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Nicole Amadon and Courtney Porter are sixth-year Pharm. D. candidates at Ohio Northern University who have traveled to Ghana to complete an elective international Advanced Practice Pharmacy Experiential (APPE) rotation for October 2012. While in Ghana, they will spend most of their time in the capital city, Accra, and they will also spend time in Kumasi and Cape Coast to experience different parts of the country.
While on this rotation, they will be staying with Daniel and Cynthia Amaning and their family. Daniel is a pharmacist who owns several independent pharmacies called "FamilyCare Pharmacy" throughout Ghana. He is also on the pharmacy council of Ghana.
Cynthia is also a pharmacist and she teaches at the Kwame Nkrumah University of Science and Technology (KNUST) in Kumasi, Ghana.
During their stay with the Amanings, not only will they be learning about healthcare and the practice of pharmacy in Ghana, but they will also be learning about the culture including a variety of foods, local dialects, and general lifestyles. They will be posting blogs as regularly as they have electricity and would welcome any questions at email@example.com and/or firstname.lastname@example.org
"And We're Back!"
After living in Ghana for a month, we have developed a new perspective on pharmacy practice and we have learned about a new culture. It is incredible how much freedom pharmacists in Ghana have compared to their American counterparts, but they also have to manage their practice in the midst of power outages and outdated reference books, which would be unthinkable back home. The country has begun its transition to the PharmD program for pharmacy students (while phasing out the BPharm degree), and we will be interested to see how this change translates into enhanced clinical involvement for future pharmacists.
Surprisingly (and thankfully), we did not end up with nearly as many mosquito bites as we had envisioned. Neither of us forgot to take any anti-malaria pills (although Courtney nearly forgot several times), and neither of us suffered from sunburns. Despite the fact that we each suffered from a bit of food poisoning, our general health could be considered a success for this trip.
Daniel took this photo in the Accra airport. We were not this cheerful when we were in the Detroit airport.
Unfortunately, Hurricane Sandy wreaked havoc on our travel home and our last flight from Detroit to Cleveland was cancelled. After travelling for over 24 hours, we both wanted to go home, so we rented a car and drove through northern Ohio. Thankfully, the weather was manageable and Nicole had little difficultly navigating the roads. After two days, we can both say we have safely arrived home (with all of our luggage) and we have concluded our journey to Ghana.
Maybe suitcases are overrated.
We appreciate the attention our blog has received and we hope everyone enjoyed learning about this new country and culture as much as we did. We also want to thank the Amanings and all of the pharmacy staff we met during the month for their hospitality and we look forward to seeing everyone again one day.
For the last time,
Auntie Nicole and Auntie Courtney
Even though it is our last week, we were able to take a field trip to Cape Coast for a day. Cape Coast is about a 2-hour drive west of Accra along the coast of the Gulf of Guinea. We began our drive by sampling the seeds from a cocoa pod. You cannot eat the seeds, but you can suck on the slime around them. The slime tasted a little sweet but had no real flavor to Nicole, but Courtney was too busy enjoying her Werther’s hard candy she brought from home to try it.
This is what a cocoa pod looks like. The pod is golden and contains cocoa seeds (brown) covered in a sweet slime (pink).
Our first stop was Kakum National Park for the canopy walk. We were in a group that also included an American family that had recently moved to Accra and a busload of Chinese tourists. After a short hike into the forest, we arrived at the first platform. The canopy walk consists of seven cable bridges that span between the trees anywhere from four to 18 meters above the forest floor.
Nicole embarks on one of the bridges. The narrow bridges had netting on both sides for everyone who did not want to feel like a tightrope walker.
We successfully stayed at the front of the tour group, which was not very difficult since the Chinese kept stopping to take pictures of everything. This proved to be a good strategy because the bridges became more difficult to traverse as more people stepped onto them. Before we started the canopy walk, our tour guide assured us that all of the bridges are inspected daily to evaluate their safety and the cables are replaced every six months. Still, some of the people behind us had a poor center of gravity and subsequently rocked the bridge more than necessary.
Rita and Courtney have fun crossing one of the bridges. It’s a good thing none of us are afraid of heights.
The view of the forest from the canopy walk was incredible. It was neat to be high up in the trees and to observe the forest from a new perspective. We are accustomed to seeing red dirt everywhere around Accra, but the forest was host to lush green plants and a darker, almost brown mud.
The view from one of the platforms. It was quiet in the forest since most of the animals are nocturnal.
The bridges seemed long with everyone making them sway back and forth, but the journey through the canopy seemed to take no time at all.
Yes, it was muddy that day. It had rained all morning across southern Ghana, but thankfully the rain had passed by the time we arrived in Cape Coast around noon. The mud did not impact the initial hike into the forest because most of the hike was up a hill “paved” with stones, but the hike back down to the visitor’s center was tricky. The three of us hiked down in the order that we were most likely to fall, with the clumsiest person in front so she would not take out everyone in front of her if she wiped out. The meant the order was Rita in front (who wore boat shoes because she did not pack tennis shoes), then Courtney (who talked about falling the whole way down the hill), and Nicole was last (since she did not want to wear mud the rest of the day, and also thought it would be nice to photograph the seemingly impending wipeouts in front of her). Fortunately, everyone made it out of the forest without falling, although there were a couple of close calls. Maybe we should thank years of treacherous winter sidewalks at ONU for our terrain skills.
After the canopy walk, we drove to Elmina Castle. The castle was built in the late 17th century by the Portuguese, who shortly turned it over to the Dutch. The castle was instrumental in the African slave trade: this was the final stop before the slaves were put on a ship to go to the Americas. Slave treatment was inhumane, with slaves kept in dungeons without adequate light or ventilation. There was one chamber specifically for rebellious slaves and anyone who was locked in this chamber did not come out alive.
Elmina Castle (in the background and behind the palm tree) is situated on the water.
This view from the top of the castle shows the activity of this fishing town. The castle was directly on the gulf when it was built, but the waters have receded over the past few centuries, giving way to a small coastline. We visited on a Wednesday, but if we had gone on a Tuesday we would not have seen any boats on the water because the locals believe Tuesday is the day the sea goddess replenishes the fish, so there is no activity from Monday evening until Tuesday evening.
After a couple hundred years of Dutch rule, Elmina Castle was turned over to the British. By the time the British set up shop in Ghana, the slave trade had slowed tremendously, so the castle was converted into a police academy and was used to train officers until Ghana acquired its independence. Today, the entire castle, as well as some others in the area, is open for visitors. Both tourists and natives visit the castle and some pay their respects by purchasing a wreath in memory of those who perished. The castle serves as a reminder that humanity must never repeat the atrocities committed in the name of the slave trade.
Courtney poses in front of the gate that served as the “point of no return” – anyone who left the castle through this gate was put on a ship bound for the Americas and the slave trade.
Our tour guide “locked” everyone in the rebels’ cell so we could experience jail for about 2 minutes. The only source of light came through the gate where he stood.
The top of this photo shows the entrance to the women’s dungeons. The governor would select a prisoner for personal use whenever he pleased. Unfortunately this photo does not show the church, which was situated directly above the women’s dungeons. How ironic.
So our field trip included a fun excursion and an educational lesson. While the visit to Elmina Castle was very informative, we enjoyed the physical activity and the amazing views of the canopy walk at Kakum more. That was possibly the favorite experience of the trip for both of us.
Auntie Nicole and Auntie Courtney
“Hold on, what does the “K – N” stand for again in KNUST????”
Besides Accra and its surrounding “suburbs”, we have also had the opportunity to travel to the central part of the country. We travelled to Kumasi, a major city located in the Ashanti region of Ghana. It was a 5 hour trip along winding two-lane roads and over countless speed bumps (a common site on Ghanaian roads). At least the roads were paved – usually. We stayed at the Engineering Guest House at Kwame Nkrumah University of Science and Technology (KNUST), one of Ghana’s major universities. Much to our liking, we not only had the opportunity to bathe with hot water, but we also had CNN on the television and a warm American-like meal (with coffee for Courtney) each morning of our 3 day, 4 night trip. We should mention that while we had the opportunity to bathe with hot water, the water heater in our room only supplied hot water on a test run of the faucet and not during any of our showers.
We arrived on Wednesday night of our third week, so our activities began Thursday morning when we went to Komfo Anokye teaching hospital (KATH). KATH is a major teaching hospital in Ghana that generally treats the most complicated disease states through referrals from other hospitals in addition to serving the local community (a medical team from Boston was there performing a cardiac surgery during our visit). One of the pharmacists, Daniel, gave us a tour of the hospital after we presented him with a copy of Lexi-Comp from Dean Sprague. Most hospitals have few hard copies of reference materials and the copies they do have are usually outdated, so the addition of Lexi-Comp will surely help the pharmacists during the many power outages.
Nicole, Courtney, and Rita present Lexi-Comp to Daniel on behalf of Dean Sprague.
We visited almost all of the pharmacies on campus. Similar to the U.S., the hospital had smaller pharmacies serving specific departments, including pediatrics, oncology, HIV/AIDS, and surgery/trauma, in addition to the main pharmacy. There was also a main storage room and compounding pharmacy on campus. Sterile clean rooms do not exist and hoods to mix medications are not common either. Personal protective equipment, such as suits and gloves, are used, though.
A pharmacy technician prepares a diuretic suspension. In Ghana, compounding is called “manufacturing”.
This is the clean room for one of the pharmacies. The only hood we saw was in the oncology pharmacy for chemotherapy preparations.
The compounding pharmacy keeps samples of every drug made for purity testing and reporting (in the case of a patient reaction).
We also toured the outpatient pharmacies on campus. We were informed that it is not uncommon to wait in line 2-3 hours to fill a prescription. Since much of the population is illiterate, instruction to take medications are not only verbally explained, but also drawn pictorially to illustrate the proper dosage and time of day to take the medications.
Some pharmacy technicians perform prescription intake for the long queue of patients.
Thursday afternoon we visited first-year PharmD students at KNUST. This is the first class of PharmD students in Ghana. Prior to the development of the PharmD program, which received assistance from Dean Sprague and the ONU College of Pharmacy, a BPharm was the only pharmacy degree offered. We presented a PowerPoint to the class informing them of pharmacy schooling in the U.S., specifically the curriculum at ONU, and what career options are available for pharmacy students in the U.S. after graduation. This was followed by a Q & A session that lasted for 40 minutes.
Daniel took a picture of our audience during our presentation. It’s a bit blurry, but it looks like everyone is paying attention!
We went back to KATH on Friday and spent time rounding with one of the ward pharmacists. Janet is responsible for rounding daily in the pediatric surgery unit (ward). Ghanaian teaching hospitals host rounds with physicians, surgeons, medical students and residents, just like their U.S. counterparts. Most of the patients were in the post-operative portion of their stay, which meant that most of the pharmacist’s input concerns prophylactic antibiotic coverage. While we stress the importance of antimicrobial stewardship in the U.S., any surgery in Ghana warrants a prophylactic antibiotic for more than just a few days since infections are so common in such a poor living environment. We already mentioned the lack of sterile procedures for medication preparation, and surgical rooms in Ghana do not have the same clean standards as U.S. units. Rounds generally last more than four hours in this non-air-conditioned hospital, so Nicole had to sneak off halfway through rounds to drink some water. We did not stay for the full four hours, though, since Janet had other patients to see.
We found ourselves at a college career fair for some of the brightest private school boys in Ghana Friday afternoon. While we initially planned on speaking about only ONU’s College of Pharmacy, we quickly found out that the students were most interested in medical school and law school. We did our best to emphasize the opportunities available for pharmacy students. It was clear that a career in pharmacy is not often considered in Ghana, and the students seemed to be very interested in what we had to say.
Saturday called for a visit to Lake Bosumtwi, the only natural lake in Ghana. It was formed when a meteorite hit the earth once upon a time, and it has become popular with biologists and other researchers who come to this region. We were informed of the lake’s history and took a boat tour, hoping no one would rock the boat because the water was something you did not want to touch.
A fisherman at work on Lake Bosumtwi. Yes, the water really is murky green.
That evening, we attended a comedy show called “Klint and Friends” in Kumasi. There were six comedians who performed solo acts. While the cultural barrier and thick accents made it difficult for Nicole and Courtney to understand all of the jokes, Rita and Daniel were laughing hysterically.
At every comedy show there is always one poor soul who is chosen from the audience to help with a joke on stage. This comedian specifically requested a white woman. Among a Ghanaian crowd, Nicole and Courtney had a 50/50 chance of being selected. Naturally, with Courtney’s luck, she was chosen to go on stage, much to Nicole’s relief. Let’s just say the joke was about a young Ghanaian couple consummating their relationship, which made for a very embarrassing time on stage for Courtney.
Courtney had her “15 minutes of fame” that felt much longer than that.
We hopped back into the car Sunday morning for the long drive back to Accra. Our time in Kumasi was filled with some great pharmacy learning opportunities and fun times. It has been one of the highlights of our trip to date.
Auntie Courtney and Auntie Nicole
“Adventures with Fufu”
Last weekend, we ate fufu for the first time. In case you forgot, fufu is very similar to banku, which we ate during our first week. Each dish is a ball of dough served with stew, but fufu is made from plantains and banku is made from corn. Since Courtney does not like tomatoes, she made her own “stew” with the flavor packet from a pack of Ramen noodles and added the fish and beef from the tomato stew. Later, she tried the fufu with the tomato stew, and we both agree that fufu > banku (Bright will not be pleased to hear this). Ruth was so thrilled that we were able to finish our bowls of fufu that she clapped and cheered when we showed her our empty bowls!
Nicole eating fufu, with Rita’s finger photobombing the scene.
Monday was a day of rest for Daniel since he arrived from London. This, in combination with everyone’s pleasure that we like fufu, meant that we not only ate fufu again for lunch, but we also learned how to make it. First, the plantains are peeled and boiled, as well as cassava, which is similar to yams. Once the vegetables are ready, they are taken outside to be pounded into dough.
Nicole works on smashing up the plantains, while Grandma enjoys her effort.
Then it is Courtney’s turn to work for her lunch as Grandma moves the plantains around the bowl.
The plantains are mashed while Grandma moves the vegetables so the person doing the smashing can target any rough pieces. This continues until the plantains form a smooth dough-like consistency (it’s not exactly dough because the only ingredients are plantains and water). The plantains are set aside, and then the process repeats with the cassava. It is important to smash the plantains and the cassava separately at first to work out all of the lumps, and then at the end both balls of dough are combined to form one large plantain-cassava mixture.
Here, the plantains (yellow) are being mixed into the cassava (white).
Grandma works on forming balls of fufu for our lunch.
Once the fufu is prepared, a ball is placed in the center of a bowl and stew is ladled over the top. The stew is generally tomato-based and spicy, and ours had some fish and beef. Ruth made a different stew on Monday that she called “peanut butter fufu”, which Courtney loved (she brought a jar of crunchy peanut butter from home), but Nicole did not like the taste much and she opted for the tomato stew.
Ruth ladles some of the peanut butter stew over fufu for Courtney.
It is interesting to note that so far, we have not encountered much food that we would call “different”, aka something we don’t eat at home. We did try the cow skin in the okro stew when we ate banku, but so far that had been the only instance. Until lunch:
Cow foot, anyone?
It just wouldn’t be a beef stew without all of the cow’s muscles, would it? Nicole actually considered trying it, but she couldn’t finish her fufu as it was. Ruth and Grandma made bigger balls of fufu since we were able to finish our meals the last two times, and this time it was too much food for Nicole. On the other hand, Courtney was so excited to eat peanut butter fufu that she requested a larger ball of fufu, so she was obligated to finish her meal. She triumphed through it and decided that from now on, she will stick with the smaller portions of fufu.
Auntie Nicole and Auntie Courtney
“Out and About in 90 Degree Heat”
The pharmacy in Dzorwulu was pretty slow last week, so we tried to have some fun on our lunch breaks.
On Tuesday, Bright picked us up from the pharmacy and we drove to Cynthia’s dressmaker because we wanted to have dresses made. We were almost to the address when Bright stopped the car because the dressmaker was walking down the street away from her business. He talked to her and it turned out that there was no power in the shop and she was on her way to meet someone, so we had to try again “any other day”. We went back on Wednesday and she was there. We flipped through magazines to select what style we wanted for our dresses, showed the dressmaker our choices and our cloths, and she took several measurements. She said it would be two weeks to make our dresses, so they will be ready to pick up on October 25 (right before we leave to come home). We can’t wait to see how they turn out!
Thursday was full of adventure and it has been our favorite day so far. The morning started off with FanIce, which is ice cream in a pouch that tastes like a milkshake. It comes in vanilla, chocolate, and strawberry, but we tried vanilla to be safe. It was tasty and it was a nice relief from the heat.
Cooling off during a hot day at the pharmacy.
The FanIce bag is the size of a large smartphone, so it is a portable treat.
Thursday turned out to be an interesting day at work. We are used to seeing patients who speak English or Twi, and Rita, Kate, and Josephine fill us in when a Twi-speaking patient comes to the pharmacy. Thursday was different because we saw three patients who spoke French. Josephine said it’s not uncommon to see a French-speaking patient on a weekly basis since all of the countries that surround Ghana are former French colonies. These patients stymied Rita and Kate, but Nicole was able to communicate with them since she can speak French. It was difficult because two patients spoke a local dialect Nicole had trouble understanding, and in the end they wanted a product they had used before even though the symptoms they described would not be adequately treated with that product. The third patient was easier to help because he also spoke some English, so Courtney and Rita did the initial consultation and Nicole followed up with counseling. Overall, Nicole was happy to be able to communicate in French.
We followed our morning counseling with a lunch break at Palace, which is a Chinese restaurant near the pharmacy. Nicole wanted to try local Chinese food at some point during the trip because she enjoys Asian cuisine and she wanted to see how it compared to Chinese food in America. America wins. We shared an order of sweet and sour chicken and white rice (which does not come with the entrée here) and it was not as good as sweet and sour chicken at home. The sauce was not very sweet and the chicken was mostly fat (so this part was like home). Not the best lunch, but it was something different to try.
After work, Rita’s friend Cynthia picked us up for dinner, but first we stopped on the side of the road to try coconut water.
The vendor used a machete to trim and open the coconut, and then you would drink the water.
Courtney designated Nicole as her official taste-tester for the trip, so Nicole tried the coconut water first.
Courtney reacts after taking a sip, while Rita talks to the vendor between sips.
The coconut contains water, which tastes slightly sweet but does not have a very distinct flavor. It tasted kind of like flavored water without any added sweetener. Once you finished drinking the water (or tossed it in the gutter if you could not finish it), the vendor would crack open the coconut and scoop out the coconut fruit. The fruit does not taste or resemble the packaged coconut in the baking aisle of the grocery store – it is slimy and has the same taste as the water.
After this detour, we went to Cuppa Cappuccino for dinner. It is a sandwich shop that also serves a variety of drinks – including coffee.
Courtney was able to drink coffee for the first time in almost two weeks and she was very happy about this.
We ordered sandwiches without any vegetables since we were not sure how the vegetables were washed, and after some very slow service, the waitress messed up our order. The sandwiches we okay, but it was nice to have food that reminded us of home. Courtney was happy regardless because she drank her cup of coffee (and then ate many of the accompanying sugar cubes), until it was 1:30am and she was still wired from the caffeine.
At dinner, from left to right: Sylvia, Cynthia, Rita, Courtney, and Nicole. Lorraine did not want to be photographed so she operated the camera.
Friday was a laid back day. Rita wanted to have a manicure and pedicure during lunch, so we walked to a nearby salon. Nicole and Courtney each opted for a manicure, and it was probably the cheapest manicure we have ever seen (5 cedis each, which is about $2.50). The quality was not top-notch, but a $2 manicure isn’t a bad way to spend a lunch break.
The funny part about this excursion was lunch. We decided to eat after the manicures and we forgot to take into account how the nail polish would not be completely dry when it was time to eat. We each ordered a meat pie for lunch (a pastry with a meat and onion filling) and requested forks from the waitress. We had to ask her four or five times to bring us silverware and she probably thought we were crazy (eating a meat pie with a fork is the equivalent of eating a fast food hamburger with silverware at home). Rita finally explained that we just had our nails done and procured some forks for us.
The Dzorwulu FamilyCare Pharmacy staff from left to right: Kate (DT), Rita, Nicole, Josephine (RPh), and Courtney
Saturday was the day we had been waiting for: beach day! Bright said he would take us to the beach and he would pick us up before the afternoon. This means noon, right? Not in Ghana! He did not arrive until almost 4pm. At first he said he was stuck in traffic all afternoon, but then it turns out he watched a soccer match while waiting for someone to show up at an appointment. Either way, we were still excited to go to the beach, even though the sun was now hidden behind some clouds. We tried kebabs made with goat meat, which were pretty good! The meat was a little chewy, but the flavor was good.
We finally snapped a good photo of Bright! He says wearing shoes around your neck will be fashionable by fall 2015.
Courtney’s on a horse – after all, anything is possible when you use Old Spice body wash. (She doesn’t.)
Courtney, Nicole and Rita at the beach
Nothing like a friendly reminder each time you light up.
Daniel arrives early Monday morning, so we will kick off two weeks of health organizations and travelling with a very early “Welcome home!”
Auntie Nicole and Auntie Courtney
Ghanaians are very hospitable people. When we arrived in Ghana, we were greeted by Daniel, who insisted that we should eat something and meet Bright since we would be working with him that week. When Rita arrived at the end of the first week, we greeted her with an entourage at the airport.
Rita decided to live with us at Daniel’s house since it would be easier to drive to work if we did not have to stop at her parents’ house. This meant that Rita would visit her family the next day, and we went with her. In Ghana, it is not uncommon for members of the extended family to live in the same house, so we met Rita’s father, mother, grandmother, and three of her brothers. It is a custom, upon welcoming a visitor into your home, to offer that person water and ask about the place from which that person came. Rita’s grandmother initiated this custom, and after a brief explanation from Rita, we understood how to properly greet guests. We shook hands with everyone (her family lined up to shake our hands, kind of like two teams shaking hands after a sports match) and the conversations began. Rita said this was her first visit home in two years, so everyone was happy to see her. Her parents live in Dzorwulu a couple blocks from the Familycare Pharmacy where we worked during the second week, so we saw her family many times.
After spending time with Rita’s family (and dropping off two suitcases full of American souvenirs), we drove to Adenta with Charles to see Cynthia’s parents, who wanted to meet the ONU students. The drive took a long time because there were several traffic jams and we were seating a lot by the time we arrived. Cynthia’s parents greeted us with the same customs, but we were offered sangria instead of water. Courtney thought it was just fruit juice and she filled her glass to the top, and then she was surprised to find there was some alcohol in the beverage. The sangria was cold, though, and any cold drink would have been just as refreshing.
After these visits, we stopped at the Accra mall. The mall is pretty new (it was built within the last few years) and it resembles American malls. It has some clothing stores, an electronics store, a grocery store, and a food court. The food court has American food – pizza, fried chicken, and ice cream. Pizza has become the go-to option if we feel sick since we know it is a safe option. The mall was a nice stop, but it is a lot smaller than most American malls. Regardless, it is a popular destination on the weekend and traffic around the mall is terrible.
The Accra mall – it reminds us of malls at home.
So far, we have eaten with Rita’s family and friends for many meals because everyone knows she is back in Ghana. We have eaten at her parents’ house a few times, which Courtney really enjoys because Rita’s mom makes kelewele (fried plantains, which is probably her favorite Ghanaian food) and a stew with vegetables and fish (which tastes like the filling for a stuffed pepper when eaten with rice). We learned that before you begin eating, it is polite to invite the people around you to join (you just say, “I invite you,” and you can eat your food).
We have also spent time with Lorraine, one of Rita’s good friends who took us to the Art Center market. At the market, we bought cloth so we could have dresses made while we are here and Courtney bought a lot of t-shirts as souvenirs for her family. The market was not very busy because it was Sunday, so all of the vendors swarmed us as soon as they saw two white girls. Rita and Lorraine were able to barter for us, which was really helpful.
Courtney examines a cloth to purchase at Art Center.
Another of Rita’s friends, Andy, learned that we want to try fufu before we leave. We have already tried banku, which is similar to fufu. Banku is a starchy ball of dough made from corn that is served with stew (okro stew with which fish, in our case). Nicole liked banku and Courtney did not, but Courtney still wants to try fufu since it is one of the most popular Ghanaian dishes.
Banku. The ball of dough is on the left and the okro stew is on the right. To eat it, you gather a piece of the dough with your fingers, then use it to scoop up some of the soup and swallow it without chewing. It’s a different eating experience from home.
Nicole eating banku, which she thought was tasty.
However, when Andy took us out for dinner, it was too late for fufu because they stopped making it for the day. We tried waakye instead (rice and beans with meat – chicken for Nicole and fish for Courtney). Unfortunately for Nicole, something in the waakye made her sick that night, so she hopes she won’t have food poisoning again this month. We were warned that we would get sick at some point during this trip, so this didn’t disrupt any plans – just some sleep for Nicole. The next day, no fewer than a dozen people inquired about her health to make sure she was okay.
We are grateful and a little surprised at how Ghanaians will go out of their way to make us feel welcome, whether it is Daniel opening his home to us for the month, Rita’s mother cooking a delicious meal for us, or Bright leaving the pharmacy in the middle of the day to take us somewhere (too bad we can’t do that at home). All of the hospitality really enhances our visit in Ghana.
Well, we could live without the awkward marriage proposals.
Auntie Nicole and Auntie Courtney
In order to get a feel for the country, we thought we should share a quick post with some information about the infrastructure of Ghana so we can illustrate some of the apparent differences between here and home.
The first thing we noticed was the state of the roads. Many of the roads in Accra are paved with asphalt, so it is easy to drive around (if you don’t get stuck in traffic – easier said than done). We are told that outside of Accra, the roads are not very good, so we will see this for ourselves when we go to Kumasi and Cape Coast later this month. Rita told us you can tell the difference between the older neighborhoods and the newer parts of the city because the older parts have paved roads, whereas the newer parts have dirt roads. The dirt roads are filled with potholes, so it takes much longer to travel on a dirt road, especially in traffic. The roads in New Weija are red dirt roads, but a winding drive through our neighborhood takes you to the highway, which is paved and constantly filled with cars. Many Ghanaians complain about the state of the roads, and we decided that a Jeep would be a good investment to pretend like we are off-roading.
We took a walk around the neighborhood on the first day. Charles, Ruth, and Nicole are trying to avoid the ditch in the middle of the road.
This photo gives you a better idea of the immediate geography. This area is somewhat hilly, so it takes about 10 minutes to drive from the house to the main highway.
Between the traffic and the state of the roads, it can take over an hour to get to the pharmacy (Mapquest can’t even calculate a route for us). Spending that much time in the car means we have become well acquainted with one radio station that Charles (our driver) particularly enjoys. Rainbow Radio is a joint station between Accra and London (you can listen to it online at http://www.rainbowradio.co.uk). The station usually plays African music or a radio program, and every once in a while we will hear an American pop song (remember Destiny’s Child?). One thing we have noticed is a commercial for “daily water”, which is mentioned regularly throughout the day. It’s more amusing than other radio ads because the announcers just keep repeating “Daily water!” with different inflections.
Ghana uses two main sources for power: hydroelectric and gas. Hydroelectric power supplies a large amount of power for the country and gas is used as supplemental power. The gas pipe originates in Nigeria and runs along the coast through Benin, Togo, and Ghana. However, there is a problem with the gas pipe somewhere in Togo or Benin and the pipe has been shut off for repairs. This means Ghana is relying on hydroelectric power right now which cannot supply the entire country, so power outages are a daily occurrence. The outages are supposedly scheduled, but no one really knows when the power will go out. Different parts of Accra lose power at different times and these outages can last anywhere from a couple hours to the entire day or night. Thankfully, the power in New Weija (where we are living) tends to go out during the day when we are at work and it comes on at night when we return, so we can enjoy air conditioning at night and sleep comfortably.
This is what everything looks like when the power goes out. Good thing we have flashlights.
The longest streak we had without power so far? 24 hours. Courtney jumped out of bed the instant it came back on so she could use the internet. Nicole’s priorities are sleep internet, so she waited until morning to go online.
Don’t worry, our other posts won’t be as dry as this one, but hey, this is important, too.
Auntie Nicole and Auntie Courtney
“Behind the Counter”
After spending our first week in Ghana working at the Madina location of Familycare Pharmacy, we decided to expand upon a post from Amanda and Jessica and describe differences in pharmacy practice through our points of view. Madina is an area of Accra that is home to many Libyan refugees that left their homes after the Arab Spring. We have not seen any protests or the like against the American film “Innocence of Muslims” that is causing uproar in other parts of the world. Some of the men and women who came into the pharmacy were dressed in Muslim attire, while other customers arrived in business suits, jeans, or dresses.
The Madina location of Familycare Pharmacy, where we spent our first week.
We tried to familiarize ourselves with the products because most brand names are different than what we are used to seeing. Daniel (our host who owns the Familycare Pharmacies) purchases products based on what is available for a reasonable price, so we saw drugs from a variety of manufacturers (some were familiar, some were unknown to us). The pharmacy generally stocks brand name medications because Ghana does not have the same strict manufacturing regulations as the United States. Ghana does have regulations on medications, but brand names here are thought to be more consistent and honest (the drug and dosage listed on the package is actually in the tablet or liquid), but generic drugs may not contain the stated drug or the stated amount. (Note: the Food and Drug Administration makes sure generic drugs are bioequivalent to brand drugs for the U.S. market, so generics are generally reliable for use in the U.S.)
Business was pretty slow during the day when we were at the pharmacy since many people visit after work in the evening. Patients would come to the counter and either hand us a prescription, tell us what drug they wanted to buy, or tell us what symptoms they were having. We filled the prescriptions or selected products based on a patient history with a lot of help from Bright (the pharmacist), Amma, and Saleh (the dispensing technicians). Some patients did not speak English, so the staff would complete the transaction and then explain the conversation with the patient and which drug(s) were given. We still needed help with patients who spoke English, too, because it was difficult to understand the accent and Ghanaians in general speak softer than Americans.
Saleh, one of the dispensing technicians in Madina, unpacks inventory. In front of her, the entire bottom shelf is devoted to malaria treatment.
In Ghana, there is no distinction between prescription drugs and over the counter (OTC) drugs. Almost any drug can be given OTC at the discretion of the pharmacist, which is based on a loosely-interpreted law about drug dispensing. This is why there are many chemists and dispensaries in Ghana – anyone can sell the drugs even though it is a pharmacist’s domain because the law is not strictly enforced. Some people do prefer to trust and seek advice from a pharmacist instead of a dispensing technician. Bright prefers to use more discretion about antibiotics, drugs for chronic disease states, and other medications that would be controlled substances in the U.S., probably because he completed pharmacy school at the University of Buffalo and is familiar with pharmacy practice in the U.S. However, since malaria is such a big issue here, he has no problem dispensing malaria treatment (which has its own shelf on the pharmacy wall) as long as the patient’s symptoms are mild and he thinks a hospital visit is not necessary.
In reference to the title of this entry, all medications here are kept “behind the counter”, including vitamins and pain relievers. In the U.S., prescription medications are kept “behind the counter,” or in the pharmacy area of the drugstore, while OTC medications are kept on the floor for customers to access. The size of the pharmacies here are smaller than what we see at home, so some medications are shelved around the pharmacy, but patients do not walk into the store and simply pick up the drug they want to buy. Instead, a patient walks up to the pharmacy counter and explains what they want, then a member of the pharmacy staff selects the appropriate medication from around the store. This set-up is similar to pharmacies Nicole has seen in Europe and Asia, where all medications are kept behind the counter and personal care products, such as shampoo, lotion, and soap, are kept out on the floor.
The pharmacy counter was often deserted during the day since most business picks up after work.
We have been spending our second week working at the Dzorwulu location of Familycare Pharmacy. We performed blood pressure screenings for patients. Many said they were “in a hurry” and did not have time to check their blood pressure, and one man did not want to be photographed. Derek, a pharmacist who is a representative from Pfizer, was a sport and we took his blood pressure. He then told us that when he was doing his practical experiences, he spent an entire month doing presentations on hypertension. His blood pressure was running high and he said it had been lately, so we asked him why he didn’t take Norvasc (a Pfizer antihypertensive drug). By the time he left the pharmacy, Josephine, the pharmacist, convinced him to try Norvasc since his job is pretty stressful and that is the likely cause of his hypertension.
From left to right: Derek, Courtney, Rita, and Nicole await the results of Derek’s blood pressure check.
This picture shows our lengthy conversation with Derek more accurately: we really just stood around and talked for an hour. Hey, business was slow.
We were able to talk to Derek about pharmaceutical marketing, since he came in to promote Zithromax and Celebrex. We spent time talking about his promotion of Pfizer drugs in Ghana and he reinforced the idea that brand names are more reliable in Ghana. He had spent the morning promoting Zithromax in a hospital, where he pulls data from clinical trials to present to the doctors to show that Zithromax is a superior antibiotic choice compared to generic azithromycin, which is not regulated as closely. Derek did not have any free gifts for us, so we were a little hesitant about supporting Pfizer drugs (we didn’t even get a free pen, let alone a free lunch). We found it interesting that he was not hesitant to say Zithromax should only be used for approved indications (even though he joked about its “wonder drug” properties). Pharmacists can give out antibiotics without a prescription if they decide the patient is suffering from a “common disease state,” but Derek was more concerned about dispensing brand Zithromax instead of a generic when we received prescriptions. All in all, it was not a bad afternoon.
Overall, it is nice to be able to recommend treatment for patients. We just need to learn the 20+ brand names for Ghanaian versions of Excedrin.
Auntie Nicole and Auntie Courtney
There’s always a little more worry when taking an international flight. Security seems to be a little stricter, international layovers are a little more nerve-wracking, and customs is always… well, frustrating, to say the least. In the end, things usually turn out for the better. The flight for us… err, Courtney, from Cleveland, OH to Accra, Ghana almost didn’t a couple of times.
First things first: baggage check (online check-in was done before arriving at the airport). This international flight offered two checked bags for free (score!). As we watched our bags being checked by security, both Nicole’s and Courtney’s were pulled for inspection. Nicole’s bag passed, but Courtney’s bags did not. Bug spray is a necessity when travelling to a country where malaria is one of the most common diseases, so both of us packed plenty of it. Courtney had to leave her bug spray behind because aerosol sprays (especially four cans) are too flammable to store on a plane, even in checked luggage. We decided to figure out how to handle that when we arrived in Ghana.
The next step was security. Naturally, Nicole walked through without a problem. Courtney’s book bag was flagged for inspection, and then a closer inspection, and then a complete body pat-down of Courtney was warranted. We still are not sure why, but at that point, our exciting mood was completely lost (don’t worry, Courtney passed the inspection).
The flights were long, but they were at least comfortable. Our route was Cleveland to Atlanta, then Amsterdam, then Accra. The international wing of Atlanta’s airport is much fancier than the rest! The Amsterdam airport had security at the boarding gates, which was different from the other airports. Fortunately, Courtney didn’t have an issue getting through security this time. We slowly became a minority with each change of plane, with less and less English being heard around us and more and more languages that we could usually identify. After about 24 hours of travel time, we finally landed in Accra.
Chillin’ in Hotlanta during a long layover.
Remember how we said immigration and customs is a little frustrating? Because mosquitoes spread many different diseases, including yellow fever, a yellow fever vaccine (and proof of documentation) is required to enter the country. Travelers receive a yellow card signifying the receipt of the vaccine which must be shown when going through immigration control. Nicole pulled out her card, but Courtney realized she left her card in her bedroom in the United States. After a few minutes of panic, the immigration officer said, “Make sure you have it next time!” and Courtney was allowed through. After getting passports stamped, picking up luggage, and fining our host father Daniel (who Amanda and Jessica told you all about last month), the trip was almost complete!
Daniel was very welcoming, giving us both a big hug once he spotted us. He took our bags, guided us both to the car, and asked us what we wanted to eat. We were excited when he pulled up to a pizza place. Yes, they have pizza in Ghana, and it tastes similar to pizza at home. We enjoyed our meal, met Bright (the pharmacist we worked with during the first week since Daniel spent time in London helping Cynthia settle in for her Doctorate program), and then Daniel drove us to his home.
While we were waiting for pizza, Daniel took this picture of us and said he was going to send it to Dean Sprague. Notice how 24 hours of travel took a toll on our hair.
As soon as we arrived, our bags were taken to our room, where air conditioning was installed, access to a shower and bathroom was just a few feet away, and a refrigerator, television, armoire, and bed were all available for our use (which exceeded our expectations!). We unpacked and went to bed for the night since it had been a long and exhausting trip.
When we awoke in the morning, we had the day to recover from our trip. Ruth greeted us when we went downstairs and offered us anything we needed to eat. Charles, Grandpa, and Grandma were all around to say hello. Daniel and Cynthia’s three boys greeted us when they got home from school and were excited to speak with us. We never could have imagined just how kind and inviting everyone would be when we arrived.
“Akwaaba” – Welcome to Ghana! The trip was off to a great start!
Until next time,
Auntie Courtney and Auntie Nicole