Mohit Kaushal and Christopher Niranjan went to Costa Rica for their elective and found that effective health care is more than clinical skills

We did our elective in an indigenous reservation in Central America. The Native Indian Reservation covers a huge expanse of land stretching from eastern Costa Rica all the way into Panama. Although the rainforests and mountains make the area visually stunning, the land is relatively infertile and is unsuitable for farming, which further exacerbates poverty.

KENT GILBERT/AP

There are an estimated 8000 Indians living in various settlements throughout the reservation. The Indians have been in this area for centuries and are believed to have originally come from inland Asia; genetic studies have shown them to be related to similar tribes in Outer Mongolia. They are nomadic people and move settlement on average every 9-18 months, frequently moving between the two countries across a border that does not exist on their reservation.

Travelling on horseback

You can drive to the edge of the reservation, but, inside it, the only forms of transport available to us were horses (where permitted) or simply trekking on foot. The healthcare team that travels through the reservation to the various outreach clinics is hindered by such limitations.

KENT GILBERT/AP

We visited about 10 different outreach clinics in the reservation. The journey to each one was profoundly different. The most memorable journey included trekking through dense forest and then riding up a mountainside. The views were stunning; the immense beauty of both Costa Rica and Panama was breathtaking. After another hour, we finally made it. The small group of Indians living there were evidently curious about our arrival. Apart from the outreach team, the reservation has few external visitors. Along with the team we enjoyed many glasses of the locally brewed moonshine with the extremely hospitable people. We later found out that it was produced by them chewing sugar cane in their mouths and then spitting out the remnants and leaving it to ferment.

The next day, we did a clinic for the whole day. The amount of pathology was disturbing and challenging. We saw the most peculiar and wonderful tropical diseases and an abundance of usual problems--tuberculosis, heart disease, and genetic problems within the tribe. Some of the more interesting cases included elephantiasis and snake bites. It was here that one of us contracted leishmaniasis.

We left the Indians early the next day. Once we started descending, the skies opened up. Never before had we experienced such a rapid and extreme change in the weather. The track became a mudslide, our horses slipped and slid their way down the hill. Whether it was fortune or something else that stopped us from tumbling over and got us down safely to the bottom, we do not know, but the doctor behind looked barely aware of our struggle; such conditions were common for her.

Different concepts of poverty

When we first arrived, one of the chief doctors posed the question, "What is the difference between poverty and culture?" We looked over the Indians' ramshackle housing--flimsy huts of wood and rusted corrugated sheet metal--their woefully inadequate water supply, their absence of separate sewage systems, and their torn clothing. Health workers here face many dilemmas. How do we attempt to improve quality of life when our Western understanding of this concept is so far removed from the Indians'?

KENT GILBERT/AP

Once we starting working, the extent of poverty became more evident. The clichéd phrase, "taking things for granted," echoed in our heads. We saw lack of hygiene manifest itself in the levels of typhoid and cholera. It was hard to believe that the things we were seeing were real. We had to re-evaluate everything that we knew, or thought we knew, about the role of medicine and its practice.

Extreme circumstances

On one particular occasion, we were working with a doctor in such awful conditions that we did not know whether to laugh or cry. The delivery was unremarkable but mothers did not have the antenatal care, ultrasound scanning, and monitoring that they would have got at home. We knew nothing of this mother's history; what if the fetus was in a breech presentation or the the mother had an unexpected placenta praevia?

The hospital was not only more than 20 miles away, but also difficult to reach considering the reservation's location. Glancing casually around the delivery room, we did not see suitable facilities with which to manage a serious haemorrhage--no bags of fluids or boxes of cannulas. We saw only a deeply committed doctor and a couple of medical students, who looked like they had stumbled in while looking for the bathroom.

The experience was simultaneously terrifying and worryingly life affirming, and left us in need of another glass of fermented saliva (the moonshine). Local doctors who volunteer in the reservation and encounter these circumstances every day must experience many extreme emotions. Not only did their skill and altruism deserve praise but also their courage.

Difficulties with the research

Unfortunately, doing any research in the reservation was difficult. The Indians view outsiders--especially any external researchers, who are nicknamed "vampire bats"--with great scepticism. Many anthropologists have visited the reservation, taken blood for genetic studies, and left without giving any explanations to the indigenous tribe. The Indians are wary of external help and interference from people who have denied them equality for generations, view them as separate to the rest of their society, and were happy for things to stay that way.

So, what can we take from our elective? We experienced an existence neither of us could comprehend--that is, poverty rooted in a bed of politics, culture, and bureaucracy. We learnt an important lesson--a great deal more is needed to improve the health of a subpopulation than the clinical skills of the doctors present. We hope to return to the rainforest one day but doubt much will have changed.

Mohit Kaushal third year medical student
Email: mohit.kaushal@imperial.ac.uk

Christopher Niranjan third year medical student, Imperial College, London

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