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The Royal College of Psychiatrists Improving the lives of people with mental illness


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October 2011 Posts

13/10/2011 16:22:21

Ghana - Week 1

Ghanaian wildlife


Dr Susie Easton has recently travelled to Ghana for a three month Out of Programme working and teaching placement at a psychiatric hospital in Pantang, on the outskirts of Accra. She is part of a partnership programme between the Royal College of Psychiatrists, the London Deanery and a charity called Challenges Worldwide which pairs volunteers with professional skills with suitable projects in developing countries.

This partnership with Ghana began in 2006, set up by Professor Sheila Hollins and Dr Deji Oyebode in collaboration with consultant psychiatrist Dr Peter Hughes. Six London trainees have already worked in Pantang over the past 4 years, but there has been a one year hiatus since the last placement. Susie is excited to be the first of a new cohort of seven higher specialist trainees from across London, who will be travelling to Ghana consecutively for three month stints, over the next two years.

Week one

After months of preparation and planning (and a little fretting) I have finally arrived in Ghana! My job here will be to supervise and teach the Medical Assistants (MAs) at Pantang; these are qualified psychiatric nurses that undertake an additional 6 month training course to help them diagnose, manage and prescribe for a range of medical conditions, including mental illness. The MA programme has been developed to try and compensate for the chronic shortage of psychiatrists in Ghana: currently there are only about 5 trained psychiatrists in the public system for a population of 24 million; just to put that in perspective, in the UK we currently have approximately 13,000 psychiatrists for a population of 61 million). There are currently two MAs at Pantang and I hope to work with them to help improve the standard of mental health care they provide for their patients.

Already I feel a bit awed to hear that at Pantang hospital, there are 450 in-patient beds, daily open access outpatient clinics that are attended by Ghanaians from all over the country, and only 2 doctors and 2 MAs to staff the place! Despite all the preparation I have done in cold, rainy London, I hope that I haven’t bitten off more than I can chew.

The hospital itself was built in the 1960s on a huge, sprawling 365 acre rural site on the outskirts of Accra. It comprises 10 psychiatric wards with approximately 50 beds in each, a large psychiatric outpatient department with a pharmacy, a small haematology lab, an Occupational Therapy Department, a drug rehabilitation project, a mortuary (which is used by people out with the hospital and apparently generates a great deal of revenue) and a number of physical health facilities including an eye clinic and an physical out-patient department which also incorporates HIV counselling and testing.

On my first day, I go to the outpatient clinic to meet my first supervisee, Ambrose, an MA. Unfortunately I find that he is looking a bit green and has gastroenteritis. The hospital is particularly short-staffed at the moment because the other MA is on annual leave. Ambrose spends a couple of hours showing me the basic ropes and then he has to go home to recover, so I am left on my first day manning an outpatient clinic by myself; talk about being thrown in at the deep end. Suddenly UK outpatient clinics seem very sedate and regimented by comparison. Sometimes over 100 people come to the clinic each day from all over Ghana, and partly due to this time pressure, I find that the note keeping can be extremely brief and that sometimes it can be difficult to establish the diagnosis or current care plan from the old notes. Although English is the official language of Ghana, most people speak a local dialect; in this southern area, usually Twi or Gaa. A nurse interprets for me but unfortunately even the nurses have trouble deciphering my Scottish accent (although that happens to me as well in London). People walk in and out of the consulting room constantly during assessments- nurses from the wards bringing case notes in to be reviewed, relatives, and even other patients popping their heads around the door to see whether it is their time to be seen yet! Mobile phones are answered with impunity by clinical staff and patients alike. It feels very chaotic and a bit bewildering. I am struck by is the high proportion of physical and neurological complaints, in particular epilepsy. Epilepsy is managed by psychiatrists here; fortunately I had been told this before I came out so I had the chance to do some revision. People also frequently present with headaches which may or may not be psychosomatic in nature; more often than not, they won’t have been reviewed by a physician before coming here and I find myself relying on my physical examination skills much more than at home (which I am sure is a good thing). The outpatient nurses do a full set of physical observations on the patients before I see them which is hugely helpful: pulse, blood pressure, temperature, random blood glucose and respiratory rate. It is not unusual for a patient to turn up with systolic blood pressure of over 200, or no known diagnosis of Diabetes and a BM of 28, just sitting there in front of you, quite the thing. I try to contain my anxiety and I am also extremely glad that I brought my oxford handbook of medicine- it is becoming extremely well-thumbed. Fortunately there is a physical outpatient clinic onsite where I can send the most physically unwell patients for review, but I also see from the notes that it is common practice for mental health clinicians here to start people on anti-hypertensives and treat a number of their more minor physical complaints: you have to bear in mind that there is no equivalent to a General practitioner here, so often patients expect their psychiatrist to be a one stop shop for all their psychological and physical health care needs. I am not sure if my physical medicine is up to date enough to be a one stop shop.

I meet with the medical director of the hospital, a Polish psychiatrist called Dr Anna Dzadney. She has worked in Ghana for over 20 years, has a formidable personality and I warm to her immediately. She explains some of the cultural nuances of working in a Ghanaian hospital and gives me some teaching and practice areas that she would like me to focus on with the MAs. An area which always needs focusing on is the in-patients wards; due to short staffing and the intensity of work at out-patients, the wards get inadvertently neglected by the MAs. Therefore they are admitting people on a daily basis, and then not reviewing them, sometimes for several weeks. Anna also gives me some helpful tips for grocery shopping. Ambrose is off for the rest of the first week and it passes in a blur of clinical work and culture shock.

My UK supervisors, consultant psychiatrist Dr Peter Hughes and Dr Lucy Aitkinson form the charity Challenges Worldwide are both very experienced in working in developing countries and they are in constant email contact, providing encouragement and invaluable practical advice. It is always a relief to realise that the feelings of bewilderment, frustration, surprise and delight that I cycle through hundreds of times each day are completely normal for this type of work. At the weekend, I travel to Accra Mall, an incongruous island of western consumerism, very different from the landscape around it. But it has a supermarket (albeit extortionately expensive by Ghanaian standards) and a mobile phone shop where I can get a SIM card and a dongle for wireless internet access. It is also air conditioned so I get to spend a couple of hours not sweating. It is my birthday on the Sunday and I don’t have any plans so I accept a wedding invitation which I see displayed on a notice board in the hospital- I have no friends here so there is no room for pride! One of the hospital admin staff is getting married and apparently everyone is invited/ Ghanaians are very warm and welcoming people and I am not made to feel odd at all for turning up, despite the fact I don’t know a soul. I also get my first chance to sample lovely Ghanaian food: lots of different rice dishes and spicy fried chicken. My first week in Ghana, my first Ghanaian wedding.

13/10/2011 16:41:39

Pantang Hospital

Pantang Hospital
My head is still spinning a bit at being here. It is just so very, very different from the UK. It is currently not as hot as I had feared - we are just coming to the end of the rainy season and it is only about 28 degrees, but with 80-90% humidity, it feels much more uncomfortable. There are hardly any mosquitoes around Pantang which is a big relief. I feel very conspicuous - I can feel curious eyes on the new white lady doctor (who also has elbow crutches, just to attract additional curiosity) wherever I go. But I also receive a warm welcome and constant greetings. I am trying to learn some basic Twi.

Ambrose has recovered, so our work together can begin in earnest. We work by seeing patients in tandem: Ambrose takes the history and mental state, then I sometimes interject with some more questions/clarifications and then we do any necessary physical examination and formulate a care plan. I was heartened by Ambrose’s basic history taking and mental state examination skills. We began to work on being a bit more focused about his line of questioning, always keeping in mind what he was trying to rule out or rule in. I also began to notice the tendency here to often prescribe more than one antipsychotic at a time, with patients often receiving “booster depot injection” doses of antipsychotic at clinic if they had any psychotic symptoms, even if they were fully concordant with their oral medications and there was room to put up their oral doses. There seemed to be a perception that giving an injection as opposed to a tablet was somehow more “potent” than oral medication. We had a short discussion about this in clinic, but i think it is quite an engrained practice and I made a mental note to cover safer prescribing practice at one of our formal teaching tutorials which I will be holding on Wednesday lunchtimes.

After lunch we had to split up and see patients separately - this is obviously contrary to the spirit of the project, where everything we do should be with an MA/nurse to ensure the passing on of knowledge and sustainability once we are gone. Having said that, it is easy to say that, but less easy to stick to when the outpatient corridor is heaving with patients, some of whom have travelled hours to be there, and there are only two clinicians to get through them. In addition, seeing all the patients as teaching cases inevitably slows down the pace. I know that we will be getting more staff in a couple of weeks, and until then I will just need to try and split my time sensibly between service provision and teaching.

In my afternoon clinic, I see a man in his 50s, who is brought in by his sister. He has a long history of alcohol use, and some 4 days previously he had apparently been admitted to a medical ward with a withdrawal-related seizure. His sister brought a letter from the general hospital, addressed to psychiatry, saying that some time after admission, the man had become “aggressive, hallucinated and uncooperative with treatment” and so they had had to discharge him and could we treat his “psychiatric problem”. The most striking thing was the man had been sent home with a bag full of all the medications that his family had bought for him on admission, but had not been administered, including about 12 glass phials of IV Thiamine. The man was very ataxic, delirious and had Wernicke’s encephalopathy. I felt upset at the way the other hospital had treated (or not treated) him and I spoke to Dr Dzadney for advice; she was not at all surprised by this type of presentation and she told me that any form of mental disturbance, even if there is a clear physical cause, is felt to be the remit of psychiatry and that we should admit him for treatment, but warn his family that we could only keep him for a maximum of three weeks and that he might possibly have irreversible brain damage. We kept him for about a week and gave him IV thiamine etc and fortunately he made a full recovery.

On the Tuesday afternoon we managed to go to the in-patient wards to do some reviews. The ten wards are very spread out across the hospital site, single storey and joined up by covered walk-ways. The buildings are fairly clean, cool and sizeable, but even so the accommodation can feel quite cramped due to the large numbers (50 patients in a ward). There is no Mental Health Act here currently (although there is a long-awaited bill currently going through parliament), so when patients are admitted against their will, it is done with the slightly tenuous agreement of family members as proxy consent. There is a real problem with people bringing members of their family to be admitted... and then leaving no forwarding address or contactable phone number, so even when the patients are well enough to be discharged, there is nowhere else for them to go and therefore they remain at the hospital.
Outpatients' corridor

There are some patients in the “Chronic wards”, who have been here for some forty years and they tend to have employment around the hospital site. There is an Occupational Therapy department, but it is mostly staffed by visiting volunteers at the moment, and the in-patients sometimes don’t always have much to do during the day. Having said that, lots of gardening and farming goes on all over the hospital site, courtesy of the patients.

Despite these difficulties, all the in-patient nurses that I have met have been professional, warm and compassionate. And I was pleased to hear that a retired nurse lecturer, Michael Brenan, is coming over to Pantang with Challenges Worldwide from Scotland in a couple of weeks specifically to work with the in-patient nurses and help them with their professional development. I noticed that a lot of their time is spent completing progress reports in the notes, and less time doing one to one therapeutic work with the patients. There is a very medical model here, with a lot of emphasis on medication and less on psychosocial interventions. I also got the impression that the nurses don’t feel particularly empowered to be autonomous, but clearly they are a huge untapped resource for working more actively with the patients.

Inpatient waiting room, Pantang Hospital
I went to Kokobrite beach this weekend, a beautiful stretch of white sand and palm trees about 30 km west of Accra. I took a “trotro” which are basically shared minibus-taxis that operate all over the country; it is a good way of feeling part of Ghanaian everyday life. It took me about 4 hours to get there though, mostly due to the choking gridlock that is Accra traffic every day, particularly on a Friday afternoon when everybody is trying to leave the city.

The government are working hard to improve the standard of roads, and there are a number of motorways under construction that will relieve the situation somewhat, but that still won’t allow for the constantly expanding population in Accra, of people moving in from rural areas looking for work. When I feel myself becoming exasperated with waiting, in all sort of situations, I have to remind myself... “African time...remember, we are running on African time”.
18/10/2011 15:15:57

Accra Psychiatric Hospital

Accra, Ghana

Week 3

I had my first full day of work at Accra Psychiatric Hospital this week in the centre of the city; I am scheduled to go there every Friday to do an outpatient clinic in tandem with one of their MAs, and then series of teaching tutorials with all 5 of the Accra MAs in the afternoon. Even though the hospital is probably only about 20km away from Pantang, I had to get my lift to pick me up at about 7am to ensure we got there for 9am because of the choking rush-hour traffic.

Accra psychiatric hospital was opened in 1906. It has some 700 in-patient beds wards and currently houses approximately 1200 patients. Those numbers speak for themselves. There are 5 doctors (two consultants), 5 medical assistants and a clinical psychologist. Like Pantang, the hospital is in a serious amount of debt. There has recently been a big push to try and discharge patients back into the community but unfortunately, often the community and more specifically, their families, don’t want them back. And community services for psychiatric patients in Ghana are very underdeveloped currently. So many of the discharges are simply brought back and left...or sometimes they never leave in the first place. As we are all too aware in the UK, in-patient provision is expensive, so a huge proportion of mental health funding is spent on providing bed and board for a lot of patients who would be much more appropriately housed and looked after elsewhere. But for the moment, there doesn’t seem to be an “elsewhere”.

As I walked around the hospital, it had the feel of an old asylum. I had been warned what to expect, but the wards were still quite difficult to take in. The level of overcrowding meant that sometimes patients had to sleep on mattresses on the ground, outdoors on terraces. The male “locked ward “in particular was full to the rafters (about 35 beds and 220 patients) - this seemed to be the equivalent of our forensic wards where patients were sent on “court orders”. However, as far as I could discern from the nursing staff, men arrived here regularly, but the outward traffic of discharge was much less frequent. Although there were lots of patients, there were no discernable outward signs of psychosis or aggression, just lots and lots of men, milling around looking bored. There was also an addictions ward, where people were admitted with substance use problems, mostly “wee” (cannabis) and alcohol. However, apparently there weren’t any in-patient resources for psychological treatment of addiction (although there was an AA groups within the hospital) and it seemed as if the patients were just taken off the streets to live here instead, out of sight.

I had a chance to spend some time talking to some of the in-patient staff. As ever, I was impressed with their professionalism in the face of very difficult working conditions. They told me of the stigma that mental illness faces in Ghana, even from within its own medical profession at times. They said that often they had experienced reactions of abject horror from their friends and family when they said that they wanted to work in Mental Health, and that their still remained a great deal of superstition and fear around psychiatric illness, with even some educated Ghanaians attributing its aetiology to spirits and demons. They described the difficulties they often faced in accessing appropriate medical health care for their patients. One nurse tells me of an incident where her patient needed to be taken for a blood transfusion at a local physical healthcare facility. During the treatment, she heard a member of their staff say loudly, within earshot of the patient, that this kind of medical treatment shouldn’t be “wasted on animals”. Obviously this is not an opinion held by the majority of educated Ghanaians, but still, it is indicative of the level of prejudice that exists in some quarters.

Probably the most starkly difficult part of the hospital to take in was the Children’s ward. This comprised a large compound which housed about 30 patients with moderate to severe learning disabilities, aged between about 8 and 35. The staff told me that children with intellectual disabilities (often with concurrent physical problems) were abandoned at the gates of the hospital by their families, or sometimes found on the streets. Once here, most had no further contact with their families and remained on the ward until their lives ended. The nurses explained that having a disabled child, particularly a child with a learning disability, can be very shaming for a family, and that it is sometimes taken as a sign of some sort of malevolent influence at work.

There are 2 nurses on duty and a couple of Ghanaian volunteers who are here three days a week to help care for the children and who also try and organise activities such as art or games. But it is very clear that relative to the individual needs of the children, the wards are critically understaffed. It is all the nurses can so to keep the children clean, fed and safe and there is precious little time left to think about their emotional or learning needs. I noticed some of the children sitting quietly rocking themselves. For the brief periods that I have been on the wards, individual children come up, grab on to you and don’t let go; I left with scratches on the back of my neck because one little girl was holding on so tightly. I try not to be the overwrought, overemotional visiting westerner, and fail. It feels like quite a lot to take in. Currently there is no available input from speech therapists, physiotherapists or child psychology.

I spoke to staff and volunteers to see if there is anything practical we could do, in conjunction with Challenges Worldwide, the charity that is supporting me in Ghana. I was thinking of trying to fundraise for some educational and art materials for the ward and I asked the staff for a list of things that the children need: although the list did include toys and art materials, at the top were more basic requirements such as detergent, gloves, nappies and second hand clothing. I need to have a think about how best to take this forward, and I leave feeling a bit numb.

Ghanaian flag
I continue with my clinic, in-patient and tutorial work with the Accra and Pantang MAs. In the main, they are enthusiastic, keen to learn and a privilege to work with. But I am starting to learn lessons that I am sure most volunteers in developing countries learn on the job (people tell you these things before you go, but they don’t really sink in).
Firstly, you can’t just go in to a new place and expect people to want to hear about how to make things “better”, especially from an outsider who is used to working in a vastly different environment; this seems hugely obvious when you see it written down, but I assure you, it is easy to lose sight of this fact. Secondly, you can’t presume that your own, dearly held professional values are going to necessarily be entirely shared by those you will be working with. This can feel frustrating at best... and at worst discharging in brief paroxysms of rage and disbelief (hopefully in the privacy of your bedroom). I am learning...not to take it personally, to reconvene my list of “goals for the week” into “goals for the month”, to be flexible and to seek compromise. Dr Dzadney, the Medical Director told me something very useful when I was sounding off about a patient who I felt had been poorly cared for at a medical facility; she told me that sometimes here we cannot always do what is best, but only the best we can manage with what we have.
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About this blog

Susie Easton

Hello, my name is Susie Easton and I am an ST6 on the UCL/Royal Free Hospital General Adult Psychiatry Rotation in North London. I have just got my CCT and when I return from Ghana, I will be moving home to Glasgow to take up my first consultant post.

When I saw the Ghana post advertised, I thought that it looked interesting, a bit scarey and an opportunity for a professional and personal adventure.

This personal blog reflects Dr Easton's own views, and not neccessarily the organisations that she is working with. However Dr Easton is indebted to the partnership between South West London and St Georges mental health Trust, the charity Challenges Worldwide and the Royal College of Psychiatrists for providing an opportunity to take part in this excellent project. She is also very grateful to Dr Peter Hughes for his regular and invaluable clinial electronic supervision, Challenges Worldwide for their excellent logistical support, and Dr Anna Dzadney the Medical Director at Pantang hospital for making her feel so welcome. And last but not least, she is indebted to the Ghanaian Medical Assistants with whom she works, for helping her learn about how mental illness in West Africa.