EUROPEAN  TISSUE  REPAIR  SOCIETY

Skin Care in the General Health Services of the Developing World
Any plan that takes skin care into general health services needs experts whose goal is to do just that. Discussing such a plan in 1987 it was realised that in Africa a majority of countries had no such experts. The Regional Dermatology Training Centre was built at the Kilimanjaro Christian Medical Centre, Moshi, Tanzania. It is a complex of student hostel, faculty housing and a purpose built training centre, fully equipped with outpatient facilities. There are two operating theatres (Figure 2) and excellent homes for Faculty looking out to Mount Kilimanjaro (Figure 3) On this site is a regional hospital and the new medical school of Tumaini University. The Melissa and Bill Gates Foundation Malaria Centre and several other international schools, can also be found on this site. The RDTC is a WHO collaborating centre for dermatology, sexually transmitted diseases and Leprosy. It has trained 100 persons capable of advising governments or universities on how to set up skin care in many subsaharan African countries. Disorders affecting the skin are amongst the commonest problems seen in general health services. In a recent study of skin care in Mali, supported by the International Foundation of Dermatology, it was found that 40% of the diagnoses were wrong and 40% of prescriptions were inappropriate. One consequence is that the cost of ineffective prescribing contributes to poverty. Another is that ineffective and expensive management causes whole populations to move to traditional health and to spurn the health centre which should be a generator for disease prevention and health promotion.

Figure 2: One of two operating theatres at the Regional Dermatology Training Centre in Tanzania

The policy at the RDTC is to teach management of the skin in the context of what is actually happening in the communities around rural health centres. For this reason it must embrace wound and burns and common tropical skin disease. Just as in Oxford we recognise a role for the unit to manage Lymphoedema, so skin care now embraces lymphatic Filariasis. (Figure 4) Managed by nurses in Oxford, Lymphoedema is the focus of the International Skin Care Nursing Group led by two of Oxford’s previous Ward Managers. Parallel to the development of the RDTC has been a close collaboration and development of Rehabilitation Medicine. It is not by chance that the first Dermatologist to be trained in Tanzania graduated at the same time that the first specialist in Rehabilitation Medicine was seconded to the RDTC. This is all about the management of skin disorders including burns or wounds or specifically Leprosy and the Diabetic Foot – as though they can either lead to destitution or be rehabilitated. Rehabilitation is no longer merely a focus on treatment of impairment but it is about retraining and employment. It is about getting around and living as an equal in the community.

Figure 3: Housing for visitors at the Regional Dermatology Training Centre, Tanzania

Figure 4: The Global Alliance for the elimination of lymphatic Filariasis claims this is the second commonest cause of disability worldwide. It requires both dermatological and surgical skills.

Traditional Medicine
Visitors to Oxford over the years will have seen an interest in traditional medicine and in alternative and complimentary medicine. This is not because we are ‘New Age’ holistic converts but because we know we must understand what our patients are being driven to. For this reason at the RDTC and in Oxford we are searching for the numbers that tell us how much of what is being used. We examine safety. Efficacy is anything that cures but it is also whatever improves ‘well being’ and we are not adverse to patient satisfaction.

Mostly recently our interest has moved to India and China taking along some of these concepts. These are continents where there are plenty of experts but they wear blinkers and sit in comfortable armchairs in urban offices. In India we are setting up a programme to compare Indian systems of medicine and Biomedicine (western practice) in the management of Lymphoedema, (Figure 5) the ulcer in Leprosy and the Diabetic Foot and Reactions in Leprosy.

In China we are looking at what our programmes can offer to the retraining of the village doctor who provides the health system that alone serves 400 million persons in west China. Against the background of common skin diseases it will focus on the old – Leprosy as a model for an ancient scourge of rural communities in China – and on Diabetes Mellitus which the new China too is seeing a rising incidence.

Probably all we are exporting is an idea. It could be just a CD in collaboration with technology aids at low cost, but ideas count. Integrated medicine focused on skin care carries messages that can make use of what is sustainable, locally available and at low cost but which is not focused merely on applications to the skin but rather on full rehabilitation within the community, free from the burden of expenditure on ineffective remedies. That is what will be achieved at the end of the journey.

Figure 5: Steering committee for integrated medicine in the fight for the elimination of Leprosy and lymphatic Filariasis in India. From right to left: Dr Kjayakrishna, Ayurveda Physician; Dr P. E. Mahadeva, Ayurvedic Physician; Professor Terence Ryan, British Dermatologist; Dr S. Narahari, Chairman Institute of Applied Dermatology, Kasaragod, Kerala; Dr K. S. Prasana, Dermatologist.