Got to Have Faith: A Story About a Girl and a Ghanaian Boy…

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…”

Just as I was about to say, “It was nice meeting you,” he swiftly and smoothly interrupts me and offers to drive me into town. The preschool rule to never follow a stranger into his car is very relevant in Ghana and I was not going to “hitchhike” into this gentleman’s car to get to town. As if anticipating my refusal, he said that he has not finished getting to know me. Beads of sweat were now dripping down my face from the heat and weariness of this long and now unpleasant conversation. I decided to try one of the last tricks in my bag: outlining the infeasibility of us being friends given that I was leaving the country TOMORROW.

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!”

I gave a hurried wave, and was on my way. I even took the more precarious, unsuitable for flip-flops, cobble stone path to ensure that he would not follow me. I didn’t look back.

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.

Hustling: Providing Sustainable Aid

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.

Currying Favor with Ghanaians

Obama biscuits!

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!"

Project Fives Alive: Two Days of Energizing Inspiration

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

Ghanaian Prints for Fall

What do you get when you send a fashion retard into a fabric store in Ghana, tell her to pick out cloth and then give specific designs to a Ghanaian seamstress to work her magic and transform the fabric into beautiful clothing?

With the help of the internet, the Marie Claire magazine that I found on my flight to Accra, and a very creative seamstress, I think I successfully avoided a fashion disaster. I handed over my fabric and hoped for the best! Tops are about 4-5 Cedi each and dresses are 8-10 Cedi each. The seamstresses have their own catalogs of traditional Ghanaian styles if you want typical Ghanaian clothing. I opted not to pick Ghanaian styles to increase the clothing's versatility in the US. I also don't think I'm curvy enough to do Ghanaian styles justice.



The seasmstress, Afriye, worked extremely fast and called me in after just a week for fittings. If there was any fabric left over, Afriye would design some extra tops for me! I highly recommend going with someone to the fittings so they can be an extra set of eyes for the little details. Shout-outs to Charlotte, Szoa, and my favorite dress-making partner, Mawusi, for helping me. Generally, simple styles are the most successful. After all of the minor adjustments, I think I'm very proud of what I was able to come up with! Afriye is a wonderful seamstress--I even got approval from Mawusi for Afriye's dexterity and creativity. So, if you are ever in Kumasi and would like to get something tailored...I'll pass Afriye's contact information onto you.

Are prints in this fall season? Well, even if they are not, I think Emily would approve of my wardrobe extension into print outfits! What do y'all think?

They Do Like Bananas!

Mona monkey eating bananas at Boabeng-Fiema Monkey Sanctuary

I can't believe I'm already at this point, but I took my last tourist trip this weekend! Since it was my last trip, I made sure that it would be blog-worthy.

It all started with hitch-hiking a ride from Tamale to Kintampo to meet the IFMSA obroni coming up from Kumasi. I am still very surprised that this haphazardly orchestrated "let's meet up somewhere in the middle of Ghana" plan worked out. I am indebted to the nice gentleman from Accra who was willing to give me a ride.

The roads are infinitely smoother from Tamale to Kintampo than they are from Kumasi, so I ended up arriving at the town's center much earlier than my Kumasi obroni. While waiting at the gas station (called filling stations in Ghana), I run into the Minister of Foreign Affairs of Ghana, Muhammad Mumuni. He was on his way to Tamale and unfortunately got a flat tire and was waiting for the tire to be changed. While we were both waiting, we discussed several topics including the public school system in Ghana and fufu. He greatly admired the shirt I was wearing that said, "Make Fufu. Not War."

After waiting for about twenty minutes, I decided that it would be best if we continued driving towards Accra and attempt to deliberately run into my friends from Kumasi so that this nice gentleman could make it to Accra by sunset (a 12 hour drive). After relaying my plans to my flatmate Shy, who was leading the obroni from Kumasi, we were on our way-- keeping our eyes wide open for a white tro-tro filled with obroni. After just 10 minutes of driving, we found them! There is apparently just one road you can take all the way from Tamale to Accra, which passes through Kumasi, so it was inevitable that I'd be reunited with the obroni.


Bringing an AADT Dai dance pose to Kintampo Waterfalls in Ghana

As soon as I climbed into the tro-tro, we sped towards Kintampo to our first destination, Kintampo Waterfalls. For a 2 Cedi admissions fee, you gain access to these gorgeous waterfalls. I thought it was too cold for a swim, so I busied myself as group photographer. The rocks just underneath the waterfall are very slippery and arranged in such a way that you can slide down the side slopes of the waterfall. The falls are located at the bottom of a small hill and at the top are pavilions perfect for a picnic. We were in a rush to reach our next destination, so after drying off, we were back on the road.

Our next and last stop on this trip was the Boabeng-Fiema Monkey Sanctuary. Even though I'd already been to Mole, I just had to see more animals! At the sanctuary, you can see two species of monkey: the playful Mona monkey and the shy Colobus monkey. Like Mole National Park, the animals at the Boabeng-Fiema Monkey Sanctuary live side by side with the humans of the village. Since most of my assumptions about animals in Ghana had been scrapped on my visit to Mole, I was shocked to see that the Mona monkeys loved interacting with humans and eating bananas! I suppose the association between monkeys and bananas extends far beyond Curious George. The Mona monkeys were all very excited to grab bananas and peanuts right out of our hands!

Just a small note: Although the Mona monkeys live freely with the villagers, two Canadian visiting zoology students reminded us that these monkeys were still wild. Our tour guide probably would never admit to this, but there have been cases where the monkeys would bite or attack the human tourists if they ever felt threatened. So them feed with caution!

Hitch-hiking, waterfalls, and monkeys! What better way to usher in my last week in Ghana?

Back to School

My last summer of medical school is very quickly coming to a close. I just received emails from the administration about our new class and exam schedules, that our first day of class will begin at 7:15AM, and a very long textbook list. AHHH!!!!

School stress can certainly follow me to Ghana. The second year of medical school in the US is arguably the toughest of the four years due to the extreme volume of information there is to internalize not just for the USMLE Step 1 Board exams at the end of second year, but also in preparation for the responsibility of being on a patient care team as a third year medical student. What we learn in our second year builds on our first year and has even greater potential to be applied to save lives. However, call me crazy, but despite this thunderous load of stress awaiting my arrival back in Michigan in less than a week, I am excited about my second year of medical school because I’m moving one step closer to seeing and taking care of patients. Let me explain.


Szoa and I after 5 hours waiting at a bus station and 6 hours on a bus to Wa...we're still smiling! Photo Courtesy of Szoa

On the same day that I received these not entirely welcome emails from the administration outlining my second year, I was preparing to welcome my friend, Szoa, to Ghana. Szoa is a premedical student who was able to squeeze one week out of her busy work schedule to come visit me in Ghana and see firsthand how medicine works in a developing country. Since Szoa had just one week, I did my best to arrange for the most meaningful medical experiences while also giving her a crash course on what it is like to live in Ghana. She had to try all the food that I’ve been sampling in the last two months in just one week…and that alone is not an easy task.

Throughout the week, Szoa got to see almost every level of the delivery of health care in Ghana from the research and policy level at my presentation of preliminary results and recommendations to the health care leadership in the Ashanti region, to the teaching hospital level through the variety of OB/GYN cases that come into KATH when on call, to the most basic point of care through the interaction between midlevel providers and their communities in the rural upper west region surrounding Wa. While I can only hope that the breadth and depth of her brief health care experiences were worthwhile as she begins her career in health care, I can say with complete certainty that my week introducing medicine to Szoa has recharged my own excitement about medicine and health care.

The first year of medical school can be tough, especially as you are memorizing the seemingly neverending adverse effects of the tetracycline class of antibiotics or struggling to construct a cohesive conceptual understanding of renal physiology. Medical school students are self-selectively eager students who are always itching to hit the ground running. So, an entire year spent with books rather than interacting with patients can be very demoralizing—to the point where I even questioned if this was what I really wanted to do. But, my summer in Ghana has erased these negative feelings and my week with Szoa took the form of a reflective capstone.

Even though most of my time was spent focusing on the clinical quality and management changes an OB/GYN can make at a district hospital, the impact on maternal health, and the policy implications of this intervention, my summer in Ghana helped tie together all of the different pieces of medicine I have experienced in the last year into one entity. The connections between policy and research, process improvement, and direct patient care were not just made clearer in my mind, but were strengthened as well.

Imagine a pregnant woman for visualization purposes. In just one individual, she represents the medical acumen that physicians and midwives will provide through prenatal, labor, and postnatal care; the continuous data collection and interpretation that the medical staff must employ in order to develop innovative process improvement interventions and ensure that life-saving techniques are applied effectively, efficiently and reliably; the policies that were put into place to spread best practices which will make her access and utilization of quality health care seamless; and the joy of adding another beautiful human being into her family. Because current medical education curricula focus just on developing the medical knowledge we will need to care for patients, I used to think that these four layers of health care delivery were siloed fields. But, my summer in Ghana has taught me that these layers are all interconnected within a patient and are difficult to tease out into four separate streams.

As Szoa and I were observing a caesarean section during a night on-call at KATH, I found myself building and jumping between these layers of health care delivery as I tried to explain what was going on in front of us. This caesarean section was being performed because of the condition oligohydramnios, which was detected and managed by her care team in order to ensure the safety of mother and baby, which was probably a result of the mother regularly attending free antenatal clinic days, which are hosted by all levels of health facilities throughout Ghana in order to improve maternal mortality, which include providing mothers with nutritional supplements and regular tracking of the health of mother and baby, and so on. As I pointed out anatomical structures like the uterus, I explained the need for the uterus to contract in order to avoid bleeding complications after delivery, the regular practice at KATH to give the mother misoprostol to avoid postpartum hemorrhage, how the use of misoprostol was introduced at the district hospitals by the OB/GYNs newly posted to work at district hospitals, how misoprostol is a controversial drug because it is abused for abortions, how the regulation of pharmaceuticals in Ghana needs to be tightened, etc. It’s all interconnected!

Although my second year of medical school will most likely be busy to the point of overwhelming chaos, I know I’ll not just survive, but I will enjoy learning about the endless number of things that can go wrong in the human body and how we have developed ways of correcting and managing these complications, while continuing to muse about health care improvement through the many layers of health care delivery.

Second year, here I come!

Journey to the North: Notes on Transportation in Ghana

As I’m writing, Szoa and I sitting in a makeshift bus station in Kumasi impatiently waiting for our journey to Wa to visit IHI’s Project Fives Alive’s project sites in the upper west of Ghana to begin. I cannot wait to get to the north to spend some time with the Project Fives Alive team and to recommence my search for mangoes (perhaps I love mangoes too much). I’ve already waited about two and a half hours and have just learned that we have about an hour left before the bus begins to board. This “organic” process of transportation is very frustrating since I hate idle time. Could I have taken another mode of transportation to avoid this three hour wait in a dusty station?

Generally, getting around in Ghana is fairly easy and inexpensive, but riddled with delays. Here are some considerations that must be factored in before embarking on a trip:

• Ghana Time:
If a Ghanaian tells you that they will meet you somewhere at a specific time, expect at the very least a 15 minute delay. Like Asian time and Hispanic time, nothing ever runs on time.
• Distance:
It takes on average about 20 hours to travel from the northern border of Ghana (Paga) back to southern border (Accra).
• Quality of Roads:
Even though a town may be geographically close, if the roads have not been paved, your travel time will increase significantly. As I was planning my trip to Wa, I had the option of taking a flight into Tamale from Accra followed by a bus from Tamale to Wa. This seemed like the fastest route since Wa is in the next district west of Tamale. However, since the roads between Tamale and Wa have not yet been paved, the travel time between Tamale and Wa would take about the same time as a bus directly from Kumasi to Wa.
• City Congestion:
If y’all thought New York City was congested, just come to Ghana and you will be surprised. Because public transportation systems don’t quite exist, the roads are “choked” with lots and lots of cars. Drivers are very aggressive here and will squeeze into any space available. A five minute journey could be a thirty minute ordeal during rush hours--usually it is much faster to walk in these cases.
• Type of Transportation:
The smaller the vehicle, the faster it travels. A large bus generally will take much longer than a taxi. The age of the vehicle is also important factor in its speed. The older the car, the slower it will drive.
• Who’s driving?:
The traffic rules in Ghana are very loose. Speed limits and traffic lights are merely suggestions. So, if the roads are clear, a fast driver will speed his way down the road until the road becomes congested. 90% of the cars in Ghana are manual, stick shift cars. This added control makes it relatively easy for the drivers to abruptly stop the car if needed.

Given these factors, I decided to take a large and established (though apparently not reliable) bus to Wa from Kumasi. Here are some other transportation options that I could have taken:

• Drop-In Taxi:
Drop-in taxis work exactly like taxi’s in the US. You stand on the side of the street to flag a cab down, or walk to a cabstand. Though, before opening the cab door, you must negotiate and agree on a cab fare. Since cab fares are always inflated for obroni, be sure to verify the price with locals. Travel within Kumsai should never cost any more than 4-5 Cedi.
• Shared Taxi:
There are some taxis that simply drive up and down some of the main city roads or highly frequented routes. If there are empty seats available in the cab, you can share a cab with strangers and pay a greatly reduced fair to arrive close to your final destination. A drop-in price of 4 Cedi reduces to 60 peswas in a shared taxi.
• Tro-Tro:
Tro-tros are old refurbished vans that travel almost all over Ghana at a very low cost. Each tro-tro can hold about 15 or so people legally. A porter assists the driver by calling out the final locations that the tro-tro will travel between. He also collects the tro-tro fare and alerts the driver when to stop to drop-off passengers and pick up new passengers. While some drivers will try to squeeze as many people into one van as possible, there are random police checkpoints along the roads that will fine drivers for overcrowding. Tro-tros only leave when the tro-tro is full, so that is an important delay that you have to take into account when planning trips. Tro-tros are probably the riskiest form of transportation in Ghana given how old the vans are and how recklessly the drivers drive. But, if you are on a budget, they are a very affordable option.
• MetroMass Buses:
These buses are government owned buses that connect most of the major cities and townships all across Ghana. Because these buses are government owned, the price is highly subsidized. Fortunately, unlike the tro-tros, these buses kind of run on a schedule. They have a certain number of routes a day and will leave within two hours of their reported departure time. If you are not traveling a long distance or don’t mind the lack of air conditioning, this is another very affordable and more reliable option. Usually, advance tickets are not needed.
• STC Buses:
These buses are a step up from MetroMass. They are newer and are a little more reliable. But, they have less routes than MetroMass. You normally do have to purchase tickets in advance or arrive very early and hope that there are spaces left.
• Motorbike:
In the north, the land is much flatter and as a result, one of the major forms of transportation is the bicycle or motorbike. However, motorbikes are not available for “rent.” To take advantage of the motorbikes, you will need to know someone who owns one for a ride.
• Hitch-hiking:
Ironically, in a foreign country where everyone is a stranger, hitch-hiking is a very viable option for obroni in Ghana. Twice, I have been lucky enough to meet generous strangers who offer to drop me off at a city on their way to their final destination. They ask for absolutely nothing in return and simply tell me that this is the Ghanaian way. As a caveat, this is not to say that everyone offering rides is a safe option. As my dad has ended every conversation I’ve had with him since I’ve been in Ghana: be smart and be safe.

The bus to Wa has finally completed boarding. It’s now five hours after the original departure time. Let’s just hope that these six hours to Wa are safe and as they say in Ghana, snappy, too!

Party Hard: Clubbing in Ghana

Photo courtesy of Dimitri...all the body

While packing and envisioning my summer in Ghana, I was sure I’d spend every evening hidden away under a mosquito net in my room since I was convinced that being out on the streets at night was too dangerous to even risk it. I was also sure that Ghanaians also didn’t leave their homes at night, so a city nightlife would be completely nonexistent. However, at the same time, I knew that Ghanaians would have a innate sense of rhythm and everyone was probably a natural dance phenomenon. I unfortunately couldn’t connect these two ideas in my head and was completely unprepared for the vibrant clubbing scene in Kumasi that the medical students introduced me to.



Some of the most popular clubs that we frequented in Kumasi include Genesiz, Vienna City, and Café Masarati. The clubs are all fairly spacious and unlike the clubs I’ve visited in New York, Boston, Chicago, Ann Arbor, and LA, they are never very crowded— something I actually prefer. A typical night out begins around 11PM with pregaming. Since drinks in the clubs are similarly more expensive then on roadside bars, the concept of pregaming also exists in Ghana (interesting fact: pregaming is known as foreplay in Norway).





If you are a beer drinker than Ghana’s own Star Beer is very popular. For mixed drinks people like myself, vodka, gin, rum, whisky, and tequila are available, but it’s rare to see people drinking mixed drinks. After pregaming we all head to a club. Clubs don’t liven up until around 1AM and the night doesn’t really begin to wind down until 3:30AM. This is very different from the strict Puritan 2AM closings in Boston.



The music in clubs is about 70% local music: Ghanaian and Nigerian hits. Even though the music is completely unfamiliar, it’s not difficult to blend right in since the beats and rhythms are just like the hip hop and R&B hits played in the US. Unfortunately for Lady Gaga fans like me, you will never hear her music being played in clubs in Ghana, even when you request it. The music played complements Ghanaian dance and Lady Gaga just isn’t of the right swagger. Ne-yo, Usher, Chris Brown, and Rihanna are popular foreign favorites. I had absolutely no idea who Justin Beiber was before leaving the US. But, this 14 year old pop sensation has made it to Ghana and does get occasional air time.



Dance customs in Ghana are slightly different: no jumping up and down, no big circles of friends, lots of bumping and grinding, almost always guy-girl pair dancing and occasionally guys dancing together egging each on (not in a homosexual way), and sometimes more traditional dance moves are thrown in (not easy to imitate despite the med students telling me that I was getting it). There is almost always an imbalance of guys and girls in the clubs, so girls (who are not prostitutes) are in high demand. The clubs are really not for girls who are shy. I know I tried to make AADT proud :) I was incredibly impressed by all of the Ghanaian med students, especially the guys, in their dance abilities. They all know how to dance really well, which is a huge difference since finding guys who know how to dance or aren’t embarrassed to just try in the US is extremely rare. This is something that I’m going to really miss when I return to the US.

Here are some of the most popular clubbing favorites...I recommend y’all add them into your party playlist!





























Thank you for all of the songs Ernest!

If You Like Art...

My sister and I are very different people. Because we don't share many physical similarities, it's not easy linking us together as sisters. One of the major discrepancies is the distribution of talent. My sister is a natural creative artist. Her very first temper tantrum was actually about art. After spending at least an hour trying to understand through her tears what "yellow paper, white paper" actually meant (this occurred when the breadth of her vocabulary included at most 50 words), every member of the family was busy turning the house upside down searching for whatever type of paper product would fit her feeble sniffle-laden description. In the end, we discovered that it was the misplacement of her Disney's The Lion King notebook that became her very first sketchbook that elicited all of the screaming and crying. She has been drawing and painting ever since.

While I am to this day still very jealous of her artistic gifts, she has helped me develop a strong appreciation for the arts. A trip to the Met or MoMA in New York is really not the same if she is not there. Since she's busy in Shanghai this summer designing all sorts of buildings, I'm also on my own here in Ghana.


One of Bernard Mensah's pieces

While I may not have the same refined eyes of my sister, I do think that the traditional arts scene in Ghana is extremely vibrant. There are amateur artists all over selling any kind of traditional arts and crafts. For the sake of efficiency, I'd recommend Kumasi's National Cultural Center for your art and souvenir shopping fix. In the Cultural Center, you will find a wide variety of expertly skilled artisans with permanent shops that not only display their refined work, but also demonstrate how these traditional crafts are made. You can find wood work, kente cloth weaving, pottery, goldsmithing, paintings, and much more. During the summer for about 6-8 weeks, local artists from the city augment the crafts in the Cultural Center with their own wares (a perfect place to hone your bargaining skills).


One of Philip's pieces

Perhaps this is a result of my sister's influence on me, but of all of the traditional crafts I've come across in Ghana, the paintings created a unique impression on me. Although most of the paintings depict seemingly ordinary facets of Ghanaian life and culture, they truly are reflective of the Ghanaian spirit. Each painting is a kaleidoscope of colors and perfect blend of broad brush strokes and detailed minutia that seems to artfully capture the essence of Ghana. The subject of a painting may just be a single woman carrying a pot on top of her head and a baby on her back, but leaping off the painting is a tangible energy--a movement that draws you in.


Outside Philip's shop at the National Cultural Center in Kumasi

Since the National Cultural Center is just across the street from the Clinical Student's Hostel, I have had several opportunities to not just stop by to enjoy the beautiful paintings, but I've had the fortune of meeting the talent behind these masterpieces. My favorite artists are Philip and Bernard Mensah. I have picked up a few of their pieces to bring the Ghanaian spirit back to the US with me.

I may still be searching for my talent since artistry completely passed over me, but these artists in Ghana clearly have a talent worth sharing. If you are interested in any of their work, you can contact them directly: Philip (popg26@gmail.com) and Bernard Mensah (kwaboama@yahoo.com).