Suzy and I came to Ghana with fairly limited and lightweight wardrobes. Our past experience in Africa taught us that clothes were not difficult to find or to make here, so paying excess baggage fees to bring along another cocktail dress or sports jacket seemed absurd.
Like many other African countries, Ghana has a lively textile industry, which produces cloth based on both traditional and modern designs for local distribution. A colleague at the University informed me that the idea of Casual Fridays, popular in the West, took hold here as a way to encourage citizens to wear Ghanaian styles and to support the local textile industry. For men, this generally means tropical-style shirts, worn outside the pants. Or, for the more traditional-minded, the shirt-robe to the knees with airy pants made of the same material. For women, the local outfit is generally a two-piece affair, with a top that ends at or slightly below the waist and a long, form-fitting skirt, either tubular or flaring from the knees down. The materials are multicolored repeating patterns, some resembling the patterns on “kente” cloth, a complicated traditional weave that is far too heavy and too expensive to fashion ordinary clothes.
Suzy and Agatha made a trip to the Central Market where Suzy bought 6 yards of two cloth styles to make into two dresses. Agatha has a sewing machine and has offered to make curtains for us in the past when that issue came up briefly. And now, she was offering to make the dresses. She had a collection of posters showing women in a variety of African dress styles from which Suzy could select. Suzy was more than happy to let her try.
Agatha took a few key measurements and then started to cut the cloth. For the next few mornings, we awakened to the sound of the hand-operated sewing machine from China, ka-chun-ka-chun-ka-chun-ka-chun. Suzy was surprised to find that Agatha had sewed together all of the pieces with straight, permanent seams before she had Suzy try on the first dress. This proved to be a mistake. The fit was not good, and this was obvious. The top looked like a sack, and Suzy could not squeeze into the skirt either by stepping in or by the over-the-head approach. So, seams were removed, and Agatha tried to fix things. We showed her other clothes of similar design that Suzy already had and which fit well. She was able to let out the skirt. The bodice was improved by adding another seam, but below that point, it looks as though Suzy has an inner tube around her waist.
Suzy will not wear the dress as it currently fits – at least not out of the house. She and I have discussed at length how we can approach this problem with Agatha without shattering her confidence. Should Suzy tell her the dress looks fine but never wear it? Should she have Agatha try to make additional alterations that may irreversibly make things worse? Or, should she accept the dress as is, then surreptitiously take it to a professional tailor to see what can be done to remediate the problem? Suzy has not decided what to do, and the second dress has already been cut and is being assembled. Here is an opportunity for the readers of this blog to influence ongoing events. Please vote your advice in the comments.
The dress-making problem has two possible causes. First, we may have expected too much from Agatha, who is, after all, not a professional dressmaker. Second, Agatha proceeded to make a dress for a Ghanaian physique (perhaps her own) with a few modification to take Suzy’s vital statistics into account. Then, she appeared with a finished product without making any attempt to customize it to Suzy’s physical appearance. Her approach was earnest and well-intended, but it was not thoughtful and did not take all of the variables involved in a custom fit into account.
So, why am I going on about dressmaking in this medical education/travel blog? I will explain by relating an experience that I had in a clinical setting in Ghana.
A 72 year old man complained of pain at the site of previous surgery six months earlier. He had undergone an operation to repair a hiatal hernia with mobilization of the herniated transverse colon back into the abdominal cavity. Now, he had discomfort under the surgical scar. He also complained of swelling of his ankles each evening and constipation. At the time of the surgery, the patient was found to be hypertensive and was placed on two-drug regimen with lisinopril and nifedipine. These were his only medications.
At the time of the visit, the patient was still mildly hypertensive. The abdomen was unremarkable. There was minimal tenderness associated with the more rostral portion of his mid-epigastric scar.
I commented that calcium channel blockers, like nifedipine, are not considered optimal agents for Americans of African descent and that they are a frequent cause of constipation, particularly in the elderly. I assumed that the physician that I was observing would solve the pain problem and take the opportunity to optimize the antihypertensive therapy. I thought about the possible causes of pain in this situation and considered the possibility that the surgery may have failed or that he had a recurrence of esophagitis that accompanied his original complaints before the surgery. Or, did he have adhesions that might be responsible for intermittent pain and constipation?
What happen next surprised me. The patient was given a prescription for an oral NSAID and a laxative. There was no change made to the antihypertensive regimen.
Medicine is an art as well as a science, so there is usually more than one solution to any given problem. However, from my perspective, symptomatic treatment was prescribed without considering the possible underlying causes of the patient’s complaint. The doctor’s prescription was the most direct response to the patient’s complaint, but not necessarily the best one. In this case, one might be concerned about using a medication (NSAID) that can cause gastric irritation or bleeding in a patient whose primary complaint is epigastric pain, and although constipation may be a routine problem of the sedentery elderly, it could also be a sign of something more in an individual who had recently undergone abdominal surgery and who takes medications that may affect gastrointestinal motility. Of course, we are in Ghana not New York City, and the clinical resources available to sort out this patient’s problems are not vast. This patient could not be referred for gastroscopy, because there are no certified endoscopists here. If there were, they would likely be preoccupied with more urgent problems. And who would pay for the procedure? Still, I am forced to ask myself whether the limitation of diagnostic and therapeutic options here has created a sense of comfort with empiric and symptomatic treatment as the default approach. Have physicians who are as intelligent and well-trained as their US counterparts abandoned the art of diagnosis?
During the past week, I met with a colleague from the Department of Internal Medicine in Kumasi, Dr. JZ. Dr. JZ and I have been working on a project together that will instruct students in the interpretation of certain laboratory tests. He has been enthusiastic about the materials that we are developing and impressed with what can be done. He has a long-term interest in creating a Clinical Skills Center in which this type of programming would be useful. Currently, Dr. JZ is also involved in the Open Educational Resources activities of our joint grant with medical schools in Ghana and English-speaking medical schools in South Africa. He had just returned from a visit to Michigan to discuss some of the objectives and aims of this grant, and he returned to Ghana with a fervor that I had not seen previously.
Dr. JZ was educated in medicine abroad and completed training in a medical subspecialty at Columbia University. So, he knows how medicine is practiced both in the US and in Ghana. Dr. JZ believes that Ghanaian physicians are not being taught how to synthesize all of the available clinical data when making therapeutic decisions, a practice that is fundamental to American medicine. He complains that Ghanaian students and practicing physicians tend to focus on a single sign or symptom and to make snap clinical decisions based on that limited information, as in the case I described above. Another classic example is the assumption that all fevers are related to malaria. In fact, a great many are indeed associated with malaria, but this assumption not only overlooks a broad range of disorders that also cause fever, it results in a massive overestimate of the impact of malaria as well as unnecessary treatment. One physician in Accra has reported that 75% of all patients who come to his clinic have malaria!
Dr. JZ wants to create and to assemble teaching materials that will force his students to put together information from various sources to solve clinical problems. Interactive, case-based e-learning materials would provide a superb platform for this goal. He is jumping ahead in the process that I had envisioned here and wants to arrange for the two of us to meet with a leader at UST in Computer Science to identify impending graduates who might be interested in learning how to develop electronic medical course materials. He sees me as a mentor for both himself and for a local computer science student so that we can create a capacity on site to continue the kinds of projects that I have started. I am, of course, enthusiastic about his approach, but a bit nervous also, since we have not yet deployed even one small example of an e-learning project here. We do not know yet what the problems and the acceptance will be. However, with Dr. JZ taking the initiative, I am much less concerned about those issues. He will be in a better position to deal with any problems than I would be.
Regrettably, I will not have the time or the expertise to generate e-learning materials concerning dressmaking. I will leave that problem to my successor.
