Looking Beyond the Surface

Half Way There Still is Not Enough.
October, 18, 2009

Sitting down to see patients in whatever community it may be, grants an unparalleled privilege. For this week I have gained access to the inner workings of the villages buried off the main road from Accra to Kumasi in Ghana. One can only see and know so much in week, I cannot claim to know anything more than that.

A few simple reflections: People are the same wherever you go, it is there expectations that change. It seems that poverty in Ghana, Mexico, India and US alike lowers one’s expectations, inversely increasing gratitude to the care received. The gratitude here is immense, for that I am grateful. However, the poverty, limited access, limited resources and lack of education have proven to be far more challenging than the illnesses I see.

Within my first day I learned that Malaria is rampant. There are four different types, we learned in medical school. Falcipurum is the kind you never want to have, it will break down your blood and penetrate your brain. That is the one they have here. My first patient: vomiting and fever. Diagnosis: Malaria. My second patient cough and fever. Diagnosis: Malaria. My third patient: headache and fever. Diagnosis: Malaria. You get the picture.

We sat down with the community health educators this week and learned about the non-scientific science behind the persistent, rampant spread of malaria. For it is not the parasite itself that is as pervasive as the lack of education. “The government provides mosquito nets and mosquito repellent at a small cost. Most of the families have them.” MaVic (the head nurse here) informed me. “They all sit around there homes unused.” I was caught by surprise and it really didn’t make sense at first glance…until we spoke to the community workers:

“Some don’t know how to put it up,” one man said.
“They don’t know what time of day to use it,” a woman added.
“A lot of the nets are old and have holes in them,” a third voice piped up.
“When our kids sit inside the net, they want us to sit with them, but we have to cook dinner. Then what do we do?” a man inquired.
Okay now we’re getting somewhere.

Like the available access to mosquito nets, I was surprised and impressed to learn that the government provides insurance for everyone at low cost. Ah ha, Ghana accomplished in 1989 what we resist, scream and bark about in the US today...
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A 24 year old came into see us early this week.
“My stomach and chest hurts,” he explained in Twi. Hawa, one of the nurse’s assistants, translated for me.
So we run the gamut of chest pain, abdominal pain questions English to Twi; Twi to English. This chap sounds very anxious I think and explain to him.
“…and I have pus coming from my penis.” He adds.
Okay. I don’t have computer screen with seven red blinking patients waiting for me in rooms. I can take my time. I take a deep breath. We run the gamut of sexual activity questions.
“I would like to treat him for UTI, Chlamydia and Gonorrhea,” I explain.
“Doctor, we have Doxycylcine and Ciprofloxacin.” Hawa explains.
“Great. What about Ceftriaxone to treat the Gonorrhea?” I ask.
“That we don’t have. He will have to get it from the pharmacy.” Hawa says.
“Ok, will his insurance cover it?” I ask.
“He doesn’t have any.” Hawa informs.

I take a step back. We have a government that insures, mostly subsidized and still we have uninsured patients? The 24 year old male is not the only one. There are many that follow after him. I am once again scratching my head. So I ask the nurse’s assistants to explain:
“They can only go on Fridays after they get paid from the Friday Market.” Says Hawa.
“Even then, they have to take an unpaid day off work and pay for transport to Ejisu (the town thirty minutes away). When they get there they don’t know what to do.” Jan adds.

Our chap came back with the ceftriaxone so we could give the injection. I asked to check him for HIV more out of habit than anything: “where one STD lurks often do many,” we were always taught in Adolescent Fellowship.

“Doctor, his test came back positive. I checked it twice.” Kingsley, the “labman” informed.
My heart sank, as did MaVics. We brought him in to talk to him. MaVic did the talking in Twi. “I have asked him why he is so worried,” MaVic informed. “He says that he completed secondary school, but has no money to go to college or learn a proper trade. His family cannot provide the support he needs.” She said.

She went on to tell him the results of his test. I sat and watched, not understanding what was said. I watched this young 24 year-old man engage in MaVic’s discussion, then I saw him breath rapidly, then I saw him disengage. “He is asking for water. Please fetch him some water.” MaVic Asked.
Our, already, anxious young man’s world just darkened. All we could do was inform him of it, refer him and hope he goes.

I am grateful for MaVic as the her name (Mama Victoria), the position she holds in this clinic and the presence she commands creates the ethereal community Mother many of the patients need. She will be the mother that the 24 year old chap needs right now as we continue to follow him.

I asked MaVic about the stigma attached to HIV in this community.
She informed me that it has improved tremendously with the onset of better and cheaper treatment (much due to Clinton’s Global Initiative). “The men no longer immediately divorce their wives or wives divorce their husbands as they once did,” MaVic informed. “They know that they can still go on to have a full life.”

The cases are so many, every patient that walks in has so much to teach me. This week I go to a nearby town, Agogo, to follow and learn about local disease and treatment in Agogo Hospital. The best part about it: internet access baby!