Let me paint you a picture of a patient lying on his back, immobile hands in the air staring with unblinking eyes at the ceiling. He's lying on a simple iron bed at the end of a medical ward in Kisiizi hospital in Uganda. Underneath his bed his wife and their two year old child are asleep on a blanket surrounded by a pot containing the leftover matoke from his lunch and a bucket that acts as his toilet. You hurry past.
Later that evening you pass that way again and find the patient in exactly the same position; hands hovering a few inches above his chest, eyes fixed at the same spot on the ceiling. This time you pause and with the help of a nurse to translate, you listen to his story. He is 35 and has been sick for 9 years with the classic symptoms of Parkinson's disease. He decided to come to hospital yesterday for the first time as he can no longer get out of bed to go to the toilet. When you examine him you notice pressure sores on his buttocks and shoulder blades. He has never seen a doctor before. It strikes you as unusual that he has developed the symptoms of Parkinson's disease at the age of 26, 40 odd years too early and you wonder if maybe the condition could be secondary to something else.
That evening you read up about the secondary causes of Parkinsonism before realising that you have no tests in order to exclude anything anyway. Theoretically he could have Parkinson's secondary to Wilson's disease but you have no way to test serum copper and no drugs to chelate the copper if it is elevated. However all is not lost as the probabilities are that it is just young onset idiopathic Parkinson's so you can at least treat that. You've seen patients in the UK leading next to normal lives with just a slight tremor to bother them so he should be OK. Except that the only anti- Parkinson's drug they have available in the hospital is benzhexol. Nothing stronger. But surely he needs L-dopa? Maybe but even if he could afford to take such an expensive drug for the rest of his life, the staff seem to think that you can't get L-dopa in Uganda, not even in the capital. So you talk to him about starting benzhexol to see if it will make a difference. He is concerned as he was a subsistence farmer and has been saving for months to afford to come to hospital. How will he be able to afford to take a drug for the rest of his life? You explain that maybe, just maybe he might improve enough to be able to work in his plot again or at least enough so his wife won't have to care for him full time, for a few years at least. He says he'll try.
A few days later you see him lying immobile on his bed staring ahead. You ask how he is and he thanks you saying he is so much better he can now get to the toilet. You discharge him on a drug that will eat up three quarters of his monthly income and provide a minimal improvement wondering if as a result of your intervention, he will now not be able to afford to feed his family or send his child to school. As you walk on to the next patient you appreciate that that decision belongs to him and you hope he has more wisdom than you.
So you return to UK medicine with wider horizons, a heavier heart and a prayer for people who have to make decisions no one should have to make.Article written by Anna McGowan