Whatever happened to the doctor's opinion?

A year or so ago I spent a short while in Africa collaborating on a validation study of the National Early Warning Score [ ]. As I went over the results of the study it was clear that African patients were much younger and sicker than in the developed world. I was left wondering why they had not come to the hospital sooner and raised this issue with my African collaborators. Warm African evenings with their intermittent power cuts provide excellent opportunities for convivial thought provoking conversations. After a long discussion I was given several explanations. First and foremost is availability: there are not enough doctors and not enough hospitals, and patients may have to travel considerable distances (often on foot) to reach them. Since the availability of medical care is so limited, patients are unfamiliar with it and can be intimidated by it. They almost certainly will not know the doctor on a social or cultural level, and he or she may well be from a different part of the country, from a different tribe or even be a foreigner, and probably not speak their language. Finally, they suspect the doctor will not be able to tell them what is wrong with them or if they are likely to get better, but instead order a whole load of expensive tests. When the tests come back the doctor may still be racked with doubt, and want to either order more expensive tests, or consult with another even more expensive doctor. In contrast, their local medicine man, from the same tribe and same village and they have known since childhood, is instantly available, always knows what is wrong with them, and is bound to have an affordable remedy for any and every complaint or symptom they may have.