YOUR DREAM, JOURNEY

Within a few days of arrival, I was whisked away on a trip to Lake Malawi by the other students and doctors staying at Kabula Lodge. Don’t worry - one dose of praziquantel taken two months after swimming is all you need to fend off schistosomiasis!

My ‘settling in’ period came to an end and I was welcomed to the Department of Medicine at the hospital. I expected to find many medical differences between Malawi and Australia - and there are many differences - but I was shocked nonetheless. The burden of disease and the hospital environment is very different in Malawi. Infectious disease affects the majority of the patients, with roughly 70% HIV positive and many patients presenting with severe disease. Many common conditions here are uncommon in Australia - Kaposi sarcoma, cryptococcal meningitis, tuberculosis, schistosomiasis, malaria, typhoid, the list goes on. Hospital wards are crowded, hospital staff are scarce (everyday someone says “we need more interns”), there is no air conditioning (I finish each day with clothing damp from sweat), alcohol handwash is limited, sharps containers are just cardboard boxes with holes cut into them, and medical students perform most of the procedures and jobs around the ward.
Doctors need to be particularly wary when prescribing medications in Malawi.

Pharmacies are unreliable, so doctors need to prescribe medications that have the best chance of being stocked by a pharmacy, otherwise the patient will go without the medication until their next appointment. Additionally, the more expensive medications are often unavailable in hospitals.

Chlorpromazine is the most commonly prescribed antipsychotic, rather than an atypical antipsychotic such as Risperidone or Olanzapine. Phenobarbitone is most commonly prescribed for seizure prophylaxis rather than Valproate, Lamotrigine or Carbamazepine. Amitriptyline is prescribed for depression rather than an SSRI. Omeprazole is prescribed for gastric reflux only if the patient can afford it, otherwise Cimetidine is prescribed. Triple therapy for H pylori gastritis is Amoxycillin plus Metronidazole plus Omeprazole, without Clarythromycin. Anticoagulants such as Heparin, Warfarin and NOACs are not usually prescribed, and Aspirin is the only antiplatelet prescribed. Self-prescribing is also very easy in Malawi as most drugs are over-the-counter. Last week we admitted a patient with Amitriptyline overdose due to self-diagnosed depression.

Despite the stark contrast between Malawi and Australia, I’ve really enjoyed my time here so far. The Malawian people are very friendly, the country is lovely and green, I’ve made great friends at Kabula Lodge, and I can actually be useful in the hospital wards. I’m looking forward to my next week!

After getting settled into my accommodation and an induction and city tour, I started my outreach placements which involve doing basic health checks for children and adults, in communities most in need in and around Phnom Penh.

I met some lovely patients with a lot of common diseases I see in Melbourne, such as hypertension and diabetes mellitus. The main difference being that many had absolutely no idea what diabetes or hypertension are. I also saw some conditions that are far more advanced from what western society sees, such as large goitres and heart murmurs that have been present for years without treatment. I saw many children with nasty infections from the most basic cuts, due to poor hygiene.

I have learned a lot about how the barriers to health care differ from Australia in countries like Cambodia, such as the false simplicity of “lifestyle change”, when there is no place to go walking or when white rice is the staple food available.

After coming back from a weekend away at Kampot in the south of Cambodia, we again started the week at Koh Sdach Island. Despite visiting a different kindergarten and community, I am realising how very similar the problems are among patients. They all have similar worries about their families and money/poverty which seems to manifest in headaches and chest palpitations for many. The answers to these troubles are far more complicated than advice about lifestyle for their hypertension. Although Cambodia is primarily a Buddhist country, sadly relaxation and mindfulness are still very difficult for the patients we see in these conditions.

This week we also had a very confronting day at “House of Hope”, an orphanage and institution for severely disabled children, adults and HIV sufferers. From very devastating diseases such as cerebral palsy, to healthy men with well managed HIV (who were simply homeless), this place seemed to be home for the people that the health care system in Cambodia, doesn’t quite have the infrastructure for. I admire the staff that work there and the resilience they show, but also hope that the drive for education surrounding health literacy from people like myself continues. Educating people like the staff at House of Hope is what will make real change to the lives of the less fortunate in Cambodia.
For my final elective week, I started off working with my HIV research project. This involved a survey that I had created regarding HIV diagnosis, treatment and symptoms and interviewing 10 patients at Home of Hope. This topic was recommended to me because of concerns about the treatments received by these patients, but the results were pleasantly surprising! I look forward to putting a paper together more formally over the coming weeks.

I also got the opportunity to review patients who had come back with test results and the likes, which was really rewarding to see the hard work paying off! It’s been a great experience and I am very sad to pack my bags and head off to Siem Reap.

I have spent the last week at one of the Institute of Indian Mother and Child’s most rural health clinics. It was a 3hr bus from the city of Kolkata followed by a short boat trip and then a 1.5hr ride by ‘rickshaw van’ which is like a motor bike attached to a wooden bench for the passengers to sit on. This brought us to the beautiful village of Raidighi where IIMC has set up a primary school and primary health care centre. The health centre focuses on skin disease treatment (fungal infections are very common due to heavy sari clothing, humid weather and not washing regularly), monitoring blood pressure and vaccination programs. They recommend patients go to better equipped health centres or hospitals which are further away should more complex medical cases arise.
During my time there, I noticed many children had kwashiorkor – a malnutrition disease caused by a severe lack of protein with signs including a distended abdomen and pitting oedema. To provide some background, the Indian diet is predominately carbohydrates (rice and flour), potatoes and oil. They deep fry everything! This means many villagers, both young and old, have nutritional deficiencies such as kwashiokor and anaemia. Diabetes and hypertension are also extremely common and education around such communicable diseases is lacking. IIMC has a nutrition program for pregnant women and children as a start to combatting this problem. They provide a free premixed nutrition powder and eggs (rich in numerous vitamins and protein) for anyone with a ‘below the poverty line’ card recognised by the government. The nutrition powder is basically a combination of soy, milk, rice, protein and lentil powder which is to be mixed with warm milk or water and drunk every day.

Amazingly, IIMC has given out loans to 22,000 women over the past 15 years allowing them to start their own business so that their families can become economically stable. Talk about impact! I saw one woman withdrawing some of her savings to spend on her husbands hospital visit as he had been in a motorbike accident- a clear example of how one’s socioeconomic status could severely impact their access to much needed healthcare.

There is still a lot of work to be done for nutrition in rural India. It’s difficult as their meals don’t come down to what is healthy but more so what is available, cheap and what they have been brought up with. In this region they are eating to live and don’t have many choices regarding their diet or opportunities to improve it which is why programs such as IIMCs are so important. I was so grateful to be able to spend time in Raidighi- it was a wonderful experience and a privilege to be accepted into such a beautiful community.

The thing I have enjoyed most about working with IIMC is that aside from their hospital work, they’re also addressing the social and economic barriers to accessing healthcare. In a country where women still face numerous difficulties and a region where many women rarely leave the house, it’s so exciting to see programs specifically addressing social inequalities be run so successfully!
Christmas in India was certainly a unique experience. We enjoyed it Indian style at the house of the founder of IIMC wearing saris and eating curry!

For my final week, I dedicated my time to the healthcare clinics attending to patients’ skin infections and giving injections. I was continually amazed by how grateful the patients were to receive even the simplest of treatments. They would wait in line for hours and never once complain. Having learnt some phrases in their language, the patients were always happy to sit and chat with me! The medical program run by IIMC has numerous outdoor clinics across West Bengal, providing primary health care and access to doctors to some of the most disadvantaged and poor communities. For many, it is there only contact with the health system so it’s a great place to discuss things like their diet and hygiene habits with them.

But this elective has also taught me how valuable other programs such as education, micro credit and nutrition are as there are so many factors outside clinical medicine which impact the health of people. By addressing such areas, you can stop people needing to come to hospital in the first place. To continue improving health outcomes, communities need education, sanitation financial stability and equality despite gender, caste or socioeconomic status.

Overall my one month elective in India has been a huge learning experience and made me enthusiastic and passionate for a job in global and public health. A huge thankyou to DPM for their support and for allowing me to experience and learn from such a wonderful community of healthcare workers. My experience in India was unforgettable and has made me excited for my future in medicine.

I’ve just competed my first week in ophthalmology at the Tribhuvan University Teaching Hospital and I’ve already learnt so much! They practice medicine differently over here compared to home. They need to operate quickly and efficiently to get through the hundreds of waiting patients!

My time at the Tribhuvan University Teaching Hospital has been extremely busy but very rewarding. I’ve been exposed to a wide variety of cases and had the opportunity to explore many different and interesting sides of medicine. I was also lucky enough to do some trekking on the weekends which was an unforgettable experience!

I have thoroughly enjoyed my time in Nepal and have no doubt that my experiences, and all the skills I’ve learnt will be invaluable to my future medical career.