One of the greatest of health needs without effective advocacy and shamefully neglected!
Authors: Terence J. Ryan
Journal: British Journal of Dermatology (2008)

Walker et al. add to the increasing evidence that there is a need to be met and that it is of a kind that, were there advocates, huge populations would benefit.1 This would be expensive only because, as stated in this paper, the numbers affected are the largest; viz: 62% of the population of five villages in Nepal in this study, even though the mostly low technology solution is one of the cheapest of healthcare interventions. This study in Nepal chooses to ask only about a restricted definition of skin disease or conditions: it leaves out burns, wounds and ulcers, which from a public health perspective are among the commonest of conditions for which primary care is sought. When all skin conditions in patients attending rural health centres are added together, the case of need enters into competition with the currently well advocated ‘Neglected Diseases’ and should win much greater funding. But so far due to weak advocacy it remains near the bottom of the list.2 As is often the case, the people affected are young and poor. In a recent WHO review based on the Mali study to which Walker et al. refer, the fact is also emphasized that it is children in need that most merit a ‘Healthy Skin for All’ programme.3 Walker et al. also mention a factor that they have not been able to take into account in their analysis of data, and that is the effect of season and distance travelled in Nepal. Perhaps more than for most countries, this determines who turns up at a health centre. Distance across mountains with no roads is one determinant of access, but the need for everyone to stay home to help with tilling the soil after the rains is another. Epidemiological studies are most likely to reveal the causes of disease amenable to public health manipulation, but they must be well done. Walker et al. have done a good job at being the first to do a study in Nepal, which is more than suggestive that there is a problem to be solved. They describe high prevalence, and discuss wrong diagnosis, leading to wrong prescribing of ineffectual and consequently costly remedies: a problem that is mostly regarded as not life threatening, and which is often a reason for governments to do nothing about it, perhaps because they seek advice from those in the medical profession who mostly deal with ‘killing fields’. As mentioned by Walker et al., pyoderma can be life threatening and when ‘absent skin’ is also included in data collection, such as burns, wounds and ulcers, none should doubt its threat to survival. Often this is through disfigurement or chronic absence of healing, both contributing to poverty. No one too should have any doubts that families so affected are among the poorest. In countries such as Nepal, birth, marriage and death are economic milestones and of these marriage is the most carefully budgeted for but the most easily disrupted by skin conditions causing disfigurement including the pigment disorders described as among the top six conditions in the five villages surveyed. As mentioned by Walker et al., the highly prevalent conditions they surveyed were all treatable. Some must be dealt with by prevention: an example is the epidemic of skin disorders that is a consequence of skin-lightening products. Common and serious is the steroid effect on birth weight in mothers who have used an excess of easily available but expensive high-potency steroid creams.4 If these common conditions were regularly researched it might be found that as an alternative some locally available sustainable low-cost traditional therapy was safe and effective. Only combating ignorance by a little education would solve this massive global case of need. Nepal is a country with a rich herbal tradition to which many skin conditions respond. Furthermore, governments should purchase and make available the biomedical Essential Drugs List and provide for their community. Making certain that health centres are attractive, and not repellant, is also a cheaper option than equipping several tertiary hospitals ineffectively with lasers, scanning devices and other expensive equipment that rarely can be given adequate maintenance. For skin diseases, a well-trained allied health professional, who cares for the health centre, and practises jointly with a practitioner of Asian systems of medicine, is favoured by the Indian Government but is yet to be approved by Professional Societies such as Dermatology Associations. Governments investing in or being advocates for a solution ultimately will solve this state of affairs. Those in government who are ministers concerned with health are very rarely specialists in skin conditions and unless they are advised to tackle a problem by people to whom they will listen, they will do nothing. How many dermatologists have made it their job to advise governance and have focused on the needs of the poor rather than the need to make a living themselves and for their families? In poor countries where wages are low one must accept that our profession can struggle to make a living and that public health is not a field that will enrich them. But every country always has a small number of wealthy specialists working for the middle class and for the leaders of their countries but not insisting on care of the poorest in the community. There have been notable missionary dermatologists of the kind needed but, as emphasized in several articles about urban China,5, 6 some medical practitioners of emerging countries have only a passion to get rich first. Perhaps the main criticism should be addressed to the priorities of the leaders of our profession in the developed world. They are for managing skin disease by expensive and enriching pharmaceuticals, cosmo-pharmaceuticals and devices and for high-technology laboratories concerned with understanding how the skin works. Such criticism would be wrong because the advances have placed dermatology in a leadership position in some respects in the developed world. But how much more outstanding would it have been if countries like Nepal had benefited or if the principle funding agencies were to have had whispered in their ears ‘we do not need new knowledge because it is usually costly. Help us to distribute what is already known and especially low technology which is less costly’. Chinese dermatology copies only the West, and its care for the poor of its Western regions is despicable. Nepal as one of the smaller countries in Asia could be a model for Asian dermatology and make water, emollients, shoes and hats, herbal gardens and the Essential Drugs List not only available at low cost, but backed by a programme of education for skin health. In the U.K. we have managed well with very few dermatologists for our relatively dense population, and a repeated case made by British leaders for a better deal for patients has never been to demand complete parity with the rest of Europe or the U.S.A. or even Japan. We have provided, as Charles Calnan from the Institute of Dermatology, London University, once said was his policy, the best of our young to work in Africa and Asia and are still doing so as Walker et al. demonstrate. Furthermore, we have encouraged allied health professionals to develop many of our skills. The British Skin Care Nursing Group is a credit to British dermatology. But note it is ‘skin care’, not dermatology, that it mostly aims to provide. The International Skin Care Nursing Group is another British-backed venture for which support from nurses in the U.S.A. and South Africa has been enthusiastic. Affiliated to the International Council of Nursing it has already provided some notable practice at low cost in the developing world. Credit must be given to the International Society of Dermatology (ISD) and to The International League of Dermatology Societies with its International Foundation for Dermatology (IFD), for having made significant improvements in education in the developing world. It has been important but, compared with the need, very much too small. The track record of these early initiatives is good but after decades they are not accelerating. Considering that the concept of the ISD began in Naples in 1964 and the objects of the IFD were discussed for a decade or two before its foundation in Berlin in 1987 they should be compared with many other organ specialties or disease specialties and will be found wanting. They have little current momentum or critical mass. Their fund raising is amateur and they are poor advocates for skin care as opposed to dermatology, especially in the private sector, where it already exists. Again it is in Britain that we can find a model for advocacy that might be copied. The Skin Care Campaign is all about telling governance about the case of need for skin care and more of this is needed globally.7 If governments begin to understand ‘the need’ as a result of the advice given then they are more likely to ask for the appropriate help. If funding agencies were to understand the need for each country to have low technology they would provide funds that are less likely to make corrupt governments and dermatology departments rich. This requires collaborations especially with patient-led societies. There is an emerging international model and that should be looked at carefully. It is the Department of Preventive Medicine of Migration, Tourism and Tropical Dermatology San Gallicano Institute in Rome that manages large numbers of the destitute. It has run a long campaign to advise the Italian Government and has been richly awarded. It held a meeting in Ethiopia in November 2006 and called for a new programme to solve developing and transitional world needs.8 This programme should be encouraged to be an alliance of societies as well as individuals. It will look at the cases of need everywhere and seek to solve them by advocacy and demanding generous funding. If successful it will meet the problem outlined by Walker et al. which, as they rightly state, is common and easily treatable. The final paragraph of this study acknowledging the funding by five donors of the first author is of note. This is a small study and not very costly. Would no one donor pay for him to be in Nepal? Typically, at the present time to get one dermatologist funded to do this kind of study will take small sums dragged out of at least five donors. Peer review of applications for funding of dermatology is much more likely to give five times as much to fund one person for a laboratory project. Dermatology must alter its priorities, imbalances in favour of high technology supporting a small elite, and perhaps its choice of advisors to funding agencies including governments, and while still funding that high technology it must become a stronger advocate of poverty alleviation, join an alliance that includes local sustainable and less costly initiatives including collaborations with other systems of medicine, and seek funding for the delivery to all of all that is known already.