$Unique_ID{COW01430} $Pretitle{353} $Title{Ghana Chapter 6B. Health} $Subtitle{} $Author{} $Affiliation{HQ, Department of the Army} $Subject{medical health areas disease hospitals training country government diseases facilities} $Date{1970} $Log{} Country: Ghana Book: Area Handbook for Ghana Affiliation: HQ, Department of the Army Date: 1970 Chapter 6B. Health Neither the 1960 census nor the preliminary findings of the 1970 census included health data. Throughout the late 1950s and early 1960s responsibility for various health programs shifted. As late as the mid-1960s there was no regular system for gathering medical statistics, and there was no information suggesting the development of one in 1970. Available figures were from scattered samplings and were collected mainly on a haphazard basis or were the summation of hospital records and therefore only partially reflected the total health situation. Projections based on a United Nations formula would indicate a life expectancy of forty-eight years. In 1965 the actual expectancy fell somewhat short of this. The birth rate had been slowly increasing from about 42 per 1,000 persons in 1955 to about 50 per 1,000 persons in the late 1960s. The death rate had remained more or less constant at about 20 per 1,000 persons. Infant mortality stood at about 156 per 1,000 infants in 1965; this represented a higher figure than in 1955, probably largely the result of improved reporting. Prevalent Diseases Accurate statistical information on the incidence of common diseases is lacking because only a limited percentage of the sick come to the attention of medical authorities and because the system of medical recording has not been adequately developed. Headaches and stomach complaints are commonplace as indicated by the large sums spent on patent headache and stomach remedies. Although statistics indicate no change, the actual disease rate seems to be decreasing slowly as government health programs reach a degree of effectiveness. The discrepancy is caused by a growing tendency of persons to seek medical assistance and to have diseases recorded that previously were not brought to the attention of the health authorities. Among the most common illnesses are malaria, various kinds of dysentery and parasitic diseases, yaws, several kinds of pneumonia, and tuberculosis. Leprosy, sleeping sickness, and venereal diseases also claim a large number of victims. Epidemic diseases, such as yellow fever, have been largely controlled through mass vaccination. In late 1970 cholera was reported in a number of West African countries, including Ghana. Steps were being taken to deal with the outbreak, and it was expected that vaccine could be manufactured locally. Illnesses are caused by the plethora of disease-carrying insects common throughout the tropics, particularly in the rain forest and along waterways; by the use of polluted water for bathing and drinking; by malnutrition, which causes specific disabilities and also lowers resistance to every disease; and by the low level of sanitation and personal hygiene, which creates breeding grounds for infection and disease. Every cut or skin abrasion is dangerous; a mosquito or fly bite may lead to malaria or blindness. Childbirth is a serious risk. Many diseases fatal to a European are endemic to large segments of the population and claim relatively few lives, although they weaken a person's whole system and shorten his life expectancy. Malaria is a major killer of newborn infants, and few Ghanaians escape contracting it at an early stage of life. For most African adults, malaria is a relatively mild disease because resistance has been either inherited or built up during childhood, but Europeans are highly susceptible and are likely to contract it in an acute and dangerous form. Poor sanitation and drainage facilities in urban areas make particularly ripe breeding grounds for mosquitoes, as do riverine areas in the north. Government efforts at control have included larval and residual spraying, drainage, and vegetation clearing. Special projects launched in the early 1960s in cooperation with WHO and UNICEF in the Volta and Northern regions experimented with the incorporation of antimalarial drugs in basic food commodities, such as salt. The second major group of diseases includes the various kinds of dysentery and parasitic diseases, which are seldom fatal but seriously debilitating. Their high incidence reflects the low standard of public health, since most are transmitted through polluted water. Both bacillary and amoebic dysentery occur, but the relative and absolute incidence of the two forms is unknown. Hookworm infection is widespread, with reported infection ranges of 40 to 80 percent in various areas. Roundworm infection exists, and several types of tapeworm are found in the northern parts of the country. Guinea worm infection disables 10,000 persons completely and 90,000 persons partially each year in the northern areas and is the major disabling disease throughout the country. Another waterborne parasitic disease, bilharziasis, has affected about 20 percent of the population at one time or another. Its reduction was one of the particular government goals during the 1960s. Venereal disease of all types occur, gonorrhea being the most prevalent. Since only the most severe cases register for treatment, the extent of these infections is unknown. The incidence of venereal disease in rural areas seems to be on a decline, possibly as a result of the extensive use of penicillin in the treatment of yaws. Yaws, highly infectious sores associated with uncleanliness, are common throughout the country. A full-scale yaws campaign, with material and technical assistance from WHO, has been in progress since the late 1950s in all regions. Mobile field units roam the countryside examining and treating as many people as possible. In the mid-1960s leprosy was widespread and afflicted an estimated 70,000 persons. Only about 30 percent of these were registered and receiving treatment. There were five leper colonies and one major treatment center. Mobile units, however, were being used to extend treatment to isolated areas. The mobile units followed a set route and schedule, providing treatment on a regular basis. Drugs for the treatment of leprosy were supplied free of charge by UNICEF. The incidence of leprosy rises gradually from south to north. Sleeping sickness, carried by the tsetse fly, is a major problem, particularly in the central areas. About one-third of the country is infested with the fly, which breeds in the dense bush bordering bodies of water and is most prevalent in a wide belt crossing the country from the lower part of the Brong-Ahafo Region, through the Ashanti Region and parts of the Eastern Region, into the Volta Region. Sleeping sickness may be dormant in a person for many years, sapping his energy and lowering his resistance to other diseases, but when it emerges quick death is certain. The activities of the mobile field units, which treat victims in the early stages of the disease, when it is still curable, have considerably reduced the death rate. Various methods used in the late 1960s to reduce the incidence of the disease included trapping, land clearing, chemical control, and the pruning of breeding areas, none of which was adequate by itself. The flies were proving particularly hardy and, for example, quickly moved to plants resistant to fires or to less accessible island sanctuaries. Some areas had been cleared and become fly free, and the incidence of the disease seemed to have been reduced. The ecological influence of the Volta River Project on the fly population has yet to be determined. The country was cooperating with the West African Institute for Trypanosomiasis in Nigeria in the study of control and elimination of the disease. Tuberculosis is one of the major diseases in the country. In some areas it is almost as common as malaria, particularly among urban laborers, fishermen, and children under sixteen. The housing available to low-income groups is a fertile breeding ground for the disease. Efforts by health authorities to provide cleaner housing facilities and treat inhabitants have met resistance. No actual figures are available as to the extent of infection, but projections from the early 1960s suggest that from 8 to 12 percent of all deaths reported by government institutions are attributable to the disease. About 3 percent of the urban population is believed to be infected. Except for acute cases, tuberculosis victims are usually treated on an outpatient basis. As a result of the general availability of drugs to the public, they have been used indiscriminately for the treatment of tuberculosis, and drug-resistant strains of the bacillus are responsible for 10 percent of infections. The incidence of blindness is high, particularly in the north. The major causes are various parasitic infections caused by contact with polluted water or carried through insect bites, trachoma and, to a lesser degree, congenital syphilis. In 1966 the incidence of blindness in the north was estimated at 3,000 per 100,000 persons. In many areas the local incidence of blindness was 10 percent or more. Over half the cases in northern Ghana are the result of river blindness (onchocerciasis). In areas where 10 percent or more of the population is blind, river blindness is the cause of 90 percent of this disability. River blindness is caused by a parasitic worm spread by a species of black Simulium fly. The fly usually bites the lower limbs, and the infection spreads upwards, causing a toughening of the skin and the formulation of nodules under the skin. The advance of the parasites into the eyeball results in blinding lesions. People in some areas have developed a natural immunity that slows down the process before blindness occurs. A rich diet of vitamin A seems to be important in the retardation. The high incidence of river blindness in certain riverine areas had led to the abandonment of land in these areas for areas beyond the flying range of breeding grounds for the carrier flies. Measles is a serious disease among children under five. Children usually develop far more severe symptoms and complications than are usually associated with the disease in the West. Respiratory and gastrointestinal problems as well as protein malnutrition and body wasting often follow. Major efforts were begun in 1967 to eradicate the disease by 1970 through large-scale immunization. Technical personnel and materials were being supplied by the Agency for International Development (AID) of the United States. The success of the program had not yet been determined in late 1970. Smallpox and yellow fever, which for centuries were major killers, have now been largely controlled through mass vaccination. In 1967 a nationwide program of smallpox vaccination was included in the vaccination program for measles. Smallpox vaccinations are required by law for both children and adults. Epidemics of these diseases since World War II have been minor and infrequent. The incidence of mental illness is about the same as in more advanced societies and covers the whole range of psychiatric disturbances. Mental illness is a problem since the facilities to care for those afflicted are inadequate. Data was not readily available on the incidence of dental disease. A 1966 survey of 950 children between the ages of five and fourteen at the Mampong-Akwapim primary school showed that, although cavities were low, there was a high rate of periodontal disease. Only about 20 percent of the group had normal oral and dental conditions. There were few orthodontic problems of any significance. The two major causes of the high rates of periodontal disease were the use of a chewing stick for oral hygiene, which often results in a good deal of inflammation and gum recession, and nutritional imbalance. Projections for the overall population suggest that periodontal disease is common among adults and would imply heavy cavity problems for 50 percent of the people. Traditional Treatment In the mid-1960s it was estimated that only about 25 percent of the population, largely among the educated classes in urban areas where medical facilities were accessible, had accepted modern medicine. There was little evidence in 1970 to suggest that there had been any major change. Three-fourths of the people still rely to some extent on native doctors and ancient cures and will seek medical help only as a last resort. The undramatic and intangible nature of modern medical practices raises doubts in many minds about their efficacy. Among those who make use of the modern facilities, many insist on receiving injections, which they assume to be a cure-all. Although the expense and inaccessibility of modern treatment are responsible for much of the continued reliance on traditional cures, the main reason is a common belief that illness and death are caused by supernatural forces, which can only be countered by other supernatural forces. Traditional medical practitioners are usually persons believed to possess magical powers, and their cures include the use of fetishes and amulets, which are carried on the person or displayed prominently in the home, and herbal potions or salves, the burning of incense. Bleeding to let out the poison is a common practice, as is rubbing herbs into an incision or inserting leaves, roots, or bark for which curative properties are claimed. Ceremonial bathing is prescribed for epilepsy, paralysis, and alcoholism. Direct applications of herbs are used to treat eye and ear problems as well as headaches. Sores, muscular complaints, and varicose veins are treated with smears from roots. Impotence is often treated with herbal potions using whiskey as a base. Other remedies exist for bronchial and venereal diseases. The infection and severe pain that may result is believed essential to the cure. The medical value of traditional remedies varies. In many cases they are harmful and may result in severe infections and death. Bush tea, made from a wild plant growing in all parts of the country and used as a cure for numerous maladies, was found to induce a liver disease that is fatal to one-third of those stricken. A few traditional practices, however, have been shown to be useful. Most northern tribes, for instance, have long practiced a form of inoculation for smallpox through vaccination with pus from afflicted persons. In 1970 at least one Ghanaian physician had undertaken to investigate systematically the useful herbs and other remedies used by traditional practitioners. The Ghanaian's susceptibility to the claims of magical cures makes him an excellent target for manufacturers of patent medicines. In fact, many of the traditional witch doctors or medicine men have become small-scale druggists and dispense patent medicines-sometimes even legitimate drugs-either outright or as part of their magical cures. Native doctors generally fall into two categories-witch doctors and herbalists-but it is often difficult to distinguish them. Witch doctors rely for their cures on the supernatural and on their knowledge of the social relationships in their villages. They are usually priest-doctors occupying places of great prestige and power in the community. Herbalists dispense medications based on what they consider to be scientific theories. Their status in the community is that of a skilled technician, trained in the medicinal properties of herbs. Many of the formulas used in preparing cures are secret and are passed on only to initiated persons. Modern Medical Services Medical services are provided by the central government, local governments, Christian missions, and a small number of private individuals and enterprises. They fall under the jurisdiction of the Ministry of Health, which is also charged with the control of dangerous drugs, quarantine, scientific research, and the professional qualification of medical personnel. Each region has a principal medical officer responsible for the administration and control of health matters in his area. The country is divided into twenty-four health districts, each under the charge of a health superintendent, who is assisted by a number of health inspectors. The superintendents are responsible to the principal medical officer of their region. A health education officer, who conducts and supervises the various health education programs, is attached to each health district. These officers are trained in public health but are not physicians. The primary problem of the health services has been to provide sufficient facilities to serve the health needs of the inhabitants, particularly in rural areas. Precedence has been given to curative rather than preventive medicine because curative services are more easily recognized and approved by the people, whereas preventive services are slow, long-term processes seldom yielding immediate and recognizable results. Many of the smaller health facilities in rural areas are constructed and supported by local government funds or by self-help schemes in which the local inhabitants donate funds and labor and the Ministry of Health provides the medical personnel and the equipment. Health facilities operated by missions or private organizations receive subsidies from the government to cover all or part of their operational costs. Private medical institutions are subject to government supervision under the Private Hospitals and Maternity Homes Act. Free medical treatment is given at government institutions to civil servants and their families, paupers, war pensioners, and students at government boarding schools. In addition, such diseases as tuberculosis, yaws, and leprosy are treated free of charge. All other medical services require payment of standard fees prescribed by the Ministry of Health, a policy that, although somewhat changed during the 1960s, favors those best able to pay for medical care. This in part explains why people in the lower income groups tend to patronize herbalists and native doctors whose services are less expensive and seek modern medical aid only in extreme cases. Facilities Sources available in 1970 often provided conflicting information on medical facilities. The range for the mid-1960s indicated between 110 and 150 hospitals, with about 8,400 to 10,300 beds. Of these, the Ministry of Health administered 9 regional and 33 other hospitals. The remaining hospitals were administered by mining companies, mission groups, or military units. Standards varied but were generally poor except in the large hospitals accredited for nurses' training. Fees at mission hospitals were generally higher than at government hospitals. In 1970 the government showed an interest in taking over the administration of mission hospitals on a joint basis with the missionary groups, since these hospitals were in many cases the only source of medical service. The regional distribution of hospitals was uneven, and many hospitals served large areas, requiring trips of more than one day's duration. Most hospitals had extremely active outpatient clinics, and only the most seriously ill were hospitalized. The most noticeable inadequacy of equipment was in surgery and psychiatrics. Complaints were voiced in 1970 over reported shortages in government drug supplies. The government denied such shortages but did admit to a distribution problem. In rural areas medical needs are served by rural health centers and by mobile field units. They operate as outpatient clinics, treating routine cases and promoting health education and maternity care. They do not usually have a permanent physician but are in the charge of a registered nurse and staffed by a midwife, health inspector, and health visitor. Problem cases are referred to the nearest hospital, and specialists from that hospital visit the centers periodically. Because of the shortage of doctors, these visits are infrequent, thus limiting the curative functions of the centers to routine treatment. The centers have had some effect in spreading health education and making the rural population aware of modern medicine. Under special campaigns the centers have aided the fight against yaws, river blindness, bilharziasis, and other endemic diseases as well as against leprosy, tuberculosis, and malaria. In the mid-1960s there were thirty-eight rural health centers, which also served areas where other health facilities were not available. Additional centers were being constructed in 1970 by the National Service Corps to help relieve congestion at regional and urban hospitals. In the late 1960s there were only two mental hospitals, both administered by the Ministry of Health, that provided for about 2,270 full-time patients. The larger hospital was in Accra, but its facilities were old. Only about 20 percent of those needing hospitalization could be accommodated. Plans included construction of a new hospital outside Accra. In the mid-1960s there were only two maternity hospitals, one at Accra and the other at Ashanti-Mampong, but maternity units were attached to many of the general hospitals throughout the country. Midwives operating private maternity centers or homes of varying sizes were subject to the requirements specified in the Private Hospitals and Maternity Homes Act. Dental services are almost nonexistent. Most of the large hospitals in urban areas have dental clinics, but only a few mobile clinics operated in the rest of the country in 1970. Aside from curative facilities, Ghana has the Institute of Tropical Medicine and Endemic Disease, which conducts research into the local aspects of significant tropical diseases and offers special training to Ghanaian doctors, most of whom have been trained abroad, in the endemic diseases that they are likely to encounter in Ghana. The Medical Research Institute at Accra is the central pathological laboratory. It also operates a training school for laboratory technicians and runs the blood bank and the clinical laboratory at the Ghana Hospital of Korle Bu. Two other clinical laboratories are located at Sekondi and Kumasi. In the summer of 1961 the National Institute of Health and Medical Research was created by the National Research Council to work in close cooperation with the Ministry of Health and with scientific institutes in other parts of the world. In 1968 the institute was transferred to the Ghana Medical School under the Ministry of Health. Personnel There is, and will continue to be for some time, a severe shortage of medical personnel of all kinds. Because of this shortage many people are often required to perform tasks far beyond their capabilities. On the other hand, many highly qualified persons must spend valuable time and effort on routine tasks, which no one else has been trained to carry out. A major cause of the shortage is the lack of secondary-school graduates and the limited training facilities for medical personnel in the country. Projections from the late 1960s would indicate that there were less than 500 doctors in the country. The majority were concentrated in urban centers. Most were employed in the government service or by one of the mission or private medical installations. Only a few were in private practice, mainly in Accra, Kumasi, and Takoradi. Less than one-half of the doctors were Ghanaian, and many of the foreign doctors were Indian. Until the late 1960s the country had no medical school, and all advanced training was received abroad. In 1965, for example, there were 800 government-sponsored medical students in training abroad; this compared with 400 in 1960. In October 1964 the Ghana Medical School was founded as an autonomous institution but associated with the University of Ghana. After October 1967 all students wishing to follow medical preparations were no longer sent abroad but were trained at the new school. In June 1969 the first class of 37 men and 3 women was graduated. The course of training lasts six years. It consists of a one-year premedical course, a two-year preclinical course, and a three-year clinical course. In 1969 there were 166 students enrolled in the program. There were sixty-eight full-time members on the teaching staff, and the school used the Ghana Hospital of Korle Bu in Accra for its teaching and training program. All physicians are required to be registered and licensed by the government. Beginning in 1968, at the discretion of the Ghana Medical and Dental Board, doctors trained outside the country may be required to pass an examination before their registration. The government has been making a special effort to attract more Ghanaian doctors trained overseas back into the country, mainly through promised increased pay scales. The Ghana Medical Association, which is a member of the International Medical Association, has been in existence since 1958. Projections from the mid-1960s would indicate that the number of nurses in the country in 1970 did not greatly exceed 3,000. The domestic schools for nursing were at Accra and Kumasi. In 1965 there were about 700 nurses in various stages of preparation at these two institutions. The training and qualification of nurses is regulated by the Nurses Ordinance and supervised by the Nurses Board. All practicing nurses must register with the board, and only training at an approved hospital in Ghana or abroad will qualify a nurse for a license. There are two types of nurses-the state registered nurse, equivalent to the registered nurse in the United States, and the qualified registered nurse, equivalent to the American practical nurse. Training for state registered nurses is available at two hospitals, Kumasi Central Hospital and the Ghana Hospital of Korle Bu, and generally takes four years. A secondary education is a prerequisite. Some of the graduates are sent abroad for further training either as specialists or as nursing teachers. Qualified registered nurses are trained on the apprenticeship system for four to five years. Secondary education is not required for admission, and training is offered at six government hospitals and a number of mission and private hospitals. Specialized training is received on the apprenticeship system except in the case of nurses who are trained at the mental hospital. Although general nursing is of high quality by United States standards, specialized nursing is lacking in quality. The nursing profession is open to both men and women, and about 40 percent of the nurses are male. Midwives form an important part of the medical establishment. They must be registered with the Midwives Board, which regulates and supervises their training. The training period of eighteen months is followed by a four-week postgraduate course after registration. The number of midwives in the late 1960s probably slightly exceeded 850. A three-year training program for pharmacists is offered at the University of Ghana, and in 1965 there were 341 pharmacists in the country. The training and licensing of pharmacists are controlled by the Pharmacy and Poisons Board of the government. The School of Hygiene in Accra trains health inspectors; laboratory technicians and other medical personnel are trained mostly as apprentices. In 1965 there were 1,200 students in training in domestic institutions as midwives, nurses, and medical technicians. There are no local facilities for the training of dentists or dental technicians, and their number is very small. In 1969 thirty-three dentists were registered, most of whom were trained in the United States. This figure was somewhat misleading, however, since some of those registered may have been out of the country either permanently or for further study.