I was lucky enough to have the opportunity to work and learn at the Pediatrics Department of Civil Hospital Jalandhar for 4 weeks in March, 2009. Jalandhar is one of the major cities in Punjab and is known worldwide for its sports goods. It is located on the intensively irrigated plain between the Beas and Sutlej rivers. According to the 2001 Census provisional figures, the total population of the district was 19,53,508 persons. The predominant religions of Jalandhar city are Hinduism (54.54%) and Sikhism (45.46%). The first language of most people in the city is Punjabi. Language never proved to be a barrier for me during my elective since my upbringing was done in similar cultural environment and I understand and speak Punjabi quite well.

Civil Hospital Jalandhar, also known as Shaheed Babu Labh Singh Hospital, is a district level hospital run by State Government. It has 400 beds. It provides treatment in medicine, general surgery, Pediatrics, Gynecology & Obstetrics, Ophthalmology, E.N.T., Orthopedic, Psychiatry, Dermatology, Chest & TB and Trauma and Casualty ward. The hospital is manned by Medical Superintendent, Additional Medical Superintendent, Chief Medical Officer, 20 Doctors, 94 Nurses, 11 Laboratory Technicians and 10 pharmacists. It also runs a Nursing Training School and has blood bank facilities.

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There are several ways a student can be motivated to pick an elective location. Some are inspired to experience the developing world on the African continent. Some wish to see cutting edge medicine in the USA. I am a massive fan of Korean Drama Serials.

New Heart© – MBC.com

The Korean drama New Heart (뉴하트) was without doubt my motivation for an elective in Seoul. The drama revolves around two interns (first year residents) entering a cardiovascular surgery department rivalled by the interventional cardiology department. The female lead plays Nam Hye-seok (Kim Min-Jeong), a top student from a top university in Seoul – but she is a female entering the male dominated world of cardiovascular surgery in Korea, a controversial theme when viewed in the Korean context. Complementing her is the male lead playing Lee Eun-Seong (Ji Sung), a below average intern from a lesser known countryside university. The duo is balanced by Cho Gang-Guk (played by leading actor Cho Jae-Hyun), a newly appointed head of the Department of Thoracic and Cardiovascular Surgery at Gwanghu University Hospital. Stubborn to the point of challenging tradition, Gang-Guk is nonetheless the genius in the drama. New Heart is without doubt the Asian Gray’s Anatomy for medical students. Intern struggles with time management, patient care and peer interaction were accompanying themes highly relevant to metropolitan medical students in their clinical years.

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The most northerly town in Thailand, Mae Sai, is adjoined to the Burmese town of Tachilek. These two small yet busy market towns, until quite recently acted as a major trafficking route for the Golden Triangle’s illicit export; opium. The area is now slowly starting to redevelop, but events in Myanmar are forcing many previously nomadic Hill Tribes to settle on the mountains just inside the Thai border. It was here that I was to spend my six week elective living and working in the most northerly hospital in Thailand.

Tim Baker and staff from Mae Sai Hospital

Mae Sai Hospital has 3 wards (one each for men, women and children) with a total of 100 beds, an outpatients department, a labour room, an A&E, two operating rooms and a clinic for HIV and TB. There are 3 consultants, 3 junior doctors and plenty of nurses. On an average day the wards will be full; most patients suffering with the manifestations of infective gastroenteritis, road traffic accidents, chronic obstructive pulmonary disease, ischaemic heart disease, chronic kidney disease, TB and/or HIV/AIDS. The emergency room will see and repair minor injuries; treat and admit illnesses if treatments are available in the hospital, or make referrals to the nearest major hospital. This was about 35 minutes away. I discovered, when asking for the rapid transfer of an 8 year old with a decreasing GCS and strong suspicion of an intracranial haemorrhage that 35 minutes, meant only if the ambulance – an old converted minibus or pick up truck – was on site and had a good engine.

Road traffic accidents were a very common problem

Forty percent of the patients in Mai Sai Hospital came from Burma despite Tachilek Hospital being just a short cycle-ride away. Wanting to understand why this was, I set off on my bicycle to find out and the answer was immediately apparent. The image of the wards in the third world, we have all seen on television, but nothing prepared me for the eerie quiet, the smell of unwashed patients and an overwhelming feeling of guilt. My desire to help was useless and compounded by a misguided perception, that a white doctor is somehow better trained than the highly experienced, fantastically trained local physicians. Walking through the overcrowded wards of rusting metal beds with wooden mattresses I was watched by desperate, hopefully expectant, eyes. Without basic equipment or medications the doctors struggled to cope; they had, however, managed to persuade the local government to fund antiretrovirals for 100 of the 300, known, HIV positive patients. Making decisions like these is an everyday occurrence. Frustratingly, a new, fully equipped, hospital had been built by a monk just minutes away, yet its official approval had been removed shortly after completion. It now sits decaying.

Before I left for Mae Sai, I was told I would learn more in my six week elective than I would in a year in the NHS and after only one day I began to believe this. The first patient I saw was having trouble with his sight; he was HIV positive and had recently started on antiretrovirals. I was clueless. Having had one week’s intensive lectures on HIV, I was desperately trying to remember the side effects of the medications. As a formality, but mostly to buy time to think, I looked at his retina. As I peered in, I saw what could only be (and is classically) described as a mozzarella pizza – suddenly from the murky depths the diagnosis appeared; CMV retinitis. An array of textbook late presentations followed throughout the day. As I was walking back to my apartment that evening, I passed a 23 year old girl on a trolley in the A&E. She had come off her moped and appeared to have landed face first. This could make for a very entertaining story if it weren’t for the blood pooling on the floor, her lack of consciousness and a very white, yet tanned, complexion. I could feel the blood draining from my own head as I realised there was no doctor around. Tensing and relaxing my legs – this I have always believed will prevent fainting – I rapidly replaced the lost fluid, arranged x-rays and a referral to the nearest hospital capable of dealing with her multiple skull fractures. This was daunting enough but made substantially more difficult by our language differences.

In the Golden Triangle, the region in which Burma, Laos and Thailand meet, language is often a problem. Migration between these three countries is relatively common and each of these countries has cultural subgroups and various Hill Tribes each with their own language. Most will speak a little Thai, and so I set about to do the same.

One of the many Hill Tribe villages in the mountains of northern Thailand

Linguistics is not a skill that comes naturally to me. By the end of my first week all I could manage was “very delicious”, “good” and “beautiful” (often a lie). This I learnt from the Laotian doctor I was living with; his only English was “beautiful lady” which he shouted enthusiastically most nights at around 3am whilst watching television. He taught me many words he felt important: “Thai boxing”, “fried insects”, “ladyboy” and “Chelsea”. I bought a phrasebook. By the end of my six weeks, I could hold very basic conversations around the weather, food or medicine. The most important word I learnt was “jeb” meaning pain.

Ever since an appointment at my school infirmary to have a (long) suture removed, I have considered pain management an essential part of medical care. In resource limited Mai Sae, pain management comes second to essential care. Women give birth without analgesia, which is a surprisingly quiet affair. If they decide they don’t want to go through this ordeal again, they can sign up for the Wednesday sterilisation list in the operating theatre. There is no anaesthetist so the tying of fallopian tubes is conducted by very skilled nurses who infuse local anaesthetics to prevent pain – if the patient is too noisy or moves too much a dose of ketamine will calm her down. About twice a day, children (and the occasional adult) will walk into the A&E with a large abscess that needs to be incised and drained. An eight year old boy who presented with four of them needed three strong porters to hold him still. The quality of his lungs was not in question. I could tell a hundred similar stories before I started on the patients who couldn’t afford treatment.

During my time at medical school I have often read the opinion that it is inappropriate to send western medical students to practise on patients from the developing world (1,2); I considered this a lot whilst I was there. I had passed my finals the day before I started my elective so had some experience of hospital medicine, yet it is well known that the day junior doctors arrive in hospitals is the most dangerous day to be a patient. This is a fact that is drummed into us and we fear it more than any patient could. Is it unethical to send medical students to be trained in the setting of a developing country? I found my answer one day as I stood in the A&E with only the two nurses on duty; in rushed simultaneously, the victim of a knife fight (multiple superficial lacerations to his torso and half a hand hanging off) and an unconscious woman who had overdosed, this was daunting enough and then I was handed a non-breathing newborn.

An x-ray of a patient who travelled for three days across Burma to reach Mae Sai Hospital only to return home because the surgery would have been too expensive.

There were times when I felt out of my depth but support was never far away. I have been trained to be one of Tomorrow’s Doctors and I heed the words of Hippocrates, I know my limitations and am honest about them. The doctors in Mae Sai did not allow me to perform procedures I wasn’t trained to do but were very happy to teach me. My time in Mae Sai has provided me with the confidence to know I can cope, whilst also showing me how much I still have to learn. I have been given a catalogue of experience, knowledge and fond memories.

All of this would not have been possible if it weren’t for the support of Christ’s Hospital School; the Judy Evans elective fund, the Benevolent Society of Blues and Michael Pugh who assisted me through Christ’s Hospital and medical school on behalf of the Society of Apothecaries. For all this support I am exceptionally grateful. I would also like to thank the Khom Loy Development Foundation in Thailand for their logistical assistance making my elective possible.

Tim Baker has just completed his final year of medicine at Barts and the London School of Medicine and Dentistry in the UK.
emailme@drtbaker.com

References

1. Bhat SB. Ethical coherency when medical students work abroad. Lancet 2008 Sep 27; 372(9644):1133-4.

2. Radstone SJJ. Practising on the poor? Healthcare workers’ beliefs about the role of medical students during their elective. J Med Ethics 2005;31:109-110.

The summer of 2008, when electives for the medical students were announced, several students found it surprising that a medical college elective would be titled ‘Rhythms in Evolution’. A primary intent of the said elective was to allow the interested students an exploration of their musical talent and the possibility of its application in medicine. In retrospect, going through that elective turned out an enjoyable, enriching, and melodious experience.

The elective involved two music classes per week, each lasting for about three hours. Three skeptic medical students, namely, Farwa, Abaseen, and Adil, each with only a limited prior exposure to music composition, enrolled for the class. A pre-course questionnaire was administered to assess the musical aptitude and interest of the three participants. The music room where the classes took place was a small room lined with computer stations and a view of the bright and sunny hills situated around the outskirts of Karachi. Except for a keyboard, perched on its stand at the far end, nothing about that room resonated a musical note. Dr. Jamsheer Talati, a general surgeon by profession and a trained classical pianist by passion, was the instructor. The computers were to be used for downloading and listening to audio files, to train the ear and wet sensibility for the main course, and to employ software to work with musical notations.

The first week of the course was devoted merely to studying the history and evolution of various genres of music over the ages, spanning music from the ancient ages, classics, rock, jazz, and techno. The activities comprised of extensive music listening and group presentations of the findings and experience. The presentations and discussions featured selected composers from different eras. By the end of the first week participants had heard and discussed a rich concoction of music from all ages and many regions of the world.

In the second week, participants took a closer look at the various elements and intricacies of music that bestow it the richness and variety that so often goes unappreciated: Rhythm, timing, frequency, timbre, organum, counterpoint and elaboration were therefore discussed. During the same week, participants listened to the works of eminent composers, including Tchaikovsky, Prokofiev, Bach, and Messian. The participants were encouraged to pick the emotion that the composer tried to communicate through music, and to understand how various tones and melodies were being exploited to create a scene in the mind of the listener. In medical language, this is known as the external locus, which is an emotion perceived to be expressed in a musical piece. The external locus is stronger than the internal locus; emotions felt in response to music [1]. Music, like speech, thus forms a mode of communication. Pleasant emotional responses to music have been localized to certain areas of the brain; ventral striatum, orbito-frontal cortex, amygdale and ventral-medial pre-frontal cortex [2]. Interestingly these regions of the brain are also relevant to motivation and reward, and judgment [2].

During the same week, participants were introduced to musical notation. Music Publisher 6; a computer software that allows the writing and playback of sheet music, was mastered and effectively used to develop musical notation. Over the course of the week that followed, these compositions were embellished upon using the concepts of counterpoint, organum, and variations of timing. Music notation is like a language; pitch, harmony and melody structure the communicating sound, whereas rhythm and meter give it temporality. It comes as no surprise that music training is considered to have potential for enhancing verbal skills [3-4].

The forth and final week of the elective, each participant was asked to choose a story or a piece of poetry and express it, or the emotion it evoked, in the form of sheet music. The written music was tried out on various instruments, with the help of Music Publisher 6, in order to experiment with the melody. Farwa, Adil, and Abaseen took, respectively, poems by the great Persian poet, Rumi and a character from the film Elephant Man, as inspiration for their compositions. The end of the fourth week marked the end of the elective. The participants had gained significant prowess in musical notation and composition, modifying and refining their original compositions and sharing them with each other. A post-elective assessment revealed they had developed an initial interest as well as a greater appreciation for music.

Farwa’s composition (Rumi)

Adil’s composition (Frere Jaques (Are you sleeping?))

Abaseen’s composition (The Elephant Man)

Music, like language, communicates shapes, patterns, textures, and scenarios. Neuroimaging studies have ascribed musical experience to the fronto-parietal mirror neuron system [5]. These neurons are responsible for how we detect the feelings conveyed by speech or music, ‘mirror’ them in our perception and generate a personalized response. Language, music, and motor activity converge at this very neural system. Musical appreciation can therefore intensify our emotional experience and enable us to empathize [6]. Skills acquired through training in fine-arts, such as music, help to cultivate empathy, emotional sensibility and consideration of humane aspects not taught by medical textbooks.

Adil Shah and Farwa Ali are second year medical students, Abaseen Afghan is a third year medical student at the Aga Khan University, Karachi , Pakistan
adil.shah.m07@aku.edu

The authors would like to acknowledge the assistance of Jamsheer Talati, a Professor in the Department of Surgery, and Syed Ali, an Associate Professor in the Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan

References:

1. Schubert, E. Locus of emotion: the effect of task order and age on emotion perceived and emotion felt in response to music. Journal of Music Therapy. 2007;44:344–368. [PubMed]

2. Blood, AJ; Zatorre, RJ. Intensely pleasurable responses to music correlate with activity in brain regions implicated with reward and emotion. Proc Natl Acad Sci. 2001;98:11818–11823. doi: 10.1073/pnas.191355898. [PubMed]

3. Foxton, JM; Talcott, JB; Witton, C; Brace, H; McIntyre, F; Griffiths, TD. Reading skills are related to global, but not local, acoustic pattern perception. Nat Neurosci. 2003;6:343–344. [PubMed]

4. Patel, AD; Peretz, I; Tramo, M; Labrecque, R. Processing prosodic and music patterns: A neuropsychological investigation. Brain Lang. 1998;61:123–144. [PubMed]

5. Istvan Molnar-Szakacs and Katie Overy. Music and mirror neurons: from motion to ’e’motion. Soc Cogn Affect Neurosci. 2006 December; 1(3): 235–241.
doi: 10.1093/scan/nsl029.

6. Marie Forgeard, Ellen Winner, Andrea Norton, and Gottfried Schlaug, Practicing a Musical Instrument in Childhood is Associated with Enhanced Verbal Ability and Nonverbal Reasoning. 2008 October 29. doi: 10.1371/journal.pone.0003566.

Radhika tells us about her time spent at speciality eye hospitals in India.

Radhika at the eye clinic. All images from Radhika Gulati.

I was privileged to be able to join the teams at two speciality eye hospitals in India. The hospitals were clean, well built and designed to provide a simple but effective use of space. I attended out-patient clinics and had hands on experience as well as exposure to an array of interesting cases. The cases varied from complications of trachoma to diabetic retinopathy presenting with a vitreous haemorrhage.

As with any area of medicine, there is a pattern of presentation common for any country or region and time of year – this was also very well demonstrated in the clinics. India is a developing country, with a hot and dusty environment. The environment predisposes to a number of conditions that I saw repeatedly in clinics – including cataracts, dry eyes, allergies, pinguecula and pterygium. As it was harvesting season, we saw a lot of patients with wheat and mustard related epithelial defects – the clinician said he was expecting 4-5 cases a day during this time. There is a lack of health and safety, even in areas where people work with metals and machinery so intraocular foreign bodies are not that rare.

Rewari, Rural Village in Haryana,

North India.India also has a high prevalence of diabetes. The World Health Organisation states this to be nearly 3000 per 100,000 population. Although in the urban community there is a better understanding of the condition and associated eye disease, this is not the case in the rural communities. In the eye hosptial in Rewari, a rural area, the patients presented late with all conditions, especially diabetes and the associated eye complications. Some were aware of their condition but had never been told to get yearly eye check-ups. Diabetes causes diabetic retinopathy but also leads to early cataracts, worsens risk of glaucoma, and delays recovery and healing in the eye from infection or trauma. I saw these complications in clinics in abundance.The clinicians have set up packages for patients to include yearly visits and education, as well as personalized care by dieticians and diabetologists. Unfortunately, they have only been running for 2 years and there is a lack of enthusiasm for these by patients in the rural communities, the ones who need it the most.In a discussion with one of the resident retina specialists, we hoped that this could be improved. Once the patients became comfortable with the hospital set up the and general principles of eye care infiltrated the community, perhaps more patients would understand the importance of eye disease in diabetes. I saw a lot of patients and tried to counsel them during my time there. I encouraged them to have regular check-ups, tried to teach them about diabetes and how to better look after themselves.

These eye hospitals are also unique within India due to their advanced monitoring system. Here the audit cycle has been put into practice, with regular surveys being conducted to track the eye care a patient receives. The questions within this survey explore the patients’ experience as a whole, from the moment they step inside the facilities (including how they are greeted) to the moment they step out. The aim is to reward the hard workers and improve the service provided, whilst ensuring best practice. This is a very effective and useful feedback system for a relatively small set up that is growing fast, with huge plans to expand all over India. It didn’t matter whether the attending patient was a poor villager or an urban businessman. The aim is to provide a high base-line standard of care – for the lowest possible price – across all the hospitals, regardless of where they were placed.

The experience I had at Eye-Q was invaluable, it was really inspiring to watch and learn from such hard working clinicians. I now truly appreciate the need for promoting good eye care to everyone and working towards reducing disparities in eye care across the globe. This is especially in those developing countries where diabetes is endemic.

“I would like to thank the Burgess Family for allowing me to have such an amazing experience by awarding me the Nicholas Burgess Elective Bursary Award 2009.”

Radhika Gulati, final year medical student at Barts and The London School of Medicine and Dentistry
missradhikagulati@googlemail.com

Daniel Kieth tells the story of his elective in Nepal, comparing his experience there with his first visit to the country, seven years ago.

I first had the opportunity to visit Nepal seven years ago. It was a short trip but at the end, I was so hooked that I promised myself I would be back, perhaps for my elective if I got into medical school. And so coming to the end of my final year as a medical student, where better to spend my 10 week elective but Nepal?

Nepal

The last time I was in Nepal, it was in the middle of a civil war. The communist rebel Maoists were fighting to end the centuries old monarchy, which was still reeling from the massacre of almost the entire royal family by the Crown Prince, who also committed suicide. Since then the war has ended; the Maoists have laid down their weapons and been elected to government; and the King has left Nepal. On top of this, as Nepal was emerging from this civil war, the world was diving into recession. Already dwindling tourist numbers have plummeted.

I was surprised to find that not much has changed in the last seven years. Many signs that formerly indicated “The Royal something or other” had been unsubtly altered. The police and military were noticeably more relaxed. ‘Hammer & sickle’ banners were proudly paraded through the street. Apart from this Kathmandu was very much the same. Like any large city in Asia it is loud, overcrowded and polluted. Thankfully though there is much more to Nepal. The surrounding countryside is some of the most spectacular and varied in the world. You can explore the jungle looking for tigers and rhino in the Terai (lowlands). Or you can hike up to snow capped peaks in the Himalaya. There is plenty to discover in the middle too. Nepali people remain among the most laid back and hospitable people I have ever met and are the best reason for anyone visiting Nepal.

Kanti Children’s Hospital, Kathmandu

I spent the first half of my elective at the main paediatric hospital in Kathmandu. The centre contained all the sub-specialties you would expect from a large children’s hospital in the west and had committed themselves to never turning a child away who was unable to afford medical care. The most impressive unit was the oncology ward, which offered new technology and modern cancer chemotherapy. They had even introduced alcohol hand gel.

Despite this it was still a children’s hospital in the developing world. Much of the money came from charitable donations, so was not always readily available. Nurse staffing levels were low. Anaesthetics was poorly represented, meaning that many procedures were performed on children with no sedation or analgesia.

I was able to see a wide range of conditions ranging from the ordinary to the tropical. The most common admitting complaint was diarrhoea, often complicated by malnutrition. Other common ailments included rheumatic fever, typhoid and fever of unknown origin.

Primary Health Care & Resource Centre, Chapagaon

Move to a rural area outside of Kathmandu and suddenly you can breathe and are surrounded by beautiful countryside. Chapagaon is a village about one and a half hours south of central Kathmandu.

The primary health centre is a physician assistant run clinic which included general outpatients, maternity services, a dental clinic and an eye clinic. The centre had its own laboratory capable of processing routine biochemistry, haematology and microscopy.

The range of cases seen at the centre included many illnesses common to UK general practice such as COPD, hypertension, upper respiratory tract infections and children with otitis media as well as more rural problems such as a human versus buffalo accident.

Conclusions

Nepal is a beautiful and incredibly friendly country that I will always have that hankering to return to. Some of the best wildlife spotting and hiking in the world exists there. On elective there you are guaranteed to see plenty of fascinating pathology and be involved in the clinical teams. Escape from Kathmandu if you want to see the real Nepal!

Practical Advice

Kanti Children’s Hospital:

The ‘BNF for children’ is greatly appreciated
Bring your own white coat
Bring a camera
A little Nepali goes a long way

Nepal:

Reconfirm your flight before you leave
Escape from Kathmandu
Electricity is only available for 4-8h/d. Bring plenty of batteries.
Check that internet cafés have broadband

Daniel Kieth is a final year student at Queen’s College, Oxford.
daniel.keith@queens.ox.ac.uk

Gemina Deepa Doolub compares the experiences from her two elective placements in Hong Kong and Mauritius.

 

My elective was split between Hong Kong and Mauritius. 

I  chose to go to Hong Kong as it has always fascinated me, being a place where both modern medicine and traditional treatment have important roles. I also wanted to “taste” a culture that was totally different to mine and learn Cantonese in the process.

Why I chose Mauritius is no secret; I am a native of this beautiful island.  To go there on my elective was a perfect opportunity to learn about the practice of medicine in my own country, and explore its current problems.

Going on a placement to these two places gave me an experience of healthcare systems which were hugely contrasting yet complementary in terms of learning experiences.

Learning Outcomes, Barriers and Experiences

My main learning outcome in Hong Kong was the opportunity to observe and learn about Tropical Diseases rarely found in the UK, such as Dengue Fever and Schistosomiasis. I was also able to practise my examination skills under supervision of the junior doctors, and had the opportunity to answer questions during the ward rounds, following which I read up on the topic and therefore gained more insight and a greater understanding of those specific conditions.   Unfortunately, I found that most patients only spoke Cantonese, and therefore taking a history from them proved difficult. As I was unable to learn much Cantonese during my four weeks in Hong Kong, the language barrier dampened my learning curve.  Thankfully, the native medical students translated what was being said, which helped me develop a friendship with them, and the experience greatly improved my social and communication skills.

In Mauritius, I was able to refine my clinical skills, especially venesection and cannulation. Being fluent in Creole (the native language of Mauritius), I was frequently involved in interviewing patients and presenting to the consultants.  This helped me improve my history-taking skills.  Furthermore, I received great teaching on Cardiac Echocardiography and I was even allowed to practise on patients. However, on the ward, the doctors were so busy that I was unable to practise examining patients under their supervision.  Despite this I still practised on my own, however without receiving any feedback.

An unexpected but very enriching experience for me was the opportunity to practise femoral access for angioplasty, under close supervision.  This improved my self-confidence and made me aware that being calm yet enthusiastic are valuable qualities in medicine.

My most valuable experience was during a day I spent at the neonatal intensive care unit in Mauritius looking after a three-day-old baby fighting for his life.  He was having severe oxygenation problems as a result of Pulmonary Atresia. The only thing that could help him was Prostaglandins, but unfortunately the hospital had run out of stock. Thankfully the staff did not lose hope but continued providing constant support for the baby and his distressed parents.  At first, I was very upset by the whole situation.  I had never been in such a situation, where limited resources had such a direct impact on patient care.  This was especially poignant due to the fact that it was affecting such a vulnerable patient. This experience made me realise that, though I probably would face limited resources at some point in my future career as a doctor, I should never lose heart and always try my best to make the patient as comfortable as possible.  Medicine is not always about curing, it is also about accompanying patients through their journey while being a source of support and reassurance to them.

Observations of Health Care Influences

In Hong Kong, the Government has invested 2.6% of its Gross Domestic Product in the Public Health sector(1). Under the guidance of the Hong Kong Hospital Authority, there has been considerable improvement in terms of high quality care and availability of new technologies.  However, there is an imbalance between the public and private sector, with Hong Kong’s public sector shouldering approximately 94% of total health burden(1). This has resulted in overcrowded hospitals and overworked doctors.  Also many hospitals have now turned to private sector for additional help.  In terms of cultural aspects, as a result of the strong Chinese cultural influence, traditional medicine still occupies an important place in people’s lives.  This has led to herbal remedy clinics being held regularly in hospital.  Concerning epidemiological considerations, since tropical diseases are more frequent in Hong Kong, a lot of emphasis has been laid on prevention of diseases such as Dengue Fever, Typhoid Fever, Leishmaniasis, Filariasis, Leptospirosis and Japanese Encephalitis(1). Also Severe Acute Respiratory Syndrome (SARS), which killed about 640 people(2) in Hong Kong, remains a major health concern.  This has resulted in the government having to re-examine its previous strategies for infection control and notification to the World Health Organisation of infection outbreaks.

In the developing country of Mauritius, a lack of finance and resources means that prioritising and planning is essential. The public sector is under a lot of pressure and medical professionals have long queues of patients waiting everyday to be seen. In order to deal with the increasing challenges, the government has invested in powerful health prevention campaigns with regards to smoking cessation, safe sex, etc. With regards to culture, Mauritius is a truly multicultural country, with ethnic groups from all over the world living in harmony. However, one common cultural pattern which stands out is a reluctance to talk about Sexual Health. As a result, the rates of teenage pregnancy and HIV-related illnesses have been on the rise for the past year, despite all efforts of sex education at school to prevent this. As for epidemiological issues, Diabetes and Cardiovascular Diseases form the bulk of disease burden in Mauritius. This can be explained by the fact that 80% of the population is of Asian origin, and oily fried sweets are very popular amongst the general population. However, habits are gradually being replaced by more healthy ones, such as exercise and cutting down on oily foods.

On the whole, this elective has been extremely challenging and stimulating. I can confidently say that being exposed to different people with their own culture and beliefs has changed my way of seeing things.  I am certain that this help make me a more reflective and less biased practitioner in the future.

Gemina Deepa Doolub, Fifth Year Medical Student, Newcastle University, UK

g.d.doolub@newcastle.ac.uk

• (1) The World Health Organization Statistics. Available at: http://www.who.int/countries/chn/en/. Accessed 13/10/08.
• (2) The Hong Kong Society For Infectious Diseases. Available at: http://www.hksid.org/. Accessed 12/10/08.