Today is a big day. This is the day that one of the UML groups will be doing their HIV program. Of course as with any of projects this year we are given a price of the items that we need for this program. We are using an inner courtyard of a home in the center of the town but we must hire chairs and a canopy for shade cover and also to provide refreshments for the participants. The students are not prepared for this expense so this is a cost I must cover. I am quoted 100 Cedes.(about 80 USD) I have no way to tell if this is accurate. I have no option but to pay. The students will be delivering a 2 hour educational program aimed at the 12-14. We see younger children in the crowd as well as older adults. We have to shoo them away. The content is too mature for the younger children and although the topic is ok for the older people we only have supplies for 50 and the activities are geared for an adolescent group.

I am again upset to learn that there is an expectation that the hypertension clinic will be happening simultaneously. I am needed at the HTN Clinic due to prescribing of meds but I am also needed to observe the students for their grade. This happened last year and I am frustrated by the lack of control I have over the situation. Maura and I work out a tag team approach to coverage of the clinic and supervision of the program. The program is conducted flawlessly and the students did very well. I believe it has been a wonderful learning experience for them. We have already discussed that they can repeat this program in another village but we would not be able to support the rental of chairs or purchase of food.

The hypertension clinic was pure chaos again. Some patients politely wait their turn and others simply step up to me even when I am in the middle of a patient exam and demand to be examined and demand there pills. I have to be firm with many of them and occasionally have to boot them out of my exam area. Patient confidentiality seems non-existent in this country. One child is brought to me because it is the mother’s hope I can cure her because she is mute. She is 5 and has never spoken a word. My exam is difficult and the room is loud and hot. I think she is deaf and there is nothing I can do. I advise her to go to Accra to be evaluated but I am not sure there is a solution for her. Another 4 year child is brought to me. Evidently she was walking fine until 3 months ago when she fell and ? injured her back. She does not have any reaction to sharp stimulus from me from her toes up to her diaper region. She cannot walk now and the teenage mother has not been given much information from the doctors. She is hoping I have an answer for her. I have none to give. Another 5 year old child is brought to me who has not walked at all since birth. I suspect some type of birth injury because there is a distinct absence of any muscle strength in her lower extremities. Deep tendon reflexes are difficult to assess as I have left my hammer back at the guest house. Even if I could assess the DTR I would not have any hope for this mother. I am amazed that they bring these severely injured children to me hoping for some type of miracle.

I am besieged by patients all with one ailment after another. I cannot even complete a rudimentary assessment before another patient barges in and starts asking for some type of help. After a few hours I tell our community leader that it is time to end the hypertension clinic. We have given out many medications. The people are not happy with their care unless they receive some pills before they leave. We have brought some vitamins so we can give out some of those but it bothers us that we are supporting their false assumption that good care = drugs. Patrick takes me on some home visits. These are some elder people who cannot make the walk to the center of town. It has been a long day and it is getting longer. Many of the people in Ghana have hypertension. We have tried to collect some data on our readings but due to the volume of patients we have not been 100% successful. My rough estimate is that 30-40% of the people tested are likely in Stage 2 or 3 hypertension and probably another 30% more are Stage 1. We do not see too many normal readings. Due to my short supply of medications I need to change my criteria for giving out meds. I am reserving my supply for the most severe cases of diastolic over 100 and systolic over 170. There is no lack of people with that reading and my supply quickly dwindles.

When I return from my home visits the students have completed their program and now we are offering HIV testing to the adolescents. We have made a big ethical decision today that some of the students do not agree with. Based on strong advice from the community leaders who know these people we have been advised not to announce that the test is for HIV. AIDS and HIV infected people are highly ostracized in this community. Families of patients with known HIV infection are shunned and often unable to earn a living. There is such prejudice against the HIV infected person. The HIV education program is intended to increase understanding of HIV and to help the young people develop safe sexual habits. The deception about the testing weighs heavily on my mind. I tell all the UML students that they have the option of not testing and three of them decline to participate. I admire their courage but also realize that some of the issues about this testing need to be considered in light of the cultural context. If our goal is to re duce the spread of HIV to others then we may need to use some deception to identify some of the infected persons. I know this decision will haunt me for a while. We have been assured by our leaders that this practice is common and that even the Margret Marquart hospital does testing on patients without consent and there is a code on the charts that indicate their HIV status. It is a difficult and tense period of testing. I am thrilled that we have not one positive result. We are fairly certain that most of the adolescents know that they are being tested for HIV due to the fact that they just had a 2 hour lecture on that topic. The youth of this country are much more open about this disease and hopefully will be able to dispel some of the prejudices.

The day has not ended yet but we leave Nkonya because we have more work to do in Kpando. After a brief rest at our guest house we gather a box of toys and clothes and deliver them to a nearby orphanage. We had originally planned on donating these items to Hardt Haven orphanage but we have met some resistance from the director. We then became aware of another orphanage in town that is equally needy. We go and make initial introductions at the facility, Missahoe Orphanage. The UML Students are enthralled with these children. The is home to about 30 boarding students and an additional 10 other students during the day. It is a very well run orphanage with evidence of an orderly organization that emphasizes the children’s health and well being. The director and staff members are loving and attentive and the children all appear happy and healthy. WE enjoy a short period of time playing with the children and tomorrow we will return to give them some of our donated toys and clothes. These children have nothing but they are so appreciative of any little toy or sticker that you give them. It is refreshing to see the young pre-teen boys ( 10-12) who actively seek out the coloring book pages and they color with great enthusiasm. An American boy of the same age would never be satisfied with the simple pleasures of coloring a page. These Ghanaian orphans represent an unusual stage of innocence not often seen. I am reminded again how fortunate I am to have healthy children and realize the vast differences in the childhood of my children versus that of a Ghanaian orphan. It is much food for thought .