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“Akwaaba!”

“Daily Water!”

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
 

“Akwaaba!”

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