In Fall 2015, Loyola University Chicago medical student, Alexis Steinmetz, traveled to Ghana with the help of the LUC Institute of Public Health. What follows are excerpts from her experience.
Well, I’ve made it through the first week! What a whirlwind. Let’s see…
So my flights getting to Accra (the capital) were all pretty smooth sailing. I felt like I actually paid a price for the several weeks off from decent exercise I took for boards study; my back was not happy after an overnight flight to Amsterdam! Good news is, free wine and movies and warm dinner helped immensely.
At the airport in Amsterdam, I found myself having a long conversation with a nun from India, Sr. Regina. Turns out she has worked in Ghana for 10 years setting up some rural health centers. She was wonderfully kind, but has definitely seen her years of hard work, and she spoke rather sadly about the reality of medicine in Ghana. Her hospital is a small district hospital about 7 hours north from Kumasi (where I am). She invited me out to work/learn/etc, but warned me that “you might not learn much. We are less of a treatment center and more of a place for people to come and die peacefully.” She estimated that about 80-90% of their patients die, partially because they present so late with such severe disease, and then the resources are simply not there (not even running water—so they collect in basins during rainy season and are careful with its use during dry season). Sometimes they can refer people to Kumasi (our hospital is a teaching hospital and a referral center); however, in Kumasi we only admit patients to the ward who have the potential to improve. In the US, you are admitted based on how ill you are. Here, where beds and medicines are limited, you are admitted if the beds and medicines are going to impact your prognosis AND if you can pay for it.
On a lighter note, Sr. Regina made sure I made it to my hotel in Accra and offered lodging at their guest house whenever I needed it. Amazing woman. She also surprised me by revealing that her 2 allotted suitcases were full of pears to bring back to her village in Ghana instead of clothes. That night, I slept in a plush Holiday Inn in Accra with a bunch of Ghanaian businessmen and a few other obrunis (technically means “foreigners”, but really means “white people”). The next day I headed to departures to buy a ticket to fly from Accra to Kumasi. I couldn’t buy my ticket online, and I had read that you had to pay cash at the airport. THAT was an interesting afternoon. I walk into this fairly small room and people are coming up to me, “Hello!!!!! Do you need a flight???? Where are you going??? Here I’ll take your bags, here come here, follow me here, now stand there, okay wait here…Madam Obruni? Hello? Here, stand here.” At one point I must have looked so silly, standing there in a long skirt and clutching my guitar like someone straight from the 70s, leaving home for the first time.
Driving through Kumasi that first day felt…familiar. It reminds me of Uganda—a bustling, busy, dusty place full of little shanty stands selling everything you can imagine, from clothing irons to pig legs (same store, by the way). We arrived at the housing complex, which is part of the large hospital campus. There are apartments and dorms for doctors, residents, medical students, house staff, etc.
My room is quaint, and pretty similar to a dorm room in the US! The water runs most of the time (although it’s been off for a day and a half now) and electricity is better here than in Accra, I’m told. I have a little mini fridge and a hot plate to cook on. 🙂 I’m even planning to go to town this week and see if I can get a pillow or two to decorate, they’re about $2 USD each and could really spruce up the place.
The first few days I was still trying to figure out where to buy things, so I ate on campus at a little stand with chairs outside to sit and eat. I ordered the special of the day and sat down. It’s customary to eat everything with your hands, including rice and thick stew (which is what I was eating). The girls at the restaurant were delighted at my attempt to ask how they were doing in Twi (the local language), and when I shook the hand of a fellow patron she exclaimed, “Such soft hands!! Everyone, come and feel!!” Which they did, of course. Haha. One girl asked if I had to be careful outside so that my fair skin didn’t tear. A few minutes later the same woman tapped me on the arm and said gently, “Only eat with your right hand, sistah!” Oops! The left hand is the dirty hand, and I imagined the girls giggling behind me saying, “Someone please help the obruni!! She’s eating with her poop hand!!”
I am very excited about the projects I’m working on. For the first, we are surveying people who are known to be infected with Hepatitis C to talk to them about risk behaviors. We’re in the process of getting it moving. Also, my supervisor here asked if I’d be interested doing a clinical audit of patients who are admitted to the ward with HIV (say, over a 3 month period), to record their presentation, hospital course, treatment, and outcome. We talked about looking solely at central nervous system manifestations vs. all presentations, and he said we could find a Ghanaian student to work with me. He said this would be useful information for the department and also a good experience for me, and so it seems very worthwhile. The research work is a nice break from the hot and crowded wards, and it also gives me a chance to feel like I’m working on something that might…matter, in terms of the bigger picture.
I was actually supposed to start on the Wards yesterday, but I had my first run-in with GI indigestion. Oy! I think I’ve been a little overzealous to try local foods! I made friends with 2 anesthesiologist students staying here at the dorm, and they have cooked me at least 3 wonderful meals. SO GOOD!! And then I met some of their local friends, who all offered me various nuts and things to try…oh dear. I think I shocked my system a bit, with all the banku, fufu, and palm nut soup. Fish and meat, too. Especially since back in the US I am about 90% vegetarian, ha…Good news is that it was a bit improved today, and in the US, some people pay good money for a colon cleanse, right?? And I think I won’t touch palm nut soup for a long time.
I can’t help but sometimes feel frustrated with the meaning carried by white skin, and of the way it makes me stand out as someone clearly not from here. My cousin is an expat and has traveled extensively as a lecturer, and I discussed this with her this week. She said that even when she was living in Hong Kong she never felt out of place, never felt like an “other”, and even scrutinized my use of the term. She brought up Orientalism and Edward Said. Hmm, yes, true…I’m not the ‘other’, I’m in the group of Western privileged that creates the concept of other (and then uses it against them!). And of course, I know we are a human people—and that we share the most basic needs for connection, belonging, and love. I enjoy relating to people simply because at the end of the day, we’re all just trying to live and make some sense of the messiness of human existence. But I am still a foreigner here in Ghana, and however welcome to a new place I feel, it takes me a bit of adjustment to establish a genuine sense of belonging. Maybe “other” isn’t the best word for my experience…maybe I’ll just stick with obruni? 🙂
I try, as an obruni, to look at a country, a people, a community—as individuals with souls and a way of life that is meaningful, valuable and important. Not to patronize people with Americanized pity for their differences. But I also think almost any person with a conscience who travels to a place ridden with almost unfathomable poverty, and then walks through the hospital ward has to feel some level of guilt and anger. And confusion. How is this possible? Who let this happen? Did I let this happen? What can be done and how should it be done? I think this is about human suffering; it’s not necessarily just an ethnocentric Western view of looking at “poor Africans” (which of course is another problem entirely). No, this is different—this is about a young woman and her baby dying of AIDS in an era of effective antiretrovirals. I feel these same sentiments working downtown Chicago, in a soup kitchen, when a man asks me if he can have an extra scoop of spaghetti because he has another kid at home, and I find myself frozen—who I am to decide how many scoops of cheap pasta this family gets?? How is this possible? Who let this happen? Did I let this happen? What can be done and how should it be done? I can’t go my life giving Tylenol to people dying of AIDS and scooping noodles for the homeless—I won’t survive it–there has to be something bigger. I mean this in the sense that…there has to be a way to understand and address the greater issues at hand. I mean, we know there is–there are people all over the world trying—I just have to find some that I can stand behind, and get to work (perhaps this is what brings me to Ghana..). And maybe I’ll come up with a few innovative ideas of my own, eventually. I have faith in the power of defiance and perseverance, because, what else is there?
In the end…maybe Amartya Sen said it better than I can, in the foreward to one of Paul Farmer’s books:
“How can we come to terms with the extensive presence of such adversity – the most basic privation from which human beings suffer? Do we see it simply as a human predicament – an inescapable result of the frailty of our existence? That would be correct had these sufferings really been inescapable, but they are far from that. Preventable diseases can indeed be prevented, curable ailments can certainly be cured, and controllable maladies call out for control. Rather than lamenting the adversity of nature, we have to look for a better comprehension of the social causes of horror and also of our tolerance of societal abominations.”
I realized I haven’t really talked about my daily life at the hospital. So let’s see…
Each day I walk the long, arduous, uphill journey of about 100 yards (hehe) to the hospital from my housing. I devote some days to research, which means I spend my day in the lovely air-conditioned office of Dr. Phillips (my supervisor) or I find some company in one of the various labs where my friends work. Thursdays are teaching rounds and presentations with the team (this week was my turn to give a lecture on sepsis), and Saturdays are our “duty days” where we admit patients from the ED to the ward. Some days I do a bit of both–help on rounds in the morning and then head to the research office in the afternoon. My medicine team works 7 days a week! I guess this means I can’t complain about work hour restrictions for residents in the US anymore??!
After 5 weeks I called uncle and took a few weekends off. My schedule is often mixed with other comings and goings as well. Earlier last week I went to a district hospital about an hour and a half away with my attending physician for a lecture and to see some patients with an ulcerating bacterial infection that is endemic here. Friday I shadowed an American ophthalmologist who is here helping with cataract surgeries and doing corneal transplants–truly amazing work. One of our patients was a 65 year-old man who lost his sight nearly 10 years ago from bilateral cataracts. After traveling nearly 7 hours to get to the hospital, he laid on his hospital bed trembling and moving his legs restlessly. I asked him if he was okay, and he reached up for my arm, “Madam, madam.” He spoke slow but clear English, “Madam, the doctor said he can fix my eyes—that, that I will see! Do you really believe him?? (shaking my arm) Do you?? Tell me, is it true??” This blind man, with pupils the color of opals from cataracts, tugging on my arm…he reminded me why I love medicine and why I believe in working for health justice. When I left him he called after me, “Pray for me please, Madam! By God’s grace…maybe I will see again!” Needless to say…it was a wonderful day. It even turns out that the American doctor I was shadowing had trained with a physician in Nepal who I had read about a few years ago. One of my favorite parts of being in a central hospital like Komfo Anokye is that I’ve been able to meet physicians, researchers, and students from all over the globe who share some of my visions for health justice. The projects and people who have awed and inspired me no longer seem so far away!! After this prolonged adolescent of being a student for two and a half decades, it’s really nice to sit in a staff lounge and talk about surgical campaigns in India and Ethiopia. I’m still waiting to wake up from a daydream!!
Being at a teaching hospital in Africa has also allowed me to learn about medicine in an entirely different context. The level of clinical reasoning and the cost effective attitude of both my seniors and peers far exceed any of my training. In the US we have “routine labs”, and on the general medicine ward we can easily spend $1,000 USD on each patient every morning without blinking (even when the tests are not always completely necessary, like a repeat blood count on someone who is clinically improving from pneumonia). That would never happen here. Money management and resource allocation are carefully calculated and taught. My house officers (residents) could tell you the cost of a CT scan and most antibiotics—trade name, generic version, Chinese version. They can rattle off the total cost of a pneumonia work up, and then know the order of priority if the patient can’t afford all of it. Of course, this way isn’t necessarily done because it’s always better, it is done because patients’ have to pay for care and they can’t afford much.
One day I asked my resident how she decides which patients get a lab test called an arterial blood gas (we do them almost daily on ICU patients in the States). She replied, “Why do I need to draw this woman’s blood to tell me what I already know? Of course she’s acidotic, watch her breathe. Do I want to use $6 USD of her $20 to learn the pH of her blood? She’s panting, I bet it’s 7.1. And if you look at her eyes and her hands you can tell she’s not anemic or jaundiced, so her hemoglobin is probably at least 10 and her bilirubin isn’t my main concern”. I’m obviously impressed, and we save the money and the tests for the patients who need it. The clinical exam is the main diagnostic tool–labs and imaging are used when the exam and history are not enough. I’m learning how to diagnose conditions such atrial fibrillation or liver disease, as well as their etiologies, from a history and physical. We even talk about the statistics involved—if certain physical exam signs are not present, what are the chances this patient really has bile duct obstruction? What else could it be?
But perhaps inevitably, seeing a lot of suffering and death has been difficult for me. I felt it rather acutely around mid-October, after I’d been here a few weeks and the excitement of my arrival started to wear off. I just didn’t really want to go to the wards as much anymore. I even started to avoid them—offering to help my friend discuss his research proposal or take a trip into town to run errands. Part of it is easily the heaviness of seeing people suffering from diseases that are completely preventable and treatable. I realized that at least in the US, we can always tell family members, “I’m so sorry. I can assure you that we’ll do everything we can, and that your loved one will not be in pain”. I can’t say either of those things here, and mean it. I could say, “I’m so sorry. I can assure you we’ll do whatever you can afford, and, as you can see, your loved one will be in a great deal of pain.” One day our team stood around the bed of young man my age who was in kidney failure. He laid in bed without looking at us. “Can he afford dialysis?” our attending asked the team. “No sir.” No one mentions the idea of a kidney transplant, as they’re not even done in this country. My attending sighed, “My final diagnosis for this patient…is that he is poor.” And we fill out his discharge papers, and I wonder if the patient grasps what just happened. I barely do.
Part of the problem–aside from poverty and resource constraints–is that people present to the hospital very late in their illnesses. Many people are afraid to come to the hospital, and our building, “D Block” is known as the “D for Death and Departures Block” by the community. You can’t blame them—many patients present so late that there is nothing left to be done, and I spend the next few weeks watching them slowly deteriorate. Often we have patients come to the ED from hours away and I’m genuinely amazed they are still alive. The human body—not to mention the spirit—is incredibly resilient. We stand around the bed quietly, and my attending will say what he always says in these moments: “I’ve seen people like this get better. All we can do is pray for her tonight when we are warm in our beds.” We nod in agreement, and move to the next patient. I have yet to see one of those such patients get better, but I look forward to the day I do. That way when he says it, I will believe it.
I guess in a way sometimes I feel like knowledge here is often a burden. The heaviness of knowing when people are not going to get better is different in Africa than in the US. In the US it’s easier to make peace with this—because we’ve exhausted every test and therapy, because the patient is quietly sleeping with pain medications and sedation, and the family can be a part of the decision of how long to prolong his or her life. The whole thing has a sense of stark sterility and an illusion of human control to it. Stand in front of the same patient in Africa, and you might find yourself despising your own knowledge, wondering 100 ifs…if we had that medication, if this person could afford that other test, if we were standing in Loyola hospital right now…Meanwhile, the patient lies on a dirty mattress in a crowded hospital, gasping to breathe and moaning in pain. There’s nothing peaceful about that death, nothing to ease your mind to let you know you’ve “done all you can”. You did what was available to you from a completely unjust system that allows some people a life of luxury and many more to lay here on dirty mattresses. I’m afraid that doesn’t help me sleep at night. And this isn’t even the poorest region or country! Ey! What are we to do? I still don’t know yet. When I’m 80 years old and bored I’m going to travel the world interviewing strangers on the bus and ask, “Tell me, what is humanity?”
One example, from my journal:
I spent the night at the hospital last night for “night cover” duty. We had to certify some patients during the shift, which is to say we had to declare them deceased. We’d be setting up an IV line or drawing blood on a patient when the nurse would call my resident to say someone died on the 3rd floor, could we stop by after? The ward is muggy and dim, 5 patients in this row, one with his face covered by a cloth. We walk over, briefly examine him, and cover him back up. My resident is chatting idly while my mind is wrapped in death (what happened when he died? Who noticed first? How do the other people in the beds surrounding him feel about this body, just laying there with a cloth over his face?). Then my resident elbows me to look at the television set by the nurses’ desk. American Sniper is playing. “A movie from your country”, he comments. I nod, “Have you seen it? I ask. “No,” he answers, “but let me guess what happens: The American saves the world?”
I think the hardest parts about being here in Ghana are the moments of homesickness combined with this kind of existentialism. Sometimes I feel a little suffocated by the city—it loses its charm, on those days. It’s noisy and congested, and full of smoke from diesel fuel. The megaphones in town suddenly feel more offensive than amusing. Open sewers run through the city and when it rains it all seems worse—they overflow and add to the red dirt creating this sort of sludge that seems to stick to everything. And everyone at home is living their lives as before, and for a bit I almost feel like I don’t exist.
So sometimes I get buried in that…I spend an hour doing mental gymnastics—Is my time useful? Does any of this matter? What do I want to do with my life? What kind of medicine will I practice, and where? Some of this reflection I enjoy, but it can wear a person down.
Let’s get back to the fun parts, shall we? Because those are certainly abundant. Overall life here has been good. I’m trying harder to find things that remind me of the beauty in life. This last weekend I went hiking in the jungle with a German student and a park ranger named Amoah who tore us a path through thick brush with a machete. Sunday I met some friends at a fancy hotel and spent the afternoon swimming and eating grilled cheese. On Monday an older gentleman taught me a respectful way of addressing people that means, “my loved one”, which earned me a few extra smiles and extended handshakes on the ward. On Tuesday I was invited to dinner at the house of a local chief, who is friends with my friend’s grandfather, and we ate mangoes from his tree and drank red wine while he told the story of how his brother once met the Pope. Twice this week I’ve had the opportunity to sit and color with the sweetest 4 year old in the world, a beautiful little human with HIV and TB who, after dinner, reminds her mom that it is time for her medications and helps her foster brother take his, too. Tonight I did laundry and hung it out to dry under the light of the full moon, with crickets chirping around me. Yes…Ghana continues to inspire, challenge, and humble me.