Heart to Heart
The ICHA Blog
Memories of Ghana |
It is always hard to put pen to paper, or finger to button, as it were, after a trip to a distant land. The obscurity of capturing living and vivid memories in succinct phrases worthy of their descriptors is, in my mind, one of most difficult tasks in writing. So continues my struggle during my recent sojourn to Ghana.
As I sit here in a Charlottesville coffee shop, furiously pecking away at my streams of consciousness, proper words to describe my experience elude me. I learned long ago that only through travel do we realize how truly provincial we all really are. The beauty of travel, particularly to a destination that challenges your own paradigm of the world, is that the memory stays with you far longer than any trinket, souvenir or written description ever will.
The trip started quietly enough. With the assistance of pharmacotherapy, my last memory was that of a bad airline movie and a stale meal. I awoke with a thump in a new continent. The first couple of days were spent getting to know my colleagues: a medicine resident from India who recently crossed the intern year finish line, a sharp-minded first-year medical student collecting data for a research project, and a seasoned and wise veteran from...well...Michigan, I suppose, though recent Locums stops include Alaska, Hawaii, and Vietnam. The four of us would be spending the next two weeks teaching local health care providers - mostly nurses - some of the basic tenets of managing chronic diseases. Main topics included hypertension, diabetes, obesity, smoking cessation, proper diet, and exercise. Each of us was to lead sessions on these specific topics, but oftentimes conversations became appropriately tangential.
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Last day in the clinic |
Today was last day of data collection and classes at the Elmina Urban Health Center. There were many people to say bye to and thank for sharing their time, open minds and the space of their clinic with us for two weeks. The class ended with more students than it started with, as healthcare workers from nearby clinics and hospitals trickled in to join us.
I felt that the class also ended with a general positive feeling of what had been learned and achieved. We decided to go over the post-test after all had taken it in an effort to solidify knowledge and address any outstanding questions. We went around the room as each person explained the answer to a question. This spirit of group-teaching had been echoed throughout the course – in which people would each take on teaching what they knew about a topic to open the discussion and teaching – rather than creating a lecture instructor-student dynamic. Healthcare workers continually seemed to seek us out to ask questions about the materials. For me, as a medical student who has not had the opportunity to do much teaching yet, I found great pleasure in explaining what my new, limited knowledge of medicine could add. The course also served as a platform to start off with making health lifestyle changes amongst ourselves – talking about the healthcare worker’s own daily lives and partaking together in an exercise walk.
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Gathering Knowledge |
I began my role with ICHA in the Records Office of Elmina Urban Health Center this week. Countless green “Ghana National Health Insurance” folders and patient health record cards pass through this room. I have set up my laptop station and two friendly clinic staff members, Justice and Ernest, have generously been helping me find the patient charts over the last year so I can record information on hypertension. From this seat in the Health Center, I have gotten the privilege of a birds eye perspective – of what patients come in saying, of how their complaints are processed, of how they are diagnosed and treated, and of how their illness resolves (or evolves) over time. The flow of a clinic has emerged from this process of data collection.
What it shows is a population of all ages experiencing a burden of the infectious diseases that we all imagine of a tropical, developing country. However, I have been struck by the large number of high blood pressure readings I have seen in my own cursory glances at the data. It has not been uncommon to see a patient diagnosed with malaria and hypertension at the same time. This speaks to the “double burden” of communicable and non-communicable diseases that countries like Ghana experience. Hopefully, this data on hypertension will help shed like on the silent processes of chronic cardiovascular disease that lie below the surface of people’s daily lives. One healthworker anecdotally estimated 5 new cases of hypertension/day in a clinic that sees an average of 150 patients per day.
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The Ghanaian Diet |
I would like to attempt a discussion about the diet here, as it is a central focus of our messages. However, though I’ve talked to many Ghanaians and I have tried most of these dishes, I know I may still get the exact ingredients and preparation wrong. So, I invite any Ghanaian (or anyone) who reads this to please comment and correct me!
Fish is obviously a great source of protein and full of nutrients that protect your heart. And they’ve got lots of it here, as Elmina is a coastal city and a major fishing hub! However, the most common way you will see fish in the market is salted and smoked, for preservation. The smoked fish is fine, but it’s the salted fish that is a concern for risk of heart disease. It is often cooked into a stew and salt is also added, making the entire dish very high in salt. We are suggesting to cook the salted fish first in water, to get some of the salt out before using it in a meal, or if cooked into a stew, don’t also add salt.
Fruits and vegetables abound here. I see bananas, mango, pineapple, oranges and watermelon everywhere – and I eat them as often as I can! Vegetables of all sorts are also in ample supply. But, like most places, it’s more expensive depending on the season and probably doesn’t go as far, when trying to feed a lot of people. We suggest to eat as much fruits and vegetables as often as possible – whichever ones are a favorite, or the most common and most affordable. They’re all good for you!
From speaking to people and paying attention to the signs on the street, the most popular dishes are:
Fufu and some sort of soup or stew (light soup, ground nut soup, fish stew)
Fufu is ground cassava and plantains. It requires a strenuous process to prepare – using a large stone bowl over a fire and essentially kneading (pounding with full force) the ingredients with a long, heavy wooden gavel, standing over the bowl. The soups vary – light soup is made with water, tomatoes and vegetables. Ground nut soup (ground nut is peanut) – the nuts are cooked over a fire in a stone bowl mixed with sand to heat them. When cooked, the nut is oily and pasty – a lot like peanut sauce in thai dishes. Fish stew can be prepared many ways. However, a common way to preserve fish here is by salting it. Once it’s ready to be cooked, it is added to broth (oil, water, tomatoes, etc.) and the salt flavors the soup. Smoked fish is also common here, which will also be used in soups giving a different flavor. All of the soups are often made with palm oil, which is most commonly a sweet red oil; though the palm nut can produce three different kinds of oils (black, white and red).
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Doing well with what you have |
There’s making do with what you have and doing well with what you have. The staff of the Elmina Urban Health Centre do much more of the latter.
Foregoing the excess packaging and attendant disposal requirements of individually wrapped band-aids, after a blood draw, patients are given a swab of unwoven cotton torn from a forearm-length bolt. Before their blood is even drawn, a piece of IV tubing suffices for a tourniquet. The plastic tubing offers an unintentional integrated safety mechanism. It snaps if pulled too tightly. For blood samples that must dessicate before or after staining, louvered windows, placed to catch the scant from a clinic courtyard, can be tilted to become a perfect drying shelf. For those serum tests, like typhoid, that must be rocked and checked for agglutination, a ceramic floor tile is an excellent tool. Its white surface provides a contrast with serum or whole blood, and its adsorbent surface assures neat mixing of serum particles. Economically placed, up to 35 samples can fit on a single tile.
In our home hospitals and clinics, with their myriad specialized gadgets, it’s easy to forget that things need not be purpose-made to be useful. Indeed, pressing everyday articles into sophisticated uses reflects and cultivates a versatility of mind that is priceless in any setting.
Doctor, heal thyself! |
As happens everywhere, health care workers share lifestyles with their clients. It's just one of the features of community health. Into the raucous joy of Ghanian life, are creeping some less healthy habits. Minimal exercise and fatty food additives are two main culprits.
Our visiting team has been treated to high fat, high salt snacks washed down with Coca-Cola after presentations of Preventing Heart Disease and Diabetes Mellitus 2. The irony isn't lost on us, nor is this counter-productive situation unique to Ghana--just look at the foods served at Western medical conferences, and the American Academy of Family Physicians decision to 'partner' with Coca-Cola to produce patient education materials on healthy beverage selection. The point is, often, patient education and community health improvement begins with the messengers.
Doctor, heal thyself! applies to both the Ghanian nurse covering her salad in dressing and the American doctor snacking on cream puffs at a Cardiovascular Disease conference. Addressing health care workers' choices are excellent starting points for changing the choices and health outcomes of a community.
Little Changes can make Big Differences |
The patients and staff of the Elmina Urban Health Centre reinforce the concept that happiness is found more in personal and community connections than in having things. This has a lot to do with how the staff at the health center were able to create and continue a sophisticated health system, complete with efficient patient flow through multiple care stations. At each step of their visit, patients are warmly welcomed--connected to their providers and this community center.
For someone who spends the majority of his professional time in patient consultations, I was very impressed with how the laboratory (typically, a faceless entity to Western doctors) contributes so much to patient care and community building. With early use of inexpensive point of care testing, lab personnel are ably to quickly and accurately diagnose malaria; enabling rapid treatment and decreasing unnecessary antibiotic use and subsequent malaria resistance. Malaria is a (likely, the) leading diagnosis at the Elmina Urban Health Centre, and simplifying the care process saves patients much time, enabling them to return to their daily activities and freeing the health care team to see other patients, a reverberation that decreases their waiting time too.
Little changes can make big differences. Those changes are happening now at the Elmina Urban Health Centre.
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A Meeting of the Minds |
With the support of the KEEA district, ICHA held its very first Heart Health Workshop. In attendance were 40 teachers, members of the district department of education, staff from the Elmina Urban Health Centre, a doctor from Kumasi, and champions for youth development in the community; essentially some of the greatest minds from the community that are willing to take the first steps of preventing heart disease in Elmina.
This workshop started well before the outreach. Much of it could not be possible without the coordination, assistance, and vision of Wilfred, the public relation officer at KEEA district, and his staff. The material (which was well received) came from many hours and revisions by a dedicated team within ICHA. And our three talented speakers sacrificed time from their busy schedule to come together and deliver a united message about 1) the importance of understanding heart disease; 2) how to prevent heart disease; and 3) why teachers are at the frontline of spreading this knowledge. For all of this, ICHA is immensely appreciative for everyone's efforts.
What has amazed me though, is the level of commitment, interest, and dedication from the teachers throughout the outreach. At times, I feel that we are all on the same page; what the teachers want are the same as ICHA's wishes. The three public secondary schools - Komenda, Edinaman, and Eguafo-Abrem - all welcomed us on to their facilities for a number of events. But it was the teachers that sat through and gave us feedback on our surveys, provided us insight on how to reach out to the students and enable them as ambassadors, and made the workshop a success with their presence and participation in discussion.
The teachers have not shown hesitation to express their opinions and ideas. They tell us when students might not understand this or suggest a better way to engage the class. But through and through, they tell us how necessary our program and organization is. The teachers are hungry for more - more material, more visuals, more activities, and more time with ICHA. And we think this is partially because they know their students are equally as hungry and enthusiastic for more.
So this Heart Health Workshop marked another milestone for ICHA. We have trained the teachers. They will share the information with students. And hopefully the message continues to spread, leading us to new ideas. A few great minds will turn into many - and this is how the community can keep Elmina safe from heart disease now and in years to come.
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Spreading the Message |
The youthful student body of Edinaman Senior Secondary School slowly filed into the large, 2 story assembly hall – all 1,000 as promised! This was the culminating event of our schools programs, and probably the one that had given me the most anxiety.
Taking a moment to reflect on the past week, I feel pleased with what we have accomplished. We started the week on Monday with the Teacher workshop, which could not have gone better (perhaps we could have started on time, but I can’t forget where we are). And we ended the week at Edinaman.
Though 1,000 high school students is not a crowd that either Vince or I have experience with, it went surprisingly well. I say “surprisingly” because I was, in fact, fearing the worst – laughter after every word we spoke in our funny American accents, or worse, blank stares! Thankfully, neither of these scenarios greeted us. Instead, the students seemed quite engaged, certainly shy when it came to volunteering for activities, but still interested and thoughtful. Because Edinaman is the only one of the three schools that has an assembly hall big enough for all of their students, it was the only assembly with the entire student body present.
I think in our favor (giving us a day to practice), we hosted a smaller assembly (for about 200 eager students) at Eguafo the day before. The assemblies included a brief interactive lecture, addressing the basics of heart disease and prevention – focusing on diet and exercise; with lots of activities throughout. The activities were the key. They included a rowdy fitness competition between students and teachers! The crowd loved this. Though young and mostly quite healthy, the students are important ambassadors to the community. The message they bring home to their families is taken as truth. Teachers are highly respected, so what they say is often heeded. So far, what we have seen is that the students are eager to learn and repeat the information, charged with good questions for us and their teachers.
We could not have pulled off these events so seamlessly without the help of the teachers and administrators. They have been committed to ICHA since we got here almost a month ago and we certainly appreciate their attention. We are counting on these leaders to remain involved once we leave Elmina. We believe the interest is there. We have planted the seed and provided the resources. Hopefully the message will take root.
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Meeting Expectations |
One of the things that I remember well from the last time I was in Elmina is the satisfaction after a good meeting. Sure, meetings are certainly full of cultural confusion which often means moments of awkwardness. But, overall, we all tend to agree with what needs to be taken care of and how. I usually learn quite a bit from these encounters and gain a new perspective, a new way to present our message; And certainly an extra spring to my step (which is especially obliging in this heat)!
Heart health, the reason we are here, is an easy message to share. It affects everyone – from children to seniors everywhere in the world! And everyone can do something to prevent it. It’s not a controversial health issue, and it’s so important. Thus, general reception of the issue is usually positive and supportive.
Today, Vince and I met with the Director of the District of Education for the KEEA Municipal. Though this was more of a formality than anything else, as we have been working with the PR officer since September 09, it was another satisfying meeting. He began by telling us that what he thinks we are doing is very good and explained why he thinks heart health is so important. To summarize, he expressed that “our heart runs our body - if our heart is not healthy, our body is not healthy. This is a problem that affects every human so it is a problem that is important to talk about. It is good to teach youth, the innocent, so they learn early”.
If I could record every meeting, we would have our package for the community. Most people we talk to understand the importance of cardiovascular health, can earnestly express the bigger picture and are eager to learn how to put it into practice. This puts us in a great position to move forward with the projects we have been working on and share ways to practice heart health.
ICHA will be hosting an all-day teacher workshop next week that, in collaboration with the District of Education, we have invited all Science, P.E., and Home-Ec teachers from the three public high schools. Along with guest lecturers from the clinic and the community, we will be presenting a heart health program to incorporate into the science curriculum. The week following the workshop, Vince and I will be leading interactive assemblies at the three high schools to engage students in the discussion of taking care of their hearts and their bodies. We will invite the students to initiate a Heart Health Club at their school, with hopes they will continue to participate in this discussion, at school and in their community, long after ICHA has left Elmina.
All the pieces are falling into place. Everyone we have worked with here in Elmina has been so accommodating and I think are as eager as we are for this project to lift off. We have great expectations!
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About ICHA
The International Cardiovascular Health Alliance (ICHA) is a 501(c)(3) non-profit organization dedicated to promoting cardiovascular health in the developing world. ICHA works closely with local clinics and community organizations to provide knowledge and tools to prevent cardiovascular disease.
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