An income is really important for me and for my family. With my livelihood as a farmer, I’m very worried about making enough money in the future to support us all. I need to regain enough ability to continue working…
Mr. Dee, a 41-year old farmer and father, lived and worked in a rural area of northern Thailand. A short fall resulted in a spinal cord injury that would have a drastic impact on his life and livelihood.
Mr. Dee had spent his life in a small, rural village. While he had some formal education, he had never completed his studies and instead began learning the farming trade as a young teenager. At 41, he still farmed, growing mangos and other fruit seasonally for his main source of income.
Additionally, he worked as a local manual laborer in the dry seasons to supplement his income and support his wife and daughter. As a result of this, Mr. Dee’s daughter was able to attend university, and was working towards a degree in business at the time of the accident.
As is common in Southeast Asia where heavy rains are frequent, Mr. Dee and his family lived in a small house which was elevated on bamboo stilts to accommodate rising water levels. Also, a pit toilet was situated about 20 meters away. These designs would have accessibility implications for Mr. Dee following his injury.
Addressing spinal injuries in Thailand - as in other lower-income countries - presents different challenges to rehabilitation in industrialized nations.
Mr. Dee's accident
Comparatively speaking, Mr. Dee’s accident was not extreme – but its results were very serious. Walking in the local mountain range, he tumbled just a short distance down an incline; the fall was quick and severe, resulting in immediate paralysis with no sensitivity in his extremities.
In such a setting, no emergency services are available. However, four friends were able to transport Mr. Dee down the mountain utilizing a blanket as a gurney. Mr. Dee was transported to a regional hospital as quickly as possible in a friend’s private car. Unfortunately, the hospital was not able to treat injuries like Mr. Dee’s.
The nearest hospital able to surgically treat spinal cord injuries was 300 kilometers away at a university in Chaing Mai Province. Consequently, Mr. Dee was transported to that specialty unit by ambulance.
Upon admission, Mr. Dee was diagnosed with a traumatic disc herniation at C5-C6 and a spinal cord contusion at C3-C4 and classified as an ASIA C.16 This meant that he had preserved motor function below the level of the injury with more than 50 percent of key muscles graded below a three.
Box 2 | Thailand and Disability
ComThailand is defined by the UN as a middle-income country with a gross domestic product per capita in 2002 of USD 7010 and a population of 65.5 million.16 A total of 65 percent of the population live in non-urban areas and roughly 40 percent are involved in agriculture.17 The writer Thienchai Srivichit describes life in rural Thailand:
The rural family in the typical village setting is an extended family with many generations living in one house... In the village, home is usually a simple house raised on posts; domestic animals, like buffaloes, chickens, etc. are kept below, and the family lives above, often in a single room.
There is little privacy, though this is not as highly regarded as in Western countries, and the communal lifestyle instills a strong sense of social harmony in which tact, compromise, and tolerance are essential. The father is regarded as the leader, but the mother also plays a significant role particularly in the family finances.18
Medical treatment and rehabilitation begin
The medical team decided to perform a spinal surgery where his fifth and sixth vertebrae were plated and he was fitted with a soft collar post-operatively. The treatment and rehabilitation course following the surgery proceeded without complications and two weeks following the accident, he was referred to an early post-acute unit within the hospital.
Notably, healthcare in Thailand is provided to its population by a government insurance program. Therefore, the Dee family would fortunately not have to worry about healthcare expenses.
Addressing spinal injuries in Thailand – as in other lower-income countries (and, in particular, in lower-income populations) – presents opportunities and challenges that are sometimes similar and often quite different to rehabilitation in industrialized nations. Box 2 gives some basic information on disability in Thailand.
Thailand has a universal coverage policy that attempts to offer access to healthcare to its entire population.19
However, challenges remain to comprehensive care and rehabilitation. There is roughly one doctor for every 4,000 people and life expectancy is about 70 years.20 About 1.7 percent of the population has some form of disability.21 Physical disabilities constitute 42 percent of all disabilities (data from 1996) and occur almost twice as frequently in men as in women, often as a result of accidents.17 For comparison,in 2005 in the US physical disabilities made up about 62 percent of all disabilities in adults and rates among men and women were roughly equal (7.3 percent and 8.4 percent, respectively).19
The societal perception of the disabled is influenced by the prevalent religion, Buddhism, which teaches both that disability results from a previous life’s vice and that mercy must be shown towards “the weak.” 21 While this may have the effect of increasing donations to the disabled, it also prevents them from being seen as equals. Despite government policies to promote employment of persons with disabilities, unemployment remains high; state allowances are given to those with severe disabilities and decided on a case-by-case basis. In addition to issues surrounding employment, those with disabilities in Thailand have limited access to both public transportation and education (only 7 percent of children with disabilities were enrolled in school in 2002).19
At the time of his arrival at the early post-acute rehabilitation unit, Mr. Dee was completely dependent with his spouse caring for him as much as was possible. A single six-week Rehab-Cycle® was planned. At that time, an accurate prognosis was difficult to< make; more knowledge was needed of Mr. Dee’s functional status in order to begin defining goals and intervention targets. This would take place during his initial assessment.