REPORT of Health and Disease in The Tropics; Public Health: International Perspective; Infectious Disease Rotation; Honours Programme

Lecture @ Radboud University Nijmegen, The Netherlands

Posted by dokterblog on May 22, 2009 By: Dr. Rahajeng Tunjung This is my report of the course activities I participated in Radboud University Nijmegen as a part of their elective course for the medical undergraduate students. The following includes report of three separate activities: Health and Diseases in The Tropics, Public Health in an international perspective, and Infectious Disease rotation in Radboud Hospital. The course took place in early 2007. This report was presented to FK Undip, and I hope the posting of this report will benefit medical students as well as doctors in getting to know the approach in learning these subjects in Radboud University Nijmegen, The Netherlands.

PREFACE

Alhamdu lillahi rabbil aalamiin. Not just a goal, the 3 months learning programme in UMC Radboud has been more of a starting point for me. Participating in this programme had been my dream since the first time I heard about it in my second day of medical school, almost 5 years ago. Its been an honour and privilege for me to be given the chance to represent Medical Faculty Diponegoro University (MFDU) this year and go to UMC Radboud. Id had the opportunity to learn in the classroom, interact with the Dutch and international students, have stimulating and exciting discussions with the lecturers and attend extra lectures in the evenings. I always looked forward to each and every morning of my stay in Nijmegen.

My interaction with the lecturers, researchers and specialists has inspired me to commit myself to what I truly love. I have understood the importance of preparing good human resource, well prepared with competence and enthusiasm, in the field of infectious disease and medical education. Personally, this programme has opened so many new doors and possibilities for me, and I am deeply grateful for the guidance, inspiration, encouragement and support I have received from my teachers in MFDU and Radboud. I thank my family for their love and support, my parents especially for teaching me to think big and giving me the freedom in doing what I am passionate about. Id like to express my gratitude to my teachers, Prof. Djoko and Dr. Husein, for giving me the honour to learn from them and undergo this amazing experience and hopefully serving this field of medicine in near future. Thank you to The Dean of MFDU and faculty members for giving the moral and financial support; Nijmegen Institute for International Health for providing the fund and making this programme possible for MFDU students; secretaries of NIIH for their assistance before, during and after my stay in Nijmegen; Dr. Monique Keuter and Dr. Andre van der Ven for their kindness and teaching me what dedication and passion for infectious disease is all about; Dr. Francoise Barten for mentoring me and giving me the humbling opportunity to write with her; Dr. Corine Delsing for the friendship and truly inspiring experience: learning from her and having fun working with different specialists and patients for 1 month in UMC Radboud; Katharina and other Radboud students in the courses for their friendship and allowing me to feel as if Nijmegen had been my home for 3 months; My colleagues in MFDU who have supported me. I hope what has been learned in UMC Radboud wont just be mine alone,

but can also be shared by my colleagues, students of MFDU. This report is a recollection of my study notes from the courses as well as the lectures made available by the teachers. PERSONAL LEARNING OBJECTIVES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Able to live abroad independently for study purpose Able to perform well in the courses and rotation Learn about the teaching and learning method of pre-clinical and clinical medicine in UMC Radboud Learn about tropical medicine from The Netherlands perspective Learn about public health from the international perspective Make use of the learning opportunities available in Radboud University Sharing experiences with other students about health and disease in the tropics and public health Learn about the Infectious Disease Department in UMC Radboud Learn about the management of infectious disease in UMC Radboud Learn about the infectious disease commonly encountered in The Netherlands Learn if I want to pursue a career in infectious disease LIST OF ACTIVITIES 1 February 2007: Course of Health and Disease in The Tropics 1 March 2007: Course of Public Health, International Perspective 1 April 2007: Rotation in Infectious Disease Department UMC Radboud March-April 2007: Evening lectures of Honours Programme, Radboud University

KVZ1: HEALTH AND DISEASE IN THE TROPICS 19 students participated in this course, consisting of 12 dutch students and 7 international students. Monday, 5/2/07 HEALTH RESOURCE ALLOCATION GAME The topic for the day is THE DISTRICT: A FRAMEWORK FOR HEALTH.

In the beginning, an introduction of the course and schedule is given by van Asten and Keuter. The international students are encouraged to mix with the Dutch students so that interaction could begin immediately in the classroom. In the practical session, the health resource allocation game is played. The students are given short instructions by the lecturer and must learn further details from the course book. Health is determined by multiple factors in the environment, as well as the health system used. Components of the primary health care are explored in this game, such as prevention, health promotion, and treatment of common conditions, and supply of drugs. In the end, the cost-effectiveness of health services is determined by the way the health system is managed. Objectives: Insight in design and structure of health system and its consequence Geographical accessibility of health care The students must design a health system for a province with a certain budget, and then test the functionality of this system by 200 cards representing 500.000 patients with different conditions and severity. Two stages of the game: 1. 1. Planning stage : design and describe the health system Operational stage : test the system through patients, then compare results between the different health systems During the parctical, we realized the limitations of providing extensive medical facilities in a region. The specific province in the game is particularly difficult because of the geographical setting, where villages are scattered sparsely, and there were very few main roads connecting different parts of the province. Most of the areas are not accessible through main roads and people must walk up to 40 km to the nearest main road from their villages. This situation is common in Africa. The limitation also come from the minimum budget allocated to build the necessary health system, which is the situation in many tropical countries. Discussion: Its cheaper to provide health care in urban settings than rural settings, as the same facility can provide service to more people than is being set up in rural setting, where there were fewer inhabitants within the same reach. From the game, we found out that there are many diseases that mostly need primary health care facility, which is the community health worker.

The community health workers are the ones who should advise a patient whether he or she need further medical treatments. The systems that the students built was weak on the ground, meaning there were fewer primary health care than the amount needed. The health care system should be mostly based on primary health care; for referral and supervision purpose then the system built upward. The patients need to be treated in different level of health care according to the manifestation and severity of the disease. There were patients who were treated at health care levels that are too high or too low because of those are the only accessible facilities. Delay in getting medical help may be caused by: the distance between health care facilities and villages limited transportation people cant leave their family or their village to seek medical help

Tuesday, 6/2/07 INTRODUCTION OF TROPICAL DISEASE An overall introduction of tropical diseases was given by dr. Monique Keuter. The tropical diseases can also be associated with being climate bound, vector bound, or even poverty bound. Poverty plays important role due to the poor living condition such as overcrowded environment, bad sanitation. The lecture also introduced the distribution, causative agent, symptoms and control of schistosomiasis and trypanosomiasis. The class was then divided into groups of two to look up the internet on the different tropical diseases, the vector, the control and prevention and focus of research. The international students were each paired with Dutch student and asked to study the more prevalent disease in their own country. The diseases selected are the ones listed in Tropical Diseases Research website of WHO. TDR focuses on neglected infectious diseases that disproportionally affect poor and marginalized populations.After the research each team do a short presentation. There were further discussion with dr.van Asten and dr. Keuter. Wednesday, 7/2/07 TOTAL BURDEN OF DISEASE The lecture analyze tropical diseases in relation to other diseases. The analysis was based on Disability Adjusted Life Years (DALY). DALY can be used for comparison of diseases.

According to WHO (2002), the biggest health problem based on DALY: 1. 2. 3. Malaria TB Lymphatic While the order based on total death: TB Malaria Leishmaniasis Epidemiological trends: Increase in mortality and drug resistance increase in epidemics Burden of diseases can be calculated from: DALY Death Economic impact Productivity lost Reduction in annual economic growth rate

1. 2. 3.

1. 2.

1. 2. 3.

From the World Health Report 2003: Communicable diseases are starting to decrease while noncommunicable diseases are increasing. Tropical diseases in the tropical countries are not the biggest health problem except for malaria in Africa. WHO 2002: DALY in developing countries: 1. 2. 3. HIV AIDS Lower respiratory tract infection Diarrhoeal diseases The highest risk factors for health problems: Underweight Unsafe water, poor hygiene and sanitation Unsafe sex Indoor smoke and fume inhalation Zinc, iron, and Vitamin A deficiency * These health risks need to be addressed to reduce the burden of disease.

1. 2. 3. 4. 5.

* Resources are lower in the area with the highest burden of diseases We were then given a chance to look at several different websites about outbreak of diseases. Were then asked to choose an outbreak disease which interests us the most and create a presentation on it. Thursday, 8/2/07 HISTORY OF TROPICAL DISEASES We had a closer look at a figure in a researcher of tropical medicine, Koch. Were divided into 4 groups, each were given a chapter from his biography that highlight the important parts of his life such as his technical contributions, his research on TB, cholera, and malaria. Friday, 9/2/07 FORUM PRESENTATION In this forum presentation, were given 30 minutes of presentation and discussion about the outbreak of diseases. My presentation with Arash Khawaja from Radboud was about avian influenza with a focus on the management by Indonesian government. Discussion: Poor compliance in cattle vaccination may be caused by disadvantages due to the vaccination such as cattle abortion. Important national and international events may affect the spread of outbreak, such as political unrest and massive imports of cattle and meat due to increasing demand from the hajj. From the chart of outbreak, there was decrease in the case number after a peak. This may be caused by interventional measures. But normally, without any kind of intervention, outbreaks may decrease by itself because of the reduction in the number of people susceptible of the disease. People who recovered from the infection or had sub-clinical infection may gain immunity and not affected by the disease. Monday, 12/2/07 Self study was instructed to answer cases regarding malaria prophylaxis and travel advice.

MENTAL HEALTH IN DEVELOPING COUNTRY A lecture is given by Prof. dr. F. Kortmann about establishing mental health service in developing country. We were then asked to do a groupwork and later on a presentation on how to do a mental illness epidemiological study in the population, convince a government to develop mental health care, and design a training program of mental health care for local staff and local community of a developing country. Investing in mental health care is necessary as there is high prevalence of mental illness and psychosocial problem in the developing country, the high burden of disease, the mental health care is proportionally cheap, and there will be high cost if mental health is not integrated into the basic health care system. Tuesday, 13/2/07 Dr. Keuter gave the class a tutorial on the cases of the self-study assignment. Lecture on epidemiological aspect of malaria. Wednesday, 14/2/07 Presentation: Case management: diagnosis, therapy, intermittent preventive treatment (IPT) Comparison of insecticide treated nets (ITN) and combination of ITN-IPT Malaria and pregnancy Drug resistance

Thursday, 15/2/07 CHILDREN AND HIV INFECTION Children may get HIV infection from the mother through pregnancy, delivery process and breastfeeding. Risk factors associated with transmission may be Friday, 16/2/07

Practical is done to observe malaria parasite and the procedure of making thick and thin smear for malaria diagnostic examination. Wednesday, 21/2/07 Written test Introduction of the research proposal assignment was given. Every student was allowed to choose one of the available topics that interest them the most. I chose to do the research proposal about malaria and iron. A tutor for each topic is available to guide the students through the process of creating the research proposal. Final version of the research proposal enclosed. 22/2/07-27/2/07 Research proposal preparation 1/3/07-2/3/07 Forum presentation of research proposal Final version of presentation is enclosed Feedback session was conducted, and all the students were allowed to give verbal and written feedback on the course. The strong points of this course the students find positive are: the use of english (especially for the dutch students)

the topics of discussions and articles used as references are up to date and recent the group works that allow interaction and exchange between the dutch and the international students the professors were able to give the lectures clearly and with good structure The weak points of this course are: the dutch students were not well informed before the course started that there would be international students, which might have allowed more dutch students becoming interested in joining this course

the international students were not well informed about the content of the course, which would allow better preparation of literature from home countries feedback of the forum presentation was not given, so the students could not improve their performance immediately

KVZ2: PUBLIC HEALTH, INTERNATIONAL PERSPECTIVE 14 people participated in this course, consisting of 7 dutch and 7 international students. The class was divided into 2 working group to allow better dynamic in the discussions. The students must prepare on different health issues in groups, and the class was also divided into 3 groups, each consisting of 4 or 5 students. The topics available for the paper are tuberculosis, HIV/AIDS, and reproductive health. I selected reproductive health as my topic, and worked with 3 other students. A tutor is available for every group. Monday, 5/3/07 Lecture: Opening and introduction of course What is public health? Public health is the science & art of preventing disease, prolonging life and promoting health and efficiency through organized community efforts Policy and planning of health systems Prevention of diseases Promotion of healthy lifestyles Protection against health hazards Partnership to build coalitions Aim of the course

After the course, the student is able to identify.. the main determinants of major public health problems efforts made within health systems to adress these for a wide range of situations assess the implications for day-to-day practice of medicine Lecture: Health and its determinants Measure of disease nMortality rates Historically important But do not provide information on morbidty of disease (and this is becoming more and more important) nMeasure for burden of disease nDisability-adjusted life years nLoss of life years, adjusted for quality of these years lived Disability adjusted life years nPowerful instrument to compare chronic and fatal diseases E.g. depression and HIV/AIDS nInfluential in policy and planning of health programs in developing countries Child diseases (0-4 yr) Enormous progression since 70s Especially in areas with economic progress Progress in Africa offset by HIV/AIDS Adult diseases General mortality decline Except in Africa: enormous increase because of HIV/AIDS

In other areas, non-communicable disease gain importance Difference in burden of disease between countries is increasing Determinants The good nLife expectancy approaches 80 years in many countries, and is expected to increase to 100 in 2050 nLife expectancy in developing countries has increased from 46 tot 64 since 70 nIn all countries of the world, child mortality has decreased between 1960 and 2002. nPolio is eridicated as epidemic The bad nHIV/AIDS kills 3 million people per year, TB 2 million and malaria 1 million nTuberculosis and malaria become more and more resistant against medical treatment nIn 2002 10,5 million children died (< 5 jr) n6-7 million of these deaths could have been avoided easily through vaccination or treatment nas caused by malnutrition, pneumonia, disarrhoea, malaria or measles. The ugly. nThe difference in life-expectancy between developing and developed countries increases up to 40 years nThe ratio of child mortality between developing and developed countries was 5,5 in 1960 10,3 in 1990 13,0 in 2002

nAlso major differences between countries also in eich countries Tuesday, 6/3/07 Work group: Health and determinants Wednesday, 7/3/07 Practical: Gapminder: exploring global health In gapminder, the human develoment index is visualized in graphs, where education and health is put as vertical axis and income (GDP) as horizontal axis. We analyzed the following graphic series: 1. 2. 3. Human development and income growth 2004 Human development trends 2005 Milenium Development Goal Achievement Graphs 2003 Conclusions: Countries with the highest HDI and income are the ones in Organization of Economic Cooperation and Development. Region with the lowest is Sub-saharan Africa.

Singapore and Hongkong are Asian countries that perform as well as OECD countries. With the same level of income, countries may have different HDI. This may be due to civil wars and other social and political unrest, and the choices of the government on where to invest their money on. Economic growth requires investing in human development first.

Indonesia, along with Srilanka and China progress in both income in 1975-2002. Some countries such as Pakistan, Ghana and Nigeria have slow income growth with increase of HDI. Iran, Oman and Algeria improved their HDI but income development was still slow due to their reliance on oil alone for the income.

Poverty is currently defined as having less than 1 USD per day. The goal is to reduce the world poverty from 26% in 1990 to 13% (half) by 2015. With the current growth and distribution trend, it is estimated that the goal can be met by 2015. Sub-saharan Africa will have bigger percentage of poor people, and Latin America will experience wider gap between the rich and the poor within the region and countries. Some countries, such as Eritrea, is very efficient in using their income to invest on human development, therefore with relatively low income they manage to achieve high HDI. Big disparities within a country is a big problem in developing countries. Income difference between rich and poor in Namibia is similar to difference between the richest and the poorest countries in the world. Asian countries have lower disparities compared to Africa and Latin America. Response lecture: Health and determinants Charts and Graphs from Human Development Reports, UNDP 1997, were discussed. Lecture: Globalisation The history and effect of globalisation is explained. In relation to health, globalisation may lead to widening gap in health equality and distribution if the determinants of health are not properly addressed. Thursday, 8/3/07 Work group: Globalisation

Friday, 9/3/07 Video about the outbreak of cholera in Bangladesh was played. Discussion took place afterwards. The determinants of the disease were poverty (poor sanitation, inadequate waste cycle), inadequate water supply, education (human behaviour regarding hygiene and sanitation, handling of patients in the hospitals, awareness of ORS and sugar-salt solution), political (denial of the problem due to economic consequences),

urbanization (transmission of strain and increasing poverty in cities), gender empowerment, and interaction of grass-root movements with the government. Response lectures: Globalisation The elements of globalisation include: 1. 2. 3. Economic growth Income distribution Social development The phases of epidemiological transition: Hunger Pandemics Man made diseases Delayed chronic degenerative diseases Re-emerging infections Monday, 12/3/07 Lecture: Health systems Government involvement is needed in the health system to ensure equal access for people to health and quality assurance of the health care services. Collective actions are needed in public health efforts, and this is possible only if there is coordination involving the government. Industrial revolution promoted the introduction of health system as healthy workers are needed to maintain the productivity of industries. Technical interventions must work within a good system before becoming effective in solving problems, therefore a good health system is needed. Health system is the link between interventions and outcomes of health; and when the available interventions are not producing proportionally good outcomes, the health system should be assessed. Health system can be broken down into 8 steps for effective implementations of services; and problems in the health system can be traced and possibly solved within these steps. 1. 2. 3. 4. 5. 6. Financial accessibility Physical accessibility Availability of human resources Availability of material resources Organizational quality Relevance of services

1. 2. 3. 4. 5.

7. 8.

Technical quality Social accountability Tuesday, 13/3/07 Discussions: what makes a good health system?

Health system is defined as all activities whose primary purpose is to promote, restore, or maintain health. While the definition of health care system is provision and investment in health services including preventive, curative, palliative interventions directed individuals or populations. Objectives and impacts of the health system was discussed. Ensuring health of the population can not simply be done with curative efforts. Once patients are cured, they will return to their environment and community, the places likely contribute to their disease in the first place. For this, public health approach is important. Impact of health system to health outcomes is difficult to measure because all the different factors which also play their role. Changes in the European health system has happened from national health system, to primary health care, to new universalism. These systems have their own characteristic, advantages and disadvantages. However, the changes of health system had always been a reaction to what happen in the population. Ideally, health system must be able to anticipate problems, not just react to them. Health systems Why need a organised health system by government? Why not trade health care as e.g. apples on market? Need collective action for prevention to control communicable diseases Ensure equal access for rich and poor Good health is equally important for rich and poor Health systems: evolved in past century From reliance on traditional remedies to highly complex networks in a century Stimulated by industrial revolution

Eight steps to effective implementation of services 1. Financial Accessibility Typical problem Formal user fees are unaffordable Exemptions used for influential individuals Insurance serves only urban elite and formal sector workers Possible remedies Reduce user fees for basic services / strengthen exemption mechanisms Develop community financing arrangements 2. Availability of Human Resources Typical problem Lack of trained and motivated staff in remote undesirable areas Poor deployment policies, wage gap between internal and global market Possible remedies Improved personnel policies, favoring hard-to-reach areas Hardship pay, performance-based payments, improved training and supervision, contracting out 3. Availability of Material Resources Typical problem Shortage of essential drugs, and low quality / fake drugs Poor management of drug supply Consumers have insuffient knowledge Possible remedies covering informal sector

Improved drug management Rigorous forecasting, transparant procurement with reliable providers, contracting out, therapeutic guidelines, equity funds to improve access to drugs for the poor 4. Organizational Quality Typical problem Long queues / underutilization of facilities, lack of respectful care Social distance between provider and community Poor service management Possible remedies Train staff in planning and management Introduce community management committees Disseminate info about patients rights Include satisfaction measures in evaluation 5. Relevance of Service Mix Typical problem Ad-hoc, history based priority setting Disproportinate supply of curative services, Little relation between services burden of disease Public spending favors the least poor Possible remedies Rational priority setting of services Establish core package adressing basic needs

6. Technical Quality Typical problem Inefficacious services delivered Lack of use of practical guidelines / diagnostic and treatment algorithms Poor training / supervision Possible remedies Improve drug management, with special focus on rational drug use Improve training and supervision Performance based payments / contracting out 7. Social Accountability Typical problem Services are unresponsive to needs, characteristics & demand of the poor Community is not participating in management Possible remedies Establish and/or improve formal entities for community participation Actively promote participation of vulnrable groups Wednesday, 14/3/07 Response lecture on what makes a good health system Lecture: Choosing the right interventions Improvement in health system can be done with two ways: choosing which interventions to be delivered or choosing how interventions should be delivered. In choosing which interventions to deliver, several things need to be

considered: how effective the interventions are, what is the background of the population that will be intervened, and result of cost-effectiveness analysis. Thursday, 15/3/07 Discussion: Quality of Care Good quality of care is important because they may encourage people to utilize the health care services and more effective for the health care providers. Perceived quality of care is how the Friday, 16/3/07 Response lecture: Choosing the right interventions Monday, 19/3/07 Lecture: Global Initiatives The lecture focuses on global initiatives, especially on reproductive health. Most of the problems in reproductive health are related to health system, education, and culture which are the issues in public health. According to the definition of reproductive health, established in ICPD Cairo, 1994, reproductive health deals with the following issues: sexual health family planning abortion safe motherhood

Tuesday, 20/3/07 Working group: Global Initiatives Wednesday, 21/3/07 Video: Millenium Development Goals

Thursday, 22/3/07 Working group: Primary Health Care Friday, 23/3/07 Response lecture: Primary health care Monday, 26/3/07 Lecture and video: Healthy cities Tuesday, 27/3/07 Working group and lecture: healthy cities Thursday, 28/3/07 Examination Friday, 29/3/07 Presentation of paper

Feedback: The course is confusing in the beginning, however, approaching the final week, the students admitted to having better understanding of the different materials taught in the course and how they are related to one another. The class was divided into two discussion groups. The students felt that this group is too small to allow interesting discussion to take place. In the last week of the course the students chose to have the discussion in one big group instead, resulting in a more lively discussion and broader views on the problems. The subjects were always repeated, by having the same problems for self-study assignment, group discussions, and response lectures.

INFECTIOUS DISEASE ROTATION Entering the third month, my programme was to have an infectious disease rotation in UMC Radboud. Dr. Monique Keuter assigned Dr. Corine Delsing to tutor and supervise me. Dr. Delsing is a fellow resident who were at the time giving consultation on infectious disease patients in UMC Radboud. The departments asking for consultations usually were the orthopaedics, cardiology, neurology and ICU. My main activity with Dr. Delsing started before 09.00 and finished around

18.00. We usually started the day by checking the latest laboratory or imaging reports of the patients. Everyday we have a printout with the list of patients and their conditions. This list is also available for the supervising infectiologists, and they usually keep track of the patients everyday. Then we started the consultation, visiting the different departments and patients in the hospital. The infectious disease department is usually asked for consultation when patients from other departments develop a fever with a suspicion of infection. The history, physical examination, laboratory and imaging investigation are conducted to diagnose the cause of fever. The infectiologists are giving diagnostic and therapeutic plans to be done in the wards. Materials obtained for culture or other diagnostic tests are sent to the microbiology department. Infectiologists must also make sure that the suggestions are being carried out by the doctors or nurses in the wards. This may be difficult as there are often many different specialists involved in the patient care who do not always immediately agree on the plans for patients. The common cause of fever in UMC Radboud is infection of prostheses, respiratory tract, urinary tract, and the heart. Culture of material from patients is important in isolating the causing organism of infection, and only after the organism and the antibiotics susceptibility is known then the antibiotics will be started. Sometimes, the presumptive therapy is given but only under protocols and guidelines used in the hospital. Every afternoon the microbiology meetings are held. This daily meetings are attended by the infectiologists and microbiologist. There is always discussion about the clinical condition of patients, materials for culture and antibiotics susceptibility test, and the response to treatment. Discussions take place regarding the sensitivity and specifity of diagnostic examinations, and whether these results are enough to start treatment or further examinations are needed. Starting treatment usually requires discussions with the microbiologist and the infectiologists, especially in choosing the antibiotics, the length of treatment and route of administration. I also had the chance to join Dr. Brouwer and Dr. Delsing in the outpatient department, meeting boreliosis and HIV patients. 1. A consultation meeting is held weekly with all the infectious disease supervisors and residents mostly for educational purpose, as different opinions on the patients are discussed. An HIV/AIDS meeting is held

weekly for discussing the latest treatment of the patients. The weekly orthopaedics meeting allow the surgeons to have a discussion with the infectious disease specialists and microbiologists regarding the orthopaedic patients. During my rotation, I had the chance to work with several different patients. Mr. R, born 11-07-1930. Consulted with fever after placement of aortic prostheses. Mr. H, born 02-01-1933. Consulted with fever and necrotic ulcer of the foot. Mrs. L, born 11-05-1944. Fever for 3 weeks after CABG. Mrs. KH, born 07-04-1952. Staphilococcus aureus endocarditis, Marfan syndrome. Mr. M, born 15-8-1939. S. aureus spondylodiscitis, fever. Mr. J, born 23-11-27. Mediastinitis with CABG and CNS infection. Mr. J, born 21-02-30. Fracture of the hip and humerus with fever. Mrs. L, born 27-12-58. Aneurysmatic bone cyst with positive culture for bacillus. Mrs.G, born 21-12-52. Fever, fracture of the hip, chronic progressive ophthalmoplegi. Mr. H, born 15-03-43. Infection of the knee prosthesis. Mr. G, born 22-11-66. Cavernous lung: aspergilloma. Mr. C, born 01-01-77. Brain abscess, Down syndrome. UMC Radboud has a computer system for the medical records, with all laboratory and imaging results. The records can be accessed from all computers in the hospital and even from the doctors home, making it easier to access up to date information on patients and make a decision. HONOURS PROGRAMME I had the opportunity to participate in the lectures of the Honours Programme. Honours Programme is a 2 year inter-disciplinary programme with several different courses during the period. This programme is for motivated students from different faculties, and there were about 20 students in the course that I participated in. The lecturers come from different disciplines and institution. Initially, on 21 April 2007 all the international students from KVZ2 were invited to come to the course, which was about Health Determinants, Health System, and Primary Health Care. However, Dr. Francoise Barten, who is coordinating the Honours Course, offered us to come again to the next lectures, which is about Right to Health and Health Care for Immigrants in the Netherlands at 28 March 2007. From then on I always attended the weekly lectures, and thus the lectures were always delivered in English. Undocumented Immigrants Health and Health Care (28 April 2007, 18.00-21.00 Aula Radboud University)

Review of lecture: The lecture highlights the undocumented immigrants in The Netherlands, which consist of: 75% of which are male and work mostly in farming, food, or sex industries Rejected asylum seekers Ex-partners or family of legal immigrants

The effects of their undocumented status in The Netherlands are: poor working and living conditions

little amount of money, and therefore stuck to stay in The Netherlands in fear and uncertainty about their condition vulnerability to violence, especially the women no social network pre-existing illness

The health problems in undocumented immigrants are: anxiety sleeping problems contraception problems abortion for economic reasons more serious illness (delay in seeking treatment) higher perinatal death more problems in pregnancy depression

HIV/AIDS TB

Problems encountered causing limited access to care by undocumented immigrants are: no health insurance no money for paying treatment cost

barriers of doctors and hospital (refuse to give treatment, hesitancy due to patients undocumented status and cultural differences) barriers of patients (patients dont know their right for health care and how to reach the health care services) Barriers from the doctors are: financial reason (patients unable to pay)

knowledge/ psychological barrier: status of patients are illegal/undocumented, doctors must comply to hospital policy practical difficulties (language, time, lack of knowledge due to different diseases lack in the continuity of care (patient is homeless and live in poor condition) Public health implications if undocumented immigrants with health problems are not treated: spread of communicable disease (TB, STI)

self treatment by using underground doctors (without quality control, promoting spread of drug-resistant microorganisms) inequity and inequality

Integrated approach for the health of undocumented migrants: improvement not just in fulfilling legal rights but also social rights (housing, working condition)

providing stability in supportive network education for doctors (about the obligation to treat everyone) education for migrants (about how to seek health care)

Why Poor People Stay Ill: Chronic Poverty and Shock (4 April 2007, 18.00-21.00 Aula Radboud University) Review of lecture: - Chronic poverty causes vulnerability to illness. - Out of poverty in the world, 30-40% is chronic poverty, meaning that they stay below the poverty line for more than 5 years. - People at risk for chronic poverty are: - Those with low level of education - land degradation - large families with high dependency - women and children - widows, caste, ethnicities (related to ownership esp. in Africa) - Type of poverty: 1. Income poverty 2. Asset poverty: - absence of critical assets required for survival - asset loss after occurrence of shocks (illness, death, natural disaster, marriage) - There is need to search for risk-coping and insurance mechanism 1. Before events happen 2. After events happen

- The shocks, or critical life events, can be categorized as follows: 1. Stochastic: affecting all households (eg. Natural disasters, wars) 2. Idiosyncratic: affecting individuals (eg. Fire hazard, thief) - Critical life events are events that have such impact that can put people in poverty after they happen. For example: flood, crop loss, illness, death, marriage, theft, fire hazards. - Level of intervention: 1. Macro: economic growth of the country 2. Meso: development of insurance network 3. Micro: asset creation (land, schooling, etc) - Conclusion: there is the need to provide mechanism that can protect people from poverty in case critical life events happen. Health and the WTO by Albert de Vaal (11 April 2007, 18.00-21.00 Aula Radboud University) The relation of WTO and health can either be direct or indirect. In direct relation, the health issues are comprised in treaties of WTO; in indirect relation, WTO contributes to factors that determine health. Free trade, according to the WTO will be mutually beneficial if both countries involved open up their borders for trade. Free trade also allows smaller countries to specialize in products and services most beneficial for them and gain is potentially higher for smaller countries. Gain will be highest also if the trade is between countries that are most different. Generally, trade improve growth, but this is empirically hard to prove. Countries involved in free trade economically grow, however, the growth may not always be equal for all countries involved where some have higher growth than others. The developing countries need better terms of agreement for free trade. Implementation is somewhat more difficult for developing countries due to the slower and costly process, thus assistance is needed. However, as international agreements are made in WTO headquarter, the countries without resource cant be involved in the decision making.

To ensure fair trade is actually fair for the developing countries, the political commitment of governments is needed. Often, the governments are not making decisions on the best interest of the people. The governments should ensure that the trade agreement is a give and take process, or else no trade will be done. Capacity building is essential for global commerce, especially for taking part in the decision making. Conclusion: reciprocity is vital in ensuring that fair trade will be beneficial for socio-economic development of people in developing countries. Food, Health, and The Role of International Community Many countries still give tied aid, meaning that the aid is tied to sets of agreements between the donor and recipient countries, such as that the money is spent on goods from the donor countries. This can lead to competition between different donors. For example, The Netherlands built a hospital in Java and equipped it, with the intention of providing health services to people. The project was however was criticized of having low contribution to health effects because of limited coverage of the hospital. The hospital also relied heavily on equipments, causing rise in the cost of service and eventually, prices of service. The water and sanitation programmes of the donor countries in the 60s and 80s had emphasized on engineering, and criticized because the project had low maintenance and therefore, low sustainability. From the 80s on, programmes have paid more attention on the importance of the position of women and people participation in policy making. Critiques were delivered by Oxfam in the 90s about the gap between the principles and practices of World Bank: 1. 2. 3. 4. Limited expenditures Introduction of user fees of public services Rejection of taxation as financing means Increasing inequities Social Capital and Health (18 April 2007, 18.00-21.00 Aula Radboud University) Social capital consists of these elements: Material resources Immaterial resources

In network of social relations Mobilized by individual or collective actors

The concept of social capital is depoliticized and considered as neutral. Social capital also includes financial, physical, human and cultural capital. With globalization, the state retreats with the increasing role of the market; there is a need for the increase of the role of civil society. This rise of civil society requires social capital to act. When discussing about social capital, it is important to understand which types of social capital is being talked about: 1. 2. 3. Bonding: not good for larger societal development, as capital is available only for people within a group, which may lead to inequities between different groups. Bridging: interaction is based on trust and may lead to joint action. Groups of the same level may join forces to change policy. Linking: from lower to higher level for increasing the resource, for example from local organizations to government. Social capital is important in health for socialization, protection during crisis, improving access to services and psychosocial process. With the alternative model, social capital are joined together in pressure groups to force policy change. In synergy model, the social capital is in collaboration with the government to ensure better health for the people. Health in Urban Settings by Dr. Francoise Barten Interventions are often focused on prevention of exposure to health risks, however, the underlying social and economic policy of the country should also be influenced. Governments are often only interested in short term plans with immediate results, when long term and sustainable plans are needed. There is a need of empowerment, the deepening in the participation of people in determining their living and working condition. Theres also a need for social contract between people and the government. Diseases are interrelated, but interventions are being singled out. Integrated approach is needed but donors pick out specific issues to deal with separately and decisions are made not according to the local context. This integrated approach involves multiple actors and multiple activities in confronting the crisis. Health and its determinants are included in the policy making process.

SUMMARY The first course is KVZ 1, Health and Disease in the Tropics. The course was coordinated by Dr. Monique Keuter. The second course, KVZ2, is Public Health: International Perspective. Both of the courses are elective courses for the fourth year medical students in UMC Radboud. In KVZ1, the programme was designed to allow intensive interaction between the Dutch and international students. After lectures, the students had to immediately work in groups, usually preparing a presentation to be presented again in the class the same day. We spent the whole day almost every day in the faculty, whether in the classrooms or the library. We were getting used to reading a lot of articles in short time, make a summary and present them. The discussions are always interesting as most of the students were actively participating, giving questions or comments about the presentations. Everyone felt comfortable asking or answering questions without being afraid. The teachers also participated in the discussion but always encourage the students to contribute more and explore different possibilities. The teachers always managed to stimulate interesting and lively discussion. When answer to a question was not known, were used to look up the answers together in a book or journals. Learning with the teacher was pleasant and we felt like we were learning together instead of just being lectured all the time. The discussions with other students were not just about the course, but also practical experiences in dealing with the diseases in our own countries. The discussion goes beyond the classroom, as we also spent a lot of our free time outside the class together. The materials used for our presentation assignments are always up to date, based on recently published articles. This is something new for me, as Ive never had this structure of learning in Indonesia where students are given articles to summarize, answer questions and present. This had been a fun learning experience for me. The proposal writing was an important part of the course. We formed a group of 4 or 5 students and given a tutor with extensive research experience to supervise in writing the proposals. I found this very helpful, as being in a small group with a tutor allows us to have a better understanding of the materials being discussed, compared to just reading articles with other students. I was especially impressed that the tutors

were all very attentive and had the time to coach us in writing a research proposal. They helped to explain concepts, structure of proposals and edit them. It was easy to communicate with the tutors. The editing could even be done by exchanging emails. I was impressed with the course also because I had experienced a different teaching and learning structure. KVZ2 was different in the structure, as we were given lectures on a subject, followed by self-study assignments of reading articles and answering problems, then meet with our group and a tutor to discuss the answers. The next day we would have a response lecture with the whole class about the problems. This resulted in us always repeating the same problems and discussions. Although we gained a deeper understanding, the repetition was found to be rather boring. There was an assignment of writing a paper throughout the duration of the course and presenting it after the written exam. However, with we could only have a satisfying view on the health problems only after the last week of the course where we could integrate and understand all the different aspects of public health as being taught by the teachers. The result is that we ended up re-writing some part of the paper just days before the deadline with this new and comprehensive understanding of the problem. I had suggested that my group focus on maternal mortality in Indonesia. We all agreed, and had a challenging experience in trying to gather data regarding maternal mortality and efforts to reduce it in Indonesia. Finding accurate and current information is difficult, as there were only few articles found in international journals regarding maternal mortality in Indonesia. This made me realized that research and publication is still lacking in Indonesia. And although national journals exist, they are not readily available online, limiting the use of information. This course deals more with health economics and the social and political aspects of health, which turned out to be a very important knowledge for health professionals. I have never been introduced to these topics before, as public health in Indonesia deals mainly with community medicine, strictly discussing only diseases, interventions and community education. I learned about the functioning of the health system, the cost-effective analyses of interventions and the international initiatives to improve health.

Health is beyond the walls of the hospitals, and that influencing health of a population requires us to step into national and international policies. Understanding these wider aspects of health is important for clinicians, as those who want to make a difference have to take into account the different determinants of health. I am personally interested in these issues and enjoyed the vast new knowledge I got from the course. Dr. Francoise Barten from KVZ2 offered me to join the Honours Programme lectures on Wednesday evenings during the second and third month. The Honours Programme is an integrated course for students from different faculties. The lecturers come from different backgrounds (university, NGO, professionals) and disciplines, enriching the course with different perspectives on problems. I also had the opportunity to give a presentation to Dutch students who considered doing their 3 months of rotation or research in developing countries. These groups of students are called Tropico. At first I was asked by Dr. Keuter to introduce rotation in Semarang and Jepara because she couldnt be in the meeting. But after seeing a report on my work with UNESCO in Paris and Italy in 2005 about intercultural learning, she suggested that I also introduce the importance of intercultural learning. I eventually gave a presentation about intercultural learning and afterwards have a discussion about living in Java. I am impressed by the experiences of the teachers and residents in the field of research. The supervisors, most of the residents in infectious disease and many of the medical students I met have had experiences in doing research, working or volunteering abroad in tropical countries. This brings the advantage of having a more realistic view about medicine and health care, rather than just rely on the fully facilitated hospitals of the Netherlands. Students were encouraged to join in other activities than studying medicine such as working or volunteering in nursing homes or retirement houses. I immediately started my rotation in the hospital on the beginning of April, and assigned to a fellow resident of infectious disease, Dr. Delsing. I joined her everyday from 9 am to 6 pm, visiting patients, discussing cases with other specialists and attending meetings. Joining the rotation has provided me with some insight of the infectious disease department. I learned more about how important it is to work closely with different specialists in patient care. The cooperation and discussion between the infectiologists and microbiologists is crucial in

ensuring the best diagnostics and treatment for patients. Following a resident full time allowed me to learn a lot about the patients and their conditions, as well as how to communicate with patients. I have learned a great deal about how to approach a patient with fever and suspicion of infection, how important it is to ensure a diagnosis before starting therapy and how to carefully choose the best antibiotics. Its especially interesting to see how old patients in the wards are, compared to ones in Indonesian wards, showing higher life expectancy. During a consultation meeting, the supervisors often asked the residents to find information regarding comparison of antibiotics efficacy, certain diseases or syndromes and treatment options based on the patients conditions. The residents then would look up in journals and present the answer on the next meeting with the supervisors, allowing continuous learning relevant to the clinical cases in the hospital. Meeting the patients in the out-patient clinic had also gave me example on how things are done differently in the Netherlands. Almost all examination rooms have their own computers. The doctors can access patient information and connect to the internet for quick research about a certain disease or even look up information regarding drugs dosage and side effects. Several times, after a patient presented a complaint, the physician looked up the hospital website to check whether the complaint was a side effect of the antibiotics. The patient seemed glad that the doctor had consulted a reference website, ensuring that she would get correct information. In Indonesia, when doctors look up to check on information, patients perhaps are more likely to doubt their competence. The cosschap in The Netherlands are similar to the programme in Indonesia. However, the senior coass can choose where they want to do the final 3 month, whether in Internal Medicine, Paediatrics, Surgery, Obstetrics or development internship in tropical countries. These senior coass doing the last 3 months in the Netherlands are assigned their own patients, with all the responsibilities of a physician. In the ward, they have the same authority and responsibilities of the residents, but with fewer patients. The whole programme has allowed me have a better understanding of tropical medicine, international perspective of public health and infectious disease. There were of course advantages of studying in a richer university, with easy and free access to the library, internet and online journals. However, learning is also about the attitude and the will to go forward despite the limitations. I believe that the experience didnt only teach me medicine, but also about lifelong learning and serving people

with our knowledge.