Summary of HART activities carried out in Ghana - 2001
Village centered research in the Amasaman sub-district
Numerous studies have previously shown that BU typically afflicts the young and impoverished rural population. It begins as a painless nodule but progresses to a more serious ulcerative form. Though the ulcer often heals spontaneously, extensive scarring, flexion contractures, and loss of limbs are not uncommon. If death occurs, it is usually not attributed to the ulcer. Unfortunately, as Dr. Kingsley Asiedu has pointed out on several occasions, decision-making bodies of national health programs often neglect diseases that tend to affect the poor and have a low mortality. HART believes that socio-economic research directed at estimating the true burden of BU in the Ga district will provide a better understanding of the magnitude of this horrible disease, as well as valuable information for health centers and policy-makers at the national level. With this in mind, a team of ten HART researchers spent six weeks in five endemic villages conducting research on the economic burden, social beliefs, and healing practices associated with BU in the Amasaman and Obom sub-districts. A brief overview of their findings is provided in this report.

Education
The goal of the 2001 HART pilot education program in the Amasaman sub-district was to increase the frequency of reporting and treatment of the pre-ulcerative forms of BU. To accomplish this goal, HART implemented a system of education based on a modified version of the collaborative health education project between the Ghanaian Ministry of Health, the School of Medical Sciences at Kumasi and St. George’s Medical School, London, United Kingdom were taken. First, in an attempt to increase community awareness of the disease progression and its consequences, HART organized large group meetings in each of the 25 villages selected in the pilot program. The meeting was scheduled after visiting the village several times to educate the local health worker, and coordinating a time at which the majority of the village would attend. Color posters were used to alert the village and in many cases the health volunteer went door to door to invite families to the meeting. During each meeting, the community health volunteer and a member of the HART outreach team presented information on the disease process and its proper treatment. Special emphasis was placed on reporting suspicious bumps and swellings to the local health volunteer and seeking early treatment.

Although addressing the cause and source of the disease is difficult given their uncertainty within the scientific community itself, possible risk factors such as contact with marshy areas, neglect of open sores on the upper and lower limbs, and personal and environmental cleanliness were discussed. Following the presentation, questions and concerns from the community were addressed. Mothers were encouraged to perform regular full body checks on their children and to report all suspicious skin lesions to the village health volunteer. The village was also informed that in the coming weeks, a team of doctors would be in the area to examine all probable cases. The village health worker performed follow-up using the visual aids and BU registry provided during training.

Outreach
HART 2001 outreach efforts included a five-week active surveillance exercise, carried out in 25 villages in the Amasaman and Obom sub-districts. The exercise was patterned after the successful Guinea Worm Eradication Program (GWEP) surveillance model. More often than not however, participants of GWEP were no longer found in the villages we worked in. Instead, district mobilization officers were used in their place or in certain circumstances the village chief appointed a community member to act as a BU officer. Three major obstacles of passive surveillance were considered during the development of the program. First, BU typically occurs in remote areas where villagers seldom have contact with health centers. In order to deal with the issue of geographic isolation, the Amasaman outreach program seeks to simplify reporting procedures. Under the established surveillance, 25 villages were divided into three zones. In each zone, a zone leader has been designated and is responsible for gathering a monthly report from each of the surrounding villages in the zone.

Finally, once a month during routine maternity and child-health visits to each of the zones, Amasaman health center staff will receive the complete zone report on suspicious and probable BU cases. In addition, each village health worker was provided with a limited supply of field dressings that could be used for those unable to travel to Amasaman. Second, community understanding of the disease and its healing process is limited which promotes the belief that it does not have an effective medical treatment. To address this misconception, HART developed the pilot education program as previously mentioned. The outreach education program sought to change the way the community felt about the disease and impress upon them the need to seek early attention for suspicious skin conditions. Third, because traditional treatment is usually the treatment of choice in the village, an effective surveillance program must take into consideration traditional beliefs and the healers that provide health services in the area.

Unfortunately, the current outreach program does not adequately address this important detail. To address this concern, HART conducted a two-week field investigation traditional management of BU. In the study, surveys of active and healed BU cases, traditional healers, and health center staff from the Amasaman/Obom sub-districts were conducted in order to better understand community perceptions and beliefs in regards to traditional vs. modern treatment of disease and in particular BU. This information will be utilized during our 2002 outreach efforts.

Medico-Surgical Mission
HART’s Medico-Surgical mission involved two important components. First, over a six-day period, a small team of HART doctors and nurses performed several nodulectomies and provided pre-surgical triage of over 150 probable cases of BU. During this time, the team worked at temporary health outposts organized at Amamorley, Macedonia, and Ayikai Doblo in the Amasaman sub-district. Several patients were also seen at the Obom sub-district health center. Additionally, our doctors and nurses provided primary health services to nearly 150 non-BU patients. At the conclusion of the mission, HART and LDS Charity (LDSC) co-sponsored a small health fair at which general community health concerns were addressed. At the fair, several nurses provided training to participating healthcare workers and village health volunteers on proper dressing and cleaning techniques for the ulcerative condition. Basic field dressing kits including hand woven, washable “leper bandages” were distributed among the community health volunteers involved in the outreach program. Second, a team of HART surgeons and nurses arrived at Amasaman and selected a number of high priority cases from the triage list prepared by the medical team. Over the next ten days, 17 patients from this list received treatment. For the purpose of research currently underway at Brigham Young University in Provo, Utah; USA, clinical specimens and demographic data were collected from each of the 17 patients.

Organizational
Throughout the 2001 trip, HART sought to extend the role of its local Ghanaian Board of Directors in the aforementioned activities. The local Board of Directors was established to provide the critical insight, facilitation, and sustained presence needed for HART to effectively operate in Ghana. Through the HART International Ghana Board of Directors, HART sought to create the strategic partnerships that would allow for its programs to become joint initiatives with other key collaborators. Greater involvement of the Ghanaian Ministry of Health was sought, as well as increased participation with local health care leaders, such as the Department of Reconstructive Plastic Surgery at the Korle-Bu Teaching Hospital. HART’s ongoing partnership with Latter Day-Saint Charities [LDSC] was solidified, as LDSC pledged its support of HART programs in Ghana in upcoming years. Furthermore, Mrs. Theresa Kufuor, First Lady of Ghana, accepted an invitation to serve as the Matron of HART International Ghana, which will allow HART to garner further support and direction as it seeks to serve her country.

Summary of findings
Role of traditional treatment in the management of the disease. Of noted interest was the observation that 84% of the cases claimed to have used some form of traditional treatment in the management of the disease, suggesting future collaboration with traditional healers and herbalists within the district may improve active case surveillance efforts in the area.

BU prevalence rates appear to be higher in the Ga district than previously believed. In just two weeks, nearly 150 active operable cases of BU were identified and documented for future treatment. This high number of cases identified in only a small number (n=25) of known communities in the Amasaman and Obom sub-districts seems to suggest that the actual burden is considerably higher than previously estimated.

Duration of the disease. The duration of BU varies according to location, age, and treatment type. Most minor cases seem to heal within the first few months. More serious cases typically last up to six months and if excessive tissue damage is present may become chronic lasting years.

Beliefs and Causes of the disease
Villagers are generally familiar with BU, its progression, and the problems it can cause. Most people identified BU in its early stages and sought herbal treatment. Perceived causes of the disease varied from community to community. All of these perceptions should be addressed in developing culturally appropriate education programs.

Age of patient and body location distribution of BU
Early analysis of the affected population supports previous reports that Buruli Ulcer affects mainly the younger population and is found mostly on the upper and lower limbs. Particular attention should be directed to number of ulcers found at joints, as these tend to be more serious and more prone to contracture injuries.

Conclusions
Although HART has made tremendous progress in its attempt to provide a more comprehensive approach to addressing the gravity of the problems BU presents in the Ga district; there are several areas of concern that must be addressed prior to 2002 activities in Ghana. The following are important areas of concern:

Unfortunately, due to administrative complications at the hospitals in Amasaman, Nswam and Korle-Bu, the surgeons were not able to operate on as many as they had hoped. On previous trips to Agroyesum and Dunkwa, HART surgeons have been able treat often up to 60 patients during a ten-day period. This year, over the same time period, only 17 patients received treatment from the team.

The free treatment of BU is not free. Although free treatment of the Buruli Ulcer has been promised according to the Yamoussoukro Declaration of 1998, this decision has not been supported. Often when patients do report to government sponsored health centers they are asked to pay money for their dressings, antibiotics and other prescriptions. Both Amasaman and Korle-Bu were questioned about the price their patients paid for “free” treatment. The staff at Amasaman explained that if the clinic does not have an item in stock, they will give a prescription to the patient to buy their medicine elsewhere.

This problem may stem from the fact that the clinic does not receive any supplemental increase in their monthly budget for supplies and reimbursement for supplies used to treat BU are either slow in coming or are not coming at all. At Korle-Bu, the staff charges the patient for items needed for dressings and dressing changes that may be sought daily in serious cases or weekly in minor cases. The average cost for a dressing change was found to be 20,000 cedis per visit. It has also been reported that some of the patients who have gone to both Amasaman and Korle- Bu for treatment were turned away because their cases “were not serious enough” or there was not enough staff or beds to accommodate them. Surprisingly, several patients were also turned away because their condition was too serious to be treated. In order to address these concerns, a careful review of the treatment cost and hospital referral system should be made at Amasaman.

Geographic isolation of the population is a major obstacle to seeking treatment during the early stages of the disease. Transportation can be costly for many whose average daily wage is about 10,000 cedi (<1.10 USD). The average cost of round trip transportation from the villages to Nswam or Korle-Bu is about 5,000 cedi per person. A limited government sponsored transit system could be developed to provide weekly transportation for those seeking outpatient treatment at Amasaman. Money should not be given directly to the patient for this expense.