on my site visits to district hospitals, my trip to Cape Coast was something special.

The KNUST-SMS Medical Students Association Exchange Committee organized a Cape Coast trip for all of the foreign and foreign-exchange students two weeks ago. Cape Coast is a seaside city known for its beautiful beaches and castles that preserve the history of the slave trade in Ghana. We were truly an international group. There were about thirty of us with representatives from Ghana, the UK, Denmark, Switzerland, Norway, Germany, Greece, Austria, Poland, Spain, and me (go USA!). From Kumasi, it takes about four hours to drive down to Cape Coast, and a portion of the ride is extra bumpy due to bad roads. Since I was one of the smallest people on the trip, I had the honor of being squeezed between two seats since there were not enough seats for everyone on the bus. These conditions could have made the trip unbearable, but the good conversations and incredible barfroat (delicious fried dough) made all the difference.


Cape Coast Castle


Cape Coast Castle

Our first stop when we arrived in rainy Cape Coast was the infamous Cape Coast Castle. Even though my family and ethnic heritage has no direct connection to the slave trade, as an American, walking through the Castle was an extremely profound experience. The staff at the Castle provided an excellent walking tour and the Castle is very well-preserved. Standing in a dark dungeon with one tiny hole for air circulation (its true purpose of construction was not to provide the slaves more bearable conditions, but to monitor the activity of the slaves within the dungeon), my heart fell to the ground when I heard that this tiny room was meant for hundreds of slaves—forced to not only sit In their own waste, but among the dead and dying as well. I felt embarrassed and ashamed to be an American—tied to this atrocity against humanity. I was very surprised to see the Ghanaian reaction to the Castle. Perhaps it is because most of them have visited the Castle before since they only seemed to react to my sullen humiliation: “It’s okay. This happened a very long time ago.” The Castle staff was very proud to say that President Obama and Michelle Obama came to visit the Castle when they were in Ghana. They were so emotionally touched that they cried. The Cape Coast Castle can really elicit those feelings. Even now, once you walk through the “Door of No Return,” your life is forever changed.




Erika's Surprise Birthday Party!

The Cape Coast trip was organized in conjunction with the University of Ghana Medical School in Accra. It was a great opportunity to meet some other foreign exchange students, but most of all this meant that I got to see Erika! Erika had moved from Kumasi to Accra for the second phase of her research. The timing of the trip was perfect because Erika’s birthday was that week. Shy and I tracked down a place (gas station “bakery”) where we could buy a birthday cake and we carried the cake all the way from Kumasi to Cape Coast to surprise Erika. I am happy to say that the cake survived the bumpy four hour journey with just minimal frosting damage thanks to Prince’s promise to guard the cake with his life. This small birthday celebration was the perfect way to end the day.


Edwin is shaking in his shoes while walking through Kakum National Park


As a contrast: Shy is so confident that he's trying out some fancy moves

The next morning, we set off to Kakum National Park, just outside Cape Coast, to walk through the rainforest at the level of the trees along canopies. Being a rainforest, it rained as we climbed, but the rain stopped just as it was our turn to walk on the canopies. Since the trees are so dense, the elevation was difficult to gauge and this should have made those afraid of heights feel better. However, in our international group the boys were unexpectedly the most nervous about the walk. It was entertaining to see these really tall Ghanaian guys inch their way across the seven legs of the canopy walk and even more fun to occasionally give them a little scare by jumping up and down.


Cocoa pod and cocoa seed


Even the cocoa pod is yummy!

Ever wonder where chocolate comes from? Usually, the sweet and divine burst of chocolate in my mouth overtakes my senses so all I appreciate and think about is the goodness in my mouth. But, since cocoa is one of Ghana’s major industries, and I’ve been unsuccessful in finding true Ghanaian chocolate in Ghana, I was very curious about where chocolate comes from. Just outside the canopy walk, several farmers sell cocoa pods. These pods kind of look a little like a yellow-colored cross between papaya and squash. Inside the pods are cocoa seeds. The seeds are covered in this white fruit that resembled and tasted like mangosteen. To make chocolate, these seeds are collected, dried, and ground into cocoa. Chocolate lovers beware: the fresh seed may look like a delectable truffle, but it is extremely bitter. DO NOT chew on them!


Mawsie and I enjoying the beach

We spent the rest of the day relaxing along the Cape Coast beach at Alberta’s Cottage (a small resort). Perhaps this will only be significant to east coasters…I was on the other side of the Atlantic!!! A short aside about Project Eva’s Tan. My skin complexion has always been a pasty, almost glow in the dark pale white. As hard as I try, I’m never able to achieve the much desired illustrious golden sparkle that all Floridians seem to have naturally. One of my ulterior goals this summer was to get some solid work done on Project Eva’s Tan. Unfortunately, that cloudy Saturday at Alberta’s Cottage was proof that higher powers were not going to make it easy for me to complete my project. Despite the overcast sky, there was plenty to enjoy on the beach. There were plenty of coconuts to eat and drink (50 peswas), mesmerizing green waves that’d make any surfer excited, and impromptu soccer games on the beach. I brought along a teeny Frisbee and much to my surprise, we got a good game of beach ultimate going! We continued our festivities into the night at a beachside outdoor club/restaurant called Oasis. Oasis is a very popular place, especially among foreigners. Though personally, I would have preferred singing to a ukulele around a bonfire on the beach.


Elmina Castle

We set off early the next morning to visit Elmina Castle. Elmina Castle is another vestige of the slave trade presence in Ghana. The Castle itself is much bigger than Cape Coast Castle and its exterior appearance is beautiful. I’m not sure if it was the sunny weather or the Dutch origins of Castle, but I was not as emotionally moved while touring the Elmina Castle. However, the atrocities that took place there are no different than what we saw at Cape Coast Castle. We had just a few hours after touring Elmina Castle and our journey back to Kumasi. We spent those last few hours a bigger and very obroni friendly beach resort: Coconut Grove Beach Resort. Because I grew up in Florida, I’m a bit of a beach snob. I have only been impressed with a few beaches in my travels (Hawaii, Santa Monica, Cape Cod) and I prepared myself to be disappointed in Cape Coast. But, I’m happy to say that I was pleasantly surprised. I highly recommend the beaches in Cape Coast. Everything is almost exactly the same as the beaches in South Florida, including the shell-based sand. The only major differences are the water on this side of the Atlantic is green rather than blue and the waves are much bigger. With the sun blazing, I spent most of that afternoon working on Project Eva’s Tan. We tossed the Frisbee for a bit and just as we were ready to start a game, it was time to go.

If I have a few extra days to travel at the end of my work here in Kumasi, Cape Coast would definitely be a place I’d revisit.

Revolting: Tro-Tro Pharmaceuticals

Tiny little pills have become one of the most important currencies in medicine. Managing hypertension? Take X. Suffering from a bacterial infection? There is an entire alphabet of antibiotics available to you. Don’t underestimate these little pills, they have the power to completely alter a body’s normal processes, even the processes that keep the heart beating and you alive. As a result of this incredible power packed into pills, most drugs and pharmaceuticals are tightly regulated. Patients don’t have access to many of them unless a doctor’s prescription is provided to a pharmacist who then dispenses the drug to the patient. While the physician’s power of the pen has been criticized in the health reform discourse for driving up the health care costs in the US through overprescribing medications and ordering too many tests, my shocking experience on a Ghanaian tro-tro this morning sheds some light on a more positive dimension of a physician’s pen and the importance of health literacy among patients.

For the last three weeks, to cut down on transportation costs, I have been taking public transportation to reach the district hospitals that I visit and assess. Tro-tros are a widely used form of transportation and as a result of its common use, it is a main hawker target. All sorts of vendors selling bread, Ghanaian snacks, water sachets, toothpaste, flashlights, handkerchiefs, really anything come to the side of the tro-tro just before departure and almost every time the tro-tro comes to a stop (at traffic lights or pit stops) to sell items to passengers aboard the tro-tro. Occasionally, lay preachers will also board the tro-tro to preach the word of God or bless the journey. The swarming of hawkers has never bothered me since I’ve seen it as a convenient way to pick up the things I may need before every trip. The preachers also never seemed to bother me since I have a deep respect for the religiosity of the people of Ghana. But, this morning, I witnessed the grossest form of exploitation and felt powerless to intervene.

Pharmacies, called chemical shops in Ghana, dot the country and many of them are privately owned, through may or may not be staffed by pharmacists. They stock all sorts of drugs from common over-the-counter drugs, basic ointments, antibiotics, a handful of illegally stocked drugs, and all sorts of concoctions that claim to cure all ailments. Whoever staffs the shops freely provides medical advice and definitely does not work in coordination with physicians or medical institutions. Unlike pharmacies in the US, prescriptions are not required. This has HUGE implications on the misuse of drugs, not to mention the promotion of antibiotic resistant strains of bacteria.

So, here’s what happened. Just after the tro-tro door closed and we began our journey, who I thought was just an ordinary passenger stood up and began his energetic speech in twi. At first, I thought this gentleman was just another lay preacher, but every so often I’d hear words in English: “medical doctor,” “kidney,” “teaching hospital,” “brain,” and “X million Ghana Cedi.” Perhaps, he was blessing and praying for everyone’s good health. Then I noticed that he had an anonymously produced booklet titled, “Hepatitis B.” What was going on? Was he trying to sell this booklet about Hepatitis B? I then heard him say “prevention is better than killing” and he pulled out a package of drugs that he was selling for 1 Cedi. Like obedient students, almost everyone on the tro-tro handed him money in exchange for a tiny box labeled Ben-70s. I couldn’t believe it. How could they be so trusting of this salesman. I asked the student accompanying me to the district hospitals who he was and he said that he never introduced himself. The gentleman ended up selling two packages of drugs earning him at least 20 Cedi in just one tro-tro.

The closest thing we have to this in the US is direct consumer advertising. I’m not going to even open up the discussion of how manipulative the TV commercials and print ads can be. At the very least, these ads always end with the statement that consumers should ask their doctor about Y drug. While we can’t regulate the type of consultation patients receive from doctors about the drugs, at the very least, we can regulate their access to drugs that have the potential to be harmful if their effects and indications are not understood. A positive aspect of the power of the pen.

Embedded in my research this summer and critical to reducing maternal mortality not just in Ghana, but worldwide is health literacy and patient education. If only you could see the looks on the faces of the midwives and physicians that I interview who discuss abortion complications with me. At the root of these cases is a desperate and uneducated woman who takes some herbal concoction that causes her to bleed profusely and begin to circle death. Even though the human body has incredible defenses and regenerative abilities, would you really risk injury and death at the word of some stranger who doesn’t have the courtesy to mention his qualifications?

If the 1 Cedi drug was advertised to prevent Hepatitis B, what are the possible outcomes of this tro-tro transaction? Assuming the drug itself is a sugar tablet, the tro-tro passengers would take the drug and happily believe that they have succeeded in preventing contraction of Hepatitis B. They will not be interested in getting the Hepatitis B vaccine, proven standard prevention against Hepatitis B, and will remain unprotected. Down the road, they may come into contact with bodily fluids contaminated with Hepatitis B and become infected. Because one can live with Hepatitis B without immediate symptoms of liver damage, they will not seek care until their liver has been overtaken with cirrhosis. The most tragic part of this likely trajectory of events is that at the point they seek care, if treatment is still an option, it will be too expensive. Now it doesn’t surprise me that there are so many hepatitis and cirrhosis cases at the teaching hospital.

Perhaps it’s radical to say this, but the salesperson just earned 20 Cedi for committing murder. Never again will I ever complain about being forced to make a doctor’s appointment for a prescription refill. It’s a premium I’m willing to pay for receiving medical advice from qualified health professionals and peace of mind that others are going through this too.

Swimming, Schisto Free!

I may have been here over a month, but I continually have to remind myself that I'm spending my last summer (ever!) in Ghana. Although I'm in a foreign country, I'm going to try to squeeze in all the things I normally like to do in the summer while here in Ghana. What do I usually associate with summer? Watermelons, mangoes, BBQs, Ultimate Frisbee, Shakespeare on the Commons, fireworks, ice cream, strawberry shortcake, ice tea, picnics, outdoor concerts, and yes, mosquitoes. There are only a handful of must-do summer activities that I can think of that don't revolve around food. The most important of those activities ever since I moved away from living in the sunshine state of Florida is swimming, especially swimming at the beach.

As I was preparing for my trip, most of the warnings and messages of concern I got from friends and family were centered not on being abducted, mugged, or killed, but were about germs and diseases. Ghana is not the filthiest place I've ever traveled to, but disease is a very real concern. So, if you are planning a trip to Ghana, check the CDC website and do make sure your vaccines are up-to-date (yellow fever, hepatitis B, typhoid, meningitis, polio, hepatitis A) and bring malaria prophylaxis with you. Aside from these vaccine preventable diseases, a type of bug that you may encounter in Ghana that I never think about are parasites, both the intestinal and crawling through your skin and anywhere else in your body forms. Parasites. This was what was standing in the way of me being able to swim in Ghana.


Ueli, Shy, Alister, and Erika swimming at Golden Hotel in Kumasi

So, where can I go swimming in Ghana? Are any of the bodies of water safe? Swimming pools are actually common in the major cities, especially at hotels and resorts. KNUST also has an Olympic-sized pool for the more competitive type of swimmer. Although I never asked how often these pools were cleaned or the source of the pool water, I assumed that since most of these pools charged a small fee (3-15 Cedi) to swim that they must be safe. Since I normally spend most of my time in a pool doing handstands and playing games like "Marco Polo", these options were plenty.


Margrit, Edwin, and I at Lake Bosomtwi

Another option about an hour away from Kumasi by tro-tro is Lake Bosomtwi. Lake Bosomtwi is Ghana's largest natural lake created by meteorite impact. It is situated in the middle of a rain forest and surrounded by lush mountains (Wikipedia calls them hills but I think they are super tall so qualify as mountains). If you have ever been to Taiwan's Sun Moon Lake, this is Ghana's version of the tranquil and picturesque getaway.

The lake is believed to be sacred by the Ashanti (largest tribe in and around Kumasi) and the villagers fish only on wooden planks so as not to disturb the spirits in the lake. The most interesting fact about the lake for tourists is that it's supposedly schistosomiasis free! Schistosomiasis is a very nasty parasite that lives in fresh water and penetrates human skin and then can bury and disrupt the function of many organs including the liver and brain by launching a damaging immune response. According to the guide, no one has ever gotten sick from swimming in the lake. Despite this allegation and seeing tons of my friends step into the lake for a swim, I was not willing to risk it. After the alleged parasitic worm infection I had while in Mole, I'm done with worms. But, as long as you are not a hypochondriac med student, I'm sure swimming in Lake Bosomtwi is perfectly safe. I on the other hand, will stick to the pools. We are off to Cape Coast next week, so maybe I'll get my beach swimming in then!

Public Health in Ghana

As Dr. Howard Koh, U.S. Department of Health and Human Services (HHS) likes to say, public health is defined as: "When you wake-up in the morning and take in a breath of clean air, that's public health. When you brush your teeth and the water coming out of the faucet is fluoridated, that's public health. When you eat breakfast and you pass up the donuts for a healthier alternative, that's public health. When you drive to work and you put on your seatbelt, that's public health. Better yet, you ride your bike to work, that's public health. When you get into an accident and an ambulance arrives and takes you to the nearest hospital in a timely manner, that's public health. When you receive great care at the hospital, that's public health....."

Despite this universal definition, the role public health plays seems to locally adapt to each country’s needs and greatest concerns. In the US, I think public health sits in a nebulous and unglorified third space where it encompasses and tirelessly pushes causes such as seasonal flu, diabetes, hypertension, drug and alcohol abuse, abstinence, food poisoning outbreaks, obesity, hospital-acquired infections like MRSA and C. diff, and pandemic scares like the H1N1 flu. Public health in the US monitors and accomplishes much, but we often take it for granted and don’t notice their presence unless something goes wrong. In the US, the coordination between public health and medical institutions where care is being provided to individuals also does not seem to be well-defined.



In Ghana, public health appears to have a much greater and more coordinated role with medical institutions. The Ghana Health Services (GHS), part of the Ministry of Health, is the public health arm of the country. While the GHS’s main concern is population health through various visible public health campaigns both through passive public service announcements and active direct outreach into the communities against malaria, tuberculosis, HIV/AIDS, and now H1N1 (affectionately referred to as “HeeNee” at the medical school) the GHS’s role as a centralized governing body that oversees medical institutions from rural health posts to teaching hospitals allows it to have a direct impact on individual care through a population health lens. The GHS collects population health measurements from provider medical institutions such as maternal mortality statistics and infection rates and uses these statistics to determine the population need for medical personnel, equipment, and skills.

At the skills level, this form of centralized coordination is a huge benefit. With a system of nested medical provider institutions, the GHS helps to keep each level in close and standardized communication from community health centers all the way up to tertiary medical centers. In several districts, the GHS organizes district wide continuing education workshops to teach the nurses and midwives managing the community health posts relevant skills such as a refresher course on eclampsia including signs, treatment, and indications for referral. These workshops are usually held at the district health office or the district hospital thus physically connecting the staff at the community outposts with their district hospital referral point staff. The GHS also sponsors leadership skills workshops for the health services administrators and physicians in the districts. One of the leadership development workshops I was able to sit in on was a demonstration meeting showcasing the results of a 90 day project that select districts undertook to practice using the model of improvement: setting an aim, determining how to measure progress, assigning group responsibilities and feedback channels, implementing an intervention, evaluating the intervention, and setting steps for the next PDSA cycle of work. Isn’t it fantastic that all leaders are provided with these essential quality improvement skills in Ghana? As an aside, I am convinced that this course that was borrowed from the US was in fact borrowed from IHI!

However, one significant disadvantage of the GHS’s centralized system is seen in its role as the main allocator of medical staff and equipment. The district hospitals and community health centers are completely dependent on the GHS to provide them with medical staff and equipment and do not have the flexibility to seek necessary support through other available supply channels. Because each district usually has a population of over 100,000 people with at least a dozen health centers, the GHS is unfortunately placed in a position of a much needed mother with more children than she can handle.

For example, H1N1 has arrived in Ghana and the GHS is now busy administering the H1N1 vaccine and educating the public about the importance of getting vaccinated against H1N1. This message was not easily communicated in the US, so just imagine how difficult it is in Ghana when the belief that HIV/AIDS was introduced to the continent of Africa via Western vaccines is not uncommon. Reports of death due to the vaccine blared on the radio also complicate the situation. However, all in all the risk of the Ghana’s population being crippled by H1N1 is minimal. With several other pressing health demands like more midwives to staff maternity wards, better distribution of emergency vehicles, and community education on the dangers of taking herbal concoctions during delivery, perhaps less resources should be devoted to the H1N1 flu. Examples such as this leads to significant delays in providing the population with quality health care.

So, can public health and the GHS’s role in Ghana be redesigned to better meet the country’s need? This situation is actually a question that all industries around the world face: how to strike the right balance between regulation and standardization in order to allow the system to operate flexibly and meet the needs of the population.

Although I admit that I do not have the clearest picture about the relationship between GHS district offices and the district hospitals or how this all works on a regional or even country-wide level, if the current centralized system were to be maintained, I’d recommend stronger channels of communication. This will allow the needs of a district hospital to be more clearly understood and will allow the GHS district office to better communicate the process and progress made to meet those needs. With stronger communication, the GHS district offices and hospitals can work together to set aims and develop plans to achieve those shared goals—better health care for all.

My Chinese Food Fix

Total Mangos Eaten: 9
Total Mosquito Bites: 22
Total Showers Missed: 2

This must be a sign that I’ve completely adjusted to living in Ghana because I am no longer frantically trying to create new mental maps to fit in all of my Ghanaian experiences. Instead, I’m falling back into old habits that I had in the US. The most obvious habits are my feeding behaviors.

I love to snack and have the biggest sweet tooth. My food counter used to be filled with my Cliff bars and fruit that I had picked up in town. But, slowly local cookies and sweets are crowding the counter. This is an unfortunate detriment to the maintenance of the weight that I have happily lost in Ghana.

Moreover, as if I was pregnant, I also developed insurmountable cravings for Chinese food. I can no longer convince myself that the Ghanaian fried rice sold on the streets is real Chinese food even though soy sauce is used to prepare the rice. My sisters delectable pictures on her blog are cruel reminders of all that I cannot have and the gluttonous delight I usually derive from eating fried plantains is slowly diminishing.

My flatmate, Shy, had suggested going out to eat Chinese food several times before. The thought of being disappointed by Ghanaian-Chinese food used to illicit the ugliest repulsive look on my face, but as the weeks passed and my sister’s food accounts increased in number while she was traveling on the China Synergy Programme, my mind became singularly fixated on wontons. My desperation had grown to a point that if someone offered me a wonton for my kidney, I’d probably say yes without a second’s hesitation. As we pulled back into the Clinical Students Hostel after a bumpy ride back from a weekend trip to Cape Coast, I woke up from my fitful sleep and proclaimed that tomorrow I’d eat Chinese food.

China’s presence is really inescapable in Ghana and there is no shortage of Chinese restaurants. After consulting with some of the Ghanaian medical students, we decided that Royal Park Hotel probably offered the most authentic Chinese food in Kumasi. After anxiously anticipating the food all day, we arrived at the door steps of the Royal Park Hotel, which was fully decorated with comforting Chinese vestiges—golden dragon wall hangings, stone guardian lions, and a big red carpet with the characters Huan Ying Guang Ling 歡迎光臨 (Welcome).



When we walked in, I saw other Asian people in the restaurant—always a good sign, even in the US, that the food should be decent. As we sat down at our round table complete with a lazy sally, I felt like I had reached my oasis. I poured through the menu and ordered over 40 Cedi worth of food, just for myself. They sadly did not have my wontons, bok choy, or the beef chowfun that would have made the perfect meal, but over six pages of other good options. I ended up ordering Jiachang Tofu 家常豆腐, beef lomein, Royal Park’s twist on lettuce wraps, and pan fried pork dumplings. The fatty in me made a valiant effort to clear the table in one sitting and I ended up with just two take-out boxes…not bad, right?

My overall opinion of Royal Park’s Chinese food? Out of five stars, I’d give it three. It was certainly better than Panda Express or your average Chinese American restaurant called any iteration of Lucky Bamboo or Happy Ding. But, it wasn’t fabulous. If in the US, Royal Park would not be a Chinese restaurant that would deserve a second visit. But, since I’m in Ghana, if I’m ever overcome with the overwhelming need to eat Chinese food, I’ll be back at Royal Park devouring another four dishes on my own.

Hair

I am kind of a failure of a girl, in that I don’t really know how to keep my hair at a level much higher than a mess. I know how to wash it, condition it, brush it, and blow dry it, but switching between leaving my hair down to pony tails is really as fancy as it gets with my hair. Now that I’ve been in Ghana for about two months, I can confidently say that my hair skills earn me absolutely zero brownie points in Ghana. I cannot compete with the constantly changing braids, cornrows, fros, curls, and updos that I’ve seen in Ghana. How do Ghanaian women manage so many different beautiful hairstyles?

For as long as I can remember, black women’s hair has always been a fascinating mystery. I can still remember hanging out in the band room on football game Friday’s in high school watching several girls get their hair done in cornrows as we waited for call time when we’d change into our marching band uniforms. The process and finished product just looked so cool! Since then, I always thought that black hair was special, equipped with qualities that my hair would never ever know.

It wasn’t until I came to Ghana and accompanied the hospital administrator to the hair salon, that I learned about a different take on black hair. As the hospital administrator’s wife sat in the chair getting her hair styled, she said, “See Eva, look at all of the pain and trouble we black women go through just to get our hair to look like yours.” What was she talking about?

I turned to Chris Rock’s documentary, “Good Hair” for answers. The premise of the documentary is that Chris Rock’s daughter came crying to him asking why she didn’t have “good hair.” Baffled by her sadness as much as I was by the hospital administrator’s wife’s comment, he decided to investigate what “good hair” meant. “Good hair” sadly means obroni hair. And the hospital administrator’s wife was right. To get obroni hair, black women have to go through a lot. Even after watching the documentary twice, I think I still have only a very basic understanding of the complexities of black hair. Relaxers (chemically hazardous derivatives of sodium hydroxide) to smooth out hair and weaves (produced in India) are just the basics covered in the documentary. And those beautiful braids? According to my friend Charlotte, those braids cost about $180 to get done in the US (just 5-10 Cedi in Ghana). It’s not just a financial consideration, it can sometimes take about five hours just to get your hair done.

I highly recommend Chris Rock’s “Good Hair” for the curious. While some may think it’s a simple message, I agree with Chris Rock’s final conclusion that there is no such thing as specific “good hair” because whatever hair you have, it’s all good.

You Can Stop Searching....!

Total Mangoes Eaten: 9
Total Mosquito Bites: 19
Total Showers Missed: 1

As I have whined about in a previous post, the internet in Ghana can drive you bonkers. Connections are difficult to find and once connected, it is usually slow. But, now that I've moved into the Clinical Students Hostel in Kumasi, I've fixed at least one of the two problems...I have a consistent connection.

So, you can finally stop searching the blog and facebook for pictures. Slowly, but surely, my pictures and videos are are finally uploading onto Picasa. I've placed a link on the right menu, so that y'all can check every so often for newly uploaded pictures.

Now that I have less than a month left in Ghana, I need to tap deep into my Asian roots and take tons of pictures since I've only taken just over 1000. Unlike most places I have visited, taking pictures in Ghana is difficult. Especially taking pictures of ordinary people doing ordinary things because in Ghana they will yell at you for taking pictures. The Ghanaian medical students have told me it is because the general population has become extremely angry about the bad press Ghana and Africa as a whole receives in the media. They are sick and tired of being portrayed as poor, underdeveloped, lacking resources, or even strange. So, I usually have to take pictures on sly, which is never easy to do since obruni's stick out so easily here.

As a disclaimer, my pictures are personal pictures that serve to document my experiences in Ghana including everything from resource poor environments to wealthy oozing with bling situations. Enjoy!

A Safari at Home and at Mole National Park

For Independence Day weekend, a cohort of the University of Michigan students in Ghana came together to take a road trip up to Mole National Park to go on a Ghanaian safari. I was extremely excited to go on this trip even though my African animal knowledge is limited to Disney’s The Lion King and trips to zoos like the San Diego Zoo and Disney’s Animal Kingdom.

Up until the trip, I had not seen many animals at all. Perhaps it was incorrect for me to assume that there would be monkeys walking along the streets with people like dogs. Don’t ask why I thought this would be the case. I blame The Lion King and TV for misinforming me. What I have seen is a “safari” of small critters and bugs in my “own backyard” that would make anyone who hates bugs and is a medical student who has passed infectious diseases (me) a paranoid wreck. Here are a few of these critters:

• Mosquitoes are my number one concern even though they are not anything new to a South Floridian. If I wasn’t such a mosquito magnet, then perhaps I wouldn’t be so concerned. If you are ever in the same room with me, you’ll be safe. No mosquito bites for you. The added worry is malaria, which is a very real concern. Of the district hospitals I have visited so far, malaria is always one of the top five complaints. And two of my Ghanaian medical school friends have come down with malaria. Two things I must manage to do consistently every day: shower myself with OFF and take my malaria prophylaxis (doxycycline). While I was in Agroyesum, sleeping with a mosquito net was an absolute must. Every day is a battle against these mosquitoes and I fear that I am losing. Mosquito bite count as of today: 19
  
  
  
• Centipedes and all other insects are significantly bigger here! The first time I saw a centipede curled up on the ground I thought it was a snake! I was even told that drying your laundry outside is a hazard because the tsetse fly will lay its eggs into your clothing. Dr. Abram’s videos of the bot fly are still fresh enough in my mind to motivate me to dry hang my clothes indoors.
  
  
  
  
  
• Scorpions are not common, but since arriving in Ghana, I have come across three. These killer critters are also unexpectedly large. The largest one I’ve seen was the size of a blue crab. The movie, Scorpion King, took place in Africa, right?
  
  
  
• Lizards and other reptiles are very common here. Many of the houses here are covered by a metal sheet and if you hear rumblings across your roof, it’s most likely a lizard scurrying across the roof. The coloring of the lizards is very different from those found in South Florida. I’m actually comforted by the lizards because they remind me of the lizards that run rampant in South Florida.
  
  
  
• Parasitic helminthes. I had a worm scare Independence Day weekend because I was experiencing extreme fatigue, a fever, complete loss of appetite, and GI irritation. Since the twins I lived with while in Agroyesum were reported to have worms, I knew it was only a matter of time before I developed worms since we ate the same food and drank the same water. While exchanging Ghanaian experiences with the rest of the University of Michigan students, I learned that two of them had worms in their feet! Worried about my well-being despite the potential positive benefit of a parasitic worm helping me lose some weight, I adamantly requested for a de-wormer pill upon arriving back in Kumasi. I do feel better now…
  
  
  
• Chickens. Almost every meal in Ghana includes fried chicken. After walking around the streets, this will come as no surprise given the number of chickens roaming around, even within hospitals! Thankfully, these chickens do not all crow at dawn every morning. Rather, the cock-a-doodle-doo can be heard at any time during the day. Every time a chicken crosses my path, I wonder if he will be a part of my next meal.
  
  
  
• Goats. Roaming goats are much more common in the districts than in Kumasi, but you can still find them jumping across gutters and picking through trash. There is nothing really special or unique about these goats. Goats around the world must be the same.

While these critters keep my daily life in Ghana exciting, they do not beat being able to walk around Mole National Park and standing just a few meters away from these amazing animals:

Blurry, but Erika's standing over a crocodile!
• Crocodiles: The first stop on our road trip to Mole National Park was Paga, a town at the border of Ghana and Burkina Fossa. These crocodiles are unique because they are tame and live side by side with the people of Paga. Legend and folklore have the people of the village intertwined with the lives of the crocodiles. Each crocodile represents a human spirit. We unfortunately arrived in Paga too late to get the best of pictures.
  
  Any mention of Paga always brings up a misinformed debate about how to tell the difference between a crocodile and alligator. Since few believe being a Floridian with alligators in her backyard is a credible source of information, here is a link that details the differences.
  
  
  
  
• Warthogs: The Lion King really did get this one right. Warthogs are not very majestic and are the “pigs” of the African wild. They were also much bigger than I had anticipated. At Mole, they run wild in the reserves, but also coexist with the humans living in Mole. If you are not careful, they will step onto your veranda in search for food. The most entertaining thing about the warthogs is how they eat. Since they have very short necks, they will bend down on their knees to eat. Though, I don’t remember Pumba doing this in The Lion King.
  
  
  
  
  Yeah for Baboons!
  
  
• Baboons: They were everywhere! They roamed around the villages, hung around the water towers, climbed up along the soccer goal posts, and were found walking around the reserves. Though they are hairier then we are, the similarities in their mannerisms is really uncanny. Baby baboons cling onto their mother’s backs not too unlike how babies in Ghana are strapped to their mother’s backs; the baboons groom with meticulous scrutiny; the curious stares they give you only reflect our own curiosity; and they sit on “toilets” to pass waste.
  
  
  The female water buck who caused the fights
  
  
• Antelope and Water Bucks were the hardest to track because they would flee at any sound. We were only able to catch them from a distance and hear the rustle of their graceful run. The antelope and water bucks are very territorial. Other male antelope and water buck cross into the marked territory of another male at their own risk. However, all females are allowed to cross. The most intriguing thing we were able to see was a fight between two male water buck for a female water buck.
  
  
  An elephant track...are we close?
  
  
  
  
• Elephants!!! Mole National Park has hundreds of elephants roaming its reserves. Despite this great number and the large size of these majestic animals, it was extremely difficult to find and see elephants. Our first safari walk in the late afternoon yielded no elephants. But, the next morning, we all woke up to take the 6:30AM walking safari to see elephants before leaving Mole. After wandering around for about an hour seeing plenty of elephant tracks and the constant buzz of horse flies driving me insane, I was about to give up. But, then, our rifle-carrying guide came through for us and we found eleven elephants! The African elephant is much bigger than its Indian cousin. The most obvious difference is probably the shape of its ears: large and square compared to the smaller and triangular ears on the Indian elephant. As we approached a watering hole where the elephants were bathing, it began to smell like a circus (my most memorable elephant encounter before Mole), so I knew we were in the right place. Watching the elephants bathe and throw sand on their backs as insect repellent was an unforgettable experience. I can’t think of any other animal that has the same silent magnanimity.
  
  Here's an excellent video of an elephant painting!
  

If you are ever in Ghana, I’d highly recommend making the trip out to Mole National Park for the extremely affordable opportunity (5 Cedi to enter with student ID and 3 Cedi per hour for the walking safari) to walk along with the animals of the Ghanaian wild because you’ll only see pesky critters in the cities.

Polar Opposites

If my sister and I wanted to make my parents nervous for an entire summer, we couldn’t have succeeded better if we tried. This summer, both my sister and I are away from home for almost the entire summer. Not only are we away from home, we are in countries that present their own set of challenges that make it difficult for our parents to lend a hand or even be aware of what’s going on.

Shanghai

Kumasi


The commonalities all end there. This summer, I’m in Ghana and my sister is in Shanghai (follow her blog here). Ghana is a developing country in Africa and Shanghai…is hyper-developed a good way to describe it? Here is a table of parallels:

	Eva	Jo
Country	Ghana	China
Work	Clinical Quality and Management Research in Ob/Gyn	Architecture Internship
National Language	English	Mandarin
Local Dialects	Twi	Shanghainese
Fluent in National Language	Yes	No
Fluent in Local Dialects	No	Maybe...
Number of Skyscrapers	0	Innumerable
Local Food Favorites	Fufu, Banku	Xiao Long Bao, Sheng Jian Bao
Ease of Blending in with Locals	Impossible	Impossible not to
Family Nearby	No	Yes
Team Represented in World Cup	Yes	No, but Chinese Ads all over stadiums
Reliable Electricity	No	Yes
Reliable Water	No	No
Most Common Form of Public Transportation	Tro-Tro, Taxi	Bus, Subway, Taxi
Common Ways Locals Use to Call Out Foreigners	"Obroni"	Staring, Calling you Crazy (Sheng Jing Bing)
Treatment by Locals	Everyone wants your name and number to be your friend; targeted to buy local crafts and no one believes I am a very poor medical student in serious debt	If they figure out that you are a foreigner, all prices for things will be overinflated
Weather	Hot, Rainy Season	Sweltering Hot, Monsoon Season
Concern about Mosquitoes	High	High but no Malaria
International Event Congesting City	None	World Expo
Ease of Finding American Food	Moderately difficult	Very Easy
Night Life Options	Handful of clubs for dancing, drinking, playing pool (Vienna City Club, Genesiz, Café Masarati)	Unknown (personally), but I’m sure Shanghai is full of at the very least bars, especially around the Nanjing Lu and Xintiandi area
Most Common Items Sold on the Street	Loaves of bread, cassava, phone cards, second hand clothing and shoes	Fruit (changes with the season), trinkets, knockoff items
Pollution	Very Bad	Very Bad

Though, even in Ghana, everything seems to be made in China. So, perhaps our summers are more similar than we think!

If you had a choice between Ghana and Shanghai, where would you spend your summer?

Another Ghanaian Food Update

The Ghanaian food journey continues. Below are some local food highlights. I don’t think variety is a characteristic of Ghanaian food…I just may have tried it all within three weeks!

Before I go on, I will admit that I broke my rule of not eating any non-local food within the first week I was in Ghana. We discovered the famous obroni restaurant, Vic Baboo’s, while wandering around Kumasi and just had to stop in to try it out. Vic Baboo’s is an Indian restaurant that claims to serve local food, American, Italian, Indian, and Chinese. I went with Indian since it was an Indian restaurant and Erika went with Hawaiian pizza--both were pretty good!

Sir Max is another obroni option in Kumasi that I think is owned by Lebanese folk. We went to Sir Max with a few of the Ghanaian med students and I don’t think they are big fans of middle eastern food. I think they were actually disgusted by the baba ganoush I ordered.

Fufu





Fufu is a very unique type of Ghanaian dish. It looks like a ball of dough, but is actually pounded and mashed plantains and cassava mixed together. I think the mixed ball of dough is then boiled/steamed, but I’m not sure, especially since obroni usually get diarrhea after their first time eating fufu (thank goodness this didn’t happen to me!). Fufu is eaten with light soup, a spicy tomato based stew that has meat and fish poured on top of it. What may be fun for some is that you typically eat this dish with your hands. I say “fun for some” because I have this inexplicable fear of eating in public because I don’t like making a mess while I’m eating and having everyone see it. I generally avoid foods like ribs and wings when at restaurants even though I think they are tasty. I prefer a white pasta sauce over red and I eat messy finger foods with utensils. So, you can imagine how painful it was for me to eat fufu with my hands especially when the hospital administrator’s wife was staring at me. I was told that you were not supposed to chew on the fufu and just swallow it. That’s not difficult to do, but it seems so strange. So, I’d let it slosh around my mouth once or twice to taste it and then swallow. The fufu is kind of bland and tasteless. You can almost taste the plantain, but not really. I thought the light soup was super spicy. I guess the fufu is a good flavor balance to the light soup. After humoring the hospital administrator’s wife by eating with my hands. I gave up and asked for a spoon.

Just a few days later, the hospital administrator’s wife asked me to help her prepare fufu. It is usually prepared by two people. One person sitting by the mortar adding water to the mixture and folding the “dough” and the other person standing holding a large stick of bamboo with a flat blunted end to act as the pestle. I was very unsuccessful at the pounding because I was afraid I’d squash the hospital administrator’s wife’s fingers. I was also very reluctant to put in work and energy after showering into something I didn’t think was all that appetizing. The cost of sweating was not worth it! Thankfully, I think she got frustrated with my hesitant pounding and asked a scrawny fifteen year old to help her who was much more forceful with her pounding. Cost: 2 Cedi

Banku




Banku can be seen as a variation of fufu, but made of slightly fermented maize meal and mashed cassava. Banku also has that big ball of dough appearance but has a little more stiffness to it…kind of like oatmeal that doesn’t have enough milk in it. Instead of light soup, Banku is eaten with okra (okro in Twi) stew. If any of you have cooked with okra before, you know that it has a sliminess to it. Chopping up okra leaves is actually slimier. The okra and okra leaves are what give the soup is gooey texture. The okra stew is also tomato based and includes palm oil (red in color) and fish. Banku is also eaten with your hands. I never thought I’d be thankful for the power going out, but I used my difficulty of eating in the dark to get a spoon to finish off my Banku. I actually really enjoyed Banku. I think it’s because I really miss the taste of vegetables! Cost: 2 Cedi

Jollof Rice



Jollof Rice is a spicy type of rice usually served with chicken. I’m not quite sure what actually gives it it’s orange color and spicy taste, but my guess is the red pepper that’s used in almost every Ghanaian dish. It could also be Shito sauce (a horribly named spicy tomato/fish sauce). My guide book calls this the West African paella, but I haven’t seen Jollof rice served with anything but chicken, so I don’t think that’s the best description. Cost: 3-5 Cedi

Rice/Noodles/Yams with Tomato Stew







Because food is extremely hard to come by out in Agroyesum, the Matron’s sister cooked for me while I was there. I think it’s now clear that she’d try to cook me “American” dishes for dinner, which I really appreciate even though everything came with a Ghanaian twist. Most of my Ghanaian-American dishes included a starch (rice, noodles, yams) along with a tomato based stew that included either chicken, beef, or fish with some chopped cabbage, green pepper, and onion mixed in. The tip-off that I was eating Ghanaian-American dishes rather than true Ghanaian dishes was when I got an entire pot filled with French fries in it and when I offered them to the hospital administrator’s family, they refused them! I’ve never met anyone who didn’t like French fries. They said that they didn’t like potatoes. This confuses me since I don’t think potatoes taste all that different from the water yam… Cost: 2-6 Cedi

Red Red





In my previous blog post about Ghanaian food, I described fried plantains served with a bean stew. It has just been clarified that this dish is called Red Red. I still think hands down that fried plantains are my favorite Ghanaian thing to eat. Cost: 2-8 Cedi

All of the above are sold on the streets, though, unlike other countries I have visited, street food is a lot less common in Ghana. You can’t really eat your way through a city. I think this is why eating and finding food is so difficult in Ghana. A trip out to get food always takes at least an hour (not including the incredibly slow service at restaurants). Below are few things that you can also pick up on the street but are not really restaurant menu items.

Ghanaian Sandwich





I don’t actually know how common this type of sandwich is, but here’s Ghana’s take on an American staple: bread, onions, lettuce, chicken, beans, hard boiled eggs, ketchup, and mayo. I bought this sandwich as alcohol poisoning prophylaxis, but I think the combo of ketchup and mayo only added to me confirming any American partying stereotypes. :( Cost: 2 Cedi

Fried Egg Sandwich

If you are really craving a nice departure from rice based meals or need a quick protein heavy breakfast, a fried egg sandwich is a great cheap option. The fried egg sandwich is exactly that, but a few things to keep in mind: 1) The eggs are smaller in Ghana and the yolk is not very yellow. Don’t be fooled, egg whites only is not the standard here. The yolk is in there somewhere. 2) Without even asking for it, you will sometimes get egg sandwiches with a few diced tomatoes and green onions (aka the Ghanaian Spanish omelet). Beware if you don’t like tomatoes or green onions. 3) Bread is sold by length rather than slices. To make a sandwich you’ll probably need about 30 peswas (Ghanaian cents) worth of bread. Cost: 1 Cedi

Meat Pies



If you’ve ever been to a potluck that my family has been invited to, you will know what Chinese curry pockets are. I like to think that this is Ghana’s version of my mom’s Chinese curry pockets. The Ghanaian version is really just a meat pie that normally doesn’t have that much meat in it. I can’t put a finger on the spices in the meat. One meat pie had a sun-dried tomato flavor to it. The pastry portion of the pie is very flaky and very dry, so eat with plenty of water! Cost: 50 peswas to 1 Cedi

Goat/Beef Kebobs



Of all of the advice my mentor gave to both Erika and I before leaving us in Ghana to fend for ourselves, he was most enthusiastic about Ghana’s goat kebobs. This is definitely your typical type of street food: a guy standing behind a unstable looking grill. These kebobs can be of any type of meat, but I’ve seen only goat and beef so far. You can also get any part of a cow, except I have not seen cow tongue, which I told one griller would be a hit, but he didn’t believe me. The meat is marinated in the same red pepper and the kebobs are cooked upon order. So, as you are salivating, you are also praying that the meat is cooked well and that the hot metal grid is hot enough to kill anything that could kill you! Cost: 1 Cedi per kebob

After almost a month in Ghana, I’m seriously craving some good Chinese food. My sister’s Shanghai food pictures only add to my cravings. After Erika’s very unfortunate Chinese sweet and sour chicken at Vic Baboo’s I’m going to steer clear of anything Ghanaian-Chinese…It’s really too bad that I’m flying back straight to Ann Arbor, where the Chinese food is not really great. I really should make a pit stop at home!