I couldn’t believe it when Impact India agreed to let me spend my elective with them on The Lifeline Express Hospital (based in a train) and with their Community Health Initiative. It was the stuff of medical student dreams – to work with top surgeons, whilst gaining experience of field medicine in a remote rural setting, and all taking place on the incredible travelling hospital on wheels! It was with great excitement that I packed my stethoscope and guidebook and set off for the train parked in Ghazipur, in the heart of Uttar Pradesh, India.

I was hoping to achieve an understanding of how the Lifeline Express and the Community Health Initiative facilitate access to healthcare for remote populations, and what it is about India that means such projects are needed. I also wanted to get involved with the work done on the train and in the community,  to feel part of the team, and of course to expand on my existing medical and surgical knowledge and skills.

China: the next frontier.

It’s the talk of the international community: a country of unsurpassed growth, truly the next land of economic opportunity. A country with a history steeped in thousands of years of tradition, turmoil and reform – it makes for an exciting place to do a clinical elective. This article will outline my experience on an elective there, and how you can go about scoring the elective of your dreams.

Source: Zhang Zhang (张涨）on WikiCommons

Part 1: My Experience in Shanghai

1. Getting the position

I really wanted to do an elective in China and had been emailing people everywhere about getting the right contacts. I emailed my old professors, talked to friends of mine with family in China, emailed random organizations in the hopes of finding someone who would get me an “in” (see Part 3: Getting into a Chinese Elective Position). Finally, one of my former professors mentioned to me that he knew someone in the Shanghai Public Health Bureau – and the lead was a go. My contact in China was the Chief of the Pudong New Area Public Health Bureau and was a good connection of my former professors. My schedule was 3 weeks long, and after some tweaking and negotiating, he offered me to spend 2 weeks in a hospital, 1 week in a community health clinic and 1 week in a rural village clinic.

2. Arriving in Shanghai

Shanghai is a giant city. On arrival, I was immediately struck by the diversity of the people. There are plenty of English-speakers in Shanghai, and it’s virtually impossible to not encounter foreigners, let alone English-speaking Chinese.

Shanghai is truly China’s world-class city, and this is reflected in every 5-star hotel and high-end shopping centre that graces the streets. Another thing that struck me was the sheer accessibility of the transit system. In preparation for the World Expo, Shanghai’s subway network has expanded dramatically and 2 new lines were opened within the last year. Getting around in Shanghai is extremely easy.

3.  First week at People’s Hospital

I spent my first week in the People’s Hospital of Shanghai – a second-tier hospital in the very north of Pudong, near the Pudong Airport. I spent 3 days working in general surgery, where I was placed with a hepatobiliary surgeon. Here I got to see Endoscopic Retrograde Cholangiopancreatography (ERCP), laparascopic cholecystectomies, and appendectomies by the dozen.

4. Second week at China East Hospital – Obstetrics/gynecology

The next week, I was transferred to a more central hospital, the China East Hospital in Pudong. China East Hospital is also a second-tier hospital right at the heart of the Pudong financial district – in fact it’s right across from the Shanghai Stock Exchange. The hospital has three tiers of clinics stratified by price. If you have a great deal of expendable income or a great international health insurance plan, you get treatment in the International Clinic, where wait times are virtually non-existent and any tests, including CT scans, can be done right away. If you have slightly less money, you will probably seek treatment in the “VIP Clinic”, where you might have to wait, but treatment is still quite fast. Finally, if you’re the run-of-the mill Chinese, you will probably go to the regular clinic, where treatment is much cheaper, but wait times are completely unpredictable, and you have to sign up early in the morning to get a waiting spot for that day!

The first part of my second week, I worked with Dr. Liu, a Reproductive Endocrinology and Infertility specialist. Dr. Liu and I shuttled between the International Clinic and the VIP Clinic in the Shanghai East Hospital, seeing patients in both. It was extremely rewarding to help so many women get pregnant, and you could see the gratitude from women whose visits varied from another round of hormone injections to prenatal checkups. The equipment in these clinics were state-of-the-art – they had a $50,000 transvaginal ultrasound for pregnancy confirmation, for example, that is still not available in many hospitals within Canada. What I learned from those few days was that excellent health care awaits you in China – if you have the money.

I spent the second part of Week 2 in the general outpatient clinic. There the situation is very different. Patients are interviewed in rooms crowded with nurses, medical students, and other curious patients poking their heads through the door. There is very little privacy for pelvic exams besides a curtain, and doctors are very rushed to get through the enormous number of patients they have to see within their shift. Tests are paid for before they are ordered, and patients run back and forth between the doctor’s office and the hospital payment department with receipts for paid tests, like ECGs (US $3) and blood work (US $2.50).

5. Lectures at the Shanghai Reproductive Health Research Institute

While I was working in the clinics and having a fantastic time in the OR, I also wanted to pursue my interest in education and public health. I had a friend from a public health research institute in Yunnan Province who was now working at the Shanghai Reproductive Health Research Institute. Given that I had experience doing public health-related systematic reviews, she invited me to come give a lecture at the Research Institute for the graduate students. It was extremely interesting to meet Chinese public health research students and work with them in this regard.

6. Third week at China East Hospital – Emergency Surgery

The weeks kept getting more and more interesting. In the third week, I was placed with Dr. Chen in Emergency Surgery. In China, this is considered a specialist clinic by itself, and patients can directly see these specialists to fix fractures, appendixes, gall bladders, and any other emergent surgery. The mornings would start off with rounds, with over 20 doctors rounding through the hospital rooms, where 5-8 people would crowd into each room. Then outpatient clinics would start, where we would fix lacerated fingers, clean head wounds, and advise patients on fractures. Then, if there were surgeries scheduled for the day, I would scrub in and assist. I befriended a couple of medical students while there – there were quite a few that would also observe clinics with me.

Part 2: Getting into a Chinese elective position

1. Preparation

Before you start looking for an elective, it’s very important to establish clearly why you want to do an elective in China. This is important so that you can articulate why you want to go, but more importantly, it helps you establish why this is useful for your clinical career.

Some questions you might ask yourself are:

-  Cultural competency: Have you ever been to China before?

- Language competency: Do you speak any Mandarin? If you go into the bigger cities, many people will speak English; however, my experience is that at least conversational Mandarin goes an infinite distance towards your education. Do you know any medical Mandarin?

- Adaptability: Have you ever done work abroad or had to adapt to new cultural climates? This can have a big impact on how much you enjoy your elective.

What if you don’t know Mandarin?
Don’t worry, you can probably still go! You’ll likely be limited to larger cities like Beijing and Shanghai. The good news? The hospitals that harbor English-speaking staff will most often be the tertiary academic hospitals – just the ones where you’re probably most interested in working.

2. Qualities that will make your time much more effective

Know your limits. If you’re not comfortable doing a procedure, you must speak up and tell them you’re not comfortable with it. While scrubbing in for my first appendectomy, I was asked whether I wanted to make the first incision. Although my initial thought was “of course!”, I knew I wasn’t prepared, and politely declined, telling the surgeon to show me the proper way of proceeding so I could learn for next time.
Be flexible. If you’re not coming as part of a fixed program, your schedule is likely to change at any moment. Be sure you’re able to deal with these changes and adapt your learning schedule accordingly. I was also not informed of several very major holidays that came up during my time there, and therefore had a lot of time off.

3. Visa Requirements

[Note from the editors: The Lancet Student does not take responsibility for the accuracy of the information provided in this section]

Entry to China requires a visa. The easiest way to go about this for shorter electives (90 days or less) is to apply for the Tourist visa, which grants you between 30-90 days in China. To apply, you will need your passport, a completed application, and a passport-size photo. Visas will usually be issued within 5 business days, but rush orders may be placed for same-day or two-day completion. Students interested in staying in China for longer periods of time may need to apply for the Student visa, which requires a more extensive process requiring a letter of admission from the Chinese college or university, and a complete medical check-up. Confirm with the closest Chinese consulate or embassy in your country for details.

4. Resources

International health programs at your university. North American universities generally have very well-established international health programs with other universities – yours might have a good connection with China. Look beyond just the traditional and general “Global Health Program” – try looking for opportunities to travel with non-medical groups, or groups with specific medical interests that are different from yours.

Contacting professors who work in China. Keep your eyes open for health projects featured in your local medical newsletters/newspapers. If there is something that interests you, contact the professors directly. How about your old professors? One of my old professors was the key to helping me find my elective in China.

International health programs at other universities. Believe it or not, some schools may allow medical students from other universities to participate in their international health programs. Check individual school websites for details.

Your own contact list: With the boom of emigration from mainland China to many western countries, you may well know of someone who was formerly a doctor in China. These are fantastic people to contact, as they will likely have colleagues in China who may  be able to help you arrange an elective.

Bottom line: In China, it’s all about who you know. If you’re able to get a good contact, doors open substantially to you.

Part 3: Lessons for my work in Canada

I study in Vancouver, Canada, where there is an extremely large immigrant community. My first rotation of clerkship was in Emergency Medicine. While there, I was constantly surprised at how many people were non-English speaking, Chinese recent immigrants. Every day, I was able to help out with translation, often being the only staff member able to take an adequate history from the patient.

One particularly memorable case reminded me of the necessity of competency in cross-cultural medicine. One day, my supervising doctor told me to get ready – a man was being helicoptered in after being found down on the side of a rural highway. When he came in, it turned out he was Chinese, didn’t speak a word of English, and had no family in Canada. The ECG indicated a new anterolateral myocardial infarction. I was the only person there who could speak Mandarin, so I immediately put my new-found Emergency Medicine interviewing skills to use, and took his medical history in Mandarin while he was wheeled up to the cath lab to have an emergency stent placement. With a clot blocking one of his coronary arteries, every second was crucial, and being able to explain the catheterization and stent placement procedure quickly to him in Mandarin and obtaining his consent was very important in making sure he received the most timely care possible – and possibly save his heart of some ischemic damage. He asked plenty of questions as well, which I tried my best to answer (or field to the right person), and I’m sure helped ease the tension when several doctors started threading a large catheter up his leg. Being there to help was extremely rewarding given that my knowledge of Mandarin contributed to this man’s care – thanks to my elective in China.

Diane Wu
Medical student, University of British Columbia, Canada.

Medicine is one of the few fields where optional is considered compulsory. Electives refer to a period of training in a research or clinical setting outside ones parent institution. Although it is not something new but it has gained enormous popularity in the recent past. Unfortunately electives are undervalued in our region of the world and either there is little awareness or scanty opportunities in this regard.

Holy Prophet Mohammad (Peace be upon Him) said- Seek knowledge even if you have to go as far as china. I always want to do electives because medicine and travelling are my passions. In these summer vacations when I decided to do electives I already knew where to go as Aga Khan Medical College is undoubtly the best medical college, hospital and research center and is the only place in Pakistan to have a world standard elective program.

The aim of this elective was to observe and learn the various modern techniques and lab tests which we study in our medical course books as it is said that seeing is believing. A secondary purpose was to observe the educational system of Aga Khan University Medical College. It follows PBL and module system. I found it very proficient. It is student friendly and according to the needs of modern world. Unfortunately AKU is the only medical institute to follow it; all others are sticking to the annual prof. exam system with more influence on conventional lecture based learning. I think they should also switch to the PBL. I was also a supporter of LBL but after observing the benefits which students get in PBL system, I had to change my views. And not just the view, this exposure has also changed my attitude towards medicine and learning.

Aga Khan University is a coeducational research university spread over three continents with eleven teaching sides spread over eight countries. Its principal campus is located in the metropolitan city of Karachi, Pakistan.
Equipped with the state of the art facilities and internationally trained health care professionals, the hospital also serves as the principal site for clinical training for the university’s medical college and school of nursing.

I selected Department of Pathology and Microbiology because Pathology and Microbiology are the core subjects in third year M.B.B.S. curriculum in addition to Pharmacology and Forensic Medicine. Importance of laboratory and diagnostic pathology is as much in clinical practice as much of theoretical pathology in medicine.

Aga Khan University is also the first choice for anyone interested in Pathology because it has the biggest network of international standard laboratories with collection centers not only all over the Pakistan but outside Pakistan too.
I will narrate the whole story chronologically to stay simple and for better understanding of others so that they can benefit from it.

The application form and complete instructions are given on the website. One has to apply two months ahead of the proposed elective period. Selection is completely on merit and is especially tough for the Department of Pathology as only one student is selected each month on the basis of academic grades.

The Department of Pathology and Microbiology is divided into

* Molecular Pathology
* Microbiology
* Histopathology
* Chemical pathology
* Hematology and
* Blood Bank

I had just four weeks for such a huge department and I couldn’t be to the chemical pathology lab due to lack of time. My first rotation was in the molecular pathology lab. It is one of the advanced facilities, equipped with Real time and conventional PCR, ELISA, Gel Electrophoresis and Roche Amplicor. Here the tests for infectious diseases (like hepatitis C, HSV, CMV, MTB, Swine flu and Dengue), neoplastic diseases (like BCR-ABL and 15 17 translocation) and genetic diseases (Thalassemia, Cystic Fibrosis and Spinal Muscular Atrophy) are done. An interesting thing about it was the frequent cleaning of the working desk and changing of gloves after each step in order to minimize contamination, as PCR assays are very sensitive to external inhibitors and the specimens (usually plasma or blood) are highly infectious. One can never forget the principle and mechanism of ELISA and Gel Electrophoresis after having actually seen them.

The next lab was Microbiology to which I was more familiar as microbiology is a subject of third year in our curriculum. But this lab was very different from our academic lab. There are thrice the number of culture media than what I had studied, the organisms are identified at the sub type and serotype levels. Blood cultures are done at the Bactec and there is a separate section for mycology and mycobacteriology. A part or the lab is reserved for Environmental Analysis. This section tests food, water and other similar specimens for bacterial load and contamination and thus coordinates with government, companies and restaurants etc. generally speaking microbiology is comparatively an easier job. All you have to do is to inoculate the organism on the culture plates and read & interpret it the other day. But this is not as easy as it sounds, you have to have the detailed knowledge, experience and up to date information as it is an everyday changing field.

Third week brought the best one, yes the Histopathology. It was a huge lab with a lot of things going on which I didn’t even know that they are included in histopathology. The acquainted things were gross examination, fixation, embedding, cutting, staining and microscopy of surgical specimens. I also saw frozen tissue sectioning, semen analysis, FNAC, special histological stains and autoantibody assays. AKUH is the only place in Pakistan to have a fully developed commercial Cytogenetics lab. Karyotyping and FISH are done here. It was a terrific experience to see the chromosomes in real. A similar experience was to see the thousands of motile sperms under microscope, all struggling very hard to find an egg and give rise to life, even the unfortunate abnormal ones. It’s difficult to describe such experiences in words. At one side they strengthen our belief and knowledge of scientific phenomenon and on the other hand they make us think about life and appreciation of nature.

Now was the turn of my fourth and last rotation in the Hematology and Blood Bank. It looked more like a factory than a lab, with a lot of small and large machines feeding on blood. Here I learned peripheral blood films, Automatic Hematology Analyzers, test for G6PD deficiency and RA, HPLC for HB variant analysis, ESR, PTT, aPTT, Bleeding time, Clotting time, Phlebotomy, Blood screening, Plasma and component separation and storage. It ended with a surprise viva exam and with that four weeks had finished like four days and it was time to go back. In last few hours my flight got cancelled and I had enough trouble, thanks to airlines.

Pakistan is a developing country and is progressing in medical field as well. Aga Khan University is a big advancement and a milestone in this regard providing quality medical education, health care and research center.

Stairs to university’s helipad

Pakistan is also a frontline country in war against terror and is paying its price in the form of terrorism, inflation and hurdles in development. During my electives period too, there were a few incidents of terrorism in the city of Karachi, which adversely affect not just the business, education and everyday life but the health sector as well. Doctors and lab technologists faced problems in coming to the hospital due to which a lot of patients had to suffer as there are some tests which are not done anywhere else in Pakistan except AKUH Labs. But the good thing is that Pakistan is still managing to develop and progress and no one ever gets to disturb the peace of the country.

I couldn’t visit much places in Karachi but the beach trip was a unique and captivating experience for me. Hundreds of different restaurants and cafes provide every type of delicious cuisine. University campus itself is a place worth visiting and the city of Karachi is an example of beauty, modernism yet simplicity and cultural diversity.

In conclusion, it was a wonderful, educational trip with lots of fun and pleasant memories. I am sure any one who goes to AKU, will definitely want to go back just like me.

Muhammad Badar Munir
3rd year medical student, CMH Lahore Medical College, Pakistan

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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