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Feb. 26 - April 4: This week started as a beginning of the end -- the last district was to be visited in the Ashanti Region, a report and presentation to the Regional Ministry of Health staff, and a presentation to all Ashanti Regional leading public health workers during their quarterly performance report meeting in Kumasi. The monthly report was now due, as well as the weekly one. This meant getting together all the official data, organizing it and providing comments and recommendations (without saying anything that might be offensive, or even hint that someone might not be doing their best. Next week I go to Brong Ahafo and start all over again with the new districts and hospital.

I'm very spoiled in that WHO furnishes me with a driver and a very nice Toyota cab pickup that uses diesel. The price of fuel jumped from $0.90 to $1.30 gal. There's a lot of complaining, but it doesn't seem to do any good. Samuel is standing by our 4 wheel vehicle and we go all over, on the roughest roads and remotest areas. Next picture Dr. Appiah-Denkiyra, the Regional Director of Health Services, is introducing me prior to my presentation at their regional quarterly meeting.. They just purchased a new PowerPoint projector and since I knew how to use it, guess who used it with great satisfaction. They were impressed with the graphics and the manner in which animation enhances the message.

The Regional Teaching Hospital is the busiest of all hospitals, and perhaps on of the better. However, in our standards you would probably not feel comfortable or very assured that you were receiving quality care. Its amazing how much they are able to do with so little. The disease control officer of the hospital indicated that the medications for treating meningitis were extremely expense. I was informed that they were using Chloramphenical (which is the cheapest antibiotic available - only $3 dollars a treatment). The thought occurred, "If they think $3 is expensive for treating meningitis what are they going to think about buying a mosquito net for $5?"

As you can see above, here is the largest hospital in the Region of Ashanti and absolutely no mosquito nets. A patient coming out of surgery has a companion convulsing with cerebral malaria on one side and another companion burning with fever. His chances of recovering from surgery might be precarious but you can bet that he / she is going to go home with a new batch of malaria plasmodium, which the mosquitos were kind enough to distribute from the friends on both sides of his bed. One reason that mothers defer bringing their children into the hospital is because, not only is the trip usually long and difficult (with no personal transportation), but once there they have to cook and prepare all meals for their children. The same is true for adults -- no hospital kitchen service. Nurses are short supply so that the mothers have to do everything a nurse usually does, except take the temperatures and give out the medications. 90% of blood transfusions are to children anemic with malaria and at that the transfusions are withheld until the patient's life is threatened with an unbelievable (to me) hemoglobin level.

The posters above are found in almost all public health clinics. It is readily apparent that there is a need for basic education on sanitation and causes of disease.

The poster that instructs one to sit rather than squat caught my attention. Coming mostly from a rural area, where human waste disposal might be an outhouse with a hole in the floor at best, the white bowl with water in it might be a mystery to some. Telling someone to sit rather than squat is something I wouldn't have thought of, since I usually lift up the seat and squat myself when in a questionably sanitary public rest room Many don't know that the mosquito is the carrier of the malaria, much of which can be prevented with bed nets And then there is the Guinea Worm, Cholera, Trachoma, Schitsosomiasis, etc., and many other tropical diseases.

I was interested noting that, although malaria is their most significant problem (60 -70% of inpatient and outpatient care ) not one report or comment was made that dealt with the problem of combating it. They just seem to be resigned that to live means to live with malaria. At this time I think that malaria would receive a deadly blow with the use of just plain cotton mosquito nets, which is something that could be made here in Ghana for about the price of a shirt (and they all wear shirts).  The strategy would be to order the cotton mills to make the mosquito netting with the proper hole sizes, purchase this in bulk and then advance a small amount of material (like for ten nets) to a select group of women in the villages and communities, who in turn would promote the use of the nets, sew them to size, sell them, keep the profit and repay a third of the advance loan for the net material. After three revolutions of material purchase, sewing and selling the nets, they would be paid off and now have their own little industry. The Ministry of Health would be the ones that would be responsible for organizing, providing the demand and giving account for the material advanced and sold.

I finally got smart and started training Disease Control Officers. Here is a picture of Osei Mensah (on the right) who we trained to provide orientation to the private sectors. Although he doesn't have a laptop with powerpoint, yet he will be visiting all the private providers and provide them with the information and sensitize them for the cause of polio surveillance and eradication. The last picture of a group of doctors and nurses of a Seventh Day Adventist Hospital who attended one of our orientation sessions and will become very involved.

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