Mental health in the Republic of The Gambia.

The Republic of The Gambia, on the west coast of Africa, is a narrow enclave into Senegal (which surrounds the nation on three sides), with a coastline on the Atlantic Ocean, enclosing the mouth of the River Gambia. The smallest country on mainland Africa, The Gambia covers 11 295 km2 and has a population of 1 705 000. There are five major ethnic groups: Mandinka, Fula, Wolof, Jola and Sarahuleh. Muslims represent 95% of the population. English is the official language but a miscellany of minor languages are also spoken (Serere, Aku, Mandjago, etc.). The Gambia has a history steeped in trade, with records of Arab traders dating back to the ninth century, its river serving as an artery into the continent, reaching as far as Mauritania. Indeed, as many as 3 million slaves were sold from the region during the trans-Atlantic slave trade. The Gambia gained independence from the UK in 1965 and joined the Commonwealth of Nations.

The Gambia is a long and narrow country, with borders following the course of the river. Commerce and government, including most of the main healthcare facilities, are based in the Western Region, near the coast. About 55% of the population live in the Greater Banjul and Western Region, and with the influence of poverty, and poor travel infrastructure, much of the population of the hinterland is isolated.

The Gambia has enjoyed relative political stability, unlike many of its neighbouring countries. Nonetheless, the country ranks 168 out of 187 nations according to the United Nations Development Index 2011, and about two-thirds of the population live below the international poverty line of $1.25 per day (Int$, 2009). The annual expenditure on health per capita is $84. Life expectancy at birth is 58 for males and 61 for females. The mortality rate for children under 5 years of age is 103 per 1000 per annum. The maternal mortality rate is also high, at 730 per 100 000 live births (2001 statistics).

In 2010, the government allocated 5.7% of gross domestic product to total health expenditure (2010 figure); in 2006, 8.7% of general government expenditure was allocated to health.

Healthcare system

Services in the country are provided by four tertiary hospitals, 38 health centres at the secondary level and 492 primary health posts. The burden of disease is high, with malaria and tuberculosis being the leading causes of morbidity and mortality. There is still work to do before the Millennium Development Goals (MDG) can be achieved, and the national 5-year MDG-based Poverty Reduction Strategy Paper (2007–11) identified health as a priority area. At the same time, there is increasing recognition of the emergent burden of non-communicable diseases, especially in urban and semi-urban areas of the country.

Medical education

The Royal Victoria Teaching Hospital (RVTH) in the capital, Banjul, is a 650-bed tertiary centre; it was built in the late 19th century and refurbished in 1953 by the British government to recognise the contribution of the West African National Front in the war effort. The Royal Victoria became a teaching hospital in the 1990s to tackle the reliance on foreign doctors. The University of The Gambia School of Medicine and Allied Health Sciences provides a 6-year undergraduate MB BS course. It had its first intake of students in 1999. By the end of 2011, a total of 76 doctors had graduated from this national medical school.

Postgraduate training programmes are very much in their infancy. Most medical graduates pursue postgraduate training at other regional academic medical centres or in the UK. Only one candidate has been identified thus far to pursue training in psychiatry in Ghana.

Mental health service

The mental health service consists of one community mental health team (CMHT) and an in-patient unit – the Tanka Tanka Psychiatric Hospital, run as part of the RVTH.

Community service

The CMHT consists of three general nurses working as mental health nurses and one nurse attendant, who operate out-patient clinics at RVTH daily; they also travel to 28 rural healthcare facilities every 3 months, and the greater Banjul area monthly. Rural areas are served by general health centres, and traditional healers. Culture dictates most patients will attend a traditional healer as the first point of call, and come to the attention of the CMHT on outreach often at a later stage of illness. However, there is some collaborative treatment between traditional healers and psychiatric services.

All of the above is achieved in the absence of a specific government budget for mental health. The primary sources of funding are grants. The government also funds some free medication for psychiatric patients, but the supply is variable.

The outreach functions to access and treat rural patients, give training to local healthcare workers and deliver medication. In-patient treatment is not possible for rural patients and they must be managed in their communities. The constraints of the outreach service are largely due to there being just one team for the whole country, no dedicated vehicle or funds for fuel, and the difficulties in attracting patients and in supplying information to the public, which is done through announcements on local radio.

Hospital service

Tanka Tanka Psychiatric Hospital is the only psychiatric in-patient facility, located in the Western Region of the country. It was built in 2009 by a Dutch non-governmental organisation (NGO), Tanka Tanka Foundation, on land donated by the President of The Gambia. It is funded by government subvention, with the assistance of NGO donations. Psychiatric patients had previously been housed in an old prison (Campama) functioning as a psychiatric unit. It is directed by the only trained mental health nurse working for the public sector in The Gambia. Tanka Tanka houses male and female patients of all ages and diagnoses. Forensic patients cannot be managed at Tanka Tanka and remain in the prison, although the service there provided by the CMHT has faltered recently due to lack of transport. Currently these patients remain without psychiatric input, unless they are brought to clinics by the prison wardens.

Epidemiology

The World Health Organization’s Mental Improvement for Nations Development in 2007 estimated that 120 000 people in The Gambia had a mental illness, with about 3000 receiving treatment per annum. Around 12% of the people in The Gambia are likely to have a mental disorder and 3% a severe mental disorder. These figures are consistent with those in similar neighbouring nations. Therefore, a maximum of 12% of people with mental disorders have received treatment through the mental health service in 2007.

In-patient studies show that the commonest disorders leading to admission are substance misuse (most frequently cannabis misuse), then schizophrenia, organic psychoses and affective disorders. In contrast, community data show that 48% of the mental health burden is accounted for by schizophrenia, 23% by epilepsy, 16% substance misuse, 3.4% depressive disorders, 4.9% anxiety disorders, 1.6% dementias and 0.4% post-malaria neurological symptoms.

Mental health workers

There are currently two psychiatrists working in The Gambia, or 0.08 per 100 000 population. In addition, two Cuban psychiatrists are in The Gambia on secondment for a period of 3 years at a time. The national totals of other mental health workers are: psychiatric nurses (trained), 1; registered nurses working in psychiatry, 2; enrolled nurses in psychiatry, 4; nursing assistants working in psychiatry, 18; psychologists, 0; occupational therapists (untrained), 2; mental health social workers, 0; traditional healers specialising in mental health, 12.

Local health beliefs

The traditional healers in The Gambia believe that what psychiatry calls ‘mental illness’ is the manifestation of a bewitchment invoked by another human, or a djinn using a charm. There is a belief that the world is populated by djinns as well as humans. Djinns are other living beings which most humans cannot see; they may or may not believe in God, and the non-believing djinns may be troublesome towards humans and use charms on them. Treatment used by traditional healers include verses of the Quran inscribed on paper, washed in water, which is then drunk by the patient. Herbal remedies are also applied.

Mental health legislation

The Suspected Lunatic Detention Act 1964 is still in use in The Gambia. In 2004 The Gambia’s Department of State for Health and Social Welfare recognised that the Act is outdated and fails to address the human rights of those with mental disorders. A mental health policy and strategic action plan were drafted in 2006, outlining how to narrow the gap in mental health services. The official implementation of the policy is still awaited but initial steps have been taken to appoint a mental health coordinator. The government pledged to draft and implement new mental health legislation incorporating patient confidentiality, informed consent, equal opportunity for care, conditions in facilities, appropriate care using the least restrictive methods, safeguards against abuse, and equal opportunities for employment, housing and justice.