Contents:
Accessing psychiatry in Ghana
The working conditions are not ‘the best’,
treatments are basic and its political priority low; still there’s
a lot involved when considering psychiatry in Ghana. This West
African country’s culture of collective, family responsibility
means that most consultations for those with mental illness are
initiated and include their concerned relatives. As superstition
and spiritual beliefs are popular and influential, informal healing
centres run by traditional and faith healers are in demand despite
the risk of maltreatment (Read
et al 2009). Meanwhile stigma and suspicion towards mental
health services often means that for many, psychiatry is ‘the last
resort’.
Then there’s whatever travel is required along
hot, dusty, pot-holed roads to reach the more developed south coast
where Ghana’s three psychiatric hospitals are based. This physical
journey can be a significant undertaking in itself, typically
achieved in sweaty, creaking, careening tro-tros, where it’s likely
to be of little comfort for their passengers that daubed on the
backdoors of these private minibuses are slogans of faith like God
is My Provider or Amazing Grace. Furthermore despite numerous,
similarly dedicated shops and literal advertising hoardings,
ongoing reminders of life’s adversity remain evident among the
eager roadside traders and hardship passed along the way.
Such issues are relevant as many psychiatric
medications and services are only available from the hospital,
where further considerations are encountered. Here, while general
health care is free, payment is expected for all prescriptions,
investigations and the file that records each patient’s notes. All
patients must also wait in the order they arrive, even for repeat
prescriptions, as there are no appointment times. This may be
further subject to handcuffed, police-escorted emergencies
receiving intravenous Diazepam on a stretcher in the waiting area.
Then when each patient’s turn comes, usually the most qualified
staff member they will meet is a medical assistant (MA) with
limited psychiatric training.
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The Out of Programme Experience in Ghana
Although its unusual to find a UK psychiatry
trainee in Ghana, I wasn’t the first to volunteer. The initiative
was proposed by Professor Sheila Hollins in 2005 after her election
as President of the Royal College of Psychiatrists. While
previously serving on the College’s Board of International Affairs,
Professor Sheila Hollins (a former VSO herself) and Professor
Rachel Jenkins established the principle that out of programme
experience (OoPE) placements by higher trainees could be approved
for training. Subsequently Professor Hollins and Mr John Rafferty,
the chair for South West London and St George’s Mental Health NHS
Trust, suggested Ghana as a potential OoPE location for the Trust’s
higher trainees.
There were close associations with Ghana
already as many of its nationals were Trust employees or resident
in South West London, though the country’s political stability and
its established psychiatric service were also important
considerations. As Mr Rafferty also chaired Challenges Worldwide
(CWW), an international development charity that arranges volunteer
placements for professionals in developing countries, CWW helped
develop the programme with the Trust’s Medical Director, Dr Deji
Oyebode and Ghana’s Chief Psychiatrist, Dr Akwasi Osei. Additional
support from the College and the London Deanery, as well as
individual input by international psychiatry veteran, Dr Peter
Hughes and Prof Hollins’ then Specialist Registrar, Dr Raj Attavar,
were also vital for establishing the OoPE in Ghana [1].
At this time I knew Professor Hollins and Dr
Attavar from my training with the Trust’s Learning Disability
service and although the latter had hoped to volunteer himself, by
the time the OoPE was approved, his training had ended.
Fortunately, thanks to his efforts and of those above, there have
been a number of successful placements starting with
Dr Norman Poole in 2007,
Drs Abdi Sanati and Olimpia Pop in 2008 and
Dr Clive Stanton in 2009. Then after successful interview and
approval by Sussex
Partnership NHS Foundation Trust as their first trainee to
volunteer, I left behind an uncertain, post-election UK for a new
world.
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Pantang’s past and future
On the rural outskirts of Ghana’s capital
Accra, Pantang Psychiatric Hospital stands testament to both former
pan-African ambitions and current reality. Opened in the 1970s as
the country’s third psychiatric hospital, it was originally
envisaged as a mental health village for psychiatry, neurology and
neurosurgery serving all of West Africa (Asare, 2010). However like
many of the grand, socialist visions of Dr Kwame Nkruamah – Ghana’s
legendary first President who led it to independence from Britain
in 1957 – the hospital’s scale of ambition wasn’t realised and now
appears faded. Still, it remains impressive in scale with ten self
contained wards, a three storey administration block and a nursing
school, connected by a large octagonal covered walkway that
stretches across its extensive rural grounds.
Here mental health care for nearly 100 daily
out-patients and up to 500 in-patients is provided by some 300
members of staff. However, there are just two psychiatrists as
limited funding, poor career prospects and a ‘brain drain’ of
professional emigration means that for a population of 22 million,
there are only 13 psychiatrists in Ghana (Asare 2010). Thus while
there were plenty of patients, I soon realised that my best role
was providing teaching and supervision to Pantang’s three medical
assistants (MAs), experienced nurses with two years of medical
training who perform a much needed doctor-like role.
I first met my new colleagues in the office of
the Medical Director and former Polish national, Dr Anna Dzadey,
where they all remembered my predecessor by six months, ‘Dr Clive’.
Before I left, Clive had encouragingly described his placement as
being his best training experience, though he added that finding
time for teaching wasn’t always possible. Still, Dr Dzadey and I
hoped that with the MA’s new rota – where two began in the mornings
and the other covered afternoons – regular sessions could be
arranged when their duties crossed over. However, as these Ghanaian
men heard from their ‘lady boss’ about the relationship they would
have with me, another European psychiatrist, the room did go rather
quiet.
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Ghana’s New Psychiatrist
Initially I observed the MAs’ outpatient
consultations, many of which occurred in English. If the patient
and family only spoke Twi or Ga, then I followed what I could
though it wasn’t always clear whether the MA knew the patient’s
language either. Whatever language was spoken though, all clinical
notes were written in English, which to my monolingual brain seemed
an impressive transcribing skill.
To experience the work itself, I began to
assess, advise and issue prescriptions myself, with a nurse
translating when necessary. There was no shortage of patients and
the staff appreciated how the waiting area was clearing. It all
seemed surprisingly straightforward and when I saw previous entries
by Clive and before him, Norman, I felt connected with a unique,
shared experience.
However, there were also more serious
decisions to make, like whether to approve hospital admissions.
While some families came expecting their relative to be admitted,
other patients were sent by the courts without advance notice.
‘What now?’ I asked Dr Dzadey, who advised that despite limited bed
availability, we should support the family. Thus within days of
arriving and my temporary medical registration approved, I was
detaining Ghanaians of their liberty [2]. Furthermore, on the cover
of these patient’s notes and under their name was now written that
of their responsible clinician, ‘Dr Neate’; our names forever
linked.
Providing supervision was Dr Peter Hughes, who
as Director of the St George’s Higher Training Programme had
previously overseen my annual reviews and also supervised the
preceding Ghana OoPE trainees (Poole &
Hughes, 2009). While securing reliable internet access for
sending my written weekly reports was challenging at times, Dr
Hughes always replied swiftly despite being in Haiti providing
post-earthquake support. Although his messages lacked for
spellchecks, they always emphasised that my contribution should be
‘sustainable’, particularly after I described seeing patients on my
own;
“>>>In general clinic should be never
with pateint and you only biut always should be trainign
opportunity with MA or nurses . MAs could leaad clinic and you can
sueprvise them. Not service job -training job”
Dr Peter Hughes, 14 May
2010 17:43:42
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Assessing the Medical Assistants
Lesson learnt, I spent one day a week with
each of Pantang’s MAs starting at 8AM in outpatients, where
evermore about Ghanaian society was revealed. Filling the centre of
each consultation room was a large wooden desk with a large swivel
chair on one side and mis-matched chairs on the other. A ceiling
fan, an out-of-date calendar and a rarely-used examination bed
emphasised the importance of this healing centre. Sat waiting on
benches along the corridor outside, patients and their families
were expected to enter the moment they were called though rarely
were handshakes and explanations offered. If the impact of this
formality bestowed upon the room’s occupant an impression of wisdom
and knowledge, well perhaps that was just as well.
Patients described physical symptoms of
tiredness or head pains, while families were concerned that their
relative was ‘over-thinking’ or ‘roaming about’. Some consultations
ended surprisingly quickly while others passed in slow motion, as
the MAs pored over limited notes and pursued unpromising lines of
enquiry. Depression, anxiety and learning disabilities were all
possible explanations though as many patients had long been unwell
before their behaviour became problematic, schizophrenia was often
diagnosed and typical (first generation) antipsychotics prescribed.
Then, when follow-ups returned for review, there was little
questioning of the original diagnosis or whether medication
remained necessary.
It all seemed so different; the way the
patients presented, how staff approached them, the family’s
involvement - everything! Sometimes I’d feel compelled to advise
the MAs to be more inquisitive or speed up a dragging consultation
though I’d also remind myself of computer tutorials where the
expert’s hands-off approach forced me to do things myself. I hoped
that was possible here, yet these were actual patients and the MAs
often appeared unaware of the risks involved. However, it was also
clear that they were the only staff available to perform an
incredible range of clinical duties, including specialities like
child and learning disability psychiatry, as well as neurology and
epilepsy. As if that wasn’t enough, I soon realised that many of
the mobile phone calls they received during consultations concerned
their external private work.
It was also noticeable that as there were few
training or career opportunities for MAs after qualifying, there
appeared little incentive for them to develop and improve their
skills. Thus, with Dr Hughes’ encouragement, I began to assess
their performance in clinic using a modified version of the Royal
College’s Assessment of Clinical Expertise (mini-ACE) forms. While
the MAs weren’t used to such evaluations, these provided a written
summary of our work together. Later when my girlfriend, Wendy,
visited we devised a simulated scenario of post-natal depression to
standardise their assessments. Their more considered approach
towards her demonstrated that they could raise their performance,
though individual variations remained evident too.
I also conducted an audit of the MA’s work
experience and learned more about their personal journeys. All had
previously been nurses at Pantang who had undertaken MA training,
nine hours travel north, at the Kintampo Rural Health Training
School (KHRTS) and had now returned to live in hospital
accommodation with their young families. Most approachable and
vocal with his concerns was Mr Aaron Baah, whose professionalism
was apparent though he was frustrated that being an ‘Assistant’
implied that he worked for someone else. In reality, he acted
almost entirely independently, but because of his title,
organisations wanting a doctor’s opinion didn’t recognise his.
That may start to change though as I saw while
teaching on the Kintampo Project, a joint initiative between KHRTS,
Hampshire Partnership NHS Foundation Trust and the University of
Winchester. The Project intends to dramatically increase access to
psychiatry specialists in Ghana by training MAs and nurses to
provide services in rural clinics and rely less upon centralised
hospitals. Thus, as well as being an exciting teaching opportunity
for me, the Project’s graduates, including Mr Baah, may be among a
new generation of mental health workers in Ghana (see Teaching on
the Kintampo Project report).
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Reviving the Rounds
Continuing with my supervision of each MA at
Pantang, I joined them for clinical reviews of their inpatients in
the afternoons. Here, across ten erratically numbered wards, each
MA had a seemingly overwhelming level of responsibility for over
ten patients per ward. During Norman and Clive’s placements, both
had arranged regular ward rounds to establish a routine of the MAs
and nurses working together, though these didn’t last long.
Furthermore when the MAs attended the wards now, they lacked focus
over who was reviewed and what was achieved, with many chronic
patients being overlooked. With Peter’s advice I suggested a
framework for reviews of ‘diagnosis, social circumstances, goals of
treatment and problems’. However, while supervising ten consecutive
consultations of men with psychosis and cannabis use, I found that
details would merge and even my own skills drifting towards
Pantang’s baseline.
One issue I couldn’t help noticing was the
severe extrapyramidal side-effects of some inpatients due to
prolonged courses of daily intramuscular antipsychotics. I asked
about Norman’s protocol for managing aggression which I heard he’d
introduced three years ago. Many people remembered his flowchart
posters though they were no longer displayed and differing views
among the staff remained about prescribing and administering
sedative medications. Nurses preferred injections to ensure
compliance, prescriber’s practices varied widely and pharmacy
feared running out. What seemed necessary was a system that all
could follow.
While this wasn’t resolved in my time, I did
update Norman’s slide show presentation for Pantang’s weekly case
review meeting, starting with a quiz before outlining the protocol
and its benefits. With photographs taken from the notes of
questionable accounts about injections, I described how the
protocol’s steps aimed to deescalate and make safe differing levels
of aggression. Although my intervention alone wouldn’t alter much,
I hoped the principles of anticipating aggression would appeal and
I reminded them of what could be achieved through negotiation as
demonstrated by Ghana’s own global diplomat, former UN president,
Kofi Annan.
In addition to my work at Pantang, I provided
teaching on Friday afternoons for the MAs based at Accra
Psychiatric Hospital (APH). Unfortunately their attendance didn’t
always reward my two hour journey by tro-tro through Accra’s
haphazard roadworks and the day of the Black Stars’ World Cup
quarterfinal wasn’t a successful one for teaching either. However,
I was fortunate to meet APH’s Medical Director and Ghana’s Chief
Psychiatrist, Dr Akwasi Osei, whose appearance and wisdom has
Mandella-esque qualities despite his own challenging
responsibilities.
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Insight into Insight
During his placement, Norman’s interest about
how mental illness affects insight led him to research whether
patients who denied their own mental illness could recognise mental
illness in others (Poole et al, unpublished). Before my placement,
we spoke about a new project to repeat a previous British study
about insight (Startup, 1997) in Ghana. My main task was to take
local advice about modifying the descriptions of mental illness
that were used in the original study so these vignettes would be
suitable for a group of English-speaking Ghanaians. I then field
tested and validated them with local health staff so my successor,
Dr Samanta Nagpal, could continue this research during her
placement.
While the idea was intellectually interesting,
its relevance was apparent when I saw that patients were often
described as having ‘no insight’ if they denied their illness or
refused medication. Having experienced other areas of ambiguity in
Ghana, this seemed an appropriate subject to present at Pantang’s
monthly teaching programme. Again, I began with a test and examples
of descriptions of insight photographed from the clinical notes. I
then outlined insight’s three aspects – illness recognition,
relabeling experiences as abnormal and accepting the need for help
– indicating how this often changes over time. To demonstrate this
I invited a patient to attend the ‘grand-round’ meeting where she
explained how her views about her family were factually true but
not agreed by them, as parentage and sibship in Ghana are not
always based on biological grounds. Thus while she was technically
correct, she minimised the extent of her family’s concerns and
later the audience questioned her inconsistencies.
Afterwards I heard it was the first time a
patient had been interviewed during Pantang’s teaching programme
and I hoped it would inspire further inquisitiveness by all. I was
then presented with two Ghanaian shirts before I gave my own
parting gift of handwritten nameplates for the staff to use on the
outpatient clinic’s unmarked doors. Along with a wonderful leaving
dinner with many of Pantang’s staff, this was my own good
‘good-bye’.
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Summary
My placement in Ghana was the most fascinating
and perspective changing experience in my psychiatry career. I
particularly appreciated observing and participating in Ghana’s
culture, which made me reflect on how I consider and teach
psychiatry. I also appreciated observing the inner workings of
Pantang, the interaction between all involved in mental health
services in Ghana and witnessing the beginning of the Kintampo
Project.
I am grateful to all who supported my
placement, as well as those I met and befriended in Ghana. I will
particularly remember feeling integrated within a country that was
accessible and at times, curiously familiar. Yet Ghana was also
unique, which despite its hardship has a generous, positive spirit
where new surprising details were revealed every day. Back home, I
have continued my Ghanaian associations and followed the progress
of the Project as one day I hope to return, where I know a warm
‘Akwaaba!’ welcome is waiting!
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Acknowledgements
I would like to thank all of those listed
above who made this experience possible and so special. Drs. Anna
Dzadey and Akwasi Osei, all the MAs, Elvis Akugmoar, Sahl Mohammed
and the staff of Pantang Psychiatric Hospitals. Professor Hollins,
Drs Peter Hughes and Raj Attavar, the London Deanery and the Royal
College of Psychiatry. Daliah Houghton, Eoghan Mackie, Winnifred
Oware and Challenges Worldwide. Drs Norman Poole and Clive Stanton
and my fellow Ghana alumni. Drs Chris Aldridge and Glen Berelowitz,
Sam Vaughan and Sussex Partnership NHS Foundation Trust. Dr Mark
Roberts and all involved with the Kintampo Project.
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Footnotes
[1] The Ghana OOPE is considered to be
‘cost-neutral’ as even though the Trust loses a trainee for three
months, the London Deanery continues to pay their base salary. In
turn each volunteer forgoes their on-call banding and London
weighting, while one month of their salary is waived to fund CWW’s
involvement and expenses such as medical registration and local
accommodation. By registering as an international volunteer with
the Royal College of Psychiatrists, trainees can also apply for
funding for the cost of their flights.
[2] After numerous attempts to pass mental
health legislation, there remains no formal mental health
legislation in Ghana though the draft Mental Health Bill 2010 is
under consideration. This bill aims to protect patients’ rights and
ensure standards of care across orthodox, traditional or spiritual
services (Asare, 2010) though delays and resources may limit its
full implementation.
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References
- Read et al (2009) Local suffering and the
global discourse of mental health and human rights: An ethnographic
study of responses to mental illness in rural Ghana. Globalization
and Health 5:13. [Accessed 10 October 2010].
- Poole N (2007)
Summary of Report on Ghana experience [Accessed 10 October
2010].
- Sanati A (2008)
Summary of Ghana Out Of Programme Experience (OOPE), [Accessed
10 October 2010].
- Stanton C (2009).
Summary of Ghana Out Of Program Experience OOPE, [Accessed 10
October 2010].
- Asare, J. (2010) Mental health profile of
Ghana. International Psychiatry 7, 67-8.
- Poole, N. Hughes, P. (2009) A training
experience to remember: working in Ghana, The Psychiatrist 33,
353-355.
- Poole, N. Crabb, J. Osei, A. Hughes, P.
Young, D. (unpublished) Insight, psychosis and depression in
Africa: A cross-sectional survey from an in-patient unit in
Ghana.
- Startup M (1997) Awareness of own and others’
schizophrenic illness. Schizophrenia Research 26, 203-211.
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