Education

PROBLEMS AND PRIORITIES FOR DERMATOLOGY IN DEVELOPING COUNTRIES

Introduction

The gradual emergence of the concept that people in the developing countries should enjoy good health as a matter of social right has far-reaching implications. The political expression of this doctrine varies tremen- dously since it is a function of political will, organizational capacity and the available human and economic resources. This em- phasis will increase demands for dermatolog- ical services for which resources are not avail able.

The Problems

The magnitude of the dermatological prob- lem in developing countries i s enormous. The subject has received scant attention from health workers, except a general recognition that skin problems are common. Defining the size of the problem i s difficult, for at a quan- titative level, information is scattered and scarce.

Two two-week period prevalence surveys of skin disease in the United Kingdom' re- vealed an overall prevalence rate of 20%,

Address for reprints: Dr. M. j. Porter, P.O. Box 660,74 6-2, Gulberg 111, Lahore, Pakistan.

Presented at the International Society of Tropical Der- matology Meeting at Las Palrnas, Canary Islands, November 3, 1976.

MICHAELJ. PORTER, M.D., F.R.C.P. (C), D.T.P.H.

From the Tropical Disease Unit, Toronto General Hospital, University of Toronto,

Toronto. Canada

with the inclusion of many trivial and trans- ient problems, while 5 % of the adult popula- tion had chronic skin disease. Restricted as the data from developed countries may be, that available from the developing countries is virtually non-existent. A recent community survey of skin disease carried out in a poor urban district of Lagos, Nigeria2 revealed a prevalence rate of 36.4% of which 81 % was attributable to skin disease of infectious ori- gin. A similar study performed in a rural Gam- bian village2 showed a slightly lower preva- lence rate, but a similar proportion of infecti- ous skin disease. These two studies show comparable rates to those described in a sur- vey of a rural tribal region of South Africa? which showed a prevalence rate of 27.6%, 60.8% of which was infectious in origin.

Other studies are more fragmentary, involv- ing special population groups or confined to infectious skin disease. Such a study in Panama4 revealed a 14.8% prevalence rate for infectious skin disease, while another study in Colombia,5 restricted to children with pyoderma, produced a prevalence rate of 12.6%. General health surveys performed in a wide range of comm~ni t ies~-~ support the

001 1-9059-78-0400-0233-0050 @ International Society of Tropical Dermatology, Inc. 233

234 INTERNATIONAL JOURNAL OF DERMATOLOGY April 1978 Vol. 17

evidence for high prevalence rates of skin dis- ease, particularly infectious skin disease. While difficult to extract precise figures from the comprehensive health information pre- sented in these studies, some desperate com- munities have 60-80% prevalence rates for skin disease.

These figures offer only a glimpse of the problem, but they do give it a dimension. It is not only a question of the size of the problem but also that infectious skin disease consti- tutes the bulk. The difference between the prevalence of skin disease in developed and developing countries is due to skin infection. It is this that poses the essential problem for dermatology in developing countries.

Statistics analyzing the presenting com- plaints of patients visiting health facilities show that skin disease invariably ranks at or near the top of a list of conditions for which aid is Respi ratory, enteric and skin diseases and trauma are the major problems that besiege health facilities in developing countries. While skin disease is of less impor- tance in terms of mortality and overall mor- bidity, nevertheless, by virtue of sheer quan- tity, enormous demands are placed on inadequate services.

The diseases present are simply the com- mon skin infections with a prevalence pattern similar to that of the United Kingdom and United States 70 years a g ~ . ' ~ > l ~ The decrease in skin infections in developed countries has been brought about by better socio-economic conditions, better housing and hygiene, im- munization and health education. From the available information it i s apparent that it i s the level of nutrition, the adequacy of the water supply and the environmental condi- tions which are the key determinants in the pathogenesis of infectious skin disease in de- veloping countries.

Comparison of two groups of Ugandan ~ h i l d r e n ~ ~ ~ ' ~ show it is the Ankole children, with poor nutritional levels and a poor level of environmental hygiene, who have a 75% prevalence rate for skin disease. Their com-

patriots, the Acholi children, with fair to good nutrit ional status and adequate water supplies, have a 29.8% prevalence rate.

A recent important study from Tanzania16 attempted to prove what is intuitively known, that the prevalence and severity of infectious skin disease i s directly related to the level of socio-economic development. Although the groups i n this study were imprecisely matched, in general terms it demonstated an inverse relationship between a socio- economic score and, in this case; the rate of pyoderma and scabies.

Response to the Problem

In defining basic health rights, the funda- mental axiom is an access to primary health care. The provision of this care to everyone is the basic goal of health care delivery. It i s an essential preoccupation of developing coun- tries at present. Expectations for dermatologi- cal competence at this level are reasonable and attainable. A dermatological right may be defined as the provision of a level of compe- tence for identifying and treatment of simple skin disease, available to all individuals at the primary health care level. The profession should adopt this concept as its fundamental task in developing countries.

Skin disease i s highly visible, produces dis- comfort and may lead to social alienation with socio-economic consequ'ences: These facts are expressed by the community in at- tendance at health facilities. In many localities it represents the prime reason why people seek medical attention.

Strategies must be evolved in developing countries to meet this large, expensive and largely unrecognized problem. The questions of what type of services are to be provided and what type of appropriately educated person- nel are needed have to be answered. The situation additionally demands an attitude of preventative dermatology.

Provision of care at the primary level wil l not be met by the imposition of a pattern of

No. 3 DERMATOLOGICAL PROBLEMS . Porter 235

dermatological care as practiced in de- veloped countries. U n fo rtu n ate I y, because educational systems are based on European and American models, the concept that such care patterns are useful in the rest of the world is maintained.

Educational Patterns and Methods

The core of the strategy to meet the der- matological demand must be resolved through education and information. Educa- tion must take place at all levels, from minis- ters of health to village health workers. The question i s who i s to carry out this program. If it is to be a dermatologist, then what kind of dermatologist? Certainly not the present prod- uct, who i s ill-prepared rationally to compre- hend the problems nor provided with the tools to face the challenge. To meet *e situa- tion, a thorough education in epidemiology, pub I i c hea I t h , education a l-gc h d q ue s , he a It h ecohomics, statistics and administration is es- senti al .

The need fsr dermatologists in developing countries is very limited. Their role should be educational and administrative, with only limited commitments to clinical consultancy. The rationale for this role description i s simply a reflection of economics and logistics. There is no other possi ble solution in the present day context.

There are several possible solutions to the training dilemma. Most developing countries have insufficient resources to train their own dermatologists. One response i s to develop

ional training centers in a country such as ia or Thailand, where there are existing

facilities, provided the curriculae meet the suggested requirements. Where no regional facilitiesexist, it may be possible for a number of states to collaborate to organize a program in a mutually agreeable locale. In principle such a program for other specialities is under development in Anglophone, West Africa.17 The concept may easily be extended to der-

matology. Such a development must ensure that the educational content i s appropriate to real needs.

An alternative solution is to set up special training programs in the developed countries. To its credit the Institute of Dermatology in London offers a one year course to students from developing countries, although making the course totally relevant to their needs has yet to be accomplished. Perhaps in this con- text American dermatology could make a last- ing contribution by establishing a training program geared to the requirements of a de- veloping country. This need not be in the United States, for training should take place in the psychological atmosphere created by a per capita health expenditure of one or two dollars per annum.

The essential job of the dermatologist in a developing country i s to teach. Primarily, this must be directed at the multi-purpose aux- iliary, medical assistant or village health worker or whoever provides primary health care. Secondly, everyone from health minister to patients must be included. As some reorder- ing of health priorities may be necessary to meet the skin problem, the health minister i s an important educational target. Teaching must be the main vocation; to teach others how best to deal with skin disease.

Methods wil l vary. Sound educational pro- grams have been prepared to train auxiliary health personnel the basics of skin disease.'* Ironically they were not prepared by der- matologists. These programs may readily be adapted locally. Another approach has been to develop flow charts. The successful de- velopment of these in Tanzania includes one for a skin rash.lg Critical evaluation of their utilization has demonstrated a substantial de- gree of accuracy and, equally important, a reduction in time spent per patient.

Simplified Medicines

The rationalization of the therapeutic ar- mamentarium must be extended to dermatol- ogy. There i s a need to evaluate simple

236 INTERNATIONAL JOURNAL OF DERMATOLOGY April 1978 Vol. 17

remedies. The use of vaseline, emulsifying ointments and calamine in Ugandaz0 sur- prised users by the efficacy of the results. The useof local materials, such as coconut oil, as a base for medications should be investigated, as should relevant packaging techniques. The aim i s to provide adequate medications at acceptable cost. What is not needed i s the plethora of expensive pre-packaged medica- tions that assault the developed world. Medi- cines must be provided in situations where the per capita income and expenditure on health i s a fraction of that in more advantaged societies.

Conclusion

Perhaps, in the final analysis, the pattern of skin disease in the developing world will only change radically when there are adequate water supplies, better sanitation, improved housing conditions and adequate nutrition. It i s essential for the dermatologist in the de- veloping country to comprehend these needs and have an input into the necessary changes. The dermatologist must be an agent of change, not a fringe observer. A combination of education, reordered health priorities, low-cost medicines and socio-economic de- velopment will eventually eradicate the prob- lems posed by infectious skin disease. The problems have always been there, now that they are recognized, the emergence of suc- cessful answers will require new attitudes and approaches.

References

1. Office of Health Economics (1 973), Skin Disorders, London.

2. Porter, M. J. (1978), In Press. 3. Ross, C. M.: Skin Disease in the Venda. S. Afr. Med. 1.

40:302, 1966. 4. Allen,A.M.,andTaplin, D.:Skininfectionsineastern

Panama. Am. j . Trop. Med. Hyg. 23:950, 1974. 5. Taplin, D. et al.: Prevalence of streptococcal

pyoderrna in relation to climate and hygiene. Lancet 1:501, 1973.

6. Feachem, R.: Environment and Health in a New Guinea highlands community, University of New South Wales, 1973.

7. Buck, A. A. et al.: Health and disease in four Peruvian villages, Baltimore, Johns Hopkins Press, 1968.

8. Buck, A. A. et al.: Health and disease in Chad, Balti- more, Johns Hopkins Press, 1970.

9. Buck, A. A. et al.: Health and disease in rural Af- ghanistan, Baltimore, York Press, 1972.

10. Bell C.: Diseases and health services of Papua-New Guinea, Port Moresby, Department of Health, 1973.

11. Calnan, C. D.: Letter from Bangkok, Trans. St. Johns Hosp. Dermatol. SOC. 58:304, 1972.

12. Shrank, A. B., and Harman, R. R. M.: The incidenceof skin diseases in a Nigerian teaching hospital der- matological clinic. Br. J. Dermatol. 78935, 1966.

13. Okoro, A. N.: Skin diseases in Nigeria. Trans. St. Johns Hosp. Dermatol. SOC. 59:68, 1973.

14. Cook, R.: The Ankole pre-school protection pro- gramme 1964-67. Department of Pediatricsandchild health, Mbaraba, 1967.

15. Jelliffe, D. B. et al.: The Health of Acholi Ghildren. Trop. Geogr. Med. 15:44, 1963.

16. Masawe, A. E-J. et al.: Bacterial skin infections in pre-school and school children in coastal Tanzania. Arch. Dermatol. 111:1312, 1975.

17. West African Health Secretariat: Brochure on West African Health secretariat 1972-75. Yaba, 1975.

18. Government of Indonesia: The child in the health cen'tre. Jakarta, Government Printer, 1974.

19. Essex, B. 1.: Diagnostic pathways in clinical medi- cine. Edinburgh, Churchill-Livingstone, 1975.

20. Vollum, D. I.: An impression of dermatology in Uganda. Trans. St. Johns H:sp. Dermatol. SOC. 59:120, 1973.

The editorial feature "Current Readings in World Literature" offering a selection of references to articles of interest to dermatologists, taken from non-dermatological journals has been temporarily suspended. For those interested in reviewing the current list of references please write to the INTERNATIONAL IOURNAL OF DERMATOLOGY, Medical lournals Division, 1. B. lippincott Company, Philadelphia, PA 1910.5. .