Shazad Aslam went to Soweto for his elective. Precautions against HIV are rigid for healthcare workers, and almost half the population is infected. He explains how he felt working in this dangerous neighbourhood

Johannesburg is one of the largest and most affluent cities in South Africa, attracting many immigrants from the surrounding areas in search of wealth and prosperity. The skyline shows off impressive buildings, large shopping malls, and man made mountains made from excavating land in search of gold and other minerals.

The many hospitals in Johannesburg range from the wealthy private hospitals to the poor government hospitals. I spent my time at Chris Hani Baragwanath hospital (Bara for short) in Soweto, working in surgery and trauma medicine.

REX/RICHARD SOWERSBY

Most middle class and some working class individuals pay insurance for health, termed "medical aid," which the poor can't generally afford. There are limitations on what funds buy, and if the money runs out, patients often have to move to a state hospital. State hospitals also charge. Fees are usually based on the patient's income and marital status and range from Rand 13-194 (£1.07-15.50; a1.50-22.70) for an outpatient visit to Rand 129-194 per admission, which includes all treatments except in emergencies where all treatment is free.1 Maternity cases and children under 6 years are treated free of charge. Patients in Baragwanath often have to wait for long periods of time to see a doctor.

Baragwanath hospital is large, covering 173 acres and serving more than 3.5 million people in Soweto and its surrounding areas. It was originally a British army hospital and has long, winding corridors and large nightingale wards. The windows have bars on them, and the hospital is surrounded with wire fences, tall walls, and barbed wire. Money is limited, and most of it is spent on treatment rather than the surroundings.

• Population of South Africa-42 million
• Languages-English, Afrikaans, and nine separate African languages
• Capital-Pretoria
• Currency-Rand
• International dialling code- +27

Patients are friendly and polite, and doctors are held in great respect. There is also great camaraderie between patients, who chat and help each other while waiting to see a doctor. Often patients and sometimes staff would break into spontaneous song. South Africans love to dance.

Patients are clerked, examined, and sent for investigations, often performed by students. A strong support structure is provided, with students supervised by interns and registrars. This is also a great opportunity to conduct minor procedures such as suturing, cannulating, incision and drainage of abscesses, and assisting in resuscitations.

Forty three per cent of deaths are HIV related.2 This is a big problem for South Africa as no treatment is available except in pregnancy to prevent transmission. The word HIV is rarely mentioned, and patients are often described as "retroviral positive." There is a large campaign to educate South Africans about safe sex and HIV.

I had discussed the dangers of performing invasive procedures with my medical school before leaving for South Africa. As exposure prophylaxis was available in Soweto, I decided not to take any with me. I have spoken to some unfortunate medical students who had needlestick injuries, sometimes because of resheathing needles. It is important to wear a face mask or eye protection in theatre in case of splashes. Doing any sort of invasive procedure is a personal choice, and I was never under any pressure from other doctors. Even when I arrived at the medical school people spent time explaining what to do and whom to see, giving me mobile phone numbers of consultants, in case I got a needlestick injury.

When taking blood, I took my time and made sure I knew where the needle bins were, and I wore two pairs of gloves. Make sure you have health insurance that covers needlestick injuries.

Human rights abuses in South Africa include child abuse, domestic violence, rape, abuse of poor and underprivileged people, and exploitation of illegal immigrants from the surrounding countries.

Some people believe that having sex with a virgin will cure HIV. This is perpetuated by poor education and desperation. HIV can effectively be a death sentence. This has led to the crime of child rape, where babies have also been victims. My visit to the paediatric unit was upsetting. The rate of HIV infection is increasing in South Africa despite mass advertising campaigns.

Being on call gives the opportunity to see many conditions including stabbings, shootings, burns, and road traffic accidents, and advanced pathology such as terminal stages of cancers and more common surgical conditions. Patients often present to a doctor late in their illness, which can be sad. This may be due to poor education and low expectations. Patients often see a Sangoma, a traditional healer, before seeing a doctor.

Johannesburg lies in the north of South Africa, below the Kruger National Park and close to Pretoria. It offers many tourist attractions, shopping malls, museums, and has an interesting history. The city is strongly metropolitan, with Jewish, Hindu, and Muslim communities. This is reflected in the medical students, who come from many backgrounds. University education is expensive, which means it is often people from privileged backgrounds who become doctors. But the university has tried to widen access to students from many different backgrounds by providing financial help.

Safety is of prime importance in Johannesburg. There are areas where you are strongly recommended not to go, even in daylight. Going out at night on your own is strongly discouraged. When driving, keep bags in the boot, and be especially wary at traffic lights (termed robots). Getting a map out in public shows you are a stranger and you do not know the area. I talked to various people who had been mugged or had their car hijacked. Some had been interrogated by the police, who wanted money for their release. This can make Johannesburg quite scary for those of a nervous disposition (or those who have just developed one).

Public transport in Johannesburg is poor. Most poor South Africans travel by "minibus taxis," which seat about 12 people.3 Drivers are notorious for their dangerous antics on the road. Metered taxis are expensive, and many South Africans therefore have their own cars. Travelling on trains is generally not recommended unless you take a "first class" service.

In some ways you have to be alert all the time. Liberties such as coming home at night on the bus can't be taken so lightly in Johannesburg. I was told not to carry too much money and to decrease the withdrawal limit on my bank cards. And in some ways this was sad, because it often felt as if I was imprisoned with so much security around, something which I did not feel in Cape Town. I was warned that if I was ever mugged, that I should hand over what was wanted rather than face a weapon. Many people in Johannesburg carry guns.

AP PHOTO/DENNIS FARRELL

Johannesburg is a "city of two tales." The apartheid era has left a strong mark on the city; black people often live in the poor areas, sometimes without running water or electricity. Rich people live in large houses surrounded by electric fences, protected by armed security personnel.

There are lots of homeless people in the city centre. A voluntary medical unit set up by medical students and volunteers sees homeless people on the streets on Wednesday evenings. This allows students to go out and see patients and provide very basic drugs such as paracetamol and lotions (such as camomile) to help symptoms. Homeless patients are often discriminated against in the healthcare system, as more "suitable patients" are often taken to see the doctor by the clinic sisters, which makes it difficult for homeless people to access the healthcare system.

Rich people live similar lifestyles to those in the developed world and pay similar prices for their commodities. Poor people have lifestyles similar to those in developing nations and are mostly black. The abolition of apartheid has not solved problems such as crime and poverty in the country.

South Africa can be expensive for students. Visa, transport, tuition fees, food, and accommodation can soon add up, and therefore it is best to plan in advance and perhaps go in a group to share costs. Visit the rest of the country to get a perspective of the range of problems and to see a truly remarkable country.

Despite the high rates of crime and poverty, South Africans are mostly warm and friendly and are more than willing to help you out. I made many friends whom I'll never forget. Johannesburg is definitely for the adventurous type, with its complicated history, its many languages, and its metropolitan and beautiful people.