Name: Sophie Harrison

Poster title: Infectious Diseases in India

Mumbai (formerly Bombay) is the most populous city in India and one of the biggest cities in the world. The city has an estimated 18 million inhabitants, of whom approximately 60% live in slums. (UNDP) The streets are rammed and frequently flooded, the trains offer only door-hanging class during rush hour, and there is almost no green or open space anywhere in the city. On the plus side, the culture is incredibly rich, varied and interesting, and the food is the best in India. Many of Mumbai's citizens are rich, but their wealth is little in evidence. More are extremely poor: after eleven at night the pavements are lined with sleeping bodies.

King Edward Memorial hospital (KEM), is a large and busy government hospital situated in the north of Mumbai, in Parel. Parel was once the centre of India's cotton industry; the area remains a densely-populated working class district. KEM has 1,800 beds and treats 1.8 million out-patients and 68,000 in-patients annually. KEM does not charge for consultations and so is the major treatment centre for poor patients in northern Mumbai. Patients present late and sick: over 6,000 patients a year die, with the rate being highest during the monsoon season (June to October) when waterborne infectious diseases are at their peak.

In my time at KEM I was attached to a general medical firm, although I also spent days in dermatology, A&E, and at the outreach clinic at Malvani slum, which is 34 km from the hospital (but still well inside the city limits!). Everything at KEM, including the ICU, is in a dilapidated state, and the hospital is extremely hot and overcrowded (humidity in Mumbai during the monsoon rarely drops below 96%). However the skill of the doctors is exceptional and they're brilliant teachers. Every kind of condition can be seen, and every kind of clinical sign elicited.

Ward rounds on the general medical ward were great learning opportunities but took stamina. An average admission was 70 patients; one saturday morning we had 116. The caseload consisted predominantly of infectious diseases: malaria, leptospirosis, dengue, tetanus, TB and Aids; however many patients also presented with cardiac and respiratory problems, neurological disease, and life-threatening anaemia. ICU, where we also did rounds, contained patients suffering from multi-organ failure secondary to waterborne infections; there was also a high incidence of Guillain-Barre Syndrome, organophosphate poisoning and snakebite. A shortage of ICU beds meant that many very sick patients had to stay on the general medical ward; it became ordinary to see people die, even during ward rounds.

The 12 ICU beds had a rapid turnover, but it admissions at A&E was the real challenge. It should not be possible to get that many people into one room. The registrars were keen for students to practise procedures, and there was ample opportunity to examine patients, albeit at high speed, and to carry out ABGs, catheterisation, cannulation and blood-taking.

My learning objectives were to increase my understanding of how clinics operate in a slum setting, and to gain a greater insight into the aetiology, epidemiology, management and prevention of a specific infectious disease. I chose tetanus as I was impressed by the number of patients presenting with an illness that is so rarely seen in Britain. I feel that my understanding of the disease was greatly improved by my involvement in the diagnosis and management of several patients, including a 12-year-old boy with tetanus secondary to minor trauma, and a neonate who had contracted tetanus after an untrained midwife applied cow dung to the umbilical stump.