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

Ghana - Week 1

Ghanaian wildlife

Introduction

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

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

Week one

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

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

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

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

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

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

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Comments

Re: Ghana - Week 1
Dr. is a good observation u made. Bit by bit mental health in Ghana will get to the top.
Re: Ghana - Week 1
Dr. is a good observation u made. Bit by bit mental health in Ghana will get to the top.
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About this blog

Susie Easton

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

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

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