Global dermatology: more than the sum of its parts

For to choose is to do; but to be no part of any body is to be nothing. At most, the greatest persons are but great wens and excrescences; men of wit and delightful conversation but as moles for ornament, except they be so incorporated into the body of the world that they contribute something to the sustentation of the whole. A widely held view of disease distribution across the world's regions is that in the tropical and often poorer areas infectious diseases predominate, and in the more affluent temperate countries degenerative and chronic inflammatory disorders occur most commonly. While there is certainly truth in this interpretation of world health, there are also many similarities between disease patterns in different geographical areas, and many of these have undergone change in recent years. A striking feature has been the shift in the prevalence of chronic noninfectious disease in the tropics, where there is growing concern about the rising incidence of diseases such as diabetes and hypertension, a trend strikingly underscored by the recent Global Burden of Disease 2010 survey.1 Trends in global health are affected by many factors, the transmission of infections being the most obvious, and the recent outbreak of Ebola virus infections in West Africa has highlighted the fact that infections can, and do, spread with serious consequences.2 But patterns of disease are also subject to the effects of social, economic and environmental change on populations. This reflects an interdependence of human populations in which some social mores such as eating habits show a tendency to become more uniform across different world regions; the growing epidemic of obesity is a good example where pursuit of high calorie intake unmatched by physical exertion is replicated across the world.3 Its relation to social conditioning and, in particular, social deprivation is a worrying trend,4 and so specific initiatives to avoid the consequences of deprivation and health inequalities have been adopted by many counties, from Sweden to Mexico.5 Disorders affecting the skin are not immune to this process of globalization, and in dermatology we have seen many examples of global interdependence. The spread of severe soft‐tissue infection caused by genetic variants of Staphylococcus aureus expressing the gene for the Panton–Valentine leucocidin, with and without associated methicillin resistance, has been tracked as a development that has spread across continents.6 In the U.K. and other parts of Europe, as well as in the U.S.A., the diffusion of tinea capitis caused by Trichophyton tonsurans in children mainly in urban areas,7 and its subsequent progress into South America and sub‐Saharan Africa, is another example of the international capacity for spread of infections.8 The increasing ease and uptake of travel through tourism and migration have facilitated these changes. Of course global disease trends are not always easily explicable, and the reasons linking them may be less understandable. The increasing incidence of atopic eczema, which started as a western phenomenon but has now rolled out to involve countries with lower incomes, is still not easy to explain.9 It should follow therefore that awareness of health problems and health solutions in other nations is not simply the province of the medical dilettante but an intrinsic part of proactive medical strategic thought. Understanding the needs and potential answers to health problems outside our own backyards, while not strictly speaking our business, is certainly justifiable. Yet for many years British dermatologists have made significant contributions to this field both by choice and of necessity. For instance James Henry Sequeira, a former editor of the British Journal of Dermatology, went to Kenya in retirement in the late 1920s to work on leprosy and, in his spare time, he edited the East African Medical Journal.10 In 1942 Louis Sefton found himself in charge of over 100 skin beds in a prisoner‐of‐war camp, where his ingenious solutions to the care of pellagra and scabies are thought provoking.11 Later it was Darrell Wilkinson12 who first drew attention to the need for international dermatology organizations to focus on the problems of populations deprived of dermatological expertise and, in so doing, set in place the International Foundation for Dermatology, a cause that was taken up and expanded with boundless energy by Terence Ryan.13 Roger Harman also stood out as an individual who championed the cause of encouraging the knowledge of tropical health among dermatologists, participating in the St John's exchange to Ibadan and then Ghana, where he was later visiting professor at the University of Kumasi. The Roger Harman scholarship award of the British Association of Dermatologists (BAD) is a worthy reminder of his contribution.14 The BAD has been a generous and stalwart supporter of this cause both through donation and encouragement of volunteer workers. These initiatives to improve dermatological knowledge across the world continue today with international masters courses at the St John's Institute of Dermatology, London and the University of Wales, Cardiff, and many of their alumni have contributed to the pages of this journal. A trend to adopt other strategies for improving dermatology on a global basis has followed these initiatives. They include long‐term programmes that range from sharing knowledge internationally with local practitioners to research on disease or disease prevention. Educational initiatives have been delivered through direct student contact or distance e‐learning. In addition there have been sophisticated attempts to use teledermatological links to help diagnose or reassure local practitioners with advice from specialist centres far beyond national boundaries. The involvement of international agencies to support and mentor these changes has been critical. The International Foundation for Dermatology has established a number of such programmes.14 15 The first of these, the Regional Dermatology Training Centre in Moshi, Tanzania was set up as a collaboration between the International Foundation for Dermatology, The Tanzanian Ministry of Health and the Good Samaritan Foundation, and is an example of a training initiative that affects many African countries. The centre trains clinical officers with regional responsibility for skin disease, sexually transmitted infection and leprosy, and more recently it has established an international dermatology residency training programme for sub‐Saharan Africa. Specific projects include a new alliance to improve the lives and care of patients with albinism in Africa. Other programs of training or assistance established in Mexico,16 Mali,17 Ethiopia,18 Haiti,19 Fiji,20 Botswana21 and Cambodia,22 among others,23 are all examples of international collaborations to improve skin health in poorer countries. While much of this is motivated by different driving forces from philanthropy to scientific curiosity, it is important to return to the theme of interdependence and global health. For the dermatologist from a country in one of the so‐called advanced economies there is of course the challenge of working in an unfamiliar environment and acting as a volunteer for short or long periods in one of the many overseas programmes. This provides a much needed boost to dermatologists wearied by management overload and huge, often repetitive and ill‐conceived, health infrastructure changes. For dermatologists from resource‐poor countries, experiencing the life of a dermatologist in a relatively well‐stocked dermatological facility in another world region is an equally unforgettable experience. Both examples have potential disadvantages, the advent of reality in the first case, with the powerlessness of having so little in order to do so much, and in the second the feeling of frustration of experiencing what might be done if only the resources were available. But despite this, dermatologists share so many common objectives, and approaches used on one side of the world may well have value and be adopted on the other. So techniques used to educate patients in Europe, North America and Australasia about the consequences of sun exposure and protection from the sun and skin cancer are very similar to those that should be employed in preventing African patients with albinism from early‐onset nonmelanoma skin cancer,24 or native Americans from suffering the consequences of inherited photodermatitis.25 We may also be able to learn by simple measures, used in the poorest of communities, that are relevant to the needs of our own patients. For example the effective techniques used to manage tropical lymphoedemas such as lymphatic filariasis26 and podoconiosis27 through limb movement, exercise and antisepsis may well prove useful in our own environment. Global dermatology is a two‐way transaction. There are many reasons why the British Journal of Dermatology should celebrate its 125 years, but its contribution to making the global scope of dermatological knowledge relevant to all of us is one of the strongest and most enduring. Despite his metaphorical references to skin lesions, John Donne was no dermatologist, but perhaps his gloomy ruminations on human aspirations and mortality should be reinterpreted as an endorsement of the benefits of a global view of our specialty.