The Neate Experience in Ghana

15Oct10

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 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.



One Response to “The Neate Experience in Ghana”

  1. 1 Lisa mukherjee

    Hi Greg, it’s lisa, we met at the obesity college meeting. I’ve finally had a chance to sit down and read your blog. And what a blog it is! I can see why you were so enthused talking about it. Your photos are truly remarkable. And what a small world it is too, Raj Attavar is a good friend of mine! Lisa


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