This past semester I lived and studied at the University of Ghana. Located right outside the capital city of Accra I was within traveling distance of a great number of medical clinics and hospitals, two of which I visited frequently. No, I was not chronically sick or accident-prone, but was personally interested and invested in learning about the healthcare facilities of a third world country. There were lots of issues that I wanted to explore - what type of resources were these facilities provided? What demographics did they serve? What ailments presented most frequent? How did patients respond to advice? How did the doctor dispense advice? How was the chain of command established? … and more - of course.

I will first say that I had little autonomy of choosing which clinics I wanted to visit; the relationship was set up through a program facilitator and his previous connections. Actually, this ‘program facilitator’ was a retired doctor, Dr. Owusu, who remained on-call for any problems that our program’s students were having. One of the clinics he introduced to me was his own doing; he established the facility and served as the Medical Director for many decades until retirement. The other health facility - the one of which I will touch on in this article - is currently directed by a prior classmate and close friend. If given a choice, I would have preferred to also visit a more rural clinic; however, I was incredibly thankful for Dr. Owusu and his connections.

In this article, I will give a general overview of my experience at one of these clinics. I will discuss the methods of the doctor, the facilities available, and peculiar trends established by the patients. The Phillips Clinic was, obviously, a ‘clinic’ by definition and provided ambulatory, out-patient care on a daily basis. It was only open from 8-2 (or as early as the doctor arrived, usually around 7) and was best equipped to handle general, non-severe ailments. There was a single doctor’s office and a single doctor (Dr. Jane). About two or three nurses and two nurses-in-training were always present, plus the ‘matron’ who could dispense medicine. Additionally, about three men staffed the laboratory. Besides the doctor’s office - which contained the doctor’s desk and one check-up bed - there was a dressing room, a holding room, a pharmacy, a laboratory, and a waiting room. Sounds extensive - right? Let me embellish.

The waiting room held about twenty seats where patients would line up - first come first serve. The dressing room housed any equipment and supplies needed to dress common ailments like ulcers and burns. The pharmacy and laboratory were about equal in size - not over 10′ x 10′ each. The pharmacy was, to some extent, with medications with one wall lined with three filled shelves. The pharmacy was additionally the social hub of the staff. Most of the time, you could find several staff members, sitting in fold-up seats, talking amongst each other.

The laboratory was stocked with one microscope whose resolution and quality were about the grade of a typical high school’s microscope. With this piece of equipment they could diagnose malaria - a vital procedure here in Ghana. I was even able to see a parasite myself! Additional blood tests could be done by applying certain chemicals to the blood sample and reading the color of the solution. Patient’s blood was kept in open tubes and often not labeled. This was much unlike the security and sanitation measures taken in the US to ensure no mix-ups or contamination. There was a point in time when I was sitting in the laboratory and the lab tech spilled a drop of blood on the counter and simply wiped it away with a paper towel. Such measures would be ruled unsanitary and dangerous in the USA.

The waiting room at the Phillips Clinic. This is what you see immediately after entering the building.

Finally - the holding room was all of two hospital beds and maybe an IV. This room was never used in my time there but was present in case of a severely ill patient who would need to transported to a larger, 24-hour care facility after the clinic closed. Here’s my over-all summary of the facilities at the Phillips Clinic: Although the resources and facilities appeared minimal and rudimentary in comparison to standards set by the United States, it was my impression that the Phillips Clinic was a highly respected facility with loyal patrons.

I’ll speak more on Dr. Jane. Dr. Jane was the only doctor to practice at the Phillips Clinic. She received her secondary school education in what is arguably the best in Ghana - the Achimota School (originally the Prince of Wales School founded by British colonists). She moved to Germany for her medical degree and residency, and ever since has practiced family medicine in Ghana for 40-some-odd years. She is nearly 70 years old but always says she has plenty more years of practicing ahead of her. Dr. Jane always, always, emphasized the importance of a strong and cordial doctor-patient relationship. I observed this in her practice; she was kind to all individuals, greeting them with a smile, saying “happy new year” (despite it being March), and occasionally asking how their son/daughter/mother/father was if she had treated them before. From what Dr. Jane said, this mind-set - of showing kindness to patients- was not typical of doctors in Ghana. She asserted that many doctors were cold-shouldered and unsympathetic, they gave instructions of care without explanation of what ailed the patient. Patients don’t respond well to this attitude, she would tell me, when a patient feels demoralized and didn’t understand their condition, there was rarely motivation to change behaviors or faithfully administer the right medication. Dr. Jane was proud of the way patients trusted her and responded well to her advice. She even claimed that her most loyal patients have been with her for over 30 years and travel far beyond their means to meet with her. I was impressed by her approach to practicing medicine, especially because it follows the current trends in more developed countries, as far as encouraging bedside manner and a more egalitarian relationship than patriarchal one.

Dr. Jane seated at her desk with examination bed in the background. Patients would enter and sit at the chair next to her desk for consultations and moved to the examination bed only when necessary.

What surprised me the most was the ways in which my expectations were altered, with respect to the types of patients and the types of ailments they brought with them. When you think “Africa” or “third-world country,” what do you think? I thought about malaria and typhoid and yellow fever and malnutrition and HIV/AIDS and parasites, etc. What’s true about those expectations was that we saw a lot of malaria. To the point where, whenever a blood test was ordered, 95% of the time the doctor would check for parasites - just in case. Malaria symptoms are pretty general, fever, sweats, fatigue, and such symptoms don’t just apply to malaria. Additionally - a patient could come in complaining about a sore throat or respiratory infection but nonetheless, a malaria test would be conducted amongst other things especially because malaria weakens the immune system and is often the cause to secondary infections.

Another shot of the waiting room. The secretary's desk is in the foreground. The doctor's office is the door sighted on the left hand side. The dressing room, pharmacy, and lab are all located on the left-hand wall (not captured by this picture), across from the blue chairs.

What I didn’t see of which I expected to were the other conditions - typhoid, yellow fever, HIV, parasites, or even Hep B (half of these diseases required expensive vaccines to even be allowed into the country!). What I did see of which I wasn’t expecting were a whole lot of diabetes and high blood pressure. Wait, what? Diabetes? High blood pressure? Aren’t these the chronic diseases that affect Americans because we’re unhealthy, fat, and lazy? I explained my complexion to the doctor. And, of course, Dr. Jane had an answer:

A huge problem in Ghana isn’t necessarily undernutrition but malnutrition. There’s a slight difference. Undernutrition signifies the lack of sufficient calories. Malnutrition signifies the lack of a balanced and vitamin-rich diet. It was this malnutrition that led to such chronic diseases such as diabetes and high blood pressure. First off - a lot of Ghanaians drank soda. Bottled soda was nearly half the price of bottled water, about 50 cents a bottle. If they didn’t drink soda - they drank beer or malted beverages - still, both drinks that incorporated an incredible amount of sugars. Ghanaians would look at me weirdly when I refused a drink of soda. To them - it’s a source of energy so it must be good for them (It was also marked as being filled with ‘minerals’ and ‘nutritious’). Long story short - this chronic pattern of soda consumption contributed to high and growing rates of diabetes. And of course, it’s not the only aspect, but Dr. Jane truly believed that it was a contributor.

Furthermore, the Ghanaian diet didn’t incorporate too many vegetables or fruit. Not to say that these items were unavailable - but in relative price - were a lot more pricier than, say, a bowl of jollof rice or bean stew. The ‘poor man’s diet’ here consisted of very heavy fermented dough (made from maize, cassava, or plantains) with a heavy, tomato based stew.  The main diet was overwhelmingly based off carbohydrates and lacked nutritious items. Additionally - there was little nutrition awareness or education in schools so people didn’t know what proper nutrition included. These issues induced conditions that I had always associated with richer, more affluent nations whose diets are filled with high-fructose corn syrup, processed foods, and trans fats.

The pharmacy at the Phillips Clinic. If the in-house pharmacy did not have the proper medication in supply, patients would have to travel elsewhere.

Since there is a lack nutrition education within the primary schools, Dr. Jane’s advice to her patients seemed like common knowledge to me. Eat fruits and veggies five times a day, cut back on that palm oil (!), and watch your portions. She did her best to explain the causes of high blood pressure and diabetes in hopes to convince her patients that their health was in their hands. This tactic is, again, atypical of the “Ghanaian” mindset. Culturally, they accept a lot of events and conditions fatalistically; they saw themselves as not having control over unfortunate events and took it as it came. A common expression in any conversation was “it will come” signifies their belief in fate and a ‘if it’s meant to happen, it will happen’ type-of-attitude. I want to attribute this to the entire nation’s intense religiosity as they viewed themselves as vessels at the hands of their god; however, I only have anecdotal evidence for this so don’t take the previous statement as 100% fact. Anyway, this method of educating the patient is unorthodox since doctors in Ghana often just give direction and expect obedience. Dr. Jane recognized that a patient should be given information and should be informed of their role in maintaining their health. I observed that many of her patients were successful in stabilizing their blood sugar and lowering their blood pressure upon return. The patients who weren’t as successful often displayed their guilt when Dr. Jane gently chastised them for their elevated blood sugar or blood pressure. They acted in a way which indicated that they, logically, knew they were doing wrong but hadn’t made the personal choice to change their behaviors. I could imagine it’s often hard to do this, especially with a strong, culturally-enforced fatalistic attitude. In this case - Dr. Jane would, again, sit them down and describe more carefully how their health behaviors affect their body. It wasn’t a matter of prescribing the wrong dosage or the wrong medication, but informing the patient and connecting with them in a way that their behaviors changed.

Since the clinic was located in a middle class area of the city, we mostly saw local middle class citizens. Additionally, the pay-per-visit fee probably discriminated against lower class persons seeking help. There were certain companies and businesses whose insurance would pay for their clients’ personal visits; yet again, this signified that these patients were employed and had a relatively stable source of income (unlike a majority of the Ghanaian population). I walked into the clinic each week realizing that the patients diagnosed here, although representative of the Ghanaian population, was representative of a certain class of Ghanaians. I’m sure if I were located in the Northern Region, where health care is everything but available, that I would have seen a different incidence of disease.

Plenty more may be discussed about my experience in this clinic or even between the two clinics I visited. However, I will address these more specific topics in separate entries as to 1) keep the scope of this article limited to a ‘general overview’ and to 2) give myself more opportunities to embellish on my experience, without removing important aspects in sake of space. Hopefully, I have communicated the general sense of an ambulatory health clinic in middle-class, urban Ghana where the provision of care, although “different” from the health care we are used to in the United States, is impressive, organized, and patient-oriented.

A picture of the matron and me on duty.