Global Engagement Spotlight: Gifty Kwakye

Gifty Kwakye, MD, MPH, Clinical Associate Professor of Surgery in the Division of Colorectal Surgery at the University of Michigan was recently our visiting presenter at Stanford Surgery’s Grand Rounds.

Dr. Kwakye addressed the challenges faced by patients in Ghana, the country of her birth, with a talk entitled “Cancer Screening: When one Scope Doesn't Fit All." The presentation exposed the hardships and healthcare challenges in Ghana and many resource-poor countries.

We have been talking about her presentation for weeks and wanted to know more. So we decided to talk with Dr. Gifty further. Here is the conversation we had.

You travelled all the way from Ghana to the US to pursue education and skills. What were your goals and expectations?

First, I was just curious!

As a child, I always wanted to do something related to medicine. My mother was a nurse in a polyclinic in one of the rural and low-income communities of Ghana in which basic services are provided, but when a patient needs more specific services they would have to travel to the big hospital in the city.

I had the opportunity to watch my mother work frequently in two main settings. The first was at the polyclinic where I used to go often since I got ill a lot as a child and had to skip days from school. The other setting was at home where she was fondly known in the neighborhood as Auntie Nurse. Almost every day people from the community would stop by with various ailments which she would tend to. She was known as the neighborhood nurse who never closed her door.

I was absolutely fascinated watching her work and cherished the opportunity to serve as her assistant at home while she provided basic care to her patients in that loving and generous manner she was known for. I wanted to be like her, a nurse. But I always wondered; my mother was always following the instructions given to her by the doctor at the clinic, while at home she was the one making the decisions and plans! I was curious to know what it took to make those decisions and why I couldn’t be the one diagnosing in addition to taking care of the patients when I grew up?

Then, I was challenged!

When I talked to my mother about it, she said that the doctors she knew were men! Everyone else I talked with said I should be a nurse, that being a doctor is a job for men! Being me, and having the massive ambition of a young girl, I couldn’t take no for an answer! When I mentioned this to a friend he said: “There is no way a man in Ghana would let a woman operate on him unless she was educated in Harvard, Yale, Oxford or Cambridge. It’s impossible for you to be a surgeon.”

So it went from just being a dream to now a clear challenge, to be honest!

So I crossed the ocean to be a surgeon.

My plan was to travel to the USA and learn some skills then return to serve my community. I never planned to stay in the US because I didn’t want to be part of the brain drain. I really didn’t know what to expect before I travelled because all I knew about the US was what I saw in movies. I only thought of the American dream, that is everything is possible if you work hard, and the sky is the only limit. Then when I came, I gradually realized that dreaming isn’t always enough and there are limitations to what you can wish for.

I learned that not having the proper VISA and required documents for an international student was a great barrier that may dismantle your dream of being a doctor.  It is a tough system to navigate if you are not a US citizen or a permanent resident. Not to mention the huge culture shock.

Can you give us some examples?

One example of cultural differences between the US and Ghana is that in Ghana its was considered disrespectful to make eye contact or talk out loud or answer unless asked; here it’s the opposite. I was often misunderstood in my classes and considered not engaging or even not smart, while I was just trying to be polite and patiently waiting for the professor to address me. To me, I was behaving consistent with my cultural upbringing and struggled to understand the disconnect between my actions and how they were perceived.

Being foreign isn’t easy to begin with, and even the legal term that identifies you is in many ways demeaning – the word “alien”!

To ambitious dreamers I say: Know that you will have to buy your own books and worry about all your expenses away from home, know that it’s not the same as being in the community you grew up in where everyone knows you and cares for you, here you will be on your own for the most part. You have to learn the language and adjust to a lot of things, you must be able to accept the new norms.

In Ghana I didn’t think much about race. I was Black but so was almost everyone else. When I first came to the US, I really struggled with suddenly becoming a Black minority and lacking all the historical knowledge to prepare me mentally and emotionally for the daily challenges. Things are not the same nowadays in the US and there is much more freedom and way better racial awareness in the last few years but studying medicine as a foreign student requires double effort, that’s the least to say. I felt lonely at the beginning and the lack of social community support made me feel lost. I was about to give up and return home, but I remembered what my dream meant to me and to my mother, so I decided keep fighting for it.

Having said that I have no regrets and would do this all over again. I would encourage everyone to follow their dream but to do their homework beforehand and be better prepared.

When did you know that you had a passion for Global Health?

My passion for Global Health started even before I came to the US. I travelled from Ghana planning to return to Ghana. Medical training in the US takes an extended time with some inflexible periods that make it hard to be away for even short periods of time. At each single stage of my training, however, I longed for home but something always seemed to get in the way, like the limitations having a student visa places on your ability to freely move around, requiring a special stamp when you do travel or complex processes to get the visa renewed.

Then life happens!

The younger me was carefree and when I was set forth on this journey, I didn’t know it would take me so long adapting to the culture during the most productive years of my life. Reflecting back, I realize I was really naïve and clueless about life. I had my heart so set on the desire to become a doctor that it was what every ounce of me focused on each single day. I didn’t think I would fall in love one day and get married. I didn’t know that I would want kids, and I didn’t know that starting a family did not always occur on your ideal schedule and sometimes it came with a lot of heartbreak.  I never predicted that one of my kids would have a chronic illness and would need constant access to good healthcare. As I grew up and juggled each additional unanticipated thing life threw my way, it made a move back to Ghana even harder, especially when that decision could have a direct impact on the life of my child.

This sounds so hard, what gave you the power and inspiration to continue?

Responsibility!

Not many people from my country will have the opportunity that I had, look at the statistics. It became bigger than just me, there was so much pride and hope from my family and friends back home and that was the fuel that I needed to move forward. I keep all the small sticky notes that my mother wrote (YOU CAN DO IT) (WE ARE PROUD OF YOU) (DON’T GIVE UP) posted on my walls.

 In spite of the distance I tried not to lose my identity, I kept connected with people who love and support me back home, they were with me every step of the way.

And I had the Sistren!

I was fortunate to meet a girl from Ghana in my undergraduate class who stood by me and battled with me against all my doubts. She then introduced me to small group of students who are also in similar circumstances, and we supported each other. We called ourselves The Sistren and our slogan was “paying it forward”. It’s been 15 years now and we are still together; hardship bonded us together and we share the same enthusiasm to mentor young people from minority groups who might not have the support systems that others do. Just like us.

Role models are critical!

It is important to have senior figures and role models to look up to in a diverse academic and clinical setting. It is even more special if those role models look like you. I don’t know if our allies that belong to majority groups truly understand that… what it means to be the only one in a room filled with people and then to look up and see someone who looks or talks or acts just like you. That sense of being known and understood, of not needing to pretend or explain everything. There’s something incredibly powerful about being around a Black female surgeon. It instils such hope in many medical students further down the pipeline who need to know that what was thought to be an impossible dream is very much possible.

I was fortunately to match into one of the best general surgery residency programs that prided itself on producing academic surgeons. We had the opportunity to spend 2 years in the middle of our clinical training focused on building our research portfolio and setting the foundation to be competitive in the future for extramural funding. Early on we were encouraged to apply for resident level extra-mural grants but as an international trainee who didn’t have a Green Card at that time, I was not eligible for any of these. We always tell our residents and students to apply for extra-mural grants, but the reality is that almost all require US citizenship or permanent residency to qualify. It’s one small example of how systems of education can be structured - consciously or unconsciously - to give one group a leg up over the other, which can sometimes have significant impact on the trajectory of an individual’s career.

Dr. Atul Gawande kindly took me under his wing. He had some unrestricted funds that he used to support me over my 2-year research period while I worked in his lab. It was an incredible experience during which I learnt so much not only about research methods but also how to intentionally mine simple ideas that could have impact on both a local and global stage. I was particularly fortunate that his lab was still working on implementation and sustainability of the WHO Safe Surgery Checklist both here in the US and internationally. Since my ability to travel outside the US was limited by various professional and personal factors, I found the opportunity to remotely engage in meaningful work within a global setting quite invigorating and fulfilling.

Then when I finished my training I had a bit more flexibility to move and some extra time to practice my Global Health activities. Especially with the advancement of telecommunications during the last decade or so, I had the chance to do consultations and other activities remotely, and then when the pandemic hit it forced countries to think out of the box and create new ways to collaborate. I spent last summer developing a colorectal surgery fellowship program all by Zoom as I worked with doctors in multiple teaching hospitals across Ghana in addition to representatives from the Ghana College of Physicians and Surgeons. We were able to have our weekly meetings without the need to travel.”. 

But breaking bread together is important

Now, I have research collaborators as well as capacity building collaborators in Ghana. I just returned from a trip as I went there to meet the folks on the ground and to figure out partnerships, because although there are the virtual alternatives they will never replace the need to be present and break bread together. That cultural aspect is crucially important.

Awareness is needed in developing countries, even for doctors.

I can summarize the problems in healthcare in developing countries in two main points; first is the lack of access and cost, and the second is lack of awareness. People have no idea about preventative screening nor can they afford it, so they just speculate about their symptoms, and try live in harmony with their pains!

 An even bigger problem is that many practicing doctors in Ghana, like other developing countries, are unaware of existing policies or guidelines. We conducted a study to understand colorectal cancer screening, for instance, and none of the doctors we interviewed who met the age qualifications to undergo colorectal cancer screening had had the test done. That’s an issue because we depend on our doctors to inform and encourage patients to engage in aspects of their healthcare. It is difficult to motivate someone else to undergo a test when you haven’t done so yourself.

Without implementation follow up, policy is just a piece of paper.

The Ministry of Health has a document about the screening guidelines but none of the doctors had any idea about that document nor the guidelines! Guidelines and policies are not enough, even when we do engagement programs and do the busywork creating policies and guidelines, its meaningless unless you have implementation and follow up with your collaborators, otherwise it’s just a paper.

When I worked with Dr. Gawande and the WHO checklist, an essential part of our work was to develop a follow-up mechanism to ensure sustainability of the intervention after it had been intentionally implemented with assistance of local champions. Doing frequent check to make sure that what you did is actually being followed is critical, because if you don’t you will first see a good improvement then over time it becomes nothing. You could go back to the same locations after 5 years and no one would know about the Checklist.

That’s the problem in developing countries, there’s been so many efforts by individuals with good intentions but there hasn’t been that consistent implementation and follow-up to make sure things are still happening. 

If you have a policy, you should also have funding to follow through the policy, implement screening and cover the cost of treatment. No patient will be able to pay out of pocket not even for simple tests and treatments. They would rather feed their family instead, there are survival priorities according to Maslow Hierarchy of Needs.

We can’t fix the whole problem, but one step matters!

In the beginning of my career I was enthusiastically advocating for initial colorectal cancer screening, but then I thought: what’s the good of telling someone you might have cancer and we need to do more advanced tests to confirm it, if once it’s confirmed you struggle to find treatment and might have complications and there’s big chance you will die anyway? All that is money that they can’t afford in the first place,  I would only be adding  stress and sorrow to their lives more than they already have.

I felt weighed down by the size of the need along with the ethical considerations and for a while I felt stuck.

With time and discussions with lots of people with varying experience, my way of thinking evolved. I realized that instead of tackling the entire humongous problem, I should instead attempt to solve one small piece of the puzzle at a time. My first breakthrough actually came in 2020 during a visit to one of the teaching hospitals in Ghana. I was talking to one of the oncologists after sitting in a Multidisciplinary Tumor Board where over 90% of the cases that had been breast cancer related. Out of curiosity, I asked why the discrepancy between the numbers and the actual cancer burden. His simple answer was that it was covered under the National Health Insurance System.  

The government covers tests, surgery and even chemo treatment related to breast cancer. They knew that it was a big problem because they had DATA. There’d been local and international efforts driven at combating breast cancer because there was DATA. So when I asked why doesn’t anyone pay attention to colorectal cancer, the oncologist replied “There’s no data!”. I asked a pathologist, a gastroenterologist and a general surgeon; they all gave the same answer. OK so let us address the colorectal DATA issue. I had found my first puzzle piece!

I started meeting with researchers in Ghana and officials in the healthcare system to establish ways to collect data that we could feed to the policy makers. It’s just one step, the next step is to train people to do the screening, then also train surgeons to deal with tumors in case they were detected.

It’s an ongoing process and we should collectively coordinate our efforts rather than being paralyzed by looking at the big problem.

What makes you optimistic in what you do? What’s your message?

What we need more in Global Health is the compassion, more people who are willing to engage, listen and act upon the needs of others. When you are young you have the dream and you are enthusiastic, you look to your goals and don’t get discouraged with the walls and barriers. As you get older your responsibilities are more and many things happen in your life that may limit your abilities to help more. I’m optimistic in the way we are focusing on the youth, medical students and residents who have the passion and might find the time to do it willingly because they believe that human beings everywhere deserve access to good basic healthcare.  Even if remotely, they can mentor colleagues in other countries from distance.

When I go to Ghana and speak with medical students or residents, they tell me how eager they are to learn how to do research, how to do literature reviews. I might not have the capacity, but residents and medical students would be excellent. They can create friendships that last for life, we have so many examples of such friendships based on mutual respect of each other’s cultures, it's so beautiful.

If you have the opportunity, use that energy because life could distract you in so many ways. Do it and break bread across oceans, and when you are no longer able to continue, pass the torch to the next set of global champions.