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Group Reflections on a GEMx Family Medicine Exchange from University of Zimbabwe to University of Kwazulu-Natal

Filed under: GEMx Regional Exchanges GEMx Student Reflections

Post by Nyasha Manyeruke, Leslie Mashayahanya, and Talent Munjombi, medical students at University of Zimbabwe College of Health Sciences who completed a elective exchange at University of Kwazulu-Natal School of Nursing and Public Health (South Africa) through the GEMx-AFREHealth Regional Exchange Partnership.

 

Students selfie in Durban

INTRODUCTION

When we signed up for the GEMx Elective experience in South Africa, we hoped to experience and gain better understanding of the clinical setup in a neighbouring African country and improve our overall clinical skills in preparation for our final year of medical school. We happily report, that the experience exceeded our expectation and broadened our knowledge overally.
Under the supervised guidance of Proffessor Mergan Naidoo, we had an opportunity to rotate in different wards at the hospital, that is- High Care Unit, Out Patients Department, HIV clinic and Accident And Emergency Department. We had multiple opportunities throughout our elective to interact with Family Medicine constultants and Registrars for “one on one” tutorials as well as group tutorials. We also interacted with other members of the clinical team including interns, counsellors and nurses, who taught us and encouraged us to perform certain procedures, such as, drawing blood for investigations, inserting urinary catheters, suturing and so forth. Outside clinical activities at the hospital, we also explored Durban –visiting the beach, shopping malls, indulging in local delicacies, and interacting with fellow Zimbabweans living in South Africa, as well as the other locals we encountered in our day to day activities. We gained a greater appreciation of the multicultural and diverse society that makes up South Africa, Durban in particular, and how this correlates to patient management in the hospital setup.
In this report, we have summarized our elective experience into experiential sections and attached pictures accordingly.

Hospital Clinical Experience
1. Out-Patients Department
We each spent a week attached to the outpatients department, participating in local procedures and guidelines. In our logbooks we had clear learning objectives and subjective measures to assess our progress throughout our elective. We enjoyed ourselves thoroughly, and below in Figure 1.1, the picture illustrates Leslie clerking patients seated on the bench waiting to be served at the Out-patients Department.

MD student looking at papers

2. High Care Unit
We each spent a week attached to the high care unit. We mainly learnt ward management of patients and ward conduct as well as protocol. Besides knowledge learnt on commn ailments in our setting, such as, HIV, TB and Myorcadial infarctions, from the various ward rounds and tutorials,we also assisted the interns in performing their daily ward duties, such as, taking blood, performing lumbar punctures, inserting chest drains and so on, as well as interpreting lab results for investigations. Figure 1.2 below illustrates Talent taking blood from a newly admitted patient, with the assistance of one the nurses.

Students taking care of patient

3.HIV clinic
We each were attached to the HIV clinic for one week, and we mainly participated in patient adherence counselling, reviews, as well as initiation of patients on Antiretroviral medication. We learnt about the importance of the multi disciplinary team and we often assisted the nurses at nearby clinic( gateway clinic) in using the referral system tool effectively in ensuring patients receive the best care. Figure 1.3, is a picture showing Nyasha, standing at the entrance for Gateway clinic.
Student in front of hospital sign

4.Accident and Emergency
We each spent one week at this department. This was a very busy department, it was very interesting learning about the triage system at this hospital and the acute management of patients. We learnt about the importance of time and sharing tasks amongst members of the clinical team in order to manage patients adequately. In figure 1.4, the picture below illustrates Leslie, preparing bloods to be sent to the laboratory for investigation.

5. Other Hospital Related Activities

Talent and Leslie reviewing clinical magazines for updates on recent research findings, new additions to clinical guidelines and for Continuing Medical learning(CME) in the doctor’s tea lounge during some of our lunch breaks.

Students Reviewing Journals

Talent(female) and Leslie, standing in front of college of health sciences building for the University of Kwazulu-Natal. We visited the medical school a few times during our stay and we marveled at the architecture

Talent(female) and Leslie, standing infront of college of health sciences building for the University of Kwazulu-Natal. We visited the medical school a few times during our stay and we marvelled at the architecture

A selfie taken after our GEMx end of elective exercise and discussion with us and Professor Ross( one of the consultants at the hospital. We enjoyed our interactions with him during ward rounds and our various tutorial sessions.

A selfie taken after our GEMx end of elective exercise and discussion with us and Proffessor Ross( one of the consultants at the hospital. We enjoyed our interactions with him during ward rounds and our various tutorial sessions.

As we come to the conclusion of our elective experience, we would like to thank all the people who made this elective experience possible, we thank you for impacting our careers in our fruitful and adventure filled manner. We hope you continue your great work.

THANK YOU
Siyabonga

Report on GEMx Postgraduate Ophthalmology Elective in Mombasa, Kenya

Filed under: GEMx Post-Graduate Exchanges GEMx Regional Exchanges

Post by W’mosi Brenda Achieng, an Ophthalmology resident at University of Nairobi Faculty of Medicine (Kenya) who completed a elective exchange at Lighthouse for Christ Eye Centre through the GEMx-COESCA Regional Exchange Partnership 

 Ophthalmology Elective Experience

Residents standing in front of hospital

Me with colleagues, I am the on the extreme left. Dr. Basha in the middle, was winding up his elective term and I had just begun.

In my second year as an ophthalmology resident I had the opportunity to do my first elective term. I chose to do it at Lighthouse for Christ Eye Centre and applied through GEMx.

Traveling:

I flew to Mombasa early in the morning. The airplane ride was short and comfortable. I had booked the ticket two weeks in advance so I bought the ticket at a good rate. I would advice anyone who wants to fly there to buy the tickets online way in advance as they are a lot cheaper as compared to purchasing them a few days to the journey. I took an uber from the airport to the hospital.

 Weather:

The weather there is generally hot and humid. It is advisable to carry lots of light clothes and some sunscreen. There were occasional rainy periods during my stay but the rainfall was quite light.

Arrival and stay:

I arrived and went to report at the hospital. I met the Medical Director who is also a Cornea specialist.

He gave me a quick orientation and introduced me to all the staff. He gave me an overview of the values and mission of the hospital and communicated what was expected of me during my elective period.

I was informed on work attire and would put on my white coat on top of my clothes or wear scrubs. I would advise on putting on scrubs to work as they were comfortable and easy to work in the hot weather.

Everyone was very welcoming and friendly. I had no doubt that I would feel at home away from home. He gave me the afternoon off to go and settle myself at my accommodation as I was to stay at a nearby flat outside the hospital for the first 3 weeks.

After 3 weeks I moved into the hospital accommodation. It was a quite a big room, with a bed, fan, fast Wi-Fi and a set of sofas. It was self-contained with a shower and toilet. The kitchen was however adjacent to it with its own key. The kitchen was clean and had a table top cooker and gas. Utensils were also provided in the kitchen.

Work experience:

Photo of the hospital

The hospital

My first day was in the general clinic which runs every day. The clinic is usually very busy. There was a visiting consultant from Japan who is an anterior segment specialist. Together with him and the medical director, we were able to see about 100 patients on day 1. Some of the other clinic staff were on an outreach in another county doing free cataract surgeries in the community.

I was able to attend the other clinics which run concurrently with the other clinics on specific days. I attended some of the cornea clinics which would run on Tuesdays. I also attended some of the Wednesday clinics which were paediatric ophthalmology clinics. Main theatre days are on Mondays, Wednesdays and Thursdays. I was able to review challenging and interesting cases with the medical director who was always available for consultation. I also managed to review interesting paediatric ophthalmology cases with the paediatric ophthalmologist. I also learnt a lot from the other cadres at the hospital. Apart from the ophthalmologists, there are also two ophthalmic clinical officers two ophthalmic nurses, and other cadres. Everyone was willing to teach and also learn something from the other.

At Lighthouse for Christ Eye Centre, there are visiting ophthalmologists from time to time. They are from various countries and different sub specialties. Apart from getting to work with the Anterior segment consultant from Japan for a week, I also got to meet and work with a visiting Cornea specialist from India. Together with the medical director and the visiting cornea specialist, I was able to review patients with them and learn a lot over the few days.

I also managed to learn a lot surgically. I did my first complete cataract surgery and managed to do 13 cataract surgeries. I was also able to learn and do other procedures like 3 excisions of pterygiums and conjunctival masses. I learnt how to excise chalazions and also how to do punctum repair when doing a lid laceration repair, and also learnt how to do YAG-capsulotomy. There are also Continuous Medical Education seminars every last Friday of the month. I was able to attend 3 seminars during my stay at the hospital which were very informative.

Day to day living:

I would cook most of my meals in the kitchen. However, at lunchtime, I sometimes would buy meals at an affordable price at the hospital canteen. The meals sold there are balanced and healthy with fresh ingredients. Price range was about ksh50-100 for a full meal. For fresh vegetables, there is a market not too far away in town where one can access fresh raw ingredients. The hospital and the central business district are very close to each other. About 5-10 minutes away from each other. I had access to the supermarkets, ATMs and banks as they were just a few minutes away. My main means of getting around were ‘Tuk-tuks’ and ‘matatus’ for nearby places as well as Uber taxis for the places that were far. Most means of transport were affordable and convenient.

For some of the cultural dishes, there are many hotels that serve the authentic coastal dishes that were affordable and a walking distance from the hospital

I did my own laundry and there is a good outdoor hanging line.

Security within the hospital was very good and it is round the clock. Both the room and kitchen had padlocks. In case of emergencies, there was an alarm within the room as well as an indoor phone which you could contact the other residences within the hospital or the main hospital block. The security officers were always courteous and willing to help in case of anything.

There are also many tourist sites that one may visit over weekends when free. For example, there are some tourist sites not too far from the hospital for example Fort Jesus. There are many beaches as well as the marine park just to mention a few.

Religion:

Lighthouse for Christ Eye Centre is very tolerant of all religions despite being a Christian institution.

It serves a community which has Christians, Muslims, Buddhists among others. All patients are treated equally and with respect regardless of religion, race and socio-economic status.

There was devotion twice a week, on Tuesday mornings and Friday mornings at 7.15 am -8 am which I attended. All staff were welcome and the sessions were always spiritually uplifting.

Overall:

My overall experience was great. The work experience was different and very interesting. I got to work with different people and cadres. The staff at Lighthouse were hardworking and professional as well as very warm. Learning was both ways and I learnt a lot from everyone. I was exposed to so many different conditions from which I learnt a lot in terms of management and surgeries. I was able to perform surgeries under supervision and my teachers were patient.

I am grateful to GEMx for granting me this great opportunity. It was invaluable in my training in ophthalmology. I would not trade that experience for anything.

Internal Medicine Elective at Queen Elizabeth Central Hospital (Malawi)

Filed under: GEMx Regional Exchanges

Post by Tebogo Bolani, a medical student at University of Witswatersrand (South Africa), who recently completed a GEMx elective at the University Of Malawi College Of Medicine (Malawi).

Umuntu ngumuntu ngabantu. This a Zulu proverb that I have never fully appreciated until I arrived in Malawi. My first experience of Malawi was the airport – it was certainly not what I expected. We were welcomed by a small group of local children standing behind a fence waving at us stepping off the plane. It was humbling and exciting at the same time. I completed my elective at the Queen Elizabeth Central Hospital (QECH) in Malawi. We arrived on the 26 of November and stayed until 23 December 2017.

When we arrived at our temporary home at Kabula lodge, we were greeted with no electricity and no food and no means to get food. The food situation certainly improved throughout our stay, the electricity not so much. Power outages and load shedding occur regularly in Malawi. The country is reliant on hydro energy, but there has been a drought of late resulting in electricity shortages. All in all, the next month looked like it was going to be a challenge. We made it work though, we started cooking outside on a coal stove, locally called a Mbalula. Funnily enough the president came to town and for the entire duration of his stay we had continuous power.

villagers sitting around a tent
Monday morning, we woke up bright and early to go to the hospital. What struck me first was the bright colours from the chitenje that the locals wear. Malawians take pride in their culture. The chitenjes are used as clothing, bedding, to carry babies and many other uses that I have never encountered. I spent a significant amount of my time collecting different patterns and colours as gifts and to wear myself.

We were allocated to the internal medicine department, at our request. When I first walked into the ward I was shocked. It was nothing like I imagined. I expected a similar setting to South Africa, instead I found poverty and overcrowding but also the spirit of Ubuntu – which translates as “a person is a person through other people”. Malawians have a true sense of community. We joined the ward round and soon found out that resources are severely limited and that receiving something as basic as an ECG can be near impossible for the low-income patient. They do not have a Blood Gas machine or CT scanner. An MRI machine is available, provided the proper procedures are followed.

There are no barriers between patients resulting in no privacy, there are inadequate beds resulting in patients sleeping on mattresses on the floor and some even in the corridors.
One of the things that impressed me most about QECH is their ability to improvise. No chest drain is available, so they use a catheter, no hand sanitizer is available so they poke a hole in a bottle of spirit and use it as disinfectant. Also, they have what they call guardians. I am used to a system whereby nurses bear the brunt of the responsibility. In Malawi patients are always accompanied by their guardians. Guardians are family members that stay with the patient at all times, they do a lot of work that would ordinarily be considered the nurses’ job. Guardians empty catheters, give patients bed pans, feed patients and provide some of the medical history. They have no medical training and sometimes, they are a hazard (force feeding a patient with a reduced GCS), but I still consider them invaluable. Guardians sleep on the floor next to their relative without a blanket or pillow or mattress. I honestly believe they keep the hospital running. They exemplify the spirit of Ubuntu.

selfie of four african medical students
I have this memory in my head. It is the image of an elderly gentleman who was very ill. He was visibly wasted, weak and confused. His son was his guardian. Every day I would watch his son position himself behind his father on the bed and allow the father’s upper body to rest on his chest as he fed him. It was heart-breaking to watch. Partly because the father was very sick and had a poor prognosis, but also because his last moments where spent in a hot hospital, with flies everywhere that he did not even have the energy to swat off himself. It just seemed like a very unpleasant way to die, my only consolation is knowing that he was never alone, and his son was by his side.

Patients in Malawi seem to have a very high tolerance for pain. I was shocked when I assisted in performing a lumber puncture and no local anaesthetic was given. This is the norm here. Of all the patients that received a lumber puncture, not one screamed in pain. At home in South Africa local anaesthetic is used, and the majority of patients scream at the top of their lungs, so much so that the nurses come and check what is wrong. One of the senior doctors was asked why patients here never complain. He claimed that in the patient’s eyes, doctors can do no wrong and they are too polite to complain. The only response patients seem to have is to reach towards the hand causing the pain. But they never make a sound.

On a more positive note, the academic teaching in the internal medicine department is excellent. They have daily case presentations prepared by the students and everything from history, management and microbiology is thoroughly discussed. I learnt most during these early morning sessions. My Chest X-ray interpretation skills have improved. I loved that it is a platform for active learning. The consultants would sit in a line in the front row and the students and registrars behind them. After the presentation the consultants would ask questions about the case. It did not come across as an interrogation at all. It was academic discussion amongst academics.

The ward rounds where similar. Students are part of the work force. They clerk all the patients with the assistance of the intern and registrar and on Mondays and Thursdays present their patients on the consultant ward round. They ordered their own investigations and drugs as well. They are very independent when managing patients. Sometimes they would even come in on Sunday to prepare for Monday’s consultant ward round.

Four African Medical Students
The ward round was another platform for teaching. I am accustomed to passive ward rounds where students do not really participate. But QECH certainly does not conform. The ward round is run by the students with help from the junior doctor. The students, which soon included us, would present most patients and then have a discussion with the consultant. It is probably what I enjoyed doing most. It was the perfect combination of theory, clinical skills and fun. Granted it was exceedingly stressful, because of the pressure and fear of doing something wrong, but it always worked out in the end.Once we got the hang of how things worked we started seeing our own patients. I found it very satisfying to be managing my own patients from admission to discharge. I was certainly grateful for the help that the students and registrar provided. It was probably the first time I have ever felt like I am really becoming a doctor. It was stressful at the best of times and writing a discharge summary in the health passport is time consuming, but the joy of doing something right outweighs it all.

Looking back now, my experience at the hospital is not what I expected at all. We were necessary labour and I appreciated that. We became part of the team. We made friends with the students so much so that even though they have left, we still chat with them on WhatsApp group. My independence has definitely been put to the test. Being away from the comforts of home was difficult but bearable. I got used to the new normal. I think I gained more completing my elective internationally than I could have at home. I developed my ability to communicate with people that don’t speak the same language and my ability to adapt to a new community and culture. I also succeeded at performing procedures that I have repeatedly failed at, at home (lumber punctures). Additionally, I have proved to myself that I can live in another country and still be happy.

Daily Reflections from a Nursing Student’s Community Health Elective Exchange in Uganda

Filed under: GEMx Regional Exchanges

Post by Akingbohungbe Oluwatosin Sonia, a nursing student at University Of Ibadan. Department Of Nursing, College Of Medicine, in Nigeria, who completed a elective exchange in Community Health through Makerere University, College Of Health Sciences, Department Of Nursing, in Kampala, Uganda.

 July 2019

All thanks to God for this opportunity, I was privileged to be one of the students selected to participate in the exchange program in Makerere University, Kampala Uganda by the Global Education in Medicine Exchange (GEMx). The exchange school was the Department of Nursing, College of Health Sciences, Makerere University, Uganda.  The program started on the 17th of June 2019 and I joined them on the 22nd of June 2019 due to logistics. We took off from Lagos Murtala Muhammed International airport on the 21st of June 2019 by 12:40 P.M, We had a stopover in Nairobijomo Kenyatta International Airport By 11P.M and board another airplane to ENTEBBE by 12:55 A.M on the 22nd of June 2019. The plane landed in ENTEBBE by 02:10 A.M and we were picked up by Mr. Martin the driver to the department from where we were taking to the prepared accommodation where we slept over for the night. The following day we were taking to Ms. Lydia Kabiri at the department of nursing around 11a.m for proper welcoming, recognition and further directives on how the program will run. Afterward we left for Mpigi to join the rest of the students in the Mpigi Health Center IV where we were also welcomed warmly by Katumba Lawrence and kwikiriza Grace followed by the rest of the students Gerald, Olivier, Innocent, Sonita, Janet, Francine, Shilla and Clement the leader of the group. The students were on a recess posting which includes Domiciliary midwifery and community health as subset of Public health nursing. The Health Centre had different units, the General ward, Out-Patient Department (OPD), Antiretroviral Therapy Department, Maternal child health Department and the Labour ward. Alongside the posting into the ward, we also took part in Continuous Medical Education (C.M.E) undertaken by health practitioners in the Mpigi Health Center IV, the forum is a productive and an interactive one which affords everyone both students and the health workers to brainstorm and learn new things through researches and new discovery for rendering health services to the people.

Day 1

24/06/2019

The day started with meeting with the senior nursing officer, in charge of the health centre and she welcomed us and then there was a brief orientation to the setting of the health facility, visiting the various units of the health centre. The various units include the Out-patient Deapartment, the General ward, the Maternal and child health unit, the Maternity unit and the Anti-retroviral (ART) clinic. Day 1 started with posting to the General ward of the health facility. The ward included the male, female and paediatric wards and conditions found there includes malaria, pneumonia, injuries and other minor health conditions. On the ward, orientation was given and the nursing duties peculiar to the ward was explained to us. Observation of the assessment of patients, administration of medications and admission was carried out.

Also, one of the students from the university, Akwanya Innocent, gave a health talk to nursing mothers and we were all in attendance. The topic was on Danger signs during postpartum and it was delivered to the nursing mothers and women who came for antenatal clinic at the maternity unit of the health facility. The student nurse spoke in English language while another student helped to translate in the local language Buganda. The education was for about 20 minutes. Mothers asked questions about the topic discussed and they were duly answered.

In the evening, it was a period for discussion among the students and the topic on Community and Prevention-oriented population-focused practice: the foundation of specialization in Public health nursing. Discussion was on what public health nursing is, the core functions of public health which includes assessment, policy development and assurance. Categories of public health workforce competencies was discussed and also health services pyramid with the largest base being population-based health care services, Clinical preventive services, primary health care, secondary health care, tertiary health care and finally the benefits of public health nursing was discussed.

Day 2

25/06/2019

Work continued at the General ward today. Admission and discharge of patients was carried out. Administration of medications was also carried out and patients were given adequate care.
Health talk on Family planning by Egwela Clement was given to mothers and women who came for antenatal and postnatal clinic respectively, they were shown pictorial guides and models were also used to explain further the various method of family planning.
Due to the unavailability of adequate data on the population and logistics of the different settlement of the community we were yet to visit the community.
In the evening, there was group discussion and it was a continuation of the topic discussed yesterday on changes and continuation that has occurred in public health nursing and also Perspectives in Global healthcare. We discussed the topic with sub-topics on primary health care, nursing and global health, major global health organizations. We all discussed the topic, questions were asked and they were duly responded to.

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Take Hold of the Learning Opportunity

Filed under: GEMx Regional Exchanges GEMx Student Reflections

Onthatile Thusi

 

Post by Onthatile Thusi, a medical student from University of the Witwatersrand Faculty of Health Sciences [South-South] who recently completed an elective exchange at the University of Malawi.

The plane cut through the clouds to reveal the first views of Malawi from the sky. The land was patterned with areas of green and brown and scattered housing. The scene was a great contrast to the landscape of Johannesburg which is populated with housing. As the plane began to fall towards the earth the exhilaration rose in my body while the thought of stepping my feet onto to a foreign land soon became a reality.

Queen Elizabeth Central Academic Hospital found in the city of Blantyre, Malawi is the largest referral health facility in the country of Malawi and was the setting of my 4-week elective along with 4 other students from South Africa. I was in the Department of Medicine under the supervision of Dr. Mallewa.  I was placed in the male medical Ward 3b and was welcomed by the team responsible for Bay 2 which consisted of Dr. Lester, an experienced consultant, Dr. Basami a proficient intern, Dr. Pink an enthusiast registrar, and Allan Masapi a friendly and helpful final year medical student. The only directive we were given for the elective was to follow the final year students timetable and we were given the freedom to attend any of the lectures or teachings carried out by the Department of Medicine.

Onthatile Thusi with her colleagues

“You are responsible for your own learning”.

This was a statement repeated to us throughout our second year of study and it is now in this elective experience, that I have come to grasp the significance of this statement. There are numerous opportunities to learn from patients whilst in the wards. The team working in Ward-3b, Bay 2, and the members of the Department of Medicine was willing to impart their knowledge onto the students. However, it was my responsibility to take hold of the learning opportunity and initiate engagement and discussion with every source of knowledge at my disposal. Other than the scheduled final year student lectures, and the bedside teachings carried out during the ward rounds twice a week, learning was often self-directed.

My day at Queens began with student case presentations which I found very valuable. In these case presentations, I saw the theoretical knowledge acquired in medical school come to life through practice.  It is in the discussions of these cases where I learned the value of the art of medicine in a resource-limited setting. Each investigation was challenged for its relevance and utility. The principles imparted in these discussions are some that I hope to apply in my personal practice of medicine in my home country of South Africa that face a number of resource limitations with a similar HIV burden. Following case presentations, were morning ward rounds often done with the intern and joined by the student and consultant twice a week. It is in these ward rounds that I was inspired by the extremely knowledgeable intern Dr. Basami and had the privilege of seeing the art of medicine practiced with efficiency and great proficiency despite the many limitations.  Under the patient guidance of interns and final year students, I was able to carry out a number of my clinical skills and acquire new skills with the encouraging consent of the patient.  It was often that the ward round and ward work was completed before 13:00, and I would find myself with nothing to do the rest of the day. I attempted to shadow an intern in the medical admissions in the Emergency Department or searched the wards for a doctor to have discussions surrounding patient’s cases.

One of the very exciting experiences was at the Grand Ward round which took place once a week. It is in this ward round where ongoing studies at the hospital were presented. Exhilarating discussions were had on the clinical relevance of the study and conclusions were made from the study. Active conversations between departments would take place on how the challenges and recommendations brought forward by the study could be mitigated and implemented. It was exciting to hear the dynamic interactions between professionals that bring tangible change in public health and ultimately improve patient care.

Malawi home

Malawi the warm heart of Africa. The pulse of this heart is felt through the people of Malawi.  The patients I encountered were willing to engage with me and consented to my intention to learn new skills with welcoming eyes. The language was a great obstacle, as most of the patients speak Chichewa, there were very few patients that spoke English. I felt that my opportunity to gain crucial experience in clerking and presenting patients was hindered. This language barrier limited my ability to perform procedures and examinations using a patient-centered approach, as all communication was done through a third party.

The pulse of this warm heart of Africa extended outside the hospital confines. The owners and staff at Home Up guesthouses, our accommodation for the duration of the elective, welcomed our arrival with expectant and cheerful spirits. Throughout our stay, they created a friendly and cozy environment. The staff was eager to help in any regard and provided valuable information to make the most of our experience in Malawi.

The vibrant and energetic spirit of Malawi is reflected in its landscape. We had the privilege of exploring some of the great sites in Malawi. We trekked through the majestic Mount Mulanje, trudged the lush green forestry of Zomba plateau and strolled through the tranquil fields at Satemwa tea plantations.

Views from Zomba Plateau

The friendly people, the warm culture and the exposure to a number of new medical experiences made these 4 weeks greatly fruitful. Despite the delays during the application process and the challenges in securing the funding before my departure, thanks to the diligent work of Mr. Motlhabani and all involved this elective experience was made possible. Each moment has been a true privilege. I have obtained valuable exposure to a wide range of medical conditions, although ideally, I would have enjoyed the chance to rotate through the different medical wards and engage with different doctors. Similarly to South Africa, Malawi has a large HIV burden and through this elective, I learned crucial principles concerning the monitoring of HIV in a resource-limited setting. The greatest personal revelation that I have taken from my 4 weeks in the Department of Medicine, is that true learning comes with an eager and earnest attempt to acquire it. I have retained a great amount of information due to a personal growth desire to gain a greater understanding of the patients I encounter and I hope to continue to grow into an experienced and proficient doctor.

 

My GEMx Elective Added Value to My Medical Career

Filed under: GEMx Regional Exchanges GEMx Student Reflections

Stephen Odiwuor

Post by Stephen Odiwuor, a medical student at Jomo Kenyatta University of Agriculture and Technology, Kenya [MEPI]

I was born around the mid-90s as a son to John Ochieng and Janet Ochieng at home in the middle of the night, with the assistance of a traditional midwife as the only complementary and alternative medicine provider on standby at that critical hour of my birth. My name, Odiwuor, means born at midnight.  I thank God that neither my mother nor I developed perinatal and post-natal complications because had my mother experienced any obstetrics complications, there would be either no ambulance or vehicle to rush us to the nearest health facility except for an old, poorly maintained wheelbarrow that could be easily accessed from the nearest neighbor.

This meant that I had to catch up with the immunizations the vaccines that I should have received at birth, at 6 weeks, at 10 weeks and at 14 weeks later on in the course of my infancy period. In the course of my neonatal period, my mother reports that she developed breast disease, which, after literature review and medical knowledge, I concluded could be either mastitis or breast abscess. I then had to be shifted from exclusive breastfeeding to completely cow milk and that was the end of me with breastfeeding at that tender age before the recommended six months period had elapsed. My parents could not afford the infant formula milk because we were wallowing in the mud and mire of poverty.

At the Zimbabwe Medical Students’ Association annual general meeting (AGM)

In our village, I had to put up with a life that meant learning how to live with malnutrition and, occasionally acute malnutrition and severe malaria due to lack of untreated mosquito nets. My passion to pursue a bachelors in medicine and  a bachelors in surgery course is being driven by these health concerns that I had to survive right from my perinatal period, the immunizations I did not receive according to schedule, the exclusive breastfeeding that I did not get a chance to enjoy, the malnutrition I suffered among other health risks that I faced.  I, therefore, acknowledge the Education Commission for Foreign Medical Graduates (ECFMG) for their Global Educational Exchange in Medicine and the health professions (GEMx) that sponsored my electives at the University of Zimbabwe College of Health Sciences, Parirenyatwa Hospital, that would help me realize my dream of giving back to the community as a doctor by addressing the health challenges that I faced.

It was in early 2017 as I was going about my normal academic obligations at the Jomo Kenyatta University of Agriculture and Technology (JKUAT) school of medicine as a fourth-year bachelor of medicine and bachelor of surgery (MBChB) student when, a bachelor of pharmacy student, whose lecturer is Dr. Karara, the JKUAT GEMx Coordinator, sent me a link about GEMx electives. It was my first time to hear about GEMx so I did not take it with a lot of seriousness that it deserved. After a period of contemplation, I decided to give it a trial. I opened a student account on the website and requested Dr. Karara to confirm my details and accept me in the system since she is the JKUAT GEMx Coordinator which, she did. I then proceeded to start my applications for elective. I applied to Kwame Nkrumah University of Ghana, the University of KwaZulu Natal and the University of Zimbabwe. My electives would be in August and September 2018. University of Zimbabwe College of health sciences accepted my applications after uploading all the requirements for the elective on the system and submitting my applications.

At the Medical and Dental Practitioners’ Council of Zimbabwe (MDPCZ)

I arrived in Zimbabwe on 20th of August 2018 at around midday and went straight to the University of Zimbabwe College of health sciences. To my amazement, the elective department had been waiting for me. After a few minutes of engagement and introduction, I was taken to the building at which I would be hosted for the 42-day period that I would be at Parirenyatwa Hospital for my elective. The awesome reception, the transport around the city and the orientation that I received from the elective department on the first day are among the many things I cannot fail to highlight in bold when talking about my elective experience. I did my clinical elective rotation in internal medicine. Among the things I learned were: The good attitude of the consultants towards both students and patients, the awesome reception by the nursing staff, the interactive sessions we had with the junior registered medical officers, the healthy discussions we had with the final year MBChB students, the vast medical knowledge that I gained during ward rounds and enjoyed the beautiful culture of the Shona community. Generally, it was such a life-changing experience for me. Moreover, I was also able to attend the Zimbabwe Medical Students’ Association (ZiMSA) annual general meeting and Dinner and the Family medicine conference at the University of Zimbabwe College of Health Sciences, Gellfand hall.

GEMx sponsored everything during my elective period. GEMx sponsored my accommodation, my upkeep, my flights to and from Zimbabwe and all other expenses. Special thanks to Mrs. Faith Nawagi, the GEMx Africa Coordinator for the constant counsel and help that she provided for me at every stage of my application, Mrs. Chuma Vunganayi, the elective coordinator at University of Zimbabwe College of Health Sciences and Dr. Monica Karara, the GEMx JKUAT coordinator. I also want to acknowledge and appreciate Dr. Reuben W. Thuo, the Dean school of medicine (SoMED) JKUAT, for the recommendation letters and the support he accorded me towards the application for my elective attachment.

Thank you GEMx, you have added a lot of value to my medical career.

 

 

 

 

Increasing Quality and Accessibility to reach everyone, everywhere

Filed under: GEMx Regional Exchanges GEMx Student Reflections

Nyasha Dzinotyiwei

Post by Nyasha Ronald Herbert Dzinotyiwei, a student from University of Zimbabwe College of Health Sciences [MEPI] who recently completed an elective exchange at Kwame Nkrumah University of Science & Technology

Acknowledgments

I would like to thank the Global Educational Exchange in Medicine (GEMx) for providing opportunities for medical students all over the world to go on exchange programmes. I would also like to thank my school, University of Zimbabwe College of Health Sciences, for selecting me to take part in the programme. I would also like to thank the Kwame Nkrumah University of Science & Technology (KNUST) for accepting my application, as well as Ms. Charlotte Osei Boateng, Bismark Addu-Appiah (the Exchange Officer) for assisting me in settling in. I would also like to thank the medical students at KNUST for welcoming me and making me feel at home. Medase pa!

Experience in Ghana

My experience in Ghana has been awesome. For sure I had never imagined that I was going to experience what I had experienced. I love so many things about Ghana – the rich heritage, the different languages, the traditional dress (called Kente), the food, and the people. More importantly, I also noted the many similarities between Ghana and Zimbabwe.  Moving forward, I can use the different things I learned to make suggestions and improvements in my home country.

Nyasha and his friends

Elective Placement

I took up an elective placement in internal medicine that lasted 4 weeks. I was based at Komfo Anokye Teaching Hospital (KATH), which is the hospital affiliated with the KNUST (Kwame Nkrumah University of Science and Technology). I was placed in 4 different departments: Cardiology, Respiratory Medicine, Nephrology, and Neurology. Each placement in the respective subspecialties lasted 1 week. I had difficulties communicating with patients, as some of them were not comfortable speaking in English.

Nonetheless, I managed to communicate with them, and I managed to examine patients as well.

Adjusting to the hospital set up was not very difficult for me because the teaching styles employed at the hospital were identical to those I was accustomed to back home. One of the major things I learned from my stay in Ghana was the provision of the National Health Insurance Scheme (NHIS), and how it aimed at providing equity in healthcare across economic divides in Ghana. I learned about the strengths & weaknesses of the system and how best the system could be tailored to meet the needs of the population.

Nyasha standing outside of the Emergency Department

The teams I was attached to were the teams that had been on duty at the Accidents & Emergencies section. The system in Ghana differs from that in Zimbabwe. While in Zimbabwe we have firms that have admitting days, in Ghana they have duties in which firms take care of patients in the Accidents & Emergencies Department (Our equivalent of Casualty). Back home, there are about

5 firms which, despite being specialized, admit all patients sent to Internal Medicine. In Ghana, the medicine subspecialties operate independently and therefore cardiology patients only attend to Cardiology patients & consults. It reduces the workload tremendously and I believe it also improves outcomes. I also learned about a triaging system for patients who present to casualty, which divides patients into green, yellow, and red depending on the triaging score, which also estimates the severity of disease/injury.

 

Food

The most intriguing part of my stay in Ghana was the new food. I had never seen such variety in dishes! Ranging from Jollof rice, fried rice, and Waache to Fufu, Omo Tuo, red red, Banku and Kenkey, I had the opportunity to experience a different array of dishes. The food was awesome, and I loved it.

Jollof Rice

Other Experiences

I also had the opportunity to meet many other exchange students who were affiliated with KATH as well: many of whom were from Germany, Finland, Austria, and Nigeria. The experience was very nice and I got to make new friends and learn about their health systems. I also got to know how their medical experiences have been and how they differ from ours. I made friends that I hope to keep for the rest of my life.

I also had the opportunity to travel whilst in Ghana. I went to Cape Coast & Elmina, and while there I visited Cape Coast and St. Georges’ Castles. I learned more about the slave trade, and how the castles were used to detain slaves while waiting for slave merchants to arrive and collect them as they began their journey across the Atlantic Ocean. I also visited Kakum forest while there. I also went to Mole National Park, which is northern Ghana. The environment was different from the one I had already adjusted to in Kumasi. I had a nice time with the elephants J and I also visited the Ancient Mosque in Larabanga, which happens to be the oldest mosque in West Africa

Elephants in the background

Last but not least, I had the opportunity to attend the opening ceremony of the 14th International Federation of Medical Students Associations’ (IFMSA) African Regional Meeting (ARM), which was held for the first time in Ghana and in Kumasi. The 13th edition was held in Zimbabwe, so for me, it was a déjà vu experience. I had the opportunity to meet people from many countries, including my own. The theme for the 14th edition was “Rural and remote healthcare – Increasing quality and accessibility to reach everyone, everywhere”. I was inspired by the address given by the Dean of Public Health, Professor Ellis Owusu-Dabo, whose message was in accordance with WHO recommendations. He highlighted 5 main aspects: providing proper healthcare financing (for which he commended the launching of the national healthcare financing scheme in Ghana); deployment of health personnel to remote hard-to-reach places in countries; availability of essential medicines; compiling health statistics and data (incorporating health informatics), and ensuring quality service delivery

Opening ceremony of the 14th International Federation of Medical Students Associations’ (IFMSA) African Regional Meeting (ARM)

 

Ophthalmology in Mombasa City

Filed under: GEMx Regional Exchanges GEMx Student Reflections

Post by David Mutanga, a student at Mbarara University of Science and Technology [COESCA]

David Mutanga

Introduction

Lighthouse for Christ Eye Centre is located in Mombasa city. Mombasa city is the coastal city of the nation of Kenya which is in East Africa. Basically, Mombasa is known as an island. It has many historical sites such as the Fort Jesus, The big Tusks, the Swahili Arab old town, and the first restaurant in East Africa. This city is an international tourist destination.

Lighthouse for Christ Eye Centre is a modern Eye hospital in Mombasa, located in the coastal region of Kenya. It has ophthalmologists and clinical officers seeing a large volume of patients.

My reason to choose Lighthouse for Christ was that it is among the highest reputable hospitals in Kenya. It is also a good place for training because there is all the equipment’s required for eye check-up (e.g. visual field machine). There is very skilled personnel with Christ love ready to support students on their campus. As a result of all this, the number of patients seen in a day is always high.

Experience during the Elective

During my tenure time at Lighthouse, I had two days in OPD, three days at the theatre every week. Towards the end of the five weeks at the campus, I was given an opportunity to work with an outreach team which took place over 194 km away from Mombasa.

  1. OPD (Out Patient Department)

In OPD, I was working with a team of 6 staff. Amongst the six, I was with three senior ophthalmologists:  one senior OCO and others were technicians. Handling the patients at OPD, I always had someone to consult and there was someone ready to assist me as much as I needed. Because of this, I really have improved my skills in the Visual field and OCT interpretation.

David working with his colleagues.

  1. Surgery

The team in theatre apart from the surgeon is composed of a team of six technicians who are highly skilled. Throughout my time here, I did around 6 small incision cataract surgeries without close supervision and this increased my confidence in surgery.

-A one-week Phaco workshop with an international expert surgeon from U.S.A permitted me to know more about Phaco machines and it was my first time to appreciate that modern technology.

-During this elective, I did my first cryotherapy after excision to a patient with a conjunctival neoplasm.

-The one week outreach to the rural areas was a good experience for me and in fact, now that I’m coming from a rural area, I would wish that will be part of my work when I graduate.

During the one week camp, I was able to see more than 350 patients and around 68 mature cataracts were diagnosed for surgery.

  1. Weekends

Mombasa is a big city with significant recreational sites. I enjoyed the walk on the shore of the Indian Ocean and had memorable days of swimming. Commuting within the city is so easy because there are the three wheel motorcycles known as Tuktuk. You can easily move from one end to the other. Security wise, the city is well beefed up, apart from some areas where you see the streets young and old people. Though a big city, it has some parts of the city that is very clean and some very dirty.

To the South, you cross over to the mainland with a ferry. I tried it and during the peak hour, the passenger ferry boards thousands of people across. From the North, you cross by a Nyali bridge and to the west through a causeway.

David on a camel enjoying his weekend.

  1. Acknowledgments

-To GEMx and COECSA for providing funds to this Elective program.

-To the Medical Director of the Lighthouse Dr. Fredrick Korir (Senior Ophthalmologist – specialized in the Cornea), Dr. Ibrahim Matende (Pediatric Ophthalmologist) and all the staff of Lighthouse.

-To the Department of Ophthalmology Mbarara University of Science and Technology.

Growing as an Individual

Filed under: GEMx Regional Exchanges GEMx Student Reflections

Post by Rumbidzai Mupfuti, MBChB student at the University of Zimbabwe College of Health Sciences taking an elective exchange to University of Kwazulu-Natal School of Nursing and Public Health.

My name is Rumbidzai Mupfuti, I’m a 23-year-old lady, currently in my final year doing MBChB at the University of Zimbabwe. Like most people, during my 4th year, I was super excited about participating in an elective but to be honest my excitement was mostly to do with the hype of getting to leave the country and going for a tourist adventure. At my medical school, we always had elective day sometime in April and medical students would share their different destinations and their encounters. When I started my 4th year, I had all sorts of plans to go do my elective overseas because I had always dreamt of doing my elective in a first world country. Finally, it was my turn to have an amazing experience I’d always thought about.

In January of 2017, I started applying to many universities abroad and talked to my predecessors on how I could approach. I had already made all my budgets for the various destinations I hoped for and had started looking for sponsorships. With all the enthusiasm I had, sadly it was now June and still, I was far away from landing any of my dream destinations.

It was just one day, as I was strolling with a friend and she mentioned GEMx…to be honest I had just heard of it briefly, as our faculty office was encouraging people to apply but I never put it to mind since I didn’t have much knowledge about it. So my friend, Tinashe, shared a little bit more about GEMx and I remember going home that day with so many questions about, why I wanted to go for an elective and what my expectations were in relation with my future goals within the medical fraternity.

GEMx was a fairly new thing at my medical school; it had been running for a few years. However, going through the GEMx website I realized how this experience would make me grow as an individual and give me an opportunity to learn more about the health care in surrounding nations, and there was no better time than NOW!

Looking back, I’m grateful I had that conversation because it gave me a different view and bigger picture towards elective attachment. It was as if I had a whole new view…..yes my dream was to do my elective overseas but I still failed to answer the why and how it would help me as a health practitioner and my goal. I realized that I’m very passionate about Global Health particularly in Africa as a whole…. so to cut the long story short, my heart was here, home in Africa.

So given the few months that were left I pursued my GEMx application, and fortunately I was selected as part of the 3 students from my medical school. I was excited and expectant to be visiting our neighbors, South Africa in the beautiful city of Durban.

Travel

We traveled from Harare to Durban by air.  It was a fairly short journey approximately 4 hours and connected in Johannesburg. Upon our arrival in Durban, it was one of the best experiences. If I was asked to describe Durban in a few words I would say, “CULTURAL EXPLOSION!!!” A place which is multi-racial with so much energy and a warm breeze climate. We were welcomed with love, with a lovely lady, Viv who we stayed with for the whole 4 weeks in the lovely neighborhood of Wentworth. With all the love she showed us, this became a second home for us.

Rue with her friends

Hospital Experience

We were nervous about our first day of elective at Wentworth Hospital. All sorts of questions were running through our heads: where we would fit in or even adjust? I remember our first day, we got lost initially but eventually found our way and we were welcomed by our coordinator, Dr. Naidoo. He was the head of Family Medicine at the hospital and he guided us through step by step concerning our 4 weeks attachment in Family Medicine where we got to rotate through Accident and Emergency, Medical ward, Chronic and Acute OPD and the HIV clinic. We had such an amazing team at Wentworth Hospital, from the doctors, nurses, and staff. They treated us like fellow colleagues.

As I said earlier, Durban is a multiracial city and served as an educational time. It was great meeting and learning from different people’s clinical experience and the fact that despite the different backgrounds they all worked as one unit towards providing the best medical care they could give to their community. This gave me a whole different view, as I noticed that we share the same disease burden i.e HIV and its associated infections and non-communicable diseases. This made me appreciate and understand that the different disease burdens and health resource challenges we encounter in my nation go beyond our borders and the first is ours together and through interactions like these and even at a bigger scale can help stop the fight against the various disease burdens in Africa. I also noted a lot of similarities in the health protocols and the differences motivated me and gave me ideas that maybe one day would love to see being implemented back in my home country.

During our 4 week attachment, we got an opportunity to do a Quality Improvement Project on Primary prevention of chronic illnesses. I got to appreciate the importance of teamwork, as it gave us an opportunity to interact with different staff of the hospital and patients giving us insight on the importance of both health practitioners and patients in our efforts as a whole continent to improve our health in Africa as a whole. Lastly, we got an opportunity to visit a government tertiary(specialist) hospital in Durban, Albert Nkosi Hospital. It was an unforgettable experience, I appreciated how people were able to access specialist care equally regardless of different economic background. This moved me, and I thought this was a positive step towards achieving Global Health Access to Africa as a whole. I can go on and on but words can never fully describe how this experience changed my view towards health and motivation towards my career goals…Not forgetting the fun bit of Durban in conclusion, we couldn’t have missed that too

Out and About

So Durban is a tourist city with so much more to show. I can say we got a glimpse of so much great stuff there is to see in Durban…the “CULTURAL EXPLOSION” makes Durban a city full of life and love!!! We got an opportunity to tour around the city Centre and got to know a bit of history about how the city came about. Not forgetting the amazing experience at Ushaka Marine World, we got an opportunity to see one of the largest aquarium, had dolphin shows and a whole lot of activities. we also toured to Moses Madhiba Stadium were also got a glimpse of the huge stadium. We also to see a glimpse of the huge malls, the Pavilion and Gateway Malls and last but not least, because of the vast Indian Ocean, we had unlimited opportunities to swim through the warm ocean currents.

Dolphin show


Looking back, I never imagined that I would have done my attachment in South Africa but now reflecting upon my journey towards SA, I’m grateful for the opportunity I got to do my elective there. In summary, this was a priceless experience with a whole full package and I’m forever grateful for the opportunity GEMx gave us to learn and develop our leadership skills as future doctors towards the effort of building healthy communities.

Rumbidzai, Zimbabwe

My Elective Exchange at The University of Zimbabwe College of Health Sciences

Filed under: GEMx Regional Exchanges GEMx Student Reflections

Joy Kinya Kimathi

Post by Joy Kinya Kimathi, a 5th-year medical student at Jomo Kenyatta University of Agriculture and Technology in Kenya who has completed an elective exchange at the University of Zimbabwe College of Health Sciences.

I was granted an opportunity to participate in an elective program in the University of Zimbabwe at the Parirenyatwa Group of Hospitals in Zimbabwe, from the 20th of August to 30th September, 2018 by GEMx. I found this as a great opportunity to learn, a stupendous chance to mingle with new people, explore a new culture, food, and new places. It’s worth noting that Zimbabwe is a vibrant country whose occupants mainly speak Shona and Ndebele, and are amazingly hospitable.

 

Reception and Accommodation

On arrival at Zimbabwe, I was treated to a very warm reception by the University of Zimbabwe elective office. We were 2 students from Kenya at the time of my elective. Throughout my stay in Zimbabwe, I was accommodated at the Medical residence elective flat within Parirenyatwa hospital grounds. This was a very convenient spot to access the hospital, and I wish to pass my gratitude to the Accommodation office at the University of Zimbabwe for this consideration.

At the Medical and Dental Practitioners Council of Zimbabwe (MPCZ).

Academics

As a prerequisite to working in any clinical area within Zimbabwe, one needs to register with the Medical and Dental Practitioners Council of Zimbabwe (MPCZ). This was one of the first exercises that I embarked on just after settling down. The elective office was kind enough to offer transport to the Board’s premises to register with them.

Clinical Areas

Being a very adventurous person, I explored various departments within the hospital during my elective. These included: Medical Ward, Hematology Department, Urology Department, Oncology Department. I have to admit that I had an awesome learning experience within the institution. The consultants were very enthusiastic and more than ready to impart their knowledge and skills to me. Special thanks to Dr. Marejela (Consultant Physician), for his well-researched discussions crowned with a special sense of humor. Being in your ward round was something each of us looked forward to every single day.

Special thanks to Dr. Mberi (Hematologist Consultant) together with the whole Hematology team, for your dedication to teaching me. Lots of gratitude Dr. Chikore for teaching me how to administer Chemotherapy.

At the Hematology Laboratory

It was a great honor to work with Mr. Dube (Consultant Urologist). His austereness kept us on our toes bringing out the best in us. A shout out to the Oncology team for being one of the most amazing teams to ever work with. I was able to participate in cancer diagnosis, staging, planning of management, radiotherapy, brachytherapy and chemotherapy sessions. Above all the team got to include me in most of their social events making me feel at home.

The junior doctors (JrMOs) in all the departments I rotated in, occupy a special part in my heart. They were not only colleagues but also mentors and probably the greatest friends I’ll ever make within such a short period of time. They shared with me tips on how to navigate around Zimbabwe and were really great chaperones.

In a nutshell, the academic part of my elective was marked with new amazing and interesting exposures. Of special note is the fact that the whole experience sparked in me, a special interest in oncology, a field that I had never ever considered prior to my elective.

Interacting with local students ZiMSA dinner

Social

Over my stay in Zimbabwe, I got to visit many astounding places. It all began with a tour around the University of Zimbabwe main campus. The institution is located in a vast piece of land, in an exquisitely serene environment at Harare.

Some of my major highlights were: A visit to the agricultural showground, visiting the National Gallery of Zimbabwe, Grabbing lunch and dinner with the Zimbabwe Medical Students Associations (ZiMSA), and visiting the Bally Vaughn Animal Sanctuary

Challenges

Zimbabwe cash crises:

I found myself in the middle of a Zimbabwe Cash crisis right from the time I landed at the airport. The challenge was brought by the fact that I couldn’t withdraw any money from the banks due to acute cash shortage within the country. This was a very unique challenge that I had never anticipated at all. To add insult to injury, some of the swipe machines in the country were not compatible with my visa cards making it almost impossible to pay for accommodation as well as the Board fee. However, I would like to take this chance to thank the UZ elective office for being patient and resourceful in handling any new challenge that came up.

At this juncture, I would also like to pass my heartfelt gratitude to the Kenyan Embassy in Zimbabwe. They went out of their way to enable us to get Hard Cash when all our efforts had hit the wall. God bless you richly.

Photo at the Kenyan Embassy

Lesson Learnt

To any student planning to travel out of their country, make a habit of getting in touch with your embassy on the intended country of travel before leaving your country. Let your embassy advise you accordingly pertaining your travel expectations and expected challenges. This will help with your planning and cushion you from any unanticipated shock.

Conclusion

My trip was amazing. In the beginning, I faced a few strains, but I still got the best out of this elective both academically, socially, and culturally. I greatly appreciate the opportunity afforded to me by GEMx team. I wish to thank everyone who went out of their way to ensure that I had the time of my life. The GEMx initiative is a great one, and I take this opportunity to encourage more and more students to enroll and be part of it.

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