Interview with a Fetish Priest
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Traditional healer, Kofie Munufie, describes his beliefs and informal healing centre near Kokuma, Ghana – July 2010.
Background
In May 2010, I taught at the Kintampo Rural Health Training School in central Ghana as part of the recently established Kintampo Project that provides formal training in psychiatry to middle grade health workers (see Opening of the MAP blog). The students were a group of experienced Medical Assistants (MAs), former experienced nurses who had undertaken further training to perform a doctor-like role. While MAs now make a significant contribution towards Ghana’s health care, within psychiatry they are increasingly necessary as there are less than 15 psychiatrists in this country of 22 million people [1].
During our teaching programme, a field trip was arranged to visit a fetish priest and the ‘informal healing centre’ that he runs for people with mental illness. Typically a fetish priest serves a ‘Spirit’ that inhabits a shrine within their community. Through the performance of rituals, it is believed that the shrine’s Spirit can take possession of the priest, who then speaks on its behalf ‘in tongues’. As mental illness in Ghana is associated with being spiritually unwell, family members often approach these priests to treat their relative, as an alternative to seeking medical advice [2].
We thus visited Kofi Munufie at his remote, rural community, near the slightly larger community of Kokuma, to observe his approach and the conditions at the healing centre. To get there involved a 30 minute drive south from Kintampo, including 10 minutes along an uneven, unpaved road and then walked for a further 10 minutes. For over an hour, our host answered questions from the students, which were translated for the non-Twi speakers among us. During this time we also met with some of the ten or so patients, who may remain here for between six and 12 months at a time.
When I returned to Kintampo six weeks later to provide additional teaching, I was keen to speak to him for longer, along with my girlfriend, Wendy, who has a personal interest in shamanic healing. We thus arranged by mobile phone to visit on Saturday morning along with one of the MAP students, Ernestina Agyei Yobo, providing translation. This time, when we turned off the main road, there was a modern sign with his photograph and directions, with a similar sign displayed at Kokuma. As before, we then made our way on foot for the remaining distance, attracting a trail of local children along the way.
On arrival at Kofi Munufie’s community we were led to his reception area which consisted of a three-sided building that faced towards a central compound surrounded by other buildings. When he appeared wearing a white woven smock, dark knee-length shorts and sandals, this charismatic, athletic man in his 30s with short dreadlocks was claerly in charge. While he initially had a serious, formidable expression, this gradually eased and later, he was prone to smiling and laughing easily. Among his assistants included a subdued, thin, shaven-headed man, who I knew from my previous visit was his ‘linguist’ and whose role would be more fully explained.
After presenting the priest with our gift of gin schnapps and cash, we then sat on a bench to speak. On his own dedicated chair, Kofi Munufie, who like other fetish priests is referred to as ‘Nana’, sat nearest to. This was followed by the linguist, with other men and women from the community completing the semi-circle, while a number of children played and watched with curiosity from a distance.
The recording and transcript
Before we began, Nana agreed that the interview could be recorded. While this would not have been possible without Ernestina and to whom I am extremely grateful, as with any non-professional translation there were occasions when the dialogue didn’t always match the reply. Although many of our questions were answered directly, undoubtedly some conversation was ‘lost in translation’ and further reduced when transcribed amongst the intermittent drumming and other stirring background activity. Where possible I have tried to retain Ernestina’s descriptions, though I’ve added words to aid meaning and clarified when there may be uncertainty about who was being referred to.
Since the interview I have since communicated with Ursula Read [3], a London-based Occupational Therapist, who has extensively researched informal healing centres and attitudes towards mental illness around Kintampo. Her experience confirms that Nana Munufie’s practice is consistent with most Akan priests in Ghana’s Ashanti and Brong Ahafo regions. On reading the transcript, Ursula confirmed there is a specific Spirit, known as an obosom, that resides within the shrine at Kokuma. On occasions this Spirit was translated as ‘He’, which I have capitalised. Ernestina also refers to ‘Spirits’, known as abosom, which translates as ‘gods’ or ‘deities’, who inhabit objects like rocks, trees and rivers. Sometimes though the singular and plural forms appeared to have been used inconsistently and I have retained what I believe was said at the time.
Ursula also advises that in Ghana references to ‘Spirits’ are influenced by the terminology that Christian missionaries introduced and which continues within the popular Pentecostal churches. Although Christian leaders often denounce traditional practices, many Ghanaians still incorporate elements of both beliefs in their lives.
The Interview
As the recording starts Ernestina translates Nana’s reply to her own question.
Ernestina: I asked him, “How does he recognise illness and what is the way he diagnoses and treats it?” He says if somebody comes for healing, he will call the Spirits to come and they will tell him the type of illness the person has brought and the treatment he can give. Then he will either make a request to pacify the Spirits or they may advise him to give the patient some medications.
Greg: Can he say, how he feels physically and emotionally after he speaks with the Spirit?
E: He says, he doesn’t feel anything physically and emotionally. When the Spirit comes to him, he doesn’t see or know anything, so he doesn’t know whatever he says or [what he] is doing. After the Spirit goes, he doesn’t feel anything physically and he is able to recognise everyone around him.
Tomorrow will be a ‘special day’. People will come around and they will beat drums and they will call [for] Nana. Then the Spirit will come on him and he will be dancing! He will be talking! The language can be French or other languages but it will not be in the local dialect. The linguist understands any language that the Spirit talks through, so after the Spirit has gone, the linguist will say “When the Spirit came, he ordered you to do these things for the patient.”
G: Can you ask, “how long that lasts for?” and also does he communicate about a number of patients at once or one at a time?
E: It depends upon the number of patients who are there. He works on every patient individually and the Spirit says what brought the person to come for healing, their disease and the treatment. At times, maybe a group of people will come and he will give a treatment. At other times he will say he cannot come and that patient has to come back another time.
G: This area we are visiting now, is it only for the healing or do other people live here?
E: The community is for him. He is here with his relatives because he cannot work alone. And some people here are patients, who don’t want to leave even after healing. But there is nobody else [who] stays here.
The recording then picks up the shaking of a rattle, which it is explained, is used on the evenings before the ‘special days’. There is lots of laughter.
Wendy: (admiring the rattle) It’s very beautiful. Can you ask him does he have a few spirits he communicates with or could they be the spirits of the patient?
E: It’s not the same but the elder Spirit [presumably the obosom - see above] is always there. Also there are many spiritual assistants, so if you call, any of the Spirits can come.
W: OK. Can you ask him, “has he always been able to do this or did he work with a teacher before?”
E: He didn’t learn it and it’s not from him. The Spirits ‘called’ him to come. It was like a prophecy [that took place] in his uncle’s home. So after his uncle died, the Spirit called him to come and work. He didn’t learn it.
Some of the men then bring out a large framed portrait of Nana’s uncle, who was the previous priest at the shrine and had died recently. The portrait is of an older man seated in traditional robes but superimposed against a spotless hotel lobby.
E: That is the uncle he was speaking about. The first group (who visited from the school over a year ago) came to meet him before he died.
G: Can you ask, “why does it have a modern setting in the background?”
E: I think it’s a studio.
Further communication occurs between Ernestina and Nana.
E: The background is from Kumasi. The photo of the uncle was taken here but they placed him in the studio to ‘beautify’ it.
W: Can you ask, “in Europe and America, healers are training students like myself to be healers and we may ‘hear the call’, because we want to do it”. Does he think that this work can be passed on like that?
E: He says, it’s not possible because the Spirits calls whoever He wants. So if I say, “I want to be trained”, Nana can train me but the Spirits cannot, will not work with me. The Spirits choose who He wants to work with. Nana can train me but it’s not possible that the Spirits can work with me.
G: And has the linguist undergone a training or did the Spirits suggest that he should do this work?
E: The Spirits called the linguist too. It’s a call. Other healers also can come for a training, to make them stronger. If I am weak [as a healer], then I can come and undergo some training and my Spirits will become stronger.
G: Is there a special significance here? Does this place have a history or is it just where his uncle lived?
E: There’s nothing special here but it was the Spirits that directed the uncle that he should come and build this place.
G And how long have people been living here?
E: They came to settle here, even before the fetish priest was born. So it’s a long time.
G: Since we were last here, he now has a sign on the road. Has that made a difference to his work?
E: This place is difficult for people to know it’s here. Now the visitors are coming in numbers, so he has to show where he can be located.
W: Would you tell him about the tradition that I have been training in? I have a beehive for honeybees. As part of my training I sit and listen to what the bees tell me. In England there is an old tradition to ask the bees when you want help. You also tell them about births and deaths and they will listen. One day I sat in front of them and asked for help because I was coming to Ghana. Then one of them came out and stung me straight there (points under her eye). It was funny and also an answer for me.
As Ernestina translates there is laughter, which continues after Nana replies.
E: The bee sting! He says, “it’s a ‘go-ahead’”. You can come (to Ghana)… nothing will happen to you!
G: Does he ever believe that insects or animals have a special significance?
E: He believes in that and that’s what Wendy reminded him of. During war, fetish priests can command and call bees to come and fight their opponents, who will die. Some [can also] use snakes or other animals and insects. So they believe in that.
W: So they are helpers, the bees and the snakes.
G: Does he ever have any concerns about the treatments the patients receive and whether they may have a bad reaction?
E: He has no concerns about the reactions of the drugs as those who come want to come. He gives a little treatment at a time and then he will be ‘topping it up’ until he sees that the patient has calmed down. As for side effects and reactions, he hasn’t seen much. If the person is on a treatment for two or three days and is not making any improvements, then he calls [the Spirits] again and they direct him to make a change in medication.
G: When I came here before there was a young man who said that he felt some pain from the medication he was given but he believed it was helpful. (This man who spoke English also said that he preferred Nana’s care than when he had been a patient at two of Ghana’s psychiatric hospitals) Does Nana think that sometimes, patients will feel worse before they become better?
E: Some patient come taking orthodox drugs and he will give them an antidote before he starts his medications. But if he doesn’t know this and he gives his medication, then there may be a reaction.
G: Could you tell him, in England I specialise in care for mental illness and I have been in Ghana for nearly three months. Is there anything he would like to ask me?
E: (after laughter from the group) He says he will come with you and work in England!
G: He will come with me? I would be happy to show him!
E: He’s asking you, “How do you manage psychiatric patients?”
G: In England, many patients come asking for help or their families will suggest they come. If they’re really unwell, the police will bring them. Then I will ask questions like a doctor about their health and about what they think is the problem. Often I am interested to know is there something they think will help them.
E: Will it be acceptable that when he comes over he can use herbs to see the patients?
G: (hesitantly) If a patient asks for assistance and he wants to help them, we would call that consent. An agreement. Now the police might be interested as well… It’s a hard question!
E: He asks do you ever see mental patients healed completely?
G: In Europe and America we sometimes see mental illness as a life long condition that has times when its better and times it relapses.
E: Its true that they relapse, if the person has offended somebody and the person has cursed him in order that he should go mad. If the patient comes to the hospital, you will give psychotropic drugs and the patient will get well. Meanwhile what the patient did is still there, so that brings the relapse. But if a fetish priest sees what’s actually caused the problem and removes it, then it will not come up again.
G: Can you just add that sometimes I see people and I don’t think there is a mental illness and I will give advice. So sometimes my job is to say to people when I don’t think there is a mental illness.
E: He says that they also have the same thing. Some people come with psychological problems like a relationship or a marital problem. He will give advice and let the person go without medication. They also believe in that.
G: Can you ask him, “does he have any views on epilepsy?”, particularly in children and what are his thoughts on the cause of epilepsy?
E: He says, epilepsy is given to them by other people, especially when the person is born. The person who delivers the child can give it to the child and then it would be in someone else. If you don’t know the actual cause and where it came from, then you cannot treat it. So he believes epilepsy is given by other people.
G Yes. OK… (resignedly) alright. I have a colleague who will be coming here in a few months time. Would he be happy for her to visit and and is there anything he would like to be brought. Anything from the UK?
E: (after some laughter) He says, the only things he needs here is a lighting system!
Further communication from Nana follows.
E: If there are people that are difficult for you to treat, you can bring the patients here and you will see how they work.
G: He’s saying he would be happy to receive patients here? Could they be treated as a day patient or would they need to stay here several days?
E: He can treat people on an out-patient basis but difficult ones, he has to observe the patient before treating.
Sensing the interview was ending I asked whether he follows events that are happening in Ghana and the wider world, like the World Cup. Nana replied that they have a radio. Ernestina then asked how do people know that the Spirit comes on Sundays and Wednesdays? Does he make an announcement through the radio? His reply suggests that like any good tradesman, he relies on ‘word of mouth’.
E: He says, that after people come here, they will send a message. So if I’m not well and I come here and I get healed, then when I see someone who is sick, I will say, “go to this man”.
W: So if I wanted a healing myself would I have to come on a Sunday or a Wednesday?
E: He said [he works] all days but Sundays and Wednesdays are ‘special days’. They will beat drums and then dance and then call him and the Spirit comes.
G: Where does he do that here? Where does it happen here?
E: He would like to show you.
Touring the compound
Interview over, we’re then taken as a group to see Nana’s consulting area, which I hadn’t seen before. As we pass through the compound, there’s a cleared area with a single thatched hut on the far side behind wooden fencing. Its significance wasn’t explained, though later I learn this was the shrine where the Spirit resides, which only the priest and his assistants may enter.
Then we’re led down a straight cleared path further into the bush towards a small clearing with an altar-like table at the back that’s covered with a cloth. We’re not allowed to enter any further but this is likely to be where the patients are brought when Nana is possessed with the Spirit.
We walk back towards the path’s entrance and the clearing next to the shrine, where the children of the community are drumming underneath a shelter. We’re treated to a demonstration of how they will prepare this evening, ahead of tomorrow’s ‘special day’. Here an impromptu burst of dancing breaks out which Wendy and I take turns joining in with, resulting in much laughter among the community, which Nana observes approvingly. After catching our breaths, we return to the reception area where we have photographs taken with Nana before leaving with a feeling of accomplishment.
During both of my visits, it was clear that there were people with mental illness present, some of whom spoke to us freely. Whether there were others being treated out of view wasn’t clear but when I visited before, we were told that a number of patients were asleep at 10:00 a.m. after having been given herbal treatments.
While I did not see any maltreatment myself, there are concerns about the conditions at some informal healing centres, both those run by traditional healers and at Christian prayer camps. For example, some patients may be held in shackles and reliant on their relatives to ensure that they are fed and cared for, while other treatments may include enforced fasting and beatings. The issues involved are discussed in considerably more detail in an excellent paper by Ursula Read et al [2].
As can be gathered from Nana Munufie’s forthcoming replies, he clearly has a strong belief in his own ability and the causality of illness. While his recent contact with the school at Kintampo may suggest an appreciation of ‘hospital medicine’, he may also be seeking to demonstrate the superiority of his methods for treating conditions that ‘white-man’s medicine’ cannot cure. For instance, this may have been the motivation for his question about whether I have seen “mental patients healed completely” [4]. I can only wonder what Nana would think of Western approaches to mental illness if he ever did actually visit.
References
[1] Asare, J. Mental health profile of Ghana. International Psychiatry 2010; 7, 67-8.
[2] Read U, Adiibokah E, Nyame S. 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. 2009. [Accessed 10 October 2010].
[3] Personal correspondence
[4] Read, U. (in press) “I want the one that will heal me completely so it won’t come back again”: The limits of antipsychotic medication in rural Ghana. Transcultural Psychiatry.
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Tags: abosom, Africa, Brong Ahafo, Ernestina Agyei Yobo, fetish priest, Ghana, Greg Neate, informal healing centre, Kintampo, Kofi Munufie, Kokuma, mental illness, Nana, obosom, psychiatry, Signs of faith, special day, Spritis, the Kintampo Project, Traditional healer, Ursula Read, West Africa
The Opening of the MAP
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Teaching on the Kintampo Project’s Medical Assistant Psychiatry degree course
The Need for MAPs
For a population of 22 million people, Ghana has just 13 psychiatrists (Asare 2010). Thus within the country’s three psychiatric hospitals, Medical Assistants (MAs) regularly perform a much-needed doctor-like role, though their psychiatric education has not previously been formalised. Furthermore, there is recognition that mental health services need to shift from being focused at the three, south coast based hospitals to the wider community.
The Kintampo Project has thus been developed by the Kintampo Rural Health Training School (KHRTS) in conjunction with Hampshire Partnership NHS Foundation Trust (HPFT) and the University of Winchester to deliver Ghana’s first dedicated psychiatric training for middle level health workers. This consists of two courses to train two new types of mental health worker known as Medical Assistant Psychiatry (MAP) and Community Mental Health Officer (CMHO). Consequently it is hoped that as this psychiatric workforce develops, mental health care can be spread more equitably across Ghana’s 170 districts.
The MAP opens
In May 2010, the Project’s inaugural 18 month MAP degree course welcomed its first intake of students. Each of the nine students were experienced MAs who had previously attended KHRTS in central Ghana for their initial MA training. While they were supported by their employers to attend, it was still a significant commitment to make towards an unprecedented course and most had left young families during the week to share dormitories with classes starting at 7:00 a.m.
For the MAP course’s first two weeks, I joined a UK-led teaching programme which included HPFT employees clinical psychologist, Dr Tess Maguire, and community psychiatric nurse, Patrice Fugah. I had only arrived in Ghana two weeks earlier as part of a three-month volunteer placement based at Pantang Psychiatric Hospital on the outskirts of the capital, Accra and a nine-hour drive south from Kintampo. While I was the fifth UK trainee to volunteer for this Royal College of Psychiatrists’ approved training opportunity (Neate 2011), the Kintampo Project was a new experience for everyone.
Although my initial time at Pantang had been brief, it provided an invaluable introduction to Ghana’s culture and its health service. Thus during my presentations on psychosis, mood disorders and performing mental state examinations, I was able to include descriptions of actual patients that I had seen. These presentations were also then linked with the corresponding chapter in the Oxford Handbook of Psychiatry, which each student had received a copy of.
In keeping with the approach of my fellow teachers, student interaction was encouraged, particularly during the reflective session that ended each day. While the students had expected a more traditional, didactic style of teaching, after some hesitancy they became more personally involved, which we hoped would encourage their future learning.
Meanwhile outside of class, Dr Mark Roberts, the Project’s UK lead, collaborated with the tutors at KHRTS on the curriculum for both courses and supervised the tutor’s personal development plans. With such measures being undertaken to ‘educate the educators’, it is intended that the Project will become sustainable and the development of an excellent mental health workforce can be maintained.
Further Collective Learning
In addition to our teaching presentations, two field trips were arranged to observe the local context in which mental illness is perceived and managed. While these were valuable learning experiences for the students, they were as much of an education for us, their UK-based teachers.
Our first trip involved visiting two spiritually based, informal healing centres that provide treatment for people with mental illness. Both functioned as communities in themselves and who welcomed us warmly, offering us seats in a circle that faced their leader’s designated, elevated chair. In the Ghanaian custom, our hosts then shook hands with us in turn, following in an anti-clockwise direction to ensure that none were approached with the backs of their hands. After prayers were said to their inspirational source, all eyes remained on the group’s charismatic healer who led through his aura and authority. Understandable really as both the traditional healer and Evangelical pastor said they could remove illness by communicating with a supernatural force!
In Ghana many traditional healers are known as fetish priests who serve a shrine, which a ‘Spirit’ inhabits. The priest at the remote, rural community that we visited said that he had been called by the Spirit of his community’s shrine to succeed his deceased uncle. Subsequently, when he underwent twice-weekly possession, this Spirit communicated through him ‘in tongues’. While the priest said he lacked for any memory whilst possessed, with the assistance of his ‘linguist’ who transcribed his unintelligible speech, he could identify what ails and which herbal preparation would treat those who sought his help.
We then met the pastor of an Evangelical church and prayer camp who provides a similar link between this world and a spiritual one through the word of God. Citing the Bible’s account of how Jesus healed a man with ‘evil spirits’ through prayer, the pastor told us that as all illnesses are caused by ‘evil spirits’, then prayer is the only effective treatment.
At one location we were shaken to see shackles used to detain and treat people with disturbed behaviour, though it has been reported that their removal may have a symbolic value as a “dramatic demonstration of the efficacy of healing” (Read et al, 2009). Other ‘healing’ treatments reported include enforced fasting and even beatings, though we did not see evidence of the latter. Back in the classroom we discussed and reflected on the role these spiritual healers play in providing culturally acceptable explanations for mental illness.
Our second field trip also revealed some unexpected approaches at the nurse-led psychiatric outpatient clinic at the nearby hospital. Here our students met with a young woman complaining of headaches and depressed mood. Although the consultation was unevenly matched, we were interested to observe the student’s assessment skills, particularly after my session on mental state examinations. What we didn’t expect was for the besieged woman to face questions in a free-for-all style that matched the busy waiting area outside.
Clearly more work was required to reinforce what appeared understood in the classroom but abandoned in the field. Therefore we arranged interview practice for the students with us, their teachers, simulating the presentations of patients. Then using their peer’s observations, we encouraged each student’s strengths and made suggestions that linked with our earlier teaching. We particularly recommended this approach to the MAP tutors and later heard that KHRTS plan to establish teaching clinics where students are supervised while assessing local patients.
Return to Kintampo
Six weeks later I returned to Kintampo to provide three more days of teaching. The students remained committed and had been taught psychology, ethics, research and management as outlined in the curriculum by the tutors at KHRTS but had lacked further actual psychiatry.
Thus, I expanded upon my earlier teaching and delivered a presentation on perinatal psychiatry. In addition, with my visiting girlfriend, Wendy, we developed a simulation of postnatal depression with and without psychotic features, which allowed for comparison and provided more interview practice. The students also presented projects that they had completed in pairs between my visits and I suggested further topics for them to prepare.
While my experience at Kintampo was personally positive, more importantly it appeared to have been a good start for the Project. The students were appreciative too but asked what would happen between UK visits? At times I wondered myself, were we just psychiatry colonialists visiting temporarily with our own values?
Here though our purpose was clear; to contribute as guests of KHRTS to a course that would receive ongoing support and further support from the UK to supplement their own resources. Thus while it was the responsibility of the tutors at KHRTS to ensure that the teaching programme was delivered, I hoped that my ongoing interest would encourage the student’s own development and that of Ghana’s future mental health service.
References
Neate, G. Out of Programme Experience in Ghana. Royal College of Psychiatrists. Retrieved July 9 2011 from http://www.rcpsych.ac.uk/members/internationalaffairsunit/volunteersprogramm/ghana-maytoaugust2010.aspx
Asare, J. Mental health profile of Ghana. International Psychiatry 2010; 7, 67-8.
Read U, Adiibokah E, Nyame S. 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. 2009
Declaration of Interest
The Royal College of Psychiatrists provided my airfare to Ghana as a registered volunteer with the College. The Kintampo Project provided my transport and accommodation while teaching in Kintampo.
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Tags: CMHO, Community Mental Health Officer, Dr Mark Roberts, Dr Tess Maguire, Ghana, Kintampo Rural Health Training School, MAP, May 2010, Medical Assistant Psychiatry, Patrice Fugah, psychiatry, Royal College of Psychiatrists, teaching, the Kintampo Project
Leaving England
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Soundtrack by Brakes
“Should I stay or should I go?” is the obvious soundtrack for any feted footballer faced with transferring between teams. Having completed higher training in psychiatry, I was confronted with this question when considering whether to move 450 miles from Sussex to Scotland. Employment-wise, changing jobs was surprisingly straightforward. Relocating itself though – despite being a previous familiar experience – proved even more challenging and draining than expected. While it might have been cathartic, given the choice again, perhaps I’d question its costs.
Technically I was ‘out of contract’ after qualifying and now working as a locum (freelance) consultant. I’d completed three short-term posts covering for other colleagues’ leave but after six months without clarity about my next placement, an opportunity to jump arose and I thought to swap one ‘known unknown’ for an ‘unknown unknown’. Glasgow might be new territory but surely it beat commuting from Brighton to Hastings!
The job offer was an intriguing proposition that I sensed couldn’t be refused. Part consultant within a suburban community mental health team, part psychiatric cover for the city’s homeless service – a crash course into Glaswegian culture! The 12 month contract also offered substantial experience and an escape route. When contacted the day after my 18-hour round-trip commute for interview, I accepted.
Still would something else turn up in Sussex? With my address of the past three years, I had my ideal home. Three stories high with panoramic sea views, I may have been renting but I’d made it my own. It would take a lot to move me.
When Glasgow called, the medical director said police and occupational health clearance would take weeks. I relaxed knowing I’d have a final summer by the sea and plenty of work soon enough. However, on returning to Glasgow a few weeks later to confirm the job plan and view my new working environment, she asked if I’d start as soon as possible! My predecessor with the Homeless Team was retiring in a week’s time, the other post was ready and waiting. Sooner I figured, would be better for all as I’d receive a direct handover, a gentler introduction and be closer to knowing where I’d be in 12 months time. Within four weeks of interview, I was in post.
Moving home though was another matter and ended up taking just as long. While in Glasgow, I’d agreed terms swiftly on the first flat I viewed, partly for its modern features, central location and underground parking. However what sealed it was the walk-in closet that I’d use for storage, ensuring both access and separation from my life’s possessions.
To get them there a removals company would have been sensible. However the one quote I took had hourly rates that would rapidly accumulate with the journey times involved and I’d never get everything done for someone else’s timetable. By hiring a van I could do this myself and squeeze in a boot sale with Lorne, who had his own CDs, comics, clothes and children’s toys to shift. We thus loaded up on Sunday morning for Brighton Racecourse with what we hoped would be a one-way journey for our cast-offs and returned somewhat lighter with pounds of coins and paper.
I still faced the first of three, 10 hour van journeys and driving late into the night. Far too late as it happened to unpack and an extra day’s hire fees were needed while working the following day. Perhaps it could have all been done as planned with two journeys but I’d underestimated the size of the second van required and just how much there was to do. Fortunately my landlady graciously allowed me an extra week, though the bills were accumulating further, my carbon footprint expanding and more time lost between homes.
Removing all I owned from the flat on Marine Parade revealed a reasonably sized space with stunning light that my stacked furniture had previously absorbed. I regretted how I allow my possessions to intrude into my world. While my Glasgow home had some space for storage – even without the bed, mattress and couch that I sold on cheaply for Matt’s unexpected flat makeover – I feared that too would soon fill and overspill. Of course, it wasn’t just the view that I was leaving behind. Over those weeks a team of friends rallied and proved memorably helpful with either accepting stuff for safekeeping, heavy lifting or hearing me out as I wobbled over my decision. I also saw how some friend’s children were growing up further with greater personal recognition and I wondered whether I’d experience that more directly.
On my final return to Brighton, I heard that new work was now available. A colleague had begun a post that I’d likely have been offered and which wasn’t in Hastings! It was a welcome opportunity for him and also likely that my former employers would have noticed my absence. Maybe I’d been too impatient or perhaps had strengthened my future negotiation position. Whatever, I was now Glasgow bound and I reasoned again if it was good enough for (football reference alert!) fellow Irish via Leicester old boys, Martin O’Neil and Neil Lennon, then for now, it would be for me.
Thanks to Lorne, Sam, Jon, Graham & Alison, Al & Rona, Matt & Craig, Rob, Lucy and Barinder for helping me with the above. I made it.
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Tags: boot sale, Brighton, Glasgow, Leaving England, motorway, Moving home, transfer, van hire
Fantasy coffin heaven
One of the many buried treasures that fell from my archives during my move from Brighton to Glasgow was this feature on fantasy coffins in the Independent Magazine from 27 May 1995! Unfortunately I only kept the centre spread (part of a feature from a book, Going into darkness: Fantastic coffins from Africa by Thierry Secretan) but 15 years ago I must have known something then that I’d go on to have a personal connection with such a culture. Apparently the practice of having your own bespoke coffin made to commemorate your significant contribution in life mainly occurs in the Ga region around Accra. Also, I didn’t see an actual fantasy coffin in use, but there’s an artist’s gallery near Labadi beach that had models available to view
Also while making one of my four separate road journeys from Brighton to Glasgow, I realised what my fantasy coffin preference would be. Should any of you ever wish to organise such a send off, then please note I would like a replica white van stuffed with as much of my vinyl, CDs, photographs, negative, photo equipment, books, journal, medical notes, clothes and other crap I can never throw away. It needn’t go in the ground either but can be rolled into an incinerator will do fine.
Anyway, I’m now all moved from Marine Parade to Merchant City with just a few more boxes to unpack and still space!. Thanks to Lorne, Sam, Al & Rona, Graham, Matt & Craig for all your help. I’ll miss you Brighton x
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RCPsych Presidential awards
Last Thursday, 30 June, at the International Congress of the Royal College of Psychiatrists in Brighton, two of my previous supervisors were honoured for their contributions to psychiatry by outgoing College President, Dr Dinesh Bhugra.
Presidential award
Dr Peter Hughes was my international supervisor while I was in Ghana and whom I’ve mentioned before on this blog. During that time, Peter was in Haiti providing post-earthquake support and was involved in helping to re-establish the country’s psychiatric services. He has since been involved in founding a Special Interest Group for volunteer and international psychiatry within the College. During the Congress, Peter spoke to a group of trainees about this Group, highlighting his previous work in Haiti, Malawi, Sudan and Somaliland, the latter he was returning to on Sunday. During that presentation I spoke briefly about the experience on being on placement in Ghana as an opportunity for future trainees. For his work as an international psychiatrist, Peter was awarded one of nine President’s Medals for 2011, an award initiated by the President last year to honour and celebrate those who have made significant contributions to improving the lives of people with mental illness.
Fellow recognition
Also recognised on the night was Dr Giuseppe Spoto who earlier in the year had been made a Fellow of the Royal College of Psychiatrists. Giuseppe has supervised me at both Senior House Officer and Specialist Registrar level in 2003 and 2010 respectively and over the past three months we were consultant peers in Crawley. On being awarded his Fellowship, his collegues at the Crawley Community Mental Health Team asked me to write a tribute for the Sussex Partnership newsletter. I was delighted to be asked and without his prior knowledge, the following words were published in May and which I’m pleased to reproduce here.
Dr Giuseppe Spoto, consultant psychiatrist in Crawley for 20 years, has been awarded Fellowship of the Royal College of Psychiatrists, as a mark of distinction and in recognition for his contributions to psychiatry.
Originally trained in his native Italy, Dr Spoto underwent further training in London at the Royal Free Hospital, Tavistock Centre and University College Hospital. In 1990 he was appointed to his first consultant post in Crawley, where he has remained a dedicated clinician to a generation of patients and an influential presence for local adult psychiatric services.
With his interest in education and training he has served as College Tutor for Crawley and as Educational Supervisor for the Arun Valley SHO Rotation, overseeing the training of numerous junior doctors and medical students in West Sussex. With his involvement in medical legal concerns, he has also been a medical member of Mental Health Review Tribunals for 15 years.
Throughout these times of change, his most consistent concern has been as an advocate for psychotherapy within psychiatry, particularly in regard to those who are seriously mentally ill. As Consultant Psychiatrist with a Special Responsibility for Psychotherapy, he has often been a lone voice in Sussex for considering psychoanalytic approaches towards psychiatry and continues to lead the Balint group for trainees in Crawley.
In addition, Giuseppe is a valued colleague and source of support to all the multi-disciplinary teams he has been a member of and a friend to many. For a lifetime’s work in psychiatry that shows no sign of easing, he is a deserving recipient of College recognition.
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Tags: Dr Giuseppe Spoto, Dr Peter Hughes, Fellowship, International Congress 2011, Presidential Awards, Royal College of Psychiatrists, Sussex Partnership
An Out of Programme Experience at Pantang Psychiatric Hospital, Ghana
10 May – 4 August 2010
My report for the Royal College of Psychiatrists website has just been published and is reproduced below. It’s a shortened, reworded version of the Neate Experience in Ghana blog that was posted here in October 2010.
Pantang Psychiatric Hospital's administration building in the frame
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.
Tro-tro stop outside Pantang Hospital
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 member of staff they will meet is a medical assistant (MA) with limited psychiatric training.
Pantang Hospital outpatient waiting area
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 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 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, while its political stability and 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 from my employer, Sussex Partnership NHS Foundation Trust, I became their first trainee to volunteer, leaving behind the uncertainty of a post-election UK for a new world.
Pantang’s past and future
Pantang Hospital corridor by Greg Neate
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 on site. However only two of them are psychiatrists as limited funding, poor career prospects and a ‘brain drain’ of professional emigration has meant that for a population of 22 million, there are just 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.
Ghana’s New Psychiatrist
Outside Pantang Hospital shop - photo by Emmanuel Amaglo
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 additional supervision was Dr Peter Hughes, who as Director of the St George’s Higher Training Programme had previously overseen my annual reviews and supervised the previous 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 emails 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
Assessing the Medical Assistants
Pantang Hospital outpatient nurses office
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.
Reviving the Rounds
Medical Assistant, Mr Ambrose Amenuvor and nursing staff on Ward 3
As part of my supervision of the Pantang MAs, I observed them perform clinical reviews of their inpatients in the afternoons. Here, across ten erratically numbered wards, each MA had a seemingly overwhelming level of responsibility that averaged 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 after they left these didn’t last long. Furthermore when the MAs did attend the wards, they lacked focus over who needed to be reviewed, while many chronic patients were overlooked. With Dr Hughes’ 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 drifted 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 he’d introduced three years ago. Many people remembered his flowchart posters though they were no longer displayed and there were differing views among the staff about prescribing and administering sedative medications. Nurses preferred injections to ensure compliance, the pharmacy feared running out of supplies while the prescriber’s practices varied widely. What seemed necessary was a system that all could follow.
Norman Poole's Protocol for Managing Aggression
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, wisdom and manner has Mandella-esque qualities despite facing his own challenging responsibilities.
Insight into Insight
Elvis Akugmoar (head of eduction, seated on left) and student nurses at Pantang Psychiatric Hospital monthly meeting - photo by Clive Stanton
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’.
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!
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.
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.
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.
Children within Pantang Hospital grounds
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Tags: Accra, Africa, Dr Greg Neate, Ghana, Pantang Psychiatric Hospital, psychiatry, Royal College of Psychiatrists
The Neate Experience in Ghana
An Out of Programme Experience in Ghana at Pantang Psychiatric Hospital, Accra and the Kintampo Project
10 May – 4 August 2010
BACKGROUND
The working conditions are ‘not the best’, treatments are basic and its political priority low; still there’s a lot involved when it comes to accessing psychiatry in Ghana. This West African country’s culture of collective, family responsibility means many Ghanaians act on behalf of their relative who lacks ‘insight’. As spiritual beliefs and superstition about mental illness are influential, healing centres run by traditional and faith healers are in demand despite the risk of maltreatment (Read et al 2009). Meanwhile stigma and suspicion of mental health services often results in psychiatry being seen as 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 itself be a significant undertaking, typically spent crammed into sweaty, creaking, careening tro-tros, where it’s likely to be of little comfort for passengers that daubed on the backs of these 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 are evident among the eager roadside traders and general hardship passed along the way.
Once at the hospital, more issues and variables are encountered. While services are free, payment for the file that records the patient’s notes is expected, as well as for all medications and investigations. Even if only a repeat prescription is required, all must wait in the order they arrive as there are no appointment times. This can be further subject to police-escorted emergencies arriving in handcuffs, whose treatment may begin on a stretcher in the waiting area with intravenous Diazepam. Then when the patient’s turn has come, usually the doctor who sees them is a medical assistant (MA) with limited psychiatric training.
From Tooting to Pantang
While its unusual to find a UK psychiatry trainee in Ghana, I wasn’t the first. The opportunity for psychiatrists on the St George’s Higher Training Programme to volunteer for three month placements was proposed in 2006 by Dr Raj Attavar with support from Prof Sheila Hollins and Dr Deji Oyebodye. I knew Raj then while working with the Learning Disability service at Springfield University Hospital in Tooting, South London. His motivation was to establish an Out of Programme Experience (OOPE) that he could do as well; though by the time it was approved, his training had ended.
That’s not so surprising when considering the number of organisations involved. Within the UK, these include the Royal College of Psychiatrists, the London Deanery and the South West London & St George’s Mental Health NHS Trust; each of whom has a direct interest with the St George’s psychiatric trainees. Ghana itself was felt to be a suitable destination due to its stable democracy, established psychiatric service and the backing of its chief psychiatrist, Dr Akwasi Osei. Lastly, coordination for the programme was provided by Challenges Worldwide (CWW), an international development charity who later helped negotiate my release from my employer, Sussex Partnership NHS Foundation Trust.
While hopes for there to be a consistent presence of trainees in Ghana have yet to be achieved, there have been a number of successful placements. These began in 2007 when Dr Norman Poole pioneered a pilot programme at Pantang Psychiatric Hospital. The following year Drs Drs. Abdi Sanati and Olimpia Pop worked in succession at Accra Psychiatric Hospital (APH), and in 2009 Dr Clive Stanton was based at Pantang. As each trainee continues to be paid by the London Deanery during their placement [1], an equivalent weekly timetable of clinical work, teaching and research was followed.
In London’s Belgrave Square – whose grand terraced buildings are home to many foreign embassies and lies close to Buckingham Palace – I attended for interview at the Royal College of Psychiatrists. While waiting in the College lobby, I flicked through a photography book about London and thought of those visiting who were new to the UK. The interview panel was itself composed of people whose origins, like mine [2], were from countries formerly under British rule including a Nigerian, two Irishmen and a woman of Indian descent. Of similar background to the latter, Dr Samanta Nagpal was interviewed before me. A year later, she would succeed me after an experience that was different to anything that I’d done before but in other ways, was surprisingly familiar.
THE PLACEMENT
On the rural outskirts of the capital Accra, Pantang Psychiatric Hospital stands testament to both Ghana’s former pan-African ambitions and its current reality. Originally envisaged as a mental health village for psychiatry, neurology and neurosurgery in West Africa, it opened in the 1970s as the county’s third psychiatric hospital (Asare, 2010). However, like many of the grand, socialist visions of Dr Kwame Nkruamah – the African legend who led Ghana to independence from Britain in 1957 – the hospital wasn’t fully realised [3]. Now Pantang functions mostly as an institution-style asylum for some 500 in-patients and also serves nearly 100 out-patients daily.
Soon after my arrival, I was given a tour of the sprawling hospital site, where covered walkways connect its ten single story wards. Here, while the nursing staff were polite and respectful, there was a clear separation between their white, short sleeved uniforms and the patient’s drab personal clothes. Along with the frequent displays of Christian imagery and the hospital’s hot, rural setting, there was a parochial feel that was similar to my former Catholic school in Florida [4].
Psychiatry’s limited appeal as a career in Ghana and its ‘brain drain’ of professional emigration means that for a population of 22 million there are just 13 psychiatrists (Asare 2010). Pantang itself has only two psychiatrists and three medical assistants (MAs) with some additional medical support for patient’s physical care. While there was plenty to do, my role would be to provide these MAs – experienced nurses with two years of additional training – with some rare supervision and teaching while integrating into the hospital itself.
I first met my new colleagues in the office of Pantang’s medical director and former Polish national, Dr Anna Dzadey. They all remembered my predecessor by six months, ‘Dr Clive’, who had said of his placement that it was his best training experience in psychiatry. Clive also said that the MA’s attendance wasn’t always reliable and mentioned some other dubious practices though that seemed surmountable and ready for me to resume. Dr Dzadey too had hopes that with their new rota – where two began in the mornings and the other covered afternoons – regular teaching 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, they did go rather quiet.
Ghana’s New Psychiatrist
Initially I observed outpatient consultations which I could follow as many occurred in English. If English wasn’t understood by the patient and family, then I followed what I could. Occasionally it wasn’t clear whether the MAs knew the patient’s language either though they would persevere rather than ask for help. Whatever the language, all clinical notes were written in English, which to my monolingual brain seemed an impressive transcribing skill.
To experience the work, I began to assess, advise and issue prescriptions myself, with a nurse translating when necessary. There was no shortage of patients and the out-patient staff appreciated how the waiting room was clearing. It all seemed surprisingly straightforward and when I saw previous entries by Norman and Clive, I felt connected with a unique, shared experience. However, there were also more serious decisions to make, like whether to approve a patient’s admission. While some families came expecting to leave their relative behind, other patients were sent by the courts without advance notice. What now? I asked Dr Dzadey and she advised that although beds were limited, we should support the family. Thus, within less than a week of arriving, I was detaining Ghanaians of their liberty! Furthermore their name would now be forever linked with mine, as written beneath theirs on the cover of their notes was that of their responsible clinician, ‘Dr Neate’!
When I could access the internet [5], supervision was provided by Dr Peter Hughes, as he had done for the previous trainees on placement (Poole & Hughes, 2009). I knew Peter already as the Director of the St George’s Higher Training Programme and was used to receiving his rapid email replies without spellchecks before. His international experience is renowned and Clive spoke highly of his own supervision when Peter had been in Darfur. This time Peter was in Haiti providing relief work after the earthquake, though he always replied swiftly to my weekly reports. Here he emphasised that my contribution should be ‘sustainable’ and when I described seeing patients on my own, Peter replied;
>>>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
Assessing the Assistants
Subsequently my days were spent with each MA in out-patients, where evermore about Ghanaian society was revealed. Each consultation room had a large wooden desk with a swivel consulting chair on one side and unmatching chairs on the other. A ceiling fan, an out-of-date calendar and a rarely used examination bed emphasised the occupant’s importance. Sat on benches along the corridor outside, the individual and their family were expected to enter when called, though no handshakes and little explanation was offered. If the impact of this formality bestowed upon the MA an impression of wisdom and knowledge, well perhaps that was just as well.
Patients described somatic symptoms of tiredness or head pains, while families complained that their relative was ‘over-thinking’ or ‘roaming about’. Some consultations ended surprisingly quickly. Others passed in slow motion, as the MAs pored over the notes and pursued unnecessary lines of enquiry. Depression, anxiety and learning disabilities were all possible explanations though as many patients had long been unwell and now had problematic behaviour, schizophrenia was usually diagnosed and typical (first generation) antipsychotics prescribed. When patients returned for review, there was little questioning of the original diagnosis or whether medication was still necessary.
At times, it all seemed so different; the way the patients presented, how staff approached them, the involvement of the family… everything! Sometimes I’d feel compelled to advise the MAs to be more inquisitive or speed up a dragging interview. I’d remind myself of computer tutorials where the expert’s hands-off approach encouraged me to learn myself. I hoped that would be possible, yet here there were actual patients and the MAs appeared unaware of their shortcomings or the risks involved. However, it was also clear that they were the only staff around to perform an awesome 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 the mobile phone calls they received during consultations were about their additional private work! Again I was reminded of America and its healthcare, where for some practitioners, entrepreneurship and practice expansion can be of greater priority than examining it.
To assess their ability, I arranged to rate their performances using a modified version of the Royal College’s mini-ACE assessment forms. As the MAs had few training or career opportunities after qualifying, there appeared little incentive for them to improve their skills. However, while the MAs weren’t used to such personal reviews, this provided a written summary of our work together and when my girlfriend, Wendy, visited, we developed a simulation exercise of post-natal depression to standardise these assessments. Their more considered approach towards her demonstrated that they could raise their performance, though individual variations remained.
I also conducted an audit of their experience and learned more about the MA’s personal journeys. Most approachable and vocal with his concerns was Aaron Baah; whose concern for patients was apparent though he was also frustrated that the term ‘Assistant’ implied that he worked for someone else. In reality, he worked independently (probably too much so), though because of his title, organisations wanting a doctor’s opinion didn’t recognise his.
Other staff approached me with their concerns and while I could only ever be a temporary witness, I felt welcomed and appreciated. Later during my second week, I knew I’d ‘arrived’ when one of the male nurses took my hand as he had something ‘important’ for me. In the out-patient department a man in handcuffs sat with his mother and two plain-clothed police officers. His complaints about his family were consistent but differed from theirs. Was he mentally unwell or did his family just want him put away? As Ghana has no mental health legislation [6], the decision rested with me. Admission was the easy option which everyone else wanted but was it right for him? Ultimately his family were persuasive and I approved his admission for assessment on the basis that he lacked the capacity to decide. Afterwards, the family shook my hand gratefully though I remained unsure. Later Peter had his own views;
>>> Tehre is no such thiong as a patient in africa -it is patietn and family. family alomost alkways know. we all need to shift mindset -family issue is everywhere in developing world -I follow what family says as he most useful adivce of all .
>>> It is just in west that we are individalistic Its not good or bad. Its just the way it is. Youy pronbbaly see how you never see aptietn on their own but always with family in. Tahts the way of most fo the developign world . They ar lucky that the family is so imrpotant. we dont have that in UK. OUr loss I think
THE PROJECT
For my third and fourth week, I joined a group of mental health professionals from Hampshire Partnership NHS Foundation Trust (HPFT) for the most innovative part of my placement. This involved a nine hour drive from Ghana’s centralised capital to near its actual centre in Kintampo for a dedicated psychiatry programme known as the Kintampo Project. Developed by the Kintampo Rural Health Training School (KHRTS) in collaboration with HPFT and the University of Winchester, the Project aims to increase the numbers of qualified, middle level specialist mental health workers and provide mental health services to Ghana’s rural communities [7].
We were here as part of a UK-led two week teaching programme on the inaugural 18 month Medical Assistants [in] Psychiatry (MAP) degree course. Our nine students were all experienced MAs and included Aaron Baah. All were older than me and most had left young families to share dormitories during the week for classes starting at 7 am. While they each had their employer’s support, it was still a significant commitment for an unprecedented course that had yet to confirm which institution would confer their degree. However, as Dr Mark Roberts, the Project’s UK lead and HPFT forensic psychiatrist, observed it was also likely that as they graduated and their numbers increased, these MAs could become influential and at the forefront of Ghana psychiatry’s service.
I delivered presentations on psychosis, mood disorders and mental state examination that I linked with the Oxford Handbook of Psychiatry, which each student received a copy of. I also referred to patients that I’d seen at Pantang, which was invaluable preparation for understanding the MAs and their patients [8]. With my fellow teachers we encouraged their interaction and ended each day with a session reflecting on their own experience. Meanwhile outside class, Dr Roberts and his UK colleagues oversaw progress on the curriculum and supervised the personal development plans of the local tutors so the Project could be self-managing and sustainable.
Observing differing approaches to mental illness
As part of our teaching programme two field trips with the students were arranged. The first was to observe and compare two different spiritually based approaches towards managing mental illness. The second was to the out-patient clinic of the nearby hospital. While these were undoubtedly valuable learning experiences for the students, they were as much an education for us, their UK based teachers.
For our first trip, we observed the healing centres of a fetish priest and an Evangelical pastor. Both communities provided warm welcomes and offered us seats in a circle that faced their leader’s designated, elevated chair. In the Ghanaian custom, our hosts shook our hands in turn, following in an anti-clockwise direction to ensure that none were approached with the backs of their hands. After prayers were said to their inspirational source, all eyes remained on each group’s charismatic healer who led through his aura and authority. Understandable really as both men confirmed that they could remove ‘evil spirits’ through communication with a supernatural force!
Photography by Wendy Quelch
At the fetish priest’s remote, rural shrine, this traditional healer said he had been called by spirits to succeed his deceased uncle, in a role that combined those of chief, priest and doctor. Thus by communicating with a deity and the assistance of his loyal ‘linguist’ who wrote down his trance-induced speech, the priest said he can identify what ails and which herbal preparation would help each of those under his care. We then met the Evangelical pastor of a church and prayer camp who provides a similar physical link between this world and a spiritual one through the word of God. Quoting the Bible’s account of how Jesus healed a man with evil spirits through prayer, the pastor told us that as evil spirits cause all illnesses, then prayer can treat all illnesses.
At one location we were shaken to see men held in shackles, though such measures are not uncommon to ensure safety and enforce treatment on those with disturbed behaviour. There have also been disturbing reports of beatings and enforced fastings as treatment at other centres, though for some communities shackles have a symbolic value as their removal can be a “dramatic demonstration of the efficacy of healing” (Read et al, 2009). Back in the classroom we discussed and reflected on the role these spiritual healers play in providing culturally acceptable explanations for mental illness and its management.
Our visit to Kintampo’s hospital also revealed unexpected approaches. Here in the outpatient department, our group of MAP students spoke with a young woman with headaches and depressed mood. Although the consultation was somewhat one-sided, we were interested to observe the student’s assessment skills, particularly after my presentation on performing mental state examinations. What we didn’t expect was for them to fire questions at the besieged woman in an unsystematic, free-for-all style that matched the busy waiting area outside. It was clear that further practice was required to reinforce what appeared understood in the classroom but abandoned in the field. Therefore back in class, we arranged simulation practice for the MAs with us taking on the role of patients. Using their peer’s observations, we then encouraged each student’s strengths and made suggestions that linked with our earlier presentations. We recommended this teaching method for the MAP tutors and it gave me an idea for later in my placement.
Overall, the UK visit to Kintampo was a thoroughly positive experience for us as teachers and a good start for the Project. The MAP students were also appreciative but wanted to know what would happen after we left? I wondered myself, were we temporary psychiatry colonialists swooping in with our own values? Here though our purpose was clear; to contribute as guests of KHRTS to a teaching course that would receive ongoing support and further visits from HPFT to supplement their own resources. For our students, we also hoped that our teaching would inspire their own self-directed learning and left them with suggested projects for them to do in pairs.
THE PLACEMENT CONTINUES
I returned to Pantang hopeful of starting regular teaching for the MAs who may be future MAP students. However with Dr Dzadey in Poland for five weeks and only two MAs working during my first week back, there was little time available. Even when all three were there, their reliability was variable due to the work volume but also confusion over the rota and their own private work. Thus teaching as a group rarely happened and I mainly provided daily individual supervision with varying success.
Arranging reviews of the in-patients would be another challenge altogether. During Norman and Clive’s placements, both established regular ward rounds involving MAs and nurses though these didn’t last after they left. With each MA averaging over ten patients on each ward, covering one of these in depth meant that others were neglected. Furthermore when ward reviews did occur, there wasn’t time to see all the patients and the MAs lacked focus. With Peter’s advice I suggested a framework of ‘diagnosis, social circumstances, goals of treatment and problems’. However, when seeing ten men consecutively with chronic psychosis and cannabis use, details would merge and I felt that even my own skills were drifting towards Pantang’s baseline. Peter had further advice about managing such ‘therapeutic nihilism’;
“i am glad you get a good experience of working in this kind of work and its frustrations – a true experience. [a] lot of thinking needed (by you) on systems to put in place that are sustainable
it sounds like you are doing all the right things and getting the right sense of frustration which is part and parcel of this project… we are not aiming for an nhs . we are aiming for something that is benefiting the patients there primarily”
Managing Aggression
One issue I couldn’t help noticing was that some in-patients had severe extrapyramidal side-effects due to prolonged courses of daily intramuscular antipsychotics. I asked about the protocol for management of aggression that Norman had introduced and while many remembered his flow-chart posters, I never saw one on display. I did however, find differing views by staff about the prescription and administration of sedative medications. While the nurses defended using injections to ensure that patients received medication, the prescribers had their own preferences while pharmacy feared running out. What seemed necessary was a system that all could follow.
While that wasn’t resolved in my time, I did update Norman’s slide presentation for the hospital weekly case review meeting. I began with a quiz before outlining Norman’s protocol and its benefits. With photographs taken from the notes that showed questionable use of injections, I described how each step of the protocol aimed to deescalate and make safe differing levels of aggression. Of course my intervention alone wouldn’t change much though I hoped the principles of anticipating aggression would appeal. Later, when I presented to some student nurses, I reminded them of the example of Ghana’s own global negotiator, former UN president, Kofi Annan.
Like the previous UK trainees, I also provided weekly teaching for the MAs based at Accra Psychiatric Hospital (APH) though their attendance didn’t always reward my two hour tro-tro journey through Accra’s haphazard roadworks. Their commitment on Friday afternoons was a possible reason and the day of the Black Stars’ World Cup quarterfinal wasn’t successful for teaching either! Nevertheless when we did meet, they were more knowledgeable as a group and I enjoyed having local supervision with Dr Osei, the Nelson Mandela of Ghanaian psychiatry.
THE GHANA GRAND TOUR
After our time in Kintampo, my teaching colleague, Patrice, generously left his BMW that he uses during visits to his family in my care. Initially I was wary of Ghana’s roads but I also knew that a return trip for teaching in Kintampo would be useful as well. Of course, with Wendy arriving for my final month and a week’s leave to take, I also hoped to visit parts of the country that I otherwise wouldn’t have seen!
Six weeks since I last saw them, all the students on the MAP course remained committed. They had been taught psychology, ethics, research and management as outlined in the curriculum, but had lacked further psychiatry. I made up for this somewhat by teaching on perinatal psychiatry (pregnancy-related disorders) which revised and extended my earlier presentations on mood disorders and psychosis, while Wendy developed her simulation of post natal depression to include psychotic features. These approaches allowed us to compare conditions and provided the students with further simulation practice. During these three days, they presented their completed projects and I suggested further subjects for them to prepare before the next UK visit. While it was the responsibility of the Ghanaian tutors at KHRTS to ensure that the teaching programme was delivered, I hoped that my ongoing interest would encourage their own development, which might be the most important achievement of my return visit.
Meanwhile during our Ghana tour, Wendy and I were able to relax at Kokrobite Beach, witness history at Cape Coast, catch the view from Kakum National Park’s canopy walkways and go on safari at Mole Park to name but a few of Ghana’s highlights from our well-thumbed Bradt guide. I also returned with Wendy to visit the fetish priest again, who showed us his consultation area and we danced with his community. While the BMW could have done with its own spiritual intervention, there was always an enterprising Ghanaian willing to help along the way!
Researching Insight
During his placement three years ago, Norman’s interest in insight led him to research whether patients who denied their own mental illness could recognise mental illness in others (Poole et al, unpublished). Before Ghana, Norman and I spoke about a new project to repeat a previous British study into insight (Startup, 1997). My main task was to take local advice on modifying the descriptions of mental illness that were used in the original study so these vignettes would be suitable for an English-speaking population of Ghanaians. I then field-tested and validated these vignettes with local health staff so that my successor Sam, could continue this research during her placement.
While the idea was intellectually interesting, its relevance in Ghana was apparent when I saw how often patients were described as having ‘no insight’ because they denied their illness or refused medication. Having experienced other areas of ambiguity in Ghana, this seemed an appropriate subject to present at the monthly, hospital teaching programme. Again, I began with a test and photographs from the clinical notes that described patients with ‘no insight’. I then outlined insight’s three aspects – illness recognition, relabelling experiences as abnormal and accepting the need for help – indicating how these can be changeable and variable. To demonstrate this I arranged for an in-patient I knew to be interviewed in a ‘grand-round’ style. Having given her consent, she explained that some of her views were true and not fully shared by her family. However, she also minimised the extent of her family’s concerns and the audience went on to question some of her inconsistencies.
Afterwards I heard this was the first time a patient had been interviewed during the teaching programme and I hoped this would inspire further inquisitiveness. I was then presented with two local shirts before I gave my own parting gift of handwritten nameplates that I’d commissioned from the Occupational Therapy department. Along with a wonderful leaving dinner at a local restaurant with Wendy and many of the staff from Pantang, this was my own good ‘good-bye’.
SUMMARY
My placement in Ghana was the most fascinating and perspective-changing experience in my psychiatry career. I particularly appreciated being part of Ghana’s culture, which forced me to reconsider and reevaluate much of what I think about psychiatry. Witnessing the beginnings of the MAP programme in Kintampo and teaching the first cohort of what potentially might be Ghana’s new psychiatry service was a privilege. I also appreciated being able observe the inner workings of Pantang and the interaction between all involved in mental health services in Ghana.
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 in 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 something new was revealed every day. I hope to continue my Ghanaian and perhaps bring me back, where I know a warm “Akwaaba!” welcome is waiting!
Note: Details of patients referred to in the text have been changed to preserve confidentiality.
Acknowledgements
I would like to thank everyone who made this experience happen and turn out so special. Drs. Anna Dzadey and Akwasi Osei, all the MAs, Elvis Akugmoar, Sahl Mohammed and all the staff of Pantang Psychiatric Hospitals. Dr Peter Hughes, Dr Raj Attavar, the London Deanery and the Royal College of Psychiatry. Daliah Houghton, Eoghan Mackie, Winnifred Oware and Challenges Worldwide. Dr Norman Poole, Dr Clive Stanton and my fellow Ghana alumni. Dr Chris Aldridge, Dr Glen Berelowitz, Sam Vaughan and Sussex Partnership NHS Foundation Trust. Dr Mark Roberts, Dr Rosie Luznet, Prof Colin Coles, Dr Tess Maguire, Patrice Fugah and all involved with the Kintampo Project. Nicki and Tom, UK volunteers in Pantang’s OT department. Victor and Francis of the Ghana Diaspora. And Wendy Quelch for her assistance, love and the fresh eyes she brought.
Footnotes
[1] The St. George’s Ghana OOPE is considered ‘cost-neutral’ as each volunteer foregoes one month of their salary to fund CWW’s involvement and expenses such as medical registration. Volunteers on placement also waive their on-call banding and London weighting payments.
[2] My own ‘Anglosphere’ background consists of Irish and Australian parents and an initial upbringing in America.
[3] Evidence of Pantang’s original ambition remains visible by the several three-story, soviet-style staff accommodation buildings that lie unfinished across the equatorial hospital grounds. Despite lacking utilities and being open to the elements and onlookers, these skeletal apartments still manage to serve their intended function, as a number of the ‘encroachers’ who occupy them actually work for the hospital.
[4] There were also similarities with the first psychiatric hospital I worked at in Dublin, though then that didn’t include the heat!
[5] Securing reliable internet at Pantang was another of Dr Dzadey’s local challenges. Therefore I relied on a combination of a ‘dongle’ device that uses credit from a mobile SIM card or an hour’s travel by tro-tro to the American-style Accra Mall; ‘Ghana’s first and only grade-A retail development’. The Mall itself is mentioned in a recent investigation by Private Eye (Brooks, 2010) as one of the successful projects that the British government’s international development company, CDC, now funds ahead of less profitable agribusinesses that the former Commonwealth Development Corporation traditionally supported. As well as the Mall’s modern retail experience, further reminders of my American past came in the form of heavy rotation of Kenny Rogers’ Greatest Hits!!
[6] There have been numerous attempts to pass mental health legislation in Ghana and currently, a draft Mental Health Bill 2010 is under consideration. This innovative bill sets out to protect patients’ rights and ensure standards of care whether they are provided by orthodox, traditional or spiritual services (Asare, 2010). However approval of the bill may be delayed as Ghana has limited resources for its full implementation.
[7] The other part of The Kintampo Project is a 12 month course in psychiatry for nurses to become Community Mental Health Officers (CMHOs), which is due to start in October 2010. Both the MAP and CMHO courses aim to increase the numbers of middle level specialist mental health workers over the next five to 10 years.
[8] I followed a similar approach when delivering a presentation on critical research using photographs of Ghana’s direct roadside advertising. As it was common to find streets of houses painted in the corporate colours of rival mobile phone companies, the students agreed that they and their patients had considerable expertise in distinguishing biased information!
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.
Briggs P (2008) Ghana. Bradt travel guides. 4th edition.
Startup M (1997) Awareness of own and others’ schizophrenic illness. Schizophrenia Research 26, 203-211.
Brooks, R. (2010) That’s Rich! The CDC scandal. Private Eye Issue 1270, 17-23.
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Tags: Africa, Challenges Worldwide, Ghana, Greg Neate, Pantang Psychiatric Hospital, psychiatry, Royal College of Psychiatrists, Sussex Partnership, the Kintampo Project
Accra in black & white
Stay tuned – final report on the Ghana placement to be published very soon!
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Mole National Park
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Cape Coast Castle
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Tags: Cape coast Castle, door of return, Ghana, Gold Coast, Gulf of Guinea, UNESCO, West Africa, World Heritage Listed
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