Around the World in Six Electives
Friday, June 13th, 2008Lucky Charlotte Hall went to six places on her elective and tells us more about her amazing experiences here
All pictures by Charlotte Hall
When I tell people I took a year out of medical school to do six electives, the first question I’m asked (with mouth agape) is where? I can say the list in less than three seconds now: Vanuatu, Samoa, Australia, East Timor, Thai-Burma border and Cambodia. The second question is why? This is slightly more difficult to answer, because in truth I’m still not sure why, though I can certainly point to the trigger. I had planned to split my elective between Samoa and the Solomon Islands, but was refused permission to do so; our electives co-ordinator pointed out that guidance says we have to go to neighbouring countries, and the two I wanted to go to are, in fact, ‘clearly thousands of miles apart when you look at a map’. Perhaps it wasn’t such a good idea to state on my application that they were right next to each other.
I did what any sensible, mature student would do: I sulked. And when I’d finished sulking, I rebelled. My idea, formerly only mentioned to my parents when I wanted to alarm them, suddenly became less a question of why, and more a question of why not. Several meetings and begging letters later, I was given permission to leave medical school for a year.
Vanuatu
My first placement was with the charity Project MARC (Medical Assistance to Remote Communities) in Vanuatu. The charity is run by a Dutch couple who facilitate clinics and provide community education on hygiene, contraception, and nutrition.
A 24-hour boat journey took me and two other medical students to a remote village in Banam Bay, Malekula. I spent the journey frantically reading “Where There is No Doctor” (it had suddenly dawned on me that when we arrived there would still, in fact, be no doctor). Our first greetings were from a group of small children, many of whom had baby sibling on hip, who looked up at us with adorable faces and spoke the not so adorable word, “Lolly?”. I wasn’t sure of the etiquette of refusing sweets to a gaggle of machete-wielding four year olds, and lollies were rapidly handed out.
Our home had been constructed specially for us - a large hut with woven palm sides and a palm thatched roof. We even had our own en-suite latrine. Our jobs for the month were to: help build a village Nakamal (meeting hut) for the women in the village, see patients at the small nurse-staffed clinic nearby, trek up to more remote villages to see patients, and hold educational meetings for kastom (traditional) midwives and local women. I’m pretty adventurous, but I did have a quiet sense of unease that night as I watched the ship sail away into the distance, only to return in a month.
We spent two mornings a week having with the midwives discussing how to improve practice; using a new razor rather than a dirty one to cut the umbilical cord, for instance. Because the nearest hospital was a five-hour truck ride away, we placed emphasis on pre-empting which women might have complications during labour and sending them to the hospital early. Two days a week we had a general clinic for women; I felt a great sense of responsibility to make these worthwhile for people, as some people walked for two hours to attend. Contraception was a difficult area to discuss; The Bay was a hot-spot for missionaries with yachts and several women told us they had been advised by people from yachts that condoms were bad and did not protect against HIV.
We gave advice on hygiene, including how to use a stick to brush your teeth, and nutrition. Laplap - a sort of carbohydrate blancmange made from pounded cassava and baked underground - is all that people in the area eat. We said they should be eating more fruit and vegetables from the ‘garden’ (plantation) - the next day families from near and far gave us all their fruit and vegetables as a thank you. One of the more random talks I gave was “How to smack your baby without damaging them” - although I don’t believe in smacking, I had seen such a high number of babies and toddlers being whacked round the head that I felt obliged to promote bottom smacking.
My Bislama (a kind Pidgin English) was not great, but in clinic there were certain phrases I could understand; “Me kat plentey weter blong nos” (I’ve got a runny nose), “pis-pis” (urine), “titti basket” (bra). Clinics were in fact the scariest aspect of my time in Vanuatu. The commonest problems were malaria, domestic violence injuries, otitis media, malnutrition, and infected wounds and ulcers. But if you asked me what the biggest problem was I would say chronic pain - people do an incredible amount of manual work, and I hadn’t realised how difficult it is even to get a paracetamol in the area we worked in. The hardest case we came across was a little boy who we suspected had osteomyelitis. His parents refused to take him to the hospital, and we had a long talk about how, with no child protection law to back us up, we could deal with this; the solution (before we resorted to talking with the village chief) came in the form of paying the truck fare to the hospital.
Before I knew it, my time spent in our hut with its cockroaches and rat’s tails through the ceiling, swimming in the bay until I was scared a shark would eat me, feeling nauseous at the thought of eating laplap, teaching the children the hokey-cokey, and scrubbing clothes on rocks was over and it was time for the next placement.
Samoa
On my first day in A&E at the Tupua Tamasese hospital in Apia, I was handed some ripped up pieces of paper (prescription pad), advised by the consultant that, “I am not much good with X-rays so I wouldn’t ask me about those”, and given my own cubicle to see patients in. After Vanuatu, the prospect of being somewhere with more medical facilities than a chair was daunting; it meant I had to think about investigations, and couldn’t just send someone off to the hospital if I thought they were ill, because I now was the hospital. It didn’t help that my first patient was a man who came in with hand on chest saying ‘pain’ before collapsing. My request for an ECG immediately was unsuccessful - “No ECG paper”.
Tuesdays were ‘inmate day’ when the prisoners would come to the hospital. One inmate complained of cough, haemoptysis and pleuritic pain for a month. TB perhaps? Not according to the consultant, “He is a prisoner - he just wants a day out. No X-ray for him”. Then to the prisoner, “How dare you ask this young lady to undress you - out!” Other experiences were more mundane - all Samoan men play rugby (even if Australia and NZ do pinch the good ones) and they have started changing the way they play from running in a straight line to zigzagging, thus increasing the number of knee injuries. Dog bites (often needing debridement because of delay in presentation) were also commonplace - the band that released “Who let the dogs out” are Samoan.
Samoa was interesting for the lifestyle that came with it - it was a tiny place, where everyone knew who you were. The country has a strong Christian following; doctors who came out with us couldn’t drink too much or someone would tap them on the shoulder and remind them they ought to be setting an example. Bars closed at midnight on the dot, with a gaggle of lava-lava (sarong) clad policeman arriving to ensure the music was turned off. Despite this, several unusual customs have persisted, including the ‘fa-afafine’ - boys raised as girls to help with women’s jobs in the house.
Australia
Tennant Creek is the only sizeable town between Alice Springs and Darwin. Its tiny 20-bed hospital serves an area the size of England, and I had been attracted there by the opportunity to do some ‘flying doctor’ medicine despite being absolutely petrified of flying. The week before I arrived, an Australian doctor said to me, “Tennant Creek? The mere words fill me with a sense of dread.” I was beginning to feel the same; I remember before I arrived I sent an email to my friends saying I wanted to leave Australia and go somewhere ‘culturally different’. How wrong I was; Tennants population is 80% Aboriginal, it’s completely cut off from everywhere around it by thousands of kilometres of red dust, and they have to fly patients who are sick to a different hospital; how similar to the London is that?
Patient presentations to the four-bedded A&E were often advanced, and I saw a lot of severe pneumonia, scabies that had become so severe it required hospitalisation, fractures that had happened a week ago, and (as the Aboriginal ‘initiation’ ceremonies were happening at the time I was there) plenty of nasty infected wounds. Injuries from all sorts of violence were also commonplace, as the concept of ‘payback’ is still alive and strong. One night I saw a lady who had been stabbed by her daughter; two hours later the daughter came in after being hit over the head with a bottle. I asked her if she wanted to report the incident and she replied, “No. It’ll be payback.” A few hours later the guy who had assaulted her came in with a stab wound. On several occasions I actually heard nurses beg patients to wait until their shifts were over to exact their revenge. Some of the staff expressed a disturbing amount of bitterness towards their patients due to this combination of self-neglect and violence, but for every person who seemed to feel this way there were wonderful people who go about providing healthcare in very harsh conditions.
I was fortunate enough to visit clinics at several Aboriginal communities; being squashed into a tiny tin hut when it is 45oC outside was not much fun, but chasing the non-attendees and giving immunisations through car windows was. I also went on flights to the cattle ranches to attend women in labour and to transfer sick patients to Alice Springs. These trips were eagerly awaited as it meant the hospital staff could put orders for fast food in, which the plane engine would keep warm on the return journey.
The night before I left Tennant Creek the leading story on the news was that there was a massive outbreak of dengue haemorrhagic fever in East Timor, my next destination. I remember thinking that at least if I was going to be ill abroad, at least this would be relatively exotic, and days later I arrived in the world’s newest country.
East Timor
East Timor had a bloody birth in 2002, when it finally separated from Indonesia. The country still bears many scars, however; 60% of the buildings in the capital are bombed out, people still whisper about the militia living next door, and a large UN Peacekeeping contingent was stationed there, along with the Brazilian military (who have the rather telling motto “Strong arms, friendly hands”).
I volunteered at the Bairo Pite Clinic, which is run by American Dr. Dan Murphy. Healthcare in Dili is appalling - there is one hospital, the BPC and a World Vision Clinic, and whilst I was there the hospital shut its outpatient department. We had 400 patients a day turning up, one doctor, and three medical students. When you have that many patients your focus of health provision changes dramatically; you try to spot people who have something life-threatening wrong with them, and move the rest on. If people have a fever, you do a malaria test. If it’s negative, you worry about dengue and do a tourniquet test. There were no blood tests at the clinic, so anyone suspected of having haemorrhagic dengue, or dengue shock syndrome was sent to the hospital. Representatives of WHO were everywhere because of the outbreak, and we were asked to produce figures of patients with DHF; with no tests, our figures were grossly unreliable, and I will never look at WHO statistics in the same way again.
I found the dichotomy of healthcare in Dili very difficult - whilst we had hundreds of patients turning up at death’s door - dozens dying from TB, patients with AIDS defining illnesses but no HIV test, babies weighing under 50% of what they should, children bleeding from the eyes because of dengue fever - the UN hospital sat almost empty. With the aid of retrospect I realise that of course this hospital needed to provide care for its workers and could not provide care to the whole local population, but seeing such good medical care alongside such poverty and illness was very hard and reminded me how privileged I myself am in terms of healthcare. I don’t think I’ve ever cried so much as I did in my first couple of weeks in Dili.
The clinic has a 4WD ambulance and several days a week I would take a translator up into the mountains with our driver and a small box of medicines. I thought I would just have a few patients to treat or decide to bring back to Dili, but in fact the number varied between 15 and 80. It is these clinics that make me say I’m not sure I would recommend going on an elective to East Timor; the degree of responsibility I felt in deciding how to treat 80 people was the most I have ever felt in my life, and I know that people both lived and died because of decisions I made up in small villages in the middle of nowhere; several times babies nearly died in the ambulance on the way back to Dili, or died shortly after arriving. When people tell you their baby has a fever I worried about dengue, typhoid, typhus, malaria, Japanese B encephalitis and a whole host of other things I had never seen before.
Despite the sadness and the stress, I had a wonderful time, and I think that this placement really taught me what kind of doctor I want to be. I saw some of the most incredible medicine - for example, I have seen over 10 forms of TB - and met many incredibly friendly and resilient people. I set off to the Mae Tao clinic on the Thai-Burma border with heavy heart but looking forward to the challenges that lay ahead.
Thai-Burma border
The Mae Tao Clinic - “Dr Cynthia’s Clinic” - was set up by Dr. Cynthia Maung, a Burmese refugee, to provide medical care for fellow refugees. The clinic is a model version of how good medical care can be even in the face of limited resources; it has out and inpatient services, a paeds unit, O&G, and a surgical department. The medics who run the clinic have been trained from scratch on an 18-month-long programme run by volunteer doctors, and they then split into two groups. Half will work as ‘backpack medics’ in the jungle along the border. This is incredibly dangerous work, due to the active fighting and landmines that exist there. Half will stay at the clinic and rotate round department, much like an internship. My boyfriend asked me, “Wouldn’t they get better healthcare if they had real doctors from abroad working there?”. The answer is a resounding no. The medics may have less training, but they are vastly knowledgeable about the things that they actually see every day (many tropical diseases, HIV, TB, mainly) and speak the necessary languages (namely Burmese and local dialects such as Karenni).
My placement here taught me much about medicine, but perhaps more about providing healthcare to internally displaced people and refugees, and also the effects that the political problems in Burma have had on the medic’s lives. I was shocked by how vulnerable these people are; Burmese migrant workers who live along the border work in factories that do not sew the labels into the clothes they are making until they reach destination so no-one knows who pays these people 10p for a day’s work. Medics who work at the clinic are ‘blacklisted’ from re-entering their country. Burmese girls have to be accompanied everywhere because, as illegal immigrants in Thailand, they could be kidnapped for the sex trade. On my first day I was handed a baby whose mother had died of HIV; he was an ‘illegal’ baby, not a citizen of Thailand, but not able to go into Burma because of the danger his family faced. My next placement was in Cambodia, and as I learnt more and more about the Khmer Rouge and the atrocities they had committed, the more disturbed I became that this was what was happening in Burma now.
Cambodia
At the National Paediatric Hospital in Phnom Penh I shadowed a doctor called Jenny. She was a fantastic doctor, but on my second day at the hospital she told me she was thinking of leaving medicine. I asked her why and she told me she could no longer afford to be a paediatrician, “I earn $25 a month. My electricity bill is $10. I have to ask patients to donate what they can and then the doctors and nurses share the money out at the end of the month - that’s usually another $25, but it’s not enough. It would be better if I was a policeman - then I could earn more through corruption.”
The paediatric care in Cambodia is interesting in that it is a split system - there are government hospitals and private, charity run hospitals, which are free. The charity hospitals have good facilities, including Cambodia’s only CT scanner, but have come under fire for providing hi-tech healthcare at the expense of more basic primary prevention care. Beat Richner (www.beat-richner.ch/), who runs the private hospitals, counters that children in poor countries have the right to the same standards of healthcare as children in the Western world. Whilst I agree completely with the theoretical argument, Cambodia is a country where malnutrition (often exacerbated by worms) and diseases preventable by vaccination are still major killers. It was very encouraging, however, to see someone who is really fighting for improvements in healthcare for children.
Lessons
I have so many stories to tell about my time away that it’s simply not possible to give any kind of meaningful overview in this article. But in the course of writing it and thinking about how I will end, I think I have come full circle to the question of why I took the year out. The answer is because of what I knew I would get out of it.
I can do all manner of things I couldn’t do when I left home - make coconut cream using a potato peeler, use a blowpipe effectively, get my clothes white with the help of a rock and not Daz, catch an octopus…
I even learnt a little bit about medicine - malaria, typhoid, typhus, malnutrition, dengue, scrub typhus, typhoid, TB, HIV, weird and wonderful murmurs and rashes… But whilst I could have read about most of them in a book, I couldn’t have learnt how I would feel seeing my first severely malnourished baby, having to tell someone they needed an amputation with no prosthetics available, knowing what was wrong with someone but not having even the simplest medication to treat it with. Even resisting the amorous advances of patient’s relatives in Samoa was a new experience! I didn’t know I was going to have to learn to see 40 patients a day on my own in a little mountain village, get caught up in an epidemic of dengue fever, learn to take histories in many bizarre languages, and a million other things.
I feel privileged to have met some of the most inspirational people I could ever hope to; Dan, who works 6.5 days a week, 365 days a year, 300 patients a day on his own in Dili. The staff at Mae Sot who never had any formal training but are some of the best doctors I’ve met - they live within the confines of their clinic because they are not allowed to re-enter Burma, not allowed to enter Thailand - I never heard one of them complain about it. Doctors in Cambodia who earn 20 pounds a month but still keep coming into work. Ordinary people too, from families who live with their relatives in the hospital because there are no nurses to the 18-year-olds who would turn up in East Timor saying “I want to help; teach me how”.
Would I do it again? I will do it again.
If you are interested in doing spending a year away…
- § When do you want to go? I took my year out between 4th and final year. If you are doing a BSc you may not want to take two consecutive years out. Equally, consider why you want to take the time out as a student and not wait until after F1/2.
- § Where do you want to go? I found the following links useful: MDU Electives Network, Student BMJ elective reports, Medics Travel your medical school elective report archive, Mark Wilson’s book The Medic’s Guide to Work and Electives Around the World.
- § How will you fund the time out? Some banks will offer loans and there are numerous bursaries on offer. You may need to stick to predominantly developing settings/places offering free accommodation to minimise costs.
- § How will I get permission to do this? Leave plenty of time to plan; I thought of going away about a year before I left. If you’re organised you may be able to plan research/audit projects, which will help you get funding. Approach your dean/medical tutor with a rough plan of what you would do; you need to consider what you want to get out of it and what you will do upon your return to ensure you can catch up if needs be (eg. I offered to complete by actual final-year elective period in the UK).
- § Don’t fill the whole year up before you leave - you’re bound to want to stay longer in some places, and you will hear of things ‘on the road’ that you want to do.
Charlotte Hall
FY2 General Medicine
Imperial College
London
charlotte.hall@ic.ac.uk
Cho Ray Hospital’s main courtyard