I wish someone had taken a picture of my facial expression on my first day at the Women’s Hospital in Kathmandu; I could have sold it to the Tate Modern entitled ‘Horror: Epitomised’. What had tickled my ‘shock’ node so intensely was the realisation that in this cramped, dark, and humid cattle pen crammed with hundreds of waiting women, were doctors peeling off their intimate examination gloves into a scum encrusted bucket, ready for re-use. Later, it transpired that these gloves were transported to a place of hygiene safety whereupon they were sterilised for the next patient. Similarly, theatre drapes, gauze and instruments were scrubbed in the courtyard and line-hung to dry. The ‘single use only’ mentality is so deeply inculcated in the medical fibres of my being that I experienced a knee-jerk feeling of disgust. However, it led me to reflect on the concept of sterility, cost of running and the relation to overall healthcare provision in both the UK and Nepal.

Many consider access to safe childbirth and women’s health a basic human right. The 1996 Nepal family health survey found a maternal mortality rate of 539 out of 100,000 live births and a neonatal mortality of 39 in 1000 live births (1). Why such a poor track record for mortality?

A recent Nepali article highlighted one of the most important causes of neonatal mortality is a high incidence of home births with no trained attendees. Nearly 90% of Nepali women give birth at home. Poor antenatal care is a critical factor, and half of Nepal’s child-bearing women still receive no antenatal care (2). Partly to blame are logistics: poor infrastructure and large hills which make travelling to clinics in rural areas unfeasible. We witnessed this first hand when trekking through the Annapurna circuit. To travel from one settlement to another requires enough people to make the ‘bus’ journey viable. No fewer than 25 people must cram onto a jeep to enable the locals to travel along a slippery ravine-edge to the next town. Whilst myself and a friend clutched each other for dear life, a woman in the front had commenced labour and was being escorted by her family to the nearest hospital. It quickly became apparent that she would not make it in time and would have to find a house in the next town to give birth.

Unsafe abortions account for one third of all maternal deaths in some parts of the world. Deaths from the complications of abortions are largely preventable with adequate access to family planning information and the provision of safe abortion care (1). Nepal took strides towards safeguarding women’s health by legalising abortion in 2002. Compared to neighbouring countries, such as Pakistan where abortion is illegal, Nepal is commendable for its provision of free and safe abortion care (3). Our first day visiting Nepal’s Women and Children Hospital was spent taking part in a training day for the Family Planning Association of Pakistan (FPAP) (4) to enhance their pre, intra and post abortion care skills. Abortion is only permitted in Pakistan to save the life of the woman, and to preserve physical and mental health. Despite this, the FPAP were obliged to take training outside of their country due to religious hegemony surrounding the issue of abortion.

Nepal is admirable in that, despite being one of the poorest countries in the world, the government and other stakeholders have been proactive for policy change. Several bodies have been set up, such as the Safe Motherhood Programme under the Directorate of Health Services of the Ministry of Health’s guidance (5). The aim of this programme was to reduce maternal and neonatal mortality by advocacy and media strategy as well as more practical interventions such as cord blood banking and improved access to skilled birth attendants. In concordance with the Second Long-term Health Plan of 1997-2017, Nepal intends to reduce the Maternal Mortality Rate (MMR) to 250 by 2017.

Upon analysis, Nepal compares favourably with countries of similar Gross Domestic Products (GDP). Afghanistan, for example, has a MMR six times as high. In comparison, South Africa has a GDP seven times that of Nepal, yet has a comparable MMR. The aspiration to reduce MMR in Nepal to 250 brings it on a par with India’s ratio, which boasts a GDP more than double that of Nepal.

Despite bring a poor country, the Government of Nepal, aided by the Indian Government, have provided free hospital healthcare to the poorest members of society at Bir Hospital since 1889. There was a trained midwife present from 1920 onwards, and obstetrics and gynaecology moved to Prasuti Griha hospital in 1985 for more space. From humble beginnings, the hospital now has 321 beds and provides outpatient services as varied as colposcopy, comprehensive abortion care, family planning services and sub-fertility clinics and is the tertiary referral centre for women in the country. The majority of these services are entirely free, with no additional basic healthcare perks reserved for privately paying patients. The atmosphere of the hospital is that of adequate provision of healthcare staff, with a greater emphasis on nurses running the wards. The overall impression was that of efficiency in terms of cost in order to afford the skilled healthcare professionals needed.

This led me to question the financial and material wastefulness of the western world. At Prasuti Griha, adequate care is provided to as many people as possible, within the context of limited resources. This is an echoing theme throughout the corridors of the world’s hospitals, irrespective of a country’s prosperity. Despite all this, if I were faced with an internal examination at Prasuti Griha compared to the shiny Norwegian International Hospital across the road, I know which I would choose.

Sian Cooper
Barts and the London Medical School
siancooper1(a)gmail.com

1. Status of maternal health in Nepal. Vaidya, Achala.
2. A glimpse on the maternal, child health and family planning in Nepal. Giri, Kanti. s.l. : N. J. Obstet. Gynaecol Vol. 1, No. 1, p. 76 – 79 May 2006.
3. Publications – Abortion. [Online] [Cited: 29th July 2010.] www.un.org/esa/population/publications/abortion/doc/pakistan.doc.
4. Association, Family Planning. [Online] 2010. www.fpapak.org/.
5. Motherhood, Safe. http://www.safemotherhood.org/. [Online] 29th July 2010. http://www.safemotherhood.org.np/pages/default.php?function=content_ssmp&secid=35.
6. World, Gapminder. gapminder.org/world. [Online] 2008. [Cited: 29th July 2010.] http://www.gapminder.org/world/#$majorMode=chart$is;shi=t;ly=2003;lb=f;il=t;fs=11;al=30;stl=t;st=t;nsl=t;se=t$wst;tts=C$ts;sp=5.59290322580644;ti=2008$zpv;v=0$inc_x;mmid=XCOORDS;iid=phAwcNAVuyj1jiMAkmq1iMg;by=ind$inc_y;mmid=YCOORDS;iid=pyj6tScZqmEcVezxiMl.

Many students plan their elective based on the 4 S’s: sun, sea, sand and sick people. However, it has always struck me that this period would be a great opportunity to explore areas of medicine to which we have little or no exposure during our medical training. Having studied at the University Hospital of North Staffordshire, there was one area that I was keen to expand my knowledge of – something I was unlikely ever to see firsthand in the Midlands – tropical disease.

I had accumulated reasonable experience in the field of infectious diseases through various placements, student selected components, conferences and also a research module in which I worked with malarial parasites. Throughout these experiences, the medical student mantra ‘Common things occur commonly’ has always held out, and I have more routinely seen evidence of complicated pneumonias, HIV and MRSA than Malaria, dengue and typhoid. I decided to make rarer infectious diseases the objective of my elective planning hoping to be able to work with cases I had only read about in text books. If I happened to find the other 3 S’s along the way, so be it!

A few days later my university was visited by ‘Work the World’, a company which organises electives in Africa, Asia and South America. I discussed my situation with Abby, the project co-ordinator and she told me about the options available through their company. I was immediately taken with the description of India, a place I had not thought about before because of friends who had battled against mountains of red tape to get the correct visas and the right kind of placement. However, ‘Work the World’ are well established and their agreement with the Kerala state government allows their students access to a range of hospitals and clinics. Most importantly for me, they could arrange a placement at a state-run hospital in Trivandrum that included 4 weeks of adult and 4 weeks of paediatric tropical disease. On top of this, accommodation, food and transfers from the airport were all included, and there is local staff on hand 24-7 that could support me if things didn’t go to plan. I didn’t need much convincing to sign up!

When I arrived in Trivandrum, I had 24 hours to settle in to the accommodation, orientate myself within the city and recover from jet-lag before I started work at the General Hospital, one of the few state funded hospitals in Kerala that treat people below the poverty line (the equivalent of 300 rupees/ £4.30 per month). The catchment area included not only the people dwelling in the city, but also the surrounding rural areas. It was filled beyond capacity at all times and outpatient clinics (consisting of 2 doctors) could see in excess of 400 patients in a day. When the wards did not have enough beds to accommodate all of the inpatients, people would just sleep on the floor. It was very clear that this hospital, while commendable for offering some kind of service to the poorest people in the community, was severely underfunded and under resourced.

My first day on the adult ward for infectious and tropical diseases and I was confronted by roughly 40 patients suffering from a range of diseases including Dengue, Malaria, Typhoid, Leptospirosis and TB. This was something I had wanted, but faced with such a desperate state of healthcare economics every day on the ward rounds was hard to accept. There were no side rooms or areas where infectious patients could be kept in isolation from the others, and despite hundreds of mosquitoes in the wards, the only method to prevent the spread of malaria from one infected patient to another, was the provision of mosquito nets. Although this makes sense on one level, closer inspection showed these nets were old and riddled with holes and many patients, not understanding their condition, simply removed them when they became too hot. TB patients fared no better, taking on another battle when it came to a lack of medication. Although a number of drugs were paid for by the government, the rest had to be funded by the patient. Needless to say, none of those living below the poverty line were able to afford any of these additional drugs, so all patients on the ward, regardless of their disease, were prescribed the same cocktail of crystalline penicillin, cefotaxime, ranitidine and B complex vitamins. When I asked one of the doctors if they were concerned about spreading antibiotic resistance by using the same antibiotics for every patient they simply asked, “What’s the alternative?”

Male Infectious Ward

Now I should probably point out that I am not so stupid as to believe that the hospitals in India would be similar to those we have in the UK. I knew I was going to a state hospital, and I had conjured up what I thought was an appropriate expectation – I wasn’t shocked that the floors were bare concrete, or that food was being cooked next to the patients’ beds. I wasn’t even that surprised that the sluice ran in a trough down the middle of the ward so that you had to jump over it to get in and out. That being said, I had not prepared myself for actually witnessing people dying as a direct result of a poorly funded healthcare system. A memory that will always stay with me is that of a 13 year old girl who was brought into the paediatric outpatient’s clinic unconscious and in a dehydrated state. Her parents reported that she had suffered 6 days of diarrhoea, and had lost consciousness during the previous night. She was admitted to the paediatric intensive care unit (PICU) and started on multiple saline infusions and a dopamine infusion in order to bring up her blood pressure (which had not been recordable on admission). On taking a detailed history from her parents, it was discovered that the episode of diarrhoea had started after she had eaten an ice-cream which they didn’t believe was made with clean water. It was decided that the girl was probably suffering from acute infective diarrhoea (AID) and was started on IV Cefotaxime. After 12 hours the girl’s hydration status had returned to normal but she had not regained consciousness. There was doubt about the causative organism of the condition, but the parents could not afford to pay for any further investigations such as a CT scan, stool or blood cultures, and these tests were not provided by the state funding. Unfortunately, the girl died after 28 hours in hospital. Post mortem revealed that she had been suffering from Shigella Encephalitis.

General Hospital, Trivandrum

Rural patients arriving at the hospital when it was too late, or when expensive treatments were the only possibility remaining, was a common problem throughout my time in Kerala. It made me realise a lack of resource by the hospital and a shortage of funds from the patient’s family were not the only problems. The healthcare system in India is hugely affected by the level of public education and although Kerala boasts nearly 100% literacy because the state provides compulsory primary education, levels of health education vary widely between the urban and rural areas. In the urbanised areas, there is a high level of awareness about common infections, what symptoms they present with and when an illness is at the stage where it requires medical intervention. This is not the same in the rural areas, where there is little knowledge of different infections, and often Ayurvedic Medicine (Indian traditional herbal medicine) is used in preference to western medicine.

Ironically, it is in the rural areas where many of the infectious agents are more prevalent, for example leptospirosis, which is spread easily amongst the workers in the rice paddy fields. There is also an ongoing problem with rabies. Over recent years there has been a change in government attitude towards the treatment of stray dogs in India and whereas before they would be culled frequently to prevent the spread of disease, the government has decided that dogs should not be killed due to widespread religious beliefs. This has unsurprisingly resulted in a rise in the incidence of rabies, which has, in turn, necessitated the provision of public health education about what to do if bitten. Whilst this information is widely known in urban areas, it is not so in rural communities and many people from those areas either do not seek medical attention at all when they are bitten or attend an Ayurvedic doctor instead. These patients then present to the state hospital in Trivandrum at a later date, once the disease has irreversibly progressed to the terminal phase. I saw one such patient who presented to the outpatients department with hydrophobia and dehydration having been bitten by a pet one month previously. He had not sought medical help prior to this point and was clearly in the terminal phase of the disease, he was admitted to one of the hospital’s ‘Rabies cells’ (darkened rooms without any stimuli to the hydrophobia). In this cell he was administered some rectal diazepam (he was not able to take it orally due to laryngospasm) to keep him relaxed. He died a day later.

Resource Room

Aside from the medical aspect of my time in India, I was also able to see a lot of the state of Kerala and experience some of the culture. I was very fortunate to be in Trivandrum at the time of the Pongala festival. During this festival, 3 million women from around India line the streets of Trivandrum and cook dishes which they then take to the temple as an offering to the gods. While men aren’t allowed on the streets during the festival itself, in the week leading up to this day there are various parades taking place across the city which everyone can attend and I was fortunate enough to be able to see one of them. It was quite a magnificent spectacle!

Pongala Festival

To finish up this article, I should probably offer some guidance to those thinking of pursuing something similar for their elective, based on my experiences. I think a few things that I would highlight are:

• The importance of travelling with a reputable company that can give you the kind of placement that would be most rewarding
• The idea that you cannot necessarily predict what you will see. Nor can you predict the patient’s outcome. So prepare to be shocked!
• It can be fascinating to go in search of something you’ve never seen before.
• UNcommon things occur commonly in India- so go and see them!

I’d like to conclude by saying that my time in India was fantastic despite some of the unfortunate cases I witnessed. I learnt a huge amount and gained a lot of experience in both tropical diseases and Indian culture and healthcare. This placement has really made me appreciate the NHS and how fortunate we are to have free healthcare for everyone, and has also inspired me to consider infectious/tropical diseases as a potential career path.

Daniel Monnery
Medical Student
daniel_monnery(a)hotmail.com

Bangladesh leads the world in exemplifying how non-governmental organsiations (NGOs) play a vital part in the lives of the poor to bring them out of the shackles of poverty and open up economic opportunities for them. Dr. Muhammad Yunus won the Nobel Peace Prize for his pioneering concept of micro-credit, which is being emulated around the world, and Bangladesh boasts of the largest NGOs in the world. During my travel to Bangladesh, I was interested to learn about the healthcare services available, particularly to the poor, and especially the role of the NGOs in this regard. Bangladesh’s healthcare system is not equipped to provide adequate ‘free’ healthcare to its citizens. A variety of NGOs have been set up to try to address this inadequacy. During the visit, I concentrated on the healthcare services provided at the grass-root level by two organisations, namely, Marie Stopes and Ghashful.

Marie Stopes is one of the earliest NGOs set up in Bangladesh and there are around a hundred branches in the country, mainly in the Chittagong region where I went. The clinic provides healthcare services to people from the surrounding areas at very low costs to those who can afford it and for free to those who cannot. The services mainly target women and children with a big focus on immunisation, pregnancy care, family planning counselling, and reproductive health counselling. One to one consultations are carried out with everyone seen. In addition, a variety of birth control facilities are provided, which is encouraged and facilitated by the government as a population control measure. These include, techniques such as vasectomy, tubectomy, injection, tubal ligation, pill and so on. Moreover, abortions are also carried out in the clinic and a huge emphasis is placed on confidentiality, as abortion is still a taboo subject in Bangladesh.

Marie Stopes are contributing enormously to the effort in curbing unplanned pregnancies as many find it difficult to sustain children with limited income. The government is hugely encouraging such efforts and both the government and NGOs have achieved tremendous success in reducing the population growth rate in the country, which remains the most densely and overpopulated country in the world. Marie Stopes also have ‘homeless vans’. These are vans equipped with medical equipment, almost like a mobile hospital and are used to target people living in villages, remote areas and people who are generally homeless. I joined in on these visits. Patients are by and large extremely grateful for the services provided, as they have no one else to turn to and would not be able to afford to go anywhere else.

Ghashful too provide a lot of services to the poor, including healthcare services. In terms of health, it provides clinical health services, immunisation, family planning, safe delivery, STD and AIDS awareness, breast cancer awareness and much more. I spent a lot of time in their ‘fixed clinic’, where people with no access to registered physicians can get health services and free medication. I also observed their ‘satellite clinics’, which involve a doctor and health assistant attending to patients at their doorstep. Another innovative programme used by Ghashful, was to target sectors like garments workers, which is a large industry in Bangladesh with mostly women workers working for long hours on limited pay. Health services are thus provided by directly going to these workers and running awareness programmes, such as on HIV, during work breaks in collaboration with the employers. Like Marie Stopes, Ghashful also offer birth control measures. Furthermore, it also had a team of midwives who work to provide safe deliveries, since death of mother and child due to antenatal and postnatal care problems is common in Bangladesh. Moreover, trained physicians provide education to pregnant women on topics such as nutrition, hygienic practice and breastfeeding.

Another incentive that has recently started by Ghashful is a breast cancer awareness and screening programme. Breast cancer is a condition that is not widely known about in Bangladesh, even though very common. Together with this, other services offered by Ghashful are in the field of education and vocational training. A number of satellite schools and skills centres have been set up in an attempt to increase the literacy rate of children and family members and impart vocational skills to help open up career pathways for the poor.

NGOs like these are bringing about much needed services to the poor. However, NGOs themselves are not free from problems – paucity of resources and the shortage of funding are big hindrances to their growth and expansion of services.

Overall, the trip was a very fulfilling experience for me. I gained an insight into the problems facing a developing country like Bangladesh and how the small efforts of NGOs are helping, alongside government initiatives to address the scarcity of health care services for the poor.

Tashmeeta Ahad is a fifth year medical student at the University of Oxford
tashmeeta.ahad(at)medschool.ox.ac.uk

I did my elective in ear, nose and throat (ENT) at the Queen Mary Hospital, a teaching hospital affiliated with the University of Hong Kong (HK).

From the Hospital

The ENT team of doctors and nurses is very used to having students around and they are extremely friendly to elective students. Learning was mainly self-directed. A time-table of the different clinics and theatres running for a typical month was given and I was free to attend sessions that interested me most. My elective period also coincided with the last academic week for the local final year students and I was able to join them for a few lecture-based teaching sessions.

I spent most of my time in clinics as I found that most useful. There were also many day-case surgeries like tonsillectomies, branchial cystectomies, thyroidectomies, myringoplasties, nasopharyngeal scopes and biopsies. In the operating theatre, student participation in ENT surgery can be quite difficult as the structures involved are small but I was still able to scrub in for most cases. ENT also uses the operating microscope frequently and on several occasions, I was given the opportunity to take over from the registrar when his assistance was not required by the consultant.

In the operating theatre

As private practice is common in HK, the incidence of serious and rare conditions presenting in a government hospital, such as Queen Mary Hospital, was high because most patients would delay seeking treatment until their disease has progressed. I got to see many children with hearing and speech problems, as well as some requiring ear reconstruction due to congenital abnormalities (this involved taking cartilage from the ribs!). I also found that the equipment used at Queen Mary Hospital was very advanced. There was a machine that could superimpose the area of intervention with computed tomography (CT) images throughout the operation in the removal of polyps so that the risk of blindness was significantly reduced. This is something that I have not come across during my time studying in Glasgow. The ENT department also has a Da Vinci robot, which only 2 experienced surgeons in the department were trained to operate with and it was used mainly for tonsillectomies.

Although clinical communication with patients was mainly in Cantonese, this was not a problem for me as I am from Hong Kong originally. Nonetheless, the attending clinician made sure that I understood what was going on and tried to take some time in between consultations for some discussion although this was not always possible due to time constraints. I also witnessed for myself, how an effective and focused history was taken, as well as dealing with the patient’s anxieties and breaking bad news. I saw a difference in the nature of how different doctors related to their patients, and how they presented themselves.

Me and Dr Ng YW

My elective supervisor, Professor William Wei, is renowned for his research and development of the maxillary swing procedure in the surgical removal of nasopharyngeal tumors, which is most prevalent in Southern China, including HK. The ‘legendary’ maxillary swing is done about once a week or a fortnight and each time, the training registrars, consultants, as well as exchange doctors from all over the world would be present. Nevertheless, Professor Wei was also committed to teaching and made sure that I got to see and feel a lot of interesting things such as various lumps and bumps like thyroglossal duct cysts and lymphadenopathies. There were also weekly grand rounds during which every doctor in the team attended. Cases would be presented to Professor Wei and he would ask the consultant in-charge questions about the best treatment available and how things could have been done better. However, I found that not all the doctors appeared to be interested and compared to my experience in the UK, there was a lack of discussion and questioning. I felt this to be attributable to the difference in culture where Asians tend to be more reticent and fearful of speaking up to their superiors.

Poyi Sau is a fourth year medical student from glasgow university
0505798s(at)student.gla.ac.uk

Guru Tegh Bahadur Hospital – Side Entrance

I did my medical schooling at University College of Medical Sciences, one of the top medical schools in India, under University of Delhi in New Delhi, India. I was very fortunate that I got the opportunity to learn and gain invaluable experience from the Medicine Department of Guru Teg Bahadur Hospital during the course of my medical education.

Guru Teg Bahadur Hospital, better known as GTB hospital, is a tertiary care Government hospital located in the eastern part of the city in Dilshad Garden area. It serves a large population of eastern Delhi and western Uttar Pradesh and has 1000+ capacity of in patient services. The GTB Hospital Complex is spread over a an area of 89 acres comprising of College Block, Library & conference block, spacious Out Patient Departments, Indoor Wards, Central Laboratory Services & O.T. Block and many other ancillary facilities [1]. GTB Hospital has 21 academic departments with 174 faculty members. The faculty provides expertise to various apex institutions like UNICEF, WHO, ICMR, NACO, DST, DBT and CSIR etc [1].

During my clinical rotation in the medicine department in GTB Hospital, my colleagues and I were introduced to the whole department and it’s functioning on the first day. The tentative schedule of our rotation and things we were expected to know at the end of rotation were described in the orientation class. I was very impressed by the friendly nature of the residents and the consultants. The speedy and efficacious working of the department, in spite of being terribly overburdened, fascinated me. The average occupancy of a bed in the in-patient ward was more than one.

I used to attend out-patient services (OPD) and in-patient services on rotation basis. During OPD days, I saw the way consultants tackled the patients and get the relevant history with their art of communication. The consultants taught us various important medical topics besides teaching the art of communicating with the patients. They also showed us important findings in the patients. During the in-patient services, we used to take an interesting case every day and present it to the consultant who then used to teach us the relevant topic and help us learn the correct method of examining the patients.

During this rotation I had the opportunity to attend few classes of Dr. Shridhar Dwivedi. He is currently Professor and Head, Department of Medicine, Division of Cardiology/Preventive Cardiology, GTB Hospital, Delhi. He is also in charge of ICCU (Intensive Coronary Care Unit) in GTB Hospital. He has made some great contribution in the field of Preventive Cardiology. I was mesmerized by the personality of Dr. Dwivedi. After his teachings only I realized the importance of ‘preventive medicine’. He has contributed immensely to the atherosclerosis research in India. He is widely known for his outstanding work on “Cardioprotective activity of Terminalia arjuna in coronary artery disease” [2], [3] and “Betel quid seller syndrome” [4]. His contribution to the understanding of risk factors particularly role of smoking, stress and heredity in young CAD puts him in the fore front of distinguished medical scientists of the country. He has put up a novel concept of cardiovascular continuum comprising “coronary artery disease, type 2 diabetes mellitus, essential hypertension and atherosclerotic cerebrovascular accident”.

I was highly impressed by his teaching and guidance. His discussion on smoking and its burden on society were awesome. He used to include few shlokas of Sanskrit language in his teaching which created an everlasting impact on the mind. The lessons learnt from him and the interest I acquired in medicine during this rotation inspired me to make my mind to go for Medicine as a specialty for my post graduation. I realized that medicine is the only complete branch where to get patient of every type. The interaction we had with patients helped me realize the burden of disease and importance of prevention of disease. “Prevention is better than cure” was not said in vain. I saw patients were terminally ill after chronic smoking and drinking. It was pity to see the crying family members. I realized that a lot needs to be done in respect to patient education to prevent further mortality and morbidity from alcohol and smoking.

The experience I had at Medicine Department was invaluable. It was really inspiring to watch and learn from such talented staff and expert doctors. It was a very enriching experience. The practical knowledge I acquired from this elective will really prove a great asset to me in future. I would sincerely like to thanks Dr. Shridhar Dwivedi, Head of Medicine Department, for providing such an invaluable knowledge and comfortable learning atmosphere.

Sourabh Aggarwal is a medical student at University College of Medical Sciences, New Delhi and Delhi University, India
drsourabh79(at)gmail.com

References:

1. http://www.ucms.ac.in/MBBS%20Booklet.pdf

2. Dwivedi S, Aggarwal A, Agarwal MP, Rajpal S. Role of Terminalia arjuna in ischaemic mitral regurgitation. Int J Cardiol. 2005 Apr 28;100(3):507-8.

3. Dwivedi S, Jauhari R. Beneficial effects of Terminalia arjuna in coronary artery disease. Indian Heart J. 1997 Sep-Oct;49(5):507-10

4. Dwivedi G, Dwivedi S. Betel quid seller syndrome. Occup Environ Med. 2010;67:144

Background
For a long time I had thought about undertaking my elective in Australasia. Whilst an elective in the outback would no doubt have been educational, if I were to be honest with myself I would only be going there for the sun and the surf. I sought after an elective that would match both physical and intellectual desires and, after several weeks of searching for alternatives, I stumbled upon the Himalayan Health Exchange website; Australia and New Zealand would have to wait.

Arriving in India
Following the hectic months leading up to the 4th year medical finals, I embarked on the elective with Robin Dawson, a fellow medical student from Dundee. We flew overnight from Glasgow via London to Delhi. The experience in Delhi is like nothing I have ever had before. Opening the doors of Delhi International airport was like stepping into a mauled steam room. Even at 6am there were seas of people that were held back by rusting metal railings. The effect was dramatic. Taxi ranks were replaced by never ending lines of autorickshaws; organisation and order was replaced by the anarchy of structured chaos; the typically unnoticed smell of cleanliness was replaced by fumes, sweat and human excrement. We had entered into the Indian melting pot of true human traffic. We got a rickshaw from the airport to our hotel in the Main Bazaar of Delhi. Throughout the journey the driver persisted with limited English to get us to go to his affiliated hotel. We quickly learned that commission and bartering are the norm in India. The entrance to the Main Bazaar involved channelling two lanes of semi-concrete traffic into a single lane dirt track. Whilst dodging the odd cow and beeping his horn furiously, the rickshaw driver pressed through the bottle neck of rickety cycles, stalls and mass expansion of people to arrive at our hotel. Sweaty, jet-lagged and emotionally exhausted from our first hour’s experience in Delhi, we turned on the air conditioning in our room and swiftly fell asleep. We had arrived in India.

The initial welcoming into Delhi was brutally honest, confounding and by no means enjoyable. We spent the first afternoon trying to navigate our way to the official tour centre in the business hub of Connaught Place. Robin and I, both quite tall by Scottish standards, had become giant magnets in India with a constant entourage of over 20 people. We promptly booked an overnight bus out of Delhi and headed north to the organised meet-up point in Leh.

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“In the past, there were repressive regimes; there was slavery, the Holocaust – terrible methods of dehumanization. In today’s world, we have bitter patterns of migration, of illegality. Refugees and exiles of war and poverty, moving from rural landscapes to urban centres, from poor countries to rich countries – the kind of journey that undoes one’s spiritual, one’s personal place in the world, making anyone uprooted from home exchangeable with anyone else, leading to betrayal in myriad forms, economic to sexual” [1]

“Sex workers are creatures of the dark. They exist in every society but are kept invisible. They are to be used but not talked about” [1]

(Quotes from the collection of narratives, AIDS Sutra: Untold Stories from India)

Initial Site Visits:

I spent this past summer in southern India researching and learning with Karnataka Promotion Health Trust (KHPT), an NGO affiliated with a Canadian University (the University of Manitoba) that is working on all aspects of the HIV/AIDS epidemic in the country. Focusing on vulnerable groups, such as female sex workers (FSWs), men who have sex with men (MSM), as well as people and children living with HIV (PLHIV), their projects span the spectrum of prevention to comprehensive care, research to project planning, and implementation to evaluation. One of KHPT’s major research projects is called “Payana,” meaning ‘journey’ or ‘travelling’ in the local language (Kannada), whose goal is to learn more about the connection between migration and HIV and translate this knowledge into more effective prevention programs and services. My qualitative research project, “HIV/AIDS risk and vulnerability among new rural female sex workers in northern Karnataka, India,” is part of that larger study and aims to learn about the life experience of new female sex workers in the study area and further understand KHPT’s preliminary research finding that women experience an elevated level of HIV risk and vulnerability during the initial period of practicing sex work (first 1-2 years).

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Introduction

“Short” is a gross understatement to describe the three summer months between pre-clinical and clinical years of medical training in Canada. As the last official summer holiday before graduation and beyond, these twelve weeks must be spent wisely. Many students choose to relax and travel, eager to recharge in preparation for the long road ahead. Others occupy themselves with research or clinical observerships to explore their vocational interests in greater depth.

It was in the context of seeking a balance between work and leisure that I applied for a two-week General Internal Medicine (GIM) elective at the Singapore General Hospital. Singapore was an ideal location; against the background of a flourishing multilingual and multicultural society, its citizens are generally well versed in English. I had planned a six-country vacation around Asia, and this elective held promise to serve as both a productive learning experience and period of acclimatization to the continent. The toasty equatorial weather and my insatiable craving for authentic Singaporean cuisine may also have contributed to the decision-making process.

The Elective

My elective took place in early June 2009 at the cusp of H1N1 influenza pandemic. Singapore, applauded for its management of the SARS outbreak six years previously, was quick to implement infection control measures in its healthcare facilities. Singapore General Hospital, the largest hospital in the country, was no exception. My arrival to the orientation required two security checks and body temperature scans, and within minutes I was donning a mandatory mask that I would wear throughout my visit.

The elective was impressively well organized from start to finish. I was attached to Professor Ong Yong Yau, a senior GIM staff, and provided with a schedule of seminars to attend throughout my two weeks. During my first afternoon, Professor Ong took me to see the GIM wards and introduced me to the House Officers, Medical Officers, and Registrars on the floors. Despite being the only medical student working in the department during my first week, everyone was extremely helpful and friendly. I was given the opportunity to decide what seminars or wards to spend my two weeks on, and encouraged to tailor the experience toward my interests.

On the ward with Professor Ong Yong Yau at Singapore General Hospital

Most of my time was spent in three wards supervised by House Officers and Medical Officers. Days would start with morning rounds at 7:30am – 8:00am and end around 5:00pm with exit rounds. I was not assigned patients to independently manage, which is a common practice in North American inpatient medicine electives. However, I certainly appreciated the flexibility to rotate amongst wards to gain exposure to a wide spectrum of clinical problems and physical findings. In one afternoon, I saw one patient with liver disease and a marked Dupuytren’s contracture, another with dramatic mitral insufficiency, one with Dengue fever, and a fourth with Herpes zoster. The House Officer on the ward in which I spent most of my time gave me opportunities to practice establishing intravenous access, drawing blood, and performing assessments on newly admitted patients.

Medical and House Officers of General Internal Medicine Ward 7C

Learning and Education

One of the features I enjoyed most about this elective was the amount of teaching that took place. I attended seminars or resident teaching rounds nearly every day. During my elective, we reviewed ECG interpretation, blood dyscrasias, dyspnea, acute limb pain, use of angiotensin receptor blockers, and approaches to common problems in dermatology, to name a few topics. Professor Ong would also recommend teaching sessions held by other departments. For example, I benefited from Radiology lunch rounds where staff from various medicine sub-specialties would bring challenging or uncertain clinical cases for a radiologist to interpret. These teaching sessions were appropriate for my level as a medical student, and in the friendly atmosphere established by the post-graduate trainees I felt comfortable taking part in discussions.

While structured learning was a valuable review of core content, it was the informal bedside teaching I received during ward rounds that I found to be a highlight of my elective. Each morning, the House and Medical Officers responsible for the ward would present Professor Ong with an updated status of their patients. He extracted at least one clinical pearl or teaching point from every clinical case we reviewed. Moreover, I learned highly applicable material, not “zebras” or academic minutiae. The knowledge Professor Ong imparted focused on direct management of each patient; not to treat asymptomatic bacteruria, how to manage electrolyte disturbances, and appropriate work-up of anemia in the elderly, to name a few examples. He would also emphasize proper physical examination techniques with immense patience as we practiced under his guidance.

Reflections on the Experience

Simply by living in a different environment, my perspective of health was vastly broadened. This too was a meaningful learning opportunity for both personal and professional growth. The context in which we work has a tremendous impact on our experience; my exposure to Singaporean health care was only brief, but the contrasts to the Canadian system became apparent from my first day. These contrasts often reflect larger societal differences, expectations of patient care that were in turn based upon cultural norms and political views. I enjoyed meaningful, and often humorous, conversations with the medical staff about the differences in our cultures and their many manifestations in medicine. Many of the House Officers, Medical Officers, and Registrars had done training in other countries prior to arriving in Singapore, and would share their unique perspectives in the discussions. Attitudes toward allied healthcare professionals were perceived to be mutually friendly and respectful. In the midst of a pandemic influenza outbreak, the rapid implementation of infection control protocols was a clear demonstration of this highly organized society. The patient population alone was entirely different. I learned to speak commonly used words, such as “pain”, in four languages, and certainly improved upon my broken Chinese. In Singapore General Hospital, I witnessed the death of a patient and the experience of breaking bad news to the family. And lunch at the Houseman’s Canteen, where a variety of Chinese, Malay, and Indian staple dishes could be had for very affordable prices, provided my stomach with the same cultural nourishment as my mind.

When all else about this elective begins to fade from memory, the friendships I formed during my short stay will certainly endure. I travelled to Singapore with a good friend and classmate who spent his time in the operating theatre on a General Surgery elective, and we stayed together at a hostel one stop away from the hospital by the ultra-modern Mass Rail Transit system. Aside from the natural bonding that inevitably occurs when sharing a cramped double bed together for two weeks, we spent many evenings reflecting on our sights, sounds, and feelings in our different hospital environments. We also met and worked with other students from Germany, Hong Kong, France, and England who shared our penchant both for international electives and after-work adventures. Together, they made an otherwise gratifying educational experience in Singapore exciting, amusing, and wonderfully fun.

Visiting students enjoying a break at the Houseman’s Canteen

Recommendations

I would highly recommend an elective at Singapore General Hospital for anyone wishing to be immersed in a fascinating culture, meet like-minded international students, and discover how medicine is taught and practiced in a city-state five million strong. My experience significantly exceeded any expectations I had when registering for it. Students interested in spending time at the hospital might benefit from applying early and enquiring about availability of the on-campus accommodations. As with any elective, having a solid foundation of common topics in the field before beginning work provided a tremendous learning advantage. Of course, a tolerance for spicy foods and affinity toward the delicate fusion of Asian cuisines would serve you in this country far better than Harrison’s latest edition.

Singapore’s famous Black Pepper Crab

Acknowledgements

I am grateful to the entire General Internal Medicine faculty at Singapore General Hospital and to all of the international students whom I had the privilege of getting to know. In particular, I wish to acknowledge Professor Ong Yong Yau, Dr. Terence Tan, and Dr. Chung Siok Chin for their outstanding hospitality and accommodation. Finally, I would like to express my heartfelt appreciation to my classmate Jayant Ramakrishna for his extraordinary patience as a travelling partner and our profoundly insightful discussions together.

Nigel Tan is a third year medical student at the University of Toronto in Toronto, Canada.
n.tan(at)utoronto.ca

Application for an elective at Singapore General Hospital: http://www.sgh.com.sg/Education/Undergraduate-Medical-Education/Pages/application.aspx

The burden of musculoskeletal conditions prompted the World Health Organization to declare 2000-2010 as the ‘Bone and Joint Decade’, highlighting its severity (1). Coupled with my interests from third year musculoskeletal PBL scenarios, I sought to futher my understanding of the field of Orthopaedics through my junior elective. From the myriad of possible centres for my elective, I decided on the National University Hospital (Singapore) because of its rigorous undergraduate curriculum and established academic department in Orthopaedics.

National University Hospital, Singapore

I was assigned to one of the medical student clinical groups where we were given scheduled teaching. This comprised of tutorial groups, lectures, seminars and clinical examination sessions. In addition, I was expected to clerk patients in the clinics and wards, presenting them to my supervisor and clinical group. Daily ward rounds began at 7:30 am, where I was part of a multi-disciplinary team that reviewed new cases. By shadowing house officers on call, I was able to gain insight to my job-scope required in future. Mondays were fixed theatre days where I would scrub in and assist my Supervisor. I found this extremely beneficial to my practical skills of gowning, suturing and anatomy.

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The last time I participated in a mission trip was back in January 2008 in Cambodia. That was part of my church’s 14-day evangelical and medical outreach. This time round, the medical trip had no religious component; it was organised by a student-run organisation – Singapore Medical Society of Victoria (SMSV). SMSV aims to bridge the gap between medical students in Victoria and the healthcare industry in Singapore. They had previously organised a trip to Hainan Island, China. Past participants have commented they were able to step above and beyond their usual roles as medical students and do ’so much more’, e.g. perform a lipoma excision. As such, when I heard about an upcoming trip to India, I did not pass up the opportunity.

Vellore is a city in the state of Tamil Nadu, India. The name, Vellore, is derived from the Tamil words : Vel and uur, means city of spears. Ancient history shows that Vellore was a battle field, where the warriors used to fight. As of the 2001 India census, Vellore City had a population of above 900,000. Vellore has an average literacy rate of 74%, higher than the national average of 59.5%: male literacy is 80%, and female literacy is 68%. In Vellore, 11% of the population is under 6 years of age.

About 15 students (all from Melbourne) were accompanied by a team of doctors and nurses from Singapore, led by Professor Fong Poh Him, a renowned plastic surgeon from the Institute of Plastic Surgery, Singapore. The aims of the trip were two-fold. Firstly, a surgical team performed surgery at the Sri Narayani Hospital & Research Center to supplement the services available there. Whilst the hospital is multi-specialty, they do not have what the local medical fraternity term super-specialties, like plastic and reconstructive surgery. A couple of cleft palate cases were arranged beforehand for Professor Fong to operate on. In line with one of the mission’s objective of capacity building, a local ENT surgeon also scrubbed in to learn the procedure from Professor Fong. I heard reports from the Director that the ENT surgeon learnt very fast, and was essentially doing the second procedure himself with Professor Fong supervising. Secondly, we ventured out into a preselected village in the state of Tamil Nadu, where we set up a makeshift clinic to provide locals with primary health screening, antenatal screening for pregnant women and basic dispensing services. There were several healthcare professionals including a gynaecologist, general practitioners, and surgical nurses. We had some basic operating sets to do simple local-anaesthesia based procedures if necessary.

Primary healthcare in rural Vellore

The village center we visited was more than 50 kilometres away from Vellore city centre. The estimated village size was about 150. The makeshift clinic was situated in a local primary school. We know that because during break time, lots of curious little ones poured out to the clinic area, eager to see who these foreigners were and what they were doing.

When it comes to the spectrum of diseases that the medical team come across here in rural Vellore, one might expect late presentation of illnesses and exotic infections only mentioned in the fineprint of general medical texts like the handy Oxford Handbook of Clinical Medicine. For the large part this was not so. The same chronic diseases that afflict any developed population also apply here: heart disease, diabetes, osteoarthritis, etc. Many did present with polyarthritis and a preceding viral illness. Only after 30 or so patients did someone with better English told us he was diagnosed with chikungunya, a type of alpha-viral arthropathy, at the hospital. Chikungunya (CHIK) is a mosquito-borne viral illness which manifests itself with an acute febrile phase lasting only two to five days, followed by a prolonged arthralgic disease affecting the joints of the extremities. The pain associated with CHIKV infection of the joints persists for weeks or months, or in some cases years. When I hear some of them make a living as farmers, and bemoan in Tamil their plight, I cannot help but fill with heartfelt sympathy.

I was told universal healthcare exists in India, and these villagers get their usual primary care from a similar mobile clinic, staffed by only a local doctor and several nurses/students from the College of Nursing. When necessary, a referral is made to the Sri Narayani Hospital or the larger tertiary referral center at Vellore Christian Medical Centre. Also, when something emergent or troubling occurs, the locals do know how to seek help at the hospital. Access to healthcare is limited but not totally absent.

Our involvement here however, was not entirely superfluous. For these 2 sessions of clinics (9am to 1pm), the medical team saw over 250 patients. Patients were first pre-clerked by senior medical students (years 3 and 4) to quickly obtain a history of presenting complaint. I was stationed here. I spent no more than 3 minutes on each. This also took into account the time taken for translation from the local language Tamil to English and vice versa. They were then directed to a blood pressure check. Time-permitting, we got the junior medical students (years 1 and 2) to listen to their chest and lungs. Our team also brought glucometers, so all had their random blood glucose tested. Next, there were 3 doctors who each had the final say in diagnosis and management. Finally, a local nurse was in charge of dispensing any prescribed medication.

An acute case lit up the second day we were there. A 4-year-old boy presented with an infected burn over his left axillary region. Thankfully Professor Fong was around so we promptly referred it over to him. Oh, did I mention there was a Channel News Asia video crew there? They focussed all their attention on that poor little boy. Essentially they cleaned up the wound and dressed it. At the same time, the nurses were educating the parents about the importance of keeping the wound clean and teaching them how to dress it.

Sri Narayani Hospital

After a sumptuous Indian-inspired vegetarian lunch, I spent some time in the hospital. I went into the General Surgical Outpatient Clinic (unfortunately their operating list was over) and joined the consultant. This was familiar territory once again – tertiary level care, general surgery, outpatient clinics. Almost everything was similar, other than the language.

One interesting thing I saw was this elderly gentleman who presented with some GIT complaint and yet he was walking around with this external fixator with no qualms whatsoever. If I am not mistaken, he had a fractured tibia in an accident several months back. I would have thought someone like this would be one some sort of bed rest. Perhaps his abdominal complaints were too much.

Future mission trips and educational opportunities

This operation is projected to span five years, with 1 to 2 trips made per year. Throughout our involvement, the team hopes to share our clinical expertise and practices with the local healthcare providers (especially in the subspecialties), and also provide primary health services and advice to selected villages which do not readily have access to health services otherwise. Talks were held to discuss the possibility of CME sessions like conferences or seminars conducted by specialists from Singapore. The Director of Sri Narayani Hospital also welcomed medical students to spend a longer period of time (2-3 weeks) at the hospital to experience the pathology unique to India. Through SMSV, future students might be able to do so A big plus for student opportunities is that S.N. Hospital is private and only staffs consultants. This means that there are no other medical students, interns or residents roaming the hospital.

Vellore CMC – World-Class Hospital

Perhaps the most well known thing that comes to mind when one speaks of Vellore to a health professional will be a Vellore Christian Medical Center (popularly known as CMC). Vellore CMC is a referral tertiary hospital and one of the largest and most renowened hospitals in India. It attracts a floating population of at least 5000 persons every day. The hospital was founded in the early part of the 20th century by a Cornell-educated medical missionary Dr. Ida S. Scudder. It is a very popular elective location for medical students from all over the world because one can experience unique Indian pathology being tended to by world-class medical and surgical teams. Since I was there, I did not pass up the opportunity to at least pay a visit.

India is a fascinating tourist destination but also a great place to see the stark contrasts between health outcomes of the poor and underserved and the rich who can afford private healthcare or health insurance. I would recommend either of the above hospitals for your elective. I for one will surely be back for more.

Jeffrey Leow is a final year medical student at Monash University in Australia
jeffrey.leow(at)gmail.com