An anxious night for my send off until a late goalkeeping howler brings huge smiles to the faces around me. Music plays in celebration and I hear the sound of a vuvuzela somewhere towards the hills. Tomorrow, for the final time, I shall awake to the sound of cockrels and the smell of indiscriminate burning. Just as for the pig, the passage of time beckons; I shall be obruni for one last day

With the final week in full swing it has become hard to find the time to write. There are loose ends to tie, reports and appraisals to complete, farewells to attend and twice nightly live football from Gabon and Equatorial Guinea to watch. Most nights I resist the temptation of 180 minutes of football but I have committed to the Ghana matches. My gracious hosts have progressed, methodically and painstakingly, to a quarter final with Tunisia on Sunday. National expectation is of an inexorable progression to a final against neighbouring Cote D’Ivoire in what would promise to be a tedious and cautious affair.

I continue to make good on my pledge to travel having visited the Avatime Hills, near the Togo Border, over the weekend. Here I found some fantastic hiking, taking a Sunday morning stroll through mountain-top villages which were in full church-going mode, to a 700m peak. The region seems rarely visited by tourists and was therefore agreeably well-intentioned. And whilst those of you in Arctic Europe will struggle to sympathise, it was refreshing to feel the mountain breeze and a five degree drop in temperature.

Thursday sees my final day of work at Pantang, with Fridays being spent in Accra. My final case is of depression, the lady mute for three weeks. Not, I think, catatonic but nevertheless with a severity of illness worthy of comment. I then complete teaching and set a revision exam, to be rewarded with evidence that some of my messages have got through after all. I hit a rare strike with all ten MAs attending, influenced no doubt by the promise of certificates of contribution. In return, and with my vanity very much under threat, I demand appraisal of my role here from these men with whom I have spent large amounts of the past months. The feedback is charming and pleasing in equal measure. ‘Dr Rampling is a very tolerable person indeed’ shall be filed alongside Kintampo’s kindest ‘He performed very well and needs to be congratulated’.

I find it hard to accept that the placement is coming to an end. After the never-ending days of Christmas and New Year it seems as if the last three months have gone in a heartbeat. Throughout, during the highs and the lows, there has been a depersonalised feeling as if I’m not completely here, that events in front of me are not quite happening. I cannot shake the suspicion that in a week or two this is all going to seem like somebody else’s memory. Ghana is strange and I could spend decades here and not ‘get it’. My lodging is now very full, yet even amongst friends I feel a cultural and social solitude; I look forward to getting back to my own place, my own people.

Saturday’s dinner has arrived…

I return from Ada to my penultimate week in Ghana with a resolution to do as much stuff as is possible in the remaining time. And then on the Monday, I get sick and witness the costs and considerations of being a patient in this environment- 16 Cidis for tests, 30 Cidis for medicines. This equates to about £20, a small price to pay for a speedy recovery from possible malaria but perhaps a damaging financial blow to some of our patients here. What if the prescription were not for 3 days, but lifelong? I realise that I have been guilty of not always considering the financial implications of my prescribing and investigation advice on this placement and I silently chastise myself for it.

Eleven weeks in and I am still confronted with firsts; my first day of epic Accra traffic (a 5 hour round trip to Accra Psychiatric Hospital without obvious cause), my first patient brought to the clinic with her arms bound by rope. I am conflicted by this, for it is clearly wrong- an assault on her human rights and a degrading reflection of mental health stigma at work- and yet the family have brought her by taxi, from many miles away. What better option have they? They are strongly criticised by the attending Medical Assistant and I am pleased, but with some sympathy for the beleaguered relatives.

Our last two case conferences have extended into a discussion on the role of community-based faith healers. It now looks unlikely that I will get the opportunity to visit either a prayer camp or a fetish priest but they are an integral part of ‘getting well’ in this country, including in the capital. Whilst there can be a role for the spiritual in what is a devoutly religious country, the medical professionals in this country tend to view the traditional healers as a major threat to the health of their patients. Many will be taken, for the initial months of their illness, to prayer camps where the most severely unwell may be shackled and left in the sun until exhaustion diminishes their troublesome behaviour. I have been given first hand reports of visits to such camps where legs are grossly swollen and infected as a consequence of the trauma of the shackles. These are extremes but an equal threat to psychiatric patients, whose illnesses invariably become more severe as they are left untreated, is that their medical requirements are neglected. A depressed patient is sent to a camp for six weeks before trying the hospital; a psychotic is referred to hospital by the camp on admission that their approach can no longer contain him. O father, why hast thou forsaken me?

I see no equivalent challenge in the Islamic culture here in Ghana and must remind myself to ask more about this.

The strength of the Ghanaian family and the spiritual conviction held in all echelons of this country provide the kind of psychosocial support that the UK generally lacks. I have come across few family units that would be seen as dysfunctional by our British standard, whilst the unquestioning belief in God’s benevolence provides reassurance, optimism and contentment. Where there are fears or doubts, one’s pastor can serve as one’s therapist. Where there are struggles, one returns to the family home. These are undeniably features of a good society and seem to be absent in much of the inner city communities where I have worked. But where they replace or dismiss the medical, they become disingenuous and malicious.

For light relief, I mention the small businesses of Ghana. In order to bring good fortune on an enterprise, it seems you must bless it with a holy name. Nationwide, shop fronts are given delightful, hallowed monikers. “God Is Here Motor Parts”, “Let’s All Clap for Jesus Barbering Salon”. I enjoyed the contrite “Please, I Remind You That God Is God Carpentry Shop” in Kintampo, and the irreligious, humourist “Don’t Mind The Wife Chop Bar”. A chop bar is a café and the name presumably refers to the wife’s chagrin at your eating out again…

Malaria works like this: a mosquito enjoys a meal from an infected person, acquiring the Plasmodium parasite along the way. If this includes the gametocyte (imagine it as the ‘pregnant’ form of the protozoa) then over the next 1-3 weeks it will ‘gestate’ within the mosquito. Towards the end of its ‘gestation’ it will go to the mosquito’s salivary gland ready for passage into its next human target. Humans have some immunity, particularly those who have grown up in endemic regions, but where immunity fails the liver tries to take over. The parasite reproduces within the liver cells which burst, spilling their content into the bloodstream. They are then taken up by red blood cells and reproduce further within. After two days this cell bursts, the parasites run riot, more red cells are affected and so on. Signs and symptoms are therefore those of infection (a high temperature and general malaise), liver enlargement and anaemia (reduced numbers of red blood cells), and they generally show between 1 and 3 weeks after the initial bite. Whilst the human immune system can fight off most episodes of malaria, some parasites remain sleeping in the liver and can reactivate years later. One type of malaria, Plasmodium falciparum, is also most likely to be self-limiting but when it’s bad it’s potentially fatal. People without immunity (young children and foreigners) are most susceptible and children can die within hours of symptoms due to involvement of the brain tissue, breakdown of blood cells and the resultant kidney damage. There is no vaccine but the medicines are pretty effective although there is widespread immunity to chloroquine and some of the other drugs.

I write this because, at some point in the past few weeks, a mosquito with gametocytes in its salivary gland may have enjoyed a meal from me. Last week I had abdominal aches, my guts felt terminally slowed down, I had sweats and chills and no appetite. Blood film was equivocal, but in the tropics all febrile illness is malaria until proven otherwise. And then, a few days later my housemate had confirmed malaria. I did not post before recovery to avoid fretting from afar- I am now well. (read/ reread, confirm it spells now rather than not). I am grateful to Yeng, the doctor in the OPD at Pantang, for seeing and treating me. I am also surprised and pleased to discover that he is a follower of this website. I didn’t realise I was quite that visible…

The harmattan is back with a vengeance this week, the air has been thick with dust. Breathing has become strenuous and my cough has morphed from a laryngitic to an asthmatic bark. There is a musty taste at the back of my throat, the weather traps the heat so the afternoons are muggy and draining. I am infected with a lethargy that is striking indiscriminately throughout Pantang. MAs close their eyes and drift off during my lectures not, I hope, through disinterest but for climatic reasons. I have lost my creativity so I take myself travelling in the hope that I will rediscover my mojo, east along the coast, at Ada Foah.

As I wait a few seconds to cross the road in Accra I am, well I don’t really have a word for it… accosted by Sharon, a 30-something Ghanaian lady. ‘hello, I want to be your friend’, she begins. ‘where are you going?’… ‘let me show you’. I know where I’m going and I’m quite capable of finding it myself, indeed I welcome the independence, but we visitors are indoctrinated into the importance of not giving offence so I allow her to show me the way. I wonder whether, through our politeness, we are being made fools of. I would like to be firm, even aggressive, but it’s not how we are meant to act.

As we arrive at the tro-tro station, she tells me that she’s never been to Ada and is going to come along. She boards ahead of me. I have known this woman for less than five minutes and she thinks she is going on holiday with me… Well politeness can only go so far and I feel a need to be direct. ‘Where are you going to stay because it’s not going to be with me’ I tell her- loudly, for the audience- and she disembarks. But she calls me four times on Friday night and I have seven missed calls by Saturday afternoon. With a contact from Kumasi calling me daily to tell me that we are no longer just friends but brothers, and another calling twice a week, my phone is becoming a useless irritant. I switch it off.

My fault, you might say, for sharing my number with these acquaintances, and to a point that’s true. But I am asked for my number as almost an opening gambit and when sat alongside somebody it is a challenge to one’s upbringing to refuse outright. Yet now I feel vulnerable having given up my number to people I hardly know. On arrival I had been lead to believe that you can share your number with no fear of being contacted, that they are merely collecting and an obruni’s number is a prized possession; since Kumasi this has proven emphatically not to be the case. It has become a means to extend a brief acquaintance and in some cases this has become uncomfortably overfamiliar, with the underlying suspicion that there may be an ulterior motive. The majority of people I meet are very kind, warm hearted and delighted to welcome me, the few who go further are laborious and these approaches have driven me irritable and paranoid.

Saturday morning saw the biggest faux-pas of my stay here and one which could have got me into a load of trouble. I took a walk a few kilometres along the beach, west from the mouth of the Volta. The beach spaced out and became empty as I walked beyond the fishing villages and guest houses on the shore. I was alone on a deserted space of beach and spotted in front of me a plump and gorgeous fish washed ashore and slowly suffocating to death. Its scales caught the sunlight and it gleamed purple, yellow and green. It would have been a great catch and had I means to cook it I would have packed it up and claimed it for my own. I had no such means so, rather than let it die a clumsy death I scooped it up and returned it to the sea, giving it a fighting chance of survival. Momentarily proud of my Good Samaritan act, I turned to spot four angry young fishermen charging towards me demanding why I had re-located their catch. I made some feeble and chastened comments pleading my misjudgement, which I suspect would not have sufficed had I not returned the fish rather close to the shore such that they were able to grab it, quite expertly, bare handed. I left the scene intimidated, feeling myself like a fish out of water. However I was soon able to laugh at this one and must remember the tenet of eco-tourism… leave everything as you found it.

Ada itself is an unremarkable fishing village, the volume of building work is indicative that it is slowly developing as an easy weekend break from Accra. As I remarked upon in Busua, Ghanaian tourism is rudimentary but there is a sense that this is about to change. If so, they are going to need to clean up their beaches which are littered with plastic, old clothing, faeces… Ada affords the choice to stay on the Atlantic or the Volta, and I choose the river as the ocean sites seem geared towards a backpacking crowd. I find the peace and quiet I am after on a clean river shore. Have I found my mojo? Well, I’m writing…

The week in Kintampo has been a highlight of this attachment. I was forced to reconsider my first impressions of the place upon arrival at the school campus, a tidy, affable hub of accommodation, lecture halls and ardent students. I have taught two separate groups, allocating the mornings to the second cohort of Medical Assistants (the first being the group I am working with at Pantang). There are six, ranging in age from late 20s to their 50s, who have diverse experience in healthcare nursing and prescribing. I approach this small group with a familiar mix of seminars, role play and case discussions and am rewarded with lively debate.

My afternoons have been spent in a large classroom with over 100 trainee Community Mental Health Officers. These students have all had two years of clinical experience in some aspect of healthcare and after this year-long course will be commissioned across the country to provide immediate assessment and initiate management for common psychiatric presentations in rural areas, referring complex cases to specialist centres in the South. They are at the beginning of their training and I have been granted carte blanche to choose my topics. We choose psychiatric symptomatology and diagnosis. I lead them through the mental state examination and case scenarios, identifying symptoms and bringing them together to make diagnoses. Electricity is inconsistent so I am forced to abandon my PowerPoint and improvise. Unscheduled, I find myself acting out ataxia, catatonia, thought disorder… When I present four disparate cases and drop the bombshell that they are all presentations of schizophrenia, I am rewarded by a collective intake of breath. The group are listening, questioning and learning; it is a lot of fun and I go home feeling good about myself.

Both groups are welcoming and polite, but this larger group is particularly so. They greet me respectfully in class and on campus, stand up to make a point and, sympathetic to my recovering laryngitis, provide me with bottles of water from their student fund. They even offer to send someone to do my washing, which I graciously decline. Outside of class I am approached for clarification of aspects of my lectures, or students wanting to tell me of their plans to study abroad. I am asked questions about higher education in the UK that I have no means to answer.

Monday’s sessions are interrupted by the stern presence of the school’s director, chastising the MAP group for the lack of cleanliness of their psychosocial centre. Teaching is put in hold while they sweep and dust. As I climb the hill to the CMHO classroom I discover that there, too, I have been preceded by the director and the day is given up to sweeping. There are reasons for this drive; although the advertising has yet to be purchased the psychosocial centre is formally opened for patients this week and a small but motivational ceremony takes place on Monday evening. It seems this is the beginning of a grand project to develop this place into a fully functioning clinical/ teaching centre.

The Grand Opening

The days here are full. We start at 7 and break for breakfast at 9. We then do 10-12 when I switch groups and do 12-2. There is a lunch break from 2-4 which may involve a little snooze, and another session 4-6. In the evening I come home and tidy or write the presentations for the following day with a view to making them as interactive as possible. At night my voice is shot to pieces but I rest it ready for the next day’s assault.

I cannot stay here indefinitely, they are feeding me far too well for that. Three cooked meals per day, large portions of stodgy Ghanaian food, have the potential to change my shape irreversibly. Before my night bus to Accra I take a stroll to the Kintampo Waterfalls and am presented with a formal shirt and beads as a token of appreciation from the class. I am touched, but when they ask me when I will come back I know better than to make false promises.

I leave with a conviction that I have had some small influence in the development of the future providers of mental health in rural Ghana, and that this group will become a wonderful resource for health promotion and service provision in the regions of this country where it is most needed.