TROPICAL DERMATOLOGY: AN EXPERIENCE IN ETHIOPIA

Morrone A.

18th Congress of the European Academy of Dermatology and Venereology
Berlino, 7-11 Ottobre 2009

Tropical dermatology used to be known as colonial dermatology, which has more of a cultural rather than geographical significance. Today, this terminology underlines the tie between this discipline and the developing countries. In fact, most cases of dermatological pathologies occur and are increasing in
tropical regions, not necessarily because of climatic conditions which, admittedly, can favour the development of certain pathogenic micro-organisms or saprophytes, but rather because of the dramatic level of poverty, the lack of public and personal hygiene, the difficulty in obtaining water, poor housing,
malnutrition and the lack of education, especially in the rural areas (all factors that have little to do with the difference among the races). To these unfavourable climatic and environmental conditions, political and cultural influences, often characterised by absurd ethnic conflicts sustained by wealthy industrialised countries, have to be added. In the last few years, in the area of dermatology and venereology, there has been a return of illnesses that, in our national territory, had apparently disappeared some time ago. Is it a result of this migratory phenomenon that sees millions of people fleeing from the Southern Hemisphere in the hope of finding a future in Europe, in the USA, in Canada or in Australia? Or does it depend on the rise in tourism that sees people from the Northern Hemisphere looking for holidays in more exotic and unexplored places? Certainly the two situations, although for different reasons, have something in common: the speed of movement of large numbers of people reduces the distance between developing tropical countries and the industrial countries of the north, eliminating the borders which once upon a time contained the illnesses. We are in the middle of a pathology that can be described as omnipresent due to the movement of hundreds of millions of
people from one end of the planet to the other. Viruses, bacteria and fungi no longer seem to be confined within specific boundaries and are spreading in areas where it seemed they had been eliminated forever.
This is the picture we are facing, with all the consequences for health it entails, both in terms of preventive and curative medicine. Although, in 1987, the World Health Organisation launched a campaign, “Health for Everybody for the year 2000”, little attention was paid to Dermatology. It is this discipline, however, that has made the biggest contribution towards a quality of life that is socially and economically more productive and valid. It was, indeed, the Dermatology and the
Venereal services who were the first to take care of the health of the immigrant. An interesting example of Tropical Dermatology, can be taken by the Ethiopian situation, where the NIHMP is carrying on health cooperation projects within the Italian Dermatological Centre (IDC), that supplies medical and scientific services in the Tigray region. The IDC consists of 2 outpatient departments and a 30-bed ward; it is situated in the University Hospital of Mekele and represents the only referral point for the prevention, diagnosis and treatment of skin diseases for the 5 million inhabitants of Tigray.
In 2008 about 10,000 patients benefitted from medical examinations in the IDC’s outpatient department and 400 people were hospitalized. NIHMP is involved in the training of Ethiopian workers: through seminars and apprenticeships on the relation between skin and internal diseases, and in particular on HIV infections, it cooperates with IISMAS to train one health worker for each district of Tigray region. The courses take place in Mekele and they are addressed to nurses, health
officers and extension workers.
In Ethiopia, skin disease is considered a common problem in both urban and rural areas, wheremore than 80% of children are affected by skin disorders, mainly scabies, pediculosis, tinea capitis and pyoderma. Skin diseases are also among the leading causes of outpatient attendance in Ethiopia, ranking sixth in 2005 and accounting for 3.3% of total outpatient visits. Of note is the fact that skin diseases are often contagious in nature and are readily treatable, with a limited number of common infections accounting for the vast majority of the burden of skin disease. Therefore, most of the dermatological cases can be managed at peripheral health units in a cost-effective and sustainable way, leading to significant health gains for both individual patients and public health. Despite this, few systematic attempts have been made to develop such public-health interventions.
Overall, our experience suggest that significant progress could be made in reducing the burden of skin disease by focusing on the small group of conditions, particularly infections, that account for the bulk of the community case load and for which cost-effective interventions are available. Moreover, through a simple skin examination early detection (or referral for confirmation) is possible of systemic diseases such as HIV/AIDS, leprosy and onchocerciasis, whose first signs tend to appear as skin problems. The control of skin problems by means of simple public-health measures is a realistic approach to alleviating a common source of ill health For this purpose, health staff working at peripheral health units should be trained in the diagnosis and management of common skin diseases and in the referral of complicated cases.
The experience in Tigray shows the feasibility of such an approach to meet the demand for dermatological care in a cost-effective way.