Erlick Pereira went to Brazil for his elective to learn Portugese and find out about the culture and infectious diseases

Key facts

• Population--161.8 million
• Language--Portuguese
• Capital--Brasília
• Currency--Real
• International code--+55

When Brazilian people claim they live in a continent, not a country, they are not exaggerating. The distance from the east coast to the western border is further than from London to Moscow, and north to south is only slightly shorter. Brazil's area is almost as large as the United States. Brazil doesn't disappoint with its scenic and cultural diversity and perhaps only lacks the mountain ranges that its neighbours boast. With two thirds of its population spread along the coast and over half concentrated in cities, Brazil retains the atmosphere of a frontier community.

I went to Brazil into this atmosphere of exploration on a journey of self discovery. Many of my relatives emigrated to Brazil from the former Portuguese colony of Goa in India. I was keen to learn my family's language, to meet my Brazilian cousins, and to learn football and samba from the world experts. Learning a little medicine too wouldn't hurt. It was with these lofty ambitions that I undertook an elective in infectious and parasitic diseases in São Paulo.

A generous host

Fun-loving Brazilians host some of the most exciting parties -- and infectious diseases. Brazil is host to yellow fever, malaria (both Plasmodium falciparum and the less lethal vivax form), Chagas' disease, leishmaniasis, dengue fever, tuberculosis, and cholera. Other less exotic but common diseases with infectious causes in Brazil include hepatitis, AIDS, dysentery, and giardiasis. Many tropical infectious diseases are concentrated in the Amazonia region, but patients who can afford it travel to São Paulo from all over Brazil in the belief that it has the best treatment on offer. I managed to see cases of almost all these diseases at Hospital das Clinicas.

Alongside Rio de Janeiro, São Paulo is one of the world's great sprawling metropolises with a population of around 16 million. Appropriately, Hospital das Clínicas is South America's largest hospital, maintaining 2100 beds in an area of 320 000 m2.

Surgery on stray dogs

spent my mornings in outpatient clinics and on wards and my afternoons in a laboratory investigating leishmaniasis. I also spent one afternoon a week observing postmortem examinations and the odd afternoon operating on dogs. In Brazil, many medical students in their first clinical year learn surgical techniques using stray dogs from the dog pound. One student operates, another helps, and a third is anaesthetist. The dogs are put down after surgery. It struck me as a neat solution to the need to train surgeons and reduce the urban predicament of canine overpopulation; I met no students or pressure groups that objected.

Laid back yet professional

I also visited public hospitals in the neighbouring states of Belo Horizonte and Rio de Janeiro, and helped in elective surgery at other public hospitals in São Paulo. I was lucky to join a small medical firm of final year students from whom I learnt lots of medicine and Portuguese from their case presentations, outpatient clinics, and ward rounds. I soon gained the confidence to examine and take histories from patients with diseases seen rarely, if ever, in the United Kingdom. The Brazilian doctors were relaxed, allowing me to do as much as I felt comfortable with.

Brazilian doctors struck me as being more laid back than their British counterparts--but still professional. Their style of communicating with patients was somehow paternalistic and didactic; they dictated swift direct management plans, rather than spending time discussing treatment options. No doubt, in common with other developing countries, limited resources and time and large queues of patients made this the most efficient and pragmatic approach. The patients certainly seemed more appreciative, accepting, and respectful of such an approach than they might be in the United Kingdom.

HIV and AIDS

The Brazilian policy of not screening blood donors for HIV seemed bizarre to me, as Brazil has a large HIV and AIDS problem, which is particularly acute in São Paulo and Rio de Janeiro. Ignorance of how HIV is transmitted remains a big problem for the public.

The spread of HIV was a concern to many Brazilians I spoke to. So it came as a pleasant surprise that the established HIV clinics I attended at Casa da AIDS had excellent staff and facilities. They also seemed to attract the right target groups of patients through a combination of generous government funding and good public support. Indeed, this was true of many departments that I saw at the Hospital das Clinicas, but this hospital is perhaps rare in being well funded publicly and having doctors bringing in considerable revenue through private practice.

Brazil has a public health system, but it has few hospital beds for all but the most seriously ill and few free medicines. In a country whose cities are covered with shanty towns, the contrast between the many poor and the few rich is stark. People in employment pay into private healthcare schemes with levels of cover dependent on how much they have paid.

Poisonous snake bites

São Paulo is home to the Bu Tan Tan Institute, one of the world's leading centres for the treatment of illnesses caused by venomous snakes and scorpions. Although slashed government funding has reduced the amount of research, the institute retains a small hospital to treat victims of poisonous snake bites and their remarkable collection of snakes is well worth seeing.

Samba style

I may not have perfected either my Portuguese or my clinical skills, but on a trip to Rio to meet the family, I did manage to try samba dancing, beach football, and capoeira--a semiballetic dance derived from combat. Sadly, I couldn't keep up and soon retired exhausted while people three times my age danced on. The Brazilian flair for sport and dance is beautiful to watch but needs stamina to take part. The players were understanding, offering to revive me with the refreshing national soft drink, guarana.

Liberal attitudes

Brazil is a great place to explore and enjoy, and it is impossible to do justice to it in this brief article. Brazilian people are extremely welcoming and always keen to help a lost estrangeiro (foreigner). My impressions were that being white or a woman would not attract undue attention as Brazil is a nation of recent immigrants of all races with more liberal attitudes than many Latin countries. A good grasp of Portuguese, or at least Spanish, is essential to talk to patients although most doctors speak some English. With the current economic crisis, Brazil is even cheaper for tourists, and most hospitals won't charge to organise an elective.

It is not just Brazil's diseases, but also the friendliness and humour of its people that are infectious. I can't wait to return to both Rio and Sao Paulo. As Marlene Dietrich put it: "Rio is a beauty... Sao Paulo is a city."

Useful links

• University of São Paulo--www.usp.br/fm/fr-gradua.htm
• Hospital das Clínicas--www.hcnet.usp.br
• Clínicas department of infectious and parasitic diseases--www.usp.br/fm/departamento/dip/index.html
• Casa da AIDS--www.zerbini.org.br/hpfzaids.htm