Ghana - Trip Notes

Ghanaian King in procession

Travel Dates - 23-27 April 2017

I traveled to Ghana for the purpose of exploring research opportunities for UNC Gillings faculty and practicum possibilities for students. Similar in size to the state of Oregon, Ghana is a West African country with an estimated population of 28 million (2016), about 48% of whom are under age 20 and a 2.15% population growth rate. The capital, Accra, is a port city of 2.27 million or 8% of the total population. Other major cities include Kumasi (1.5 million), Tamale (361,000), Takoradi (233,000), Achiaman (203,000), and Tema (156,000) through which the prime meridian passes at 0 degrees longitude. 

Oil and gas fields along Ghanaian coast

Economic Profile

Ghana is important to U.S. government interests, with U.S. 2016 overseas development assistance (ODA ) funding at $146 million[1], its rich natural resources, stable government (seven peaceful democratic transitions) and increasingly strong economic growth (8.7% GDP in 2012).

Developed in 1995, the "Ghana Vision 2020" plan intends for Ghana to be the first African nation to become a developed country by 2029 and a newly industrialized country by 2039. This would seem to be on track, according to the World Bank, as GNI per captia [2] in Ghana has increased 428% from $280 in 2002 to $1480 in 2015.

Currently, over 70% of Ghanaian exports come from crude oil (28%), gold (23%), and cocoa beans (23%) which together generated $7.4 billion in export revenue in 2014 [3].   Regarding cocoa, according to the Ghana Cocoa Board, the cultivation of this cash crop employees 800,000 farm families in six of the ten Ghanaian regions and produces about $2 billion in foreign exchange annually.

IMR 1960-2015 Ghana

Health Profile

According to UNICEF's most recent Multiple Indicator Cluster Surveys (MICS), Ghana has made very strong progress in basic health and economic indicators during the past two decades. For example, there has been a 39% and 44% decline in under-one and under-five mortality rates, respectively, between 1990 and 2012. Immunization rates in 2012 for DPT3 and Polio3 are at 92% and 91%, respectively, and the total fertility rate that has declined by 30% from 5.6 births per woman since 1990 to 3.9 births in 2012. About 34% of the population of reproductive age used modern contraceptives and adult HIV+ prevalence was 1.4% in 2012. These strong health indicators portend success for Ghana to become a developed nation in 12 years, following the Vision 2020 plan.

Research, Teaching, and Service

Ghana offers numerous research, training, and service opportunities that may be attractive to UNC school of public health faculty and students in an environment supportive of the UNC Gillings school mission to address “big public health problems with scalable solutions."

University of Ghana - Legon

The Noguchi Memorial Institute for Medical Research (NMIMR) was established in 1979 with
support from Japan as a semi-autonomous institute of the University of Ghana. As the major biomedical research facility in Ghana, the Institute is committed to research on

Ghanaian health priorities and training of biomedical scientists from Ghana and West Africa. I met with Institute Director, Professor Kwadwo A. Koram [email: KKoram@noguchi.ug.edu.gh], who indicated the Institute has enjoyed long-standing academic partnerships with Yale University (soil helminths research), University of Copenhagen (25 years joint training programs), the Swiss Tropical Institute (supports PhD training), the University of Sussex (implementation science, evidence to policy and practice, barriers to service delivery), and the WHO TDR Special Programme for Research and Training in Tropical Diseases (currently sponsors 6 post-doc Fellows ).

The Institute has traditionally focused on infectious diseases that were most prevalent in Ghana, e.g., malaria, HIV, the neglected tropical diseases (NTDs), and mycobacterial infections, and following traditional funding sources and international engagement in these areas. However, according to Director Koram, the Institute is now shifting its research efforts to reflect the epidemiological and demographic changes underway in Ghana. Increases in chronic diseases, such as diabetes, other kidney diseases, and breast, cervical, and prostate cancers are being observed in the Ghanaian population. The interface between infectious and non-communicable diseases complicates this dynamic. Given the rich flora of Ghana, the Institute is also increasingly focused on the area of medicinal plant research.

The Institute has departments of epidemiology, nutrition, histopathology, electron microscopy, parasitology, immunology,

Lab facilities at NMIMR

chemical pathology, virology and bacteriology. The main laboratory building hosts a biosafety level 3 facility for work with infectious agents, such as HIV and TB, and a separate building for laboratory animals. Routine studies include molecular biological experiments, PCR, plasmid cloning, DNA sequencing, and immunological studies, such as lymphocyte culture, immunofluorescence, EIA, ELISPOT, generation of monoclonal antibodies, and flow cytometry. The Institute has a multiplex assay system and the parasitology department maintains an insectary on site. The Institute’s genetic analysis platform has 11,000 sq ft of dedicated laboratory space. This permits genotyping and single-nucleotide polymorphism (SNP) discovery studies.

Professor Koram introduced me to Dr. Daniel Kojo Arhinfu [email: DArhinful@noguchi.ug.edu.gh], immediate past head, Dept of Epidemiology (2009-2013) at the Institute, whose research interests include social health insurance, access to medicines and health commodities, maternal and child health, health systems, and the chronic disease burden in African populations. Kojo shared with me a few of his recent publications including: Health Facilities Survey in Ghana, Household Survey to Measure Access to and Use of Medicines in Ghana, Knowledge, Attitudes, Behavior, and Practices study on Low Generics Prescribing in Ghana.

The Institute has a strong Institutional Review Board (IRB), established in 2000, which is an independent body that ensures the protection of human subjects and ethical treatment of animals. The IRB serves the Institute, the school of nursing, the school of public health, the school of allied health, the medical school, and private organizations, on demand.

Historically, the Institute is named for Japanese scientist, Dr. Hideyo Noguchi, a bacteriologist who in 1911, while working for the Rockefeller Institute for Medical Research, discovered the spirochete bacterium Treponema pallidum as the infectious agent of syphilis.  In 1926, Noguchi joined the British Medical Research Institute in Accra, the Gold Coast, as a member of the Rockefeller Yellow Fever Commission in West Africa. Unfortunately, two years later, in 1928, Noguchi died at age 51 from yellow fever which he believed, incorrectly, was caused by a bacillus. It was Max Theiler, a South African, who determined in the 1930s that yellow fever was the result of a viral infection, a discovery for which Theiler was awarded the Nobel Prize in 1951 for his development of a yellow fever vaccine.

Ghana School of Public Health

I had the pleasure to meet with School of Public Health (SPH) Dean and Professor Richard Adanu [email: rmadanu@ug.edu.gh] who warmly welcomed me to his office to share ideas about research opportunities and student and faculty engagement from University of Ghana and UNC Chapel Hill. The Ghana

Ghana School of Public Health campus

SPH was established in 1994 and offers bachelors (36 months), masters (12 months), and doctoral degrees (48 months) in public health. The Ghana Health Service and Ministry of Health require all district health directors to have at least an MPH degree, as part of their job qualification requirements. This provides a steady flow of students seeking training one of the following masters degree concentrations:

1. Biological Basis of Public, Environmental and Occupational Health
2. Epidemiology and Disease Control
3. Health Policy, Planning and Management.
4. Population, Family and Reproductive Health
5. Social and Behavioral Sciences

Professor Adanu indicated the SPH has an on-going relationship with the University of Michigan which sends ~ 6 MPH students each summer for 6 week research projects with SPH faculty and students at field sites identified by local community NGOs in the greater Accra and Eastern District areas. The SPH also has an on-going partnership with NYU College of Global Public Health for a 2 year cross-continental MPH program. NYU also supports a strong undergraduate semester-long study aboard program with the University of Ghana called NYU Accra.

Institute for Statistical, Social, and Economic Research (ISSER)
In order to learn about local survey research opportunities in Ghana, I met with Dr. Issac Osei-Akoto [email: ioseiak@ug.edu.gh] Senior Research Fellow and Head, Statistics and Survey Division at ISSER. Issac has worked closely with UNC faculty, including Gillings Maternal and Child Health Department faculty member Kavita Singh on an evaluation of a maternal and newborn health project in Ghana, as well as with UNC School of Social Work's Gina Chowa on a youth savings project funded by the Mastercard Foundation.

ISSER facilities

Issac indicated that ISSER offers a strong and reliable platform for conducting complex economic, social, and statistical research in Ghana and the West African region. Research priorities include health system strengthening, health care financing and private insurance, HIV/AIDS, drug accountability and use, reproductive and women's health, NGOs and faith-based facilities service delivery, and malaria (a new malaria vaccine is currently being tested in Kumasi). Environmental health concerns in Ghana are also priorities for ISSER, including climate change, illegal mining, and electronic waste/dumping.

Electronic waste or e-waste may be of particular interest to students in environment sciences, health behavior, and health

Truck overloaded with E-waste

policy, as e-waste is serious issue in Ghana. E-waste is the dirty underside of electronics disposal that results from the world's love-fest with new smartphones, computers, and other e-gadgets, as described by the Basel Action Network. E-waste is a major threat to human health in low-income countries like Ghana, e.g., see this recent study on health seeking behavior by Ghanaian electronic waste workers. Examples of the e-waste disposal issue in Ghana can be found in this clip produced by the BBC and this slide show from Greenpeace.

As background on ISSER, the institute "was established in 1962 as the Institute of Statistics to provide a programme of teaching and research in statistics. In 1969, it was reorganized and renamed the Institute of Statistical, Social and Economic research with an expanded mandate to conduct research in the social sciences in order to generate solutions for national development. ISSER currently serves as the research wing under the College of Humanities, University of Ghana." ISSER also convenes the IRB for humanities studies and currently hosts 22 research fellows and has served as a consultant group to UNICEF and the Ghanaian Health Service, among others.

USAID and CDC

During my visit to Accra, I was warmly welcomed at the U.S. Embassy by Dr. Akua Kwateng-Addo [email: akwateng-addo@usaid.gov], USAID Health Office Director, and her colleagues, USAID Presidents Malaria Initiative (PMI) Resident Adviser, Mr. Sixte Zigirumugabe [email: szigirumugabe@usaid.gov], and CDC Country Director, Dan Baden, MD, [email: aix2@cdc.gov]. Overall, my takeaway from our discussion was all three Ghanaian institutions described above have been strong and reliable partners for the USG. Akua emphasized that Ghana also benefits from 4 excellent research centers located across the country, including the Kintampo Research Center, Navrongo Health Research Center, Dodowa Health Research Center, and Kumasi Centre for Collaborative Research. Ghana's strong national health insurance scheme has been in place for over 12 years and covers about 40% of Ghanaians. It is viewed as a model in sub-Saharan Africa and widely studied as a harbinger for other economically emergent Africa countries and attracts health economics researchers from across the globe.

Regarding the future of overseas development assistance (ODA) in Ghana, in concert with the Vision 2020 plan and the current and projected GDP growth, Ghana is likely to see fewer bilateral donors in the next decade. That being said, increased private investment and government funding of public health programs will need to offset reduced ODA, thus changing the donor landscape in the emerging economy of Ghana.

UNC Gillings Faculty Active in Ghana

Gillings has a number of faculty with research experience in Ghana, including Clare Barrington, Rohit Ramamswamy, Heidi Reynolds, and Ilene Speizer. A snapshot of their work is available from the Elsiever REACH NC mapping product by selecting Ghana on the map, as shown on this screenshot below.

REACH NC map

Akwaaba (Welcome) to Ghana!


Jim



[1] http://beta.foreignassistance.gov/explore
[2] GNI is calculated using the Atlas method https://datahelpdesk.worldbank.org/knowledgebase/articles/378832-the-world-bank-atlas-method-detailed-methodology
[3] http://atlas.cid.harvard.edu/explore/tree_map/export/gha/all/show/2014/

Fall 2016

Welcome New and Continuing Students! 

A warm welcome to new and continuing students at the Gillings School of Global Public Health this fall semester 2016.

This is Jim Herrington and I have the humble honor of leading the Gillings Global Gateway™team here at the School. The mission of the Gillings Global Gateway™is to promote and facilitate the global public health activities of the School by connecting faculty and students with research, teaching, and service opportunities in global public health, both domestically and overseas.   Naya Villarreal, Program Coordinator, oversees the Global Health Certificate, Global Internships and Funding, and Student International Travel requirements, among other programs in the Gillings Global Gateway™and is a great resource for you.  Dr. Dilshad Jaff, is a Kurdish physician who worked previously for the International Committee of the Red Cross (ICRC) and serves as an Advisor to the Gillings Global Gateway™ on Conflict Prevention and Disaster Preparedness research and programs.  Elisia Black is our administrative assistant who will make you feel welcome when you stop by our offices in 104 Rosenau Hall to seek advice, ask questions, or share your ideas about our global public health.  Also, be sure to check out the Student Global Health Committee (SGHC), led by Christine Pettitt-Schieber, which is "committed to creating awareness and understanding of global health issues among the UNC community through education, advocacy, and service."

A few SGHC members plus Jim and Naya (in glasses)

I came to UNC about a year and a half ago from a 27 year career as a public health practitioner with CDC and the NIH (read my personal story here).  My goal is to use the Gillings Global Gateway™ to build a strong global public health platform with the fantastic students, faculty, and staff at UNC.  This global public health effort at UNC has been long in the making with the School's Associate Dean for Global Health, Peggy Bentley, at the vanguard for over a decade in promoting global public health at UNC with the mantra that "global health is local health."

What's in a Name?

So, what's in a name? What does it mean to you as a student that UNC Chapel Hill is the only public health school in the US (and the world) with "global" in its name?

For starters, just consider the fact that there are over 100,000 daily commercial international flights around the world and over 29,000 daily domestic commercial flights in the US alone. According to the World Bank, air transport carried almost half the world's population or 3.44 billion passengers in 2015.  As you will learn, "person, place, and time" are central tenets to understanding how a disease is distributed in a family, community, or nation.  We have all three when considering air transport.

"Breakbone Fever"

https://en.wikipedia.org/wiki/Aedes

Let's use the dengue virus to illustrate the effect of globalization and why this is important to you as a student at Gillings. A recent article in the Lancet by researchers at Brandeis and Univ of Washington estimates that in 2013 there were a total of 58 million symptomatic dengue virus infections, including 13,586 fatal cases, in the world at a total annual global cost of $8 - 9 billion.   How is it that a little mosquito can wreak such havoc?    In a word: "globalization."

USS North Carolina (1941-1947) had a complement of 2,339 men.

Earlier in my career, I worked at the CDC vector-borne disease lab under Duane Gubler, a dengue expert who taught me much about this pernicious disease. Here are a few important facts that explain, in part, why the dengue burden is so large.

There are five dengue virus serotypes and they are all transmitted in a human-mosquito-human cycle, primarily by the daytime biting, anthrophilic, female Aedes aegypti mosquito, also a vector of Zika virus (a disease with very similar symptoms).

Dengue illness typically presents 4-7 days after infection (indicating rapid viral replication) as a severe fever with muscle and joint aches (hence the nickname “breakbone fever”) and, less frequently, as fatal dengue hemorrhage fever (mainly in children and adolescents), a result of low blood platelets and blood plasma loss. The physiopathology for this shock syndrome is poorly understood.

Discarded containers favored by female Aedes aegypti. Photo: CNN

The spread of dengue increased dramatically during and after WWII, as military troops and troop transport vessels facilitated the movement of the virus and vector, respectively, from southeast Asia to the Pacific Islands, Central and South America, and the Caribbean Islands.  Beginning in June 1945, "Operation Magic Carpet" transported millions of soldiers, marines, and sailors back home, with a peak of 700,000 troops returning in December 1945 from the Pacific theater.   Some researchers suggest that dengue's distribution continued during and after the Vietnam War and other military operations, "From the 1960s into the 1990s, dengue often occurred in US troops in Vietnam, the Philippines, Somalia, and Haiti. We found attack rates as high as 80% and periods of convalescence up to 3-1/2 weeks beyond the acute illness."

Dengue is now endemic in most tropical latitudes around the globe where Aedes aegypti mosquitoes are present. The female Aedes aegypti mosquito can lay eggs in small containers, such as discarded bottle caps, tin cans, and tires.  She is more common in urban tropical environments, given her preference for humans as blood meals (blood protein is necessary for egg production).

Environmental control and health behavior are the primary keys to preventing dengue infection, given there is no treatment for the illness nor a vaccine against the virus, though Drs. Ralph Baric and Doug Widman, UNC Department of Epidemiology, are actively conducting research for a suitable vaccine candidate.

So, I hope using dengue and the Aedes aegypti mosquito help illustrate what "global" means in terms of person, place, and time, and why this is important to you as a student of "global" public health, whether you are working in Sampson County, North Carolina, or  Sédhiou, Senegal.


Very best wishes for a successful year at Gillings!

Jim