Just don't get mad in Ghana!

I have major issues with the title of this article as outlined above. Indeed not only is it politically incorrect to refer to 'mad people', as a health worker, I should know better than to paint the medical discipline of psychiatry or mental health in dark uncomplimentary shades. But I am not finished especially since it is only 'mad' health workers who will opt to engage with the mentally ill. At the very least, if the said mental health workers were not 'mad' before training for their profession, then surely, a few years of engaging with the lunatic fringe of society should lend them over to just the tinniest bit of madness of their own!

Now I can very well imagine that I really have gone overboard. I shouldn't be talking like this, you are probably saying. Hear me out, please. A little honesty from everyone would probably reveal that you share the above views far more than you care to admit. This is the reason why when your brother, son or daughter wants to specialize in Mental Health or Psychiatry, you ask them whether they are either crazy or intend to go that way. It is also the explanation for the fact that a third of the patients currently on admission at the Accra Psychiatric Hospital are patients who have been seen, treated and discharged and whose relations have simply refused to come for them. It is also the explanation why some health workers themselves will swear to the high heavens that a patient of psychiatric illness can never truly be cured which is sad considering the efforts they put into their work.

Reassuringly, Dr Akwasi Osei, Acting Chief Psychiatrist pronounces that none of the above resembles, even remotely, the truth.

The stigma is however thicker than you think. It colours everything from the policy adoption stage, through commitment to implementation of the policy once adapted to comprehensive management including community based care. If the politician and the people of Ghana had simply not given up on the mentally ill, the informal prison system for them will not thrive so. I promise to explain what I mean later.

It would also not take forever to design, pass and implement the Mental Health Bill. We would not be saddled with 15 Psychiatrists, only 4 of whom are in active service with two combining care with teaching activities in the medical school. We would never have been proud of 600 psychiatric nurses when we need not less than 3000 or 115 community psychiatric nurses when over 2000 would have been nearer our targets. It would never have been the case that not only is Psychiatry not covered under the National Health Insurance Scheme leaving the authorities chronically starved for cash, but the total lack of appreciation of their situation will not lead to the 'cozy' situation where authorities at Accra Psychiatric Hospital according to Dr Akwasi Osei “have suppliers who are supplying them items on credit”. Understandably, the civil servant/doctor is too diplomatic to tell us for how long the Accra Psychiatric Hospital has been running on credit and for how many months his accounts have been in arrears. But he needs not bother to tell us. His silence is loud enough. Some of us are listening and do hear his loud silence.

My earlier reference to an informal prison system leads me to the story of my childhood friend Akyea who suffers from a Psychiatric disorder, what you may disdainfully refer to as madness. Perhaps he is a good example of the fact that mental patients are more human than you think. To his credit however, it must be pointed out that he was lucky that his condition allowed him to have insight into his illness which is to say that he recognized that he had a mental illness and accepted the fact that he needed to be on regular medication. In fact, in good times, he could take a course or two in one endeavor or the other. Never mind that he never got a distinction. In the mean time, he had been sent by well-meaning relations to a powerful prayer camp where he had been grounded with chains around his wrists. This must have gone on for so long that by the time I saw him, both wrists were brutally scarred with the disfiguring marks of the chain. This was not all. He was starved well well in what was at the time labeled a spiritual fast.

When we met, with both wrists raised, Akyea asked me, “Have you seen a mad man who has been healed through chaining and starvation before?” I don't remember my giving any sensible response to him. Today, I can confess that I was silenced by my deep shame. We, me, you, everyone failed Akyea and continue to fail other sufferers of mental health.

Mind you, I do not hereby ridicule faith-based approaches to comprehensive Mental Health management. It would be recalled however that in the Gospel according to Mark, after the disciples had tried time without number and with no success to cast out the offending demon, they had called Jesus who in one sentence, sent the very same demon packing. It was then that our Lord himself said “that this kind cannot come out except through prayer and fasting”. It would seem to me that Jesus was prescribing prayer and fasting for those who, like his disciples, would be inspired to cast out demons and never any overwhelming endorsement of our penchant for starving mental health patients. Such prophets would be truer to their calling if they were given to prayer and fasting themselves while foregoing the tendency to stuff themselves full of juicy chicken, mutton and soft lamb while starving my poor friend Akyea.

If we cared that much, what would explain our actions or inactions all the facts notwithstanding? According to a WHO report, mental and neurological illness is already responsible for 12% of the disease burden in the world. By 2020, they project that Depression will be second only to Cardiovascular Diseases like Hypertension etc. In Ghana, Dr Akwasi Osei at last year's Mental Health Forum organized under the theme of 'Reviving the Collapsing Mental Health Service', talked about the current limitation of all institutions to the South not to mention uncompleted buildings e.g. Pan tang which had been taken over by encroachers. Then was the severe manpower shortages, unmotivated staff exposed to all manner of dangers as portrayed by a nurse whose right eye had been completely destroyed in an attack by a patient. Needless to say, there had been no pre-existing package to cater for the needs of this nurse/victim and others like her. Overcrowding at Accra Psychiatric Hospital featured prominently with the 400 bed capacity hospital housing over 1200 patients. According to Dr J.B Asare, from a situation of 9 Psychiatrists for 8 million people in the early 70s, Ghana shot…no not UP unfortunately, but down to 5 Psychiatrists in 2005 with responsibility for over 20 million people!

Dr Akwasi Osei decried the absence of useful modern drugs, modern diagnostic equipment like Electro Encephalogram, CT Scans which would help diagnose behavioral changes secondary to organic causes.

As if the above do not constitute enough challenges, today cocaine has been thrown into an already murky situation with ill-prepared Ghana facing the real threat of moving from a transit-nation to a user-nation. Of course this falls within the domain of Psychiatry! In fact, Psychiatry or Mental Health is very much about Alcohol and Substance abuse as much as it is about Depression and Schizophrenia.

Since it is hardly my aim to depress you, I will conclude by putting forward some solutions suggested by the Professionals themselves at the afore-mentioned Mental Health Forum and end with a plea of my own to the press and to civil society groups as election 2008 approaches.

They call for a serious review of the manpower situation with increased training of more Psychiatrists and Community Psychiatric Nurses together with a look at their working conditions. While mental health care is now shifting more and more from Institutional to community-based care, there is the need to seek further integration of mental health care into general health care delivery. Perhaps as pointed out by Dr Akwasi Osei in his recent interview on Joy FM's Front Page programme, a speedy passage of the Mental Health Bill and appreciable commitment to its implementation would form the basis of that comprehensive overhaul. If the over three year-drafting period is viewed against what efforts if any, have gone into the implementation of the Disability Act once it was passed, then it may require much more than a passage of the Mental Health Bill to get us to the promised land.

For me, I hereby launch a passionate plea to the press and to civil society groups to develop staying power to crusade on issues such as these to their logical conclusion till something tangible happens. Further more, I urge these powerful groups to make the issue of Mental Health Reform a major campaign issue in the 2008 presidential and parliamentary election. In addition, it would be appreciated if they could get political parties to commit themselves to really doing something about the millions who are having monthly deductions on account of the National Health Insurance Levy and who, two years after registering with the scheme, are still waiting to enjoy its minimum benefit package for which they have already been levied.

As things stand now, I maintain that Ghana is not a safe place in which to go 'mad'. The hospital is ill-equipped to care for you and your family doesn't want you either. In fact if Dr Akwasi Osei is to be believed, (and I have no reason to doubt the distinguished physician), your relatives will give Abeokuta in Nigeria as your home address knowing all along that you live at Dzorwulu, in Accra, Ghana. That way when health professionals seek to return you to your family after caring for you, your guess would be as good as mine as to how they would locate your family house. If it is really true that one out of every four people will suffer from a mental illness and especially if looking at the three people with you now, you look like you may be THAT one, then I humbly appeal to you to place any such thoughts of falling mentally-ill on hold. Of course that ridiculous advice from me should at once portray how absurd the thorny issue of Mental Health has all become. For how can one consciously suspend or postpone mental ill-health when contracting it is not akin to being bitten by a mosquito?

By Dr. Sodzi Sodzi-Tetteh, General Secretary of the Ghana Medical Association.