Working in the Tropics

Cultural Context

All illness exists in a cultural context. It is essential to understand the cultural background of the society in which one will be working if one is to be effective. Beliefs about the cause and treatment of disease can differ profoundly from scientific orthodoxy. Ignoring or dismissing these beliefs can result in poor compliance, at the very least. At the other extreme, strong offence may be taken at the cultural insensitivities of a well-meaning but ignorant visitor to a community.

Anyone planning medical mission work should begin by reading in depth about the country, its history, religions, culture, and customs. How do people feel about being examined physically? Is an examination by a physician of the opposite sex out of the question? How much eye contact is uncomfortable? Are certain treatments, for example injections, viewed locally as the only worthwhile treatment? An attempt should be made to acquire a basic vocabulary in the local language to cover greetings and simple civilities. The words for a few key clinical terms (“itch,” “pain,” “getting better / worse,” etc.) can, used with a questioning inflexion, greatly speed up the consultation. Of course, the services of an interpreter are essential for explaining the disease and its treatment to the patient, or when a detailed history is sought.

An understanding of what is financially affordable for the patient is a concern of all physicians everywhere. Enquiries should be made to ascertain what is a realistic imposition before prescribing treatment in an unfamiliar setting. Due deference and respect should be shown to local power structures of the health providers and civil authorities. Visiting consultants, by the manner in which they deal with local colleagues, can be extremely influential in either strengthening or undermining the way local doctors and nurses are perceived by the populations they serve.

As a rule, the straightforward, blunt, time-obsessed approach of westerners needs to be softened considerably when operating in many other cultures. What is required is a calm, courteous, and patient demeanor, unruffled by delays or setbacks.

Clinicians visiting developing countries do of course make a useful contribution by diagnosing and treating disease. However, it is of far greater value to the host country if one is able to “leave something behind” in the form of knowledge and skills imparted or equipment donated. In this way, the visit is likely to provide some lasting benefit.

Clinical Context

Every effort should be made to become familiar with the local pattern of skin disease. As a rule, in tropical dermatology, infections of all types and infestations are much more common than in the temperate zones. On the other hand, skin cancer and degenerative disease, common in temperate, western zones, are almost unknown.

One should refresh one's knowledge of the clinical features and management of the prevalent diseases, understanding that they are often much more extensive and severe than what one might be accustomed to, as a result of remaining untreated over a long time.

The intensity of pigmentation can affect the appearance of common skin conditions such as psoriasis and atopic dermatitis. Clinicians who have little experience in managing patients with deeply pigmented skins should familiarize themselves with the spectrum of disease in non-Caucasian skin.

In most countries, good statistics exist on the prevalence of leprosy and human immunodeficiency virus (HIV). These figures should be sought as a guide as to what to expect in clinics. The particular geographic zone may have a high prevalence of a particular disease such as leishmaniasis.

Some diligent reading on such unfamiliar entities is essential preparation.

Traditional Therapies

The term “traditional medicine” encompasses all those modalities of health care that date from the dawn of time to the advent of scientific medicine.

From time immemorial all societies have sought remedies from their immediate surroundings for the illnesses that have afflicted them. Parts of local animals, plants, or various minerals have provided the basis of treatment. Many of the treatments have become well-known household remedies in those societies.

Others are administered by healers, who are often highly respected members of their communities. Some treatments involve manipulation or invasive procedures such as acupuncture. Childbirth and mental illnesses have their own traditional specialist healers.

It is still true that most of the populations of developing countries continue to depend on their traditional medicine for primary health care. Practitioners of scientific medicine should therefore accord due respect to traditional healers and those who have faith in them. “Scientific” doctors should seek to understand and work alongside healers rather than denigrating or patronizing them.

Undoubtedly many traditional treatments, hallowed by centuries of use, will, when subjected to scientific evaluation, prove to be effective. Aspirin, quinine, and digoxin, all “traditional” remedies, have become incorporated into mainstream medicine.

At the same time as developing countries are being exposed to scientific medicine, there is an increasing interest in traditional herbal remedies (alternative or complementary medicine) in the populations of developed countries.

The World Health Organization (WHO), through its Traditional Medicine Program, is encouraging the compilation of national formularies and the study of efficacy. Plants with medicinal potential are being subject to systematic pharmacologic research.

Equipment

Inevitably, this is a trade-off between what is desirable and what is practicable. In general, supplies of all types will be less accessible in most tropical settings. This includes banal items such as pen, paper, and batteries. One should aim to be self-sufficient and impose as little logistical strain on local facilities as possible.

Good management depends on accurate diagnosis. This in turn is the product of a satisfactory clinical examination. The situations in which clinical examinations are performed are often not ideal, with poor lighting. This is a particular problem with the darker skins usually encountered in the tropics. The most important item for the dermatologist is therefore a headlamp with binocular loupe and rechargeable, belt-mounted battery pack. One should ascertain on what voltage the local power system operates and obtain the appropriate adaptors. Solar rechargers can be invaluable in situations where the electricity supply is unreliable.

Photographic documentation is essential for teaching purposes. One should be familiar with one's camera equipment and carry adequate supplies of batteries.

The following list of dermatologic equipment may be trimmed or expanded to fit the circumstances, such as available transport and the nature of the host facility:

• Notebook, stationery, and pens

• Local anesthetic: with and without epinephrine (adrenaline); syringes, needles

• Biopsy kit: punch biopsies, 2–8 mm scissors, skin hooks, needle-holders

• Excision kit: scalpels, blades, forceps, needle-holders, suture material

• Corticosteroid for intralesional injection

• Gloves, dressings, antiseptic sachets, alcohol gel hand cleanser

• Cautery / diathermy

• Wood's light

• Pathology:

  • Bottles with formalin

  • Envelopes for skin scrapings

  • Microscope, slides, cover slips, potassium hydroxide

  • Culture media (bacterial and fungal).

Pharmaceutical Supplies

Topical and systemic drugs are limited in range and availability in most developing countries. It is helpful for any visiting dermatologist to take as much in the way of pharmaceutical supplies as cost and transport facilities permit. The choice of drugs should reflect the local pattern of skin disease. Antifungals (topical and oral) and topical corticosteroids are the most needed. There is still considerable merit in some older preparations that may be regarded as obsolete in western countries. An example is topical gentian violet, which is cheap, stable, and effective for candidiasis and the commonly encountered secondarily infected eczema patient.

Pharmaceutical companies are often willing to donate supplies. Several western countries have organizations that collect drugs for distribution to individuals or bodies to take on missions. There is, however, no place for the use of products that have passed their expiration date.

Arrangements will need to be made with the host country, pointing out that the supplies are for dispensing gratis and thus facilitating passage through customs.

Personal Preparation

Visitors on medical missions should be physically healthy, including dentally. Adequate supplies of personal routine medications should be taken, as well as a first-aid kit, insect repellent, and sunscreen. Again, the principle of self-sufficiency applies.

An early visit to a travel medical centre is essential to ensure that the appropriate vaccination program is completed on time. If visiting a malarial area, advice will be given as to the appropriate chemoprophylaxis.