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Elective Report by Laura Shorthouse, 4th Year Medical Student, University of Liverpool

Below is Laura's report following her recent IME elective in Zambia earlier this year ......

A personal reflection of ethical dilemmas encountered, and the cost-benefit analysis to Livingstone Central Hospital in Zambia for hosting my elective in maternal, neonatal and child health.

During my five-week elective I gained hands-on experience in maternal, neonatal and child health at Livingstone Central Hospital, and in three local community districts served by the hospital - Linda, Maramba and Mwandi. Working days contained rich and varied learning opportunities to accomplish my goals and professionally develop, but also, provided powerful ethical dilemmas and lessons in people, life and myself, forever shaping my future medical career and character.

Ethical dilemmas

I was introduced to the labour ward on my first day, which was an unforgettable first impression. From the initial ethical 'horror' I felt and not wanting to return to the ward, to the in-depth personal and professional thinking it evoked, to finally overcoming it- it was a life changing experience in growing as a future doctor and person. In a large curtain-less room three women were giving birth in silence and shouted at when they made a noise. The first delivery I witnessed in Africa was stillborn twins.

They were left for over five minutes unwrapped on their mother's lap while the midwives cleaned the floor. They were then disposed, without any opportunity to say goodbye. I wanted to comfort the mother but felt it an inappropriate first impression. Instead, I stood there shocked holding back tears.  I found this opening hour to 'obstetrics in Africa' cruel, insensitive, detached and degrading with no patient empowerment. I did not want to go back and play any further part.

As the initial shock of witnessing a different cultural and geographical approach to labour eased, I shamefully realised I was being judgemental. I was impinging my ideology of ethical practice onto others, disregarding their culture and traditions as though the ' west' approach was best. I was determined to overcome this dilemma by returning to the ward and learning more about their culture and ideology. I came to understand that Zambian women have adopted a tough 'carry on' exterior because sadly losing a baby is more of the 'norm' in their culture than mine, as well as them feeing grateful to still be alive post childbirth- to them it is the best way of moving forward. They prefer silence because it is important for them to introduce their baby into a calm environment. Being silent is their personal, empowering and autonomous choice, rather than the oppressive, degrading and paternalistic one I wrongly assumed. Subsequently whilst this was foreign to me, I had chosen to work here and believed it important to respect their wishes and culture moving forward. I therefore felt I was subconsciously empowering my patients and respecting their autonomy thus providing good medical practice; albeit in a very different way to home.

The English language, whilst the official language of Zambia and that of medicine, was predominately limited to wealthy well-educated families, or young children benefiting from international volunteering projects teaching English. Consequently there were several occasions, notably obstetrics and gynaecology, where I needed translators. These were not third party impartial translators like in the UK, but either other doctors, the patient's family or their own children.  Where possible I would have preferred doctors, however I did not want to ethically burden my overworked and understaffed host, so relied mostly on the latter two.  Taking obstetric and gynaecology histories involve asking many sensitive, intimate and personal questions, which I found not only uncomfortable asking others but took longer. I overcame this discomfort by remembering it was necessary to gather information to treat effectively. In paediatrics, I tried to obtain the history from the child which given their good level of English was more possible and I preferred.

Zambian doctors rarely introduced themselves to the patient, asked how the woman or child was, or sought consent appropriately.  No curtains separated the beds and handwritten patient notes were left on makeshift tables often next to the wrong person visible for all to see. Doctors would discuss patients loudly for others to hear and examine them in full view on the ward. Whilst I could not change this practice, I conducted myself in the manner I would back home with some improvisation where necessary. I always introduced myself especially explaining why I was working in the hospital, spoke quietly so only the patient could hear, and asked a colleague to hold a sheet up around the patient's bed when I wanted to examine them privately.

Medical tourism: cost-benefit analysis

I believe my elective benefited the hospital and population it served. Livingstone Central is adjusting to a significant time in its history and facing added pressures that come with a tertiary status. I was an enthusiastic and highly active team player getting involved, and providing teaching opportunities for clinicians to undergo professional development especially on ward rounds. I also impacted my knowledge and experience, which having just completed and passed my medical school finals was of a high standard, and therefore, I believe I facilitated a mutual learning environment. I worked within my competency independently clerking and monitoring patients with minor complaints, so senior clinicians could attend to major complaints and emergencies. I therefore crucially alleviated staffing problems safely without compromising reputations or the work of other staff members.

However, despite only asking the doctors to translate when no-one could speak English I felt guilty for creating extra work for them. Subsequently, if patients could speak some English I preferred to spend longer taking a history than asking the doctors. I would advise medical students to act this way, learn some local/ tribal language where possible, and be acquainted with a place's culture/ customs before arriving.

Conclusion

A complex relationship exists between medical ethics and external influences. Successfully navigating cross-cultural medical ethics requires sensitivity, non-judgemental attitude, and enhanced communication and clinical skills. Through a rich and enjoyable personal elective experience, this study supports the evidence-base 8-10 that electives in developing countries can be beneficial to all.

Word count (997- excluding title, acknowledgement, references)

Acknowledgement

Thank you to the 'Institute of Medical Ethics' for a Medical Elective Bursary.

References

The CIA world fact book (2016) 'Zambia' https://www.cia.gov/library/publications/the-world-factbook/geos/za.html. (Accessed 26th August 2016)

World Health Organisation (2012) 'Country cooperation strategy at a glance: Zambia'. http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_zmb_en.pdf (Accessed 26th August 2016)

World Health Organisation (2016) ' Zambia' http://www.who.int/countries/zmb/en/ (Accessed 26th August 2016)

World Health Organisation (2015) 'Zambia: WHO statistical profile' http://www.who.int/gho/countries/zmb.pdf?ua=1 (Accessed 26th August 2016)

Unicef (2016) ' Zambia: HIV and Aids' http://www.unicef.org/zambia/5109_8459.html (Accessed 26th August 2016)

Our Africa (2016) 'Poverty and Healthcare' http://www.our-africa.org/zambia/poverty-healthcare (Accessed 26th August 2016)

Post Zambia ( 2015) 'L/stone hospital starts operating as tertiary medical institution' http://www.postzambia.com/print.php?id=3441 (Accessed 10th November 2015)

Ackerman LK. The ethics of short-term international health electives in developing countries. Ann Behav Sci Med Educ2010;16:40–3

Hanson L, Harms S, Plamondon K. Undergraduate international medical electives: some ethical and pedagogical considerations. J Stud Int Educ 2011;15 (2):171–85.

Banerjee A et al, Medical student electives: potential for global health?Lancet 2011;377 (9765):555.