Medical Incompetence Is not an Aberration in a Developing Land

Dear Editor, From the moment I decided to become a doctor in a developing land, I imagined I’d bring hope-cut through suffering with clarity, science and compassion. Like many who enter medicine, I had childhood dreams of helping people, especially in communities where suffering felt normalized. But real-world medicine, particularly in developing lands where scarcity meets systemic neglect, often transforms idealism into disillusionment. Incompetence here is not rare – it’s woven into the fabric of daily care, quietly accepted by a public with no other choice. Her name was Ms Y, a 32-year-old woman who walked into our emergency hidden under layers of cloth, her bones stark beneath sunken cheeks and hollowed eyes. She had been diagnosed with diabetes more than a year ago. Her blood sugars had never dipped below 300 mg/dL, yet she was still on oral medications. Over the last 9 months, she had lost nearly 50 kg. That is not a typo-fifty. She spoke softly, between breaths that came too quickly for someone sitting still. ‘I used to be strong’, she said. ‘Now I can’t even walk to the bathroom without resting’. She described chronic diarrhoea – up to 15 watery episodes a day – and a complete disintegration of her energy. Her husband, equally gaunt from worry, pulled out old photographs from his purse. ‘This was her a year ago’, he said, showing me a vibrant, shy woman standing by their roadside shop. And then I wondered: How could this have gone so wrong? The answer, like in many such stories, lay in a slow cascade of missed opportunities, wrong assumptions and fragmented care. She had been managed by local practitioners who, seeing her age and diabetes diagnosis, assumed type 2 diabetes. Oral pills were started first metformin, then sulfonylureas, then combinations. No one measured her insulin levels. No one questioned the weight loss. When she did not improve, she was simply told to ‘eat more’ or ‘take the tablets properly’. What she had was autoimmune diabetes type 1 diabetes, a condition thought to be the domain of children, but not uncommon in adults.[1] In her case, there had been no insulin at all. Her body, starving despite high blood sugar, had cannibalized itself. A C-peptide level of 0.07 ng/mL and positive anti-glutamic acid decarboxylase (GAD) antibodies confirmed the diagnosis. But this was not just a clinical failure, it was a reflection of a much larger reality. In a developing country like ours, where the population vastly outnumbers healthcare providers, and where basic diagnostic facilities are either inaccessible or unaffordable for most, wrong assumptions become the standard. Many demand treatment first, investigations next approach. Many of these patients are managed by undertrained or overwhelmed providers, with few mechanisms for second opinions or systemic correction. Incompetence from both sides is not an aberration – it’s often the norm. And for the suffering masses, resignation is easier than resistance. They have learnt to live with broken systems, hoping that time, or God, or fate will somehow intervene. Her story is not rare – it is structurally predictable. It reflects how clinical misjudgement becomes endemic when systems fail to support reflective, evidence-based care. As a clinician, this case unsettled me. Not because of its rarity – it was not rare. But because it echoed what happens all too often in overburdened health systems, where shortcuts become normalised. Diagnostic inertia – where early assumptions aren’t revisited – can be deadly. There is a kind of moral distress in watching a patient’s health unravel due to a failure that is entirely preventable. Y.’s case was also a lesson in listening – not just to lab values, but also to the body’s louder cues. Very severe weight loss, a loss of more than 10% of body weight in a short time, is a medical scream. And in a diabetic patient, it should raise red flags. But in the era of rising obesity, cachexia has become an underappreciated sign, an anomaly we often overlook, especially in developing land context. For Y., starting insulin therapy was almost miraculous. Within a week of hospitalisation, her sugars stabilised, her diarrhoea resolved and her appetite returned. But her body had been through a war, and rebuilding would take time. What she had lost was not just weight – it was trust in the system, faith in the people who were supposed to help. Her husband said something that stayed with me: ‘We kept going to doctors, but no one told us what was wrong. We thought maybe it was fate’. It’s painful to hear. Because we train for years to recognize disease, yet miss it when it defies stereotypes. Because ‘fate’ should never be a substitute for medical explanation. I often think of the closing moments of her last visit with me – her thin hand gripping mine, her voice still soft, but steadier now: ‘Doctor, thank you (in a shy smile)… for believing me, for shaping my adulthood’. It wasn’t heroism. It was just doing what we’re supposed to do. But in places where diagnostic clarity is clouded by assumptions and systemic gaps, even small acts of attention can feel radical. Looking back, I realise my childhood dreams were not wrong – they were just incomplete. I did not account for the frustration, the ethical discomfort or the quiet grief of knowing that better outcomes were possible but delayed. Moral distress is not always dramatic. Sometimes it’s the quiet weight we carry after patients such as Y., a mix of guilt, reflection and determination. Yet, amidst that distress is also hope. Her recovery, although slow, reminds me that timely action can reverse even prolonged neglect. That weight loss, in this context, isn’t just a symptom-it’s a cry for help. And that listening – really listening – is still our most powerful diagnostic tool. In Y.’s case, what disappeared was not just weight – it was time, confidence and safety. What she regained, with insulin, was not just glucose control – it was life. And for me, a quiet reminder that in a land where medical errors are too often normalised and accountability too rare, our purpose must be louder than the silence of systemic failure. If systems are failing, then the stories from within them must become louder. Editorial is not just catharsis: It is advocacy [Box 1]. It reminds us that when incompetence becomes routine, our compassion and vigilance must become relentless.Box 1: Clinician’s own rules[ 1-3 ]Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.