I have come to The Gambia for 6 months Out Of Programme
Experience. The mental health services in The Gambia have not
hosted a psychiatric trainee on such a programme before, and I
spent my first few weeks working out with the staff here what my
role would be. So having arrived all fired up to get on with
things, it was a little bit of a slow start – but I should not have
worried as 6 weeks later I’m very involved in such interesting
work!

The Gambia is a small country on the West Coast of Africa, with
a population of about 1.7 million people. I am based in the Western
Region, where the capital city Banjul is and about half the
population live here. The Royal Victoria Teaching Hospital in
Banjul, is a 650 bedded tertiary centre, and Tanka Tanka
Psychiatric Hospital is about half an hour outside the city, it
runs at a capacity of about 50 and is Gambia’s only psychiatric
inpatient facility. There are 2 Cuban psychiatrists working in the
country, on secondment from their own country, otherwise there are
no psychiatrists, and although the service is well staffed by
competent nurses and assistants, there is only one trained
psychiatric nurse.
I have been splitting my time between the Outpatient clinics at
RVTH, which run every day and are always busy, and Tanka Tanka. In
the first week of clinics I learned that you cannot predict who
will walk in the door and what they’ll be presenting with. It’s a
self referral system, and the range of psychiatric problems is
vast; all ages, all problems. Several people per day are
transferred from the clinic to the inpatient unit, most often with
substance abuse disorders and psychosis, although unusually for The
Gambia we’ve had a run of psychotic depression in older women in
the past week. The nurses who run the clinic are very experienced
though without any formal psychiatric nursing training. They are
experienced in making diagnoses and treating, and know the system
and are incredibly supportive, which I’m hugely thankful for as a
CT2 and very used to having seniors around to ask advice! It’s safe
to say I’m learning fast.
On first sight the psychiatric hospital looked unusual to me, as
patients are not confined to certain areas as they are at home in
wards. It is a large enclosed open air plot laid out with separate
buildings for male and female dormitories, offices, and other
facilities such as kitchen and dining areas. The patients choose to
spend a lot of their time outside, sitting in the shade or walking
around the grounds. Over the ensuing days, I learned there is value
in allowing people to have freedom within a large space: when
patients are distressed and agitated they tend to manage themselves
differently, and use the space well. Another difference is that the
patients are not split into different wards depending on their age
or presentations, they are all together, so keeping an open mind
and being aware of risks is particularly important.
Having spent 3 weeks settling in, I joined the CMHT on their 3
monthly trek to the South Bank rural regions, visiting local health
centres and doing a clinic in each place. We visited 8 towns, and
stayed with the staff in their quarters each night. It was an
amazing trip, and probably the most challenging experience of my
medical career so far! I have to mention the heat, and the dust,
and the endless tinned sardines. The work itself was incredibly
interesting – in those rural areas people do not have access to
mental health care, and they do not have a ‘Western’ style
understanding of what problems represent mental illness. Therefore
many of the patients attending had long histories of untreated
mental illness, and all the complications in their lives that this
entails. The CMHT make huge efforts to arrange for the clinics to
be announced on local radio and sometimes in the local mosques
beforehand, inviting people to attend the clinic or bring in
relatives they are concerned about. The attendance is variable,
depending on how many people have been reached by the news and
whether they’re able to get there.
At our first stop, Kudang, we were preparing for our clinic and
the team were unsure how many people would attend, having had only
a few on a previous visit. Next door was the public health clinic,
and already at 9am a crowd of people was waiting for the clinic to
open. The lead nurse of our team suggested we give an impromptu
talk to the crowd, with the aim of educating them about mental
health, what to look out for in mental illness, and encouraging
them to bring in any of their relatives. There were men, women and
children listening to our talk; I spoke about how a person might
behave with mental illness of different types, and this was in turn
translated into the local language. The locals listened intently,
and I was wondering how we were being received as their faces gave
little away except for clearly concentrating on what we were saying
and studying us (me in particular as I rather stood out in the
rural Gambian village environment!). As we were winding it down,
people started stepping forward out of the crowd, one woman said
she was experiencing seizures, another man said he wanted to come
to see us as he feels unwell and hears voices, and a third elderly
gentleman told us that he has 2 younger people in his family who he
is concerned about who he will go home and bring directly back to
us. With these spontaneous visitors, and others, the clinic was
pretty busy that day.

The elderly gentleman, the head of a large local family, brought
back his 25 year old son who presented with a 3 year history of
psychotic symptoms, which the family had been managing at home, at
times of agitation having to confine him to his room, his 24 year
old daughter who was having frequent seizures, and then personally
revealed that the last few years have taken their toll on him and
talked about his difficulty sleeping, loss of appetite and constant
rumination on his own death. I had had misgivings about giving the
talk in the morning but obviously it had been helpful, for these
people at least as we
were able to start involving them with treatment.
Throughout the 8 days people brought their relatives from far and
wide to our clinics, some even came from across the border in
Senegal, as one town was about 4 km on the Gambian side and they
listened to the local radio. The majority of cases were epilepsy
and psychotic disorders. I saw a large number of people with
untreated psychosis, and was amazed at how their families and
communities absorb their challenging behaviour and sustain them,
even through florid periods. The interesting cases we saw and
treated on the trek are too many to talk about here. I want to
mention however, a 20 year old woman who was the daughter of one of
the nurses working in one of the health centres, and her mother had
asked her to attend. She described an 8 month history of paranoia
and depressed mood, she was quite suspicious and took quite a
paranoid stance throughout the interview. She was losing weight,
sleep, and referred to vague nihilistic ideas she had about
something in her body. She was tearful. There was a marked rash
across her cheeks, sparing the chin and forehead. She said the rash
started at the same time as the depressed mood, and admitted to
suffering with aching joints. In that rural environment I was
rather stuck how as to proceed, so as well as starting some
treatment, we took her contact details, and advised her to come
into Banjul, as a visiting dermatologist from Dakar is here to do
some teaching at the medical school for a few weeks, and I can
arrange the relevant tests. I must admit to having never seen
untreated SLE with psychiatric complications outside a textbook
before, and we are yet to find out whether this is the case here.
She’s agreed to come next week, but her mother called today to say
she’s refusing her medication before the telephone line cut out.
Another hazard of working in less wealthy countries. Fingers
crossed we’ll see her in Banjul soon, otherwise we’ll have to wait
until the next trek in 3 months time. Her case demonstrates the
constraints of the service here.

Most people’s first point of call for illness in The Gambia is a
traditional healer, especially in rural areas. We were invited to a
well known traditional healer’s practice specializing in mental
health, to collaborate with him in his patients’ treatment.
He explained the treatments he uses which include locally
sourced herbs and particular recitations from the Quran. We saw
similar presentations you would expect to see in a psychiatric
hospital, however people had travelled to see him from a wide area
including Mali and Senegal as well as The Gambia due to his well
recognized family tradition of healing. The collaborative treatment
effort is quite in its infancy, and the CMHT will be developing the
relationship, and will follow up on the next Trek in June.

My training programme in London can seem a long way away
sometimes, and it’s important to strike a balance between learning
and doing as much as is helpful, and knowing my limits. Email
support from my supervisor at home, Dr Peter Hughes, is invaluable.
So far however, this is a truly enlightening and enjoyable
experience, and I would recommend it. I’ll be spending some more
time in Tanka Tanka next, and will be preparing for some teaching
of the medical students at RVTH.
The Gambia has a lot more to offer outside the city – and the
people are friendly and energetic, keen to share their beautiful
country with you. Some new Gambian friends took me out with a bird
watcher at the weekend. European tourists flock here to twitch the
local birds, and as a complete novice I had a go.
We went to Lamin Lodge on the creeks around the River Gambia,
and went out on the mangrove waters in a tiny canoe. To my relief
our guide told me that they don’t get crocodiles in those creeks
any more, and they rowed us silently through the mangroves creeping
up on beautiful bird species – they were very excited to have found
a pair of white backed night herons which I’m told are quite rare,
and blue cheeked bee eaters. Oysters grow on the roots of the
mangroves which the village women row out and collect with
machetes, and the men take tourists out bird watching by day and
fish the waters by night catching small fish for the village market
and barracuda which they trade with the large hotels; one barracuda
for 50kg bag of rice. Young men spend 18 months doing this service
after finishing school, proving themselves as having a good work
ethic and being community minded to the village elders who then
consider them for favourable jobs. The revenue goes back into the
village, to maintain the schools and any building required.
After the creek we visited the village, and I found myself in
the middle of a naming ceremony for a baby girl – seemed like the
whole village was out, dressed in colourful and sequined dresses
and kaftans. Of course all the children surrounded me, shouting
“Toubab” meaning white person, and wanting to shake my hand.

As a born-and-bred Londoner, it can be a challenge to lose any
anonymity and there’s no room for shyness! But you just have to
take it as it’s meant; a friendly greeting of a very obvious
stranger! In Britain we tend not to mention people’s skin colours
for fear of causing offense, but here it could never be the
elephant in the room and is spoken about immediately. I was taken
into the parents’ bedroom to meet the week-old baby, who was fast
asleep and being passed around for everyone to admire. And
everyone’s favourite game here is try and teach me to speak
Mandinka or Wolof, which is showing very slow progress, but it’s
certainly a source of amusement for them!