Friday, March 27

Our last day in the Ashanti Region was centered around a visit to the Nkawie-Toase Hospital. This hospital is one of seven centers of excellence for treatment of Buruli ulcer patients. Services include in patient and out patient care. This particular center has a feel towards more comprehensive care of the patient. Not only do they provide non-surgical and surgical care, they have an excellent rehab facility for patients to maintain range of motion and function of affected areas of the body. For example, this may include the elbow, knee or ankle areas. A very high percentage of ulcers affect these areas of the body. The two physical therapy assistants and the to-be-hired physical therapist have plenty of work to do!

Like so many of the Buruli ulcer treatment resources, the rehabilitation equipment was donated by an external NGO, in this case, the Anesvad, Spain, the benefactor of this facility.

Medicine ball hams!

Charles Yeboah gives it all he's got!

Dr. Ampadu, we're impressed!

John feels the burn!

In an effort to sort out how treatment is paid for, we discovered that the cost of treatment for an early category 1 lesion (nodule, plaque, small ulcer) is about 25 dollars. This is compared to the cost of a larger category 2 ulcer, which is 1000 dollars. Treatment funding is fragmented. There is a national health insurance system, for which one must register and pay 7.2-45 cedis annually. However BU treatment is not included as a benefit. The Ministry of Health provides wound dressing supplies and antibiotics (Rifampin and Streptomycin) for treatment. However, all other BU-required services are not reimbursed by the national health insurance program.

Receipts will go to the Ministry of Health, which will reimburse the facility if they have funds. There is currently a great deal of effort being put forth to change national health legislation to include BU treatment as a benefit. In the meantime, since patients do not pay for treatment (a fundamental point underlying success of the National Buruli Ulcer Program), hospitals and clinics provide a great deal of. BU care without reimbursement.

Fortunately, on March 25, 2009, President Mills made a strong statement indicating his interest in "uprooting" Buruli ulcer. This provides hope for those individuals from the Ministry of Health and the 46 treatment centers who work tirelessly to help the patients and families afflicted with this stigmatizing and debilitating disease.

Our Ministry of Health hosts have very gracious in showing us all calibers of facilities and in answering all of our questions. It's been invaluable to be able to see the effects of BU and what is being done to lessen and even eliminate suffering of so many individuals, families and communities.

Thursday, March 26

With the thoughtful guidance of our hosts from the Ministry of Health, Dr. Edwin Ampadu and Charles Yeboah, we had another full day of driving from Kumasi to remote clinics with varied levels of services. Our day was spent in the Amansie Central District (pop'n 85,000 in 206 communities). We began with the Catholic Mission St. Peter's Hospital where we visited with the staff, including their one doctor. At every clinic, during our staff meeting, it is interesting to hear their thoughts on the cause of Buruli Ulcer. Today the issue of land disturbance due to sand and gold surface mining was discussed. This has been mentioned at other sites as well.

The doc at this clinic sees over 100 pts per day, not including inpatients. Inpatients today included Malaria, Sickle Cell Disease, cellulitis of the leg, and a post op hernia patient. They have a functional lab where they can do blood smears, urinalysis, blood cross matching, as well as some other tests. They have surgical services with an operating theatre.

Interestingly, this clinic sees mostly adult Buruli patients. Their "temporary" Buruli ward was a short distance from the main hospital and much more basic than any other inpatient facility we have seen thus far. It had five inpatients (ages 40-75).










The facility had few physical resources: mats on the floor for beds, a few linens, unreliable electricity, and some supplies.








This clinic has been using the McCord wound care hydrogel product according to a pilot protocol put in place by the Ghanaian Ministry of Health. It was fascinating to see the product in the "supply room."




















Despite the fact that this hospital sees mainly adult patients with BU, the disease impacts the children of those adult patients. We met a sweet 12-year old girl who accompanied her guardian to the hospital since no other caretakers for this child were available. The girl had lost both her parents. When her guardian required hospitalization due to BU, there was no option but to have her live at the hospital as well. She cared for her "mother." As a consequence, she had not attended school in almost 3.5 years. Overall, the level of need at this site was very sobering for the entire group.

From here we visited the Office of the District Chief/Director. It is a the district level that many health related policies and programs are initiated in Ghanam. (There are 10 regions in Ghana, which are divided into at least 130 districts). Our discussion included issues such as medical staff retention, the Ghana Feeding Program for inpatients (also for one free meal per day per inpatient), and progress in building a much needed new Buruli patient ward.


On our way back to Kumasi we stopped at Akutuase ("Under the Orange Tree") to visit with an elderly villager whose leg ulcer healed completely with antibiotics, wound care and (McCord) hydrogel. She was an inpatient for approx. 6 months). The success for this elderly woman was a success for the entire village. Her successful healing did a great deal towards demystifying Buruli Disease and lessened the fear of Buruli Ulcer disease in her village. The attentions paid to her during today's health care visit, and other visits, have made this lovely woman a rather popular village figure. Children no longer shun this lovely woman out of fear of the Buruli Ulcer.


The gentlemen dressed in his funeral garb is the local health surveillance volunteer. He has been trained by the Ministry of Health to detect various diseases and medical conditions in his village. He was very moved by the fact that visitors had come from such a long distance to witness the positive results of the McCord hydrogel.





Finally, we were invited to dance at a funeral taking place in the Village. The event was truly a celebration of a ninety year old woman's life.















We were all honored to experience this joyful event.

March 24, Visiting the Clinics

Today was an intense and fascinating day. We visited three different clinics: Obom Health Centre, Kojo Ashong Community Clinic and Amasaman Hospital. The clinics ranged in services provided. Obom and Kojo Ashong are out patient clinics which have capacity to administer Rifampin and Streptomycin to patients for their 56 consecutive day course, as well as provide wound care. The children and their parents walk up to several miles to reach the clinics.























The clinics are very basic, but they are staffed by amazingly strong and committed men and women.


















At Amasaman Hospital the services are more comprehensive. It is an in patient facility for patients being prepared for surgery. They receive nutrition and wound care pre and post surgery. The hospital provides a school so that the children can continue some education as they reside at the facility.

At this facility a parent must stay to provide basic care and cook for the child. Often the mother must bring her other children with her, as she is often at the hospital for several weeks. The families share a common court-yard like space where they wash, cook and sleep. We met strong loving nurses who are vested in the happiness of these mothers.














Tremendous effort is spent in supporting these resident families. Often the women and children have come to the hospital against the advice of other village members who have deeply rooted superstitions about the cause of Buruli. The hospital nurses and staff never turn patients away and do their best to enable the families to continue with treatment. Relationships develop among the Buruli families. The reliance of these women exemplifies the resilience of the Ghanaians in general.

March 23, Meeting with Edwin Ampadu

* Photos coming soon! *

Today was an "official" day. We met with Edwin Ampadu, the Program Manager for the Buruli ulcer (BU) with the Ghanaian Ministry of Health. We had a very productive day with Dr. Ampadu. He described the remarkable progress his country had made in identifying the incidences of BU in Ghana.

About 1,000 cases of BU are identified in the country each year. Identification and treatment have been assisted by mobilizing a group of community volunteers who provide information to fellow villagers and who assist in screening villages for this disease and others.

Children between the ages of 5 and 15 make up the majority of BU cases. Although the cause of the ulcer is unknown, it is suspected the disease is associated with bodies of water. Behavior such as playing in ponds and rivers may explain why children are more susceptible to getting the disease.

Following our time with Dr. Ampadu, we toured the nearby plastic surgery hospital where BU patients are treated. The group distributed candy, pencils and toys to the children at the hospital. While no BU patients were at the facility while we were there, the group visited with children who were being treated primarily for various types of burns and cleft lip/palate.

We spent the evening with the wonderful family of Charles Yeboah. The food they prepared was incredibly beautiful and delicious. It's another late evening and it will be another early morning. It was a productive and beautiful day with our new friends.

March 22, Sunday at the Market

Dr. Pam Small (U of Tennessee), Dr. Rich Merritt (Michigan State) and Dr. John Wallace (Millersville U) arrived this morning. We reminisced and made introductions.

Mollie, Ryan, Charles Yeboah and Charles Quaye got an early morning start to conduct additional water testing in a couple of villages. No rest for the wicked. Lol!







On the other hand, Claudia, John Wallace, Emmanuel, Monica and our driver, John, set out for the market. We would not have survived without the magnificent "intervention" of Emmanuel and John. The merchants at the market are very aggressive at their trade! We bargained for everything we purchased and got good at making purchases at our "walk away" prices. It actually got to be fun!











After the market, we needed a bit of down time at the beach. What a magnificent place! The breezes were wonderful and the surf was magnificent. We had a late lunch outdoors with a view of the beach. This was exactly what we needed.




















We met up with the rest of the group for dinner and even watched snippets of the NCAA games. Due to poor internet access, the MSU group had to go to bed without knowing the outcome of the MSU/USC game - we felt their pain! Lol!

Claudia and Monica ended the evening at midnight attempting to pirate internet service at a nearby hotel - without success.

Tomorrow we meet with Dr. Edwin Ampadu, the director of Buruli ulcer at the Ministry of Health. We will tour the nearby plastic surgery facility.

Goodbye for now.

Saturday, March 21 - Second Work Day

Today are off to a quicker start! No shopping for pvc pipe etc.. We hoped to fully sample three villages ( well, river and ground water ). However, one village's well was dry, so we only fully sampled two villages.


At our first village Otuaplem, we met a very little 9 yo girl, who has a Baruli Ulcer on her right arm. She had been treated with a skin graft, however it broke down and she was back to dressing changes. Charles Yeboah and this child seem to have a special caring relationship.


At our second full sampling site Kojo Ashong, the children ( about 20 ) again followed us everywhere and sat and watched and watched and watched. They were especially helpful carrying our equipment and buckets (on their heads, even the tiny children).


Several played with Monica's hair and touched her sunburn. Several scampered to hold Claudia's hand. Generally the children are very well behaved, joyful and fun. They taught us a Ghanaian song and we all sang as we worked. We tasted palm wine right out of the tree (still warm) and ate a coconut collected by a young man who shimmied up a tall tall tree. The children seem to be constantly fetching water from a well, or the Densu River. They Always balance the water in buckets on their heads. Claudia showed village children pictures of her family. They laughed and laughed.

Second day of field work and still smiling!

Ground water testing

Charles Q and Mollie collecting surface water for testing

Charles Q returning with a surface water sample

Ryan protects himself from the elements!!!!

The two Charles conduct additional tests

Friday, March 20 - First Day in the Field - Wonderful Work!

This has been a wonderful day in so many ways! Our day started early. Our drivers, John and Abraham from the Health Minister's Office picked up Emmanuel, Mollie, Ryan, Claudia and Monica. We stopped at the Noguchi Institute to pick up the two Charles! Our team then stopped at a couple of stores to pick up supplies such as PVC pipe to use as a measuring device and rope. We then were off to a couple of villages with documented Buruli ulcer cases.


Both villages we visited have no electricity or running water. Although school for the children is mandatory, it is not enforced.


We met with the elders of the first village Kankafionaa who welcomed us to their community. Armed with mosquito repellent, serious sun block and tons of equipment, we headed to the town's well to take several samples. The previous evening, Claudia and Monica transferred 200 wafer-like filters with a tweezers into aluminum foil packets they had fashioned.
Besides the well samples, we also sampled and filtered river water and ground water. The children of this village were particularly helpful with carrying supplies to the sites. Young scientists in the making!

Charles Q and Charles Y acting up - science is serious business

We took similar samples in the second village Djorsee. While filtering the water supplies, the children of this village serenaded us with songs (with Monica's wonderful encouragement and leadership). The children are beautiful and very curious.

Charles Q and Charles Y of the Noguchi Institute sampling water in the Densu River - March 20

We trekked to the water and away from the water for every sampling site - always, with able assistance.

Only one snafu at this second site. The Kemmerer, a water sampling device broke from its rope and fell to the bottom of the well about 20 below. At just about this time a villager who was a village chosen, Ministry certified, community health volunteer came by. He spoke to us passionately about his work with his village. He has been educating his community about the cause of Baruli Ulcer and successfully encouraging afflicted villagers to seek treatment. After telling us all about his work, he fetched a very, very long piece of bamboo. The two Charles and Emmanuel used the bamboo and a nail to fish the equipment from the well. - now to figure out how to repair it.

Rescuing the Kemmerer sampling tool at the second village - oops!!!

We ended the day in the field at 6 pm and, in the interest of time, even went to dinner before showering - a new experience.

It's now 12:40 and the alarm will ring in about 6 hour! Good night! More tomorrow.