The Gambia

Maribu (traditional healer)

Wed, 31 Oct 2012 15:05:19 GMT

As a British doctor working in The Gambia the local beliefs about mental illness become a part of understanding the patients and their lives.

Of course the local beliefs reflect in patients’ and families interpretations of mental illness. Many people diagnosed with schizophrenia will complain that a Maribu (a traditional healer) has put a spell on them.

To clear things in my own mind, I find I have to look closely at the symptoms of schizophrenia as ICD 10 describes them, but the individual’s interpretation and understanding of what is wrong with them is quite distinct. It’s expressed as a recognition there is something wrong and out of their control, and it’s a problem in their mind that they want to resolve. I’ve found that people can work with psychiatry on this, and collaborate in their treatment. Indeed it doesn’t always hinder their relationship with medical treatment, although it does delay them in seeking it, having invariably already sought help from a Maribu first.

The message to patients is that the two approaches can work together to avoid losing their engagement in a medical approach which after all, they have not grown up with.

A young woman was brought to Tanka Tanka by the police last month having been charged with infanticide of her 4 day old baby. Rather tragically, she had defaulted treatment for schizophrenia some 3 years ago. Her family have been supporting her at home in the way they believed was best for her, intending to help her care for her baby at home but with no intervention from services. During her illness, she offended a neighbour by interfering with their good luck charms by cutting them off her body. The family may have believed a spell was cast upon her as revenge for doing this, explaining her state of ill health and their reason for not seeking medical treatment.

After arrest the police were convinced of her unstable mental state at the station and brought her to hospital. We negotiated an agreement with them that she should stay in hospital rather than on remand. They advised me that her mental illness would be taken into account if provided with a medical report, as no one was in doubt of her condition.

She has somewhat improved with treatment from a fluctuating catatonic state and is now able to communicate and speak about all that has happened, which she finds unbearable but seems to be coping. There is no relevant forensic mental health law to help here, and plans for the patient's future care will be a challenge considering a lack of outreach community services. The staff will of course do their best but in constrained circumstances.

"He told me about the beliefs of the causes of mental illness, which are based in the work of djinns and spells invoked against people by other Maribus."

The need for a secure unit has complex implications to the community, not least in that some families despair of bringing their relatives for care after they abscond, and turn back to traditional medicine, taking their relatives to a local Maribu (traditional healer).

I went with the CMHT to visit a traditional healer, specialising in mental health, who is about an hour and a half’s drive outside Banjul, near the South Gambia-Senegal border. He has a large compound in a rural village with rooms for inpatients and consulting rooms for outpatients. The treatment is by way of the Quran, using recitations of certain verses, and herbal remedies.

He told me about the beliefs of the causes of mental illness, which are based in the work of djinns and spells invoked against people by other Maribus.He said he believed there are psychoses which do not respond to his treatment and took me to meet such patients.One young man had been there for 7 months, his mother staying with him in the healer’s compound.

He was floridly psychotic and threatening, and being kept there with no improvement in mental state despite the healer’s best efforts.He had absconded from the hospital twice before his mother took him there in desperation.The healer is allowing us to work with him, including supply him with appropriate medication, in fact he asked the CMHT to help.Of course the first instinct is to wade in with medical interventions, but the services here are well aware that without providing a safe alternative, that would be a naive and potentially dangerous interference.

I have been made aware of lessons learned with these issues in other countries in Africa, and that a thoughtful approach is needed. Work is being done in The Gambia to find funding to develop Tanka Tanka into a more secure inpatient environment, to prevent absconsion and provide a seclusion facility, and in all to work towards a more comprehensive service. I have found I have needed to put so much of my assumptions aside, and look at things in a pragmatic way, locate my thinking in this environment and culture rather than superimposing my experience of psychiatry in a developed country onto the complex needs of this one.

"Of course the first instinct is to wade in with medical interventions..."

Tanka Tanka

Wed, 31 Oct 2012 15:05:19 GMT

I have recently spent much of my time working in the inpatient setting, which is a separate 60-place psychiatric hospital about half an hour outside Banjul, down a 1km dirt track from the highway. It’s a bustling and vibrant place, with large grounds for the patients to use including a vegetable garden that they work on themselves as part of their occupational therapy. It’s always full or over capacity, and the turnover of admissions is quite high – every day is different and challenging, caring for a very diverse patient group in limited circumstances.

The in-patient service has been restricted for the last month by inconsistent supplies of medication. Any one preparation of a drug may run out: usually there is at least one antipsychotic for use, but the patients will experience the medication being changed from one drug to another. The antipsychotics used here are oral haloperidol and chlorpromazine, and fluphenazine depot. The only antidepressant available is amitriptyline, and for sedation there is IM haloperidol, IM diazepam, but no oral benzodiazepines at all. There is also carbamazepine. This week the hospital finally ran out of all antipsychotics. The families of some patients are able to take prescriptions to local pharmacies and bring back the medication for them, but for most this is not financially possible. We’re told by central pharmacy this situation will be resolved in the next few days, but for now the hospital can only take emergency admissions (which is most of them!), and we have tried to discharge as many people as is safe, with prescriptions for those who can afford to buy their treatment in local pharmacies to carry on treatment at home. I have found the decisions about whether to discharge people for this reason difficult, but I’ve had to ask myself what the point of admitting people is if we cannot treat? So the decision has been based on risk assessment for each person and how well the family could manage and support them at home.

"People seem to be less averse to injections here than at home; I think they expect injections from doctors and that is part of the road to recovery."

There are so many challenges here to what I have come to expect, based on how we work at home. The inconsistency of antipsychotics, of necessity at the very least, leads to skewed prescribing practice, as we are always aware of the low supplies, and prescribing rationale is based on practical issues. Depots are used very often as the supply is usually more reliable, as they only need to be available once per month for each patient, and they are always available at one time in a month. This way the patient has the most reliable treatment without missing doses and the best chance of achieving a steady state of medication. People seem to be less averse to injections here than at home; I think they expect injections from doctors and that is part of the road to recovery. Side effects are obviously a constant battle and source of distress, but thankfully during my time here so far the supply of trihexyphenidyl has not faltered!

The matron of Tanka Tanka Hospital is keen to share our practice from the UK; so we’re working together to develop some staff training, starting with the management of agitated and challenging patients. There is a seclusion room in the unit which was closed last year after it became clear it was not being used safely.

"The extended families are very involved in the care of their relatives here.."

This makes the management of some patients very difficult, and appropriate means of rapid tranquilisation is not always available. The staff do an impressive job of keeping the calm and managing the risk with these limited facilities, but the outcome is not always favourable, and the potential for assaults and distressing situations is often borne out.

Having limited means to manage patients’ distress can make me feel very impotent. It makes me wonder about how much we tend to use our other skills to calm patients and make them feel safe, and how much we rely on medication.

The training is designed to empower the staff, who are not all trained nurses or mental health nurses. It also improves risk management, safety for patients and staff, and reduces incidents. The matron and I are planning to go through de-escalation techniques, physical techniques, rapid tranquilisation and safe use of seclusion. We are designing a protocol for secluding patients, and paperwork for record keeping and monitoring.

A study at Tanka Tanka last year showed that as many as 50% of people admitted abscond from the unit, and the largest group are those admitted with psychosis associated with substance abuse. I have found that those who abscond are often brought back by family members the next day, or come back again in some weeks, but many are not seen again for some time. The extended families are very involved in the care of their relatives here, compared to what I have experienced at home. I don’t think I have often seen families bringing back patients who have absconded at home, perhaps this is because our services take responsibility for us, and here without social or outreach services, families naturally take up the burden themselves and are much more assertive.

In high risk situations the police can be involved, but there is no obligation for them to bring back absconders, unless of course there is a public disturbance. This leads me on to mental health legislation; there is a Mental Health Act 1917, amended 1967. There is provision to detain patients for a renewable 6 month period. The police may use an “emergency certificate” which is similar to a Section 136 to most intents and purposes, although rather more simply described.

The CMHT in The Gambia run busy open access outpatient clinics in Banjul every day, but are not able to provide home visits or outreach services. There just isn’t the funding for a vehicle, the fuel, or indeed enough staff. I have found that working without being able to rely on an outreach service is very different, and indeed more is expected from the families here to fill this gap. Working in this way with people who strive to offer the patients full care in such constrained conditions, has given me a keen awareness of the sophistication and development of our mental health system in the UK. Things we take for granted, like having another professional to refer to who will step in and offer follow up care, would indeed be a luxury here, although very much needed.

An update on my last entry: the young woman I suspected has lupus; I introduced her to the visiting dermatologist from Dakar who agreed it was likely lupus, and did her best to arrange for her bloods to be sent to Dakar for immunology. Unfortunately the best laid plans were thwarted and her bloods did not get there, so we settled for a clinical diagnosis, with a high ESR and low CRP, and treated her for lupus. She went back to the provinces in April, and plans to come back for review after 3 months. So far I’ve not heard how she is.

Out of Programme Experience

Wed, 31 Oct 2012 15:05:19 GMT

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

The Gambia is a small country on the West Coast of Africa, with a population of about 1.7 million people. I am based in the Western Region, where the capital city Banjul is and about half the population live here. The Royal Victoria Teaching Hospital in Banjul, is a 650 bedded tertiary centre, and Tanka Tanka Psychiatric Hospital is about half an hour outside the city, it runs at a capacity of about 50 and is Gambia’s only psychiatric inpatient facility. There are 2 Cuban psychiatrists working in the country, on secondment from their own country, otherwise there are no psychiatrists, and although the service is well staffed by competent nurses and assistants, there is only one trained psychiatric nurse.

I have been splitting my time between the Outpatient clinics at RVTH, which run every day and are always busy, and Tanka Tanka. In the first week of clinics I learned that you cannot predict who will walk in the door and what they’ll be presenting with. It’s a self referral system, and the range of psychiatric problems is vast; all ages, all problems. Several people per day are transferred from the clinic to the inpatient unit, most often with substance abuse disorders and psychosis, although unusually for The Gambia we’ve had a run of psychotic depression in older women in the past week. The nurses who run the clinic are very experienced though without any formal psychiatric nursing training. They are experienced in making diagnoses and treating, and know the system and are incredibly supportive, which I’m hugely thankful for as a CT2 and very used to having seniors around to ask advice! It’s safe to say I’m learning fast.

On first sight the psychiatric hospital looked unusual to me, as patients are not confined to certain areas as they are at home in wards. It is a large enclosed open air plot laid out with separate buildings for male and female dormitories, offices, and other facilities such as kitchen and dining areas. The patients choose to spend a lot of their time outside, sitting in the shade or walking around the grounds. Over the ensuing days, I learned there is value in allowing people to have freedom within a large space: when patients are distressed and agitated they tend to manage themselves differently, and use the space well. Another difference is that the patients are not split into different wards depending on their age or presentations, they are all together, so keeping an open mind and being aware of risks is particularly important.

Having spent 3 weeks settling in, I joined the CMHT on their 3 monthly trek to the South Bank rural regions, visiting local health centres and doing a clinic in each place. We visited 8 towns, and stayed with the staff in their quarters each night. It was an amazing trip, and probably the most challenging experience of my medical career so far! I have to mention the heat, and the dust, and the endless tinned sardines. The work itself was incredibly interesting – in those rural areas people do not have access to mental health care, and they do not have a ‘Western’ style understanding of what problems represent mental illness. Therefore many of the patients attending had long histories of untreated mental illness, and all the complications in their lives that this entails. The CMHT make huge efforts to arrange for the clinics to be announced on local radio and sometimes in the local mosques beforehand, inviting people to attend the clinic or bring in relatives they are concerned about. The attendance is variable, depending on how many people have been reached by the news and whether they’re able to get there.

At our first stop, Kudang, we were preparing for our clinic and the team were unsure how many people would attend, having had only a few on a previous visit. Next door was the public health clinic, and already at 9am a crowd of people was waiting for the clinic to open. The lead nurse of our team suggested we give an impromptu talk to the crowd, with the aim of educating them about mental health, what to look out for in mental illness, and encouraging them to bring in any of their relatives. There were men, women and children listening to our talk; I spoke about how a person might behave with mental illness of different types, and this was in turn translated into the local language. The locals listened intently, and I was wondering how we were being received as their faces gave little away except for clearly concentrating on what we were saying and studying us (me in particular as I rather stood out in the rural Gambian village environment!). As we were winding it down, people started stepping forward out of the crowd, one woman said she was experiencing seizures, another man said he wanted to come to see us as he feels unwell and hears voices, and a third elderly gentleman told us that he has 2 younger people in his family who he is concerned about who he will go home and bring directly back to us. With these spontaneous visitors, and others, the clinic was pretty busy that day.

The elderly gentleman, the head of a large local family, brought back his 25 year old son who presented with a 3 year history of psychotic symptoms, which the family had been managing at home, at times of agitation having to confine him to his room, his 24 year old daughter who was having frequent seizures, and then personally revealed that the last few years have taken their toll on him and talked about his difficulty sleeping, loss of appetite and constant rumination on his own death. I had had misgivings about giving the talk in the morning but obviously it had been helpful, for these people at least as we were able to start involving them with treatment.

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

Most people’s first point of call for illness in The Gambia is a traditional healer, especially in rural areas. We were invited to a well known traditional healer’s practice specializing in mental health, to collaborate with him in his patients’ treatment.

He explained the treatments he uses which include locally sourced herbs and particular recitations from the Quran. We saw similar presentations you would expect to see in a psychiatric hospital, however people had travelled to see him from a wide area including Mali and Senegal as well as The Gambia due to his well recognized family tradition of healing. The collaborative treatment effort is quite in its infancy, and the CMHT will be developing the relationship, and will follow up on the next Trek in June.

My training programme in London can seem a long way away sometimes, and it’s important to strike a balance between learning and doing as much as is helpful, and knowing my limits. Email support from my supervisor at home, Dr Peter Hughes, is invaluable. So far however, this is a truly enlightening and enjoyable experience, and I would recommend it. I’ll be spending some more time in Tanka Tanka next, and will be preparing for some teaching of the medical students at RVTH.

The Gambia has alot more to offer outside the city – and the people are friendly and energetic, keen to share their beautiful country with you. Some new Gambian friends took me out with a bird watcher at the weekend. European tourists flock here to twitch the local birds, and as a complete novice I had a go.

We went to Lamin Lodge on the creeks around the River Gambia, and went out on the mangrove waters in a tiny canoe. To my relief our guide told me that they don’t get crocodiles in those creeks any more, and they rowed us silently through the mangroves creeping up on beautiful bird species – they were very excited to have found a pair of white backed night herons which I’m told are quite rare, and blue cheeked bee eaters. Oysters grow on the roots of the mangroves which the village women row out and collect with machetes, and the men take tourists out bird watching by day and fish the waters by night catching small fish for the village market and barracuda which they trade with the large hotels; one barracuda for 50kg bag of rice. Young men spend 18 months doing this service after finishing school, proving themselves as having a good work ethic and being community minded to the village elders who then consider them for favourable jobs. The revenue goes back into the village, to maintain the schools and any building required.

After the creek we visited the village, and I found myself in the middle of a naming ceremony for a baby girl – seemed like the whole village was out, dressed in colourful and sequined dresses and kaftans. Of course all the children surrounded me, shouting “Toubab” meaning white person, and wanting to shake my hand.

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