I did my elective in Gambia as I thought it would be a good introduction to medicine in an African country in a safe and cheap environment, as well as a chance to enjoy the lovely beaches, music, food, and buzz of west African life.

Gambia is a sliver of a country, less than half the size of Wales and the smallest African nation. It is situated on both banks of the Gambia River and is surrounded on all sides except the Atlantic coast by French speaking Senegal. Gambia's population of 1.4 million is made up of five different tribal groupings, all with their own languages, of whom 90% are Muslim and the rest are Christian.

By the standards of many countries in west Africa-think most recently of Liberia-Gambia is a haven of peaceful civil society. That is not to say the political scene is without event. A bloodless coup in 1994 by young soldiers brought Yahya Jammeh into power. He has now legitimised his rule through elections in 1996 and 2001. The hyperbolic 22 July arch in the capital city, Banjul, fronted by a gold statue of Jammeh dressed in fatigues and clutching a rifle and a baby, give a flavour of the man. Jammeh has accrued great personal wealth but has also built roads, schools, and health centres.

Subsistance society

Gambia's rural people are mostly subsistence farmers, and 98% of food in the cities is imported. Gambia's only export is peanuts. Although package tourism is also an important source of cash, much does not filter through to the local economy. It is no surprise therefore that Gambia is among the poorest countries in the world and according to the United Nation's human development index, the average Western citizen is up to 100 times better off than their Gambian counterpart.

Poverty is the major cause of a life expectancy of just 50 years. Although the birth rate is 3%, one of the highest in the world, 10-20% of children die before their fifth birthday. Healthcare facilities are basic and the bulk of the medical care is delivered by the 200 Cuban doctors sent over by their government on two year contracts. Patients present late because of difficulty getting to hospital or clinic and fears about the high costs of treatment.

Gambia has only one major hospital-the Royal Victoria Teaching Hospital-which was renamed as such when the medical school was set up last year. The hospital is in Banjul, which feels more like a small town-triumphal arch excepted. Treatment is largely free, although some drugs and investigations have to be paid for. The large paediatric unit with more than 200 beds offers medical, surgical, and neonatal care and rehabilitation wards for tuberculosis and malnutrition.

Key facts

• Population - 1.1 million
• Language - English
• Capital - Banjul
• Currency - Dalasi
• International dialling code - +220

The (British) Medical Research Council has had a facility in Gambia for longer than 50 years and is a Mecca for tropical disease researchers from around the world. It provides free health care to those villages "upcountry" where it has stations and clinics and beds for 40 patients in its headquarters which is situated near the coast in beautifully manicured grounds full of exotic birds and flowering trees. The high standard of research and clinical practice give a Gambian elective an added dimension-you get all the gritty exposure to tropical diseases but also clinical meetings where the latest research is discussed by international experts.

The major disease burden in the Gambia is falciparum malaria, which becomes epidemic in the rainy season from June to November and overall accounts for a quarter of childhood mortality. Other big killers are malnutrition, tuberculosis, renal disease, and hypertension. HIV/AIDS is a growing problem, with a current prevalence of 2-3%. The government has only recently launched HIV/AIDS education programmes and awareness remains distressingly low.

I spent most of my medical time at the Royal Victoria Teaching Hospital on the paediatrics special care unit, a 25 bed ward for the sickest children. Cuban doctors and a Voluntary Service Overseas paediatrician from England supervised me. I also took part in clinics and clinical meetings at the Medical Research Council's facility.

Urban smiles

My first day was a shock. Urban poverty in the Gambia is quite masked. People dressed vibrantly and exuberantly. Markets are piled high with masses of fruit and vegetables and, clichéd but true, everywhere there is laughter and smiles-Gambia has dubbed itself the "smiling coast" for tourist purposes and for once the hype is true. Inside the hospital there were still, remarkably, the smiles and the exuberant clothes, but also lots of wretchedly sick children in a dark, dirty, hot, and poorly ventilated ward. On my first ward round I saw children with bronchopneumonia, bronchiolitis, cerebral malaria, meningitis, iron poisoning, malnutrition, HIV/AIDS, renal failure, sickle cell crisis, and Burkett's lymphoma. Patients were thoroughly examined by a doctor and a history taken, with the aid of nurse interpreters, from the mothers, who stayed with their children at all times and played an important part in their care. The only investigations reliably available were packed cell volume and blood film for malarial parasites, drugs were in short supply, and blood was usually only available if a compatible relative could donate.

As the malarial season kicked in, the ward filled up and patients were often doubled or tripled up in one bed. There were about 100 admissions each week and about 20 deaths. In a masterstroke of forward planning, 150 Cuban doctors completed their contracts in the beginning of July and went back home. The new cohort of doctors did not arrive until the end of August, meaning that during the busiest time of the year the number of doctors was effectively halved. Not surprisingly, I was co-opted into seeing patients independently and prescribing drugs. Occasionally I felt slightly pressured to take on more than I was competent to do, but, if I asked, doctors were always happy to supervise and even teach, and I always ensured that my notes and prescriptions were signed off. The lack of staff, equipment, and medicines and the overwhelming numbers of patients was frustrating and often heart wrenching.

DAVE PENMAN/REX

I've got a lovely bunch of coconuts

Relieving rains

Away from the hospital I enjoyed going to the beach; eating wonderful fish dishes that cost next to nothing; hanging out with volunteers, doctors, and research students and spending time with the Senegalese family who I rented a nice room from. Despite being the rainy season it rarely rained during the day and when it did it was such an all out torrential downpour that it was quite exciting. It was also nice to see the countryside changing from dusty brown to lush green, especially since droughts last year had ruined the harvest. Gambia has its own, quiet beauty with pancake flat mangrove swamps and savannah punctuated by weirdly shaped baobab trees and grass thatched villages. Other places in Africa that surely have more startling and beautiful landscapes and architectural attractions. It is the people that make the Gambia so special.

So would I advise an elective in the Gambia? Definitely-you will get terrific exposure to tropical illnesses, great educational opportunities (with a chance to do funded research projects if you arrange your elective through the Medical Research Council), and an opportunity to be beguiled by the people of the smiling coast.

Mark Wilson author of The Medic's Guide to Work and Electives around the World, University College Hospital, London
Email: H.R.Clompus@ncl.ac.uk

March 2004

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