The "Working in Ghana" Project


[Dr. Margit is a small, gentle, warm person. She received medical training in her home country of Hungary. She has practiced medicine in Ghana for 18 years. Her private pediatric practice is located in a clinic that she and her husband--also a physician--operate in central Accra. They are in their fifties, and have two sons. For the past three years, she has also operated a general practice clinic annex on a part-time basis at their home in a suburb of Accra. She talked with Allan Wicker at the pediatric clinic.]

At this clinic, I treat only children. I also educate women about the proper care and feeding of the child, about family planning, about illnesses. And I try to learn their family and medical background. It is not always the case that the problem is that the child is sick. Sometimes the problem is in the family, for example, between the husband and wife, or lack of money. I generally see patients over several successive days to be sure of the diagnosis and to monitor their progress.

In the clinic annex, I treat adults as well as children. In that area, there is no other clinic and there is always somebody who is sick or who needs medical attention.

Monday and Friday are usually my busiest days. On a Monday, I arrive at 7 or 7:30 in the morning. Monday is busy because I haven't been here at the clinic since Friday. All cases that I saw on Thursday or Friday, I call back on Monday. And all cases that my husband has seen on Saturday or on Sunday--the clinic is open one hour on Sundays for injections--I will see them, too. You can't run a private clinic without follow-up, because they will say "I'm seeing a private doctor and I'm not getting well." This means you have to do more work than at a hospital, where people can always come back. A problem for patients now is transportation. Taxis are so expensive, and some people, especially those in outlying areas, can't afford to come back to be seen again.

Fridays are busy because I try to see again before the weekend, the patients who have come in on Monday or Tuesday. With malaria or typhoid, for example, I need to check patients' progress and get back results of laboratory tests. I may need to change the treatment.

There is less measles and chicken pox than before--measles was common here in the 1980's. And now almost all children are vaccinated for yellow fever. We make available to the government health service a room in our clinic to vaccinate children who live in this area; they come on Mondays for that. I send my patients there for vaccinations.

I normally work until I've seen all patients who come to see me. It could be 12:30 or 3. Then I go back home to the clinic annex, which is open from 4 to 7 in the evening.

At the annex I see adults as well as children. The population is older, and my cases include hypertension and dealing with emergencies--cuts and other injuries from work, falls, snake and scorpion bites. The population there is very poor. They don't see doctors often. Only in the advanced stages will they bring a child or other sick person in. Even at government hospitals in Ghana people have to pay something for medical services. As a physician, I must do something to save a life if I can.

If people can't pay, I give first aid to stabilize the patient. Then I discharge them to a government hospital, although the nearest one doesn't have much in the way of facilities.

At the clinic annex, I also see cases of cholera and typhoid. These people have no good water source--they have to buy it by the barrel. And it is not clean water. Yet they are eating, cooking with it, making kenkey (a food made with cornmeal). I myself take water from here in Accra to my home--we have no running water there because our house is on a hill and the water system doesn't reach there with sufficient pressure.

Sometimes, of course, people come to my home at night after clinic hours--for treatment of convulsions, asthma, abrasions, snake and bites and the like. There is no other clinic nearby, so when they come I must treat them.

Although we don't have our own laboratory, we have an arrangement with one in Accra and can get reports back in a day's time.

Getting drugs here is a problem. One can't get much from the government. You have to go to private pharmacies. Before, we used to get a lot from my country. But due to changes in currency exchange regulations, that is difficult. Now, patients have to go to the pharmacies and buy drugs. Many of the drugs are imported, and expensive. The prices are going up, up, up.

As I've told you, the people are poor. Sometimes they try to save money by going directly to a pharmacy and buying drugs that pharmacists recommend. In this country you can buy any drug that you can pay for--without prescription. Then if a child doesn't improve, they come and see me. In the pharmacies, the sales people may not take into account the age or weight of the child. Or they will say "a spoonful" but spoons can be of different sizes. Even in some clinics people don't know proper regimens for treating malaria. My fees are not large; drugs may cost six or seven times as much. And when patients come to me I look after the child until the sickness is gone.

Self-treatments and traditional medicine treatments can be a problem. I recall one case in which the mother overdosed her child, and the child died from convulsions. When I worked in a hospital in a rural area, there were problems from people's giving herbal drugs, including ginger enemas. Sometimes the children died. Here, I tell people that if they use local medicines, I will not treat their child. The local herbs have effects that may "cross" or interfere with drugs I prescribe, and the result is not good. The parent must stop one of them. I say, if you believe the herbs, use only them. If you believe me, stop using the herbs. I can only be responsible for what I do, I tell them. As you can see, much of my job is to educate the parents, as I have said. Actually, education is probably more of my work than treating illness.

[How do you feel about the work that you do?]

I'm very happy. I like it. Because I think of how much I have learned from my lifetime. Here in Africa I'm doing more for people than I could in my own country. There, when I was working in a medical school hospital in my own country, there were lots of colleagues around who could treat patients. You didn't have to set your own path. There were supervisors around. However, I don't think one should go from a medical school directly to clinic work. One needs to work in a hospital, such as I did in a rural area here in Ghana, to get the experience needed.

I do a lot of charity work. I am a member of the Women Doctor's Association. We had a two-year project in a village on the coast. Drugs were sent from America for the village and we did clinical work there. That project is over. Now we are running a well-women clinic. This type of clinic started in Kenya and now is in Ghana. We do pap smears and check for breast cancer. All members of the Association take turns staffing the clinic.

I'm also a member of the Ghana International Women's Club. We do fund raising for projects such as mental hospitals, purchasing medical supplies or equipment for rehabilitating patients. Another project is a vocational school for girls who have been given by their parents to fetish priests to do the priests' wishes. The school is to receive and train the girls, whose parents are reluctant to take them back. In general our funds are used for education and health.

[What is the most satisfying aspect of your work?]

All of these pictures (she smiles and points with two open palms to several bulletin boards covered with photographs of children). These are all children I have treated. When they come to give me the photos they are proud. They may say, "you see, I was small like this, and now I bring for you my baby...."

In my home country, there is more of a connection between the pediatrician and the patient, because there doctors typically spend the morning in consultation and the afternoons making home visits. Here, it is needed, but I can't afford it. I have too many patients.

[What is the most frustrating aspect of your work?]

(promptly, without hesitation) When somebody dies. But I am lucky because in this clinic that has happened only 3 or 4 times in the past 10 years. If I can treat and follow up my patients, there is no problem. Without question, I would again choose to do this kind of work. My son is a great help in the clinic annex, because there is no nurse there. Both he and his brother, now in medical school in America, have helped. I will miss him when he goes abroad to college this fall. When a patient goes into convulsions, you must immediately do something, and if you don't have a helping hand, it takes more time. It is better to ask parents to leave the room because seeing a convulsing child is not pleasant. Parents are then not much help.

Another frustration is that when patients are told to come back at a particular time, during clinic hours, they may not do so. They often come at other times, early in the morning and late at night. And you know, I am living there. There may be a strict regimen for giving drugs, but people don't recognize this. If they don't follow the regimen, and don't get well, they may spoil my name. I give good treatment, I do good follow-up. Yet they may say, I went to the doctor and got some drugs, but didn't get well. But it may be their own neglect of the treatment regimen. Many of these people are illiterate.

I've noticed that if a patient's employer is paying for the treatment, he is less likely to return for follow-up. He makes excuses of going to a funeral, going to the market. But if a person pays with his own money, he generally returns. I can usually tell if my patients will come back. In some cases, I prefer giving injections rather than prescribing tablets, because I can't rely on parents to give them or the child may not really swallow them.

A problem here is that diseases are becoming resistant to treatment with common medicines. The more effective drugs are imported, and can cost a lot. For one type of typhoid, the drugs can cost one hundred forty thousand cedis (then about $115). Some drugs can cost $3 per tablet. A full regimen can cost half a million cedis (about $415).

Sometimes, even educated people may take a maid servant--perhaps from a village or a poor area of Accra--and not give them a de-wormer. And she is the one who cooks and looks after the baby. She may also have typhoid already. The whole family can be infected. I always advise, if you take such a girl, spend a little money to check her health. And educate her to boil the water. I have several entire families that have gotten typhoid in that way. And testing and treating such a group is expensive. It may be that the richer people get these diseases more easily. They haven't built up immunity from exposure to such things as street food. Another problem is that children may buy contaminated food at school.

You know, sanitation is a major problem here. One thing that worries me very much is that in the suburb where we live, a new market has been built. It is without toilets, and without a drainage system. Yet market women who sell food stay there from morning to night. I don't know where they go to toilet, where they wash their hands. And the children urinate in front of them. That is an old system--like a hundred years ago. Flies light on the urine or feces and then on a piece of meat or fish in the market. People go to school, but they still don't understand this. Anytime I go to the market, I tell them.

And the vegetables sold by the roadside, they are all washed in "dark" water. If you don't wash it right, you get typhoid. Gutter water is also used to irrigate the plants. I don't know what they learn in school.

Here's another problem. You have seen along the roadside girls who sell ice water in small plastic bags to motorists. Before the bags are filled, someone blows air in them to open them. The person who does that might have TB. The government prohibited the sale of such bags of water, but that law is not enforced.

[What advice would you give to someone who was thinking of coming to Ghana as a physician?]

First you have to understand the people. And you can't think about sophisticated laboratory work. You have to work with the existing situation. You can cry that this or that is not available. If you do you will be miserable. I know of a doctor who came from a Western country--a well-trained, brilliant Ghanaian. But he was always sad: "We can't do this, we can't work here." You have to accept what there is. And we are gradually improving. But if you are sad or disappointed because conditions are not like Europe.... But you can work here. It is no problem. But if someone comes and says, "it can't be done, it can't be done," they can't work here.

In the West, physicians don't learn much about tropical medicine. I was lucky because at home I worked with a European physician who had served in Ghana for seven years. The physicians trained in this country, at Korle-Bu, get very good training in treating the common diseases here. The most prevalent are not heart disease and that kind of thing, but infectious diseases: typhoid, cholera, malaria, which do not require sophisticated equipment and techniques to treat. The kinds of diseases Western doctors are trained to deal with are not that common here.

Preventive medicine is very important. I'll give you an example. A woman may bring to me a baby suffering from diarrhea. Inside her handbag is the baby's bottle, the child's soiled diaper, money, bread--all in the same place. Cloths with childrens' vomit may also be put in the bag. I say, "Go and buy a plastic bag to put the soiled diaper in it. Put the food and money in a separate containers."

Here is another example. In Ghana people use a kind of fibrous sponge for scrubbing in the bath. It can be contaminated and spread skin rashes over the whole body, and even to other family members. Usually these scrubbers are kept in the bathroom, without exposure to the sunshine. I tell mothers to use a simple cloth, wash and iron it to avoid spreading the rash. I also show young mothers how to prepare healthful food for their children--food made from cooked vegetables, for example.

The task is huge, you know. There are perhaps eight hundred to a thousand physicians who work for the government in Ghana. That is a lot of people for each doctor. And about two years ago, there were 15 pediatricians in the country--there may be a few more now. There is a very large children's population here.

[How available are the medical supplies and equipment that you need?]

Sometimes supplies are difficult to get: syringes, needles. Here at the clinic we use only disposable ones. But you know, pediatricians do not need very sophisticated equipment--an examining table, stethoscope, the device for looking in the ear and nose, syringes, needles. Generally, private physicians don't import these--the government does, and we get them from the government. Sometimes, even thermometers are hard to get.

[From the pictures of the children here it is obvious that you have admirers among your patients. In general, how do you get along with the people you treat?]

Very well. Some of them even come with adult sicknesses, after they are married. I have good relations with the grandmothers; usually it is they who take care of the children. If my former patients who are now adults come to see my husband for treatment, they always come to greet me as well. People here are often quite impressed when they get well after treatment. They may not realize the power of medicine and the fact that most illnesses are curable. Some are in awe when they compare my treatment with herbal treatments, which may not work.

You know, back home I had a professor who told the class that we should write notes about personal matters of patients on their records, so that when we see them again we can ask about something special to them. That way they will know that the doctor cares about them. That is especially important for me, because of the language problem. Many of the women I see only speak a Ghanaian language--Ewe, Akan, Ga, or whatever. I must rely on my nurse to translate. I don't speak any Ghanaian language.

I come from a medical family--7 relatives back home are physicians, as well as my husband. I get a lot of support from my sons and from my husband, who takes care of the clinic on weekends.

If I should need drugs not available here in Ghana, I can arrange to get them from my home country. But now the prices are high there as well. For example, an antibiotic I sometimes prescribe costs fourteen thousand cedis (about $11) for a 3-day supply--and that is not the only medicine a patient may need.

When patients need drugs, I generally send them to the pharmacy rather than dispense them myself. That way they will know that it is the drugs, and not my fee, which is so expensive. But I keep samples here to show patients the exact item they should buy. Sometimes pharmacists may say, "I don't have that one, but this is a good substitute" when it is not. In Ghana very good drugs are available, but the common people cannot afford them.

To be a successful physician, you have to understand family problems. And for me, having my nurse to translate is essential. You have seen the child lying across the hall. His mother is a market woman who is now working. She has left the child and some money. If he gets hungry, I will send my nurse to buy some food for him. If he weren't allowed to stay here, no one would care for him during the day. You know, even in government clinics or hospitals, if a person is sick, someone from the family needs to stay there to nurse and feed him. If I closed the clinic now, this child would have to go, but no one would come for him before five p.m.. He had a temperature of 41 degrees (105.8 degrees Fahrenheit). He may have typhoid or malaria, I'm not sure. I think malaria, though, because two days ago his brother was here with malaria, and they stay in the same room. The same infected mosquito might have bitten them both.

I try to get the background on each patient, because it is sometimes important. Language can be a barrier. For example, women may be reluctant to tell my nurse things that they would tell me as a physician. For example, that their husband will not give them money for the child's treatment. Also in law, for example, Ghanaians may not want a third person--a translator--to hear what they say, maybe in making a will. Private problems aren't so private if they go through a third person.

In some cases people may not want to talk to me because I am white. I may then tell my nurse to go and talk to her in private. They then discuss the problem in their own language. The nurse will then come back and tell me the problem. Being white has not been a problem, though. I say that my patients will come back if I treat and cure them and keep them healthy. That becomes a good recommendation for me. They will tell others of their experience. I continue to get new patients; those who have been here may stay healthy and thus not need my care, and they eventually grow up.

[You mentioned that some people may be reluctant to talk to you because you are white. Do you think some patients may be reluctant to talk to you because you are a woman?]

No, I don't think so. Most of the people I see are women--mothers and grandmothers. Not even the men who come to the clinic annex. Even the men with gonorrhea show you the infection. There can be a problem with the Muslim women. If they have a gynecological problem they don't want to tell us or be examined. They may be looking for a Muslim gynecologist.

My main problem with men is that when they have several wives or girlfriends, they may not or maybe cannot supply enough money for the early wife to buy drugs for their sick children. The women may say that they have to wait until the man gives them the money. But the child is sick. The women may ask for a receipt in advance in order to get the money from their husbands, but I cannot give it until the payment is made.

But Ghanaian women may also not pay their own money if their child is sick. It is not just the husbands. If my child is sick, I can buy everything. But they know they must get permission from their man for everything. I had a bad experience at the rural hospital. We needed blood or a child would die. There were people outside. We needed less than a pint. None of them would give blood. They're crying, they're dancing, but not one would do it, and the child is dying. That I cannot understand. And the mother wouldn't give either, even though she had the same blood type. She ran away. She didn't understand it would not permanently affect her.

Fortunately, the blood system in Ghana is much better than it was 15 years ago when that happened. There is a blood bank. We can get blood--even can buy it. But before--in the early 1980's we could get only directly from donors. Blood is screened well now in Ghana.