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There continue to be reflective medical articles about the early days of the war which have appeared in both general and medical media.

Dr Pesach Lichtenberg from Kiryat Shaul Hospital wrote in The Atlantic about how Jews and Arab doctors work together and communicate following October 7th and his article can be accessed here.

Prof Mark Clarfield reflected on the fate of older people, both on October 7th itself, and subsequently. These people suffer disproportionally during humanitarian crisis. His article can be accessed here.

Misinformation about the events of October 7th and about the role of Hamas in particular continues to appear. Dr Philip Robinson responded to a BMJ article and highlighted the importance of being clear that Hamas is indeed a designated terrorist organisation in the UK. His letter can be accessed here.

A Gazan physician, Dr Khamis Elessi, published a letter in the Lancet (28th October 2023): “Save the Gaza residents from imminent catastrophe” about the deteriorating situation in Gaza. There were several inaccuracies in this letter.

In a response to Dr Elessi “The conflict in Gaza: a view from Israel” (published on 1st November 2023), Shelley Sternberg and Edward Breuer say that they share his concerns, and that they pray for the protection of innocent lives on both sides of the border, but that these concerns must begin with recognising that a terrorist organisation currently governs Gaza. Sternberg and Breuer’s letter can be accessed here.

A reflective comment about the ethical issues that healthcare professionals are encountering during the current conflict was published in the Journal of the American Medical Association on 8th November and can be accessed here.

One of the most disturbing features since 7^th October 2023 has been the silence of many of the International Healthcare Organisations about violence to women and children. The Israeli medical community have united to call for condemnation of gender – based crimes, for safe return of victims, and for support of those who are victims of such trauma. The full statement can be accessed here.

The issue of gender – based violence (GBV) on 7th October was also taken up by the Lancet, saying that medical societies, journals, and governing bodies must take a clear moral stance by vocally condemning the GBV atrocities. Their article can be accessed here.

The Israeli Medical Association issued a formal statement to colleagues worldwide about the current war. This can be accessed here.

The situation is ongoing and on 13th October two letters on the topic were published by the Lancet.

Prof Mark Clarfield, who is a geriatrician, reflected on the report about a Holocaust survivor hostage.

1500 Israeli physicians signed a letter about the ongoing crisis about the Israeli hostages who are being held in Gaza

On 16^th October Prof Mark Clarfield spoke to the Association in a webinar on “Update from Israel – One Doctor’s Perspective”. Watch the video recording here.

On 24^th October Dr Ruth Waitzberg spoke to the Association in a webinar on “Challenges and responses of the Israeli healthcare system during the first four days of the attack from Hamas”. Watch the video recording here.

Introduction:

From July to September 2018, I undertook a six week elective in the trauma and emergency medicine departments at Tygerberg Hospital, South Africa. This tertiary hospital is situated about 20 minutes drive from central Cape Town. Opened in 1976, it is the largest hospital in the Western Cape with 1899 beds and is state-funded by the National Department of Health. It serves as a teaching hospital for students from Stellenbosch University’s Health Science Faculty and manages a population of over 3 million people (South Africa has a total population of around 55 million).

In terms of hospital resources, my visit to Cape Town coincided with the end of a severe drought which had lasted almost three years. There had been concern that in the months running up to the start of my elective the city’s water supply would dry up, an event referred to as ‘Day Zero’. At this point water taps would cease to function and Capetonians would have been forced to collect water from local municipality spots throughout the city. Hospitals themselves wouldn’t have their water supply revoked, however a spike in admissions was still predicted due to the acute effects of the supply ban in the community. Fortunately sufficient rain throughout July and the rapid construction of desalination plants had removed this acute threat, however water was still used sparingly in the hospital. There was a scarcity of other resources too due to chronic underfunding from the Department of Health which limited access to investigations such as blood tests and imaging. A positive consequence of such shortages was that doctors were diligent at relying on signs and symptoms to form diagnoses.

Departments and Ambulance Work:

Unlike hospitals in the UK, Tygerberg Hospital has separate emergency and trauma departments. The emergency department handles similar cases to Accident and Emergency departments in the UK. The vast majority of cases presenting to the trauma department were shootings and stabbings of young males from the multitude of townships surrounding the hospital. Many of these patients were involved in the Number’s Gangs:a collection of rival gangs which is prevalent in Cape Town prisons. Former inmates often remain associated with their respective gangs even after release where they are known to impose tyrannical control over township communities. I had the opportunity to see first hand the violence in these townships whilst joining the ambulance crew who often had to venture into the townships under police escort. On some occasions, the police refused to escort ambulances into the most dangerous townships, so-called ‘red zones’. In these situations, the patient would have to rely on self-admission to hospital which  would have worse prognoses. Aside from ambulance shifts, I had the option each day to work either in the trauma or emergency departments. The trauma department was generally busier during weekend night shifts and busiest on a payday weekend, with alcohol-fuelled violence causing a surge in trauma admissions.

A typical shift:

Shifts would last up to 12 hours, although it was not uncommon to be working with doctors on 24 hour shifts. A typical shift in the trauma department would involve shadowing a junior doctor or clerking my own patients as part of triage, performing a variety of clinical skills including venepuncture, arterial blood gases and catheterisation. I had learnt the foundations of sutering from courses with the Cutting Edge Surgical Society and I was very keen to develop these skills in the trauma unit. Following teaching at the skills lab at Tygerberg and ward teaching from the junior doctors, I was able to suture some of the patients that were admitted with sharp trauma, for example knife attacks. With the clinical skills I was performing, I received constructive feedback which I believe improved my clinical performance. After a few shifts I was inserting chest drains for haemothoraxes secondary to sharp chest traumas, and performing lumbar punctures (all under close supervision!). As with my experience in the UK, it was incredibly useful for my learning to follow patients from their admission to discharge and understand the reasoning behind each clinical decision in the patient’s management plan.

Unlike the trauma department, I would normally attend day shifts at the emergency department, mainly so I could attend the morning ward round which may have involved up to 15 medical professionals from different specialities. The ward round would take around three hours and involve reviewing up to 70 patients. Despite the number of patients, the consultant leading the ward round would consistently provide teaching to the medical students. My key observations from the emergency department were: firstly, the late presentation of so many patients – this could be put down to multiple factors including poor health education meaning patients are far less aware of urgent symptoms, socio-economic factors affecting their ability to transport themselves to hospital and the lack of screening programmes to enable early disease identification; and secondly the prevalence of HIV and TB.

Public health concerns: HIV and TB

Nineteen percent of South Africans are believed to have HIV, making it the country with the largest population of HIV patients. However antiretroviral drugs, health education programmes and increased condom usage (amongst other factors) have contributed to a reduced incidence of HIV by up to 44% from 2010-2016.This comes after a period of ‘AIDS denialism’ when Thabo Mbeki, the president of South Africa from 1999-2008 publicly denied that AIDS was caused by the HIV virus. This belief delayed public health authorities into commencing anti-retroviral (ARV) programmes. HIV remains a significant public health concern, however, and was accountable for a substantial number of immune-related hospital admissions that I witnessed. Furthermore, stigma towards HIV remains high which has reduced ARV compliance.

Aside from HIV, TB is a very common comorbidity with a co-infection rate of about 60%. Screening programmes have become more prevalent and public health authorities now believe that TB and HIV should be given the same attention. Previously undiagnosed late-stage TB was a common presenting complaint in the emergency department at Tygerberg. Whilst distressing to witness, it was beneficial to develop my chest x-ray interpretation skills and respiratory examinations during the management of these patients.

Conclusion and reflection:

I thoroughly enjoyed my elective in South Africa: I felt that my clinical skills improved and I became more confident in carrying them out competently and safely. I was also glad that I saw a wide range of admissions to the emergency department. Moving forward I would like to focus on the clinical skills and knowledge that I have obtained from my elective and put this into practice during my placements this year. I also feel more comfortable performing the types of jobs that will be expected if me as a foundation year doctor.

Noah Stanton

Leeds

As a part of my elective I chose to spend three weeks at a general practice in Israel.  As I am hoping to move to Israel after I qualify, and am interested in pursuing general practice, I thought I could use this as an opportunity to get more familiar with the Israeli medical system and determine whether I could be comfortable working in Israel.

I chose the practice based on good reviews from British students who had done electives there previously.  It also had the advantage of being in Netanya, where I had access to a flat so that accommodation was free!

The practice is located in the centre of Netanya and has four doctors and a nurse on site.  It is associated with the Maccabi Health Fund, but is not controlled by them, so that private patients are also seen.

The population in Netanya is very diverse and includes a mixture of Israeli born, English, French, Russians, South Africans, Germans and several others.  The four doctors spoke at least six languages fluently and the practice had become so well known for this in Netanya that several holiday-makers had come specifically to the practice and waited for hours to see the doctor that spoke their native language.

I spent most of my time sitting in with a South African doctor who was fluent in English and Hebrew.  Approximately 40% of the patients he saw were English speakers. As my Hebrew was not very good, this mix was advantageous as I could easily understand a lot of the consultations and could improve my medical understanding as well as working on my Hebrew. Unfortunately, my level of Hebrew prevented me from being able to clerk patients before they were seen by the doctor unless they were English speakers, but by the end of the placement I could understand most of the Hebrew conversations as well and was starting to be able to speak more confidently as well.

The multitude of languages in the practice led to a rather unique challenge for the doctors as it was important for them to know in which language to greet the patient.  The practice was so busy that they rarely had time to look at a patient’s notes before they came in and, if they were greeted in the wrong language, the patient would immediately know that the doctor did not remember them, thus creating a breach in their relationship.

During my placement, I was most struck by the computerised system the doctors used to document their notes.  The Maccabi health fund has an internet-based system that can be accessed by any other Maccabi-associated-doctor in the city.  This meant that the doctors could simply write their notes from the consultation on to the system and this would then be accessible instantly to another doctor in the city.  This removed the need for referral letters as the doctors would simply give the patient a form to make an appointment with a specialist who would be able to look at the reason for the referral on the system.  This saved an enormous amount of time and was much more efficient than the UK system.  It meant that the doctors could send a patient for blood tests and chest x-rays and see the report as soon as they were available, allowing them to act promptly where necessary.

It was also interesting to note that, because the population is almost completely Jewish, in the week preceding Yom Kippur the doctors had to be slightly more wary than usual in prescribing drugs such as antibiotics as they were aware that most people would be fasting and inclined to miss pills.

Overall the experience was extremely valuable and I gained a huge amount of medical knowledge as well as very valuable information about the way medicine works in Israel.  It has given me a lot more confidence to consider working in Israel in the future.

Miriam Burns

King’s College London

I undertook my elective at the Microgravity Centre in Porto Alegre, Brazil. This facility was part of the Pontifícia Universidade Católica do Rio Grande do Sul.

During my time in Brazil I was involved in two projects, both in the field of space medicine. I have always been interested in extreme environments, and especially space travel. I saw my elective as an excellent opportunity to gain experience in the field of space medicine and conduct original research in this area.

The Microgravity Centre specialises in simulating microgravity and hypogravity to investigate the effects of these environments on the body and on medical procedures. This is achieved by means of body weight suspension and lower body positive pressure (LBPP). The primary focus of my own project was to use a LBPP and treadmill system that had been set up to simulate walking on Mars. Once this was accurately achieved, open circuit spirometry was used to measure respiratory gases. This data was then used to investigate the metabolic changes that occur when walking in simulated Martian gravity. Details of the project were summarised in the abstract below:

The metabolic cost of walking in simulated Martian gravity and its implications 

Elliot Brown, Thais Russomano, Brenda Bueno, Leonardo Bandeira, Leandro Disiuta, Ingrid Lamadrid, Michele da Rosa, Julio C M de Lima, Rafael R Baptista, Raquel da Luz Dias

INTRODUCTION: Understanding the metabolic cost of walking is vital to the success of future missions to Mars. Lower body positive pressure (LBPP) is an effective way of simulating hypogravity. A small number of studies have shown that oxygen consumption (VO₂) decreases when walking in LBPP simulated Martian gravity. This study measured the submaximal VO₂ and other respiratory gases when walking on a LBPP treadmill at 1G and simulated Martian gravity (0.38G). Specific focus was given to analysing calorific expenditure and substrates metabolised.

METHODS: Twelve healthy participants with mean age (± SD) 22.75±5.38 years took part in this study with full consent. The LBPP box used was designed and built by the Microgravity Centre. A VO2000 gas analyser measured respiratory gases and a Polar S610 heart rate monitor measured heart rate. Volunteers walked for 8 min at a control of 1G and then for another 8 min in simulated 0.38G two weeks later. Student’s t test for paired samples determined if the data from the two environments were significantly different.

RESULTS: Mean (± SD) VO₂ was 1.00±0.61 ml/kg/min in 1G compared to 0.68±0.33 ml/kg/min in simulated 0.38G (p<0.05). Average Calorific expenditure was significantly reduced (4.79±2.80 Kcal/min) when compared to the control (3.37±1.49 Kcal/min) (p<0.05). The average heart rate at the control weight was 118.49±15.07 bpm, significantly reduced to 106.20±11.17 bpm when body weight was unloaded (p<0.05). Average respiratory quotient (RQ) was significantly increased (p<0.05) from 0.83±0.13 to 1.14±0.19 in simulated 0.38G, with no significant difference seen in the fraction of expired carbon dioxide.

DISCUSSION: Energy consumption significantly decreased when walking in LBPP simulated hypogravity. This agrees with previous studies which also measured a reduction in VO₂. Reduced calorific expenditure was also measured during the Apollo 15 Lunar landing. Observed calorimetry and respiratory gas findings can be used to calibrate EVA suits and advise on diet and exercise regimes for future astronauts. RQ indicates that a higher proportion of carbohydrates were used as an energy substrate. On Earth, LBPP can be used to remobilise patients effectively whilst reducing joint loading. Rehabilitation regimes can now be tailored with an understanding of how metabolism changes.

During this elective I was also able to participate in two other projects.

One of these focused on testing a novel method of delivering cardiopulmonary resuscitation (CPR) for use on the Moon and Mars. Hypogravity was simulated by using a body weight suspension system. This project was mainly led by another medical student from Glasgow Medical School.

The other was a telemedicine outreach clinic to the village of Palmares do Sul. I helped to run a cardiology and dermatology clinic with the aid of 2^nd year Brazilian medical students. Clinical information such as ECGs and dermatological photographs were gathered by our teams and sent back to consultants in Porto Alegre. Through this system, patients who live far from specialist care could be reviewed. Acutely ill patients were treated by the outreach team on site.

In addition, I also scrubbed into surgical theatre at the São Lucas Hospital in Porto Alegre and attended lectures on hypoxia and space suit physiology.

Following the elective I was fortunate that my research abstract was accepted for presentation at the Aerospace Medicine Association (AsMA) annual scientific meeting in Denver, USA. The Jewish Medical Association (UK) made my attendance at the five-day conference possible. This gave me a unique opportunity to present my work internationally, and to network with professionals in the medical specialty I would like to pursue.

AsMA was founded in 1929, and is the largest international meeting of aerospace medical professionals. Over 50 nations were represented, and approximately two thirds of the delegates had a military background in the air force or navy. The medical staff from major space agencies such as NASA and ESA were also present. Several NASA astronauts were also in attendance at the conference.

My abstract was selected for a 15 minute slide presentation in the session ‘Future of Space Medicine Part 1’. Following my presentation I discussed my project with experts in the field and explore ideas for future work. The medical student from Glasgow also presented her work on CPR.

This experience provided me with an unparalleled opportunity to gain career advice from a multitude of flight surgeons working in both the military and in space agencies. Everyone was extremely welcoming to us, having come all the way from the U.K. In particular, it was wonderful to meet and talk to Dr J D Polk, Chief Medical Officer for NASA, and fascinating to gain insights into his job in Washington and his opinion about the future of manned space flight. Dr. Chuck Berry, the flight surgeon for the ill-fated mission of Apollo 13 was also present. In his lecture, he discussed the medical challenges that were faced during the crisis. From the U.K. it was a pleasure to meet Dr. Kevin Fong from the UK, who delivered the Royal Society Christmas lectures on space medicine in 2016.

Whilst I was in Denver I made the most of engaging with the local Jewish community. I spent the first Shabbat spent with the one of the local Chabad families and was invited to their son’s barmitzvah! I spent the second Shabbat with the Hillel House at the University of Colorado in Denver. I got to know many Jewish students studying there university and I am still in contact with them today.

Elliot Brown
Birmingham