“The best way to improve a nation’s health in the long run, is through the care of it’s young ones” (Nkrumah, 1992, p. 13).
I’ve spent the last 5 weeks working on the paediatric in patient ward. Nkrumah, former medical professor of child health stated, “At no other time in the lifespan of the individual is the quality of his health and life so interrelatedly dependent on his total environment, as in childhood” (Nkrumah, 1992, p. 7). Childhood is a time to develop physically, mentally, and socially. As a result of prevalent conditions like severe anemia related to sickle cell disease or malnutrition, it’s common to see children who look much younger than their actual age. Malnutrition has been attributed to one third of child deaths worldwide and also worsens the prognosis of common childhood infections such as measles, diarrhea, and respiratory infections (Oliver-Commey, 2001). With 45% of the population within Ghana being under 18, addressing child and adolescent health is of utmost importance (UNICEF, 2013). In this reflection, I will present cases, some of my experiences as well what the literature states pertaining to child health in Ghana.
A young boy 9 years of age came in with the worst pressure ulcers I’ve ever seen. The wounds had been debrided of necrotic tissue and I was there to assist with his first dressing change. To my surprise, this little boy didn’t flinch nor did he show any emotion. I comforted him regardless as I assessed his ulcer, which was so severe his bone was exposed. Following this procedure, I read his chart and assisted the physician to take a more comprehensive physical and social assessment, when I found out he was paralyzed. After conducting a few tests, the physicians determined that this was due to spinal tuberculosis which causes vertebral destruction, spinal cord narrowing, and can progress to neurological complications (Rasouli, 2012). The initial clinical manifestations presented as small dark areas of skin discolouration which lead to ulceration. Since the boy was left in the same position for extended periods of time and due to a loss of sensation, these ulcers became quite complex. The parents wanted to cure him of his illness and sent him to a prayer camp for a month, which only prolonged necessary treatment. The majority of Ghanaians use religion as a coping mechanism, some believe that health ailments are the result of evil spells, or punishment from ancestors (Tannor, 2013). In the treatment room, while observing his wound for the first time, one of the nurses turned to me, shook her head and said “god can heal almost everything, but not this.”
Had he sought treatment earlier, it could have been managed with medical and surgical therapy to prevent paralysis and minimize the extent of the tissue damage. At this point, it’s almost inevitable that he will get an septic infection as the sore on his coccyx is covered by a dressing which doesn’t get changed after each bowel movement and sterile technique is simply not feasible due to a shortage of supplies. The physicians want to do further testing however the parents can’t afford it. His general condition as the nurses would say is “fairly ill” which downplays the severity of his prognosis. This is just one heart breaking case of many.
With that in mind, I have been pleasantly surprised with the competence, forward thinking, and knowledge base of the paediatricians. Launched in 2011, SickKids Canada collaborated with Ghana’s health system to establish a sustainable training program to address the shortage of paediatricians and specialized nurses (SickKids, 2011). Each week, a new group comes to the unit where they are expected to assess, take histories, analyze X-rays, advocate for patients and eventually act as specialized paediatric nurses with an even broader scope of practice in remote settings. This has been influential in my learning of unfamiliar conditions which are so common here like sickle cell disease, malaria, tuberculosis, nephrotic syndrome and meningitis. The head paediatrician expects a lot which facilitates and encourages learning. He will test everyone’s knowledge by going around the circle quizzing students and putting them on the spot during doctors rounds by asking the side effects of prednisone or the clinical manifestations of sickle cell disease. They have educational sessions twice a week on topics like mortality rates at the hospital, infant feeding, and failure to thrive.
Although the national health insurance scheme subsidizes some aspects of care, procedures, medications and duration of stay typically come out of pocket. To stay on the children’s ward is about 5 cedi or $2.50 Canadian per night for Ghanaians and 100 cedi or $50 Canadian for non-Ghanaians, which adds up. As a result, parents can’t afford their child’s treatment and must ask extended family members for financial support. For instance, a child had fallen out of a tree and required spinal surgery. The family had exhausted all other methods of funding. I was at the patient’s bedside when the paediatrician announced that she would pay for his surgery. His mother, overwhelmed by emotions fell to her knees, wept uncontrollably, thanked the paediatrician profusely, and began to pray.
From my time at 37 Military Hospital, I’ve become attached to the children, their stories, and have such an admiration for how they are able to find happiness in the most challenging of times. In Ghana, optimal child health is constrained by larger social and economic constructs. This is a problem which must be addressed through collective efforts. It’s amazing how the parents on the unit act collaboratively to care for each other’s children, often catching naps when they can on the concrete floor at the back of the unit. A 2 year old girl was walking across the street with her mom when her mother was struck by a car and died on scene. Having no identification, a witness dropped the little girl (who didn’t sustain any injuries) off at our unit. Social work is trying to contact family. In the mean time, the patients’ mothers on the unit have stepped up to feed, change and take care of this young girl. Ghanaians exemplify the notion that it takes a village to raise a child.
It seems as if the children are forced to grow up quicker here. No matter how sick they are, when you ask them how their doing, they reply in a soft spoken, timid voice “I’m fine”. Although I still have much to learn about Ghanaian culture, I’ve learned how to incorporate cultural competency into my nursing care. Through truly gaining an understanding of the reasoning behind interventions, the impact of greeting Ghanaians in their language, and the power of doing seemingly minuet unskillful tasks like helping dust the unit in order to gain respect and spend time asking the nurses about their life outside of the hospital. From a nursing perspective, I will take away aspects of their creativity and ingenuity in their ability to conserve resources. I’ve seen everything from a sandbag being used to prevent foot drop to a water filled glove to prevent pressure ulcers. I’ve learned to appreciate the smallest things, as days with running water in the treatment room made preparing for dressing changes a little bit easier.
An issue that is presenting globally is how to allocate appropriate resources for curative versus preventative services. Nkrumah stated, “A health system has to evolve which, not only is responsive to the immediate health needs of the large numbers of ill children already threatened with physical extinction but also, more important, firmly lays the foundation for disease prevention and health promotion for better quality child life and health” (Nkrumah, 1992, p. 12). In my humble opinion, I think this is a global issue as health promotion measures must be expanded to encourage healthy child development to ensure long term health, longevity and quality of life of our future generations. Educating parents can help to prevent health ailments, lessen their duration, prevent the progression and decrease the strain on the tertiary health care system.
With that being said, as a result of this experience which has given me so much insight and perspective of child health, I’ve developed a passion for this area and I hope to further pursue a career in paediatrics.
Nkrumah, F. K. (1992). The quality of child life and health an indictment against society. Legon: Ghana Universities Press.
Oliver-Commey, J. O. (2001). notable causes of disability in Ghanaian Children. The disabled child in Ghana (pp. 5-12). Accra: Ghana Universities Press
Rasouli, M., Mikoohi, M., & Rahimi-Moyaghar (2012) Spinal tuberculosis treatment and management. In Asian spine journal. Retrieved March 5, 2014 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3530707/
SickKids Canada (2011). Ghana SickKids pediatric nursing training programme launch. Retrieved March 2, 2014 from http://www.sickkids.ca
Tannor, A. (2013). Millennium development goals and rehabilitation in Ghana. International journal of therapy and rehabilitation. Ghana: MA healthcare Ltd.
UNICEF (2013). At a glance: Ghana statistics. Retrieved March 3, 2014, from http://www.unicef.org/infobycountry/ghana_statistics.html