On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.98 n.4 Cape Town Apr. 2008
J V Larsen
181Amberfield Private Bag X010 Howick 3290 email@example.com
To the Editor: J is a 29-year-old rural Zulu man, tall and muscular, intelligent and stoical. In July 2007, he developed difficulty in walking, which progressed over the next few weeks. His family gathered the funds to pay for him to go to the nearest district hospital in Pietermaritzburg, where he was found to have a neurological defect in his legs, and to be HIV-positive. An appointment was made for an MRI scan in the nearby tertiary unit, and he was also given an appointment to return to the hospital with the result. He was sent home because of the pressure on beds.
He kept his MRI scan appointment, but the family had used up all their money by then, partly because his sister had stopped work to nurse him (she was the main breadwinner), so he could not keep his follow-up appointment. They managed to gather the funds together by the end of November. J now had a flaccid paraplegia with no sensation below his T6 dermatome, large pressure sores, and clinical signs of pulmonary tuberculosis. When his MRI scan was retrieved, it showed multiple subdural abscesses and a psoas abscess. His paraplegia is now probably irreversible.
Were J and his family stupid? It is true that he did not properly understand the explanation of his probable pathology given at his first visit, but he was willing to co-operate nonetheless. I submit that it was not J who was stupid, but carers and a system of care that does not listen to patients and has never taken the trouble to find out what it means to be poor and sick in a rural environment. No one asked him: 'How far away do you live? What did it cost to get you here?' - not at the first visit, or when the scan showed pathology requiring urgent intervention. Assumptions were made based on the conveniences of city life. So a management plan that would have been acceptable in a city failed utterly.
Rural poor often live with such limited resources that carers are given just one opportunity to hit the target. Miss that at the first visit through a failure to listen and empathise, and the result can be catastrophic; which, as in this case, can pull a whole family yet deeper into poverty.