Mission Diary 2010, Assin Praso and Adjoube, Ghana
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Ghana trip 2010
Our second mission in 2010 was to Ghana. We originally intended to return for a third time to Abetifi, a stronghold of the Presbyterian Church and home of the Presbyterian University College. Our gracious host, the Presbyterian Church, suggested another area where no eye-mission had ever been before. There were six of us from the United States. Mara Jeffries, a student from New Jersey, joined us for her first mission. Two nurses, Pamela Spranger and Marta Leirer, from Baltimore and San Jose respectively, brought expertise and experience gained from several previous missions. A third nurse, Chris McSherry, a Professor of Nursing at William Patterson University, was excited about her first mission. Two ophthalmologists, Donald Macdonald and our team leader, Judith Simon, rounded out the group. We were fortunate to have two Ghanaians join us too. Dr. Kennedy Opoku, an ophthalmologist who has trained with our group on several previous missions, and Ernest Kwaku, an accounting student who was on our team last year in Dormaa-Ahenkro, both made a long and arduous journey to be with us.
We got off to a rocky start on a hot summer day in June. One of our Ghanaian friends who had volunteered to transport us to the airport mysteriously did not show. We had to call another friend in the last minute and tie most of the bags on the roof of a jeep in the scorching heat – it was good warm-up for Africa. Fortunately the rest of the trip went smoothly. We were able to check in all15 of our 50 pound bags without a fee, courtesy of Delta Airlines. We always hold our breath at baggage claim, fearing not all bags will arrive with us and thus our mission will be compromised. When they all did, we all breathed a sigh of relief. The two large bags of eyeglasses, which were sent out ahead of time for our last year’s mission and disappeared on the way, also happily surfaced after nearly a year and were miraculously waiting for us on the airport.
The Presbyterian ministers, including Chairperson Emmanuel Agyei and Alex Sekyere and Chief Alfred Kissi welcomed us at the airport and transported us to our first location, Assin Praso. It is a small village with a population of 8000, about 4 hours drive from Accra, the capital. There is a small health clinic with a few nurses and a midwife, and this is where worked for a week. As we got out of the air-conditioned car, unbearable heat hit us – there was no AC anywhere and even the few fans did not work. There are no thermometers in Ghana and we never heard anyone discussing the weather. We envisioned two weeks ahead of us in unbearable heat and decided it was impossible to survive. But in the excitement of meeting our hosts and setting up our clinic and operating room, we acclimated to the ungodly heat very quickly.
We had a welcoming ceremony by the clinic staff and the ministers-with a printed “Programme of Activities” given to each of us! It is really surprising how strict social protocol is in Ghana-one would think that in such poverty being formal would not be important at all-but it is just the other way around.
As has been the case on each mission to Ghana, the Church provided for us in every way. The staff lived on site and some of them sacrifice their rooms for us. The food was plentiful and excellent. Also Reverend Emmanuel took it upon himself to personally look after us throughout our trip. In addition, Reverend Vincent Tekyi-Mills stayed and worked with us in Assin Praso. He prayed for us and said grace each meal, as well as said morning prayers with all the clinic patients, which always involved an offretory. He had the interesting habit of listening to prayers and music real aloud on his cellphone during meals, making conversation rather difficult at times!
Upon arrival we visited the village elders, as custom dictated. We had to shake hands with each of them, which was quite a lengthy process. Conversation was a bit limited, as none of them spoke English, only Twi, the local language there. The following day was Sunday, and we attended the local presby church’s mass. It was a bare concrete building without any decoration, the sides open to have ventilation. The preacher spoke in English in addition to Twi for our sake but we could not hear a single word as tropical rain fell incessantly (rainy season begins in April and ends in September) and the children’s choir sang and beat the drums throughout the service. As is the usual custom, there were three offratories, all involving a long song and dance on the way to giving an offering to the church.
We started clinic and surgeries on Monday and worked until Saturday. The routine was the same as on previous missions: Half of the group, the translators and the local nurses worked at the clinic, and the other half in the OR. In the clinic we selected the surgical patients, the rest received advice, eye drops and eyeglasses if they needed them. We saw many patients with glaucoma who were irreversibly blind; it was extremely demoralizing to tell each of them that nothing could be done.
Glaucoma care is virtually nonexistent in developing countries, including Ghana. It causes irreversible blindness because of high eye-pressures; it requires life-long therapy with eye drops. Surgery is also available but technically challenging, requires frequent follow-up, and does not improve vision. There are tens of thousands of people in Ghana alone blind from glaucoma, placing a huge burden on society. Even those patients who could afford to purchase the glaucoma drops go eventually blind, as there is no follow-up, education or understanding about the disease. Patients are just told briefly that they have glaucoma (no word exists in Twi for this), their pressure is high and they will eventually go blind unless they use eye drops. We diagnosed one of our clinic workers, a 28 year-old translator with advanced glaucoma, one of his eyes was already close to blindness. His story is typical: he was found to have glaucoma accidentally 5 years ago, during an exam for eye-trauma; was given drops which he eventually ran out of and never returned for follow-up. He started drops again a few years later, then he stopped them as they did not help with his vision. After seeing many patients, lots of them young, being blind from glaucoma during his week with us, he was visibly shaken and began anew a course of glaucoma drops.
The local eye-nurse referred us quite a few patients for cataract surgery, but less than half of them were surgical candidates. First we thought he was just poorly trained, but later we learned that lots of patients insisted on seeing the “American doctors”, hoping for a miracle cure even after he explained them nothing could be done. He also did not own an ophthalmoscope, and without one it is not possible to decide who needs surgery in many cases. We were pleased to donate an ophthalmoscope to him.
We also saw an 8 year old girl with a penetrating eye trauma; her eye needed to be removed. We referred her to the nearby hospital, 25 miles away, where the eye-nurse worked and where he could perform the surgery. We visited him on Saturday and saw the girl in the hospital. She was so anemic upon arrival from malaria and so severly malnourished she was close to dying. She needed transfusions, nutrition and malaria treatment to save her. Sadly loosing an eye was the least of her problems.
Dr Opoku, who finished his residency last year, joined us for the full 2 weeks. Prior to his ophthalmology residency he was a general doctor for several years, (as are all African specialists) and he was called upon frequently to handle medical problems, as he was the only doctor at the clinic. One day he examined a woman in labor for several days, and he decided she needed to be sent to the nearest hospital (about half hour away) for C-section, as the baby was in danger. After some commotion the ambulance was ready to go, but the baby started to emerge. The woman was hurriedly pushed into the clinic with her IV dragging after her on the ground, and she gave birth on the concrete floor of the clinic to the horror of some of our volunteers who observed the events.
One day we had a very embarrassing situation: The head nurse of the clinic announced that they ran out of money to feed us. Even that we gave our “donation” – enough money to cover all our expenses while in Ghana – to the minister on the first day, he never forwarded it to the clinic. After a few phone-calls the situation was solved, but we still had to lend money to the clinic as they did not have any cash and there is no bank in the village.
The reason why the clinic is “broke” is the malfunctioning National Health Insurance Scheme. It was introduced in 2004, and was a huge step towards providing at least some kind of health care to the majority of Ghanaians. Prior to this, only wealthy people could afford it. The insurance costs 10$/year per person, 20$/year per family, and most people are able to pay this much. By 2010 about 70% of the population was enrolled. It provides basic care for free, or with some “copay” introduced by local health care facilities, as the reimbursement does not fully cover their costs. For example for cataract surgery insured patients are expected to pay 50$ to cover surgical supplies; without insurance it is 200$. The government pays for this mainly from the sales tax. In 2009 a new government was elected whose priorities changed; it did not reimburse the clinics/hospitals for six months, spending the money allocated for health-care on other projects. Some facilities went on strike, refusing patient care altogether. The Adjoube clinic for instance had to borrow several thousand dollars to be able to operate, and after they threatened with a strike, they received 5% of the money the government owed. And so it continues…
On Sunday we packed up all our instruments and supplies and said goodbye to the clinic staff. We were driven to Adjoube, a small village about 3 hours east of Assin Praso. As we arrived, we saw a huge crowd on the streets, singing and dancing to loud music. We first thought there was a feast there coincidentally, but then we figured out they were there to greet us! We have never received such an impressive welcome anywhere before. We joined in the procession, and we walked through the streets of the village to the main square, where the elders were already sitting waiting for us. We received flowers and there was a long ceremony in the scorching heat with speeches and handshakes. We learned that our group was the first ever to do a medical mission there, which explained why they were so excited and why the whole town turned out to greet us.
We were lodged in the house of a local businessman who was away. The house was brand new but not too solidly built-things literally fell apart as we occupied it: The door fell off, the showers curtains ripped, taps and toilets leaked flooding the whole house, shelves broke, beds fell apart…. We felt we were like a plague of locusts! Actually it was luxurious by local standards and we were grateful to have running water, electricity and bathrooms, not to mention hot meals brought in by the Bishop himself.
We started to work the next day. The clinic consisted of a few rooms transformed from concrete buildings built many years ago to house diamond miners. The mine had closed long ago. There was one midwife and one nurse working full time. On the first day nearly 300 patients came, which was an intimidating sight. Quite a few had serious eye-diseases but the majority had only minor problems like blurry vision upon reading, tearing, irritation, redness, sensitivity to sunlight, or no problems at all. First we were surprised that in a country like this where people are used to terrible hardships on a daily basis would come with such minor complaints. But it was soon evident that most of them came just for the “show”. We were the “circus in town.” In addition, the promise of free glasses brought in the crowds. In spite of the huge crowd, we performed a vision check and a short exam on everybody, and we gave at least advice-the people were happy just so someone listened to their complaints, even if briefly.
The clinic had no bathrooms or running water, which presented challenge for us. Some of us held it for the whole day, some of us tried the bushes but there was no way to hide-the crowd cheered and pointed us to spots where we were at least partially hidden.
Overall, we saw close to 2000 patients, and performed 55 surgeries during the two weeks, mainly cataracts. But the most important aspect of our mission was to interact with the local ophthalmologists. It is just a drop in the ocean of blindness to operate on a few cataract patients, but if we help to train local doctors, who will stay and work in Ghana for the rest of their life, we can have a lasting impact on eye care in this country. We trained Dr Opoku in small incision cataract surgery; he operated on more than half of our cases, with the constant supervision of one of the ophthalmologists in the group. This kind of training is usually unavailable for doctors here, as there is no time, resources, patience or personnel for it. He became excellent by the end of the mission. He wrote us since and told us that now he was operating independently without a problem. We also trained him in the use of diagnostic equipment. He also learned organizational skills – something Africans are sorely lacking in general – just by watching us. He actively took part in our case selection and we always listened to his advice when in doubt. He also taught us many invaluable things, as he has much more experience in Third World ophthalmology. He “saved” our mission when our autoclave broke down and we had to sterilize the instruments with Chlorox and boiling – something we would have never dared to resort to without previous experience.
We also had the pleasure of working with Dr. Dawson, the ophthalmologist from a nearby town. She interrupted her extremely busy schedule just to work with us. She was extremely capable and shared with us her knowledge. We also watched each other’s surgical technique. She saw many patients with very serious eye-problems who needed care we were not able to provide and referred them to her clinic. Her salary is exactly the same regardless of the number of patients she sees, so we were worried that she would resent us for generating extra work for her. But she was “awesome”, as one of our volunteers put it, had tremendous empathy, and was one of the best third world ophthalmologist we have ever met.
At the end of the mission I asked the participants if we could do anything better next time. The first suggestion was: “Why don’t we come in the winter next time?”
“But it IS our winter now – the rainy season – this is the coolest time in Ghana! “ – answered one of the Ghanaians.
Overall, this was a successful mission, even that we performed less surgeries than we would have liked to. The eye-care in Ghana has improved significantly in the past few years since the introduction of the National Health Insurance, so if we decide to return there we will probably go to North Ghana which is much more remote as it is very far from the capital, and thereby the need is much greater. Dr Opoku already volunteered to organize a mission there.
Judith Simon
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