Global health dermatology: An emerging field addressing the access to care crisis

There are more than 1 billion people living with skin diseases around the world, but less than half have access to adequate healthcare.^1,2 Healthcare access itself is complex and can be characterised by the five A’s: affordability (cost and the client’s ability to pay), availability (of personnel and technology), accessibility (geography), accommodation (how care meets the needs of the client) and acceptability (client’s comfort level with care).³ The global healthcare system is increasingly focusing on the quality of healthcare delivered in under-resourced settings. If a patient can access a healthcare provider and pay for the services, but that healthcare provider is inadequately equipped to make a diagnosis, then the system is considered inefficient.⁴ In dermatology, global health means ‘an area of research and practice “that places a priority on improving health and achieving equity in health for all people worldwide”, both on an individual and public health level’.⁵ This does not necessarily mean care delivered ‘somewhere else’ or across an international border. Instead, the focus is on underserved communities and populations wherever they are, including our own communities. India has a long history of efforts to increase access to care through ‘community dermatology’.^6–8 Global health dermatology is an extension of this work rather than a departure.

The status of dermatologic care not only varies by region but also within regions by community. For example, in sub-Saharan Africa, there are 0–3 dermatologists per million population.⁹ In the United States, this number reaches 34 dermatologists per million; however, this more robust number camouflages inequitable distribution across the country, with many rural or minority groups having no dermatologists serving in their area.¹⁰ For example, the density of dermatologists in urban areas of the United States is ∼40 per million, in contrast with less than 1 per million in rural areas.¹¹ Even in communities where dermatologists exist, vulnerable patients may not have adequate access, such as persons experiencing homelessness. In India, there are an estimated ∼9.5 dermatologists per million, but similar to the United States, these dermatologists are often concentrated in urban areas or around academic centres.^10,12,13 To address this gap, there has been an increasing formalisation of global health dermatology as a field. For example, the British Journal of Dermatology, one of the top three dermatology journals based on impact factors, launched a new section on Global Health & Equity in 2021.⁵ This section focuses on global health and equity topics, including capacity building, race and health, sexual and gender minority health, indigenous health, climate change, healthcare policy, the global burden of disease, infectious diseases, humanitarian crises, and global healthcare delivery and innovation, among others. This section has recently instituted Authorship Reflexivity Statements, which is a structured way to report on research partnerships and contributions, to focus on equitable authorship in scientific literature.¹⁴ The World Health Organization (WHO) is increasingly recognising efforts by the dermatologic community to improve global access to skin health. The International League of Dermatological Societies (ILDS), of which the Indian Association of Dermatologists Venereologists and Leprologists (IADVL) is a member society, is in ‘Official Relations’ with the WHO. The ILDS assists across multiple departments of the WHO. For example, the ILDS team provides expertise in cutaneous neglected tropical diseases for the WHO’s Neglected Tropical Disease Programme. In this capacity, the ILDS helped support the launch of a course on superficial fungal infections via the OpenWHO platform, a free educational platform hosted by the WHO to promote free, high-quality education. The course accrued more than 1000 registrations in just the first few days following launch.

Social responsibility efforts by industry partners are also helping to formalise the field. For example, the ILDS and L’Oréal delivered the International Awards for Social Responsibility at the World Congress of Dermatology in 2023. In addition, L’Oréal has pledged 2 million euros to tackle the lack of open access to dermatology literature for those working in low- and middle-income countries.

What are ways that we, as individuals, can contribute to moving the needle on global access to care in underserved communities? One outlet is through joining and supporting organisations that promote health equity and access to care. An example of this type of collaborative community is GLODERM, the International Alliance for Global Health Dermatology (www.gloderm.org).^15,16 GLODERM launched a first-of-its-kind international mentorship programme aimed specifically at emerging leaders in dermatology and focusing on leadership skills rather than clinical skills. GLODERM has enrolled its first 17 mentees from 14 countries, who have gone on to start residency programmes, work to fight skin disease stigma in their countries and create outreach programmes impacting thousands of underserved patients.

A second way we can increase access to care is by engaging in expanding educational opportunities. This can be through volunteering time as a visiting faculty member, sponsoring residency training slots, or providing financial support to emerging residency or other training programmes in dermatologically under-resourced areas, among others. GLODERM also hosts a monthly free webinar series on clinical topics with leading international experts, available for free to trainees and dermatologists worldwide, in an effort to reduce barriers to high-quality educational content.

The third approach is to invest in and mentor diverse talent. As a dermatologist, you may already mentor many different cadres of students and healthcare workers, from medical students to colleagues looking to start their own practice. Mentorship does not need to be limited to clinical care; it can include leadership skills, business skills or peer-to-peer support. Mentorship can occur through a formal programme, like those sponsored by the IADVL,¹⁷ GLODERM, the Medical Dermatology Society, the International Society of Dermatology or the Women’s Dermatologic Society, or it can be an informal sharing of expertise. Considering who we are mentoring is also important. For example, consider engaging in purposeful mentorship of students and colleagues who are traditionally underrepresented in medicine. Sharing our time and skills to promote bidirectional exchange is a way to contribute to a richer and more representative dermatologic workforce.

As we work together to address the access to care crisis in dermatology, we acknowledge the history and continued impact of colonialism and structural racism in our field.¹⁸ Whether through large-scale programmes such as the WHO or industry investment or through smaller grassroots efforts such as supporting organisations focused on global health and equity, involvement in educational opportunities that uplift local champions or diversifying our mentorship, we can all contribute to reducing inequity in access to skin health.