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!