Skin health in Bangladesh: An overview

Pritish Barua

 Skin VD Center, Lab One Health Services, Chittagong, Bangladesh

Correspondence Address:
Pritish Barua
Skin VD Center, Lab One Health Services, 205/216, Jamal Khan Road, Chittagong - 4000
Bangladesh

Introduction

According to "World Bank Development Indicators Database, April 2006"- Bangladesh is the seventh most populous country in the world. The population is approximately 140 million in a land area of 55,598 square miles and the population density is 2,639 per square mile. Despite its huge population, extreme population density and high levels of poverty, Bangladesh has made significant progress in health in recent times. Most of the health indicators show steady gains and the health status of the population has improved. ^[1] But the skin health status in Bangladesh cannot claim its partnership in the progress. It remains static because skin care services are still based on the century-old concept which has failed to reach the whole population.

Dermatology Care: Current Trends

At present, skin care in Bangladesh means costly and time-consuming service provided by specialist or trainee dermatologists at the teaching and district hospitals or private clinics. Most of the work of dermatologists is concerned with curative care without paying much attention to preventive or public health measures of dermatology. Moreover, their skill and knowledge are under-utilized due to financial and technical limitations. Dermatologists often have to provide primary care due to unnecessary but unavoidable over-referral by the primary care physicians or by the patients themselves. Dermatologists in the private sector are trying to provide more sophisticated care, but it is only accessible to some rich people. Even in government hospitals, patients have to spend money almost for everything except the doctor′s fee! This city-centric expensive skin care covers only around 20% of the total population. The remaining 80% of the poor, urban, semi-urban, rural and remote population have just no access to proper skin care. There are few dermatology posts at the sub-district (upazila) government hospitals which work as healthcare hubs and private sector dermatologists are not interested in rural and remote practice. So the population at this level has to depend partly on a few registered doctors or largely on other informal heathcare providers who do not have basic dermatology knowledge. Skin care at this level consists mainly of a prescription having a cocktail of oral and/or topical antihistamine-antibiotic-antifungal-steroid combination and a common ban on food. So a combination of poor disease recognition, poor treatment regimens, and inadequately explained treatment regimens often results in persistent disease burden, wastage of limited resources on ineffective and sometimes dangerous treatments and huge referrals to the tertiary level. A question may arise-why is the picture like that? Skin disease is in general poorly taught in medical colleges because of its nearly non-inclusion in the qualifying examination; it has not been allotted its proper place either in the allocation of teaching and or training time. So when a young doctor is posted at the sub-district level, she/he has to face a lot of problems regarding the diagnosis and treatment of dermatological disorders. ^[2] Moreover, the large numbers of informal healthcare providers who are the first contact of rural poor people, deeply embedded in the local community and culture, and easily accessible, do not have a basic knowledge of dermatology. Although they have proven their ability in improving the health status in Bangladesh after getting some training in other fields, they have never been offered any kind of basic skin care training.

Drawbacks

With such a large healthcare workforce, why are we unable to provide effective dermatological care? The policymakers in the health service system often fail to realize or ignore the importance of skin care probably because it does not possess the high drama of other specialties. In assigning health priorities, skin diseases are thought of, in planning terms, as small-time players in the global league of illnesses compared with diseases that cause significant mortality, such as HIV/AIDS, community-acquired pneumonia and tuberculosis. ^[3] High cutaneous morbidities never came into focus. Up to 60% of people in both rural and urban areas in developing countries suffer from skin diseases which create detrimental effects on people′s quality of life and productivity, produce discrimination due to disfigurement and indicate the presence of some serious diseases. ^[4] But the importance of skin health have so far failed to penetrate properly into the existing healthcare policy. Moreover, one-sided focus on specialist care with sophisticated technology used for cosmopolitan dermatology is another handicap for developing accessible and equitable skin care services in Bangladesh. So the overall status of skin health in Bangladesh is generally poor and unsatisfactory. Although Bangladesh has made important gains in providing primary healthcare since the Alma Ata Declaration in 1978, surprisingly, "Skin Health for All" has been unable to get its rightful place in the Primary Health Care (PHC) system in Bangladesh. This is why the PHC system in Bangladesh is neither comprehensive nor community-oriented.

Conclusion

It has been proven that without focusing on community-oriented approaches and or the public health aspects of dermatology, the overall skin health status will never improve. This is why many developed and developing countries have given their maximum effort to develop primary care dermatology services. Training of primary health workers in the care of skin diseases has been identified as a key factor to tackle the problem. Perhaps the best current example of a concerted, community-based approach is the Regional Training Center for Dermatology in Moshi, Tanzania, which focuses on developing a primary care skills′ base in African countries for the care of patients with skin and sexually transmitted diseases. ^[5] Emphasis on an undergraduate medical curriculum addressing common dermatological diseases could also play an important role in combating the problem. Telemedicine holds great potential for revolutionizing the delivery of equitable dermatology services to underserved areas. We can implement low-cost, store and forward teledermatology to provide skin care facility to hard-to-reach populations. Keeping all this in mind, an intuitive, secure and affordable plan is urgently needed for improving skin health in Bangladesh.

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