Francis Botwe (right) / © Magdalena Eriksson
A Day in the Life: Francis Botwe
Living with hepatitis B virus in GhanaSeventeen-year-old Francis Botwe wants to become an accountant. He looks disciplined and serious in his pressed blue uniform and spectacles, as he stands across the street from Central Regional Hospital in Cape Coast, Ghana. One of only a few students from his nearby village ever to reach senior high school, he’s brought hope to his poverty-stricken family. However, Botwe now carries another burden on top of schoolwork and his family’s expectations. In December 2009, he tested positive for the hepatitis B virus (HBV), which affects nearly one in every ten Ghanaians. If left untreated, his infection could cause cirrhosis and liver cancer. HBV spreads through infected body fluids via unsafe injections, sexual contact, or from mother to child at birth. “I don’t know when I caught this disease,” says Botwe.
Since learning his HBV status, Botwe has become acquainted with Ghana’s healthcare system and the challenges facing a poor, inexperienced patient. He paid only 11 Ghanaian cedi (GHS)—approximately USD $8—to join the National Health Insurance Scheme for one year as he is among the country’s least privileged subpopulation. The health plan only covers basic care and generic medication, but did not seem affordable to Botwe’s family previously. “It’s costly,” says Botwe’s uncle, Nana Akoto Bruce, who earns about GHS 150 (USD $110) per month and wishes to help his nephew. In addition to the cost, finding the prescribed services and medication requires extensive scouting and the logistics are daunting for a schoolboy who lacks even a bicycle. But Botwe has paid several visits to an HBV clinic, where doctors at a nearby major hospital see patients only on Tuesdays.
On a February morning, Botwe goes to the hospital, hoping to take some tests his doctor had requested. He’s brought two referrals, one for a liver-function test and one for a viral load count. A hospital laboratory staff member tells Botwe that they don’t perform viral counts, and that they do liver-function tests for free, but that the necessary equipment is not functioning. Of three other medical laboratories in the Cape Coast area, only one private outfit offers the viral count, but without assistance, the GHS 200 (USD $140) price tag puts the test far out of Botwe’s reach.
On an early morning the following week, Botwe returns to the hospital to visit the HBV clinic. After three hours in the sweltering waiting hall, Botwe meets Dorcas Obiri-Yeboah, who heads the clinic. She carefully explains Botwe’s test results, starting with his immunology test. “The virus is actively multiplying now,” she says. “This is not a dormant condition so you’re quite infectious.”
Neither Botwe’s liver-function test nor his abdominal ultrasound indicates any reduced organ performance. His viral load, however, is high, confirming the rapid spread of the virus.
Obiri-Yeboah says that only a liver biopsy can establish whether Botwe’s liver is still intact. But because the procedure is expensive and possibly painful she instead recommends monthly liver-function tests. She then prescribes interferon-a injections and two other antiviral medications. To find these drugs, Botwe will have to travel to Ghana’s capital, Accra, more than 120 kilometers away.
In young chronic HBV sufferers, such as Botwe, the virus can multiply in the liver without causing symptoms or activating the immune system. The multiplying virus does not actually harm the liver cells. Liver damage results when the immune system attempts to kill the virus, which may not happen until decades after infection. To save his liver, Botwe must start antiviral therapy. But Obiri-Yeboah says few patients actually receive proper treatment. “Most clients end up telling you that they can’t afford the treatment.”
Three days later, at the urging of his doctor, Botwe returns to the hospital with his two younger siblings, Mercy and Emmanuel, and their mother to test them for HBV. Although Ghana has no national policy for testing pregnant women, some prenatal clinics screen patients. An infected mother can protect her baby through immunization at birth, but only if she can pay for the vaccine herself. As of 2002, the Ghanaian government mandates that all children receive the complete HBV vaccine series of three injections starting at six weeks of age. Nobody knows for sure, however, whether Emmanuel, born in 2003, has been immunized.
Most babies who contract HBV at birth or within their first six months develop chronic infection. Later in life, acute infections that can be cleared by the body predominate. Botwe may have carried the virus his whole life without knowing.
Botwe’s brother and sister test negative but his mother tests positive. Upon hearing her results, she shows no emotions and only nods quietly as the paramedic advises her to be careful with blood and cuts. “So now my mother has to follow what I have done,” Botwe says.
Author Bio:
Magdalena Eriksson is a medical school professor and a freelance journalist, writing about medical, science and development issues. She is based in Cape Coast, Ghana.
Photo: Francis Botwe (right) / © Magdalena Eriksson
