Yesterday, I ran a half-marathon as part of the Accra International Marathon (“AIM”). Well, actually I ran-walked it, finishing in roughly two and half hours. They didn’t have a clock so that’s an estimate from my watch.
According to the race director, the marathon’s mission is to “attract national and international participants to a world-class marathon running and walking event in the nation's capital and to be a fundraising vehicle in support of The Longevity Project (the Project). The mission of The Longevity Project is to increase the life expectancy and quality of life of Ghanaians. The prevailing life expectancy is approximately 58 years.”
The marathon was quite the adventure, different from any race I’ve ever done in the US. While we started in a fairly rural area and did at least 3-4 miles along a beautiful Oceanside road, a large part of the race was run through busy suburbs of Accra. This means that I spent most of my mental energy focusing on not getting flattened by a car (although I was hit by a car door), dodging people (or gently pushing them out of the way), and preserving my ankles in uneven roadside ditches.
The race was truly international, however. In a field of only 400, I spoke with runners from Poland, Holland, Russia, the UK, South Africa, Liberia, Japan, and the US. A six-year old girl and several Peace Corps volunteers also competed. We finished the morning eating jollof rice (to be explained in my food posting) and dancing to a Ghanaian drummer on the beach. Amazing day!
(Pictured: the awesome handmade bag given to all runners)
Market day finally arrived! (i.e. the day the girls across the hall agreed to accompany me to Makola Market, because according to them, "You can't go alone!!") And I am now the proud owner of a bucket (and some other necessities).
*Great sigh of relief*
Shopping in Accra is NOTHING like anything I've ever encountered, even in Ecuador or Black Friday at the mall. I'm attaching a few pictures for your viewing pleasure, but sadly they really don't capture the stifling hot energy of the place. Chisom (my friend across the hall) wouldn't let me take my camera out for more than 1 minute though, because she was already worried about my safety. (Chisom: "Meghan you walk between me and Fareedah, for safety." "Meghan stay with us!")
Bargaining was also a challenge. Chisom and Fareedah would succesfully bargain a price, and then when I popped out from behind whatever I was casually hiding, the vendor would see me (read: my white skin) and immediately try to raise the price. But we did alright. Kaneshie Market is next, where I'll visit the tailor to have a dress made. Woohoo!
One of my concerns when I decided to take a year off from medical school was that I would forget all my clinical knowledge. After just two days of rounds on the pediatric service at Korle-Bu, I am now assured that I will forget very little and learn a lot.
Pediatric rounds at Korle-Bu differ in several ways from UMDNJ:
Since the ward is one giant room, all rounds are bedside. No chance of hallway rounds here (phew)!
Since the ward is one giant room, privacy is a concern. The doctors and students talk in hushed voices and I have to crowd in tightly to hear everything!
Rounds are quick! No extended conversations, too many patients!
Korle-Bu is a regional referral center for almost all of Sub-Saharan West Africa, so every child on the ward is very very sick, generally with diseases I wasn’t able to see during my pediatric rotation at home. I could go on for hours (or pages) on all the patients I’m seeing. So as part of this blog, I’ll post a case with discussion every few days.
(Disclosure: I’m not directly involved in patient care here, and so the information I post here will be limited. It will also spare identifying details. And I’m a medical student, not a doctor, so please, don’t be too hard on me! If the details are a bit vague, it’s because I wasn’t able to get them. I’m posting random tidbits at the end for any med students reading. See? My blog is like studying!)
CASE 1: Hepatocellular Carcinoma
The patient is a 6-year old boy who was referred for weight loss and yellowing of the eyes. Lab tests showed elevated liver enzymes, and he was diagnosed with hepatocellular carcinoma before I first saw him. He received his first round of (cisplatin/5-flourouracil/doxorubicin) chemotherapy this week.
The boy is emaciated, with temporal wasting and abdominal distension. His eyes are not currently icteric (yellow). He is weak, and still on the inpatient service for febrile neutropenia. It is decided that his next course of chemotherapy will be delayed from 2weeks to 3weeks from now.Blood cultures and a white count are pending.
Hepatocellular carcinoma is a primary malignancy of the liver. It’s usually secondary to either Hepatitis (B or C) or Cirrhosis (usually due to alcohol abuse). It is relatively rare in developed Western countries, and is found more commonly in China and Western Africa. In these regions, chronic hepatitis is usually the culprit.
Hepatitis B is more common in West Africa than in the United States because routine childhood vaccination for the virus did not begin until 2002. This means that our 6-year old patient slipped through the cracks in 2003 as the vaccination was being established. Hepatitis B, when transmitted perinatally, increases the risk of hepatocellular carcinoma significantly, and is correlated with earlier disease onset.
The prognosis for Hepatocellular Carcinoma depends on tumor size/stage/ grade/vascularity, but is poor, estimated at approximately 3-6 months. Surgical resection and liver transplant have generally shown only 50-65% survival rates, and chemotherapy is considered palliative. Interventional radiology or Radiation oncology may offer potential treatments, but these are still in development, and definitely not available in resource-limited settings.
So, through my reading, I discovered that we’re essentially treating this boy palliatively, and he likely won’t survive my stay here in Ghana. This is my first taste of the difficulties of pediatric heme/onc….
Random tidbits from reading:
-In developed countries, patients with no other known risk factors for hepatocellular carcinoma should be screened for acute porphyries, which are risk factors for HCC.
-Aflatoxin infection is also associated with Cirrhosis-linked HCC
-All heme/onc patients at Korle-Bu are screened for HIV.
Today was an exercise in contrasts. And in patience. My lab director Mr. Sagoe called it my “baptism” to Africa.
6:30am: no running water today. still don’t have a bucket. really need to get to the market. no shower for today.
7:30am: standing in the Medical School Administration, trying to pay rent for the second time. The offices were closed Friday when I stopped by, as well as all weekend and Monday for a national holiday, but that didn’t stop the porter from rapping on my door daily to remind me that I needed to pay. As expected, the secretary tells me that the cashier isn’t in, that I should return at 9am. I’m scheduled to be at morning rounds at 9am. Oh well. I have until 4pm to return and only 2 hours of “work” to do all day. No problem.
9am: Morning rounds.
10am: I’m escorted across campus to the Virology lab, where I’ll be processing samples in a secondary project on patterns of resistance evolution in the HIV Reverse Transcriptase (RT) Gene. Mr. Sagoe, a doctoral student, is my point man here. I find him working on sequences. What a surprise! While across the street families can’t afford portocaths or antibiotics, Mr. Sagoe is working on genetic sequence data, using software that I first used during my undergraduate thesis, and was repeatedly reminded, “This is expensive!” I’m excited to do genetic analysis again, but surprised at the sudden shift in resources. Mr. Sagoe finishes his morning work by processing his sequences through Stanford University’s online RT Gene Resistance Profile software, to determine if his samples are resistant to any medicines.Incredible. Thank you Stanford!
11am: Mr. Sagoe invites me to run a “quick errand” with him across town so that I can see the city of Accra.
11:30am: Far from the high-tech Virology lab, I’m reminded of where I am. We drive through shanty towns where children are bathing in the streets, and Mr. Sagoe asks me to keep the windows closed to keep vendors out of the car.
12noon: The car breaks down. I’m pushing our Peugot sedan through downtown Accra. Perfect time of day in the tropics to be pushing a car….
12:30pm: Mechanic shows up! Diagnosis: a carburetor problem. We’re on our way.
1pm: Car breaks down again. I’m pushing again. People are cheering me on from the passing tro-tro’s, “Go Obruni go!” (Obruni = white girl)
1:30pm: Mechanic is called. We sit in a parking lot.
3pm: On our way again.
3:30pm: Mr. Sagoe gives in to the temptation of a vendor selling groundnuts (boiled peanuts) in the street. He stops the car to purchase them, and it doesn’t restart. I marvel at my own patience.
4pm: Sitting in a mechanic’s parking lot where we’ve pushed the car. He’s very congenial and offers me some rice. I pass, not quite ready to eat with my hands from the bowl where the mechanics (read: greasy hands) have all been eating. Maybe I’ll get there soon!
5pm: The car gets a makeshift new carburetor, and we’re finally back at Korle-Bu. Mr. Sagoe offers me a ride home, but I volunteer to happily walk the final mile.
I’ve decided to make a blog! As an easy way to open it, thought I’d answer some of the most common questions I’ve gotten over the past few months:
Are you taking a year off from medical school?
Yes! I was awarded a Doris Duke Clinical Research Fellowship from YaleMedicalSchool to research pediatric HIV in Ghana. This means that I’ll be living and working in Accra, the capital of Ghana, from September 2009 through May 2010. I’ll return to school for my fourth year next fall.
Wait, I thought you were in New Haven?
As part of the Doris Duke fellowship, students spend one month at their “host” institution learning the basics of statistics, clinical research methods, and getting to know their mentor. While I was in New Haven I got to know Dr. Elijah Paintsil, a native Ghanaian pediatrician who now works at Yale and is overseeing my project. We developed a research protocol, and he gave me hints on life in Ghana.
I also got to meet the other Yale Doris Duke Fellows. There are 12 of us total. 9 will be staying in New Haven all year, and three of us are here in Africa. You can check out the other two (awesome) girls at:
How did you pick Ghana? (I get this a lot from people here in Ghana.)
The short answer is, “Ghana picked me.” (People here like this. Sweeet & simple.)
The slightly longer one is that I applied to the Doris Duke foundation with the general goal of doing research abroad in a developing country, and I was selected to work with Dr. Paintsil in Ghana. I also have a mentor in Accra, Dr. Lorna Renner, who I work with on a daily basis.
For those who haven’t studied a map recently: Ghana is a small country about the size of Pennsylvania on the coast of west Africa. It overlooks the Atlantic to the south, and has a tropical climate. Accra is the capital, and is located right on the ocean.
What is your research about?
I’m going to be evaluating different biomarkers for monitoring HIV progression in children. Right now the standard of care in the US is to use percentage CD4 count (because the absolute count varies with age in children), viral load, and clinical symptoms. However, the lab costs associated with measuring percentage CD4 count and viral load are prohibitive in resource-limited settings. Absolute CD4 count is a moderately cheaper option. The question is: Can absolute CD4 counts be used in children to reliably monitor HIV progression?
This is an important question because in places where every IV line is counted and patients frequently discontinue treatment because of cost, every lab test must be considered carefully. A preliminary trial of this study in New Haven showed that absolute CD4 count was adequate, and we hope to strengthen these results by a similar trial in Ghana.
Where are you living?
I’m living in the “International Medical Students’ Hostel” on the Korle-Bu Teaching Hospital campus. International means mostly Nigerian students, although a few Americans come each month for electives (read: You should come visit me! Get credit, have fun!). I have a roommate named Amma, a first year medical student, from Ghana who has been indispensable in helping me settle in.
The Korle-Bu Teaching Hospital campus is huge, including the hospitals, nursing/public health/midwifery/every other health profession schools. It’s also surrounded by a huge wall.This means that in a crowded city, I live in a relatively safe haven with little to no traffic and extra green life. It’s pretty nice! Great jogging grounds!
Not everything has been an easy adjustment, however. The running water went out today (this apparently happens a few times a week), and I haven’t yet bought a bucket to shower with. So after returning from a long sweaty run this morning, I was greeted with the lovely option of not showering or not showering. Oof. Have to buy that bucket!
Can I get in contact to send you hilarious emails and leave ridiculous voicemails?
Yes! I have what I like to call an angel of a roommate, who not only set me up with a cell phone, but also hooked up our room with wireless internet. No running water, but wireless! A tradeoff I’ll gladly take. So go ahead and email me. Webcam with me. Whatever you like. I’ll work on getting my Skype set up so you can leave those ridiculous voicemails too.
Are you going to update this blog regularly?
As long as the internet access holds up, and you keep reading, yes.
