Their obvious strengths are in their familiarity with the many nuances of West African culture, their unflappable flexibility and resourcefulness in the face daily novel clinical challenges, and their ability to assess and process a volume of patients that we as clinical staff in the UK would possibly baulk at:  would you fancy seeing over ten new patients at outpatients each day, on top of your reviews?  Me neither. They are also in a brilliant position to educate the population about the causes and treatments for mental disorder, helping Ghanaians to integrate a biopsychosocial model in with the more traditional concepts of “spiritual causes” for mental disorder. But inevitably, the necessity of speedy assessments affects the quality and depth of the history taking and mental state examination. And similarly, without an arsenal of paramedical support services on hand, such as the OTs, psychologists, CPNs and social workers that we sometimes can take for granted, the desire to be able to “offer something” quickly to the patient often plays out in the issue of a prescription. Interestingly and unexpectedly, one of my main challenges here has been to try and get the MAs to think more systematically about the possibility of NOT prescribing. Possibly this is also a cultural issue- I have noticed that Ghanaians expect to go away with a script in their hands. It is a definite contrast to the UK, where I think often the current trend is for patients to be reluctant and somewhat reticent about taking psychotropic medication (and often, quite rightly so!)

And so we continue to work together in clinics and on the wards; we see and assess the patients, we discuss the cases, I ask them questions about their reasoning around diagnostic or management decisions. Sometimes we disagree, and often I find that “what I would do if I was in the UK” is an irrelevant and pointless proposition. For example, we see a fifteen year old boy whose Father brings him in with what sounds like grand-mal seizures. In the history we find that he experienced quite significant developmental delay, not walking until the age of 2 and a half, and not speaking until the age of five and he never managed to learn to read or write, but he has never formally been diagnosed with a learning disability. He has an odd, telegraphic style of speech and it was also unclear if the seizures were new, because until recently the boy had lived with his Mother in Nigeria and there appeared to have been very little communication between the two parents. His physical and neuro exam were normal. Basically he had an undiagnosed mild-moderate learning disability of unknown aetiology and seizures that were possibly new, but not definitely. The family couldn’t afford any form of neuroimagaing, and only basic blood investigations. There is no sense in searching and searching for a possible aetiology unless there is likely to be an effective and accessible therapeutic intervention. So we started him on carbamazepine, gave his family some basic psycho education about his learning disability and his seizures and arranged to see him back for review. No neuropsychological testing, no MRI, no full organic screen, no LD support services: just… managing.