During my second clinical block of 2018, I was placed on my community block in Mitchell’s Plain in the Western Cape. I was placed at UWC Project at Lentegeur Hospital. Part of this clinical block entailed that we as physiotherapy students go on home visits with Rehabilitation Care Workers (RCWs). The role of the RCWs is to check up on patients who were previously hospitalized and to monitor their progress and to ensure that the patients are continuing with their home programs as these patients are often unable to access their local hospitals or clinics for re-evaluations due to a lack of transport or funding.

On one particular home visit, we met a 57-year-old male who presented with a Left Below Knee Amputation. The incidents leading up to his amputation are as follows: The patient stood on a rusted nail, which he pulled out of his foot himself. He proceeded to clean the wound himself. The wound was not cleaned sufficiently and thus it got infected. The patient did not go to a doctor immediately. He eventually went to the hospital 3 weeks later, by which time the infection had spread and thus an amputation was needed.

The patient previously worked as a truck driver on a daily basis. The patient is receiving a disability grant since the amputation but would like to go back to work as he does not feel that the disability grant is sufficient in order to provide for his family. He lives with his wife and 2 teenage children. There are 4 steps before his front door and 9 steps inside his house that he needs to be able to climb to get to his bedroom. The patient is overweight and has hypertension and diabetes. He used to smoke 1 pack of cigarettes a day but stopped 5 years ago. He has started to learn how to mobilize using elbow crutches as he cannot fit a wheelchair in his house. The likelihood of him receiving a prosthesis from the public sector is very poor due to his co-morbidities.

The public medical sector in the Western Cape uses a guideline when deciding which applicants are more likely to get a prosthetic limb. The decision whether a person should be referred for a prosthesis is challenging because post-prosthetic outcomes must be predicted based on pre-prosthetic ability (Gailey, 2006). Age and medical co-morbidities play a huge role in deciding whether an applicant is appropriate for a prosthesis. There is an extremely long waiting list for prosthetic limbs in South Africa. The South African public health sector is particularly short of resources, hence why a tool is needed in order to choose the most appropriate candidate.

The guideline has shown to address long waiting times and is able to fight the backlog through prioritizing (Mduzana, Visagie, & Mji, 2018). It was however noted that there is a need for caution as the backlog dates back as far as 2008. Therefore patients who have waited for a longer period might be disadvantaged because of weaknesses that had developed post-amputation (Mduzana, Visagie, & Mji, 2018).

The World Health Organization (WHO) collaborated with The International Society for Prosthetics and Orthotics which showed that were only 24 orthotic and prosthetic schools across all developing countries and thus only 400 graduates annually in 2005. This places a huge strain on health systems due to the lack of trained professionals. An study in 2008 declared prosthetic service delivery in developing countries a problem owing to lack of a sufficient number of prosthetists being trained to meet the growing demands of persons with a lower limb amputation in developing countries (Pearlman, 2008). According to the South African Orthotics and Prosthetics Association, there are only 2 institutes in South Africa in which you can study Medical Orthotics and Prosthetics (SAOPA, 2019).

The South African Human Rights Commission (SAHRC) states in section 27 (1)(a) that “Everyone has the right to have access to health care services, including reproductive health care…”. The SAHRC also states “These should be available to all on a non-discriminatory basis” (SAHRC, 1996). However, this then means that 2 candidates could submit their application for a prosthesis at the same time and have the same co-morbidities but the one candidate would be chosen over the other, based on age and thus this is discriminatory.

For this patient, because he is slightly older, his application may be over looked. He also has other medical co-morbidities but he has not been educated on how to increase his chance of receiving a prosthesis. For example, is his diabetes and hypertension under control? The patient is overweight; therefore, he should be educated that to increase his chance of receiving a prosthesis it is advisable that he loses some weight. Not to say this will mean he will definitely receive a prosthesis thereafter, but purely that it will improve his application.

Should this patient not be able to receive a prosthesis he will not be able to return to work. He still has at least 5 years in which he should be working and contributing to the economy and be able to provide his children with the lifestyle that he has been for the past several years. This then means that his quality of life is affected and his rehabilitation has not been effective as rehabilitation should enable a patient to function at an optimal level within the limitation of their condition as well as optimize the patient’s quality of life (Geertzen, 2011).

This lack of resources in the health department not only affects the patient directly, but affects his whole family and even the economy of South Africa. He now places an economical strain to an already economically burdened society in which only 13% of the South African population of 56 million people are paying income taxes as he must now receive a disability grant (Coomer, 2017).

Whilst there is no solution to the problem and it would seem that prioritizing the so called ‘best candidates’ is the only way to manage a limited amount of resources, it does create an ethical dilemma on how does one choose the ‘best candidate’ without being discriminatory with regards to one’s rights.

References

Coomer, J. (2017, October 26 ). BusinessTech. Retrieved from This is who is paying South Africa’s tax: https://businesstech.co.za/news/finance/207631/this-is-who-is-paying-south-africas-tax/

Gailey, R. (2006). Predictive outcome measures versus functional outcome measures in the lower limb amputee. Journal of Prosthetics and Orthotics, 18(6), 51-60.

Geertzen, J. H. (2011). An ICF-based education programme in amputation rehabilitation for medical residents in the Netherlands. Prosthetics and orthotics international, 35(3), 318-322.

Mduzana, L., Visagie, S., & Mji, G. (2018). Suitability of ‘guidelines for screening of prosthetic candidates:lower limb’ for the Eastern Cape, South Africa: A qualitative study. The South African journal of physiotherapy, 74(1).

Pearlman, J. (2008). Lower-limb prostheses and wheelchairs in low-income countries. IEEE Engineering in Medicine and Biology Magazine, 27(2), 12-22.

SAHRC. (1996). Right to Health Care: Chapter 4.

SAOPA. (2019). South African Orthotics and Prosthetics Association. Retrieved from Where to study orthotics and prosthetics: http://www.saopa.co.za/where-to-study-orthotics-prosthetics/