Embed Size (px)
Citation preview
International Journal of Dermatology
2007,
46
(Suppl. 2), 42–45 © 2007 The AuthorJournal compilation © 2007
The International Society of Dermatology
42
Abstract
As India shines in its enviable achievements, one after the other in rapid succession, it also
invites criticism from visitors for what they witness. It is imperative to delve deeper to fathom
the realities of the predominantly rural India with its poverty and lack of awareness which are
stumbling blocks and are major pitfalls in the practice of dermatology. The urban–rural divide,
the phenomenon of migration, poverty, lack of awareness all affect practice of dermatology in
this country. These are battles that have no ready answers. However a deeper understanding
of the ground reality is a worthwhile exercise for the increasing tribe of international
dermatologists who like to explore “cross cultural dermatology”.
Blackwell Publishing LtdOxford, UKIJDInternational Journal of Dermatology0011-9059© 2007 The International Society of DermatologyXXX
Report
Nonclinical challenges of Indian dermatology
Verma
Nonclinical challenges of Indian dermatology – cities vs. villages, poverty, and lack of awareness
Shyam Verma,
MBBS
,
DV&D
From 18 Amee Society, Diwalipura, Vadodara, Gujarat, India
Correspondence
Shyam Verma,
MBBS
,
DV&D
18 Amee Society Diwalipura Vadodara 390015 Gujarat India E-mail: [email protected]
I am happy to be invited to write this article for an issue ofimmense global importance. The world has been increasinglycompressed by globalization, electronic information relaysystems, media, and travel. In this era of development, themood is upbeat and optimism runs high in all fields ofmedicine, especially in the hallowed urban centers of somedeveloping countries, such as India. We boast of mushroom-ing modern medical schools, state-of-the-art hospitals,ultramodern equipment, impressive fellowships attained byphysicians, increasing willingness to pay for healthcare byhealthcare seekers, and more awareness. This same optimismalso applies to dermatology and dermatologic care seekers inIndia. Nevertheless, this growth and development in derma-tologic care, encouraging and impressive as it may sound, isone-sided. Unfortunately, the above attributes and positivetrends apply to a very minute fraction of society and cannottherefore be generalized. Only an insignificant minority areprogressing in the true sense and benefiting from develop-ment when the dermatologic scenario is examined in itsbroadest perspective. We seem to forget this basic fact as wecontinue to admire our achievements in terms of developmentand modern outlook.
As we continue to hurtle down the expressway of growthin the field of dermatology – a privilege enjoyed by a minutefraction of the population – there is a need to stop and takestock of all those who do not have access to this expressway.These unfortunate individuals are still stumbling along thedusty, uncomfortable track of inadequate dermatologic careenveloped in poverty and lack of awareness. Dermatology isone of the fastest developing fields of medicine, and we are alltoo eager to accept this and celebrate the status of our field.We seem to be ignoring its large and ugly underbelly, which
is like the hidden portion of an iceberg, many times largerthan the impressive portion that is visible for all to see. Thisarticle is intended to share some of the pitfalls of dermatologicpractice in one of the largest countries in the world, wheredermatology is developing in leaps and bounds, and whereboth dermatologists and the population are in constant battlewith nondermatologic issues.
India is a unique country with unique problems. It is thesecond largest country in the world with a population of 1.1billion. Interestingly, it has the youngest population in theworld, with more than 30% below the age of 15 years. Only5% of the population is over the age of 65 years. If this trendcontinues, the population of India will equal that of China by
ad
2040.This mammoth population is serviced by about 5000
dermatologists, with a ratio of one dermatologist for about200,000 people. This is where the detail becomes even moreinteresting. Of the 1.1 billion people in India, over 70% livein rural areas. Although no clear figures are available, it canbe safely assumed that over 90% of dermatologists practicein urban areas. These are frightening statistics. For the ruralpopulation of approximately 750 million, there are insignificantnumbers of dermatologists in villages. People from villagesdepend on urban-based specialists for their ultimate dermato-logic needs, which can be inconvenient logistically and finan-cially. This directly affects their motivation to be treated, andhence their compliance with treatment. Moreover, government-run hospitals in these areas are understaffed with regard todermatologists. In addition, it should be remembered thatthe health sector in India is predominantly private practicebased, irrespective of whether it be dermatology or any otherfield of medicine. Both rural and urban populations seek
© 2007 The Author
International Journal of Dermatology
2007,
46
(Suppl. 2), 42–45Journal compilation © 2007
The International Society of Dermatology
43
Verma
Nonclinical challenges of Indian dermatology
Report
their primary dermatologic care predominantly from generalpractitioners in private practice who have an inadequateknowledge of dermatology. Many of these general practitionerspractice alternative medicine systems, such as homeopathyand Ayurveda, and illegally practice allopathy (Fig. 1). Worsestill, some individuals practice with no valid qualification atall! This is a frightening combination, especially when it isconsidered that even qualified allopathic general practitionershave an inadequate training in dermatology during theirstudy for medical degrees and, later, during their rotatinginternship. This leads to erroneous diagnoses and treatments.The economic burden of ineffective remedies is well known,not to mention the adverse drug reactions and developmentof resistance to antimicrobials.
The unauthorized practice of dermatology by charlatans,many with degrees in Ayurveda and homeopathy, is the real-ity in India. Unfortunately, laws against such dermatologicpractice are not implemented. In a country with such a vastpopulation, issues such as these are not treated as a priority,and hence there is a blatant disregard for the law. It is possiblein most medium-sized urban centers to buy almost any derma-tologic drug without a prescription, despite the law that makesit mandatory to insist on prescriptions and to keep a record ofsales. The same applies to refills on original prescriptions. Itis possible to buy any drug in any quantity without any pre-scription in most pharmacies in most urban areas. Thesepharmacies are often run by individuals who do not have apharmacist’s licence. These individuals are very often advisorsor advocates for the use of various dermatologic prescriptiondrugs on sale. All of these factors are responsible for derma-tologists being confronted with severe dermatoses caused byneglect, or inadequate or inappropriate therapy. Topical andoral steroids are used endlessly without supervision, as aretopical and oral antimicrobials, according to the “whim” or“fancy” of the pharmacist or the patient. This places a severely
increased burden on the treating dermatologist who literally“cleans up” after the “ill deed” has been done.
It is clear that three of the major stumbling blocks todermatologic treatment in India are overpopulation, poverty,and lack of awareness. The success stories and huge develop-ments in dermatologic practice are encouraging, but areessentially urban phenomena. India has a minute populationof rich individuals and a rapidly increasing middle class whichhas overtaken the entire population of the USA. Although thisis very encouraging, there are still over 750 million who liveon less than $2 per day! India is home to 40% of the world’spoor. Who can provide dermatologic care for these people?The provision of a diagnosis is very different from the provi-sion of adequate treatment, including a sufficient quantity ofdrug for an appropriate duration and an explanation of thedisease to the patient in order to improve compliance. Theseare not readily available in overworked hospitals dealing withmultitudes of patients.
In addition to the vital area of urban vs. rural issues in der-matology in India, there are other subjects which have neverbeen discussed in the dermatologic literature, including theway in which rapid urbanization has affected dermatologiccare. In 1947, 75% of the Indian population resided invillages, and agriculture accounted for about 80% of thegross domestic product (GDP) of the country. Today, in2007, 70% still live in villages, but agriculture accounts foronly 30% of GDP. This, in turn, means that there are millionsof people in villages for whom agriculture is no longer a viableoption. The world sees India as an information technology(IT) giant in all its resplendent glory. Bangalore, a city insouthern India, has been dubbed the “silicone valley” ofIndia. Glorious and impressive as it may sound, IT has createdonly about 5 million jobs, if ancillary jobs revolving aroundIT are taken into account. Thus, there are hundreds ofmillions of villagers still desperately hunting for an alternativelivelihood. The average farmer is a small land owner withabout 1–5 acres. When these farmers are forced off their land,for whatever reason, they migrate to the cities (Fig. 2), wherethe vast majority live well below the poverty line. (There areapproximately 350 million individuals living below thegovernment-defined poverty line.) Cities are places in whichaffluence and destitution collide. India has four cities of overfive million people and 35 cities with over one million people,making it the second largest urban system in the world afterChina. It is a system in the doldrums as a result of unregulatedgrowth, widespread corruption, lack of infrastructure, andmany decades of callous neglect. Who will look after the der-matologic needs of these migrants who flock to the cities onlyto end up in slums and in conditions which are no better thanthose in sub-Saharan Africa (Fig. 3)? There is an urgent needto devise dermatologic treatment programs that will effec-tively deal with this rapid urbanization and also be sustainablein villages. This requires a healthy alliance and symbiosis
Figure 1 Unauthorized dermatologic practice
International Journal of Dermatology
2007,
46
(Suppl. 2), 42–45 © 2007 The AuthorJournal compilation © 2007
The International Society of Dermatology
44 Report
Nonclinical challenges of Indian dermatology
Verma
between the government and the private sector, i.e. specialistsin private practice. In order for this to take place, mindsetsand attitudes will need to change. If the government insiststhat its perceptions and decisions are final, the system will fail.Moreover, if the average dermatologist in private practicecontinues to be “oblivious” to these nondermatologic prob-lems in practicing dermatology, no progress will be made.
Dermatology in India is progressing. It is a power to bereckoned with and will continue to prosper and grow. Never-theless, there is an urgent need to look beyond our immediateclinical and financially oriented sphere. There is a need formajor reforms in dermatology. These include an improve-ment in patient awareness, better patient education, the avail-ability of rational treatments, the provision of a mandate onpractice eligibility for nondermatologists, the provision of amandate for pharmacists, adequate dermatologic training forfresh medical graduates, increased access to dermatologists in
villages, and, most importantly, mandatory continuation ofdermatologic education, which is currently nonexistent. Thecost of dermatologic treatment should be kept low andaffordable, at least for the needy, an ideal that is not withinthe dermatologist’s control. Issues, such as keeping cosmeticdermatology in its proper perspective and not letting it ruleour practice at the cost of the treatment of common derma-toses, are equally pertinent.
I had the good fortune of being invited to organize andchair the first ever session on “Dermatology in India” at theXVIth European Academy of Dermatology and Venereologyin Vienna early this year. Our session generated an unexpectedlevel of interest, which was very reassuring. I also spoke onurban and rural issues in dermatology at the InternationalSociety of Dermatology session on “Global Dermatology” atthe same conference. Many of the points made in this commu-nication are from these talks. It is refreshing to see so muchinterest being generated in international dermatology or, as itis also known, “global dermatology” or “community derma-tology”. As stated at the beginning of the article, the world isshrinking and knowledge is easier to share and disseminate inthe present era. It is time for more dermatologists from allover the world to appreciate the trials and tribulations ofdermatologists who work in a setting of poverty and lack ofawareness, and who are constantly battling with a lack ofgovernment action and poor infrastructure. It is a commonobservation of many physicians working in government-runestablishments that many plans for development exist, but arenot implemented. Despite all of these obstacles, these aredermatologists who have an enviable wealth of clinicalknowledge. It is crucial that “cross-cultural dermatology”becomes more popular. The onus on “popularizing” shouldnot just be on poor countries, but also on dermatologists fromthe developed world who are relatively much more securefinancially and do not have to worry about so many distracting
Figure 2 Migrating lock, stock, and barrel!
Figure 3 Urban slums in India
© 2007 The Author
International Journal of Dermatology
2007,
46
(Suppl. 2), 42–45Journal compilation © 2007
The International Society of Dermatology
45
Verma
Nonclinical challenges of Indian dermatology
Report
day-to-day issues that plague dermatologists from develop-ing countries. It is only by comparing and contrasting that oneis able to learn to appreciate and criticize one’s profession. Iend this article with a personal viewpoint. At the cost of usinga cliché, “seeing is believing.” Dermatologists from the devel-oped world would benefit immensely from traveling to coun-tries such as India to see how dermatology is practicedeffectively there, and to appreciate the clinical diversity,clinical skills, and relative independence from diagnosticgadgetry of dermatologists in this country against a resource-poor setting. Visits such as these should be more actively pro-moted by dermatologic societies, such as the InternationalSociety of Dermatology and other national dermatology soci-eties. Private exchange programs between dermatologists indifferent countries need to be encouraged, both formally andinformally. I have been doing this for over a decade, havinghosted dozens of dermatologists from all over the world andhaving been the recipient of their hospitality in their respectivecountries. This fosters learning, teaching, the establishment ofa strong sense of camaraderie and goodwill, and the forgingof lasting ties, leading to a better bilateral understandingbetween different systems and philosophies of dermatologicpractice. I would urge the younger generation of dermatologistsall over the world to transcend the natural and tempting desireto earn “quick money.” They can earn, but also learn con-stantly, not just clinical dermatology but also the philosophyof practice and the nonclinical issues involved in the practiceof dermatology in any given country. It also makes immensesense to provide a formal platform to these issues in everymajor international dermatology meeting, where people canattend, discuss, opine, and exchange ideas. We often hear theexcuse that these meetings are too hectic with too much to doin too little time. At the same time, we see dozens of peoplethronging exhibition areas displaying appearance-enhancinggadgetry and queuing to collect gifts, most of which are oflimited value and of no consequence in the long run. Some ofthis time could be spent discussing issues such as the theme ofthis article. Reputable dermatologic journals impart muchneeded education to their readership by sharing clinical andresearch experiences of well-known individuals and institu-tions. In doing so, they often forget that these are issues thatneed to be documented and discussed. Only then will the
much desired awareness and interest in “cross-cultural der-matology” be apparent.
It is one of the worst misfortunes for the poor to be sick inIndia (Fig. 4). Over 95% of Indians do not have any formalhealth insurance; this figure may be an underestimate, mean-ing that individuals must pay for all consultations, investiga-tions, drugs, and procedures. Against a setting of poverty, thistranslates into individuals seeking cheaper and often sub-standard dermatologic care from unauthorized healthcareproviders, and also a lack of compliance because of insuffi-cient funds to make dermatology visits and to buy prescribeddrugs. A lack of awareness regarding dermatologic disordersfurther fuels the fire by the desire for quick cures, leading to“doctor shopping,” the use of home remedies, and a failure toseek timely dermatologic care, all resulting in a confused andsevere clinical picture. In the final analysis, the economicburden of dermatologic disorders, coupled with the lack ofawareness, is an explosive combination wreaking havoc inboth rural and urban settings in India.
Figure 4 Misery of no health insurance
