Opened in 1996 in Mandritsara, a town of 30000 people, HVM is the chief healthcare provider for a radius of approximately 200km. We saw patients who walked, canoed or cycled for at least two days to get to the hospital, sometimes carried on a home-made stretcher by their relatives. The hospital runs off charitable donations, alongside small patient contributions.

The staff team comprises both locals and long and short-term missionaries. Two consultant general surgeons run the hospital supported by a large staff team which include 4 junior doctors, two midwives, an ophthalmologist and a public health specialist, all of whom we shadowed, dividing our time across their respective specialities. The hospital has two operating theatres and 44 in-patient beds.

Every morning starts with prayer and a Gospel message in the outpatients department and on the ward, and prayer really does underpin the work of the hospital. Patients are encouraged to pray with their families and the staff, and we saw some patients walk out who were never expected to recover. A girl became a Christian while an inpatient and is now being visited and supported by the community team in her village to set up a church there. In fact, some of our most memorable experiences came from our time spent with the community health team. Madagascar is technically a Christian country, but particularly out in the rural areas, there is a lot of ancestor idolatry and spirit worship, and the community team combine their vaccination trips with evangelism and supporting growth of new churches.

Since then they have set up a church in their village, and a youth group has developed too, now numbering about 150 young people. We went to this youth group and sat for hours round a fire with teenagers who had walked for miles to join together, learn about Jesus, and praise him. It was amazing to get the opportunity to share some of our stories of faith with them, and hear how they had come to know God. One boy was the only Christian in his village, and his family tried to discourage him from coming, but he would not be stopped, and in fact, he had walked 60km to come!

The work God is doing in this country was so evident to us, as we met people who had turned from spirit worship to Jesus, churches springing up in villages where for years there has only been one Christian faithfully praying, and the many young people we met who had such passion, dedication, and love for Jesus and his work. We could go on…!Most of my time was spent in out-patients and surgery. The latter was a good opportunity to practice clinical skills, from assisting in surgery, performing spinal anaesthetics, cannulation, minor surgery and suturing. It was valuable to help with admissions and take histories where possible, particularly whilst on-call. Unfortunately, however, the English-Malagasy language barrier was a frequent limitation. Attending ward-rounds and keeping an eye on patient notes meant I saw a whole range of admissions, from patients with digestive haemorrhages related to schistosomiasis, seizures associated with malaria, and the admission of a young woman with Steven-Johnson's Syndrome. I was frequently struck by the hospital's limitations, from the lack of further imaging such as CT or MRI, or even an endoscope, to the restrictions on prescribing drugs due to the shortage of pharmacy stocks, or due to some medications simply being too expensive for patients. One young man with candida in his urine sample was prescribed a nystatin pessary to suck as there was no systemic treatment available. Fluconazole continues not to be stocked at the pharmacy, a drug that would be highly valuable as fungal skin infections are a frequent presentation. There were no psychiatric services, a resource limited in many developing countries, possibly associated to on-going stigma towards mental health illness. Although the hospital provided support for these patients, the stigma associated with mental health was strikingly apparent from the families' attitudes.

Resource limitations are an obvious weakness, such as being unable to do urea and electrolytes, or to give oxygen at a higher flow rate than 5 litres/minute. Language barriers often restricted history-taking, be it due to differences in dialects, or doctors speaking Malagasy as a second or third language. Patients also often attended village doctors and were unsure of what medications, never mind dosages, they had received. We are so fortunate to have the National Health Service, and should not take neither the resources we have, nor the ability to communicate with patients (either directly or via translation services) for granted.

Although time was limited on campus, the community team prioritised health education in villages, alongside providing spiritual support and encouragement. Some of my happiest memories are those with this team. In reflection I value the different healthcare staff roles in a new way (such as children's workers and physiotherapists), and recognise the importance of true care and concern for each patient.

I was fortunate to receive a grant for an audit based with maternity. This allowed me the opportunity to be 'en-garde' for the majority of the elective and therefore I spent a lot of time working with the two midwives. Assisting in a numerous amount of deliveries allowed me the opportunity to observe decision-making, and the consequences of such decisions. I also sadly saw some very challenging situations, including stillbirths, neonatal deaths, and a maternal death due to pulmonary oedema on coming round from general anaesthetic. Reading over 150 notes for the audit highlighted the importance of good note-making and gave me insight into the management of different obstetric situations and emergencies. It also helped me get alongside the team, and become far more integrated as they saw the commitment I gave the project and my passion for the subject.

Starting the elective, my first aim was to improve my medical skills. Although I am sure my skills have improved, I think my main lessons (as reflected on above) are far from what I expected. The elective has encouraged an interest in obstetrics and gynaecology, and I hope that the audit will be valuable and I look forward to continued communication as we analyse the results together. Principally, I return acutely aware of what I take for granted. I have no doubt that my future career choices will point directly to the experiences I have had in the last eight weeks.

Finally, going on this trip was such an incredible experience for us that we would recommend anyone who is considering short-term mission to go for it! St George's short-term mission fund was able to help fund us, for which we are so so grateful. Seeing a completely different part of the world and seeing that God is still the same God, in charge, with a plan, and bringing people to him, taught us so much in those two months.