Leprosy Mailing List – November 13th, 2007
Ref.: Training
material in Dermatology and Leprosy
From: Ryan T.,
Oxford, UK
Dear Salvatore,
I was glad to read Erik Post's letter (LML
November 8th , 207).
I was at ALERT briefly on Friday 9th Nov and
discussed some of the issues raised for their proposed courses. I am glad the WHO Child Health
reference was mentioned. Pierre
Bobin and I helped to set this up by a programme in Mali often
referred to over the years in his French speaking journal. It is also referred to in the
March Leprosy review by Faye et al.
A special; issue of The International Journal of
Dermatology published under the heading of "Global Theme Issue on
Poverty and Human Development" should be read by anyone wishing
to take Dermatology as a partner into General Health Services. http://www.blackwellpublishing.com/ijd
Dermatology is such a complex subject with a
majority of dermatologists unlikely to want to enter into the kind of
primary health care the world needs them to be interested in. For this reason a two pronged
approach to the needs of Primary Health Care is required.
1)
Identify the Commonest skin diseases
overwhelming general health services and referral hospitals and
arrange training of all health care workers to manage them. Typically as I saw on a recent
visit to Malawi about 10,000 skin cases seen annually in a small
hospital might have 3-4000 identified as bacterial, fungal and
parasitic. (+ 30 - 50 cases of leprosy as a minority disease). A twelve hour teaching
programme for all health care workers supported by essential
drugs (such as is available in Malawi's Essential Drug Package)
can provide the management solution for these skin conditions and
should prevent the referral hospitals being overwhelmed by such easily
managed problems.
2)
Avoiding Dermatology's jargon (some 10,000 named
entities) a second programme should be about skin care of skin
failure. This addresses
supporting skin functions of which there are essentialy four.
i)
Communication (this covers all the issues of
privacy and display or the look good feel good factor. It is all about the management
of 'Stigma'.
ii)
Barrier function, (this is all about the
intactness of the skin, it covers the loss of the protection due to
skin injury and ulceration). It
can be managed by very low technologies of washing, emollients,
movement and nutrition.
iii)
Thermoregulation, (this covers both cooling and
heating). It is managed by other technologies such as the blanket and
shade.
iv)
Perception (this is all about loss of sensation
as in leprosy and diabetes or the pressure ulcer of the sick). It
deals also with itch and pain.
These can be written for all who manage the skin
from birth to death. It
can be very low cost and uncomplicated by Dermatology's
language. Like other
organ failures care can be based on a very few home based procedures. Breathlessness from heart
disease and diarrhoea from gut disease have some very simple
management technologies which can help without having to immediately
to seek higher technologies.
The same is so for skin failure.
The Ben Naafs and Colette Van Hees book I would
willing give to every Trainer but when I watch what the nurse
attending a neonate or a dying elderly patient, or someone in an
onchocerciasis programme wanting to help the scratching after biting
insects, or the caring for the lymphoedema of a number of causations,
a much more basic technology needs to be taught about the skin. It is a technology with an
evidence base and to give just one example how to use water, the
following needs to be known. How
to conserve, how much to use for how long and how often, at what
temperature, how made bacteria free, whether adding a pinch of salt or
a drop of vinegar (see some leprosy leaflets) is helpful. Whether to follow by drying
and or emollients (each having an evidence based technology).
You will not find this in Ben's book.
Terence Ryan
