As a British doctor working in The Gambia the local
beliefs about mental illness become a part of understanding the
patients and their lives.
Of course the local beliefs reflect in patients’ and families
interpretations of mental illness. Many people diagnosed with
schizophrenia will complain that a Maribu
healer) has put a spell on them.
To clear things in my own mind, I find I have to look closely at
the symptoms of schizophrenia as ICD 10 describes them, but the
individual’s interpretation and understanding of what is wrong with
them is quite distinct. It’s expressed as a recognition there is
something wrong and out of their control, and it’s a problem in
their mind that they want to resolve. I’ve found that people can
work with psychiatry on this, and collaborate in their treatment.
Indeed it doesn’t always hinder their relationship with medical
treatment, although it does delay them in seeking it, having
invariably already sought help from a Maribu first.
The message to patients is that the two approaches can work
together to avoid losing their engagement in a medical approach
which after all, they have not grown up with. A young woman was
brought to Tanka Tanka by the police last month having been charged
with infanticide of her 4 day old baby. Rather tragically, she had
defaulted treatment for schizophrenia some 3 years ago. Her family
have been supporting her at home in the way they believed was best
for her, intending to help her care for her baby at home but with
no intervention from services. During her illness, she offended a
neighbour by interfering with their good luck charms by cutting
them off her body. The family may have believed a spell was cast
upon her as revenge for doing this, explaining her state of ill
health and their reason for not seeking medical treatment. After
arrest the police were convinced of her unstable mental state at
the station and brought her to hospital. We negotiated an agreement
with them that she should stay in hospital rather than on remand.
They advised me that her mental illness would be taken into account
if provided with a medical report, as no one was in doubt of her
condition. She has somewhat improved with treatment from a
fluctuating catatonic state and is now able to communicate and
speak about all that has happened, which she finds unbearable but
seems to be coping. There is no relevant forensic mental health law
to help here, and plans for the patient's future care will be a
challenge considering a lack of outreach community services. The
staff will of course do their best but in constrained
"He told me about the beliefs of the causes of mental illness,
which are based in the work of djinns and spells invoked against
people by other Maribus."
The need for a secure unit has complex implications to the
community, not least in that some families despair of bringing
their relatives for care after they abscond, and turn back to
traditional medicine, taking their relatives to a local Maribu
I went with the CMHT to visit a traditional
healer, specialising in mental health, who is about an hour and a
half’s drive outside Banjul, near the South Gambia-Senegal border.
He has a large compound in a rural village with rooms for
inpatients and consulting rooms for outpatients. The treatment is
by way of the Quran, using recitations of certain verses, and
He told me about the beliefs of the causes of
mental illness, which are based in the work of djinns and spells
invoked against people by other Maribus.He said he believed there
are psychoses which do not respond to his treatment and took me to
meet such patients.One young man had been there for 7 months, his
mother staying with him in the healer’s compound.
He was floridly psychotic and threatening, and
being kept there with no improvement in mental state despite the
healer’s best efforts.He had absconded from the hospital twice
before his mother took him there in desperation.The healer is
allowing us to work with him, including supply him with appropriate
medication, in fact he asked the CMHT to help.Of course the first
instinct is to wade in with medical interventions, but the services
here are well aware that without providing a safe alternative, that
would be a naive and potentially dangerous interference.
"Of course the first instinct is
to wade in with medical interventions..."
I have been made aware of lessons learned with these issues in
other countries in Africa, and that a thoughtful approach is
needed. Work is being done in The Gambia to find funding to develop
Tanka Tanka into a more secure inpatient environment, to prevent
absconsion and provide a seclusion facility, and in all to work
towards a more comprehensive service. I have found I have needed to
put so much of my assumptions aside, and look at things in a
pragmatic way, locate my thinking in this environment and culture
rather than superimposing my experience of psychiatry in a
developed country onto the complex needs of this one.
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