Ghana

1. Ghana Alice Chi, Natalie Clark, Dipa Joshi, Christine Pipitone October 25, 2010

2. Travel to Ghana

3. Getting permission • Visa application • Travel clinic for vaccinations and prophylaxis • Travel insurance • What to pack Before You Go

4. Get Permission from U of M • Decide when you want to go, and keep track of period deadlines • Inform Dr. Tim Johnson and Jennifer Jones (his assistant) • Fill out the following forms: • M4 Elective Form for Outside Institutions (signed by Dr. Johnson): http://www.med.umich.edu/medschool/osp/forms/M4_outside_elective.pdf • Medical Student Acknowledgement Form: http://www.med.umich.edu/medschool/osp/forms/Med%20Student%20Acknowlegement.pdf • Submit the forms to Cindy Murphy • Cindy Murphy will create a dean's letter of good standing for you to submit to the UGMS

5. Get Permission from UGMS • Inform Kofi Gyan (kofigyan@umich.edu), the contact at University of Ghana Medical School, about your travel plans • Can also contact Samuel Acheampong for this information (academicaffairsugms@yahoo.com) • Fill out the UGMS Elective Form (from Kofi or Samuel), submit to Kofi • Submit to Kofi the letter of good standing that Cindy Murphy wrote • Kofi will create a UGMS acceptance letter for you, as well as a course description, both of which you should also submit to Cindy Murphy • Kofi will send you a letter indicating tuition and lodging fees

6. Visa - $60 Single Entry • http://www.ghanaconsulatenewyork.org/visa.html • Supporting documents required besides 2 copies of the application: • Passport • Photocopy of biodata page of passport • Two passport-sized photos • Travel itinerary • Copy of student ID card • Copy of UGMS acceptance letter including dates of enrollment • Copy of permanent residence card if applicable • Self-addressed Post Office Express Mail Stamp, for return postage • Once submitted, the consulate took 1-2 weeks

7. Travel Clinic • Follow instructions on U-M Travel Clinic website: http://www.uhs.umich.edu/travelhealth • Common vaccinations recommended/required: yellow fever (proof of vaccination required to enter Ghana), typhoid, hepatitis A, polio, TDaP, influenza • Cost will depend on coverage and how many vaccinations you need: • http://www.uhs.umich.edu/sites/webservices.itcs. umich.edu.drupal.uhs/files/uhsdocs/vaccines.pdf

8. Malaria Prophylaxis • Doxycycline: Start 1-2 days before travel, daily while traveling, daily for 4 weeks after return • Pros: cheap, protects against traveler's diarrhea • Cons: GI upset/reflux, photosensitivity • Malarone: Start 2 days before travel, daily while traveling, daily for 1 week after return • Pros: better tolerated than doxy • Cons: much more expensive • Although the hostel has screened windows, you might want to bring a net (e.g., Mobasa defender, a pre-treated net) • 35% DEET insect repellent (100% not necessary)

9. Travel Insurance • http://www.uhs.umich.edu/tai/ • Required by U of M for any student traveling abroad for elective • Costs $1.25/day plus $5 administrative charge • Coverage: detailed on website, includes medical evacuation • Cindy Murphy will purchase it for you - you are required to reimburse the university • Or you can purchase it on your own, just inform Cindy ahead of time

10. What to Pack • For international flights you can have 2 checked pieces of luggage, a carry on, and a personal item (eg. Purse) • Keep in mind that there's a 50lb luggage limit and if you exceed this, you can be charged up to $200 • Bring 2 smaller suitcases instead of one larger one • Try to split up packing so that you and your travel mates are not packing redundantly

11. It is very hot and humid and there is no air conditioning, pack accordingly. • Hospital Attire • Ladies: knee-length skirts, capris, light blouses, nice sandals • Men: slacks, collared shirt (can be short-sleeve), tie, dress shoes • Flip flops, walking/hiking shoes • Light raincoat or hoodie • Long sleeves and pants for national parks • Hat and/or sunglasses What to Pack - Attire

12. MCard for ID (and student discount) purposes • 1-2 pairs of scrubs • OR masks, hats, shoe covers, reusuable eye protection • OR shoes • Stethoscope • Penlight • Latex gloves • Small and large bottle of Purell • Pregnancy wheel • Pharmacopeia • Basic OB/GYN book What to Pack - Hospital Supplies

13. What to Pack - Electronic Items • International adapter(s) • Laptop (you can purchase internet there for approx 60 cedis - beware it is not fast) • Camera w/charger • If you have space, travel speakers and small fan are nice • SIM card capable cell phone • Flashlight and batteries

14. What to Pack - Personal Items • Toilet paper (1-2 rolls, you can buy more there) • Toiletries • Luggage and laptop locks • Ziploc bags • Alcohol swabs and/or wet wipes • Some cutlery (or you can buy stuff there - we had a Swiss army knife and plastic cutlery) • A string is helpful for hanging hand-washed clothing, although they have laundry services there for a cost (they will not wash underwear) • Medipore tape (helpful for blisters) • Duct tape (always helpful) • Fast-drying towel • Flip flops for shower

15. What to Pack - Personal Items (cont'd) • Sunscreen • 30-40% DEET mosquito spray (you do not need 100%) • Earplugs! • Eye mask • Travel pillow • The hostel provided sheets and a pillow for us • Bradt Guide Book • Pens, books, journal • International phone w/SIM card capability (Kofi might have one for you to borrow, or you can buy one there) • Granola/protein bars/snacks

16. What to Pack - Cash • At least $500 USD cash (if not more) for the first day to cover tuition, lodging, transportation • Traveler's checks are not easily exchanged and not that helpful • VERY few places take credit card, so bring a debit card (VISA only) • You can exchange money at the airport or at a Forex bureau • 1 USD = 1.43 cedis

17. What to Pack - Meds • Malaria prophylaxis (doxy or malarone) • Cipro for traveler's diarrhea • Ibuprofen • Bandages • Neosporin • Benadryl (for mosquito bites, anti nausea, and sleep aid prn) • Don't forget your personal prescriptions

18. What to Pack - Paperwork • Passport and visa (with copies just in case) • Proof of yellow fever vaccination • Acceptance letter from UGMS • Travel health insurance card

19. Communication • Everyone communicates by cellphone in Ghana - having one is essential to get a hold of your travel mates and Ghanaian friends • Bring a phone w/SIM card capability (or borrow one from Kofi Gyan or purchase one) • Can purchase local phones from Vodafone or Zain • Vodafone sells phones for 35 cedis (included in this is 10 cedis of phone credit)  • Vodafone phones receive phone calls and texts for free • Internet cafes are all over Accra • You can purchase wireless internet for your laptop for approximately 50-60 cedis from Zain or Vodafone - it is slow but we found it helpful to check emails

20. Once You're There • Getting to the ISH • The first day • Costs • Clinical Teams • A Typical Week • Conferences and Curriculum • Sightseeing

21. Getting to the ISH • Travel from the Kotoka airport to the International Student Hostel at Korle Bu Teaching Hospital costs approximately 10-20 cedis in a regular taxi • Kofi Gyan will arrange transportation for you that includes a stop to the grocery store and Forex bureau, however, this cost 60 USD • Korle Bu Teaching Hospital is in the opposite corner of Accra from the airport, so, in traffic, the ride might take a while • The ISH is very deep in the campus, and not close to the MD or local student housing, about a 20-minute walk from the wards (there is a morning shuttle that leaves daily at 7:45)

22. The First Day • At the ISH, you will receive a receipt for lodging • Go to the Administrative building near the medical school, speak with the administrative assistant, who will ask for your acceptance letter, and your lodging receipt • He/she will direct you to the cash office, where you will pay for tuition • Go to the OB/GYN block to meet with Dr. Obed and his secretary to find out your team assignment and where you should meet your teams

23. Costs • Lodging: 5 cedis per day in regular rooms, however, you will likely be offered the elective student room (10 cedis per day) • Regular rooms: public bathroom, TV or fridge not guaranteed • Elective student room: private bathroom, TV, fridge • Tuition: <____> cash

24. Clinical Teams

25. Structure of Clinical Teams • There are 5 teams, A-E • Each team has ~10 medical students, ~3 house officers, ~1 junior resident, ~1 senior resident, ~1 consultant, and ~1 specialist • Medical students: Start after high school, 6 total yrs of training • House officers: MDs that rotate through the major fields of medicine for 2 years prior to picking a field and applying to residency • Residents: MDs that have completed house officership and have chosen their field (e.g., Ob/Gyn resident) • Consultants: like our attendings • Specialists: like our specialists • Each team is assigned to a obstetrics floor, and round on their obstetrics patients every morning • Prior to this, they attend morning meeting where the cases in the previous 24h are discussed • Then they attend the activity assigned to that team for that particular day • E.g., on Monday, Team B is assigned to take call

26. A Typical Week

27. Try to scrub in so that you may assist (you may need to be a bit aggressive, otherwise you will just watch) • Air conditioned • You may be provided scrubs but bring your own just in case, and bring OR attire (shoes, shoe covers, cap, mask, eye protection) • When scrubbing, grab a rubber apron and put it on over your scrubs • Follow your house officer's or resident's example when scrubbing • Everyone is generally very nice to the med students in the OR, especially scrub nurses • If you really want to go to the OR right when cases begin, follow a resident out of morning meeting, since house officers may spend much time rounding on their ward patients • Types of cases: open, range from simple TAH, to myomectomy, to long gyn-onc cases • The consultant or specialist surgeon does the majority of the case with assistance from another consultant, a resident, or house officer Day 1: Theatre (OR)

28. Rounds are quick • One of the house officers will admit patients through the Emergency Department (or "Accident Centre")  • Another house officer will go to L&D and assist with cesarean sections (emergent and scheduled) • Your residents and consultants won't start performing c-sections until 5pm, otherwise they are done by the morning team • There is one OR for c-sections • The warden in this area will provide scrubs and lunch • Try to assist in c-sections • A third house officer will go to prenatal/postnatal clinic • Midwives perform all uncomplicated vaginal deliveries • Try to attend as many vaginal deliveries as you can, and try to observe breech and twin deliveries • You are welcome to stay overnight on call, though you are not required to Day 2: Call

29. Your team will present at morning meeting, followed by obstetrics rounds, then gynecology ward rounds • This is a good day to go perform and observe vaginal deliveries with the midwives • Otherwise, this day ends early, and you can take your time to explore Accra or get errands done when there is no traffic. Day 3: Post-Call

30. Formal, extensive teaching rounds, where medical students get questioned extensively on patient-specific health topics (e.g., post-partum hemorrhage, sickle cell disease in pregnancy, etc) • This is kind of like "Reynolds Rounds" on gyn-onc • You probably won't get questioned too much, and if so, the questions are generally about American medical practices • Very educational • Afterwards, there might be inpatient procedures/biopsies to watch, or you can go to the labor ward with the midwives Day 4: Major Ward Rounds

31. Gynecology Outpatient Department • This is a day of clinic with both obstetric and gynecology patients • Like usual, you will start out at morning meeting, then go to your floor to round, then you will attend clinic w/the house officer • Although the official language of Ghana is English, most of these patient encounters will be in mixed English/Twi, and many patients may not understand enough English to complete an interview • That said, if there is a patient who is willing you can conduct the interview and do the physical exam • Otherwise, you can make the most of your day at the labor ward • Usually clinic ends at 1-2 pm Day 5: Gyn OPD

32. Conferences and Curriculum

33. Morning Meeting • Daily 8 am meeting going over previous day’s cases and deliveries • Mortality Conference • Last Thursday of the month • Very different from our Morbidity and Mortality conferences • Incredibly eye-opening and educational; try to take notes Conferences

34. Curriculum • The curriculum consists of daily clinical duties, and didactic lectures • Professor Obed, the chair of the UGMS Ob/Gyn department, will lecture you on specific obstetrics/gynecology issues in West Africa • Take advantage of this valuable educational time with the department chair • Residents may also offer review lectures to the medical students

35. Accra

36. Kwame Nkrumah Memorial Park • National Cultural Center (shopping) • Osu for Ghanaian and international food • Lighthouse of Jamestown • National Museum • La Beach/Labadi Beach Resort • Local soccer match What to do in Accra

37. Travel Within Ghana

38. Cape Coast

39. 1st capital of Britain's Gold Coast Colony • Castle • World heritage site, one of the largest slave-holding sites during the colonial era • Slaves traded to British by local tribes in return for EtOH and guns • Great beaches • Oasis Beach Resort • Elmina Beach Resort-beautiful pool on the water • Where to stay • Oasis Beach Resort: good food, on the water, near the castle • Getting there • STC buses: 4 cedi, run daily, buy tix early • Awesome Nigerian TV shows • Tro tro: cheap, but less comfortable and more difficult to figure out Cape Coast

40. Kakum National Park • ~1 hour away from Cape Coast • Take a tro tro or hire a taxi (make sure the driver stays there and waits for you) • Canopy Walkway: 40 m in the air, only one in Africa • Go early in the morning, less crowded! • Not if you are afraid of heights • Forest walk • Medicinal plants, greater chance at seeing wildlife • Museum • Camping overnight on platforms available • Animals you may see: forest elephants, monkeys, birds

41. Mole National Park

42. Mole National Park • Getting there • Flight to Tamale Antrak Air ($175 cash one way, book early) • Or…STC bus to Tamale via Kumasi • THEN Metro Mass bus from Tamale to Mole park • Best idea: get a driver from Accra via Avis (~$300/person w/4 people) • Along the way from Accra stop by • Kumasi • Tamale • Boabeng-Fiema Monkey Sanctuary (mona and black and white colobus) • Kintampo Falls • Staying there • Mole Motel • Sits on a cliff with a restaurant and swimming pool overlooking 2 watering holes

43. National park since 1971 • Ghana's largest wildlife sanctuary (4840 sq km), the best for game viewing • There are 90 mammal species and at least 344 bird species • Elephant, buffalo, warthog, antelop, monkeys • Walking or 4X4 safaris • Other things to do: • Mongori village • Canoe safari Mole National Park

44. Kumasi

45. The cultural capital of Ghana • Visit the Ghana Cultural Center - includes a museum on Ashanti history and a large crafts center • When we were there, Ghana was playing Sudan in soccer • Palace Kumasi

46. Wli (Agumatsa) Falls • On Togolese border in eastern Ghana • largest waterfall in west Africa • within Agumatsa Wildlife Sanctuary with numerous straw-colored bats • Volta Region • Theoretical ferry • Hippos! • Boabeng-Fiema Monkey Sanctuary Other Places to Visit

47. Contact Info • Ghana contacts: • Kofi Gyan: kofigyan@umich.edu • Samuel Acheampong: academicaffairsugms@yahoo.com • Michigan contacts: • Jennifer Jones (Dept admin, Ob/Gyn): jjlynn@umich.edu • Tim Johnson (Dept chair, Ob/Gyn): trbj@med.umich.edu • Cindy Murphy (OSP): camurphy@umich.edu • Us: • Natalie Clark: naclark@med.umich.edu • Alice Chi: amchi@med.umich.edu • Christine Pipitone: pipitone@med.umich.edu • Dipa Joshi: dmjoshi@med.umich.edu

48. References Flag on first slide: http://think0.deviantart.com/art/Ghana-Grunge-Flag-153462332 Briggs, P. (2010). Ghana: The Bradt Travel Guide. Guilford, Connecticut: The Globe Pequot Press.