So Much for the Color Commentary, What About the Work?

I am currently involved in a review of the seven, first-year M. Sc. Students in the Department of Microbiology.  During their first year, they take the Medical Microbiology course with the 3rd year medical students, and they are also required to do independent study and to prepare a 20-minute Powerpoint seminar.  This week, Tuesday through Thursday, the seven students are delivering their seminars to the faculty.  I have thus far heard a talk on the success (or lack there of) of the “Roll Back Malaria” (RBM) program, and an excellent talk on the epidemiology of Cryptosporidium outbreaks worldwide by the only female student.  I found the malaria presentation to be problematic from the standpoint of the local data collection.  The success or failure of the program was being judged based on a summary of malaria reports from clinics, and these numbers do not show any improvement after implementation of the RBM program.  The student reported that 40% of outpatient visits in Ghana were for malaria, and one physician at a clinic in Accra claimed the 75% of his outpatients have malaria.  I found these claims not to be credible based on what we know about the incidence of diarrheal and respiratory infections in this part of the world.  My colleagues in Microbiology confirmed that the clinic reports are likely based on whether antimalarial medications were dispensed because of the presence of compatible symptoms, rather than on the results of blood smears.  I doubt that distributing bednets is going to affect the overall incidence of fever in this country, so I hope that someone has found a better way to evaluate malaria control here than the student did.

For this exercise, each faculty member scores the presentations and the Departmental Examinations Officer tallies the results.  These scores combined with their performance in a basic experimental design course will determine their grades.  This afternoon I will hear talks on global approaches to reducing maternal-child transmission of HIV, another talk on the value of impregnated bed nets, and the epidemiology of intestinal perforation (with an emphasis on typhoid fever).

My impression is that the students are doing public presentations for the first time, so there is more emphasis at this level on their ability to use Powerpoint effectively and to give a professional presentation than on the absolute quality of the content.

The two photos below show the Microbiology Lab in which the presentations are taking place and me sitting in the very comfortable office that the department has made for me out of a former lab space.

My own e-learning projects are rapidly becoming a full time job for me.  When I was in Accra recently, Suzy and I stayed at the guesthouse within the College building (a very comfortable accommodation and very economical at the reduced rate for College members).  I had prepared a demonstration of the Pathology program to show the Rector.  He seemed to be very pleased, and he contacted a senior pathologist at the University of Ghana, Dr. ATJ, to establish a collaboration to proceed with the project.  Dr. ATJ came over to the College the next afternoon; we met in the College Library and reviewed the project together.  Dr. ATJ is quite experienced having practiced in London, Riyadh, and Kuwait before returning to Ghana for “semi-retirement.”  He likes the idea of e-learning and seems to be enthusiastic about contributing to the project.  He wants to make sure that the program has the appropriate tropical disease coverage, so he will be locating local pathology resources at the University to include.  I am fortunate to have this kind of support.  Dr. ATJ will be an excellent collaborator.  The Rector also spoke of involving a hematologist and a clinical microbiologist as well, to bring in more resources and help make sure the program is locally relevant.  If I am not careful, I could spend my entire sabbatical doing this one project, although that does not seem possible, given the other commitments I have made.

The hysterectomy teaching program is on hold while my GYN colleague gets clearance from his superiors to film in the operating room.  Hopefully, we will do the video part of his project on my next trip to Accra.

While in Accra, I also met with the Head of the fledgling Family Medicine program at the Korle-Bu Teaching Hospital.  Dr. EA has a plan for creating a problem-based curriculum in Family Medicine, and 6 weeks ago he had provided me with a list of 20 topics that he eventually wishes to cover.  However, this was the first chance we had to meet and discuss his educational goals in person.  Dr. EA is smart and ambitious, and therefore willing to try something novel.  He would like to establish some credentials in Medical Education, and even spoke about the possibility of enrolling in a degree program at University of Michigan at some future time.  For the present, we agreed to start with one topic on his list that I felt comfortable addressing – “STDs and Pelvic Infections.”  We agreed on a general approach to collaboration on this project.  I would the project working on a draft of 9 case-based lessons on this topic and then send it to him to adapt to local practice.  I now have a draft with the first 4 cases programmed in HTML and have sent a CD to Accra.  When Dr. EA receives the disk, his first task will be to review what I have done and edit it for realism in the Ghanaian and Family Medicine context.   Eventually, I will video him commenting on these cases, explaining how local patients describe their complaints (in local language) and how the system actually works with regard to diagnosis and treatment in most cases.

Today in Kumasi, I visited another Family Medicine physician and faculty member, Dr. DK, at an outlying hospital in Kumasi.  She was very interested in the work I am doing with Dr. EA and would like to participate in the development of new materials.  Initially, she identified “Asthma” as a topic she would like to address in this context.  However, she later proposed modules on tuberculosis and HIV care, recognizing that these are among the most serious problems in the country.  I am happy to help her with either.  However, there are some interesting caveats with the latter two topics.  Dr. DK told me about a patient she has treated twice for TB and who still has a 3+ AFB smear.  AFB culture is not readily obtainable here, and second-line drugs are not available.  Apparently, Ghana is part of a global TB program, and the country has not yet demonstrated the capacity to do accurate culture and sensitivity testing on M. tuberculosis to the satisfaction of the sponsor who supplies the medication.  Thus, second-line drugs are not being supplied.  At Dr. DK’s request, I brought the matter up with the Head of Microbiology here, and he is arranging to have Dr. DK send a specimen from her refractory patient to the Public Health Referral Laboratory in Accra.  So, most of the learning objectives in a program on tuberculosis (if we do one) will involve epidemiology and clinical diagnosis.  Treatment strategies will be mostly of theoretical concern.

I also learned that most of the HIV care in Kumasi is done in a few HIV-AIDS-dedicated clinics.  Specialized nurses in these clinics manage the large numbers of patients using detailed algorithms with the oversight of a supervising physician.  So, as in the U.S., the administration of HAART is not something that is done by every physician in the system.  Dr. DK and I will have to meet again to discuss the objectives of learning programs on HIV and tuberculosis and perhaps consult with the experts here in these fields before proceeding.

Meanwhile, the Head of Microbiology has asked me to put together a presentation of my e-learning interests to the Medical Microbiologists here so that they can decide whether they would like to incorporate self-learning modules into their medical school course.  It was always a goal of mine to determine whether developing a few pilot programs would create a demand for this kind of teaching approach.  I am already finding a lot of interest before anything has been completed and fielded, and I hope I am not getting in over my head.

With Six, You Get Eggroll

Since our first trip to Kumasi almost three weeks ago, Suzy and I have been back and forth to Accra; to move ahead with projects I have undertaken with physician collaborators there, to vote in the U.S. Presidential Election at the U.S. Embassy, and to pick up our checkbook and ATM card from EcoBank.  [Pop Quiz: Which most resembles a maximum security prison, the bank or the embassy? Answer to follow.] I will have much more to say about the Accra-based educational projects in the next entry.  This posting will focus on travel in Ghana, the character of Kumasi and its University, and our adventures finding living arrangements here.

The trip from Accra to Kumasi is most comfortable, I am told, if one starts very early in the morning, at about 5:30AM.  The reason for this advisory is that the first 20 or so kilometers of the trip is on a rutted dirt track that meanders around construction areas, where workers are laying down the base of a modern, multi-lane highway.  For the present however, the gridlocked traffic is forced onto a highly problematic and crowded dirt, rock, and mud surface.  So, to avoid spending hours in the dust and sun, it is considered necessary to cross this River Styx before everyone else is out of bed.  But even at the earliest hours, one feels claustrophobic from the congestion, probably because everyone else has been given the same advice.

There are no markings, signs, or boundaries to define the road margins on this Stygian leg of the trip, so the highway is essentially one-way going in both directions at the same time. Have I mentioned that it is also hot and dusty?  Naturally, everyone’s frustration levels are high.  I saw tro-tro drivers take their passengers through deep patches of mud and water to pass a line of traffic on the right and then force their way back into the same line of traffic, a few cars ahead.   I saw drivers make a left turn through the southbound (oncoming) traffic and head north on the opposite shoulder before crossing oncoming traffic again to break back into the northbound lane. At what may have been an intersection, a man in a BMW who appeared to be driving his young daughter to school crossed in front of us at a right angle, engaged bumpers with the car ahead of him (heading to our left), and literally pushed the obstacle car forward.  Simply honking the horn was an insufficient expression of his urgency.   And then there is the tie-up that predictably ends at a vehicle broken down in the middle of the road or an overloaded truck that has given all of the angry drivers a demonstration of what happens when its center of gravity moves outside of its wheelbase.  Yams spill all over the highway.  At one particularly chaotic junction, I saw a man standing among the backed-up cars in front of a gas station sweeping jetsum off the dirt road with a broom. Someone in authority must have ordered him to do that, as no sane man would do such a thing of this own volition.  I was reminded of the Myth of Sisyphus, extending the infernal metaphor a bit further.  This morning at 6:00AM, we negotiated this leg of the trip in about 45 minutes, which I consider to be a palpable victory.  I never looked back for fear that I would turn into a pillar of salt.

The cars that make it to the other end of this trial are rewarded with several kilometers of divided, four-lane highway, a promise of things to come in the indefinite future.  However, too soon, this turnpike ends with a toll booth.  Ten pesewas, about nine cents, is the tariff.  Hmmm, 45 minutes of being parked in an incubator, breathing oil-burning exhaust and red dust, and 5 minutes of ”pedal-to-the-metal” ecstacy.  Nine cents seems fair.

After the toll booth, the road reverts to two lanes with abundant potholes early on but with improved highway quality the farther one travels away from Accra.  It is as if Accra is at the center of a gradient of road misery, and by attaining a certain escape velocity, you can break free of its influence.

Once free of the gravitational field of Accra, the highway enters and leaves numerous small villages and cities.  They each have their charms, but the one I find most intriguing is the city of Nkawkaw.  It is situated on foothills and centered near the base of an escarpment that rises abruptly several hundred feet to a western plateau. Depending on the terrain as one drives through Nkawkaw, one may look up to the mountains, or down over crowded rooftoops with home-made, bamboo television antennas,.  The city has been bustling the three times I have passed through.  There is always lots of truck traffic and active markets.  It appears to be a prosperous place.  I am told that “Nkawkaw” means “cocoa”, and this town is the center of a prominent cocoa-growing region. Some pictures of Nkawkaw taken in sunshine and rain are shown below, and there is a photo of the highway and countryside around this region (outside the spell of Accra).

I am particularly taken with the public health message on the steps of the colonnaded building – “Control Your Lust; HIV-AIDS is a Killer,” it reads.  I have observed numerous public health messages on Ghanaian billboards – “Tuberculosis can be cured; come for treatment,” “HIV can now be treated,” and my personal favorite, seen in the carpentry section of a Kumasi market – “Hammer with care, use condoms.”  Although I have no data to prove it, I suspect that these signs are very effective means of educating the public here.

Kumasi – Like Ann Arbor, a Tree City

When the Asante King (also written as “Ashanti”), Osei Tutu I, was looking for a new capitol for his Nation in 1695, he planted trees in two locations.  In one location, his sapling did not take root.  In the other, the tree grew and became the center of the Asante Nation – Kumasi (a name which implies that the tree grew).   The king’s famous Shaman, Okonfo Anokye (“Oh-kohn-fa-no-chee”), planted a sword in the ground at the place where the King’s Golden Stool (i.e., throne) descended from Heaven.  The Shaman swore that the Asante Nation would stand as long as the sword remained in the ground – an African echo of the Arthurian legend.  Several have tried to remove it — the most famous of whom was Muhammed Ali — but no one has been able to budge the sword in over 300 years.  Okonfo Anokye clearly understood the role of legend in nation building.  And perhaps he also knew the secret of concrete.  Today, there is a sheltering structure (the Sword House) built around the sword site, which is serendipitously on the grounds of the Okonfo Anokye Hospital, the public teaching hospital for the local medical school.  The Golden Stool has been hidden since the British tried to make off with it over a century ago.  It was last seen when the current Asantehene, Osei Tutu II, ascended to the throne in 1999.  Its resting place is a well-kept secret.

The original city of Kumasi was burned to the ground by the British over 100 years ago, but it reemerged from the ashes after the Asantes formed a peace treaty with the Brits, an offer I am sure that they could not refuse.  Today, post-colonial Kumasi is everything that one could expect of an African City.  It is dense, busy, crowded, and modern.  It boasts the largest open market in West Africa, and the surrounding neighborhoods are exotic and picturesque.  In contrast, Accra is big and sprawling with expansive suburbs.  I think of it this way: if Accra is the Los Angeles of Ghana; then Kumasi is its San Francisco.  I would love to be able to prove this visually, but I do not yet have any images of urban Kumasi to post.  I anticipate that this will be a topic for a future posting.  However, both Suzy and I were intrigued enough by the style and feel of this place to want to live here.

The Kwame Nkrumah University of Science and Technology (KNUST) is situated on the outskirts of Kumasi on an enormous campus featuring schools of various disciplines (including medicine), noisy high-rise residential halls, and commercial centers with shops, banks, and recreational facilities.  There is a botanical garden somewhere on campus that I have yet to see.  To me, as temporate climate denizen, the entire campus is a botanical garden.  It is a sheltered, sequestered, academic environment only steps away, through the gates, from the traffic and chaos of the surrounding marketplaces.  On weekdays, the roads and sidewalks within the gates of UST are filled with students on their way to and from class.  And taking a stroll across campus on a weekend, one will invariably see club and group meetings taking place (mostly religious or political in nature) and one may hear various student choirs practicing.

An Opportunity Arises

Initially, we were directed, via Dr. GK, to an acquaintance who was interested in renting a house to us in Kumasi.  If KNUST is at three o’clock on the Kumasi map, this house is in a new suburb at six o’clock.  The house is in a pleasant neighborhood (Daban New Site), featuring many unfinished houses and unfinished roads.  The one we were shown has a finished exterior and functioning water and electricity, two small bedrooms with primitive armoirs, and a bathroom that was fully tiled and functioning.  But the interior of the house was bare — cement floors and scarred cement walls – with no furniture, and a kitchen with a sink but no stove or refrigerator.  Someone had lived in this place with no more than these appurtenances.  We were told that the landlord would finish the house “to our taste” if we were willing to give a few month’s rent in advance.  We would be responsible for furnishings.  This practice is common in Ghana.  Landlords ask for at least a year’s rent in advance because they sometimes do not have the cash at hand to improve or finish the property.  Renting the house for a year is a way to finish the project.

We gave this option some serious consideration, even to the point of making a list of “to dos” for the landlord.  But we hesitated to accept the proposal because we wanted to see what might be available by consulting my colleagues at the University.  And that was where we finally got lucky.

Matthew F, one of the new lecturers in the Department of Microbiology, had recently moved to Kumasi from Accra.  He was living alone in a guest house and also hoping to find a permanent residence in Kumasi into which he could move his family from Accra.  He had been shown a few houses by a real estate agent.  [An interesting aside: the real estate business is entirely different than we are used to in the US.  The agent works for the landlord, but the renter not only pays his 10% commission but also pays him smaller amounts to show a property.  Essentially, the landlords call the shots in this country; it is a seller’s market.] One of the houses Matthew saw was near the UST campus.  He was very happy with it, but the rent was more than he could afford.  Without revealing what the rent is, I will say that it was not more than I can afford.  In fact, it was quite a bargain compared to what I had seen in Accra and half of what the landlord of the unfinished, unfurnished house in Daban was asking.   Matthew told me about this house and offered to take me there to see it.  Suzy and I took him up on this offer.  To my amazement, the place was a fully-furnished, spacious 6-bedroom house with a garage.  It has no air conditioning and no hot water, but we did not consider those to be essentials.  The foam mattresses are questionable, but the beds (6 of them) are firm and comfortable.  The house has ceiling fans in all of the rooms, spacious bathrooms (some with separate bathtub and showers), and a kitchen with a refrigerator-freezer, and a 6-burner stove (two of which work).  Water is pumped from a well on the premises to a small tower holding a black polyethylene tank that leaks.  Six bedrooms is far more space than we wanted, but the price was right.  And there were advantages to this arrangement, as the reader will soon learn.

The landlord was willing to rent the place to us at the same price offered to Matthew F. for a year paid in advance, in cash.  He was apparently pleased to rent the house to a Visiting Professor and spouse, since the group of Nigerian students who last rented the place apparently trashed it.  The lump sum rental payment required a meeting with the landlord’s brother to hand over the cash, since I did not want to carry such a large amount out of the bank.  The exchange occurred at the Ecobank branch on the UST Campus.  We also had to pay off the real estate agent, who was a victim of an end-run on this property.

Photographs of the house are shown in the photo gallery above.  Notice the yellow and pink exterior wall, metal door, and decorative razor wire, signaling “Welcome to our house.”

Apart from cleaning up the place, the main thing that we asked the landlord to do before we moved in was to repair the window screens, which they refer to as “mosquito nets”.  This was done, and we have been relatively free of pests, although I removed a giant millipede from the house on the first day.  It looked like a panatela maduro cigar slowly crossing the floor as though it lived here.  As the new tenant, I introduced it to the street.

We also discovered that Joseph, the caretaker, had been living in one of the back bedrooms next to the back entrance to the house.  He was well-installed there; he has a large-screen TV.  Joseph is a pleasant fellow who speaks decent English, and is very reliable, according to the landlord.  He knows a lot about managing the house and seems to be able to fix anything.  A case in point: the threshold of the auto entry was raised to prevent snakes from entering the compound, with the consequence that the car cannot enter the garage without seriously scraping bottom.  There is a picture above of Kwame and Joseph redesigning the auto entrance with 10 cedis worth of cement.

Initially, we were told that Joseph was lonely staying in the house and wanted to move out.  Indeed, he has a wife and small children who are housed a block away in the neighborhood, but I think he has gotten used to the comforts of the big house, and is happy to occupy it when we are away.

There is also a housemaid, Agatha, who was employed part-time by the landlord before we moved in.  She speaks not a word of English, and it is entertaining to watch her trying to communicate with Suzy in Twi.  Both Joseph and Agatha were willing to continue working for us at their previous monthly salaries.  So now, with Kwame, the driver occupying one back bedroom, Joseph in his lair, and Agatha showing up daily for household chores, we have essentially hired an extended family here, an unexpected bonus of occupying an oversized house – “With six, you get eggroll.”

[Answer to the pop quiz question above: You don’t have to surrender your computer jump drive and your cell phone when you go to the bank.]

It’s Nobody’s Fault; It’s Just the Way It Is.

If I had spent a year preparing for this sabbatical (and I almost did), I still could not have gotten things set up correctly.  My wife, Suzy, and I each had visas valid for two years.  So, I thought, our residency issues were resolved.

Finding a place to live in Accra was going to require some investment of time there, because we could not commit to living for a year in a place we had never seen.  I had arranged through the internet to occupy a furnished one bedroom house for the first 10 days at a vacationer’s rate of ~$50 per night. We picked the place because it advertised access to the internet, something I felt that I would need, both to start my work and to manage our financial affairs. Ten days, I thought, would be enough to see some properties in Accra and to find a furnished place to move into.  In addition, my Ghanaian-American colleague in Ann Arbor, Dr. GK, kindly arranged for a man to help us look for appropriate places to live.

Then, there was the issue of access to money.  Before leaving Michigan, Suzy arranged for us to access our US bank account on-line.  And for selected purchases, we had a Visa credit card, which is widely accepted here.  Suzy called Visa to advise them that we would be in Ghana and possible make credit charges from there.  However, to pay rent and utilities, obtain cash for routine purchases, and pay for a car and petrol, we assumed that we would need a local bank account.  We knew that checks drawn on American banks, even cashiers’ checks, take a minimum of three weeks to clear in foreign banks.  Since I was leery about the prospect of walking around town with thousands of dollars in my pocket, we came up with a simple, logical plan to circumvent the check-clearing delay.  My invaluable colleague, Dr. GK, kindly served as a conduit for us to transfer funds to a Ghanaian bank so that we could open an account of our own at his bank.  We wired $10,000 from our US dollar account to his Ghana cedi account at the Pan-African Ecobank in Accra. This amounted to about 10,100 Ghana cedis when converted to Ghanaian currency, and this was the amount of his personal check, which we carried with us to the bank the day after our arrival. We were assured that the wire transfer would go through the following day.  In addition to the check, Dr. GK gave us a letter of introduction to the bank and made a personal call to his contact at Ecobank, Ms. OE, to let her know in advance that the check we would be presenting would be valid to draw out the transferred funds.  It was a brilliant plan.

We also knew that transportation would be a problem, so we arranged to lease a car from the same provider that Dr. GK uses when he is in Accra.  In addition, because of the peculiarities of driving in this country, we were advised to have a driver at a small additional cost.  GK knew someone in Ghana that he trusted to drive for us.  Kwame A. is a farmer from a village near Cape Coast who had driven a “tro-tro” in the past (N.B. a tro-tro is a private minivan that serves as public transportation all over Ghana).  According to the plan, Kwame was to stay at the home of a friend of Dr. GK in Accra and to meet us each morning with the leased car to do whatever business that needed doing.  If this arrangement worked out, and we eventually found a place to live, he would continue to drive and to do other errands for us in return for room, board, and a modest salary.

So, everything seemed to be in place when we left Ann Arbor.  Getting settled would require some effort, but this would be an adventure that we would enjoy. Perhaps, in retrospect, the experiences we had were exactly that.  Only more so.  They were certainly enlightening, but there was non-stop anxiety on nearly all fronts.  So, here is how things actually transpired. . .

Adventures with Immigration
At the airport, our passport was stamped for a stay of 2 months only.  We were informed that we would have to stop by the Ghana Immigration Service in downtown Accra to have it extended for the full length of the sabbatical.  But — no problem – we had two months during which to extend the visa.  Anticipating that something so simple could not possibly be so simple, we went to Immigration on our first day in Accra.  It turned out that we each had to fill out a one page form, obtain a letter of invitation from our sponsoring institution, and bring two passport size photos.  We filled out the form, went to Osu to have while-you-wait passport pictures taken, and we managed to get a letter from the administrator at the Ghana College, Mr. A, explaining my purpose in the country.  We brought all of this back to immigration on the Monday after the weekend to find that the rules for expatriate residencies had changed.  Because we were staying for a year, and in spite of the fact that I was to draw no salary here, we were required to have a work permit.  According to the new rules, the sponsoring institution was required to apply on our behalf, a new letter was required, and we were asked to supply a police report from the U.S. certifying that we were not Bonnie and Clyde.

So, who do you call for a police report?  I didn’t expect the FBI to be too responsive to our request.  And we live outside the Ann Arbor city limits, so the Ann Arbor Police were not likely to be interested either.  Eventually, I had my older son contact the Washtenaw County Sheriff’s Department, and to my surprise, they did not find the request particularly unusual.  However, they had their requirements.   They wanted a letter explaining what we wanted, the reason for the request, an address to send the police report, and a money order for $24.  The letter had to be accompanied by copies of photo identification, and everything had to be notarized.  I typed and printed a letter explaining our situation (by the time this was happening we were in Kumasi), made copies of our passport identification pages, and took everything to a lawyer in Kumasi to be notarized.

The law office that we were referred to was a second story affair in the center of the downtown Kumasi commercial district, accessible from the stairs behind the street level shop. The reception area was sparse on the furniture and décor line, and the entire support staff seemed to be asleep with their eyes open.  The young secretary regained consciousness long enough to call her boss to inform him of the presence of foreign walk-ins. I noted that she addressed him on the phone as “lawyer” as one would address an American physician as “doctor.”  “Lawyer,” we were told, was presently at the courthouse, but he would be back in the office momentarily.  I took out my laptop and got some work done during the 15 minutes or so that we waited.

When he finally arrived, the lawyer was a charming and jolly gentleman of 77 years, still in active practice. His demeanor was remarkably pleasant and inviting. Clearly, he was more interested in learning who we were and how we got there than in our problem per se.   He wore a dark suit and dark tie with subtle food stains on it.  Had I not been told that he had come from the courthouse, I would have assumed that he had just attended a funeral with a buffet.  His bookshelf contained dusty law books that have likely appreciated in value now that they are rare.  The wall behind his desk displayed the usual array of documents and a photograph of a young black man in barrister’s robes (wig included) that turned out to be Lawyer himself some 50 years earlier after obtaining his degree at the University of London (UK).  Since Suzy and I had lived in London for 6 months in 1980, we were able to reminisce about the city when it was not so expensive a place to be.  (As the reader will later learn, we were finding Ghana to be a much more expensive proposition than London in the 1980s).  Lawyer went about the business of notarizing the documents automatically while covering a number of other, unrelated topics of conversation with us.  When all was properly sealed, he sent us off with a warm handshake that communicated, “thanks for breaking up the routine” and “don’t worry, it’ll all work out.”

The following week, we entrusted the notarized documents in an envelope addressed to the Washtenaw County Sheriff’s Department to two members of the University of Utah School of Social Work.  These lovely ladies, whom we met at the campus guest house where we stayed, agreed to carry the letter to the U.S. for us and mail it on arrival in New York City.  A $24 dollar money order was unobtainable here, even at a Western Union office.  So, we are depending on our Ute friends to mail the letter and on our children to deliver $24 to the Sheriff when the letter arrives.  If all of this actually happens, and the police report on our good behavior is generated, we have asked that it be sent to our home address so that our children can fax and mail it to the Ghana College of Physicians & Surgeons.  We will then go back to Immigration in Accra with the fax and the revised letter from the College.  And who knows if this will be acceptable?

Spintex Road to Nowhere
The night that we arrived at the Accra airport, we were greeted by 5000 waving taxi drivers and Kwame A. sporting a sign with our name on it.  This part of the Plan worked well, and only 2 hours later, we were 10 km from the airport where our short-term rental house was located.  The rental house was on Spintex Road, a two-lane thoroughfare that we would later learn is notorious for its traffic congestion.  As it was originally plotted, Spintex Road probably made sense.  It connected the north airport area, starting at the Accra Mall to the southern beach neighborhoods.  The problem with Spintex Road is that it exists in a one-dimensional universe.  Once you are on it you can go forward for about 20 km or backward, but you cannot go anywhere else.  Development has created commercial businesses, industries, and both high- and low-end neighborhoods on both sides of the road, but for a stretch of ~20 km, any turn you take off Spintex Road eventually ends in a cul-de-sac.  The logo of the Accra Mall, a serious nidus of gridlock, should have been a warning to me.  It consists of a circle with curved arrows from four directions pointing inward (but no arrows pointing out).  And that was the essence of Spintex Road.  You can sometimes enter it, but when you do, don’t expect to be able to get out.

This eventually created a problem for Kwame, our driver, who was expected to stay the night at the home of Dr. GK’s friend.  Unfortunately, the friend’s house was on the other side of the city, and it took hours and liters of petrol to make the trip back and forth each night.  Imagine that we were staying in, say, Bridgeport, Connecticut, and Kwame was making a round trip every night to Newark, N.J. for his accomodations.  When we added up the damages incurred in time and petrol by this nightly foray, it seemed most practical to find a place for Kwame to stay near us on Spintex Road and to give him food money.

The rental house that we stayed in was pleasant enough (see photos).  It was located a few hundred yards down one of the many dirt roads that lead off Spintex, to nowhere — a road on which goats and people are second-class citizens to the automobile elite going in and out of the cul-de-sac neighborhood.  The side road features bilateral open drainage culverts, an outdoor market consisting of wooden stalls that never seemed to be fully occupied, night clubs, bars, and chop bars extending streetward from the modest houses of the proprietors, and the occasional, metal cargo container converted into a personal storage facility cum domicile.  The house we rented was on a side road from the side road and part of a walled mini-cluster of three houses, one of a few in the neighborhood that constitutes the top end of the socioeconomic scale there.  However, our particular house was more the equivalent of the servant’s quarters to the two enormous villas in the same walled-in property.  One house on the property was occupied by a Ghanaian-Canadian couple on vacation; the other by a Nigerian businesswoman, her children, and their governess.  We did not actually meet either of these families, but we did discover that they had internet service, while we never did.  Apparently, in response to our rental request from the US, the owner of the villas (a Ghanaian living in England) ordered an internet connection for the one-bedroom house from Ghana Telecom and charged us $4 (US) per day in advance for it.  Instead of an internet connection (and hot water), we had an amazingly complicated array of electronic audio and video equipment and 24-hour satellite TV, none of which I really needed (see photo below).  The hot water would have been nice also, but the Wall of Sound was completely unnecessary, since there were local bars and nightclubs blaring music from several directions all night and a functioning sawmill over the concrete wall behind us with the rotary saws buzzing continuously during the daylight hours Monday through Saturday. One could not feel lonely in this neighborhood.

The local staff at this vacation villa complex (the gatemen, the driver, the maid) were really the best thing about the place.  Several of them consulted me about medical matters when they learned that I was a physician.  One had some form of soft tissue rheumatism that responded promptly to some of Suzy’s ibuprofen; another had some diarrhea, terrible GERD, post-prandial fullness, and upper abdominal bloating following an extended stay in the Ivory Coast.  He needed antacids and serious consideration for giardiasis to address potentially reversible causes.  In the US, this man would get esophagogastroduodenoscopy.  But I knew that this would not happen here, because a colleague of mine from the US is currently helping Ghanaian internists at the University to establish a training program and competency assessment for endoscopists in Accra.  I dearly hope that Oliver does not have something obstructive that would be very difficult to address here.

The difficult part about staying in this area was, as I have already mentioned, getting in and out.  Unless properly timed, living on Spintex Road and working in central Accra required 3-4 hours of sitting in traffic, inhaling non-catalytically-converted truck fumes every day.  If I left the house at 10:00am in the morning and left central Accra after 8pm every night, I could reduce the total commute to 1-2 hours.  So, I was not pleased when the fine young man who wanted to find us rental properties restricted his search to the area around Spintex Road.  He also had a seriously distorted view of who we were and what we were looking for.  The first place he took us to was a brand new “hotel” in neighborhood with houses that would be hard to top on square-footage in any Ann Arbor neighborhood.  The hotel had a full staff, but no guests.  All of the floors were marble.  Every inch of the two-story atrium walls was covered with artwork; some very expensive, some kitsch.  The rooms were on the second floor accessible by either of at least two (and I think more) spiral staircases with marble steps.  The furniture was all heavy mahagony and overstuffed, leather-upholstery.  My overall impression of the place was that it needed a Dubai oil executive to live there to finish the picture.  They wanted $1400 (US) a month for us to occupy two rooms, with a year’s rent in advance.  Who does this??!

The mini-shopping mall down the road was also an awakening.  Well-manicured, uniformed sales personnel were happy to show us the finest cell phones from a display case that looked like it might have once held the Hope Diamond.  A few short steps across the corridor brought us to a convenience grocery store that featured the same items one would find at a 7-11 in the US, only three times the price.  We bought a small can of tuna, pita bread, a clutch of green onions (grown locally), and a couple of packages of instant ramen for about $20.  A conversation with our host-guide stressing our interest in trying to live in the local economy and within modest means, he subsequently invited us to look at other houses off Spintex Road.  We fired him gently but firmly.  A subsequent, brief conversation with the U.S. Peace Corps Director about local housing and landlord’s routine demands for literally years of rent in advance convinced me that Suzy and I would probably not be able to afford to live in Accra.  We were planning a trip to Kumasi anyway.  We would look there.  Supposedly, Kumasi was not yet in the overinflated real estate cycle.

It’s Like Money in the Bank (or a facsimile thereof)
Our first night in Ghana, Suzy and I took advantage of the Novotel in Central Accra to eat dinner and use the wireless internet there.  One of the restaurant supervisors at the Novotel, Ms. A, is the same close friend of Dr. GK that was initially housing Kwame, our driver, and she had been very welcoming and helpful to us early in our stay.  We count Ms. A. among the Ghanaians who have helped us and to whom we are indebted.  She was delighted to see us there for dinner, and afterwards, accepted our Visa card for payment.  Unfortunately, the Visa card charge was not approved.  We paid cash instead, and I immediately called the toll-free number to find out what was going on.  Apparently, our pre-travel advisory to the card company was not enough, and they were still blocking payment from Africa.  Fine.  That was corrected – until a few days later when we again tried to use the card at the same hotel restaurant.  Another phone call to Visa revealed that our card account was deactivated, and we were being sent new cards to our home and a fraud report to fill out.  Apparently, between the first and second charge that we attempted, there was another charge (of only about $3) that we did not make to a company that was known to Visa as a “fradulent enterprise.”  So, after one exposure of our Visa card, we were already experiencing attempted identity theft.  Well, no matter.  We had our plan to open a bank account with a check drawn on the same bank.

I had known that African banks tend to follow the British and French formalities.  They are oriented toward the customer’s money, but not toward the customers.  Almost any transaction that involves interaction with a bank employee rather than an ATM is going to take time.  Knowing this, Suzy and I were pleasantly surprised when we were able to open a new account, order checks, and order an ATM card all within about an hour.  Everything worked as planned.  The account was opened on a Friday, and we were assured that the large check we were carrying would be credited to the account on Monday.

When Wednesday rolled around and the account was still not credited, we went back to the bank to make an inquiry.  Ms. OE attended to the problem and was able to locate our 10,000 cedi check.  Why was it still uncashed and not credited to our account?  Apparently, on the basis of insufficient funds in the account from which it was drawn. When we found a place to connect to the internet, we tried logging onto our US bank account information, but access was denied with the correct username and password.  Why?  When we called, we learned that our bank would not accept log-ins from Ghana because of fears about fraudulent on-line transactions from here.  So now, my paranoia was reaching climax.  What had happened? Did someone intercept the wire transfer and divert it elsewhere? Was the Visa interloper on our identity trail? Did Dr. GK, who is one of the most honest and upright people I have ever met, decide to begin a new life of crime and take off to Mexico with our money?  All sorts of crazy scenarios were caroming around in my head.  All except for the correct one.  Which was that our trusted bank in Ann Arbor had failed to wire the money.

Dr. GK solved this one, and he persuaded the bank to execute the electronic transaction.  Needless to say, I was relieved when the transfer finally arrived the following day (more than a week late).  And I felt chastised having thought first that the fault was with Ecobank when it was TCF trying to protect our funds that caused the problem.  Another case of “it’s nobody’s fault, it’s just the way it is.”

In the next installment to this blog, I will describe our experiences in Kumasi, and give an account of our “settling-in” here (“With Six, You Get Egg Roll”).

Initial Experiences

After having arrived in Ghana on the 25th of September, it is only now that I feel ready to begin contributing to this blog.  My experiences during the first three weeks here have involved some amazing logistical problems and frustrations, belayed in part by warmth, enthusiasm, and generosity of many Ghanaian colleagues and acquaintances.  With their help, I am now feeling sufficiently rooted to allow me to focus on my medical education work and to worry less about the practical matters inherent in living here for an entire year.  Since none of the University of Michigan faculty that has preceded me here has committed to spending an entire year, many of the obstacles that I have encountered, both in Ghana and Ann Arbor, should be instructive for anyone who follows me.  But I will deal with those issues later.  First, I should outline where things stand on the projects that I came here to do.

1. The Ghana College of Physicians & Surgeons (in Accra) is becoming the primary source of certification for physicians finishing their specialty training in Surgery, Medicine, Pediatrics, Family Medicine, and OB/GYN.  Previously and currently, this role has been served by the West African College of Physicians & Surgeons, but Ghana is striking out to establish its individual identity in the House of Medicine here. The Ghana College administers certifying examinations, large parts of which are oral.  It also seeks to provide support for diplomates in practice in the field after certification.  The Rector of the College has been interested for some time in establishing the capacity for telemedicine at the College, and he would like to create appropriate educational review materials for candidates to use in preparation for examinations.  In particular, he feels that candidates need to review pathology and pathophysiology.  He has asked me to propose a review tool to be provided by the College.
I have started to produce such a tool using a case-based, interactive format with written feedback, photographs of gross and microscopic pathology, and reference materials for further reading.  At this point, I have generated a structure and created 4 cases for the “Basic Principles” and 4 cases for the “Kidney and Urinary Tract” sections.  I now propose to provide the Rector with a CD demonstrating this much of the course to determine whether he thinks this will serve his purposes.  If he is happy with the format and style, he has already suggested putting me in touch with pathologists here who may have local materials and perspectives to shape the project going forward in exchange for authorship.  The challenge will be to produce something useful using only open or local resources.

2. I have also initiated a project with Dr. AR in Accra.  This faculty member is in the Department of OB/GYN at the University of Ghana Medical School.  He is concerned that, because of the large numbers of medical students who rotate on the OB/GYN service at the same time, some may never have the opportunity to see a hysterectomy done.  He has asked me to help him to generate an instructive video demonstrating and explaining the procedure.   Initially, he wanted to include surgical atlas pictures to orient the students, but the kind of images that would serve this purpose are not open resources and would need to be redrawn.  I think I have convinced him that stopping the action on the surgery and labeling structure on the video may be the best way to orient the student viewing.  The program will also be case-based, using some of his case material, and it will deal with indications for the procedure, pre-operative preparation, and post-operative complications.  I will try to make a video of his surgery the next time I am in Accra on his surgery day.  I will then edit the video for time and arrange to have him do a voiceover.

3. In Kumasi, The Head of the Department of Microbiology, Dr. SAY, has indicated an interest in reducing the number of lectures for an overburdened faculty by presenting some parts of the medical microbiology curriculum electronically.  Last week, to help with the lecture log jam, I volunteered to give 3 hours of lectures already scheduled on the topic of Anaerobic Infections.   This gave me some ideas about how we might proceed with instructional materials.  However, the experience of lecturing to the students at K.N.U.S.T. /S.M.S. (Kwame Nkrumah University of Science & Technology/ School of Medical Science) was one that I will never forget and always cherish.  And I look forward to doing more of it in the coming months.

Permit me to add some personal impressions and color to these events.   The lecture hall is relatively small and cramped for the class of ~150 students, all of whom come to the lectures on time at 8:00am and listen attentively.  There is only a small space free at the front of the room for the lecturer to stand, and there is a standard connection to a ceiling mounted LCD projector.  There is no audio system, so the lecturer is obligated to project his/her voice back to the 20th  row.  For me, this is the closest I will ever get to performing on the operatic stage.  It takes a lot of energy, and it is excellent exercise for opening the “pipes.” The room is equipped with two window-style air-conditioners and ceiling fans, but this equipment cannot keep up with the mounting African heat, which becomes oppressive by about 9:00am.  By the end of lecture, the students are all calm and dry, while I have sweated through the front and back of my shirt (note to self: bring a bottle of water to class next time to avoid possible syncope, i.e., combined dehydration and Valsalva effect from vocal effort).

The students’ attitude about learning is something I have never before seen.  They are like sponges for knowledge.   They do not ask what will be on the test.  When I start the class by saying “Good Morning Class”, they respond in loud unison, “Good Morning, Professor Engleberg.”  When I pose an open question to the class, students actually try to answer.  When I tried to pronounce the name of the department Head and missed the proper intonation, I got a hearty round of laughter from everyone in the class.  (God only knows what I actually called him.)  But I also got a demonstration of the correct intonation, and I repeated it to everyone’s satisfaction.  I then said, “Mii sua Twi” (“I am learning Twi”), and I must have said it correctly, because the response was an exuberant mixture of approval and amazement.  When the first lecture was over, several students wanted to talk with me and to carry my bag for me.  Several students commented that they were pleased at the way I had presented the materials, in a clinically-based format.  Isn’t this what teachers live for?  I hope they will be as excited about electronic learning materials.  I distributed my PowerPoint slides on a CD-ROM disk, long with book chapters on Clostridia and Bacteroides from my textbook and a review on C. difficile infection by John Bartlett from the Annals of Internal Medicine.  I gave the disk to the Class President to distribute.

In my next contribution to this blog, I will touch on some of the difficulties I’ve encountered try to get settled for an extended stay in Ghana, subtitled, “It’s nobody’s fault, it’s just the way things are. . .”