A memorable patient: It's the community that counts

BMJ 1997; 315 doi: (Published 05 July 1997) Cite this as: BMJ 1997;315:j
  1. Samuel Ghebrehewet, research fellow in public health
  1. Liverpool

    Soon after qualifying in 1988 I was assigned to a remote health centre in Ethiopia. People would travel for days to reach the centre and then queue for hours to see a doctor. During this time I encountered an old man with his son who were to change my outlook on public health.

    The old man had brought his son to be treated. They were both diagnosed as having scabies and were given appropriate instructions and prescriptions. But the old man refused his prescription and emphasised that he was concerned only for the welfare of his child. I asked him why? He didn't answer the question, so then I tried to explain the complications that might follow if he was not treated, such as the superimposed bacterial infection leading, for example, to infection of the kidneys. He was not impressed by the explanation and he said that he wished he could develop serious complications and die. I was shocked, and asked again: “Why?” He replied that his life was a misery; he had no education, job, money, or future to look forward to and said that he came to the centre only because he could not bear the distress his son was suffering from the continuous itch caused by the infection.

    He walked out of the office leaving his prescription behind. I followed him to the door not knowing what to say, but suddenly something came to my mind and I said that treating his son would be meaningless unless he was also treated because of the contagiousness of scabies. He said that if that was the case there was no point in treating him because his wife, his eldest son, his neighbours, and most of the people in his village all had scabies. I could not agree more.

    This encounter taught me a valuable lesson: that to make a difference in the health of the population there needs to be a change in emphasis from that on the individual to that on the community. It was apparent that the greatest potential for improving the health of the population lay in changing peoples' social, economic, and physical environments.


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