Two weeks of infectious diseases study in Jogja

Introduction

I spent the second half of January in Yogyakarta (say the Ys as Js and you’re saying it right), Indonesia, studying infectious diseases. This placement is the shortest placement that I have planned for 2014, and it was with some dismay that I departed from Yogyakarta after two weeks for a short stay in Bangkok on route to Ethiopia.

Long-term travelling undoubtedly teaches the traveller lots of things about themselves, and for me the time that I spent in Indonesia was one of self-discovery.

The first thing that I have discovered about myself is that I hate good byes. I flew to Indonesia after a 16-hour transit in Bangkok that was devoted to eating some decent food and buying some business clothing to wear in Indonesia (my placement had strict dress requirements and I lacked any clothing that would satisfy these requirements). The morning that I left Bangkok was extremely hard for me. I had spent the previous two weeks travelling with one of my closest friends, Emily, and had become comfortably accustomed to having her pleasant and easygoing company 24/7. Emily also completed a Hoc Mai placement in Vietnam, albeit in Da Nang (she was the friend I visited over Christmas), and she was the final vestige of homeliness that my travels will have until I next meet up with people from home (friends and parents) in Europe in May. So, saying good bye was extremely hard and, it turned out, a bit unceremonious, as I had to leave for the airport at 4.30am. I managed to hold it together during the bit where she was there and we were uttering pleasantries, but then had a bit of a cry in the hotel lifts, at the airport, and then again at KL airport where I had a long transit, which was quite embarrassing really. 

I immediately liked Indonesia and was happy to be there despite the fact that I was in a bit of a mood rut for the first couple of days until I decided that I needed to proactively ensure my own happiness even when feeling a bit unsettled and alone. This was how I came to learn the second thing that I learnt about myself in Indonesia, that I shouldn’t assume that everybody will dislike me before they’ve even met me, because that’s just silly. It’s very unhelpful when you’re travelling to avoid talking to people and making the effort to meet you people simply because you’re scared of being rejected. Once I realised that my happiness required being a bit brave, I arranged to meet some people and keep myself busy, and as a result I had an amazing two weeks.

Sightseeing and socialising in Yogyakarta

On the first morning of my placement I was met by Maria, a very sweet first year medical student from UGM who’d been assigned to me to help me settle in to my placement. We had lunch with Maria’s friends and, despite the language barrier, I had a nice time. That evening I decided to take myself somewhere with lots of tourists, hoping to meet some fluent English speakers because I was just bursting to have a good conversation because I love talking. After looking online at restaurant recommendations I decided on this travellers’ café called Via Via, purely because it shared its name with one of my favourite cafes in Arusha (Tanzania). It turns out that this shared name was no coincidence, as the two cafes are actually part of a global chain of travellers’ cafes. This made my night, along with the realisation that Via Via had a great travel desk where you could book a range of short tours, many of which could be done on an evening after finishing up at the hospital for the day. They also had a notice board where people could advertise for people to join them on tours. I saw a note from somebody called “Heather” who was looking for somebody to join her on a tour called “Spiritual Java” and I immediately decided that this would be a nice idea (my, only slight, moment of hesitation was when I realised that Heather is the given name of my former school principal and for a fleeting moment I was concerned about the possibility that this person could be her, but then I googled Australian school term dates and realised that it was probably too close to semester starting for her to be gallivanting around Indonesia). Joining the tour with Heather turned out to be the best decision I made during my time in Indonesia, as it meant that I met two fascinating, inspirational and just altogether lovely ladies who made the rest of my stay in Yogyakarta amazing (more on that later).

ViaVia cafe, Yogyakarta

ViaVia cafes around the world!

My second day in Indonesia was an unexpected public holiday (for the Prophet Muhammed’s birthday) and Maria offered to take me to the Kraton (old palace) on the back of her motorbike for some sightseeing. With the exception of a one day rural motorbike trip that I took in Vietnam in 2007, I had never been a passenger on a motor bike and was a bit apprehensive about the whole thing, especially after hearing horror stories from my mother, a former physiotherapist, and also seeing several people in ICU in Vietnam with horrific injuries following motorbike accidents. Nonetheless, I got on the motorbike and managed to refrain from both screaming and also overbalancing the bike on corners, and consequently had a pleasant day at the Kraton. It was extremely crowded due to the public holiday, and lots of people had apparently travelled there from rural areas to attend the festivities. As such, I was stared at a lot, and one woman even grabbed a handful of the skin on my arm and stood there pointing and laughing, which was something that I didn’t quite know how to react to (I’ve since developed a deep tan and this has not recurred).

That evening, I met up with Robbie, a friend of a friend of a friend. It turns out that asking your friends if they know people at your destination (or simply just mentioning where you are going (often met with “oh, I have a friend who lives there. I’ll put you guys in touch”)) is a great way of meeting people. Assuming that you like your friends, you’re probably going to like their friends, which has universally been my experience so far with this networking strategy. I had dinner with Robbie and his friends (which I guess makes them friends of a friend of a friend of a friend) at this lovely restaurant in a garden setting called Gadjah Wong. We had a great night, which concluded with us going to this bar with live music where we were the only bules (Indonesian slang for foreigners). Unfortunately for me Robbie and his friends were taking a bit of a vacation to a beach somewhere in Java for the next few days, so I wasn’t able to hang out with them again, but it was nice to meet some fun people even if I could only see them once.

On Thursday evening Maria and I went to the silverwork part of town to attend a lesson on silver jewellery making. This turned out to be quite a fun activity and we now have (almost) matching friendship rings that would have been matching if I hadn’t melted part of my ring with the blowtorch due to sheer stupidity.

Friday evening and the weekend were real highlights for me. On Friday afternoon I went on the ViaVia Spiritual Java tour with Heather, and one other girl, Cory who had also seen Heather’s notice. The tour was interesting, but needed to be much more developed in terms of structure and explanation, as there were large periods of time where the three of us had little idea of what was occurring whilst the guide sat there meditating. Nonetheless, I’m glad that I went on the tour as it meant that I met Heather and Cory. Heather is a British lady who is on a long (about 7 months I think) trip. Interestingly, Heather, for sustainability reasons, has chosen to avoid air travel. Hearing about her trip, including the 20-something days that she spent on a freight ship from Spain to Singapore and all of the fascinatingly unconventional experiences that travelling this way has led her to experience, really made me question my own travel choices for this year. I am well aware that my plans involve substantial carbon emissions, but I’ve never seriously considered alternative modes of transport and travel styles (spending longer discovering a region rather than jumping around the place) until I met Heather and heard about the world of possibilities when it comes to sustainable travel. Cory was also fascinating and very sweet company. She is my age and hasn’t travelled extensively, yet she had the guts to quit her job and fly to Asia to look for new and exciting life experiences. She has secured a job in Kuala Lumpur for several months and plans to travel around Asia before and after this internship. Kuala Lumpur was actually the first place that I visited independently of my family or school group (in 2006) and I remember at the time finding the city intimidating and also feeling immensely homesick, even though I was only there for a few days. I can’t even begin to imagine the courage that it takes to commit to living somewhere that you know little about when you are not yet a seasoned traveller, so props to Cory!

This is every body else meditating on the beach during the spiritual Java tour. I had missed the memo that this was meditation time and instead thought that it was time to take some long exposure photographs.

Spiritual Java tour. Haven't got the faintest what's going on here, but it involved an old man, fire and incense. 

After the Spiritual Java tour we organised to meet up with each other a few more times before Cory left Yogyakarta. We dined at an amazing vegetarian restaurant (Milas), had a fun time looking around a supermarket and taking photos of bizarre condom boxes that featured tacky 80s art, and we spent a morning at a local market called Sunmor (situated between two universities: UGM and UNY), where I bought a tacky PSY hand sanitiser to attach to my stethoscope, as this was a bit of a fashion statement at the hospital where I was undertaking my placement. Here are some condom pictures from the supermarket:

yeah, i got some weird looks from Indonesian people who saw me and my friends taking these photos

The rest of that weekend was spent visiting Borobodur and Prambanan. These experiences were very similar to my experience at the Kraton; I spent more time obliging various photo and interview requests (no, I am not a celebrity, just a bule) than I spent enjoying the attractions. Luckily, I had a brief moment of respite at both attractions as it started bucketing rain causing all but the most die hard tourists (typically those who have paid the inflated foreigner entry price and will not have an opportunity to simply come back on another day) to leave the attractions. Here are some photos from when it was bucketing down rain:

Borobodur in the rain (it was still hard to get this photo without people in it)

Prambanan with Mount Merapi peaking out from behind the clouds

I had one more sightseeing opportunity in Yogyakarta. I undertook a walk through the Kali Code area of town (a former dangerous slum, now industrial area that gives visitors an interesting exposure to local culture). I booked this tour (having a guide who understands the local culture greatly enhances your experience in situations such as this) and was joined by Heather (from my other tour) as well as two lovely Dutch ladies (mother and daughter). Some of the highlights from the tour included: watching a display of homing pigeon training, meeting people who collect song birds as a serious hobby and learning about songbird competitions and the social status that victory in such competitions brings the owner, meeting an amazing artist who makes bespoke stamps for batik printing, and learning various other curiosities about Indonesian culture, including that the red and white of the flag symbolise women and men respectively (have a think about specific bodily excretions and you will come to the same conclusion that our guide told us about why these colours have been assigned to the sexes). We concluded the evening by dining at our favourite vegetarian restaurant and sharing life stories (Dorine, the daughter of the mother-daughter pair had some fascinating stories about her time spent in Yogyakarta as a medical student 20-years ago, and also about various other places where she has lived and worked, including Khartoum).

Kali Code river at sunset

2000 words later and I have finally reached the part about my actual student placement

I undertook a two-week student placement at Universitas Gadjah Madh in the Faculty of Medicine. I was based at Rumah Sakit Dr Sardjito, a large hospital situated conveniently next to the campus. I was placed in the internal medicine department, specifically infectious diseases.

Faculty of Medicine, UGM. Sorry about photo quality, was taken with a much abused iPhone 3 circa 2008

Some of the interesting cases I saw during my placement included:

• -       TB patients
• -       Multi-drug resistant TB patients
• -       HIV patients
• -       Patients with a whole host of diseases, often TB and HIV (being HIV positive increases the likelihood of contracting TB due to the way that HIV damages your immune system) and occasionally a third infectious disease, such as viral hepatitis
• -       Tetanus
• -       Snake Bite
• -       Malaria-induced jaundice
• -       Sepsis

One of the main things that I observed during my time at the hospital was how the patients were mostly poor people from rural areas. This is not to say that infectious diseases were not also endemic in the city, but rather that for the diseases to reach the level of severity where the patients required hospitalisation generally meant that there was a triad of poverty, lack of health awareness, and lack of education. Most of the patients I saw from urban areas were in relatively good condition and just in hospital to attend outpatient clinics for routine management of their chronic infectious diseases.

The physical condition of some patients was quite shocking. Many of the patients had severe wasting syndrome and looked like they could barely weigh more than 30kg. These patients reminded me of photos that I have seen of victims of the Holocaust upon being released from concentration camps at the end of the Second World War. In some cases I was unsure whether this was attributable to their medical problems or more broadly to social disadvantage. I guess it was probably a combination of both factors. Either way, I found it quite shocking to see adult men who were lighter than the luggage that I have been hauling around the world for the past few months.

The 5 moments of hand hygiene. I am a bad person because I can only ever remember 4 of them.

The highlight of the placement for me was spending a day at the HIV clinic. The clinic had 40 patients that day, which was quite a busy day for them. The clinic is where patients are required to attend (on a monthly basis) to collect their anti-retroviral treatments. Every six months the patients are supposed to have a blood test prior to their attendance, so that they can bring the results and the doctors at the clinic may monitor their CD4+ T-cell count (a proxy for measuring viral load). There are a variety of ways for HIV to be transmitted, those I saw at the HIV clinic that day were (from most to least common): unsafe sex, injecting drug use, tattoo and piercing (2 patients).

Most patients had fairly well controlled HIV, having attended the clinic regularly since diagnosis and been reasonably compliant with their treatment regime. There were however some patients with terrible treatment compliance. I saw two patients with CD4+ counts of <10 (shockingly low, as a normal count is 500-1200 and treatment for HIV commences when the count drops below 200 in Indonesia (the threshold is higher in many other countries)). Some patients would send a proxy to collect their medication on their behalf (due to convenience mostly) and this was creating problems with monitoring, as, obviously, a proxy cannot have his or her blood tested on behalf of the patient, nor can the physician make valuable observations about a patient’s general health status when the patient is not there to be observed. The clinic had a clever way of handling this problem. Patients could not send proxies for more than one consecutive appointment unless there existed extraordinary circumstances. For general poor compliance (which is easy to detect either by blood test results, by the patient admitting that they had stopped treatment, or by multiple missed appointments) the clinic had a counselling service. Patients with poor compliance were referred to mandatory counselling, which seemed to primarily take the form of educating patients about differing prognoses and the role of treatment in preventing the progression of their HIV infection into full on AIDS.

Mount Merapi teasing me by almost revealing itself from the clouds one day

One patient really sticks in my mind from this day at the HIV clinic. He was a man in his early 30s who had contracted HIV many years earlier through injecting drug use, and was highly involved in a peer group (other IDUs) several of whom had died horrible AIDS deaths. Nonetheless, he had decided to pretend that he was not infected with HIV, despite the fact that several of his friends had died of AIDS related complications.  I found it difficult to understand why somebody would take such little care of his health after witnessing the horrible outcome of letting HIV destroy an immune system, something that should be a powerful motivator to comply with treatment. The only reason he had attended the clinic that day was that he had just been offered a job working on a cruise ship and the company required him to be on treatment for the duration of his employment contract. The doctors dealt with this man well. The head of the clinic sat him down and asked him lots of probing questions about his attitude to treatment and then said to him “you’re an adult now and it’s time for you to grow up. A big part of growing up is looking after your own health, and for you it will soon be too late.” I think that it would be difficult to be this direct with patients in Australia, but this was exactly what he needed to hear. Unfortunately, I don’t think that the message really sunk in, as, in a brief moment alone with me in the treatment room whilst the doctors were sorting out paperwork, the patient asked me where he could buy drugs to take whilst he was on cruise leave in Sydney (I told him that I believe drugs are difficult to find in Australia, but we have lots of great food and outdoor activities that he might enjoy instead).

A final interesting thing that I saw in the hospital were the Waria. Waria are Indonesian Lady Boys. Unlike their counterparts in much of Southeast Asia, the Waria suffer from extreme social marginalisation, mostly due to the fact that Islam is the dominant religion in Indonesia and this is not at all accommodating of their gender identity, despite the fact that most Waria are practicing Muslims. Warias are highly visually confronting; the first time I saw them I was confused and a little apprehensive, and the best explanation that I could summon to explain their bizarre appearance (they are not at all like Lady Boys in Thailand, who often make better looking women than most people born with two X chromosomes) was that they were victims of failed plastic surgery experiments. Mostly, the Waria look like what you will find if you google image search something along the lines of “plastic surgery disasters”. It turns out that I wasn’t too far off the mark, as the Waria frequently undergo “backyard” plastic surgery, for example the injection of hot oil under the skin behind the nipples to create breast-like enlargements, and also the insertion of various prostheses behind the skin of various parts of their faces. As the only Waria I encountered in Indonesia were either attending the hospital or begging on the streets, I was unable to get a photo, however this article includes photos and further information about the Waria for anybody who is interested: http://www.vice.com/the-vice-guide-to-travel/the-warias-full-length (this is not a publication that I would normally read, but it’s the best information that I could find on google).

Where to now?

I am writing this in Ethiopia (I wrote my first draft in a terrible mood so decided to bin that and re-write, so this has taken me quite a while). After 6 weeks of medical placements in Asia I have seen some fascinating things and had my beliefs challenged in ways that would never occur in Australia. I left Asia feeling desperate for a vacation and feeling relieved that I had scheduled 6 weeks of “vacation” before my next medical placement. It turns out, however, that I have a very strange idea of vacationing; instead of soaking up beautiful landscapes, indulging hedonistic desires, or lounging about on a beach, I have spent the past couple of weeks in Southern Ethiopia seeing some pretty confronting things (for example ritualistic whipping of tribal women by their male relatives – I never EVER want to witness whipping again, once was definitely more than enough). I am still collecting my thoughts on Ethiopia but hope to have another blog post out in the next few weeks.

Me in Ethiopia. This photo really doesn't do justice to my deep suntan