Are Ghanaians Entrepreneurial?

Four business minded people and two students of law were having dinner at the Accra Imperial Peking Chinese Restaurant when this topic of discussion came up. The claim was made that Ghanaians were not entrepreneurial which is to say, we are risk averse, are unwilling/unable to get others to take risks to our benefit and/or are unwilling to move out of our comfort zones. An example was offered of the cobbler who after twenty something years still spoke of his dream of expanding into a shop but remained sat at his small table by the roadside, the only change being his graying hair.

I’m sure you know of many other instances of people setting up one room shops and grinding it out the rest of their lives or of those satisfied with being the wealthiest people in a village and no more. And then there are our students who study and pray that one day they might get a chair and table in a civil service office or a bank and obtain security for their families.

I vehemently argued that we were indeed entrepreneurial. The problem was the lack of credit from banks, the killer interest rates on loans, a society which is quick to punish failure, a government unwilling to foster the right environment for entrepreneurship and business, and a culture of filial duty which forces the individual to settle in the most secure jobs like medicine, law, engineering and the like—to wit, everything outside of the individual.

When saner minds prevail, however, true as these arguments may be, and there are current indications that some of them are increasingly false (With some mild improvement over the past years, it now takes on average seven procedures, twelve days and a cost of 20% income per capita to start a business. Our ease of doing business and starting a business still lag those of many countries with ranks of 67 and 99 however – World Bank), the Cedi stops with us. The many small businesses indeed show we are willing to take risks but the few Ghanaian owned large business and the burgeoning ranks of the unemployed college grads suggest we are unwilling to dream big or act on big dreams.

This is where we need to change and grudgingly I admit the truth of my friends’ arguments. Only recently have we begun to build an entrepreneurial culture/an enabling environment with numerous award schemes for entrepreneurs. These do not go far enough. I dream of the day when it is okay to start a business and lose money, where past business failures do not mean lack of access to future credit and are not negatives on resumes/CVs. We must teach entrepreneurship in our institutions as a viable career option. Malaysia is already reinventing itself with efforts to incorporate it into its formal curriculum. We can learn something there.

As usual, our generation is setting the pace. From IT/Software companies to education-related enterprises, there are people out there holding true to the Harvard Business Schools’ The Entrepreneurial Manager course definition of entrepreneurship as “the pursuit of opportunity without regard to resources currently controlled”. So get out there, start a business, innovate in another person’s business, hedge your risks if you must, do it after work if you must, use someone else’s money if you must, but for Ghana’s sake, do something.

An interesting research on entrepreneurship in Ghana can be found here.

Prime

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This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
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Mu’ammar’s War…Cote D’Ivoire and The illegitimacy of the African Union

Unless you have been living in a hole for the past few weeks, you know there is a war going on in Libya, many anti-establishment protests across North Africa and the Middle East, and Cote D’Ivoire has had two “presidents” since its elections in November, 2010. La Cote D’Ivoire is in another civil war with hundreds certainly dead. The only question is at whose hands. You have also read the news articles and the commentary from all sides and obviously have an opinion on whether the US should be in Libya and France in La Cote D’Ivoire. So let’s dig through the emotions and have a human discussion.

Why are we in the current situation? I fear it is because the African Union no longer represents the ideals of the African people. Here was an organization, its predecessor Organization of African Unity anyway, formed by revolutionary thinkers of their time to give Africa a voice and counter its perceived looting by the West and Soviet Union alike. Those were the days of promise. Sadly, many of those leaders drank the palm wine of their glory. They came to believe that they and only they were the repositories of all solutions and visions to move their people forward. That and…leadership came with tremendous wealth.

So they became oppressive dictators and neo-democrats who held elections with only one outcome—a guaranteed victory. And with these relics of the past still on and presiding over the AU (Qaddafi was its past president), it lost its legitimacy. What could one expect of it? Laurent Gbagbo threw the gauntlet down when he asked what any of the leaders knew about democracy to seek to mediate it in his country. Indeed they knew naught; which explains the union’s lack of action or inability to resolve to any just end the various disputed elections or holds on power in Kenya, Zimbabwe and Togo.
The problem with dictatorships is when things go right, some level of tolerance is garnered but when economic conditions deteriorate, instability arises. The response of leaders to this instability ends up determining their fates. In Africa, the usual response is to stoke ethnic and anti-imperialist sentiments, kill a lot of people, and stay in power. Mobutu did it, Amin did it, Mugabe is doing it. And usually, each AU leader fetches water to set by his beard as he watches another’s burn.

The AU was ineffective in La Cote D’Ivoire, unheard in Egypt and Tunisia and silent in Libya until the specter of UN intervention was raised. With no organization to look out for the interests of “we the people” then, what gives? The international community, that’s what. Yes there have been many protests toppling regimes before this—La Cote D’Ivoire did it with General Guei, Indonesians went against Suharto, and a lot of the monks in Myanmar were abused and in all, the international society stood and watched.

Currently, Bahrain is oppressing protestors, Yemen did the same, both Cote D’Ivoire and Syria has shot into protestors. The less said of Iran, the better. Maybe it’s because the former two are allies of the west and the latter two too big or too cozily aligned to the east to be bombed. Maybe Cote d’Ivoire only holds interest for the French and maybe Qaddafi’s day was always coming with Lockerbie still in people’s memories and him sitting pretty on all that oil.

Maybe it’s more complicated than that but what is certain is the US-led, France-inspired, UN endorsed onslaught shows the international community is suddenly acting. And so is the illegitimate AU, apparently—condemning the use of force in Libya on the one hand while asking for it in Cote D’Ivoire on the other. The AU, full of its dinosaurs, is not my voice. It is not the voice of the African people. So here is my voice (which is not the voice of the African people).

I do not support arbitrary interventions in the sovereignty of other nations. But I also do not support the killing of a nation’s people by its government. We will see in due time how Libya turns out especially with Mu’ammar seemingly unflappable. But I will not sit here and wax lyrical about some idea of sovereignty. I will not condemn action taken to protect innocent lives. I certainly hope someone takes action if my people are ever under siege. Whether force should be used is a legitimate question but the litmus test for me is whether action or non-action leads to the protection of more lives.

If Qadaffi goes, another dictator may yet rise in his place. A western puppet may be installed but the Libyan people could yet be alive to decide how to react to that. If it be for Libya’s oil, then so be it. It might be the first time oil is a blessing instead of a curse. After all, as the saying goes in Eʋe, “agbenɔxevi metsia fumato o” (As long as a bird lives, it will certainly grow feathers).

Prime

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This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
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The Good… and The Bad

Another year, another stay in Ghana, another rendering of accounts. Let’s start with the bad:

1. Roads: There is a rapid uptick in the number of roads being repaired or expanded in Ghana. Some, like the Accra-Sogakope road, have been completed but others, like the New Hampshire highway, remain perpetually under construction. Of particular note, the Tetteh Quarshie Roundabout-Dodowa road looks rather similar to what it was a year ago. This has led not only to bone jarring bumps and car wrecking conditions but a lot of dust coating everything red and damaging our lungs.
2. Pollution: Of land, air and water. You’ve heard of the dust but what you haven’t heard are the multiple bush and other fires, and cars with bad exhausts spewing smoke into the air. I only breathe fresh air in my village. One still sees trash like (un?)pure water sachet bags on the ground and our water bodies are clogged or dead from dumping of trash and waste. And the smell, oh the smell...
3. Driving: If you take a taxi in Accra, sit at the back, put on your seat belt, and pray. From overspeeding through the bad roads, taking risky short-cuts, disrespecting road traffic laws, attempting to pass a mile of cars in a rush of oncoming traffic to riding the shoulders of roads, drivers in Ghana have invented a code that is neither safe in the least nor for the faint hearted. Why, I saw someone drive onto the shoulder of the opposite lane so one set of tires could avoid a speed bump.

The good:
1. The Changing Landscape: I now know not where Accra ends and the rest of Ghana begins. Inside and outside of the city, buildings are springing with rampant regularity along the major roads. It is turning the city into a really metropolitan one but also creating a suburban class. Maybe the economy is good after all.
2. Street naming exercise: This was started a while ago and continues. With Google map and GPS functionalities catching up or ahead of it, you can now find exactly where that wedding is held or a business is located without driving to the big tree and then finding the roasted plantain seller is not there to be asked for the rest of the directions.
3. The business climate: There has been a spur of investment in Ghana in recent years with an especial resurgence of the financial sector, among them real estate trusts, commercial and investment banks and private equities. They have provided employment to more than a few graduates, albeit at crazy work hours, and contributed to the glut of cars on our streets.
4. Rural business section of TV3 News: I was particularly gladdened to see a news station dedicate a part of the news hour to highlighting rural business successes and opportunities for financing. Being interested in business at the base of the pyramid and small scale enterprises, this is indeed, welcome news.

The unclassifiable:
I have noticed that in spite of government efforts to relocate them, street hawkers in our Drive-Thru Malls (apologies to Aisha Saaka), continue to run the roads. It is of course heartwarming to see people engaged in legitimate business but the risks of their trade—being run over by cars—and the fact that a lot of child labor goes into it as well gives me pause for concern. Did I miss something? Leave a comment, let me know.

Prime

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This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
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People and Places

On this stay in Ghana, three of my friends from business school visited and forced me to explore Accra more than I had previously cared to. These are some of the things I enjoyed doing. You will see some common threads of touristy things but also a yearning for the old.

1. +233 – The aptly named spot is on Ring Road central, between the Ako-Adjei interchange and the Kanda overpass. I spoke to one of the managers and learnt it was set up by three brothers for the 2010 World Cup. They brought their skills to bear so that you have a wide open space with the dark, starry African night as your ceiling, food and drinks overseen by one brother, and live Jazz music overseen by another. It is a very calming atmosphere, even romantic, and the food is affordable. On Sundays, you are treated to a live performance by Gyedu Blay-Ambolley, one of the pre-eminent Ghanaian musicians of old.
2. Chez Afrique – This East Legon joint is another place where live music and food mix at night. This one gives a blend of highlife, the smooth Ghanaian music of old, some hiplife—a blend of hip hop and highlife—and a touch of reggae from Marley to Dube. In contrast to +233 where the band is behind a glass wall, there is a dance floor where dancers interact freely with the musicians.
3. Labadi Beach Reggae Wednesdays – A GH₵5 charge will grant you access to this wide expanse of white sands and the roaring Gulf of Guinea where interspersed with the nicely decorated tables and chairs for drinks are pots of fire in the sand and an elevated stage with live reggae music spanning local creations, Peter Tosh, Bob Marley and Culture. It provides a nice mix of expatriates and locals if you are inclined to that atmosphere and you can dance your heart out into the wee hours of the dawn.
4. Buka – This is a surprisingly affordable restaurant in Osu with a nice afro feel and food from Nigeria, La Cote d’Ivoire and Ghana. With bamboo paneling, wooden décor and a large neem tree blowing a nice breeze, the only anomaly is the flat panel blaring “Whip My Hair”. You can also down your grilled tilapia and banku, jollof rice and goat stew, ampesi and kontomire stew or fufu and groundnut soup with my preferred non-alcoholic frozen fresh palm wine which you can make alcoholic by fermenting through letting it sit. Do go after 1pm however because they are woefully understaffed and the food takes long in coming.
5. Bojo Beach – The traffic to and from this haven off the Accra-Cape Coast highway is horrible, and the road from the highway to the beach is a shame. It could take you anywhere from an hour to two from the center of Accra to get to this beach. The view of Bojo will wipe those memories away. Located on a sandbar between the Gulf of Guinea and a lagoon, one has to cross a moat and the river to get to it. The cruise, access to the beach and amenities will cost you GH₵6 and you are not allowed to bring food or drinks. Not to worry, they are relatively affordable. The beach itself has thatch structures providing shade, a volleyball net, a jet ski at GH₵15 per 5min cruise and a very swimmable sea. You can stay all day long. I have been here a few times and thoroughly enjoyed them all.

These are of course only a smattering of the many enjoyable places in Ghana – my friends went to Cape Coast and Kumasi among others – but these are the places I recently found and was thrilled to see exist. Next time you are in Ghana (and you should go to Ghana), try them out.

Prime

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This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
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The White Man is Dead

It goes by many names; bend-down-boutique, night-mall, second-hand. Yet, the name most widely associated with used clothing in Ghana is “Oburoni w’awu” viz “the white man is dead”. It is a rather morbid play on the fact that these are discarded articles. They were, for a long time, my boutiques (from my goalkeeping jerseys to my “cambous”) and have provided employment to many a Ghanaian. And now, some of them are being banned.

Oburoni w’awu is widely popular because it is very cheap, you can still get premium brands if you have a good eye, and you usually haggled with the seller from a likely 10 times markup to a 3-5 times markup knowing you’d been had but okay with that as well. Kantamanto, in Accra, is the commercial capital of the business with stalls selling anything from belts to suits. There, many of our likely-to-be-otherwise-unemployed youth make a legitimate living.

It all comes at a cost, of course. Locally manufactured goods are very expensive; I still cannot figure out why—is labor not cheap in Ghana? Do we not have raw materials? It may well be because of high fixed costs spread over low volumes of sales. Anyways, the cheaper Oburoni w’awu crowd out Ghanaian innovation and enterprise as these cannot compete on price.

I am not a protectionist and do ascribe to the theory of comparative advantage with each nation doing what it does best. However, two trends make me indifferent or supportive of this action. There has been an upsurge in the number of Ghanaians labeling themselves with made in Ghana goods since the previous administration. This is so even though they are premium priced. Their competition is now more from “first hand” Chinese clothing than second hand western ones. A ban should thus have little, if any effect on the nascent Ghana-made clothing industry.

More importantly, the health risks as laid out in the BBC article give pause for concern. Clothing in intimate contact with such disease prone areas as the crotch should probably not be shared, especially when they are not industrially cleaned before resale. Better a healthy population.

Sadly, this means some youth will be out of work for a while but these are highly entrepreneurial spirits and they will be back on their feet. Plus, I am sure they would not want to survive on peddling disease. Ideally, they will succeed in some innovative Ghanaian enterprise so that when, in future, we say the white man is dead, it would mean less and not more dependence on his castaways.

Prime

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This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
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No Mr. Electoral Commissioner, I Will (might) Not Vote

As I wrote this, I had spent close to a month in my beloved country working on a project. I had thoroughly forgotten what it felt like to be cold and alone in a foreign land; I did miss my girlfriend. I wrote from the village in which I was born and the room in which I had slept many a night. The nostalgia may have made me put the “might” in the title. A month prior, it was, a strong “Will”.

Ghana, has changed and not only for the worse. Things got more expensive once the four zeros were dropped from our cedi, yes, but there is a certain sense of stability and dignified standing that I have not seen in a while, nay in my lifetime. And this is in the sphere of politics.

My readers know well I do not believe in the political system and the lack of alternatives in Ghana with a revolving door shuffling in the same thieves and looters (see The Politics of Recycling) every eight years. I had come to decide then, that even though I had recently registered as a voter in my country, actually voting was a waste of my time. Having never voted, I imagined it gave one a warm and fuzzy feeling to vote another into or out of power and maybe even turn the derelict on the corner into a wealthy baron overnight but I could not quite see the difference it made.

All most governments need do in Ghana is loot enough to sustain them the eight years of opposition before they get back on the horse. But two recent things have made me waver a bit. In the recent Ivorian crisis, President Mills came out against military intervention, a threat made by the Economic Community of West African States, ECOWAS, of which Ghana is a signatory. Then he turned around and raised oil prices 30% to GH₵7 or about $5 per gallon thus removing most of the government subsidy. And he is up for re-election in a year.

Mills has his critics, chief among them me. He has been ineffectual on other fronts, has arguably been slow in prosecuting malfeasance in the past administration, allowed hooligans in his party to run loose and loaded his administration with old dogs. However, he has been very comfortable making unpopular decisions which he perceives, rightly or wrongly, to be necessary for the country’s progress and has stood calmly resolute in the face of an onslaught from his party and the opposition. Others have come close to doing similar things but Rawlings mostly did them in a dictatorship with no specter of electoral defeat and Kufuor went HIPC but spared more suicidal decisions till his second term when no further votes stared him in the face.

Mills may yet lose the next elections for a variety of reasons. The likely alternative, Akufo-Addo, I do not rate highly and has said some rather stupid, if overblown, things lately. But I may yet vote in those elections…for someone. Whoever it turns out to be, it will be someone, like Mills, who is convicted in their vision for the country and are willing to stake their political careers on it.

After all, the countless voting may be futile for many years but once in a blue moon, one comes along who is worth the struggle.

Prime

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This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
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Your Donations Dollars at Work -- REACH Ghana Screenathon Results

A couple of months ago, I came here to ask for your assistance in implementing a REACH Ghana project in Glefe, Ghana. Through the help of many of you, readers, friends, family and other REACH Ghana associates, we raised close to $4,000. The official tallies are yet to be made but I am here to give you thanks for your support and to give you an unofficial account of the difference your money made.

We arrived that morning to Glefe to a water body, whose banks were filled with filth, puddles with stagnant water and trash. It was readily apparent the community needed some sort of intervention and, at the Ghana Health outpost, people were trickling in for it.

Through the course of the day, we screened approximately 200-300 children, women (including nursing and pregnant mothers), and men for malnutrition, diabetes, high blood pressure and breast cancer. Once attendees passed through the screening process, they were transferred to a final station where they were counseled on healthy eating and lifestyles and where needed, given medication supplied by Cocoa Clinic for malaria.

At this station, one hundred insecticide-treated mosquito nets were distributed to nursing mothers and pregnant women in the hopes of decreasing the incidence of childhood malaria in those homes. Parallel to this, one hundred and seventy one children and elderly people were registered for the National Health Insurance Scheme allowing them access to free healthcare and some medications for a year. REACH capped off the day by donating weighing scales, an electronic sphygmomanometer and the canopy tent under which we held activities to the health outpost.

Moving forward, REACH has initiated work with the Member of Parliament for the area, and Zoomlion, a waste management company towards establishing a waste disposal system in the community. We will be commissioning studies of the project’s effectiveness in the coming months.

As the organization looks forward to another year full of ambitious projects like the HIV/AIDS Intervention and Clean Water for Life initiatives, I would like to thank all our sponsors and ask for your continued support in making a better Ghana a reality.

For pictures of the event and other REACH news, go here and here and become a fan on facebook.

Special thanks to Maame Sampah, REACH Ghana Executive Secretary, Marie-Stella Essilfie and William Okyere Frempong, Local Operations Directors of REACH Ghana, students of the University of Ghana Medical School, volunteering members of REACH Ghana, REACH Ghana Executive and Advisory Boards, Cocoa Clinic, Citi FM and the New Ghanaian Newspaper.

Prime

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This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
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Imagine That

In this admittedly old news, Slate explores the recent occurrences of law students suing schools or citing them in bankruptcy lawsuits. The students argue that these schools knew there were few to no jobs available for students post graduation yet continued to encourage prospective students to apply. The schools then loaned such students large sums of money. The argument, then, is if schools advanced these loans knowing full well students would default on them, then they acted in bad faith and students should not have to repay loans.

If that sounds like the subprime mortgage crisis that plunged the US into a recession, it’s because it is pretty much like it. It also sounds like the SSNIT (Social Security and National Insurance Trust) loan scheme in Ghana. After all, the government does know the job market is bad, to put it mildly. The universities are fully aware they offer a lot of theoretical discipline and very little employable skill. Yet, they continue to exist.

And each year, thousands of graduates default on SSNIT loans that saw them through college leaving their guarantors, ordinary Ghanaians roped into the scheme, bearing the loss of retirement income among other things. And it’s easy for SSNIT to do this because the government of Ghana is the main employer and can deduct income from the cheques of guarantors.

Should the SSNIT loan scheme be shelved, university admission rates decreased and the building of new universities stopped then? I think not. Universities are in the education business. They offer an asset from which a consumer can generate income over a period of time. They, however, do not guarantee such a stream of income. They cannot, for instance, commit crimes to generate caseloads for more lawyers. I’m being facetious but the point is the onus is on the consumer to understand what such an education is worth to him and what he could possibly expect from it.

In Ghana, it is a simple case of looking around and knowing your only hope of getting a job in the first place is with a college degree. One goes to college then to make herself competitive for the next available job, not to ensure employment. But since neither your parents nor you can afford the cost of such a degree, the guaranteed SSNIT loan becomes an act of humanity from government and guarantors. Without them, the student would just find another way of paying for school or stay at home and not have that educational asset at all, for better or worse.

Who to blame, then? I vote government. Why does it exist if not to ensure prosperity of the nation? In as far as the public sector has lacked in additional job creation and has failed to create a conducive environment for private sector job growth, I blame the government. My question, therefore, is, “can we sue the government?” Come to think of it, this could make those law school loans worth it.

Prime

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This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
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Screenathon: REACH Ghana and Health Redistribution

Over the past year, I was involved in the founding and running of an organization, REACH Ghana, committed to improving the health-care system in Ghana and promoting equal access to quality health-care by all communities in the country. We work in partnership with stakeholders at improving health-care through sustainable projects while building local community capacity for long-term health maintenance. We need your help.

We are capping the year off with a Fundraising Screenathon at Glefe, Ghana, designed to bring together hundreds of volunteers for an extraordinary day of service and provision of health-care and health education services for this under-served community.

We are raising funds from individuals and corporate sponsors alike to spread the holiday cheer to these people and ask that you visit our webpage to donate. For less than $10, you could offer a family health insurance coverage for a year. For more on Glefe, the REACH Ghana Annual Screenathons and on REACH Ghana’s activities over the past year, please read on.

Glefe is a trading village which a University of Ghana Medical School study found has poor sanitation and high rates of malaria, gastrointestinal illnesses and other febrile diseases especially in the age-group 1-4yrs.

The Screenathon will thus provide essential education on disease prevention while testing for these and chronic problems like high blood pressure and diabetes. We will provide basic care at the event and transfer complex cases to the local health authorities ensuring care continuity. Depending on funding, we will register a limited number of inhabitants in the National Health Insurance Scheme.

REACH Ghana was founded by a group of young Ghanaians and is proudly advised by luminaries like Dr. Isabella Sagoe-Moses, National Child Health Coordinator at the Ghana Health Service, Dr. Paul Farmer, Professor of Medicine at the Harvard Medical School, and Dr. Andrew Arkutu, former Director of Country Support Team for Southern Africa of the United Nations Population Fund.

REACH Ghana has accomplished a lot in a short time viz a partnership with Kua, a US-based design brand committing a percentage of profits to REACH programs, and a Health Education Enhancement Initiative which has enabled shipment of medical education books from the US to Ghana.

In addition, REACH is in advanced stages of planning for an HIV/AIDS Intervention Project which will provide comprehensive HIV education, prevention and treatment services for young people on major university campuses and surrounding communities in Ghana. This effort meets an area of special need as it targets people between the ages of 18 and 35 who contribute almost 50% of new HIV infections in Ghana. As a first step, REACH Ghana placed HIV/AIDS awareness messages through innovative advertising on taxis in Accra earlier this year.

Finally, the Ghana based membership has been particularly active in our activities and are spearheading a project to address the high rates of HIV at Agomanya in the eastern region of Ghana through empowering women by facilitating access to foreign markets of the local bead-making community.

I encourage you to become a member of REACH Ghana by signing up here, and get involved in making a difference in Ghana.

Prime

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This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
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Waiting Tables to Operating Tables

You ever wonder how your physicians are paid? The first thing an immigrant to the US complains of after agonizing over the evil exchange rate regime that forces him to spend a buck fifty on a bottle of Coca Cola when he could get three bottles for that much in his country is the fact nothing is what it appears here. Only at the register do you find out your $1.50 coke actually is $1.60 with sales tax. But what really grinds our gears in the early goings is tipping. Yup, that 15-20% gratuity that says if you do not have fourteen bucks, do not go to a restaurant for a twelve dollar meal.

Tipping is annoying because it makes an otherwise simple matter complicated; it leaves the customer to determine the waiter’s salary. Why can’t the restaurateurs pay their employees and include the cost in the price of my meal? I presume this all started in some good faith—people showing their appreciation and societal status by leaving money for good service, an admirable incentive system.

But the times it seems, have changed. Tipping is now a given. Thus, even though my cab driver offers no help with luggage and is on his phone all trip, I still give him the 20% tip to elicit his only words (thank you) to me. It got me thinking about physician reimbursement. In the traditional system, physicians and hospitals are reimbursed a specific amount for providing care for a disease or condition. There isn’t much of a measure of the quality of that care involved in the payment system. The patient is left to decide which physician is better through available ratings and some other measures of outcome like surgical complications. Critics argue there is thus little incentive to improve upon current practices. Of course most doctors are not callous and most hospitals continue to find ways of providing better care for the patient. But would financial incentives push them along faster?

Earlier in this decade, there was a lot of talk about pay for performance. It was pretty much a tipping system. You provide me with medical care; I pay you depending on the quality of that care. There was some uptake but the system had its problems. Just how do you measure the impact of a physician’s actions on a complex entity like the human being? The consensus, as it now stands, is to withhold payment if processes of care (e.g. a specific question) were not followed. This is a rather cumbersome process contributing to more paperwork for doctors and less time to spend on patients.

Getting around the measurement problem partially, Medicare, the federal health insurance program ruled it would no longer cover costs for “preventable” conditions like hospital acquired infections. This made the cost of mistakes visible to hospitals and ensured they would innovate. Of course a cynic can argue how exactly a preventable condition will be ascertained but we will leave that for another discussion. It is a positive step towards inspiring even greater commitment to quality care from care providers. But it cannot end here.

Personally, I prefer a modified process analysis approach—two levels of payments; insurers to hospitals and hospitals to physicians. On the former level, using weights based on the mix of patients, a hospital can be paid based on its overall outcomes. Hospitals can then pass these on to physicians by paying for adherence to pre-determined best practices but rewarding initiative. This is not an argument for standardized care per se but a way to reward innovation.

Physicians can vie for peer respect and financial reward by coming up with improvements (which then become best practices) to existing best practices. The problem with pay for performance is not that it is a bad idea. It is that physicians are not empowered in the system. The only people who can determine where the problems with care exist, are the people on the frontlines. By incentivizing healthcare providers to reward physician quality improvements, healthcare payers can help lower costs and improve care. Of course this whole argument is based on the premise that physicians are at least partly motivated by money. In Ghana, then, we might want to think of a move from guaranteeing all to only a percentage of doctors’ salaries.

Prime
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This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
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Healthcare (Monkey?) Business

With the recent financial meltdown and the apparent non-repentance of the industry even in the face of the severe backlash that has accompanied the tax-funded support of its institutions, one might say it is foolhardy to mention business and health in the same sentence let alone propose their marriage but that is exactly what I have set out to do.

Let's examine what a business is. In its simplest form, it is a purposeful activity. As one scales up discrete units are added until it takes on the complexity of a behemoth enterprise working towards a particular goal. In our contemporary world, this has come to mean turning a profit; the bigger, the better. Turning a profit instead of a loss (negative profit in normal parlance) has been the primary motivation of most businesses—create some value at a cost, try to capture part of that value by receiving a price, and hope that the fraction of value you capture is greater than your cost. One can do this either by creating or praying for a high price and/or keeping costs down.

In the medical field and in many other realms, the idea of business is seen as evil. This has been based on a long history of financial malpractice, questionable trade practices and lack of corporate commitment to society. A particular criticism is the ruthless efficiency with which the business world goes about, well, business. It is the one thing the common man hates about business; the lack of emotions in making personnel decisions, the drastic shedding of human resources when productivity falls and the quest to extract more and more such productivity from labor while keeping the wages down make companies appear uncaring and downright callous. This perception is worsened when profits are used for top brass bonuses. So why would anyone want this for medicine?

Medicine is usually seen as a benevolent, humanity-based endeavor geared towards providing that most basic of human needs, health. And that it is. It also, costs money and recently, exponentially increasing amounts of it. Suggestions for funding it abound and are outside the scope of this article. Regardless of how funding is provided or who provides it however, a basic equation must balance; cost must equal revenue. Consider a hospital which violates this rule. It would in time be unable to support its operations and the services it provides and will ultimately end up bankrupt depriving society of a necessary good.

One can argue that hospitals must not have profit as an incentive. However, they must still meet their costs. This just means they have a target profit of zero dollars as revenues are just enough to pay for expenses. Since many people will pay anything to maintain good health however, the incentive for hospitals to reign in cost is rather weak. To counter this, there are numerous reforms that limit reimbursement rates for healthcare providers. So let us assume prices and revenues remain constant. Then the only way to break even is to decrease cost. How does one do this? By becoming efficient.

Consider how long you have to wait in the emergency room before you see a doctor, are admitted or discharged home. How many times a day do you get stuck with needles for lab tests? What are the best distributions of work hours for your doctors to ensure they are available to take care of you and are alert/awake while doing it? What is the best means of physician-physician-patient communication/information system to ensure the best care for you? How do you design workspaces to minimize medical errors/accidents? In my Technology and Operations Management class in business school, I have already begun to learn about how people, resources and information flow through a system. The goal, of course, is that ruthless efficiency we talked about earlier; finding the bottlenecks and improving them, decreasing waste and increasing yield.

If there is one thing there is a general consensus on, it is that there is a lot of waste and organizational inefficiency in healthcare. An application of the concepts of business to healthcare organizations (which are inherently businesses by our definition above) will go a long way to saving money and decreasing the cost of care. The principles that underlie business are not intrinsically evil. They have just been used so often in the pursuit of individual goals that society frowns on. But they can be used for good too. Ruthless process efficiency, brewed in the context of compassionate care, can save costs while increasing the quality we deliver to our patients. Rather than swear off them, then, let’s apply business tools conscientiously for the general good. Society’s appreciation can then trickle down to the care providers who sacrifice for it. As one of my professors said, no one is begrudged for capturing value they create.

Prime

*************************************************
This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************

“If you can read this, thank a teacher”

“A courage which looks easy and yet is rare; the courage of a teacher repeating day after day the same lessons - the least rewarded of all forms of courage” – Honore de Balzac

If you attended school in Ghana, West Africa, or I daresay any African country, you have probably been lashed/received corporal punishment. I remember all six teachers who ever lashed me; two of course being my parents. I never cried. I was a big boy. I was close a few times though—my classmates at Mfantsipim can tell you about one. But these traumatic experiences do not form the basis of my memories. I can tell you the names of at least 90% of my teachers so far from Ms. Amenyui through Mr. Azasoo, Frimpong, Collins Aguzey, “Harriso wo yɛ tall”, “Adorable – Paul Adu Kumi, “Coomson aka Fuck”, “Baffoeman, Yeboaman, “Borlɛɛ”, “Karishika/Matriculation”, “Duncanman aka “The Son of Man”, “Aboa Apɔnkye” to “Duoduman”.

From Louis Baffoe intoning “you are mad!” because I screwed up a mathematical calculation to Aboa Apɔnkye teaching us temperature was the sixth sense and that HIV stood for “Highly Infections Virus” (it stands for Human Immunodeficiency Virus by the way), there are many unique stories by which we remember our teachers. I recall Mr. Kusi forcing us to buy his useless pamphlets, Karishika skipping English periods while trying to induce our paying her for extra classes and Borlɛɛ’s tag line “as for you Edo, you are a baaaaaaaaaaaad boy” anytime I went for an exeat (signed permission to leave school) for the town of Cape Coast. I also remember Yeboahman allowing me to attend his high-cost but effective extra classes in Physics for free, Baffoeman lending me his Math texts for study, “Adorable” buying me an English-French dictionary, and Duoduman screening World Cup matches at his house. What I’m saying is my development as an individual and my success as a student has been entirely due to my teachers. Same could be said for the larger majority of my friends. So why are they paid so little?

I was a rebel growing up – at home that is. In school, I was always an angel, well, with the teachers anyways. Maybe it was fear of corporal punishment. Whatever, it worked. In my village, teachers wielded extraordinary power that extended to time outside school. A parent could request punishment of kids for some wrong committed at home. When teachers decreed that funerals were no place for children, it meant you did not want to be seen at a funeral by a teacher or, God forbid, the headmaster. And you did not want them to catch you doing something wrong outside of school. Teachers were our moral compasses, our role models, our number one fans, our most severe critics and our fiercest supporters.

There were inspections on Monday mornings for cleanliness – white socks, washed and pressed uniform, hair cut short, fingernails clipped, teeth brushed, it was a beauty. And this was outside of the fact they were actually doing teaching in the classrooms. When I was practicing my cursives in the sand under the big Neem tree in Dabala, it was a teacher who held my hands. And it was a teacher who taught me about “Air Pressure” and how I could turn a glass of water upside down with covering as flimsy as a cardboard and it wouldn’t spill.

The most widely heard saying in Ghana regarding teachers, however, remained “a teacher’s reward is in heaven”. But is it? I have been wondering about how society judges the value of different services. In Ghana, we were of the view that the US valued its teachers more and that they were among the highest earners in the country. How wrong we were! Teachers earn a pittance here and, it seems, everywhere else. How can that be? I do not know much about the requirements for teaching in the US but at least in my country, this usually involves attending a three-year Teacher Training College, a tertiary institution. The admission criteria for these schools are less stringent than for four year universities which meant they became places for students who did not make the college grade. One can then boost her pay grade, albeit marginally, by attending a “mature” students degree course in university although most look at this as an escape from teaching. Rather than fault this set-up, however, I fault the human condition.

Society as a whole is obsessed with education and the level of education achieved resulting in pay levels increasing as you achieve higher and higher levels of education even if your degree is as useless as Latin outside of the catholic church. No, I am not arguing against education. Ask my family, it’s the only thing I seem to offer them when we speak—go back to school, get another degree and the like. But shouldn’t the future value of a person’s work be indicated in their remuneration?

A profession which seems to be at the extreme end of this value-based remuneration is medicine where doctors are paid large amounts of money for barely keeping a patient alive. Even here, primary care doctors who save the system hills of money by preventing complications before they arise earn the least pay. What influences the value of a man’s work seems steeped more in how immediate the results are than what the actual contribution to society over time is of his work.

We are blinded by the college graduates who generate millions sometimes doing mind-numbing work on Wall Street so we pay them in loads and cap it all by giving some CEOs significant portions of GDP even when companies fail. But we are unable to foresee the fact that we would have a society of illiterates and no professionals without the teacher. Imagine a society without doctors, lawyers, businessmen, farmers, historians, technicians, to mention a few. We’d be back in the ice age in no time.

Supply and demand and the curse of Adam Smith continue to numb us into decreasing the reward of teachers because, well, they are easily replaceable. They are, of course. But is this enough to keep their pay low? Imagine waking up each day, writing the same teaching plans albeit modified for the characteristics of the class that year, standing in front of students and repeating the same information over and over again. And most of them do it faithfully and cheerfully, knowing the only reward they have is hearing of their students who made it. And the only way they could ever be rich, at least in Ghana, is go into politics and become parliamentarians.

So even though it is not teachers’ day today, shout outs to all my teachers, past and present. Part of your rewards are in heaven all right but the larger part is in our pockets as a society and especially, in those of our politicians. I pray one day it is returned to you.

Prime

*************************************************
This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************

The Politics of Recycling

One said to Confucius: “Why are ye not in power, Sir?”

The Master answered: “What does the book say of a good son? 'An always dutiful son, who is a friend to his brothers, showeth the way to rule.' This also is to rule. What need to be in power?”

(Confucius, Confucius. The Sayings of Confucius. Hayes Barton Press, 478 B.C.).

Tuesday, November 3, 1992: Do you remember where you were? I do. I was 7yrs old, in Class 3. It was the first presidential election of the Fourth Republic of Ghana. It was 13 years in the making. 11 since Junior Jesus, Chairman Rawlings had completed his second coup d’etat. The election results would come to live in infamy as “The Stolen Verdict” but those were remarkable times to be alive. Oh yes, that evening, I was playing football on the little volleyball court adjacent the perpetually uncompleted Evangelical Presbyterian Church building in Dabala. This was the Volta Region. This was the World Bank…for the National Democratic Congress that is. It was the stronghold of the party formed by the newest “democrat” on the block; the soon to be President Rawlings.

The NDC had run a particularly shrewd campaign. There was the catchy “No retreat, no surrender. No curve, no bend. Straight to victory. NDC, Akatamanso” which blared from loudspeakers mounted on the newly minted Toyota pick-ups. Then there was the play on people’s superstition with fishermen suddenly catching crabs with the distinctive colors and umbrella of the NDC indelibly imprinted on their backs. The rumours spread like a harmattan fire; God and the gods had anointed the NDC. Thus when there was a funeral held behind the Post Office with a coffin for the elephant of the New Patriotic Party, it seemed only appropriate. The elephant had it coming. And that day when we all stopped play for a moment and shouted after the rickety old lady, tottering to the old JSS campus to put thumb to paper, to vote for Rawlings, we were only repeating the refrain so often sang--what I had heard from my grandfather’s Sanyo radio for 7 years, Chairman Rawlings…, Chairman Rawlings…, Chairman Rawlings. That,….and nothing else.

But this is not some trip-down-memory-lane piece. This is about a remarkable aspect of the political landscape of Ghana and of the many parties in our multi-party, very African Democracy. It is that long before the developed world started the green revolution, before the “pure water” sachets would dance freely in the putrid waters of the Korle Lagoon we were recycling. See in 1992, I heard of Rawlings, Adu Boahen, Limann, Arkaah, Mills, Mahama, even Kufuor. 18 years on and these same names ring out. Some, may they rest in peace, have since passed on. But as these parties proclaim allegiance to the Nkrumahs and Busias, so their leaders continuously descend directly from these dead presidents or the people around them. Welcome to the world of dynasties. Welcome to Political Recycling.

As I write this, Nana Addo Dankwa Akufo-Addo, the incessant chatterbox with the affected slang twang has been elected the flag bearer of the NPP beating virtually the same field he did the last time round. He is the son of Edward Akufo-Addo, member of The Big Six, and later president of Ghana in the Busia administration. Junior lost the last presidential elections as flag bearer for the NPP. But as surely as current President Atta Mills was elected again and again by the NDC in spite of losing two straight elections, so it seems, the NPP is recycling its limited resources. There is of course something to be said for brand and name recognition; it is arguably a major reason Mills won the last election. And within a party, loyalists at the top will push to get their candidate in place, helped by the specter of incumbency and inertia of the masses. So the recycling continues and the same trash gets put out over and over again.

But at what point is recycled material unusable? My dad used to say that the useful span for a man to implement his vision is at most 10 years. He is of course no expert but one would be hard pressed to find a politician who has ideas to last the first week of office let alone one hundred and twenty moons. So why do they keep coming back? My sister says it is because every rich man’s dream in Ghana is to be president. It is the ultimate status symbol. And since there really are no qualification requirements, anybody from the high school drop-out, Rawlings, through the non-practicing lawyer Kufuor to Akufo-Addo and the heart surgeon Frimpong Boateng with management lessons learned at the Korle-Bu Teaching Hospital can up and stand for the presidency. How one runs a country with absolutely no understanding of basic economics, surrounded by people practicing the economics of Adam Smith's time, is baffling to say the least. But alas, politics is a popularity contest and the lawyers are the best at painting black white so they inevitably rise to the top. It is worth noting that Akufo-Addo's wikipedia page and other biographies state he was called to the English Bar (Middle Temple). However, my search of the internet has no mention of a law school and his name cannot be found here.*

But even if this is our lot, even if we are eternally cursed with the same political parties going through our government like a revolving door, even if our state coffers have become like a street walker, screwed at every turn by the NDC, the NPP and once more by the NDC for the go around, must it be by the same men? Does neither the NPP nor NDC have any new blood? Are there no young women or men in the folds of these parties who can radically rethink our progress as a nation? Why does the old guard not step aside? Surely a lesson or two learnt in defeat can show the younguns the way to rule?

This nation deserves a better bunch of the criminals, ahem, politicians (apologies to The Dark Knight). Today, it is Akufo-Addo. Tomorrow, it will either be the ineffectual Mills or Nana Konadu Agyeman Rawlings, wife of ex-chairman, sorry, ex-president Rawlings. From the twenty years of Rawlings through the fourteen and counting of Mills and the thirteen since Akufo-Addo junior has been in parliament, the years have grown no kinder to our leaders. Wisdom, it seems, does not come with age. Their ten years are over; their visions depleted. And what is left are the depleted shells, dazed and confused and shouting the hollow promises of addicts looking for their next fix. We need, indeed we demand a viable alternative; for party, for president and for parliamentarian. Because if there is one arena where going green is bad for business, it is that of politics. Let’s keep the recycling to the environment. God Bless Our Homeland Ghana.

Prime

*************************************************
This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************

* It has since the publishing of this article been shown, through some fine piece of investigation by Dzidzorli Agbleze, that Nana Akufo-Addo did pass Part II of the transitional Trinity Term Bar Final Exam and was invited to the Middle Temple of the Inns of Courts. His name can be found in the published list of examination successes in "The Times", Friday July 2, 1971. As of today, the law school he attended is still unknown.

Exams should be banned...but since they wont be, this is how I prep for them.

Hey, wasup, how're yall doing? A couple of months ago, a friend who has more illusions about me than me Mom asked me to write out how I prepare for exams. Since I am preparing for another tedious exam anyways, I figured why not. Then a study partner took a look and said put it on facebook so I put it on my blog. Now before you read this, I want to put out the disclaimer that these are my thoughts, this is my modus operandi. These are observations that I have made on my study habits and patterns and may or may not work for you. As usual, it is important that you find your personal style and work with it. This is a general theme that you can vary as you wish. Oh, it also makes liberal use of the pronoun "you". Forgive me. So..

1. Set a target score.

2. Give yourself time – Do not over-estimate your abilities. Afford yourself as much time as you can to study for the exam. This should take into account the fact that you are likely to burn out at some point and will need a few days rest before you begin again. Pace yourself appropriately so you remain interested in what you study. And set aside days of the week (it can be a night per week) when you can relax, with no studying and stick to them.

3. Study hard – There are two stages of studying, intense studying and review.

i) Months before your exam, study hard and study detailed material. This period is for understanding the fundamental concepts of the field, the threads that run through every other topic. You can then build upon that as you go. Begin memorizing factoids if these are needed in your exam so you can go through the cycle a couple of times before the exam. At this point, read the concepts you are more likely to remember; the ones that are easier to take in. If you are stumped by a concept, an advanced concept or one which is not essential to further studying, write it down and move on. This is the time to experiment with study habits. Work with one at a time. If it does not work, switch to another. Do not be married to one study habit but do not also follow all and sundry’s suggestions. Choose the book that works best for you and the study materials that do and stick to them. Switching between things gets you confused and nowhere.

ii) Review stage – this depends on the amount of material you need to cover for your exam. Again, pacing and realism on time needed is the most important factor. This is not the time for detailed reading. This time is for you to glance over material to make sure they are at the forefront of your mind going into the exam. You are unlikely to remember everything in detail but you will have an idea about most things. Towards the end of your review period, you should plan a time when you read and memorize the concepts you were stumped by in the study period. These can be chewed, poured, and forgotten after day of exam.

4. Keep a routine – the brain works best when it knows exactly what it needs to do at a particular time. Maintain exact study times, keep a good sleep hygiene/protocol – go to sleep at set times, go through the same routines before sleep, keep a 30min block when you do nothing but relax before sleep. In the weeks before your exam, do practice exams at the exact time of and of similar duration as your actual test. In this, try to simulate as much of the test day as possible – preparations, sleep and all that.

5. Two nights before the test day, wrap up your readings, go to sleep on schedule. This is particularly important as sleep deficits will generally catch up with you in 48hrs. This is probably the day to take a quick look again at all those hard things you never could get your head around

6. The day before the exam – this works differently for different people. Some prefer to look again over some high yield material, keep the brain going. Others prefer to take this day off and do activities they enjoy like read, shop etc. Do not watch TV or spend hours behind a computer. They will put your brain to sleep. If you haven’t already, take this day to visit the test center and plot your transportation details. Get all the documents you need ready, put your food, drink, calculator, money for transportation, pens, pencils, all logistics in one bag. Needless to say, get a good amount of sleep. Through this whole study period, it is advisable to maintain at least 8hrs of sleep per night. Do not change your schedule in the final week and certainly not on the last two days. More sleep in those days will only make you groggy on the day of the exam. Less sleep will make you high.

Throughout this period, it is important that you continue to exercise and engage in other activities that refresh you and get your mind outside of books. They are not only healthy for mind and body, they decrease your stress levels and you don’t want to be stressed at this time.

On the day of exam – sometimes it doesn’t come quickly enough; other times you want it to stay away.
- give yourself more than enough time to get to test center
- Choose/ask for a quiet area of the exam room.
- bring earplugs. You will likely need them
- For food, eat a good breakfast, lunch should not be heavy. The advice generally given is to bring dried fruits like raisins and nuts instead of sugary energy drinks which can make you crash really fast, and carbohydrates which will make you sleep.

Before the exam – PRAY

During the exam,
- As soon as you sit down, write down the formulae and other memory aids you will not remember and do not erase them. When a formula you do not know is given to you or you derive it on one question, write it down. Do not erase drawings you use for one question. You might need them later.
- Read the instructions carefully. You miss points if you do not answer the question being asked.
- Read the question at the end of the preamble/blurb to guide you on what you should be looking for in the preamble.
- Formulate your answer before you look at the options you have. Reason through the scenario and apply the concepts you have learnt.
- Even if you know the answer, humor me and read through all the options
- Do not get tripped by answers that are too obvious
- Do not get tripped by answers that are too complicated
- If an answer does not sound right to you, it’s probably wrong.
- Go with your instinct. Memory is fickle and the associations between concepts tenuous. You are more likely to reason yourself out of a correct answer than into a correct one.
- If a question is too hard, guess and move on. Most exams do not penalize for guessing (the SAT does) and this might be an experimental question anyway.
- If you have no idea about a question, use process of elimination. Cross out the answers you know cannot be right. Then guess on whatever’s left.
- On mathematical questions, if are asked to find x, plug the options in if that’s easier. There should only be one that fits. Remember plug and play.
- If you have no idea about a question or the options, choose an option you are familiar with or have vaguely heard of rather than one you have never encountered.
- Work deliberately, work fast, pace yourself. Do not spend too much time on one question. All questions are worth the same points on most exams. Computer Adaptive tests like the GMAT are different so read about the tests so you can strategize.
- Between sections, take a moment to breath. Do not carry baggage over from one session to the other.
- Thou shalt not panic. One question or run of questions will not ruin your exam. Breathe easy. I mean literally breathe. Look off from your question paper, think of the happiness at the end of the test. Then, continue.

At the end of the exam, pray, thank your God, get out of there and move on with life. Do not believe there will be a profound sense of relief/happiness. There, most likely, will not be but that is normal. Move on. Enjoy life and don’t think of the results until they return.

Prime

*************************************************
This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************

Up on a hill

Up on a hill
- garland of crop and flower as neck,
the Eagle dwells
House of twigs and thorns
her rounded iron beaks
make into feather beds for her young.


I remember!


Young birds thrown gently over rocky cliff
Forced to fly
with wings not dry


Mother soars above—eyes watching
Sharp!
Glides in, gentle breeze
lest we break.
Rock-solid span
soft, comfortable, sure!
Unlike the rockier death to which we plunge
our dance
of life and death


Can I ever marry?
Would my heart anyone else love?
A taste of you
is the first drop of rain
that teases the parched, broken land
that is the landscape of my heart
whispering of the louder downpour
blood through venous cracks
giving life—and mending


I thirst some more!


Nurture the new plant—green
head high, stem straight without a bend
Give the adult strength
to make its food
Independence!!

So what locks my jaws—strangles me
prevents me from telling
I sing your love
speak my love
for you on your hill
The world hears, its heart listens, feels
The ear that’s valued the most
becomes the island
wondering, feeling, wondering

About a son’s love


Prime
*************************************************
This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************

Musings from my time away – Akpa evelia (second part)

Hi, my name is Akpa evelia. If you have not read Akpa gbator, it may be difficult for you to know me. But if you are brave anyway, here goes ...

Next up were Neurology, Psychiatry and Radiology. Neurology was a large field with many unknowns but it made a lot of sense to me. In many ways, it was logical. Like 1+1 = 2 and very rarely was it something else. It could be summarized in deficits or excesses. Deficits naturally were the easiest to see as in strokes when someone suddenly cannot use an arm or cannot feel temperature differences or touch on a part of the body. Reasoning through the losses and what normal function is, one can usually pinpoint which region of the nervous system the problem lies, something called “localizing the lesion”.

Excesses are much more difficult to notice. For example, when does an old lady who suddenly becomes hypersexual and happy come to attention or when does someone with repeated vocal ticks and a propensity to burst out in curse words realize it is Tourette’s syndrome? Much has been achieved in the medicine of the nervous system but a lot still needs to be done and I found it difficult to come to terms with the futility of a lot of it. We could determine what the problem was in most cases. We could not always treat them. One of my patients died with us knowing neither what caused his problem nor how to definitively treat him.

The most important thing I found in Psychiatry is we all have mental problems to an extent and if you dig below the surface, you could very easily come up with a diagnosis of yourself. It is also not for me. Radiologists are some of the smartest people in the medical field and not only because they make the best lifestyle decision of us all. The breadth of differential diagnoses they have to know is beyond belief and they know more than just the names, they know the pathophysiology and they know the best management practices. They are everyman’s doctors with no direct patients.

The best, and the reason I have been incognito for the past 3 months, was saved for last. Surgery was the light at the end of my proverbial third year tunnel. Since I was a child, I have wanted to be a surgeon. The simple idea of getting into a person’s body, fixing a problem and closing up like nothing had happened in the first place was just amazing to me. It is as good as instant gratification goes. As I grew, I got more and more excited about the heart. I saw a heart come back to life after being stopped for surgery and oh my! It was poetry in motion. But I jump forward. Let me rewind for a second.

My surgery experience ran the gamut from an attending telling me she would “take away [my] scissors if [I] cut like [I] did again” and duly taking it away on the next cut then not saying a word to me for the rest of the day’s surgeries outside of sending me to get her camera for a picture of an interesting pathology, through opening the six pack muscle to enter the abdominal cavity to resecting a lipoma, replacing a hip and suturing multiple incisions closed. Through all this, I never did tire of cutting into human skin…for good, of course.

I would have to say as a pre-clinical student, I thought watching a surgery was incredibly boring. I did not understand a lot of the pathophysiology, I did not know much about the procedures and in many cases, I could not even see what was going on. However, once I got into my third year and started putting together the link between pathology and physiology, it was easier to think through what procedures were going on, how the problem would be approached, why surgery was indicated in the first place and most importantly, the anatomy of the situation. In addition to this, I started looking at how surgeons exposed problem areas, how they were holding instruments and what instruments they were calling for during various parts of the surgery. And of course I thought through what the anesthesiologist was doing.

Let me tell you a typical day. I woke up at 4am, got to work by about 5am to pre-round on all patients on the team. This involved getting their vital signs, fluids in and out and for my patients, reading through the consult notes from the previous night, checking out on events overnight and writing a preliminary plan of action for the day. I was lucky to have another student, “Goose” to my “Iceman”, on the team and we could very easily divide and conquer. I felt the sting when he moved on to another service. We rendezvoused at 5:50am with the Intern and then rounded with the Senior (Boss – he hates it and this is the last time I will call him that) at 6am. Then we did “gravity rounds”; starting with the patient on the topmost floor and ending down on the surgical floor. Our role as we saw it as students was to get the patient charts, do dressing changes, get pimped (tested on multiple surgical and non-surgical knowledge) and in general make the morning a smooth and enjoyable one for our team.

7am saw us in rounds where we went through the trauma admissions of the previous night and the cases for the day and then we were off to the operating room of which you have heard enough. Suffice it to say, there was a totem pole and we were at the bottom of it. Our work mostly involved transferring the patient onto and off the OR bed, transporting them to the post-anesthesia care unit and in-between, cutting stitches and retracting other organs out of the way so the surgeons could get a better view of what they were doing and if we were so fortunate, getting further pimping. And NEVER contaminating the field.

And here-in lay the bane of the medical student’s OR existence. The circulation nurse. Yes I have been lucky to have the best of them. The ones looking out for you and the ones who were only vested in your success, helping you maneuver the OR adroitly. Yes I have also had the worst including those who invented more and more ingenious ways to charge you with being “contaminated”. You remember that totem pole in the OR? The circulation nurse, see, is on top of it. They are the people tasked with setting up the operation room, getting things and people moving and overall, making the operation a success. And they take their work seriously. If you are ever in an OR, make sure you have had your orientation and know who they are. Ask what you can do to help, get the temperature of the situation and act accordingly. One source that helped me with this is found here. Seriously though, a lot of them are very nice people who are more than happy to teach you and you should learn from them.

Back to the time line. Between cases, we checked on our patients “post-op” to ensure we did not screw up that physiology or the other anatomy. Then it was off to didactic lectures at 1pm during which we ate lunch. The rest of the day was spent either in cases, managing the patients on the floor or answering consult requests. We sign out to the night team at 6pm and go home to begin in another few hours. For the medical student, that meant dinner, and hitting the books for however long you spirit or body could take. Then sleep beckoned and before long, the annoying alarm goes off and you are back again.

As far as my personal experience, it was awesome. I have to say these were the most brutally honest people I have ever worked with and that was refreshing even if it meant there were harsh critiques half the time and I felt worthless the other half. I had, most of the time, teams with doctors who were committed to the philosophy of education and challenged my thinking, knowledge base and surgical skills. They also gave me a lot of responsibilities during cases, handing me large parts of the simpler cases and making me experience first hand, the art and science of what the French call Chirurgie. It is a time I will always cherish and most of the people will be remembered by me through my career. Above all, what made surgery great for me, and what keeps me excited about it, is seeing the problems in peoples’ bodies with my eyes and then seeing them solved. As one Senior said to me after we witnessed a ventricular fibrillation, “internal medicine doctors can only read about this in books”.

Prime

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This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
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Musings from my time away – Akpa gbator (first part)

Hello, good day, how have yall been for the past 3 or so months? Yes, that is how long it has been since my last post and no one has been more cognizant of those months than me. However, since you, my loyal readership deserve better than spotty writing, I would like to apologize for my unannounced hiatus and ask that you continue with me as we resume this journey. So let me tell you what I did in the time I was away. The short of it is I completed my General Surgery Rotation to wrap up third year of medical school.

It was an interesting year overall, one of the greatest periods of growth in my life. The year begun with Internal Medicine which was three months of what can best be described as intense investigative work. The diagnosis, to be sure, was generally known to residents by the time the patient came up to the medicine floors from the emergency department. However, the student was required to work things out himself and from the often varied history elicited from the patient and the carte blanche physical exam of a beginning third year medical student, he was expected to formulate differential diagnoses and gather information to rule them out or in.

After extensive literature review, pimping (aggressive questioning) by resident and possibly senior resident, and for the lucky like myself, a lot of teaching, one was usually ready to nail the presentation and answer the questions to follow from attending physicians. This was what could be considered good reward for 5-page scholarly medical notes and 30 plus hours spent in the hospital often with little sleep every four days. But sometimes, things were not so rosy. Sometimes, you got lost in the details and stumbled through tedious notes that did little justice to the work you put in. Those times, one could get discouraged but there were luckily few of these occasions.

Obstetrics/Gynecology, ObGyn for short, was my next gig, my first surgical experience as it was. The birthing process was awe-inspiring and much more violent/terrifying than I had anticipated. It was a rather weird experience, not the most pleasant. Getting the privilege of delivering twins increased my appreciation of the pain my mother went through delivering my big-headed brother and sister twins with no pain control. But those crazy mothers were always so happy when they saw the babies and swearing to have others. I decided then never to get a woman pregnant.

I intend to become a cardiac surgeon so it was the surgical aspects of ObGyn that really appealed to me. Typically, the life of the third year medical student involved standing silently for hours on end, sometimes scrubbed which meant you could not even scratch an itch, watching the laparoscopic screen. It was mind-numbing at times but one lived to put a stitch through the skin and throw a few knots at the end of everything and if a harried pace made that impossible, it felt like someone had robbed one of his very soul.

Pediatrics rounded out the half year and is a memory better forgotten. I loved it, I did and I absolutely loved the little kids as well. But the one thing it came to show me was the need for self evaluation and the politics of the hospital and grading policies. It seemed the nature of the pediatricians I worked with was non-confrontational and accommodating, which was in line with the work they do and made them very good doctors. But this was not always the best environment for the student because what it fostered was a situation where students could not get the most straight forward feedback when they elicited it. You could thus find yourself doing the same things and garnering praise for them only to end up with rather lukewarm written evaluations which allowed people to say things they could not tell you in person. If nothing at all, it was an experience that would change my approach to third year and for the better, I’d argue. It also showed me my need for honest feedback, good or bad from working colleagues in my future practice.

In my next piece, I will tell you about neurology, touch briefly on psychiatry and radiology and a closer look into the workings of surgery. Ask me questions about the more details you would like to know and if the HIPAA laws allow it, I will let you know.

Prime

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This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
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"You Speak Such Good English" – Ten Things You Now Know About Ghana And The Ghanaian

Two weeks before I was to embark on my first trip to the US, I finally went to an internet café to find out exactly where the state of Ohio was on the map. I was to spend the next four years in Oberlin College, Oberlin, OH where I had applied and being accepted for a Bachelor of Arts program but I had no idea where it actually was. Thus when people have asked me whether I am from Africa, I often wonder if I should give them an education, offer a blunt reply or just plain ignore them. Of course I went on the internet to do my research and so could everyone else but I only did it because I needed to. So instead of a ranting piece on the lack of curiosity about the world that is exhibited by many an American, I will just go ahead and give a Ghana 101 from my perspective with the hope that someone reading this piece even by accident can help spare me a few awkward moments.

1. My English is good, yes. This is because we actually speak and learn English – the Queen’s English, that is –comprehension, grammar and composition.

2. Just like you do not speak American, we do not speak Ghanese or African. There are at least 47 different languages spoken in Ghana alone.

3. Ghana is the country. Africa is a continent, not a country. I am Ghanaian, and African, just like you are American and North American (North America, by the way, is a continent that includes Canada, Greenland, Bermuda among others).

4. No. I do not know your church member from South Africa. Enough said.

5. We live in houses in villages, towns and cities not in the bush living a primitive life in hunting/gathering tribes (apologies to random lady I met at Cleveland Cavalier’s game). In that vein, most of us first see wild life in the zoo either at home or in the US – cue student surprised to hear I saw my first elephant at a circus in New Haven and excited when I apologized and said we actually lived in huts carried by the elephants.

6. Football, as in the one kicked with the foot, not thrown all game long, is a Religion. It is to be worshiped and not derogatorily referred to as soccer.

7. No. I did not come to the US because there are no good schools in Ghana. Our educational system is screwed up, I agree, but they are not that bad. A lot of us come here for school because of the opportunities for training outside the classroom, the free education, and sometimes, because we could not get into the professional schools in Ghana e.g. medical schools.

8. Yes. My accent is sexy, I know, but your mentioning I have one is definitely not a turn-on.

9. Yes. I am a card carrying member of the LONG (League Of extraordinary Negro Gentlemen) but your knowing me is no guarantee of membership privileges.

10. And finally, I am grateful you volunteered in Ghana as a high schooler and you are welcome again. Your semester abroad, though, does not an expert make. Do not present yourself as an authority on the subject of Ghana.

To the Ghanaians out there, send me a comment on something you would like known about Ghana/the Ghanaian. To those who want to learn about us, send me a comment asking what you would like to know. Till then, cheerio.

Prime

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This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
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Une Idée

What did, the world, create
I asked my Lord
An Idea!, said He, not Fate.
And the Will to see it lored.

Prime

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This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
*************************************************

$2000 Roundtrip – Delta Airlines and the Ghanaian Traveler II

Thankfully, a bottle of water awaited each of us on the plane and throughout the flight, snacks were made available at the back of the plane—a unique experience if I may say so. Anyone who knows me of course knows I am probably pickier about my food than anything else and will thus not be surprised at my dismay at what presently happened. It was partly my fault because I requested the beef option, not being one who eats poultry but since I was met with some concoction of beef sauce, assorted veggies and white rice not becoming at all of someone who likes jollof, I promptly reconsidered my options and would have gone for the chicken option with jollof but Delta had run out of that option with many passengers still to be served. Next, I asked for apple juice and the flight had run out of that as well. Finally, on entering the US airspace in evening both destination and origin time, Delta served breakfast, with one unifying option of cheese and ham sandwich, a yogurt covered granola bar and a box of orange juice. I said a silent prayer for those hungry passengers on monoamine oxidase inhibitors (fermented cheese and some other foods can lead to a sympathetic crisis when ingested by someone using MAO-Is). I neither like cheese nor un-fried bacon so I was a little stuck there.

Of course I naturally expect airline food to be horrible and have been known to fly days on only water and apple juice because of this. However, more than the food, the manner in which stewardesses responded to my queries of “can I have this or that option” is the point of contention here and the reason for this entry. My questions were met with sharp and stiff “we don’t have anymore” and “that’s the only option” delivered in a devil-may-care tone. These were the things that grated on my senses. I can only imagine the stresses of being an Air Steward but that is no justification for displacement—taking it out on another. Having been on a Lufthansa flight with disastrous customer service between Accra and Frankfurt and impeccable service between Frankfurt and New York and having transited in other European cities, I am aware of the deplorable service provided by major carriers to and from Ghana and Delta has come in for a lot of flak on this point even necessitating a rebuke from the Transport Minister in Ghana. It seems that this has fallen on deaf ears. These airlines are indeed providing invaluable services to Ghanaians but they are in the SERVICE business and at over inflated prices given travel and demand over comparable distances, it is important that they recognize they are offering very little value for their money. In April of this year, I flew to and from Ghana on a British Airways flight which cost less than $1400 and was infinitely more comfortable with service rendered with deference not seen on Delta flights. I am a fickle flyer with little to no airline loyalty. While expanding the current number of days with direct flights to Accra from JFK, New York and adding an Atlanta line, Delta might do well to realize that in spite of our politicians running national airlines into the ground, there are other options and we will pursue them.

Write in and comment. Let me know what you experiences have been on other Delta flights to Ghana and the Western world. Are there any notable differences in service delivery? Happy New Year and may every one who wants water on a flight they have paid for, receive it with smiles.

PS: I have made it to Boston safely after missing my scheduled flight. And my bag is here with me as well though torn on one side. Transition from 27+C (81+F) to 1C (34F) is not helping my mood much. See you in another piece.

Prime

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This is the way I choose, the destiny I pursue
To help the unfit and the fit
To treat each according to his need
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