Vikram Patel gives an illuminating account of the practice of psychiatry in extreme low resource environments. He talks about the steps necessary to establish effective mental health care, describing first the assessment of needs, the importance of measuring the types of illness, prevalence and impact on daily life and the importance of efficient resourcing when planning. Whilst talking about the problems associated with institutions that still exist in some parts, he also talks about the beneficial work being carried out by other mental health care organisations. He is encouraging of the contribution that psychiatrists from more developed areas can make by working in these low resource environments.