University of Gadjah Mada (UGM), Yogyakarta (Indonesia)

Impressions of University of Gadjah Mada

• Harry Walker – medical student from Sydney Medical School, undertook an ILA at Universitas Gadjah Mada in 2011–12
• Belinda Poon – medical student from Sydney Medical School, undertook an Elective at Universitas Gadjah Mada in 2011–12

Harry Walker – medical student from Sydney Medical School, undertook an ILA at Universitas Gadjah Mada in 2011–12

"As my first prolonged exposure to the health care system of a developing country, two weeks’ placement at UGM provided invaluable learning opportunities, which I will draw from throughout my career. From the three classes of patients and VIP ward in the large city hospital, to the diagnostic and management methods employed by staff in the startlingly resource-poor regional clinics, I experienced why, and when, a core understanding of disease processes is so important.

In Australia, for good reason, we aim to control the environment from which we can issue health care: The essential drugs, devices, scanners, and theatres are constantly available to clinicians so that the desired intervention is possible almost all the time. Being involved with tuberculosis and HIV in Java required a repositioning along that dimension. Patients’ education and financial situation, the budget of the healthcare facility, culturally unique notions of health and sickness, local linguistic variability; the environment in which to provide care was often more unpredictable than the diseases themselves.

Experiencing the healthcare system of Yogyakarta exposed me to a bevy of barriers to, issues in, and perspectives of health, to which we are largely unaware in Australia. The staff and students at Dr Sardjito Hospital and Universitas Gadjah Mada were always eager to help me understand their system and assist with my learning. Perhaps the most valuable insight from the experience was that despite the differences from country to country or hospital to hospital, being a doctor anywhere in the world requires working within these same limitations; financial, communicative, technological, and others. In urban Australia, the bar is just set much higher."

Belinda Poon – medical student from Sydney Medical School, undertook an Elective at Universitas Gadjah Mada in 2011-12

Medical centre in rural Central Java, inserting hormonal contraceptive implant in woman’s arm

Overview of Elective:
Maternal and Child Health: I spent two weeks in a rural village in Central Java staying with a local midwife. I attended the local medical centre and was involved with early childhood health and immunisation, contraception and family planning, and antenatal care. I was also involved with field visits such as early childhood clinics, general health clinics, primary school visits, postpartum home visits, and leprosy screening in remote villages.

Tropical Medicine: I spent two weeks in Yogyakarta at the Sardjito Teaching Hospital and was involved with infectious diseases, in particular tuberculosis and HIV. I visited regional respiratory clinics and inpatient facilities specialising in tuberculosis diagnosis, treatment and public health. I also visited specialised facilities providing methadone programs, STI screening and needle exchange programs in high HIV risk communities. At the teaching hospital I spent time on the wards with patients with fever/sepsis and other infections, including tetanus and malaria.

Early Childhood Clinic rural Central Java, measuring height and weight in children under five

General Comments and impressions:
I found the experience very enjoyable – the people are friendly, the food is fantastic, and the culture is fascinating. UGM Faculty of Medicine staff are kind and helpful. Yogyakarta is a great city to stay in, cheap to live in, easy to get around, and excellent for tourism/sightseeing. Indonesian language in the city is helpful, and essential if you want to travel to rural areas.

Seeing healthcare in a developing country has helped me to appreciate the health system we have in Australia, in particular access to diagnostic testing and imaging. Often in the rural areas only very basic blood tests and X-rays are available. Without the benefits of further investigations, doctors have to rely on clinical examination skills much more. I feel that often junior doctors in Australia have many diagnostic tests and imaging techniques at their fingertips, and perhaps are vulnerable to becoming too dependent on them. Doctors should always remember to treat the patient in front of them, and not just a test result. Thorough history taking and physical examination is essential to becoming a “better” doctor, and this experience has definitely reinforced this for me.

I admired the multidisciplinary approach to community medicine I observed in rural areas, including the large role of nurses and midwives in women and children’s health. Many midwives had practices in their own homes, and were always available for women’s and childrens health advice, which meant more of the poorer village women could access medical help more readily than going to a medical centre or hospital. I believe that I will continue to appreciate the importance of all medical and allied health professionals working together to improve patient care and outcomes.

The key cultural lesson that I learned during my placement was that when attempting to address health issues, you must use strategies that will be culturally appropriate. My supervisor explained this to me like this – “I had an elderly female patient who had heart failure as a result of chronic lung disease. She had spent forty years of her life cooking over a wood stove, inhaling the soot every day. Should I buy her a gas stove? How can I afford to buy a gas stove for every single woman like her? Even if I did, would she use it? She has done the same thing every day for forty years, she won’t want to change. We need to come up with something that she will accept.”

Introducing new technologies into healthcare systems in developing countries is not always appropriate or successful. I observed that many midwives had foetal heartbeat Doppler probes in their practices. Often, however, they were broken or the batteries were flat. They were quite often not used, but rather the midwife would use the old fashioned Pinnard stethoscope to hear the foetal heartbeat. In that environment the newer technology was less useful than the older technology.

Medical treatments are heavily influenced by local cultural and religious preferences. This was particularly evident in contraception. Rural women have low uptake of the oral contraceptive pill compared to Australia, but have much higher uptake of long lasting contraceptive injections, implants and IUDs. This is more convenient for women who live far from medical services. Condoms are less readily available than Australia due to widespread religious disapproval. Being aware and sensitive of these issues is very important if you want to provide medical services that will actually be used by the local community.