Elective – Taupo, New Zealand, July-September 2007

Title and Aims
The title of my project was an elective in general practice in an urban area of New Zealand focussing on nutritional and integrative medicine and researching health inequalities.

My main aims were to gain an insight into cultural and socioeconomic health inequalities and differences in health behaviours in a developed country, and to learn about the significance and uses of nutritional and integrative medicine.

I am also particularly interested in the field of general practice as a possible future career. I valued the opportunity to gain more of an insight into the day to day work of a G.P. and hoped to improve my skills in differentiating between signs and symptoms that necessitate secondary referral and those that can be adequately managed in the general practice environment. I also aimed to improve my practical skills in areas such as minor surgery and suturing, steroid joint injections and swabs and cervical smears.

Dr Davies is a renowned expert in the field of nutritional and integrative medicine and I was very keen to have the opportunity to learn from his knowledge and experience in this area of medicine. I felt that this was a field about which I knew relatively little. Yet many patients I have met during my clinical years of medical school have enquired about the differences that nutritional medicine and alternative medicines can make to their health. I hoped to gain the confidence and understanding to give patients more certain advice concerning these factors in the future. This is relevant to patients who keep kosher as well, as many eat a mainly vegetarian diet if kosher meat is difficult or expensive to get hold of, so it important that such patients do not develop deficiencies of vitamins or minerals such as iron.

Reflection on Elective Period
During the elective period I led consultations, before seeking concurrence from Dr Davies at the end. I was therefore fortunate to see a wide variety of patients with conditions including nephrotic syndrome, post traumatic stress disorder, autism, impetigo, Achilles tendon rupture, bipolar disorder, dermatomyositis, and many more.

I learnt many useful skills during my elective placement. I gained experience in practical procedures, including suturing, minor surgery, urine analysis, administering intramuscular injections, smear tests, calculating paediatric drug doses. I feel that having led many consultations with patients my history taking, examining, management and teamwork skills have improved. I now feel much more confident with these skills, which I hope will help me with many areas of medicine.

Having my own consultation room to see patients, with minimal time pressures gave me a unique opportunity to get to know the patients well and to listen to their opinions and fears. I feel that I learnt a great deal from this. The elective experience has made me realise how important, even as junior medics, our time and effort is to patients and how ultimately, respecting their individuality and their choices, will make me a far better doctor.

I also learnt how to deal with complicated and challenging consultations – including patients who were being diagnosed with cancer and multiple sclerosis, and a patient who was at the end stage of metastatic prostate cancer. The consultation with Mrs CM, an anxious and demanding patient, was also difficult, as she had felt let down by doctors in the past, and also presented with confusing and unusual symptoms of itchiness and burning pain all over her body. She had already been seen by a neurologist, who had found nothing wrong. I was confused by this, but when I questioned her further I discovered that she was going through a divorce and finding life difficult in general. After discussion with the GP, I suggested a course of an SSRI, and although Mrs CM was initially reluctant, she eventually agreed to this. I found this consultation challenging, but learnt that listening to your patients concerns is vital, and sometimes a problem cannot be solved immediately but may need persistence and time. I also realise now the need sometimes to look beyond my immediate impressions and be open to other possibilities.

I now understand a great deal more about nutritional medicine, particularly the vital roles of minerals such as zinc, iron and selenium, and how imbalances of these minerals can contribute to a variety of health problems. I feel that the knowledge I have gained concerning nutritional medicine and the differences that adequate nutrition can make when tackling many diseases will be invaluable to me in my future career, and will hopefully enable me to offer further help to my patients. I realise now that this is something I have seldom considered in the past, as I have often concentrated heavily on pharmaceutical treatments when seeing patients on the wards, without asking them about their diet and appetite. In the future I will try to also ensure that patients realise the importance of a balanced diet as well as their medications, and will aim to look into possible nutritional or mineral imbalances in patients who are not recovering as well as expected or have unusual symptoms.

I also discovered that there appear to be inequalities in health between Maoris and European New Zealanders. Many Maoris who I saw had health problems related to smoking, mental health problems particularly alcohol and drug addictions, and a higher rate of unemployment. I still do not fully appreciate the reasons for these inequalities but feel that I have a greater understanding having undertaken this elective – it seems that social inequalities and relative poverty are heavily linked to the health inequalities I observed.

I feel grateful to have had this opportunity and very much enjoyed my elective.

Reflection on Logistics

Having travelled independently before, I was aware of the importance of forward planning therefore I organised flights, insurance and accommodation well in advance (figure 1). I should have applied for my visa earlier as I found myself worrying that I would not receive my passport in time to travel! I have not travelled to the developing world before and found my ‘to-do’ list slightly daunting. This included vaccinations, anti-malarial tablets, personal medical supplies and trying to make the most of a seemingly very limited luggage allowance. In June I tried to make contact with the people I would be working with in Kenya. I was assured that I was expected but was unable to make contact with the staff independently. In the future I would make sure to leave extra time when contacting people from a country where the communication links are not as advanced as those in the UK.

Figure 1.

Elective Period Experience and Learning

Half of my time was spent volunteering with the KOP staff working in the rural areas surrounding Kisumu. The remainder was spent at the Provincial General Hospital. I originally aimed to spend as much time as possible working in the community however, on arrival it became apparent that communicating with the relevant people in the community was difficult. Transport links were poor and travelling alone as a white woman was unadvisable. Therefore, I made all my visits with KOP social workers and a community health worker. During my first week at PGH I was attached to a different specialty each day, allowing me to gain a general introduction to medical practice in Kenya. (figure 2). It is impossible to describe everything that I experienced here but most importantly, I was given the knowledge and tools that I needed to actively participate in the paediatric department.

Figure 2.

It quickly became obvious that this was not going to be like previous medical placements. The wards were dirty and crowded with two patients to a bed. Three nurses were often responsible for one hundred patients, including some who were critically ill. Drugs and medical equipment were in short supply and nothing was free (figure 3). The majority of patients were poor and often had to forgo expensive drugs and tests. A doctor informed me that 15% of all admissions died in hospital. During the first week I learned a lot about general tropical medicine and undertook some background reading on these subjects to help prepare me for the rest of the placement.

Figure 3.

Price list of patient contributions for common procedures/investigations at PGH (N.B. average adult salary is 65p a day).

Paediatrics at PGH

I was immediately included in day-to-day ward work (see figure 4). The paediatric building had four wards (main ward, high dependency, oncology and malnutrition) and various outpatient clinics. I assisted doctors on the main and malnutrition wards by clerking patients, assisting on ward rounds and with emergencies. Figure 5 is taken from my personal notes and gives an indication of the conditions I was being exposed to on a daily basis and learning how to diagnose and manage. Whilst I was working on the ward I helped one of the nurses to complete a mini-audit of the past few months. This involved looking through notes and entering data onto a computer program (figures 6 and 7).

Figure 4.

A typical day on the paediatric ward at PGH

Figure 5.

Figure 6.

Admissions to the paediatric ward at PGH January-May 2007

Figure 7.

Mortality by primary cause January-May 2007

Community Work with KOP (Kenyan Orphan Project)

I spent 1-2 days a week doing community work. Some days were spent with a community health worker doing VCT (voluntary counselling and testing for HIV) and home visits. My experience with VCT was fantastic. The staff had been trained to see HIV/AIDS as a disease which affects people holistically (figures 8 and 9). I was also given the opportunity to accompany health workers by bicycle on home visits to people living with HIV/AIDS.

Figure 8.                     

VCT (National Guidelines for VCT, Kenyan Ministry of Health.

Figure 9.

KOP looks after many vulnerable children who have mostly been orphaned by HIV/AIDS and live with carers. Others are supported financially so that they can continue to live with their families. KOP also runs other projects, which I visited, including a street childrens’ centre and several rural feeding programmes. Unfortunately, it is beyond the scope of this summary to talk in detail about the children whom I came into contact with (figure 10). Meeting the children and discussing them with their social worker gave me an insight into their lives and the problems that they face. Whilst I was living in Kisumu I had a chance to visit most of the children KOP looks after in their homes and to speak to them and their carers. I also visited the charity office in order to meet other staff members and learn more about the children.

Figure 10

A brief summary of some of the KOP children whom I met

Reflection on Elective Period Itself

Being in Kenya was a steep learning curve. As well as learning what British textbooks say about tropical diseases I was given an insight into how they are managed in developing world conditions with limited resources. In particular, I learned a lot about HIV/AIDS. The work I did at PGH and with VCT provided me with a good background understanding of HIV/AIDS helping me to engage with the KOP children on a personal level and to consider problems that arose.

I had to adapt quickly to a new culture and ways of doing things. For example I often had to consider how to manage a patient when resources were limited, something I rarely consider in the UK. In Kenya people have a very flexible approach to timekeeping which made forward planning difficult. However, as the weeks went on I learned to adapt to this more spontaneous system. Kenyan society approaches child-rearing differently to the UK. For example, children often wander alone outside their houses as soon as they are old enough to walk. In hospital I was surprised to see most of the parents just lying with their children in bed. During painful procedures the parents often had to be encouraged to help calm the child. When asked, one nurse said that many Kenyan parents do not believe in displaying affection openly. Children are expected to be brave and strong. One day I was invited to lunch by one of the KOP foster parents. The children were called in after we had finished eating and were allowed to eat the scraps of food that we had left. Two children were under 18 months old. Nobody helped them to eat but they had already learned to eat anything without much assistance or coaxing. I did not see children with behavioural or feeding problems which British healthcare professionals are confronted with on a regular basis. Daily life is a struggle therefore children become resilient and resourceful from a young age. Interestingly, all the children I met were friendly, helpful, polite and excited about by their surroundings.

I knew that I would have to deal with very difficult situations. However, I found that the most challenging were simple and avoidable. Many babies died at PGH due to dehydration secondary to diarrhoea. The mothers did not realise how simple and affordable treatment was and waited too long before seeking help. Similarly, many children died from aspiration as staff were unable to monitor them closely enough. I continued to be challenged, frustrated and upset by these situations throughout my time in Kenya but I did learn to restrain my emotions and get on with the task at hand, a skill that will be useful in the future.

Post-elective period

I have returned to the UK with a much better understanding of tropical medicine and the challenges confronted daily in the developing world. I feel that I met my personal aims and objectives although I undertook a broader range of activities than originally anticipated. Through direct contact I learned about the needs of children affected by HIV/AIDS. I visited some schools, orphan feeding centres and a street children centre but did not feel that I had sufficient information and experience to undertake a project focussing specifically on the different models of care for these children as most of the KOP children were being fostered in their own communities. Instead, I was provided with opportunities to do hospital paediatrics and VCT which were logistically much more accessible to me. Next time that I plan a trip I will consider logistical obstacles i.e. transportation much more carefully to ensure that my aims are achievable. I have also learned that it isn’t always possible to make detailed plans and sometimes one must be prepare for the unexpected.

I want to spend time working abroad later in my career. My work on the ‘front-line’ in Kenya has taught me a lot however, I think that if I undertake further work in the developing world my skills would be put to better use on a more specific project. For example, there was an American team at PGH whilst I was there who had come solely to operate on burns patients. I have spent a lot of time considering the people I met and the difficult situations that I was confronted with. For years I listened to British politicians discuss debt relief and the importance of HIV/AIDS education. However, I needed to experience the situation in Africa on a first-hand basis to appreciate what was being said. Education, particularly of women and children, is crucial. Health education is an area which I am particularly interested in as it combines my background in youth work and informal education with medical knowledge.

Practicing medicine in Kenya is very different to that in the UK primarily due to financial limitations. Being in Kenya has made me aware of the value of the medical equipment and drugs used in the UK. I have returned with a new appreciation of the NHS. Overall, I am very grateful to have been given this opportunity to work abroad and experience daily living in a completely different culture to my own. Having time on my own away from the daily pressures of the medical course in the UK has reminded me why I initially wanted to become a doctor and has provided me with skills and knowledge which will be used for the rest of my career.

Dana Niry

Elective Report

I spent the first 3 weeks of my elective at the Emergency Department of Ichilov Hospital, Tel-Aviv.

Ichilov General Hospital is one of the three hospitals comprising the Tel-Aviv Sourasky Medical Centre, the main hospital in Tel-Aviv and the third largest hospital complex in Israel. Tel Aviv Sourasky Medical Centre is affiliated with the Sackler Faculty of Medicine of the Tel Aviv University. 

Ichilov is situated in Central Tel-Aviv and is famous in Israel for being the hospital to which Prime Minister Yitzhak Rabin was driven to, and later died, in November 1995 after he was shot during a peace rally.

The Ichilov Hospital Emergency Department is the only emergency department in the city of Tel-Aviv. As such, it has sole responsibility for 24 hour-a-day medical and disaster care for a population of some 400,000 permanent inhabitants of the city and some 1 million daily transients. Admission causes include approximately 40% medical cases, 30% surgical and 30% trauma/orthopaedics.  The department is permanently staffed by emergency medicine, medical, surgical and intensive care specialists.

Israel is generally influenced by the USA and the delivery of medical care is no exception.  However, money for health care and education in Israel is provided exclusively by the national government. This is similar to the UK, and different to the US, where funding for patient care and education is mostly private.

The Israeli approach to Emergency Medicine training is different to EM training in the UK and the US. In Israel, Emergency Medicine is a super-speciality rather than a primary speciality as it is in the UK and the US, and the Emergency Department is staffed with specialists in other medical and surgical domains, who have undergone another 2.5 years of training in EM.

The routine work in all departments is carried out in Hebrew. However, Emergency Medicine is the only department which requires fluency in Hebrew to undertake an elective. Most doctors speak very good English, and many patients do as well. The hospital staff is used to communicating in English with experts from other countries and students from the Tel-Aviv University American MD program and would assist students who require help with non-English speaking patients.

The doctors were very friendly and communicative and I received a lot of bed-side teaching. At first I was shadowing other doctors clerking patients. Fairly quickly, one of the doctors said, in the typical Israeli directness: “You should see patients on your own; you won’t learn anything from watching others”, at which time I started doing the same kind of job as the first year doctors (equivalent to FY1) - clerking the patients, writing up a management plan and presenting it to a senior doctor who must sign any investigation or treatment plan. Seeing patients in this manner gave me a safe environment in which to become more confident in all aspects of my history taking and examination, as well as forcing me to work on my diagnosis and planning. The ED doctors asked many questions and encouraged me to think laterally and systematically.

I gained a lot of hands-on experience and was encouraged to perform procedures including wound care and suturing, abscess incision and drainage, lumbar puncture, gastric intubation, venepuncture and catheterization, and arterial blood gases.

Theoretical lectures are not given as part of the Emergency Medicine elective program. However, I was invited to join lectures given to Tel-Aviv University medical students by doctors and surgeons from the ED. The lectures were of very high standard and I found them interesting and useful. I also got a lot of opportunistic teaching from the very enthusiastic and knowledgeable staff.

The electives are what you make of them.  Doctors are very open and approachable and one can learn a lot.  If enthusiasm is shown, they respond very positively.  In a spare hour, I decided to take a look at other departments as well in order to gain a broader insight into the medical care in Ichilov. 

As an example, on my first day I met a German student who was doing an elective in Internal Medicine. She was very impressed by the team and offered that I should join her department for half a day to see what they did. Although I was not officially rotating in Internal Medicine, I was very warmly accepted by the department\'s staff who included me in their discussions and even invited me to their weekly case presentations meeting. I was also impressed by their efforts to make my friend feel welcome and included by conducting the discussions and the meeting in English instead of Hebrew.

Another example is of the neurosurgeon I met at the ED, and when asked whether he thought I could spend a day in the Neurosurgery department, he immediately organised for me to be in theatre the next morning.

The difference in mentality between Israelis and Brits is, as expected, reflected in the dynamics between the different hospital staff as well as between the doctors and patients. The hierarchy between the different health professionals is not as obvious as it is in the UK. Junior doctors may call senior doctors by their first name. Surprisingly, nurses would often tell doctors if they disagreed with their management plan. On one striking occasion I accompanied a senior doctor to see a patient who was a drug addict and who was suspected to have infective endocarditis. The doctor took his blood as he said that “the nurses wouldn’t do it”. Nevertheless, the Israeli lack of formality also has its advantages and the atmosphere between the colleagues and between the hospital staff and patients is more open and personal, which means a pleasant working environment and  that patients feel less nervous and more at ease to share their thoughts and concerns.

Israelis work a lot, but they are also laid back and know how to relax. The friendly attitude made it easy to quickly become friends with the junior doctors, who are all knowledgeable high-achievers and taught me a lot about compassionate and professional patient care, but at the same time the difference in pace and relaxed atmosphere meant coffee breaks were longer than I was used to from hospitals in the UK.

How to apply

Nothing could be easier!

The application is through Tel-Aviv University: http://www.tau.ac.il/medicine/Electives

Israelis do not like bureaucracy and filling out lots of forms, so no personal statements, references or transcripts required. All you need to do is fill out a form with your personal and Medical School details, your elective choices, a list of specialities you learnt so far and have it signed by the medical school.

The administration fee is the only cost and that is €25 (₤17).

As far as housing accommodation is concerned, I was staying at home, so did not have to worry about that. However, in the application form you can indicate if you need accommodation, and Tel-Aviv University will provide a room (I\'m not sure about exact prices, but it would be a lot cheaper than any college accommodation in Cambridge). Ichilov Hospital is located in a very nice area of Tel-Aviv. It is just adjacent to \"Kikar Hamedina\", a very posh and expensive shopping area. But if you do not want to pay over the top price tags, you can find more affordable shopping by walking 10 minutes to Ibn Gvirol or Yehuda Maccabi Street, where you can find many shops, cafes and bakeries.  

Not to mention the 20 minute walk to the beautiful coastline, dotted with cafes and restaurants, white sand beaches and the blue Mediterranean sea! Or the nightlife scene!

If you are interested in going to Israel for your elective, please do not hesitate to contact me with any questions you may via info@jmeduk.org. 

Acknowledgments

I would like to thank the Jewish Medical Association UK for their financial assistance with my elective.

Sefwi Wiawso – The Jews of Ghana

Carly Szasz

c.szasz@bsms.ac.uk

On completing my elective, Amy, a Catholic friend from university, and I began our trip to the Jewish community in the village of Sefwi Wiawso, in the western region of Ghana. After a full day’s travelling on various busses, we arrived in the wilds of rural Ghana at half past five on a Friday. The Jewish community is well known by the other locals and whilst waiting to be picked up, we were asked on more than one occasion ‘are you Judaism?’

Once we arrived we were greeted by our host family with a ‘Shabbat Shalom’ and given the best room in the house. Imagine a basic 1950s living room and add two beds. Once they realised we hadn’t eaten, we were fed in true Jewish style. The Friday night candles were lit and the Kiddush wine I so fondly associate with Shabbat was replaced with Coke and Sprite.

The community of about seventy families is run by brothers Joseph and Alex Armah. Joseph, the elder, is the father of six children with an array of biblical names such as Rachel, Rebecca and Isaiah. On Saturday morning we walked to the Synagogue which was an unimposing, single storey brick building with no electricity. Inside there were rows of benches, a table used for a Bimah, covered by a white cloth and embroidered with a Chananukiah and the Hebrew letters spelling ‘Shalom’.

There were about thirty people at the Shabbat morning service, most of them children. There seemed to be very few of the older generation and whether that was representative of the community as a whole was difficult to say. The service was mainly in Twi, the local language, interspersed with a few words in English, for our benefit I think, followed by blessings in Hebrew. An American visitor who had recently been to the community had taught them basic Hebrew and many songs and like at home, the children went up on the Bimah at the end of the service and sang Adon Alom.

We spent the afternoon at the family home, playing cards with the children, teaching them songs and immersing ourselves in village life. It was a strange and an exciting experience seeing young African children, I had never previously associated with Judaism, sitting around a blackboard learning Hebrew and singing Hebrew songs. My weekend in Sefwi Wiawso was totally surreal and our short stay was but a moment’s glance at the diversity of the Diaspora. From the wealth and glitz of London communities to the basic, no frills Bimah and Shul in Ghana. Who would have thought?

My Elective in Ghana

Carly Szasz 

4^th year at Brighton and Sussex Medical School

Elective Country: Ghana

Institutes: Elmina Clinic, Ewim Clinic and Cape Coast Central Regional Hospital

I spent my elective in Cape Coast, in the central region of Ghana, West Africa. For the first two weeks of my placement I was at Elmina Clinic, providing outpatient and maternity services for the local rural population. Here I was able to obtain one of my key learning objectives, to compare my experiences on the labour ward with those in the UK. I spent a few days in the ante-natal clinics and was fortunate to also see and assist women deliver on the labour ward. There was no offer of pain relief and women were expected to deliver in silence, with no physical or emotional support. I found it very hard to stand back and not give any comfort to these women, during or after childbirth, as I was told that this was out of place and would have been alien to their culture.

I also spent time in the family-planning clinic, where I gained insight into services available to both sexes. I often saw pregnant teenagers expecting their second child. Even with the ever-growing population and increasing rate of sexually transmitted diseases, condom use is still not widely practised. Many use religion as their reason for lack of contraception; however despite their own religious views, midwives still educated patients on the importance of contraception.  My time spent in the family-planning clinic allowed me to achieve my objective to gain an understanding of the services available in a developing country as compared to the UK.

My third and fourth weeks were spent in Ewim Clinic, which was situated in the centre of town and attracted a higher volume of people than Elmina. Here, I experienced, along with two fellow medical students, more of a GP setting. We sat in clinics run by the ‘Chief’ and were also given the opportunity to run our own clinics. Most of the patients we saw were suffering from the early stages of malaria and I learnt how to recognise the key symptoms and how to manage and treat the disease. I also spent time in the laboratory, identifying malaria parasites, testing blood groups and haemoglobin levels. This gave me a ‘behind the scenes’ experience, allowing me to be familiar with the procedures involved when sending patients for tests. In the UK, where so much emphasis is placed on patient confidentiality, the lack of this in the clinics was a total culture shock. Patients were often told to wait in the corner of the room whilst another consultation was being held.

My last two weeks were spent in various departments at Cape Coast Central Regional Hospital. Due to the high number of students placed here, my time here was not as hands-on as I would have liked. I observed common medical procedures, such as chest drains and lumbar punctures, as well as spending some time in surgery. Daily ward rounds gave me an insight into the management and treatment of common conditions such as malaria and HIV.

The lack of communication between doctors and patients remained a common problem throughout my time in Ghana. Patients would leave the clinic, no wiser about their diagnosis or problem than when they arrived. Patients were almost always prescribed some sort of medication, yet no explanation was given to them about what it was for. I was told that the pharmacies inform them of dosages and any side effects, however I am sceptical as to how much of this information poorly educated patients actually understand.

One major difference from my experiences in Brighton was infection control, in Ghana it was almost non existent. Doctors would carry out a ward round, moving from patient to patient, not once stopping to wash their hands. Experiences in Accident and Emergency were particularly shocking, with blood on the floor and used needles stuck in the bed due to an overflowing sharps bin. Even when speaking to staff members, they were aware of the need to keep the wards clean, yet simple tasks such as wiping beds down were rarely carried out.

Only the very poor are entitled to free healthcare and therefore patients are strongly encouraged to sign up for the ‘National Health Insurance System’. Those who do not feel it necessary to take out insurance have to pay for tests and medications and some, who can not afford the costs, are forcibly kept in hospital until they are able to pay their bills. This often means that patients, including children, who have been medically discharged, are held in the hospital for weeks until their account had been settled, which seems to me to be a rather counterproductive policy.

My experiences of medicine in Ghana opened my eyes to a world where health and safety and patient confidentiality, which are given so much emphasis in the UK, are almost non-existent. I was surrounded by a culture where there are no pleasantries between doctor and patient but conversely their ability to work through the adversity of regular electricity cuts and lack of basic amenities was admirable. Overall my time in Ghana, both inside and outside of the medical environment, made me appreciate our much criticised NHS and the creature comforts of home. I fulfilled my objective, to gain an understanding of a healthcare system totally different from the UK.

With thanks to funding from;

Brighton and Sussex Medical School

The Jewish Medical Association

Provincial General Hospital and Community Work with KOP (Kenyan Orphan Project)

It quickly became obvious that this was not going to be like my previous medical placements. The wards were dirty and crowded with two patients to a bed. Three nurses were often responsible for one hundred patients, including some who were critically ill. Drugs and medical equipment were in short supply and nothing was free. The majority of patients were poor and often had to forgo expensive drugs and tests. A doctor informed me that 15% of all admissions died in hospital. I worked on the paediatric ward assisting doctors by clerking patients, doing ward rounds and helping with emergencies.

I spent 1-2 days a week doing community work. Some days were spent with a community health worker doing VCT (voluntary counselling and testing for HIV) and home visits. The VCT staff had been trained to see HIV/AIDS as a disease which affects people holistically. I was also given the opportunity to accompany health workers by bicycle on home visits to people living with HIV/AIDS. KOP looks after many vulnerable children who have mostly been orphaned by HIV/AIDS and live with carers. Others are supported financially so that they can continue to live with their families. KOP also runs other projects, which I visited, including a street childrens’ centre and several rural feeding programmes. Meeting the children and discussing them with their social worker gave me an insight into their lives and the problems that they face.

 Reflection on the Elective Period

Being in Kenya was a steep learning curve. As well as learning what British textbooks say about tropical diseases I was given an insight into how they are managed in developing world conditions with limited resources. I had to adapt quickly to a new culture and ways of doing things. For example I often had to consider how to manage a patient when resources were limited, something I rarely consider in the UK. I knew that I would have to deal with very difficult situations. However, I found that the most challenging were simple and avoidable. Many babies died at PGH due to dehydration secondary to diarrhoea. The mothers did not realise how simple and affordable treatment was and waited too long before seeking help. I continued to be challenged, frustrated and upset by these situations throughout my time in Kenya but I did learn to restrain my emotions and get on with the task at hand, a skill that will be useful in the future.

I have returned to the UK with a much better understanding of tropical medicine and the challenges confronted daily in the developing world. Through direct contact I learned about the needs of children affected by HIV/AIDS. I want to spend time working abroad later in my career and my work on the ‘front-line’ in Kenya has taught me a lot and lead me to consider undertaking a future project in health education. This is an area which I am particularly interested in as it combines my background in youth work and informal education with medical practice.

Practicing medicine in Kenya is very different to that in the UK primarily due to financial limitations. Being in Kenya has made me aware of the value of the medical equipment and drugs used in the UK. I have returned with a new appreciation of the NHS. Overall, I am very grateful to have been given this opportunity to work abroad and experience daily living in a completely different culture to my own. Having time on my own away from the daily pressures of the medical course in the UK has reminded me why I initially wanted to become a doctor and has provided me with skills and knowledge which will be used for the rest of my career.

Hadassah Medical Relief Association UK

PRESS RELEASE

October 23rd, 2007

Hadassah helps prevent HIV/AIDS in Africa through circumcision.

The Hadassah Medical Organization and the Jerusalem AIDS Project have teamed up to help prevent the spread of HIV by improving the provision of male circumcision in a number of African countries.

“Operation AB” was launched this week through a pilot project in Swaziland, which will focus on capacity building and personnel training.  Teams of specialist surgeons and public health experts including Hadassah medical specialists will provide training at community-based clinics and government hospitals. Several hundred procedures are planned and 15 local doctors will be trained to carry out the procedure.

Clinical trials in Uganda, Kenya and South Africa have concluded that removal of the foreskin reduces HIV transmission by up to 60 per cent; and the World Health Organization has called on African countries to integrate male circumcision into existing national and community-based HIV prevention efforts.

With over 70,000 hospital/clinic-based male circumcisions having been carried out in Israel since 1989, and over 52,000 infants undergoing circumcisions every year, Israeli doctors have much experience to offer in this field.

 
Read the full story at:

http://www.jpost.com/servlet/Satellite?cid=1192380595093&pagename=JPost%2FJPArticle%2FShowFull

The Hadassah Medical Organisation is an academic centre that consists of two hospitals and five academic medical schools in Jerusalem, Israel. A world-class university medical institution, it has achieved a global reputation for excellence in healing, teaching, research and outreach. It is distinguished by its innovative approach to complex medical problems and the cooperative efforts of its medical and research teams. Its mission to extend the benefits of modern health to the third world goes back over forty years and Hadassah has been active in over 90 countries.

Response from the Israel Medical Association (IMA) to Derek Summerfield in the British Medical Journal (BMJ)

We have been asked to refute the allegations and so-called “evidence” produced by Derek Summerfield in his never-ending campaign against Israel.  Unfortunately, it is next to impossible to refute baseless allegations.  The burden of proof should be on Summerfield to prove that his “facts” are true, and not on Prof Baum or the IMA to prove that they are not.   I am curious to know what evidence Summerfield himself would provide to prove he is not involved in torture if we had accused him of being so.

Nonetheless, as our silence is erroneously interpreted as admission, we will address some of the points raised by Summerfield in his most recent letter to the BMJ (Response and challenge to Professor Baum: what counts as evidence? BMJ 335 (7611) 125). 

The first source Summerfield brings is a quote by Amnesty International that Israeli doctors working with the security services “form part of a system in which detainees are tortured, ill-treated and humiliated in ways that place prison medical practice in conflict with medical ethics.” This statement is a blanket allegation without any proof attached.  How can one hope to refute such allegations?  One can show Dr Summerfield thousands of Israeli doctors whose ethical standards are above impeachment and who are no in no way involved in anything that can be construed as torture.  Yet neither he, nor anyone else, has, despite repeated entreaties on our part to do so, provided us with the name of one doctor involved in torture in order that we might properly investigate the allegations.

Summerfield states that Physicians for Human Rights-Israel (PHRI) reported in 2003 that since 1992 they had been attempting to get the IMA to join their opposition to torture, but in vain.  I can state with certainty that the IMA has always opposed torture, and, in addition, in the last several years, we have worked hand in hand with PHRI on various issues.  In a recent three month period, ten letters went out to various officials and bodies in the army, government etc. after we received potentially problematic information from PHRI.  Summerfield further claims that “Amnesty told me in the 1990s that they too had made various approaches to the IMA on this account and had always been rebuffed.” Unfortunately, no one at the IMA has any idea to what approaches he or they are referring.

Summerfield slams Prof. Baum for using the statements of Dr Blachar as evidence against his claim that the IMA is complicit in the ill-treatment of prisoners.  And yet he cavalierly asserts that “Torture continues to state policy in Israel” by relying on a Btselem report (an organization that can not be called neutral in their allegiances) that cites testimonies of 73 Palestinian detainees to “confirm that almost all Palestinian detainees suffer physical and mental abuse amounting to torture.”

Summerfield continues to make unequivocal and uncorroborated statements such as “Palestinian health professionals are regularly shot dead or wounded on duty.”   He also notes that health workers in ambulances are questioned and searched, people are detained at checkpoints and the security barrier has negatively affected coherence in the primary health system, statements which are likely true.  Unfortunately, we are well aware of the difficult living conditions in which the Palestinian population finds itself.  As long as terrorists continue to infiltrate from the Palestinian territories, the roadblocks are regrettably a security necessity.  Further, ambulances and ill patients have abused the system in attempts to commit terrorist attacks, such as the 2005 case of Wafa al-Bas who took advantage of a humanitarian medical clearance granted to her by Israel to attempt a suicide bombing at Israel’s Soroka Hospital, the very hospital in which she was hospitalized for over a month early this year while doctors worked tirelessly to save her life, after she was severely burned in an accident at home. 

In addition, ambulances have been used on more than occasion to transport terrorist or explosives.  For instance, on March 26 2002, Ahmed Jibril, a Tanzim operative and ambulance driver for the Palestinian Red Crescent (PRC) was arrested while driving an ambulance belonging to the PRC in which were found an explosives belt and explosives under the stretcher on which lay a sick Palestinian child. Nidal Abd al Fatah Abdallah Nidal, an ambulance driver from Qalqilya employed by UNWRA, admitted to using the ambulance to transport weapons and explosives for Hammas.   And Waffa Idris, a PRC employee, perpetrated the suicide bombing on Jaffa Street in Jerusalem in January 2002. She was dispatched by a PRC ambulance driver who is also a Tanzim operative, and she was assisted by another PRC employee. It is also believed she may have traveled in a PRC vehicle, and used PRC documents to go through IDF checkpoints.  Unfortunately, these are not isolated incidents.

Summerfield notes that “PHRI accused the IMA of basically being an arm of the political establishment.”  However, neither he nor PHRI has provided any reason or evidence to support such an absurd claim.

Unfortunately, I can not address, nor do I want to, all the usual rants made by Derek Summerfield, and his reliance on such known “politically neutral” bodies and figures such as Amnesty International, Btselem, Edward Said and Noam Chomsky to support his positions.  Summerfield also takes issue with the fact that the WMA and the BMA have repeatedly refused to condemn the IMA and oppose an academic boycott against Israel.  Does he feel that they, too, are an arm of the Israeli political establishment or perhaps there are unbiased, rational people who see things differently from him?

Although, we do not feel the need to defend ourselves against the likes of Dr Summerfield, we will nonetheless cite a few examples of actions taken by the IMA and Israeli doctors in an effort to alleviate the difficult situation of Palestinian civilians:

1. 2,346 Palestinian children with birth defects were treated last year in Israeli hospitals (up from 1,604 in 2005), 29, 919 Palestinian patients were granted permits to undergo medical treatments in hospitals in Israel (up from 24,076 in 2005), and 1,600 Palestinian emergency patients were transferred by ambulance from the PA to hospitals in Israel (up from 800 in 2005).
2. IMA has intervened in cases where a Palestinian patient was to be evicted from an Israeli hospital due to lack of funds.  For example, in one instance a patient was to be evicted from a Tel Aviv hospital because no money was forthcoming from the PA; IMA chair of ethics convinced the hospital to waive the charges if money was not received from the PA.
3. IMA has intervened, including petitions to the High Court of Justice, in situations where Palestinian patients, physicians or medical students encountered difficulties at Israeli checkpoints.   Two examples: Joint IMA-PHR petition to HCJ regarding patients in need of life saving treatment (a settlement was reached in this case) and another regarding an entry permit for an AIDS patient (in this case, the petition was dismissed when the court found that there was a legitimate security interest in disallowing his entry).
4. The IMA has called for funds to be transferred to the PA in the form of food and medicine so that help could be given where it is truly needed, including a letter to the Minister of Health to see what the government is doing to prevent a shortage of medicine and medical supplies to the Palestinian territories.
5. The IMA has, at several points in the past, attempted to meet with its Palestinian counterparts in an effort to foster mutual cooperation and better understanding, including the release of a joint statement. Almost none of these meetings have taken place, because of refusal on the Palestinian side.
6. IMA has issued ethical statements regarding imprisonment in hospitals and has intervened where necessary.
7. IMA attempted to assist Al-Quds University in East Jerusalem gain recognition by the Council for Higher Education.
8. IMA issued a recent appeal to Israel Railways Authority regarding the unnecessary detention/discrimination by railway authorities of two Arab physicians.
9. IMA established a hotline for Arab physicians wishing to complain of discrimination at airport and action taken on their behalf.

Although we are an apolitical organization, we certainly do speak out on behalf of the assurance of proper health services for the Palestinian population.  I attach a sample letter (Appendix A) in this regard.  Regarding Gaza in particular, I would remind you that Israel withdrew from the Gaza strip two years ago, in accordance with Palestinian wishes and at great economic and emotional expense to its own population, many of whom find themselves without jobs, homes or stability to this day.   It is therefore incumbent upon the Palestinian leadership to ensure the health care services of its population there.  Nonetheless, in cases where necessary health care was unavailable in either Gaza or the West Bank, Israel has frequently taken it upon itself to provide these services, often at its own expense. 

Regarding the issue of torture: we will once again-hopefully for the final time- unequivocally state that we completely oppose the involvement of physicians in anything that can be construed as torture.  The IMA has taken a public stand against torture in various forums, in letters to the BMJ and as a signatory to the Tokyo Declaration.  I attach a sample letter (Appendix B) we have recently written on this matter to Mr. Yuval Diskin, head of the Israel Security Agency (ISA).  We also recently addressed this issue in the Knesset (Israeli Parliament) where we stated our position that doctors employed by the ISA or security services and involved in the questioning of Palestinian detainees or prisoners are absolutely forbidden to take part or assist in any way in questioning that is accompanied by torture. (July 3, 2007).  Finally, we have been working for the last several months to incorporate a translation (done by PHRI) of the Norwegian Medical Association/World Medical Association course on “Doctors working in prisons: human rights and ethical dilemmas”; this course was recently made available to Israeli doctors.

Summerfield interprets the silence of Baum and the IMA as an admission of guilt.  In actuality, it derives not from guilt but from an intense weariness of having to respond time and time again to baseless attacks from someone with a very clear agenda.  Summerfield expects self-flagellation on our parts for wanting to live in peace, to protect our children from attack, for trying to balance security needs with the very real and pressing need to assure proper health services for all, Israeli and Palestinian.  But for that we can not, and will not, apologize.

Malke Borow, JD

Manager, Division of Law and Policy

Israel Medical Association

Appendix A

July 12, 2006

To:  Maj.-Gen. Joseph Mishlav, Coordinator of activities in the Territories

Brig.-Gen. Yechezkel Levi, Chief Medical Officer

Brig.-Gen. Avichai Mandelbeit, Chief Military Prosecutor

Re:  Invitation to a meeting regarding the health status in the territories-promoting cooperation between the IMA and relevant bodies

The IMA has been repeatedly approached by both local and foreign organizations regarding the status of the civilian population in the West Bank and Gaza.

It goes without saying that we do not address political or security issues; nonetheless, we are sure that you share our belief that we must do everything in our power to preserve an acceptable level of health even during armed conflict and to concern ourselves with the essential humanitarian needs of the civilian population.

The IMA is interested in trying to advance fruitful cooperation with you, in order to improve the channels of communication and activity between us, to understand the scope of inquiries you receive and to see how the IMA can take part in medical and humanitarian aid to the civilian population during this difficult period.

Therefore, we would kindly request a joint meeting.

We will be in touch within the next few days in order to schedule such a meeting and hope you will positively answer our request.

Sincerely,

Dr. Yoram Blachar

President

Israeli Medical Association

(Translated from the Hebrew)

Appendix B

July 12, ‏2007

To: 

Mr. Yuval Diskin

Head of the Israel Security Agency

Re:  Reports of B’tselem and the Center for the Protection of the Individual on the matter of torture and abuse of Palestinian detainees-implications for medical personnel working in interrogation centers

We would appreciate your response to the enclosed letter, which was forwarded to us yesterday.

It appears from the letter that the report in question allegedly raises suspicion that the ISA still uses physical and emotional measures that can be defined as torture. 

We would note that the position of the IMA on this matter remains as it always was, namely that it is absolutely forbidden for doctors employed by the ISA or security services and involved in the questioning of Palestinian detainees or prisoners are absolutely forbidden to take part or assist in any way in questioning that is accompanied by torture.

We, too, would like to receive answers to the questions posed in the letter of Physicians for Human Rights, and would appreciate a response at your earliest convenience.

Sincerely,

Dr. Yoram Blachar

President

Israeli Medical Association

(Translated from the Hebrew)

I believe strongly that Universities must encourage a spirit of enquiry, where members join in dialogue, with freedom of expression, learning from each others narratives. Lord Adonis expressed this in the House of Lords (3):

“Not only would a boycott be inconsistent with the spirit of openness and tolerance that should inform public life. It would also be counterproductive. Education plays a vital role in developing and aiding understanding between different people. It is therefore all the more important to keep open channels of communication with academic and educational institutions in the Middle East during these difficult times”

There are two narratives concerning the tragic history of the Israeli-Palestinian conflict. Both have verity, yet they are recounted as if one had the monopoly of truth. To accept one side only and deligitimize Israel shows either ignorance or malice. For a balanced account interweaving the competing narratives I commend “City of Oranges” which tries to look at the history of Jaffa, a microcosm of the wider conflict, from both sides (4).

The Star of David (Magen David) has always been a symbol of Jewish pride. In World War II it was used by the Nazis to segregate and terrorise Jews. However as a gesture of solidarity with his Jewish subjects the King of Denmark wore the star as a symbol of commitment to keep all Danes safe from harm. Maybe to-day we (Jew and Gentile alike), should wear the Magen David as a symbol of our commitment to peace and reconciliation. To achieve this end why not affiliate yourself to an Israeli University, and lend support to the petition lead by 17 Nobel laureates and countless academic leaders all around the world(5) ?

However, if you still support the boycott, remember to stop using laptops with Pentium processors, and do not transfer files using USB hub drives.

References

[1] Medical ethics, the Israel Medical Association, and the state of the World Medical Association; IMA President’s response to the open letter in the BMA. Yoram Blachar, BMJ 2003;327;1107-

[2] Personal communication, Israel Medical Association address, Jerusalem, April 2007-06-22

[3] Hansard; 18 Jun 2007 : Column 10

[4] City of Oranges; Arabs and Jews in Jaffa, Adam LeBor, Bloomsbury, London, 2006

[5] http://www.spme.net/cgi-bin/display_petitions.cgi?ID=9

"Medical decision-making: Physician, Patient or Rabbi?".

Prof Shimon Glick is one of Israel's leading authorities on medical ethics, and is the Ombudsman for the Israel Ministry of Health. Prof Glick studied at Yeshiva and Mesifta Torah V'Daat in Brooklyn, New York, and received his MD degree at Downstate Medical Centre, New York, in 1955. He trained in internal medicine at Maimonides Medical Centre, Yale University Medical Center, and Mount Sinai Hospital. He was a research fellow in the Berson and Yalow laboratory where he made major contributions in the field of endocrinology. His last position in the USA before leaving for Israel was as Clinical Professor of Medicine at Downstate Medical Centre, New York.

He served on the board of the Association of Orthodox Jewish Scientists in the USA, and was president in 1965-7. He was co-chairman of the medical sciences section of the Committee of Concerned Scientists in 1973-4, and traveled on several missions to the Jewish communities of the former Soviet Union. In 1974 Prof Glick and his family made aliya, and he became Professor of Medicine and founding Chairman of the Division of Medicine at the newly - opened Ben Gurion University of the Negev Faculty of Health Sciences. Subsequently he served as Dean of the Faculty, head of Health Services for the Negev region, and head of the Moshe Prywes Centre for Medical Education; and as head of the Jakobovits Centre for Jewish Medical Ethics. He is a member of the Israel National Advisory Committee on the Ethics of Human Experimentation, a founder of the Israel Society of Medical Ethics, and a member of the National Health Council. Prof Glick is married to Brenda (nee Rubinstein) and they have 6 children and 39 grandchildren.