Wealth gap: A doctor's dilemma

2015-03-08 15:00

As I navigated my way through the sleepless nights, inhumane horrors and small triumphs that punctuate every junior doctor’s internship and community service years, I would recall the advice of a gentle, patient professor who taught me everything I would ever need to know about medicine.

I remember my anxiety about never being able to recall the 10?000-plus diseases known to man. He coolly reassured me, saying I would only ever need to remember three diseases: “Illness associated with poverty, illness modified by poverty and illness due to poverty.”

He was right: like the Fates in Greek mythology, these three diseases weave the thread of every mortal life, from birth to untimely death.

The illness most glaringly “associated with poverty” is undoubtedly HIV/Aids. When I graduated, I knew enough about HIV to diagnose and treat it, but by the end of my internship at Chris Hani Baragwanath Hospital, HIV had become an old foe: familiar but no less frightening than when we first met.

I remember the night I met Olwethu*. I didn’t need to look at the lab results to know with certainty she was HIV positive. She was 15 years old when I took over her care, and she had every defining feature of this ghastly disease: from the stunted stature to the oddly long eyelashes.

I sat down beside her and asked her why she was here and how we could help her. Without making eye contact, she instructed me to open the bag at the foot of her bed, and it was only then that I realised she was completely blind – the result of a severe viral infection that had destroyed her retinas.

Inside the bag, I found a file that housed an improbably organised medical history: page after page of hospital-discharge summaries, pathology reports and blood results that told the story of a life of suffering. This time around, she had severe pneumonia. TB had destroyed her lungs and left behind cavities that provided the perfect breeding ground for bacteria to flourish. We treated her with antibiotics and oxygen and eventually sent her back to the orphanage she called home, adding one more page to that growing file.

But there’s a story here that isn’t quite captured in the pages of that file. There was no antibiotic or antiretroviral that could reverse the damage done by poverty, or give this child the stable home she so desperately needed to aid her recovery.

Sadly, this remains the untold story of so many patients who enter our care. Perhaps this is because, as doctors, we prefer to avoid problems we don’t know how to fix.

Fortunately, incremental improvements in the diagnosis and management of HIV have resulted in far fewer babies being born positive today, but without addressing the underlying socioeconomic determinants of the disease, the fight against Aids will continue to be fraught with insurmountable challenges.

The progress made over the past 15 years should not go unnoticed, but unfortunately these small victories are overshadowed by the looming threat of the second class of illnesses: those that are modified by poverty.

“Diseases of lifestyle”, such as diabetes, strokes and heart disease, were once afflictions of kings and aristocrats. Today, these chronic conditions have added an extra burden of disease to the poor.

Migration from rural to urban areas in pursuit of work and better opportunities – and the accompanying changes in diet and lifestyle – has resulted in a steady rise in the prevalence of these conditions. Treatment often entails a complex set of interventions, ranging from dietary and exercise advice to carefully dosed injections.

Optimal control is difficult to achieve in the very best of circumstances. Now imagine offering foot-care advice to a diabetic patient who has no shoes. Uncontrolled diabetes leads to poor circulation and sensation. Small wounds often go unnoticed until the infection has spread, the toes have blackened and flies have laid their eggs in the rotting flesh.

I have seen a frightful number of diabetic patients lose their sight or limbs due to complications that are indisputably less likely to affect those with the financial and social support to adequately manage the disease.

With illness associated with poverty reaching a steady plateau and illness modified by poverty on the rise, one can only hope that illness due to poverty is coming to an end.

Though global indicators suggest there has been a significant reduction in extreme poverty worldwide, the paediatric wards in our public hospitals tell a different story. I remember being shocked by how frequently we would admit young children with severe malnutrition, a disease directly caused by poverty.

Thinking back to my internship, I remember so many of their little faces. Some had the wizened frowns of marasmus, others the puffy “bulldog” faces of kwashiorkor. What struck me most was not their shrunken bodies, swollen bellies or flaky skin, but rather their unwillingness – no, inability – to smile or play. It would take weeks of careful feeding and intensive physio and occupational therapy before these little souls would resurface, as if woken from a nightmare.

As soon as they laughed, you could be certain they had recovered, and they would be sent on their way. “Healed” and happy, their devoted mothers would carry them back to their impoverished homes.

And so the cycle continues and these three diseases of poverty are woven into the tapestry of our country’s collective history.

On second thought, there is one thing my professor was not able to teach me. He never mentioned the cure for poverty. I suspect we still have a lot of work to do to find it.

*Not her real name

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