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Non-Communicable Disease
8. Non-Communicable Disease The growing importance of non-communicable disease in tropical regions of the world is highlighted by the 2015 Global Burden of Disease study with emerging prominence of diabetes, ischaemic heart disease, cardiovascular disease and cancer, whilst haemoglobinopathies contribute significant morbidity and mortality. A number of genetic blood dyscrasias are especially common in some tropical areas. Some, such as sickle cell trait, may have afforded a positive selective advantage in areas highly endemic for falciparum malaria. However, as they are well documented elsewhere, only passing reference is made to these conditions here.
Fig. 8.1 African child with Burkitt’s lymphoma of the maxilla. Denis Burkitt originally described the endemic form of this high-grade B cell lymphoma in African children and young adults with facial swelling. The co-occurrence of immunosuppression due to falciparum malaria and persistent Epstein Barr virus (EBV) infection increases the risk of chromosomal translocation in replicating germinal centre B cells, explaining the geographical distribution of disease. Over 50% of cases present with mandibular or maxillary bone involvement. Sporadic forms outside malarial regions more often present with lymphadenopathy or intra-abdominal masses. (Courtesy, Professor O. Malik.)
Fig. 8.2 Burkitt’s lymphoma in an Asian adult. The photograph shows enormous cervical lymphadenopathy, which was initially suggestive of tuberculous lymphadenitis but which biopsy revealed to be due to Burkitt’s lymphoma.
Fig. 8.3 Maxillary tumour at autopsy. The extensive infiltration of both maxillae by Burkitt’s lymphoma tissue is evident in this autopsy specimen. (Courtesy, Professor M. S. R. Hutt.)
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8 NON-COMMUNICABLE DISEASE
ASIR(W) per 100,000 men < 0.5 0.5~1 1~1.5 1.5~2.5 2.5~4.5 > = 4.5
A
ASIR(W) per 100,000 women < 0.3 0.3~0.6 0.6~1 1~1.5 1.5~3 >=3
B Fig. 8.4 Global estimates of age-standardized incidence of nasopharyngeal carcinoma in men (A) and women (B). This condition, which is also associated with Epstein–Barr virus, has a high incidence in southern China, South East Asia and North Africa. Incidence is falling globally, believed to be due to reducing tobacco use and economic development, whilst drops in case fatality are attributed to diagnostic and therapeutic advances. (From Tang, L.-L. et al. Global trends in incidence and mortality of nasopharyngeal carcinoma. Cancer Letters, Volume 374, Issue 1, Pages 22–30, Figure 1. Copyright © 2016 Elsevier Ireland Ltd.) Fig. 8.5 Endemic (non-AIDS) Kaposi’s sarcoma of the hand and foot. The sporadic form of this malignant spindle cell tumour was originally described in elderly eastern European men by Hungarian dermatologist Moritz Kaposi. A male preponderance also appears in the endemic form seen in Africa. Typical nodular lesions are seen on the hand and foot of this man from Lesotho; these may run a chronic, indolent course, though may sometimes be more aggressive with infiltrative lesions and associated gross limb swelling. Human herpesvirus 8 is causally associated with HIV-related Kaposi’s sarcoma. (Courtesy, Professor S. Lucas.)
Non-Communicable Disease
Fig. 8.6 Squamous cell carcinoma. Chronic exposure to solar radiation, particularly in people with fair skin, can result in degenerative or neoplastic changes in the sunexposed parts of the body. Thinning of the ozone layer is predicted to result in an increased frequency in conditions such as squamous cell carcinoma seen here on the shoulder of an albino patient. (Courtesy, Professor K. F. Schaller.)
Fig. 8.7 Malignant melanoma. A sudden increase in pigmentation and enlargement of freckles following prolonged exposure to sunlight may be precursors to the development of a malignant melanoma in a fair-skinned individual. The large melanoma seen in this 54-year-old Caucasian woman shows marked local infiltration and carries a poor prognosis. (Courtesy, Dr W. A. D. Griffiths.)
Fig. 8.8 Malignant melanoma of the foot. In dark-skinned people such as the African patient seen here the primary site of this condition is usually the non-pigmented sole, or occasionally the palmar surface of the hand. Similarly a malignant melanoma may occasionally occur in an area of vitiligo. (Courtesy, Professor K. F. Schaller.)
Fig. 8.9 Low-cost oral morphine solution. A broader approach to palliative care is gradually gaining traction in many resource-limited settings. Morphine solution can be prepared locally and distributed at relatively low cost. (Courtesy, Dr K. Wakeham.)
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8 NON-COMMUNICABLE DISEASE
Births per 1000 infants with a major haemoglobinopathy <0.1 0.1–0.19 0.2–0.99 1.0–4.9 5.0–9.9 10.0–18.9 >19
Fig. 8.10 Incidence of major haemoglobinopathies. The map indicates the estimated numbers per 1000 births, of infants with major haemoglobinopathies. This can be compared with Fig. 8.11. (Courtesy of WHO GENOMIC RESOURCE CENTRE.)
Key HbS HbC HbD HbE β-thalassaemia
Fig. 8.11 Distribution map of haemoglobinopathies (excluding the Americas). The most important abnormal haemoglobins (Hb) in the tropics are HbS, HbC and HbE. Thalassaemia, which is the result of decreased synthesis of one of the chains of haemoglobin (alpha or beta), is also widespread. HbD has a limited distribution and is clinically mild. The abnormal haemoglobins also occur in Central and South America (not shown) because of migration, and among African Americans in the United States. The haemoglobin AS phenotype in the same population, which renders the erythrocytes unfavourable to the development of Plasmodium falciparum, favours the survival of the gene in tropical Africa, where falciparum malaria is holoendemic, although the SS phenotype increases host mortality.
Non-Communicable Disease Fig. 8.12 Dactylitis due to sickle cell disease. Severe bilateral dactylitis (hand-foot syndrome) is a common presentation of sickle cell disease in children, caused by vaso-occulsive bone infarction. (Courtesy, Professor P. Hamilton.)
Fig. 8.13 Bossing of the skull. Bossing of the skull due to hyperplasia of the marrow is another feature of sickle cell disease; the skull height is increased with lateral indentations (‘bosses’). Similar appearances may be seen in thalassaemia and in any other severe, congenital haemolytic anaemia. (Courtesy, Professor R. Hendrickse.)
Fig. 8.14 Radiograph of skull in thalassaemia. Thalassaemia produces this typical ‘hair-on-end’ appearance of the skull in radiographs. (Courtesy, Dr G. D. Scarrow.)
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Fig. 8.15 ‘Mossy foot’ in an Ethiopian. Podoconiosis is a geo-genodermatosis caused by a genetically defective skin barrier permitting the passage of micro-particles from certain soils through the skin into the lymphatics. This sets up a destructive obliterative lymphangitis that leads to progressive debilitating lower limb lymphoedema. It is effectively restricted to barefoot farmers in highly fertile volcanic highlands such as Ethiopia. Recurrent acute episodes (of presumed cellulitis) incapacitate the individual and worsen the lymphoedema. The surface of the skin becomes hyperkeratotic and ‘mossy’ in its appearance. (Courtesy, Dr C. Fuller.)
Fig. 8.16 Nodular appearance of long-standing podoconiosis. As the limbs get larger, many patients additionally develop fibrotic nodules which restrict shoe-wearing. The condition can be prevented by the wearing of shoes before it has developed. In those with established disease, benefit can be achieved with simple washing, moisturizing, compression with socks and protection from further damage by wearing shoes. (Courtesy, Dr C. Fuller.)
Percentage change
< –50 –50 to < –30 –30 to < –20 –20 to < –10 –10 to 0 >0 to 10 >10 to 30 >30
Fig. 8.17 Change in age-standardized road injury disability-adjusted life year (DALY) rates, 1990–2013. Whilst road injury-attributable disability has been falling in high-income countries over the past 2 decades, rates have been increasing in South Asia and West and South sub-Saharan Africa. (From Haagsma, J.A., Graetz, N., Bolliger, I., et al. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Injury Prevention, 2016, Volume 22, Pages 3–18. Copyright © BMJ Publishing Group Limited.)
Non-Communicable Disease
Fig. 8.18 Mercury poisoning due to artisanal gold mining in Colombia. There is growing recognition of the large public health burden of accidental domestic poisonings of children from household products and of larger-scale population poisonings arising from environmental degradation due to human activity, with poorer countries disproportionately affected. The use of mercury in artisanal gold mining is one example. (From Webster, P. C. Not all that glitters: mercury poisoning in Colombia. The Lancet, Volume 379, Issue 9824, Pages 1379–1380. Copyright © 2012 Elsevier.)
Fig. 8.19 Talipes equinovarus (clubfoot). Clubfoot is twice as common amongst male as amongst female infants. The heel is rotated inward and the whole foot is deviated inward at the ankle. Untreated, this congenital deformity can cause significant lifelong impairment. (From Graham, J. M., Sanchez-Lara, P. A. Talipes equinovarus (clubfoot). In: Smith’s Recognizable Patterns of Human Deformation. 2016, Pages 39–46, Figure 5-8 A.)
Fig. 8.20 Partial correction of talipes equinovarus with carefully directed pressure and taping. There has been a major shift away from complex tendon release surgery and towards serial manipulations and weekly casts (the Ponseti method) of infants born with this condition. Taping and manipulation alone corrected this foot. (From Graham, J. M., Sanchez-Lara, P. A. Talipes equinovarus (clubfoot). In: Smith’s Recognizable Patterns of Human Deformation. 2016, Pages 39–46, Figure 5-8 B.)
Fig. 8.21 Hand-pedalled locally built wheelchair in Sierra Leone. Impaired mobility can be particularly challenging where terrain is uneven and wheelchair ramps are never seen. Innovative local solutions overcome supply chain hurdles, offer business opportunities and benefit from easily accessed maintenance know-how. (Courtesy, Dr V. Sawicki.)
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Fig. 8.22 Full-thickness burns. Burn injuries are a major cause of morbidity in low-income settings, though disability can be substantially mitigated by simple early interventions and appropriate management. Training and capacity building by organizations such as Interburns enhance burns care in both the immediate aftermath and during recovery. Falling into the household fire due to undiagnosed or poorly controlled epilepsy remains an all-too-frequent cause of life-threatening burn injury. (From Kiser, M., Beijer, G., Mjuweni, S., et al. Photographic assessment of burn wounds: A simple strategy in a resource-poor setting. Burns, 2013, Volume 39, Issue 1, Pages 155–161, Figure 2. Copyright © 2012 Elsevier Ltd and ISBI.)
Fig. 8.23 Betel nut. Chewing of a stimulant betel nut ‘quid’, variably containing the betel nut and/or leaf, slaked lime, tobacco and additional flavourings, is very common in Asia but is associated with high rates of oral cancer. Shown here is the commonest type of betel nut preparation in Taiwan called ‘Ching-a’, made by wrapping together an unripe betel fruit (1), inflorescence of Piper betle Linn slaked with lime paste (2), and a piece of betel leaf (3). All three parts are chewed together. (From Lin, C.-Y., Young, Y.-H. Effect of betel nut chewing on the otolithic reflex system. Clinical Neurophysiology, 2017, Volume 128, Issue 1, Pages 138–146, Figure 1. Copyright © 2016 International Federation of Clinical Neurophysiology.)
3 2 1
A
B
Fig. 8.24 Betel nut dental staining (A) and two betel nut 'quids' (B). The characteristic red staining of the teeth reveals the habitual betel nut user. The nut is wrapped within its leaf in each of the quids seen here. (From Swartz, M. H. The oral cavity and pharynx. In: Textbook of Physical Diagnosis. 2014, Pages 278–314.e1, Figure 9–51 A.)
Fig. 8.25 Shackles used to restrain a patient with psychosis. Mental health problems are hugely neglected in many countries. Ignorance and a lack of a suitably equipped healthcare system mean that approaches to management of disturbed behaviour are sometimes unacceptably violent. (Courtesy, Dr M. Wilkinson.)
Non-Communicable Disease
Fig. 8.26 Global suicide rates. The age-standardized suicide rates (per 100,000 population) show considerable regional variation globally. Around 800,000 people die due to suicide each year, with almost 80% in low- and middle-income countries. It is the second leading cause of death in 15–29-year-olds worldwide. (Courtesy, © WHO, 2014. All rights reserved.)
Fig. 8.27 Distribution of sun protection products to children with albinism in Malawi. The autosomal recessive condition of oculocutaneous albinism has long been associated with stigma and superstition often leading to social marginalization. The increased risk of skin cancer and other solar damage demands constant attention to sun protection. A sinister development in recent decades has been the emergence of the notion that albino body parts are imbued with magical powers, resulting in an increase in attacks and mutilating murders. (From Cruz-Inigo, A. E., Ladizinski, B., Sethi, A. Albinism in Africa: stigma, slaughter and awareness campaigns. Dermatologic Clinics, Volume 29, Issue 1, Pages 79–87, Figure 1. © Elsevier 2011,)
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Fig. 8.1 African child with Burkitt’s lymphoma of the maxilla. Denis Burkitt originally described the endemic form of this high-grade B cell lymphoma in African children and young adults with facial swelling. The co-occurrence of immunosuppression due to falciparum malaria and persistent Epstein Barr virus (EBV) infection increases the risk of chromosomal translocation in replicating germinal centre B cells, explaining the geographical distribution of disease. Over 50% of cases present with mandibular or maxillary bone involvement. Sporadic forms outside malarial regions more often present with lymphadenopathy or intra-abdominal masses. (Courtesy, Professor O. Malik.)
Fig. 8.2 Burkitt’s lymphoma in an Asian adult. The photograph shows enormous cervical lymphadenopathy, which was initially suggestive of tuberculous lymphadenitis but which biopsy revealed to be due to Burkitt’s lymphoma.
Fig. 8.3 Maxillary tumour at autopsy. The extensive infiltration of both maxillae by Burkitt’s lymphoma tissue is evident in this autopsy specimen. (Courtesy, Professor M. S. R. Hutt.)
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8 NON-COMMUNICABLE DISEASE
ASIR(W) per 100,000 men < 0.5 0.5~1 1~1.5 1.5~2.5 2.5~4.5 > = 4.5
A
ASIR(W) per 100,000 women < 0.3 0.3~0.6 0.6~1 1~1.5 1.5~3 >=3
B Fig. 8.4 Global estimates of age-standardized incidence of nasopharyngeal carcinoma in men (A) and women (B). This condition, which is also associated with Epstein–Barr virus, has a high incidence in southern China, South East Asia and North Africa. Incidence is falling globally, believed to be due to reducing tobacco use and economic development, whilst drops in case fatality are attributed to diagnostic and therapeutic advances. (From Tang, L.-L. et al. Global trends in incidence and mortality of nasopharyngeal carcinoma. Cancer Letters, Volume 374, Issue 1, Pages 22–30, Figure 1. Copyright © 2016 Elsevier Ireland Ltd.) Fig. 8.5 Endemic (non-AIDS) Kaposi’s sarcoma of the hand and foot. The sporadic form of this malignant spindle cell tumour was originally described in elderly eastern European men by Hungarian dermatologist Moritz Kaposi. A male preponderance also appears in the endemic form seen in Africa. Typical nodular lesions are seen on the hand and foot of this man from Lesotho; these may run a chronic, indolent course, though may sometimes be more aggressive with infiltrative lesions and associated gross limb swelling. Human herpesvirus 8 is causally associated with HIV-related Kaposi’s sarcoma. (Courtesy, Professor S. Lucas.)
Non-Communicable Disease
Fig. 8.6 Squamous cell carcinoma. Chronic exposure to solar radiation, particularly in people with fair skin, can result in degenerative or neoplastic changes in the sunexposed parts of the body. Thinning of the ozone layer is predicted to result in an increased frequency in conditions such as squamous cell carcinoma seen here on the shoulder of an albino patient. (Courtesy, Professor K. F. Schaller.)
Fig. 8.7 Malignant melanoma. A sudden increase in pigmentation and enlargement of freckles following prolonged exposure to sunlight may be precursors to the development of a malignant melanoma in a fair-skinned individual. The large melanoma seen in this 54-year-old Caucasian woman shows marked local infiltration and carries a poor prognosis. (Courtesy, Dr W. A. D. Griffiths.)
Fig. 8.8 Malignant melanoma of the foot. In dark-skinned people such as the African patient seen here the primary site of this condition is usually the non-pigmented sole, or occasionally the palmar surface of the hand. Similarly a malignant melanoma may occasionally occur in an area of vitiligo. (Courtesy, Professor K. F. Schaller.)
Fig. 8.9 Low-cost oral morphine solution. A broader approach to palliative care is gradually gaining traction in many resource-limited settings. Morphine solution can be prepared locally and distributed at relatively low cost. (Courtesy, Dr K. Wakeham.)
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8 NON-COMMUNICABLE DISEASE
Births per 1000 infants with a major haemoglobinopathy <0.1 0.1–0.19 0.2–0.99 1.0–4.9 5.0–9.9 10.0–18.9 >19
Fig. 8.10 Incidence of major haemoglobinopathies. The map indicates the estimated numbers per 1000 births, of infants with major haemoglobinopathies. This can be compared with Fig. 8.11. (Courtesy of WHO GENOMIC RESOURCE CENTRE.)
Key HbS HbC HbD HbE β-thalassaemia
Fig. 8.11 Distribution map of haemoglobinopathies (excluding the Americas). The most important abnormal haemoglobins (Hb) in the tropics are HbS, HbC and HbE. Thalassaemia, which is the result of decreased synthesis of one of the chains of haemoglobin (alpha or beta), is also widespread. HbD has a limited distribution and is clinically mild. The abnormal haemoglobins also occur in Central and South America (not shown) because of migration, and among African Americans in the United States. The haemoglobin AS phenotype in the same population, which renders the erythrocytes unfavourable to the development of Plasmodium falciparum, favours the survival of the gene in tropical Africa, where falciparum malaria is holoendemic, although the SS phenotype increases host mortality.
Non-Communicable Disease Fig. 8.12 Dactylitis due to sickle cell disease. Severe bilateral dactylitis (hand-foot syndrome) is a common presentation of sickle cell disease in children, caused by vaso-occulsive bone infarction. (Courtesy, Professor P. Hamilton.)
Fig. 8.13 Bossing of the skull. Bossing of the skull due to hyperplasia of the marrow is another feature of sickle cell disease; the skull height is increased with lateral indentations (‘bosses’). Similar appearances may be seen in thalassaemia and in any other severe, congenital haemolytic anaemia. (Courtesy, Professor R. Hendrickse.)
Fig. 8.14 Radiograph of skull in thalassaemia. Thalassaemia produces this typical ‘hair-on-end’ appearance of the skull in radiographs. (Courtesy, Dr G. D. Scarrow.)
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Fig. 8.15 ‘Mossy foot’ in an Ethiopian. Podoconiosis is a geo-genodermatosis caused by a genetically defective skin barrier permitting the passage of micro-particles from certain soils through the skin into the lymphatics. This sets up a destructive obliterative lymphangitis that leads to progressive debilitating lower limb lymphoedema. It is effectively restricted to barefoot farmers in highly fertile volcanic highlands such as Ethiopia. Recurrent acute episodes (of presumed cellulitis) incapacitate the individual and worsen the lymphoedema. The surface of the skin becomes hyperkeratotic and ‘mossy’ in its appearance. (Courtesy, Dr C. Fuller.)
Fig. 8.16 Nodular appearance of long-standing podoconiosis. As the limbs get larger, many patients additionally develop fibrotic nodules which restrict shoe-wearing. The condition can be prevented by the wearing of shoes before it has developed. In those with established disease, benefit can be achieved with simple washing, moisturizing, compression with socks and protection from further damage by wearing shoes. (Courtesy, Dr C. Fuller.)
Percentage change
< –50 –50 to < –30 –30 to < –20 –20 to < –10 –10 to 0 >0 to 10 >10 to 30 >30
Fig. 8.17 Change in age-standardized road injury disability-adjusted life year (DALY) rates, 1990–2013. Whilst road injury-attributable disability has been falling in high-income countries over the past 2 decades, rates have been increasing in South Asia and West and South sub-Saharan Africa. (From Haagsma, J.A., Graetz, N., Bolliger, I., et al. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Injury Prevention, 2016, Volume 22, Pages 3–18. Copyright © BMJ Publishing Group Limited.)
Non-Communicable Disease
Fig. 8.18 Mercury poisoning due to artisanal gold mining in Colombia. There is growing recognition of the large public health burden of accidental domestic poisonings of children from household products and of larger-scale population poisonings arising from environmental degradation due to human activity, with poorer countries disproportionately affected. The use of mercury in artisanal gold mining is one example. (From Webster, P. C. Not all that glitters: mercury poisoning in Colombia. The Lancet, Volume 379, Issue 9824, Pages 1379–1380. Copyright © 2012 Elsevier.)
Fig. 8.19 Talipes equinovarus (clubfoot). Clubfoot is twice as common amongst male as amongst female infants. The heel is rotated inward and the whole foot is deviated inward at the ankle. Untreated, this congenital deformity can cause significant lifelong impairment. (From Graham, J. M., Sanchez-Lara, P. A. Talipes equinovarus (clubfoot). In: Smith’s Recognizable Patterns of Human Deformation. 2016, Pages 39–46, Figure 5-8 A.)
Fig. 8.20 Partial correction of talipes equinovarus with carefully directed pressure and taping. There has been a major shift away from complex tendon release surgery and towards serial manipulations and weekly casts (the Ponseti method) of infants born with this condition. Taping and manipulation alone corrected this foot. (From Graham, J. M., Sanchez-Lara, P. A. Talipes equinovarus (clubfoot). In: Smith’s Recognizable Patterns of Human Deformation. 2016, Pages 39–46, Figure 5-8 B.)
Fig. 8.21 Hand-pedalled locally built wheelchair in Sierra Leone. Impaired mobility can be particularly challenging where terrain is uneven and wheelchair ramps are never seen. Innovative local solutions overcome supply chain hurdles, offer business opportunities and benefit from easily accessed maintenance know-how. (Courtesy, Dr V. Sawicki.)
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Fig. 8.22 Full-thickness burns. Burn injuries are a major cause of morbidity in low-income settings, though disability can be substantially mitigated by simple early interventions and appropriate management. Training and capacity building by organizations such as Interburns enhance burns care in both the immediate aftermath and during recovery. Falling into the household fire due to undiagnosed or poorly controlled epilepsy remains an all-too-frequent cause of life-threatening burn injury. (From Kiser, M., Beijer, G., Mjuweni, S., et al. Photographic assessment of burn wounds: A simple strategy in a resource-poor setting. Burns, 2013, Volume 39, Issue 1, Pages 155–161, Figure 2. Copyright © 2012 Elsevier Ltd and ISBI.)
Fig. 8.23 Betel nut. Chewing of a stimulant betel nut ‘quid’, variably containing the betel nut and/or leaf, slaked lime, tobacco and additional flavourings, is very common in Asia but is associated with high rates of oral cancer. Shown here is the commonest type of betel nut preparation in Taiwan called ‘Ching-a’, made by wrapping together an unripe betel fruit (1), inflorescence of Piper betle Linn slaked with lime paste (2), and a piece of betel leaf (3). All three parts are chewed together. (From Lin, C.-Y., Young, Y.-H. Effect of betel nut chewing on the otolithic reflex system. Clinical Neurophysiology, 2017, Volume 128, Issue 1, Pages 138–146, Figure 1. Copyright © 2016 International Federation of Clinical Neurophysiology.)
3 2 1
A
B
Fig. 8.24 Betel nut dental staining (A) and two betel nut 'quids' (B). The characteristic red staining of the teeth reveals the habitual betel nut user. The nut is wrapped within its leaf in each of the quids seen here. (From Swartz, M. H. The oral cavity and pharynx. In: Textbook of Physical Diagnosis. 2014, Pages 278–314.e1, Figure 9–51 A.)
Fig. 8.25 Shackles used to restrain a patient with psychosis. Mental health problems are hugely neglected in many countries. Ignorance and a lack of a suitably equipped healthcare system mean that approaches to management of disturbed behaviour are sometimes unacceptably violent. (Courtesy, Dr M. Wilkinson.)
Non-Communicable Disease
Fig. 8.26 Global suicide rates. The age-standardized suicide rates (per 100,000 population) show considerable regional variation globally. Around 800,000 people die due to suicide each year, with almost 80% in low- and middle-income countries. It is the second leading cause of death in 15–29-year-olds worldwide. (Courtesy, © WHO, 2014. All rights reserved.)
Fig. 8.27 Distribution of sun protection products to children with albinism in Malawi. The autosomal recessive condition of oculocutaneous albinism has long been associated with stigma and superstition often leading to social marginalization. The increased risk of skin cancer and other solar damage demands constant attention to sun protection. A sinister development in recent decades has been the emergence of the notion that albino body parts are imbued with magical powers, resulting in an increase in attacks and mutilating murders. (From Cruz-Inigo, A. E., Ladizinski, B., Sethi, A. Albinism in Africa: stigma, slaughter and awareness campaigns. Dermatologic Clinics, Volume 29, Issue 1, Pages 79–87, Figure 1. © Elsevier 2011,)
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