National University of Singapore 2014
I was posted to a tertiary government hospital in Iloilo City, Philippines, where I volunteered as a medical student for two weeks.
A Wide Chasm
From the outset, there was a stark contrast between the standards of healthcare in Singapore and Philippines. A lack of beds meant that sick patients who had to be warded spilt into the emergency room. As a result, the ER doctors were duelling with treating urgent cases that had been rushed in, as well as monitoring the other sick, warded patients. In the Philippines, families will purchase basic equipment like catheters and lines for fluid infusion when it is needed from the local pharmacy. There is little excess stock in the hospital. In the hospital, doctors have to rely on their medical knowledge and rudimentary equipment to treat their patients. We also were required to apply our own knowledge in clinical history taking and in performing physical examinations on patients.
One patient, an uninsured middle-aged man who was suffering from end-stage chronic kidney failure, had to be told to go home because he could not afford hemodialysis anymore, and the machines were already serving a long line of patients. It is never easy to make such a decision, especially when access to healthcare is widely considered to be an inalienable right.
Prevention Is Worth Its Weight In Gold
Many patients present with complications of poorly managed chronic disease. Nevertheless, the lack of primary prevention, combined with a myriad of socio-economic and structural factors that discourages patients in the Philippines in presenting for their health check-ups until they are very late in disease presentation, means that the hospital was filled with many patients who were already nearing the ends of their lives, even though some patients are young. It is common for very young teenage patients who have never been tested for HIV before, who come in for Pneumocystis pneumonia, a fungal infection of the lungs that occurs in people with weakened immune systems, to have CD4+ counts (a type of immune cell) that are lower than their age number.
I also got to discuss medical practices in the context of differences between the Philippines and Singapore. For example, HIV medications, which are notoriously exorbitant and have to be taken for life, are not subsidized in Singapore because "HIV is not curable". In contrast, the government of the Philippines has made HIV anti-retroviral treatment free, and patients are encouraged to come forward to get tested. However, while these drugs are available and affordable, the Philippines struggle with the distribution of drugs, meaning that those who need the medications do not get it because of inadequate infrastructure, delivery of services and information to at-risk populations. Some of these populations, like teenagers living in the slums of the Philippines, are mostly not aware of such policies, and the heavy stigma society tags on people living with HIV further compounds this.
A Valuable Lesson Learnt In Death
It was on this trip I had my first encounter with death. On the night I had volunteered to do a night-shift with the doctors in ER (pictured left), I assisted in a resuscitation effort of a man suffering from chronic lung disease who came in feeling extremely breathless. Upon admission, he was hungry for air, gasping as if every breath was his last. In about fifteen minutes upon admission, doctors rushed to his side to put in a breathing tube down his throat, and metal pieces on his chest that would capture how his heart was functioning. CPR was commenced without hesitation, and we took turns compressing the man's chest. Despite our best efforts, the patient did not make it. When the machine flat-lined, I was asked to confirm that the patient was dead by opening his eyes, ensuring that they were fixed and dilated, and there was no response when I brushed his cornea with a thin wisp of cotton.
It is often too easy to take for granted the resources that we have in Singapore, where medical supplies are more readily available to everyone and sophisticated technology is used to diagnose and manage patients.
On placement, I saw a wide spectrum of disease being treated, ranging from tetanus to dengue fever to HIV; complicated by a multi-drug resistant tuberculosis strain in the body of a 19-year-old boy. As medically exciting as it is to be able to understand and appreciate the signs and symptoms of diseases I rarely get to see back home, it was against the sobering backdrop of healthcare inequality. Even if the correct diagnosis is made in time, long-term care is expensive and difficult to comply with. Imagine having to take 10 different pills every day, each having its own nasty side-effects, accompanied by high costs, it is little wonder that many patients often drop out of their treatment early on, despite the doctors' best efforts. This is a reminder that as future healthcare professionals, we ought to constantly encourage our patients to take stewardship of their own health.
Sharing Is Indeed Caring
In public hospitals in the Philippines, many of the generic medications available are often not as efficacious as branded ones pushed forth by pharmaceutical companies. However, impoverished patients simply cannot afford the branded drugs they desperately need. Filipino doctors sometimes pitch in, pooling all the branded drug samples they have obtained from pharmaceutical representatives every week, and give them for free to indigent patients. Sometimes, this meant a quick recovery for patients suffering from pneumonia where the same disease treated by a less efficacious, albeit cheaper, drug would have cost the patient a delay in recovery that is fraught with complications and suffering. In the maternity ward, I first noticed that one hospital bed held at least 5 babies arranged with little space in between. Mothers of their newborns would surround the bed, and the less poor would often donate excess diapers, formula milk and medications to the poorer mothers next to them. The room - filled with wailing babies and mothers fanning themselves and their babies in the heat - could barely contain the love and care shared amongst all of them.
I came back feeling enriched by my experiences working on placement in Iloilo. Learning how medicine is practiced in a low-resource setting has made me appreciate the healthcare we have back home. Yet, I am also humbled by the competence of the doctors I had the privilege of working with, managing so much with so little. It brings to mind the importance of maintaining this perspective as I transition into my clinical years, and to always keep in mind that there is so much we can do with our own two hands and our own mind, amidst all the sophisticated technology and machines that surround medical practice. All in all, it was an adventure.