EUROPEAN  TISSUE  REPAIR  SOCIETY

Management of disease and the promotion of health in the developing world is influenced by war, climate and epidemics as well as in shifts in the virulence of infections and in human responses. While ‘mans inhumanity to man’ is fuelled by aggression, and epidemics such as AIDS are fuelled by sexual drive, finding ways to manage their consequences requires initiative and ingenuity. The office of the Wound Healing Institute at Oxford is host to some such initiatives through the links with International Dermatology which in turn has collaborations with organisations concerned with sexually transmitted diseases, Leprosy and lymphatic Filariasis. The challenge is to find effective and affordable management strategies at a time when resources are expended on using humans to ‘research mouse drugs and diseases’. To quote the UK’s Sunday Telegraph (news.telegraph.co.uk 8.12.02). ‘despite year’s of research at a cost of millions of pounds, genetic medicine has yet to cure a single person of any serious disease.’ These are hard words, but for the Wound Healer simple exaltations such as ‘Stop smoking; keep walking’ are cost free benefits.

We have been told of a shift in the balance of our immune system as infections are brought under control and autoimmune disease takes over. Leprosy disappears and everyone has Diabetes Mellitus! There was a brief period of optimism in the mid-nineties when it was expected that Leprosy would be defeated within a few years. Effective drugs were available free for every patient. Early diagnosis would mean a cure before the cutaneous nerves were damaged and there would therefore be fewer patients affected by disability, blindness or loss of fingers and toes. Only a few years back at the beginning of the WHO led campaign to eliminate Leprosy as a public health problem armies of Leprosy worker were available. Now it is stated that the residual problem will be taken care of by the general health services and the skills of these workers will be used for other purposes. One purpose will be to treat the increasing prevalence of diabetic foot ulcers. However, it is not actually working out like that. Where Leprosy has been almost eliminated, it has become a rare disease that has been forgotten and new cases are not recognised and the disability rate of the newly detected case is very high. The focus on elimination of the bacteria has sidetracked the care of the disability. The closure of Leprosy villages has scattered the patient. Some attempt to preserve a community, some live by begging and only a few earn a living and obtain an existence above the poverty line. There are of course religious foundations that still care for such patients but they are not recruiting the young carer, and the old are not always up to date with rehabilitation skills.

Figure 1: November 2002 - the foundations for a fly laboratory are laid at the Regional Dermatology Training Centre in Tanzania. In the trees in the background there are bee hives producing the honey that is used in the bed sores of paraplegics.

The most worrying fact is that in many parts of Asia, South America and Africa there is no decline in new cases. This is unexpected because the total number of treated and cured of bacterial infection has fallen to below the level of estimated danger to public health. It is now being asked whether there is an animal or vegetable reservoir and whether persons showing no signs of infection are nevertheless infectious.

The vertical programme has been disbanded; since when there is alarm that there is no effective public health strategy to manage a disease that has survived the system that was meant to eliminate it. The call for taking Leprosy into general health services and provide there a horizontal approach to a wide range of diseases and disabilities gets louder but the response is weak. On the average, an allied health professional in the rural health centre of the developing world, will see a case of Leprosy quite rarely and the need in a health centre is for knowledge of the appropriate management of common skin disease such as impetigo, scabies and fungus infections. There is a need for the skilled attention to burns and wounds Leprosy and diabetic foot ulcers together with a breakdown of tissues due to opportunistic infections in Aids are top priorities for general rather than specific skills.

While all this has been happening, wound healing in the USA and tissue repair in Europe has appeared on the scene. They propose to strengthen the general health services where they will find both Leprosy and Diabetes Mellitus. Seeking exactly what is on offer, namely a discipline which is a highly specialised and expensive team, adopting the tertiary level much which is high technology but collaborating with and often based in skin orientated departments that work with allied health professionals and nurses in particular, to generate and deliver self help and other locally available, sustainable and low cost solutions – maggot therapy being one example.(Figure 1)