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Background, problems, and perspectives of management of common pediatric skin problems in developing countries
Background, Problems, and Perspectives of Management of Common Pediatric Skin Problems in Developing Countries OUMEISH YOUSSEF OUMEISH, MD, FRCP (Glasgow) LAWRENCE CHARLES PARISH, MD
P
ediatric skin problems faced by developing countries are not merely “their” problems but are in fact global. It is then the duty of developed countries to use the knowledge and skills that they have to help millions of people suffering from a variety of pediatric problems, or at least try to solve some of them.1 It is, after all, the moral voice of nations that dictates that physicians and scientists have an obligation to be at the forefront of efforts to alert and educate government officials, patients, and the general public about the potential health care crisis and to help people in the developing world to find solutions for and manage common skin problems, especially among children.2 The training of dermatologists is a basic issue and an essential prerequisite for understanding how to manage common skin problems, especially in developing countries. The International Foundation for Dermatology (IFD), in support of the 12 Nations of the Commonwealth Regional Health Community of Eastern, Central, and South Africa, was the pioneer in building in Tanzania in 1993 a student hostel and creating a curriculum, along with providing full-time faculty. All of this was funded by dermatologists, their societies, and some patients. Students were awarded a dermatology diploma after 2 years. A similar center was established in Guatemala, where 23 physicians, 180 professional and auxiliary nurses, and 23 health instructors received 2 years of training, thus providing dermatology services for 500,000 inhabitants. This model of training center has been established in many places in developing countries, through various societies and organizations other than the IFD, and even by several universities and some official health From the Amman Clinic, Amman, Jordan; the Department of Dermatology, Tulane University School of Medicine, New Orleans, Louisiana; and the Department of Dermatology and Cutaneous Biology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania. Address correspondence to Oumeish Youssef Oumeish, MD, Amman Clinic, PO Box 65 Prince Rashid Suburb, Amman 11831, Jordan. E-mail address: [email protected] © 2003 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010
groups. The target of establishing such centers has been to promote the idea of community health and its relationship to development. It is the end target for global community health and sustainable human development.3 Major pediatric skin problems are related to various factors such as malnutrition, sanitation, immunization, poverty, education, and environment.
Teaching Dermatology Management of common skin diseases among children in developing countries needs qualified and sufficient numbers of well-trained dermatologists. The teaching of dermatology should be initiated in medical schools and included in the curriculum for undergraduate medical education, where dermatology should be a required clinical rotation.4,5 Dermatologists should participate in curriculum development by keeping abreast of changes in medical education and using opportunities for interdisciplinary teaching.6 Introducing an integrated curriculum in medical schools is essential for the education of medical students about cutaneous medicine. There should be an interactive and mutual mechanism for such teaching.7 In addition, postgraduate master’s level and fellowship courses in such dermatology subspecialties as epidemiology, histopathology, cosmetic and laser surgery, oncology, photographic biology, and others should be offered. Such courses should integrate preclinical and clinical teaching and should concentrate on the major problems facing developing countries. The best examples of such courses are those that have been started in centers like Boston University (Boston), Jefferson University (Philadelphia), and Tulane University (New Orleans) in the United States. Such centers have attracted many dermatologists from the Middle East and other developing countries. Board certification in dermatology is granted in many developing countries after successful completion of a board examination. Candidates eligible to take the 0738-081X/03/$–see front matter doi:10.1016/S0738-081X(03)00054-3
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examination must have completed 4 years in a residency training program, including 1 year in general medicine, in a recognized teaching hospital. The examination includes multiple-choice questions (part I) and oral, pathology slide, and clinical case examinations (part II). This system has been implemented in Jordan and for all Arab candidates and is called the Arab Board. It is also essential to use some problem-based learning in addition to other teaching methods, especially “field teaching,” and epidemiologic surveying. Medical instructors who can be trained as assistants for dermatologists, in addition to practical nurses and orderlies, can help educate people about preventive dermatology, as well as to train people about the correct use medications that have prescribed for them or to care for their chronic skin problems. This might include field as well as house visits. The media must also play a major role in the education of people in developing countries. Distribution of simple pamphlets that include educational data, simple information, and recommendations, along with some photographs, might also be helpful. Radio and television programs can also be of great benefit.
Doctor-Patient Relationship in Dermatology Practice Skin problems are still considered by the general public in developing countries to be infectious, dirty, shameful, or disgraceful. People may be ignorant of and hold prejudices about skin diseases, as they believe that all such diseases are all contagious and infectious. We must remember that one of the major goals of physicians is to prevent and treat diseases, in particular, the common ones. This is mainly accomplished through daily and direct interactions with patients.8 The relationship between the physician and the patient should be characterized by confidence, trust, openness, and a relaxed environment. The physician should be a good listener rather than behave like an academician or researcher; the physician should attempt to explore the depth of the social and human aspects of the patient’s problem.
Improved Prevention and Management of Skin Diseases Several national programs of “health for all” include prevention of major and common skin diseases, which impose a great burden on the social and economic growth of nations, especially in developing countries. Dermatologists undoubtedly have a great deal to offer as the epidemiologic patterns of skin diseases become clearer. Despite the fact that dermatology has become a wellrecognized specialty, it must and should be considered
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a major part of primary health care and fulfill its objectives.9 Such objectives include the numerous aspects of human development, including education, sanitation, and prevention and treatment of major dermatologic problems, particularly among children. It must include education about nutrition, vaccination, and sanitation and access to safe drinking water. It must also include methods for recognizing the early signs and symptoms of diseases. This can be done through home and field visits, workshops and seminars, and distribution of educational pamphlets containing instructions with visual aids. It is also important to establish continuous contact and dialogue between both the medical staff and the families of children. Education also includes protection of the newborn from environmental hazards, such as extremes of cold and heat, contact with infectious sources, such as animals, or harmful sun exposure. Education is essential so far as family planning is concerned, particularly when 1 or more children of the family have already been born with a hereditary disabling skin disease. Prenatal diagnostic procedures are essential in such situations.
Major Health Problems Facing Children in Developing Countries Major health problems facing children in developing countries include: 1. Malnutrition and Starvation—The United Nations’ World Summit, which was convened in Rome, Italy, June 10-13, 2002, discussed the means that will help reduce in half the number of starving people by the year 2015. The last summit on starvation was held in 1996, and since then, the number of starving people has reached 800 million. It has been estimated by the Food and Agriculture Organization (FOA) that worldwide, 1 death occurs every 4 seconds due to starvation. It has also been estimated by the United Nations Children’s Fund (UNICEF) that ⬎200 million children under the age of 5 in developing countries are malnourished. Malnutrition contributes to more than half of the nearly 12 million under-5 deaths in developing countries each year. Some 600 million children still live in poverty, and ⬎100 million girls are not in enrolled in schools.10 Malnutrition is a silent emergency and an invisible 1, leading to a real crisis that endangers our societies and the future of humankind. It is also a crisis about the death and disability of children on a vast scale, about women who become maternal mortality statistics partly because of nutritional deficiencies, and about social and economic costs that strangle sustainable development. Political, economic, cultural, and social elements con-
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tribute to the poverty, malnutrition, and starvation of children. Malnourished children are much more likely to die as a result of a common childhood disease are than those who are adequately nourished. The last FAO report on malnutrition indicated that worldwide, 790 million suffer from chronic malnutrition. 2. Poverty—Poverty is considered to be the main enemy of human health and the major single cause of death and suffering worldwide, especially among children. More than one-fifth of the world’s 6 billion people live in extreme poverty, with almost one-third of children being undernourished; more than half a billion children live on less than US $1 a day. Half of the global population cannot obtain essential drugs and does not have access to unpolluted water. Almost 1.6 billion people live in abject poverty, with 90% from the Third World, where the average income per person is only $350 per year. A total of 1 billion are unemployed, and 22 million children in Africa have no access to secondary education, despite the UNICEF Annual Report for 2000 that stated the efforts of the world community to ensure that all children enjoy their human right to high-quality education and health care.11 It is also surprising to realize that almost 1 billion people are illiterate and have entered the 21st century unable to read a book or sign their names, and are doomed to live in more poverty and poor health. Facing the problem of poverty, education, and child health problems requires planning and funding by large organizations, such as the United Nations and World Bank.12 As health services become more costly on the 1 hand, they are nevertheless essential for sustainable human development on the other. They compete with other services for securing public funding, such as education, information technology, and different social and economic infrastructures. It is believed that poverty reduction begins with children.13 3. HIV/AIDS—The HIV/AIDS rate has increased dramatically over the world in the last 5 years. Approximately 31 million people have HIV/ AIDS; 1 in every 100 adults aged between 15 and 49 years has the disease, with an approximate daily rate of increase of 16,000. Ninety percent of the cases occur in developing countries, with ⬃14% of them being children ⬍15 years of age. AIDS is expected to create ⬎30 million orphans in developing nations by the end of the decade.14 Sub-Saharan Africa has the fastest-growing epidemic, where roughly 34.3 million people are infected with HIV or AIDS and even more orphaned children. In the Central African Republic, Malawi, Rwanda,
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Zambia, and Zimbabwe, 1 in 5 children ⬍15 years of age is an orphan of AIDS, and this rate is likely to rise to 1 in 3 in African countries during the next decade. The latest combined report by the United Nations program on AIDS, UNICEF, and the US International Development Agency pointed out that the estimated number of orphaned children due to AIDS will reach 25 million by the year 2010. Asia has a lower infection rate of AIDS, but the epidemic is more recent, and it is a cause of concern owing to the high-density population, especially in a country like India, which has an estimated 6 million people living with HIV.15 If current global trends continue, it is estimated that ⬎50 million people will be living with HIV worldwide at the end of the year 2001. The solution for this problem is that the countries involved must adopt effective health strategies hand in hand with developmental plans, stability, and national security.16 In July 2002, AIDS activists and researchers gathered in Barcelona, Spain, at the International AIDS Conference, which is held every 2 years to exchange ideas about how to control the spread of this disease.17 In the 20 years since the disease was recognized, ⬎20 million people have died of AIDS. Another 40 millions are infected. New infections are occurring at a rate of 15,000 per day, and the rate is still increasing. Unless there is a significant change for the better, almost all of these people will also die of the disease. At the previous conference, in Durban 2 years ago, it was agreed that there was sufficient knowledge of what needed to be done to slow the rate: first, increase the use of condoms; second, curb mother-to-child transmission with an inexpensive, 1-shot drug given just before birth; third, empower women to choose freely whether and with whom they have sex and the type of contraception that they use; and fourth, perhaps most importantly, educate people about the risks that they face. A global fund for AIDS is necessary to slow the disease, an idea proposed by Peter Piot, the head of UNAIDS, and which Kofi Annan has supported. It is now a fund for tuberculoses and malaria as well. 4. Access to basic education—UNICEF now recognizes education as a basic human right enshrined in several international declarations and conventions, including the 1989 Convention on the Rights of the Child, the 1990 World Children’s Summit Declaration, and the 1990 Jomtien Declaration on Education for All. The UNICEF Regional Office for the Middle East and North Africa (MENARO) is committed to enrolling all children into school, keeping them in school, and ensuring that they learn what they need to know to cope with changes and to take advantage of opportunities in an increasingly complex social environment. It has been established by now that educa-
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tion is the key to ending poverty. It is astonishing to realize that ⬎100 million children do not attend school because of poverty, discrimination, or a lack of resources. The principal goal of UNICEF’s basic education strategy has been to achieve universal primary education by the period 2005-2010.18 The World Declaration on Education for All employs needs-based terminology to express and elaborate the educational rights of children, as stated in the Convention of the Rights of the Child. The main aims are as follows: first, developing individual personality traits, talents, and mental and physical abilities to their fullness potential; second, developing a respect for human rights and fundamental freedoms; third, developing a respect for the child’s own culture and for other cultures; fourth, preparing the child for “responsible life in a free society, in the spirit of understanding, peace, tolerance, equality of sexes, and friendship among all peoples;” and fifth, developing respect for the natural environment. The international elements of global education for children include temporal, inner, spatial, and issues dimensions.19 Inner dimension includes self-awareness, human potential, and personal growth. Temporal includes active citizenship and interaction with others. The issues dimension is interpersonal and includes perspectives and moral values. Spatial is the interdependence dimension.20 The idea of education for all has recently been brought to a halt, in many developing countries, by the debt crisis and consequent cuts in government spending. The past few years have witnessed an unprecedented halt in the growth of basic educational services and a stagnation and deterioration in educational quality. In nearly half of developing countries, the goal of universal primary education is now receding.21 Major changes are required if education is to reach the periphery and serve those children who are of the greatest concern to UNICEF—the disadvantaged and the peripheralized. While large changes are required, much that is under consideration today is no more than fine-tuning the existing, centralized bureaucracy. Several of these conventional initiatives have been reviewed here, but it is doubtful whether they will make much difference; these reforms will tend to follow the pattern of past reforms, making education better for those who already enjoy the best.22 A radically new approach must be considered that puts the periphery first. The 1 suggested here is not a “Robin Hood” approach: peripheral areas cannot be improved simply through a massive infusion of central aid. Rather, the periphery, to move forward, must rebuild its spiral and local organization, which has largely been subverted by decades of piecemeal central intrusion. If the periphery is seriously committed to improvement, it will have to assume a major part of the
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responsibility for planning where it wants to go and even for financing the journey. The present authors suggest that educational institution should assume a central role in the resurrection of the periphery, so that the future course of development can be integrated from below rather than fractionalized from above. Identified in this chapter are many specific initiatives that might be launched; however, it is doubtful that true success in deperipheralizing society will be possible without a comprehensive approach to change, which includes reforms at all levels. 5. Conflict and discrimination—Of the 45 million refugees and displaced people in the world, 80% are women and children. Between 1990 and 2000, 3 million children were slaughtered, 7 million injured or permanently disabled, and 12 million left homeless because of conflict. Between 80 and 90% of those who die or are injured in conflicts are civilians, mostly children and their mothers. Conflict has orphaned or separated ⬎2 million children from their families in the last decade of the 20th century. Of the ⬎100 million out-of-school youth, 60 million are girls. Between 60 and 100 million women are “missing” from the world’s population—victims of genderbased infanticide, feticide, malnutrition, and neglect. Ninety percent of domestic workers, the largest group of child workers in the world, are girls between 12 and 17 years old. In some areas, HIV infection rates are 5 times higher for girls than for boys. More than 100 million children are out of school because of poverty, discrimination, or lack of resources. On May 25, 2000, the General Assembly of the United Nations adopted the Optional Protocol to the Convention on the Rights of the Child on the involvement of children in armed conflict, reaffirming that the rights of children require special protection and calling for continuous improvement of the situation of children without destruction, as well as for their development and education in conditions of peace and security, and condemning the targeting of children in situations of armed conflict and direct attack on areas protected under international law, including places that generally have a significant presence of children, such as schools and hospitals 6. Access to safe drinking water, lack of proper sanitation, and environmental hazards—With 1.5 billion people not having access to clean water and 2 billion without access to proper sanitation and with increasing demand for water by industry and agriculture, effective means of distribution, delivery, discovery, and conserving water are fundamental. So, too, is a strategy for sewerage, which not only pollutes water supplies but also affects health in a
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dramatic way and increases skin problems, especially among children. The global problem of water supply will have an increasing impact on all aspects of human development, particularly on children and women in rural and urban areas.23 There is growing agreement that problems of the environment are issues for all of humankind and that this translates into regional, national, and local strategies. Pollution can not only kill but it can also cause severe adverse impacts on economic activity, on growth, and on the state of health of children. This includes the preservation of natural resources, from forests to biodiversity; the quality of air and water; and the hazards of ozone depletion. The continuing degradation of important natural resources represents a silent crisis that will be difficult to reverse. 7. Immunization—Achievements in child health are mixed with concern over what, in 1990, seemed like unstoppable progress toward universal child immunization, which has stalled somewhat in the decade since. It is now clear that levels of immunization at the time of the World Summit were actually lower (73%) than were assumed at the time. Not only has the summit goal of 90% coverage not been achieved but also the world has struggled to maintain approximately the same levels of coverage; more than one-fourth of the world’s children are still not reached by routine immunization. In Sub-Saharan Africa, only 47% of children are immunized against diphtheria, whooping cough, and tetanus.24 The 4 major vaccines that are essential for infants (1 year old) are BCG, triple, polio, and measles. In underdeveloped countries, the percentage of vaccination ranges from 30-65%; in developing countries it is 8095%; and in developed countries it reaches 99-100%. 8. Infectious diseases—One of the major causes of death among children of the world is still infectious diseases, in particular, pulmonary and gastrointestinal. Malnutrition, poverty, lack of access to clean water, and poor sanitation are important factors in the high incidence of infectious illnesses. The main criterion of infectious disease outcome is infant mortality rate per 1000 live births. It is 35-69 in low-income countries (excluding China and India), and it is in middle-income countries, such as those of East Asia and the Pacific,37 South Asia,77 the Middle East and North Africa,49 Latin America and the Caribbean,32 and Europe and Central Asia,23 but in high-income countries it is only 6 in 1000.25
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Conclusions Management of common skin diseases among children in developing countries is a major problem and a challenge for general practitioners and pediatricians, as well as dermatologists. There number of physicians who take care of children is insufficient, and there are also are not enough medicines to treat the thousands of sick children. Prevention is essential, but it depends on the political, economic, and social aspects of developing countries. There are 8 major problems facing children in developing countries that are essential factors giving rise to the incidence in skin diseases among children. It is important that these problems being examined and that governments try to solve them as a prerequisite for a better state of health of the children in developing countries.
References 1. Wolf K. From the editor. Dermatol Int 1993;2:1. 2. Annual Session ’95’. ACP Observer 1995;15:23–62. 3. Oumeish OY. Global community health and sustainable human development. Clin Dermatol 2001;19:77–82. 4. Marks J. Teaching dermatology to undergraduates in the 1980s. Clin Exp Dermatol 1984;9:263–6. 5. Sneddon LB. Thoughts on undergraduate education in dermatology. Br J Dermatol 1970;83:98 –102. 6. Burge S. On behalf of the British association of university teachers of dermatology: teaching dermatology to medical students: a survey of current practice in the UK. Br J Dermatol 2002;146:295–303. 7. Hartmann AC, Cruz PD Jr. Interactive mechanisms for teaching dermatology to medical students. Arch Dermatol 1998;134:725–8. 8. Kauzler MH, Gorsulowsky DC. Patient’s attitudes regarding physical characteristics of medical care providers in dermatology practice. Arch Dermatol 2002;138:463–6. 9. Lombardi C. Dermatology and primary health care. Int J Dermatol 1994;33:863–865. 10. Kofi Annan A. Foreword: UNICEF’s state of the world’s children. Oxford: Oxford University Press, 1998:6. 11. UNICEF. The state of the world’s children 2000. New York: Library of Congress UNICEF House, 2000:2. 12. World Bank. Making markets work better for poor people. In: World development report 2000/2001: attacking poverty. Washington, DC: World Bank/Oxford University Press, 2001:61-76. 13. United Nations Children’s Fund. Poverty reduction beginning with children. New York: UNICEF, 2000:25, 28. 14. Oumeish OY, Parish LC. The state of health of the world’s children. Clin Dermatol 2000;18:639 –42. 15. Desjeux P. Global control of leishmania HIV co-infection. Clin Dermatol 1999;17:318 –9. 16. World Federation of Public Health Associations. Background document for WFPHA 7th International Congress, Bali, Indonesia, December 4-8, 1994. 1994:1-4. 17. AIDS: hope for the best, prepare for the worst. Economist 2002;July:65-7.
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18. Dall F. Making learning a more socially relevant, childfriendly experience. Toronto: UNICEF MENARO, University of Toronto, 1995:1–5. 19. Lawson J, Silver H. A social history of education in England. Toronto: OISE Press (London: Methuen, 1973), XXXX:353-6, 397– 401. 20. Pike G, Selby D. Reconnecting: from national to global curriculum. Godalmines: World Wide Fund for Nature, UK, 1995:4 –21. 21. United Nations Children’s Fund (UNICEF). Strategies to promote girl’s education: policies and programmes that work. New York: UNICEF, 1991:3.
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22. Walberg H, Chapman DW. The role of basic education in promoting aggregate effects and marginalized populations: international perspectives in educational productivity. Greenwich, CT: JAI Press, 1992. 23. Wolfensohn JD. A proposal for a comprehensive development framework: a discussion draft. World Bank 1999: 15–18. 24. Bellamy C. Immunization plus: world summit for children and development in 1990s. the state of the world’s children. New York: UNICEF House, 2002:14 –15. 25. Oumeish OY. Global community health and sustainable human development. Clin Dermatol 2001;19:78.
P
ediatric skin problems faced by developing countries are not merely “their” problems but are in fact global. It is then the duty of developed countries to use the knowledge and skills that they have to help millions of people suffering from a variety of pediatric problems, or at least try to solve some of them.1 It is, after all, the moral voice of nations that dictates that physicians and scientists have an obligation to be at the forefront of efforts to alert and educate government officials, patients, and the general public about the potential health care crisis and to help people in the developing world to find solutions for and manage common skin problems, especially among children.2 The training of dermatologists is a basic issue and an essential prerequisite for understanding how to manage common skin problems, especially in developing countries. The International Foundation for Dermatology (IFD), in support of the 12 Nations of the Commonwealth Regional Health Community of Eastern, Central, and South Africa, was the pioneer in building in Tanzania in 1993 a student hostel and creating a curriculum, along with providing full-time faculty. All of this was funded by dermatologists, their societies, and some patients. Students were awarded a dermatology diploma after 2 years. A similar center was established in Guatemala, where 23 physicians, 180 professional and auxiliary nurses, and 23 health instructors received 2 years of training, thus providing dermatology services for 500,000 inhabitants. This model of training center has been established in many places in developing countries, through various societies and organizations other than the IFD, and even by several universities and some official health From the Amman Clinic, Amman, Jordan; the Department of Dermatology, Tulane University School of Medicine, New Orleans, Louisiana; and the Department of Dermatology and Cutaneous Biology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania. Address correspondence to Oumeish Youssef Oumeish, MD, Amman Clinic, PO Box 65 Prince Rashid Suburb, Amman 11831, Jordan. E-mail address: [email protected] © 2003 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010
groups. The target of establishing such centers has been to promote the idea of community health and its relationship to development. It is the end target for global community health and sustainable human development.3 Major pediatric skin problems are related to various factors such as malnutrition, sanitation, immunization, poverty, education, and environment.
Teaching Dermatology Management of common skin diseases among children in developing countries needs qualified and sufficient numbers of well-trained dermatologists. The teaching of dermatology should be initiated in medical schools and included in the curriculum for undergraduate medical education, where dermatology should be a required clinical rotation.4,5 Dermatologists should participate in curriculum development by keeping abreast of changes in medical education and using opportunities for interdisciplinary teaching.6 Introducing an integrated curriculum in medical schools is essential for the education of medical students about cutaneous medicine. There should be an interactive and mutual mechanism for such teaching.7 In addition, postgraduate master’s level and fellowship courses in such dermatology subspecialties as epidemiology, histopathology, cosmetic and laser surgery, oncology, photographic biology, and others should be offered. Such courses should integrate preclinical and clinical teaching and should concentrate on the major problems facing developing countries. The best examples of such courses are those that have been started in centers like Boston University (Boston), Jefferson University (Philadelphia), and Tulane University (New Orleans) in the United States. Such centers have attracted many dermatologists from the Middle East and other developing countries. Board certification in dermatology is granted in many developing countries after successful completion of a board examination. Candidates eligible to take the 0738-081X/03/$–see front matter doi:10.1016/S0738-081X(03)00054-3
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examination must have completed 4 years in a residency training program, including 1 year in general medicine, in a recognized teaching hospital. The examination includes multiple-choice questions (part I) and oral, pathology slide, and clinical case examinations (part II). This system has been implemented in Jordan and for all Arab candidates and is called the Arab Board. It is also essential to use some problem-based learning in addition to other teaching methods, especially “field teaching,” and epidemiologic surveying. Medical instructors who can be trained as assistants for dermatologists, in addition to practical nurses and orderlies, can help educate people about preventive dermatology, as well as to train people about the correct use medications that have prescribed for them or to care for their chronic skin problems. This might include field as well as house visits. The media must also play a major role in the education of people in developing countries. Distribution of simple pamphlets that include educational data, simple information, and recommendations, along with some photographs, might also be helpful. Radio and television programs can also be of great benefit.
Doctor-Patient Relationship in Dermatology Practice Skin problems are still considered by the general public in developing countries to be infectious, dirty, shameful, or disgraceful. People may be ignorant of and hold prejudices about skin diseases, as they believe that all such diseases are all contagious and infectious. We must remember that one of the major goals of physicians is to prevent and treat diseases, in particular, the common ones. This is mainly accomplished through daily and direct interactions with patients.8 The relationship between the physician and the patient should be characterized by confidence, trust, openness, and a relaxed environment. The physician should be a good listener rather than behave like an academician or researcher; the physician should attempt to explore the depth of the social and human aspects of the patient’s problem.
Improved Prevention and Management of Skin Diseases Several national programs of “health for all” include prevention of major and common skin diseases, which impose a great burden on the social and economic growth of nations, especially in developing countries. Dermatologists undoubtedly have a great deal to offer as the epidemiologic patterns of skin diseases become clearer. Despite the fact that dermatology has become a wellrecognized specialty, it must and should be considered
255
a major part of primary health care and fulfill its objectives.9 Such objectives include the numerous aspects of human development, including education, sanitation, and prevention and treatment of major dermatologic problems, particularly among children. It must include education about nutrition, vaccination, and sanitation and access to safe drinking water. It must also include methods for recognizing the early signs and symptoms of diseases. This can be done through home and field visits, workshops and seminars, and distribution of educational pamphlets containing instructions with visual aids. It is also important to establish continuous contact and dialogue between both the medical staff and the families of children. Education also includes protection of the newborn from environmental hazards, such as extremes of cold and heat, contact with infectious sources, such as animals, or harmful sun exposure. Education is essential so far as family planning is concerned, particularly when 1 or more children of the family have already been born with a hereditary disabling skin disease. Prenatal diagnostic procedures are essential in such situations.
Major Health Problems Facing Children in Developing Countries Major health problems facing children in developing countries include: 1. Malnutrition and Starvation—The United Nations’ World Summit, which was convened in Rome, Italy, June 10-13, 2002, discussed the means that will help reduce in half the number of starving people by the year 2015. The last summit on starvation was held in 1996, and since then, the number of starving people has reached 800 million. It has been estimated by the Food and Agriculture Organization (FOA) that worldwide, 1 death occurs every 4 seconds due to starvation. It has also been estimated by the United Nations Children’s Fund (UNICEF) that ⬎200 million children under the age of 5 in developing countries are malnourished. Malnutrition contributes to more than half of the nearly 12 million under-5 deaths in developing countries each year. Some 600 million children still live in poverty, and ⬎100 million girls are not in enrolled in schools.10 Malnutrition is a silent emergency and an invisible 1, leading to a real crisis that endangers our societies and the future of humankind. It is also a crisis about the death and disability of children on a vast scale, about women who become maternal mortality statistics partly because of nutritional deficiencies, and about social and economic costs that strangle sustainable development. Political, economic, cultural, and social elements con-
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tribute to the poverty, malnutrition, and starvation of children. Malnourished children are much more likely to die as a result of a common childhood disease are than those who are adequately nourished. The last FAO report on malnutrition indicated that worldwide, 790 million suffer from chronic malnutrition. 2. Poverty—Poverty is considered to be the main enemy of human health and the major single cause of death and suffering worldwide, especially among children. More than one-fifth of the world’s 6 billion people live in extreme poverty, with almost one-third of children being undernourished; more than half a billion children live on less than US $1 a day. Half of the global population cannot obtain essential drugs and does not have access to unpolluted water. Almost 1.6 billion people live in abject poverty, with 90% from the Third World, where the average income per person is only $350 per year. A total of 1 billion are unemployed, and 22 million children in Africa have no access to secondary education, despite the UNICEF Annual Report for 2000 that stated the efforts of the world community to ensure that all children enjoy their human right to high-quality education and health care.11 It is also surprising to realize that almost 1 billion people are illiterate and have entered the 21st century unable to read a book or sign their names, and are doomed to live in more poverty and poor health. Facing the problem of poverty, education, and child health problems requires planning and funding by large organizations, such as the United Nations and World Bank.12 As health services become more costly on the 1 hand, they are nevertheless essential for sustainable human development on the other. They compete with other services for securing public funding, such as education, information technology, and different social and economic infrastructures. It is believed that poverty reduction begins with children.13 3. HIV/AIDS—The HIV/AIDS rate has increased dramatically over the world in the last 5 years. Approximately 31 million people have HIV/ AIDS; 1 in every 100 adults aged between 15 and 49 years has the disease, with an approximate daily rate of increase of 16,000. Ninety percent of the cases occur in developing countries, with ⬃14% of them being children ⬍15 years of age. AIDS is expected to create ⬎30 million orphans in developing nations by the end of the decade.14 Sub-Saharan Africa has the fastest-growing epidemic, where roughly 34.3 million people are infected with HIV or AIDS and even more orphaned children. In the Central African Republic, Malawi, Rwanda,
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Zambia, and Zimbabwe, 1 in 5 children ⬍15 years of age is an orphan of AIDS, and this rate is likely to rise to 1 in 3 in African countries during the next decade. The latest combined report by the United Nations program on AIDS, UNICEF, and the US International Development Agency pointed out that the estimated number of orphaned children due to AIDS will reach 25 million by the year 2010. Asia has a lower infection rate of AIDS, but the epidemic is more recent, and it is a cause of concern owing to the high-density population, especially in a country like India, which has an estimated 6 million people living with HIV.15 If current global trends continue, it is estimated that ⬎50 million people will be living with HIV worldwide at the end of the year 2001. The solution for this problem is that the countries involved must adopt effective health strategies hand in hand with developmental plans, stability, and national security.16 In July 2002, AIDS activists and researchers gathered in Barcelona, Spain, at the International AIDS Conference, which is held every 2 years to exchange ideas about how to control the spread of this disease.17 In the 20 years since the disease was recognized, ⬎20 million people have died of AIDS. Another 40 millions are infected. New infections are occurring at a rate of 15,000 per day, and the rate is still increasing. Unless there is a significant change for the better, almost all of these people will also die of the disease. At the previous conference, in Durban 2 years ago, it was agreed that there was sufficient knowledge of what needed to be done to slow the rate: first, increase the use of condoms; second, curb mother-to-child transmission with an inexpensive, 1-shot drug given just before birth; third, empower women to choose freely whether and with whom they have sex and the type of contraception that they use; and fourth, perhaps most importantly, educate people about the risks that they face. A global fund for AIDS is necessary to slow the disease, an idea proposed by Peter Piot, the head of UNAIDS, and which Kofi Annan has supported. It is now a fund for tuberculoses and malaria as well. 4. Access to basic education—UNICEF now recognizes education as a basic human right enshrined in several international declarations and conventions, including the 1989 Convention on the Rights of the Child, the 1990 World Children’s Summit Declaration, and the 1990 Jomtien Declaration on Education for All. The UNICEF Regional Office for the Middle East and North Africa (MENARO) is committed to enrolling all children into school, keeping them in school, and ensuring that they learn what they need to know to cope with changes and to take advantage of opportunities in an increasingly complex social environment. It has been established by now that educa-
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tion is the key to ending poverty. It is astonishing to realize that ⬎100 million children do not attend school because of poverty, discrimination, or a lack of resources. The principal goal of UNICEF’s basic education strategy has been to achieve universal primary education by the period 2005-2010.18 The World Declaration on Education for All employs needs-based terminology to express and elaborate the educational rights of children, as stated in the Convention of the Rights of the Child. The main aims are as follows: first, developing individual personality traits, talents, and mental and physical abilities to their fullness potential; second, developing a respect for human rights and fundamental freedoms; third, developing a respect for the child’s own culture and for other cultures; fourth, preparing the child for “responsible life in a free society, in the spirit of understanding, peace, tolerance, equality of sexes, and friendship among all peoples;” and fifth, developing respect for the natural environment. The international elements of global education for children include temporal, inner, spatial, and issues dimensions.19 Inner dimension includes self-awareness, human potential, and personal growth. Temporal includes active citizenship and interaction with others. The issues dimension is interpersonal and includes perspectives and moral values. Spatial is the interdependence dimension.20 The idea of education for all has recently been brought to a halt, in many developing countries, by the debt crisis and consequent cuts in government spending. The past few years have witnessed an unprecedented halt in the growth of basic educational services and a stagnation and deterioration in educational quality. In nearly half of developing countries, the goal of universal primary education is now receding.21 Major changes are required if education is to reach the periphery and serve those children who are of the greatest concern to UNICEF—the disadvantaged and the peripheralized. While large changes are required, much that is under consideration today is no more than fine-tuning the existing, centralized bureaucracy. Several of these conventional initiatives have been reviewed here, but it is doubtful whether they will make much difference; these reforms will tend to follow the pattern of past reforms, making education better for those who already enjoy the best.22 A radically new approach must be considered that puts the periphery first. The 1 suggested here is not a “Robin Hood” approach: peripheral areas cannot be improved simply through a massive infusion of central aid. Rather, the periphery, to move forward, must rebuild its spiral and local organization, which has largely been subverted by decades of piecemeal central intrusion. If the periphery is seriously committed to improvement, it will have to assume a major part of the
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responsibility for planning where it wants to go and even for financing the journey. The present authors suggest that educational institution should assume a central role in the resurrection of the periphery, so that the future course of development can be integrated from below rather than fractionalized from above. Identified in this chapter are many specific initiatives that might be launched; however, it is doubtful that true success in deperipheralizing society will be possible without a comprehensive approach to change, which includes reforms at all levels. 5. Conflict and discrimination—Of the 45 million refugees and displaced people in the world, 80% are women and children. Between 1990 and 2000, 3 million children were slaughtered, 7 million injured or permanently disabled, and 12 million left homeless because of conflict. Between 80 and 90% of those who die or are injured in conflicts are civilians, mostly children and their mothers. Conflict has orphaned or separated ⬎2 million children from their families in the last decade of the 20th century. Of the ⬎100 million out-of-school youth, 60 million are girls. Between 60 and 100 million women are “missing” from the world’s population—victims of genderbased infanticide, feticide, malnutrition, and neglect. Ninety percent of domestic workers, the largest group of child workers in the world, are girls between 12 and 17 years old. In some areas, HIV infection rates are 5 times higher for girls than for boys. More than 100 million children are out of school because of poverty, discrimination, or lack of resources. On May 25, 2000, the General Assembly of the United Nations adopted the Optional Protocol to the Convention on the Rights of the Child on the involvement of children in armed conflict, reaffirming that the rights of children require special protection and calling for continuous improvement of the situation of children without destruction, as well as for their development and education in conditions of peace and security, and condemning the targeting of children in situations of armed conflict and direct attack on areas protected under international law, including places that generally have a significant presence of children, such as schools and hospitals 6. Access to safe drinking water, lack of proper sanitation, and environmental hazards—With 1.5 billion people not having access to clean water and 2 billion without access to proper sanitation and with increasing demand for water by industry and agriculture, effective means of distribution, delivery, discovery, and conserving water are fundamental. So, too, is a strategy for sewerage, which not only pollutes water supplies but also affects health in a
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dramatic way and increases skin problems, especially among children. The global problem of water supply will have an increasing impact on all aspects of human development, particularly on children and women in rural and urban areas.23 There is growing agreement that problems of the environment are issues for all of humankind and that this translates into regional, national, and local strategies. Pollution can not only kill but it can also cause severe adverse impacts on economic activity, on growth, and on the state of health of children. This includes the preservation of natural resources, from forests to biodiversity; the quality of air and water; and the hazards of ozone depletion. The continuing degradation of important natural resources represents a silent crisis that will be difficult to reverse. 7. Immunization—Achievements in child health are mixed with concern over what, in 1990, seemed like unstoppable progress toward universal child immunization, which has stalled somewhat in the decade since. It is now clear that levels of immunization at the time of the World Summit were actually lower (73%) than were assumed at the time. Not only has the summit goal of 90% coverage not been achieved but also the world has struggled to maintain approximately the same levels of coverage; more than one-fourth of the world’s children are still not reached by routine immunization. In Sub-Saharan Africa, only 47% of children are immunized against diphtheria, whooping cough, and tetanus.24 The 4 major vaccines that are essential for infants (1 year old) are BCG, triple, polio, and measles. In underdeveloped countries, the percentage of vaccination ranges from 30-65%; in developing countries it is 8095%; and in developed countries it reaches 99-100%. 8. Infectious diseases—One of the major causes of death among children of the world is still infectious diseases, in particular, pulmonary and gastrointestinal. Malnutrition, poverty, lack of access to clean water, and poor sanitation are important factors in the high incidence of infectious illnesses. The main criterion of infectious disease outcome is infant mortality rate per 1000 live births. It is 35-69 in low-income countries (excluding China and India), and it is in middle-income countries, such as those of East Asia and the Pacific,37 South Asia,77 the Middle East and North Africa,49 Latin America and the Caribbean,32 and Europe and Central Asia,23 but in high-income countries it is only 6 in 1000.25
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Conclusions Management of common skin diseases among children in developing countries is a major problem and a challenge for general practitioners and pediatricians, as well as dermatologists. There number of physicians who take care of children is insufficient, and there are also are not enough medicines to treat the thousands of sick children. Prevention is essential, but it depends on the political, economic, and social aspects of developing countries. There are 8 major problems facing children in developing countries that are essential factors giving rise to the incidence in skin diseases among children. It is important that these problems being examined and that governments try to solve them as a prerequisite for a better state of health of the children in developing countries.
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