[Caribbean-flavored suspense theme playing]

When a roll is complete, it is useless and can be recycled.

In the above picture, each of the rolls depicted have been depleted beyond general use. The small bits of toilet paper visible would not be considered sufficient in quantity to serve on their own. It is common to toss the roll away at this point. However, an individual who is especially frugal might feel compelled to use even these last scraps, potentially in combination with the start of another roll.

"There is still meat on them bones" is used to humorously convey this frugal response, likening it to food that is going to waste. By analogy, the cardboard tube is the inedible bone, while the toilet paper represents the last scraps of still edible meat that would be going to waste.

A black emo skink (Emoia nigra) at Togitogiga Waterfall, Upolu, Samoa

This results in every chronically ill and disabled person to be neglected and never diagnosed or treated.

Doctors are taught that it always must be horses, zebras are so rare that that cant possibly be what they have. Doctors are told they are smarter than their patients, that they always know whats best for them, and that they know more about the patients body than they do. They are taught that anyone who is not easy to save or cure must be lying or exaggerating because "zebras are rare".

When someone chronically ill and undiagnosed does their own research and asks the doctors to test for specific things, this challenges what doctors have been taught: that they are smarter and better than patients, and know everything they need.

This results in doctors becoming defensive, hostile, abusive, and neglectful towards their chronically ill patients.

Doctors are not properly trained to deal with people with illnesses that are chronic and cannot be cured, their practice is based around helping abled people. This is because our society doesn't care about disabled people, and actively lie and say we are rare and meaningless and therefore should not be considered.

Doctors quickly become desensitized to human suffering in their job. Instead of caring about their patients they worry that they are drug addicts and if they give the drug addicts drugs they will lose their job. They would rather let everyone suffer than possibly give medication to someone who may be lying. They believe the worst thing imaginable is someone lying to them for drugs, so they assume every person with complex problems must be a drug addict and they must protect themselves by not treating them.

This leads to pain, suffering, and the death of many chronically ill and disabled people.

When you hear hoofbeats, think of horses, not zebras.” This maxim coined by Dr Theodore Woodward in the 1940s is a useful reminder that we should diagnose the common causes rather than search, at exorbitant length (and cost), for low probability causes. A corollary of this is that rare complications of common diseases are more common than rare diseases. Young doctors at teaching hospitals where rewards come from diagnosing rare diseases must unlearn the habit of searching for them when they stray from the savannas of the wards into the jungle of primary care. Yet “zebras” do exist, and when one arrives, we must know enough that once in a lifetime we can identify the purpuric rash of meningococcal meningitis— or these days, the Koplik spots of measles. Every primary care practice has a few patients who have been diagnosed with rare diseases—diseases that might occur in 1 per 10 000 people, 1 per million, or even less often. But there are many such diseases and each of us will have a different selection. At various times in my own practice I have cared for people with Friedreich ataxia, albinism, type I neurofibromatosis (von Recklinghausen disease), uterus didelphys, specific immune deficiencies, angiodysplasia of the duodenum, and very rare cancers. Some rare diseases are mentioned in the small print at the end of chapters in standard medical textbooks. Others appear only in small print within highly specialized textbooks or are featured only in a few case reports in the literature. These diseases are the lesser-spotted zebras: until one arrives in the office, most doctors consider their existence to be as likely as unicorns or hippogriffs. ...

Zebras also have all the other medical, psychological, and social problems that other patients present with. They get ordinary common infections and injuries, and develop common chronic diseases, such as obesity, hypertension, diabetes, and heart disease. They need screening, diagnosis, treatment, and care like anyone else. We need to learn the interactions between the unusual medication they use and the other drugs that we frequently prescribe. Expecting a non–family physician specialist will undertake their complete care is neither prudent nor possible, as that doctor might not have the knowledge to treat primary care problems or the systems to do so. Family physicians must distinguish issues related to the disease that actually need specialized care from those we can handle ourselves. Furthermore, if zebras have a disorder that affects more than one system, they might need to see several other specialists, and someone has to coordinate the often-times conflicting recommendations. When a zebra is in hospital, whether on a generalist or subspecialist inpatient service, the hospital doctors must also grapple with trying to reconcile conflicting recommendations from various consultants. Therefore, we should all take the trouble to learn about our zebras.