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.

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

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!

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.

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.

If Coca-Cola and Guinness Can Get There, Then What About Health Care?

On Wednesday (June 29), I joined the Amansie West Ghana Health Services District Director and his field team on a site visit to one of the community health centers that refers patients to St. Martin’s Hospital in Agroyesum. St. Martin’s Hospital is the only hospital, only facility with physicians, and only facility staffed with medical personnel that are prepared to handle obstetric emergencies in the entire district of Amansie West (over 100,000 people). Since I was unable to get a good grasp from my conversations and interviews with midwives and other staff as to how far some of these pregnant women travel to seek care at St. Martin’s Hospital, I jumped at this chance to find out for myself.

My first indication that this trip would be a long and bumpy one was when the District Director said he’d need to borrow a truck from St. Martin’s Hospital to get us there. We were traveling to the Keniago sub-district to visit the Nunipankyeremia Community Health Planning and Services Zone (CHPS pronounced “chips”). A CHPS zone is a health facility that is located “at the door steps of clients” and is either staffed by a nurse, midwife, or medical assistant trained to provide basic health care and know when to refer patients to the hospital if necessary. The Amansie West District has seven sub-districts and each sub-district has an average of three community health facilities.

Everyone at St. Martin’s hospital has said that the roads to Agroyesum were terrible. However, they neglected to mention that a lot of the people coming to their hospital do not have the luxury of even dirt or rocky roads. I discovered a new level of terrible on Wednesday. These roads were not just unpaved, but at least thirty percent of the trip was driving through a riverbed that was nearly all dried up. Every time we approached a large puddle, I’d begin to picture myself standing behind the truck and pushing it with my weak little arms. Thankfully, those images remained images. I’m a relatively healthy young woman. Though after two and a half hours of being tossed up, down, and every which way to get to Nunipankyremia, I felt rattled and exhausted. Just imagine an eclamptic pregnant woman in labor seizing on that same journey in the middle of the night. Health care, it’s really not easy to come by.



Along the way to Nunipankyremia, we passed through several other villages. Some of them had some sort of community health post like a CHPS zone and some were completely without. But, nearly every village had at least one tiny convenience store that carried Coca-Cola and Guinness. Does this strike anyone else as strange? I bet access to a reliable source of electricity and water is not as reliable as finding Coca-Cola and Guinness whenever you want it. How did Coca-Cola and Guinness manage to penetrate every remote village in Ghana? Is it their marketing strategy (they do have the best World Cup commercials) or is it the product itself? If Coca-Cola and Guinness can reliably be transported to these remote villages, why can’t quality health care follow suit?

Our arrival at Nunipankyremia prompted a town meeting. Leaders and citizens of the village all gathered in the “main square” of the village to voice their concerns and grievances about the CHPS zone health facility. Some of these included more trained staff who could treat trauma cases and increase the amount of cases that don’t need to be referred to St. Martin’s Hospital and transportation support for emergency transport. My impression from the exchange at the meeting is that one of the major challenges that Ghana’s health care system faces is one of human capacity (topic of my research). There simply are not enough trained mid-level providers (nurses, midwives, medical assistants) and higher-level providers such as physicians and specialists at the district level and rural communities. They are still concentrated in teaching hospitals of the bigger cities. While in the US we are facing a supply generated problem of too much heath care (a conclusion of the Dartmouth Atlas Study), Ghana’s current human capacity building strategy tries to leverage the supply-driven economy of health care to its advantage. If you build a community health facility, staff it with at least one trained provider, then the patients will come and the overall health of the community will improve. But, it’s not that easy to recruit trained providers to work in these community health facilities.

I think the reason why access to Coca-Cola and Guinness is so easy to come by in relative terms is due to the product’s self-sufficiency. Bottles of the beverages require a minimum amount of infrastructural support to be spread and maintained at the rural villages. Health care providers are a completely different story. What kinds of incentives are there for a health care professional to move and work in a rural community where basic aspects of daily life become prohibitive challenges? Here’s what would go through my mind as a physician if I was asked to practice in Nunipankyremia:

Poor Roads

• Will I be able to travel to and from the village safely and in a timely way?
  
• Will my patients be able to travel to and from the village in case of an emergency?
  
• How far away is the hospital I will send difficult cases to?
  
• How far will my patients be traveling to see me?
  
• Do I have a car?

Electricity

• How often do power outages occur and how long is each episode?
  
• What kinds of electricity dependent medical equipment and accessory equipment (i.e. computers) will be able to withstand daily power outages? In other words, what kind of damage and electrical equipment turnover will I have to manage due to the power outages?

Accommodations

• Where will I live? If in the village, how close will I be to the health facility so that I can rush to handle emergencies?
  
• What kind of amenities will my living accommodation have?

Water

• How can I maintain a level of sanitation that I am comfortable with if access to water is inconsistent?

Personal Life

• Will my family move with me to this village or will I commute back to Kumasi (4 hour + journey) to see my family?
  
• Where are food and other daily living products purchased? Are they readily available in the village?
  
• Is there a competitive school nearby for my “children”?
  
• How well will my family and I integrate with the village?
  
• Is compensation for my work at minimum competitive to working in big cities?
  
• Will a job that is both fulfilling and competitive be available for my “husband”?
  Medical Practice
  
• Will I be able to provide the same type of quality care that I was trained to provide my patients given the lack of resources?
  
• Will I have enough experience to treat the disease burden of the village?
  
• What kind of medical and administrative support will I have in my practice in terms of staff?
  
• Will I have access to necessary medical equipment and pharmaceuticals?
  
• What is the literacy level of the population? Will a significant portion of my work include community outreach work to educate the village on how to recognize when to seek care?
  
• How will I be able to stay current with best practices and emerging medical knowledge?
  
• What kind of support will I have from the village and the Ghana Health Services in my work?
  
• What will the patient load be like? Can I take care of them all on my own?
  
• Will I have access to professional development opportunities?

And those are just the first few things that come to mind. Coca-Cola and Guinness as products sometimes don’t even need a fridge (depending on your beverage preferences). Until these infrastructural and professional considerations can be addressed, simply training more health care providers will not be enough to improve the health of the entire country. This is not a problem unique to Ghana. The US also faces difficulties in recruiting providers to practice in rural communities.



As a global community, we need to design a training and employment structure that not just provides incentives to work in rural communities, but also the infrastructural foundation to make health care in rural communities as self-sufficient as Coca-Cola. Then, as the Coca-Cola song Wavin’ Flag” says, the people of the world will be equipped with quality health care in their pockets and will have freedom…”just like a wav’in flag.”

So Obviously Preclinical

Total Mangos eaten: 5
Total Mosquito bites: 14

Since I’ve moved out to Agroyesum, I have been traveling back to Kumasi for the weekends to visit Erika. Erika has moved from the Kumasi Catering Rest (where we were staying in Kumasi before I moved to Agroyesum) to the Medical Students Hostels (where I will be staying when I return to Kumasi). We’ve traded our modern comforts of air conditioning and consistent water supply including hot water at the Catering Rest House, for a decent wireless internet connection throughout the dorm and the good company of both Ghanaian and other foreign medical students. Even though it’s stressful to worry if there will be water the next time we want to shower, it is a very welcome change to be friends with people our age rather than the old security guard at the Catering Rest House who requests that we bring him bread whenever we go out for dinner!

The Ghanaian medical education system works like this. Medical school is a total of six years and starts right after high school. Three years are spent doing preclinical work: anatomy, physiology, biochemistry, pathology, histology, pharmacology, etc and the students earn a bachelors of science equivalent degree. Then, the next three years are spent doing clinical training. The fourth year is junior clerkships: medicine and surgery rotations and then the fifth year is spent doing OB/GYN and peds. Then, in the last year the students do medicine and surgery again in their senior clerkships. Most of the students in the dorm we are staying in are rising fifth year students and rising sixth year students. So, they are about the same age as me, but know so much more medicine than I do!



In the last two weekends I have been in Kumasi, I have tagged along with the KNUST Medical Student’s Association on their “mini clinic” excursions. Mini clinics are like the health fairs that US medical students busy themselves with except that in Ghana, the mini clinics have a different purpose. In the US, most of the health fairs are for targeted populations (underprivileged or at risk populations for specific diseases and conditions) with a health education and health screening purpose. The mini clinics in Ghana have the added component of raising funds for a specific cause. The mini clinics are hosted at churches on Sundays. A short five minute presentation is made about the campaign cause. Then after the service, the medical students provide BP (blood pressure) and BMI measurements for free and the mini clinic participants then can pay for HIV, Hepatitis B, syphilis, and blood typing blood tests. The tests are provided and interpreted by lab technicians of MediLabs (Ghanaian third party diagnostic test company like Quest Diagnostics).The tests are cheaper than they would be in hospitals (3-5 Cedi per test of 10 Cedi for all of the tests). The medical students also sell watches for 5 Cedi to help raise funds for their campaign cause.



This year’s campaign is awareness of club foot and other birth defects. The traditional view is that if a child is born with club foot, then he/she has been cursed by demons and that there is nothing that can be done about it. The campaign is to increase awareness that club feet can be treated and I believe funds are raised to pay for corrections too. Last year, the campaign was raising awareness about childhood malaria.

The mini clinics are primarily staffed by rising fifth year students because they are the only ones who have some “free” time during these few months. The rising sixth year students are taking and preparing for exams and the rising fifth year students are taking community health classes aka fluff classes. After a year of rotations, taking BMI and BP is busy work. The rising fourth year students are itching to do consulting (more hardcore diagnostics and treatment). As the only preclinical student in the bunch with another year of preclinical lectures ahead of me, I’m still very excited by the opportunity to take BPs since the number of times I’ve interacted with a patient can still be counted on my fingers. One of the rising fourth year students is an aspiring surgeon and has already begun to nurture his surgeon mindset by saying that he would not take BPs because surgeons will never have to take BP!

I’ve noticed that we take BP a little differently than they do in Ghana. After placement of the BP cuff, the Ghanaian medical students slowly inflate the cuff while feeling for the radial pulse in order to get a rough estimate of the systolic blood pressure. They then inflate the cuff only a little farther, release the pressure, and begin to listen for systolic and diastolic pressures. At Michigan, we were taught to inflate the cuff to about 220 and then slowly release the pressure while listening for systolic and diastolic pressures. Hm…anyone with a stronger clinical background want to comment on the advantages and disadvantages of the two methods?

I do feel a little uncomfortable at these mini clinics because I am the most inexperienced and I’m afraid the patients think I know much more than I actually do. I’m not even wearing a white coat, but perhaps my stethoscope wields a lot more power than I realize. I haven’t yet sensed that bring a obroni (corrected spelling) makes too much of a difference in interacting with the patients except for one drunk patient (what was he doing at church drunk?) who kept telling me that he wanted to die tomorrow and screaming “obroni” in my face as I tried to take his BP.

Despite my preclinical eagerness, I think I’d be ready to at least help interpret the BP measurements and turn them into some general health advice. The attitude of the rising fifth years is rubbing off on me!

Do You Speak China?

Despite China being heavily involved in a ton of infrastructural investments all around the continent of Africa, seeing someone with an East Asian background is a very rare occasion. On top of that, whenever I introduce myself to a Ghanaian, they are surprised that I have the “Christian” name (Eva) and have an American accent. Perhaps it’s too vain to think this way, but whenever this happens, I’m not offended. Instead, I feel almost proud that I’m bringing what it means to be an American Born Chinese (ABC) to Ghana.

I was prepared to explain my appearance to Ghanaians, but I thought my Chinese background would end there. Who knew that I’d be asked to use my Chinese while I’m in Ghana!

During an early car ride back to Kumasi in the new truck of one of the St. Martin’s hospital employees, one of the passengers found a first aid kit in the glove compartment. The first aid kit must have been manufactured in China, because there was Chinese on the packaging of all of the kit contents. The majority of the contents were easily identified despite the foreign packaging: Band-Aids, surgical tape, cotton balls, gauze, etc. But, there were two medications in the kit that were less straightforward. After examining the two boxes for a long time, the passenger turns to me and asks, “Do you read China?” I’m immediately startled from my dozing by his question and try to clear my head as I stare at the Chinese characters on the instructions of the two drugs. I recognized all of the characters for the first one: an analgesic cream, but the second one was much harder to figure out since it has been at least two years since my last Chinese class and I’m not the best at reading simplified Chinese. I think the second one was a blood clotting drug to stop bleeding.

As we drove down the bumpy road towards Kumasi, I hoped not only that we wouldn’t get into a car accident, but also that no injuries in the potential car accident would result in massive bleeding! I definitely didn’t trust my Chinese enough to rely on that drug to save lives.

Perhaps I’m Destined to be a Surgeon: C-Sections, Hernias, and Buruli Ulcers, Oh My!

I think I’m in the minority in that I am a med school student and I have no idea what I want to specialize in. I’m under the impression that all of my classmates know that neurosurgery, cardiology, infectious diseases, pediatrics, or urology is their calling and I still can’t even make the decision between medicine and surgery. However, my time here at Agroyesum in St Martin’s Hospital may change that.

In addition to my research work, the physicians and staff at St. Martin’s have been kind enough to let me shadow and observe their work. I have been in the maternity wards to watch deliveries, and in the pediatrics ward to see the buruli ulcers on children. But, without a doubt, my favorite place to be in St. Martin’s hospital is the operating theater.

It could be because that this is the only area of the hospital with air conditioning, or the only place I feel clean, or that surgery is the only area of medicine that I feel confident enough be able to follow the entire procedure (yeah for anatomy!). In just three days, I shadowed three different attendings and got to see a caesarean section, a breast biopsy, the repair and suturing of a severe mouth wound, an inguinal hernia repair, an incisional hernia repair, an abscess debridement, and four skin grafts to repair buruli ulcers. The technical precision and clinical creativity of each procedure, no matter how routine, absolutely fascinated me.

Even though there is a standard best practice for surgical procedures from administration of anesthesia all the way through to the close of the surgery, each body seems to contain within it a different collection of details as if carefully selected by a curator with a keen eye. This degree of human variation affects all of those standard best practices. How quickly will each individual metabolize the anesthesia? How much subcutaneous fat does each individual have? How much blood will the individual lose throughout the surgery? What kind of sutures would promote healing and minimal scaring? These are all considerations and decisions that surgeons must calmly, quietly, and efficiently make while standing with an individual’s health and life in their hands. Isn’t that awesome?

There is just enough uncertainty within the certainty of surgery to keep things interesting. And the best part is that at the end of the procedure, after you have finished closing, you have the satisfaction of contributing to the health of the individual’s life with your own hands.

What would totally convince me is if I was asked to assist by holding onto a retractor or even helping with cutting through the subcutaneous fat. How could you sit in an office all day when you have this excitement happening in the operating room?

Agroyesum: A Cutting for Stone Experience

Number of mangos consumed: 3

Number of mosquito bites: 1

I left Kumasi on Wednesday (June 16) to officially start my project in Agroyesum. I will be based out of Agroyesum for the next three weeks conducting facility assessments and interviewing physicians and administrators at St. Martin’s Hospital (Agroyeseum), St. Michael’s Hospital (Jachie-Pramso), and Bekwai Government Hospital. My research will specifically focus on the changes that have occurred since the arrival of permanent obstetricians at these district hospitals and compare these clinical and management practices as well as maternal mortality outcomes with district hospitals who have not yet received permanent obstetricians. I will also be designing a complications register to implement at Agroyesum and hopefully the 7 other sites I will be visiting this summer to help the Ghana Health Services collect data on the number and types of complications these hospitals see on a day to day basis. This complications register will help hospital staff and the Ghana Health Services strategically target areas for improvement in the quality of clinical care and clinical management of these obstetrical complications.

Agroyesum is about a 1.5 hour drive south of Kumasi. It takes about 45 minutes on nice paved roads, and then another very bumpy 45 minutes on rugged clay dirt roads to get to the district hospital. Stay tuned for videos! I really don’t know how the tro-tros (bus/minivans) make it out here. These road are also not lit, so if there is an emergency after 6PM, I don’t know how drivers can navigate these roads! Questions that I need to answer by the end of my assessment! I think Agroyesum is located at a higher altitude or perhaps just being far removed from the city and in the trees makes it feel a little cooler than Kumasi. The drive to Agroyesum, though bumpy, was breathtaking. It is so lush and green. The best analogy and probably embarrassingly most inaccurate analogy I can think of is the scenes from the movie “Mighty Joe Young”-- the movie with Charlize Theron and this huge gorilla. Just think of that, and that’s where I am!



Before moving out to Agroyesum, I was lucky enough to do a quick day visit last Friday (June 12) to get familiar with the facility and meet the entire staff. As I entered through the hospital gates, I felt like I was stepping into the book Cutting for Stone by Dr. Abraham Verghese. Cutting for Stone is a rich fictional narrative that follows the lives of Siamese twins, Marion and Shiva, set in Mission Hospital, a district hospital in Addis Ababa, Ethiopia. Like Mission Hospital, St. Martin’s Hospital is a Catholic hospital and the staff are managed by a Matron. The Matron at St. Martin’s hospital is Sister Helen. She is authoritative, maternal, and sweet. I feel so well taken care of when I am with Matron.

The hospital provides several different types of services and is much larger than I had expected. There are outpatient services with three consulting rooms, female and male wards, labor and delivery wards, two operating theaters, a pediatrics ward, physical therapy, lab facilities, x-ray facilities, a pharmacy, nutrition services, and they are expanding to create an emergency medicine ward. As Matron and I walked around the hospital, I couldn’t help but think about the characters in Cutting for Stone (I highly recommend the book and am thinking of sending St. Martin’s Hospital a copy). When Matron asked me what I thought of the hospital, I kept saying, “This was wonderful!” She just laughed at my enthusiasm. I then explained to her that I was a preclinical medical student, so just being in a hospital is a novel experience. She then promised that I’d be able to see all sorts of different cases that I could learn much from. I am so glad I packed some scrubs with me!!!



To tickle my imagination even more, I am staying at St. Martin’s Hospitals as a guest of the hospital administrator, who has the most adorable twin sons (picture pending). It’s like I’m guest at Ghosh and Hema’s house! The room I am staying in is very nice and has everything I could have asked for. I have a bed, a sink, my own bathroom with a flushing toilet and shower (cold water only), a ceiling fan, and plenty of room to spread my stuff out. The windows don’t seem to be completely reliable in keeping mosquitoes out, so I set up my mosquito net. After taking my cold shower, I kept seeing tiny bugs flying towards me, so I have taken refuge in my bed under my mosquito net. I look absolutely ridiculous, but at least I feel more at ease while sitting with my bare legs exposed. I’m sure my courage to sit outside of my mosquito net will build as the days go by.

Wish me luck with my continued goal of not getting devoured by mosquitoes and my first day of real work tomorrow!

Wo kƆ he?

Wo kƆ he? = Where are you going?

To celebrate my last summer, I am going to Ghana! It'd be a shame to let Emily's ingenious blog title go to waste, so here it is: "Eva Ghana Wild."

I fly out in just two days to spend my summer doing clinical quality and management research on maternal mortality at six district hospitals in and around Kumasi. With cans of bug spray packed, I think I'm ready! This is my first trip to Ghana and my first time venturing out to Africa, so stay tuned for pictures, impressions, and hopefully not too many vignettes about embarrassing myself!

Psst...if you are in Ghana this summer, let me know!