Dermatology of Human Mobile Populations

It has been said that movement is “the salt of progress”. In the past, the belief was that ideas moved while people stayed where they were. Today we have learnt that ideas “walk on the legs of men”.

Between 60 and 70 thousand years ago, Homo Sapiens had already reached a level of technical ability that made it possible for him to adapt to living in very different environments and areas. Slowly, slowly as a population grew and reached saturation point, so increased the need to emigrate and look for more open spaces.

Migration is characterised by the journey towards lands that, one hopes, are propitious and welcoming. There is, however, also an element of danger and illness when this journey takes place. The word “journey” has in itself a semantic link with illness. In Greek, the original meaning of the noun epidemia and the verb epidemeo signify “to stay”, to arrive in a foreign place and remain there.

Immigration from developing countries has only just recently become a reality for Europe, the USA, Canada and Australia and has caught all of them unprepared both on a socio-economic level as well as on a health level.

The World Health Organisation (WHO) defines immigrants, refugees, political exiles, migrant workers, travellers and tourists as people who, for one reason or another, move from one country to another,

as Human Mobile Population. According to the WHO in 2003 they numbered 1 billion and 250 million, of which 175 million were emigrants looking for work – an ever-growing reservoir of desperation, if one takes into consideration that the number in the 80s was 70 million.

This book, which avails itself of the collaboration of the most important international experts in dermatology, shows, without doubt, that borders no longer exist. What was once thought to be an illness typical of a specific geographical area, for example in the tropics, can now be found anywhere, especially in the northern hemisphere which is the goal for most of the ever-growing number of the better organised immigrants.

At the beginning of the most consistent flow of this migratory phenomenon, the state of health of the immigrant was defined as “healthy migrant effect”, because the emigrant was substantially a healthy, educated, young adult who had chosen to emigrate rather than being forced to because of necessity. Today, however, this is only partially true and, paradoxically, the immigrant falls ill more easily than before.

The immigrant, as can be deduced from the data collected from a large sample, appears to be quite a strong person, young, with a lot of initiative, more psychologically stable, in other words healthier than average. The fact of being healthy is the only resource that the immigrant has for himself and for his family, whose members often have to wait quite a long time in their country of origin before being able to complete their migratory project.

If the immigrant manages to arrive in the country of his destination in one piece, the “heritage of health” with which he left his country, slowly begins to disappear (“the interval of well-being”) due to a number of risk factors: psychological hardship, lack of work, working in dangerous jobs with no labour protection, poor living conditions, no family support, the climate, different food habits which often lead to nutritional problems, and discrimination when in need of the health service. The time between the immigrants’ arrival in Europe, Canada, USA or Australia and the need for them to see a doctor is gradually getting shorter. Illnesses, named as “hardship illnesses” or “degradation illnesses” can soon manifest themselves. If these are not properly checked, other illnesses can follow, not necessarily confined to the immigrant but also found where there is social relegation, for example among the homeless. These can be classified as “poverty illnesses”: tuberculosis, scabies, pediculosis, some viral infections, mycotic and venereal diseases.

Tropical dermatology used to be known as colonial dermatology, which has more of a cultural rather than geographical significance. Today, this terminology underlines the tie between this discipline and the developing countries. In fact, most cases of dermatological pathologies occur and are increasing in tropical regions, not necessarily because of climatic conditions which, admittedly, can favour the development of certain pathogenic micro-organisms or saprophytes, but rather because of the dramatic level of poverty, the lack of public and personal hygiene, the difficulty in obtaining water, poor housing, malnutrition and the lack of education, especially in the rural areas (all factors that have little to do with the difference among the races). To these unfavourable climatic and environmental conditions, political and cultural influences, often characterised by absurd ethnic conflicts sustained by wealthy industrialised countries, have to be added.

In the last few years, in the area of dermatology and venereology, there has been a return of illnesses that, in our national territory, had apparently disappeared some time ago. Is it a result of this migratory phenomenon that sees millions of people fleeing from the Southern Hemisphere in the hope of finding a future in Europe, in the USA, in Canada or in Australia? Or does it depend on the rise in tourism that sees people from the Northern Hemisphere looking for holidays in more exotic and unexplored places? Certainly the two situations, although for different reasons, have something in common: the speed of movement of large numbers of people reduces the distance between developing tropical countries and the industrial countries of the north, eliminating the borders which once upon a time contained the illnesses. We are in the middle of a pathology that can be described as omnipresent due to the movement of hundreds of millions of people from one end of the planet to the other. Viruses, bacteria and fungi no longer seem to be confined within specific boundaries and are spreading in areas where it seemed they had been eliminated forever.

This is the picture we are facing, with all the consequences for health it entails, both in terms of preventive and curative medicine.

Although, in 1987, the World Health Organisation launched a campaign, “Health for Everybody for the year2000”, little attention was paid to Dermatology. It is this discipline, however, that has made the biggest contribution towards a quality of life that is socially and economically more productive and valid.

It was, indeed, the Dermatology and the Venereal services who were the first to take care of the health of the immigrant.

Migration has always been a complex social and political phenomenon, with considerable implications of a social and health nature.

Immigration has completely upturned the human geography of the planet.

THE MIGRATORY PHENOMENON IN THE NORTH-SOUTH CONTEXT OF THE PLANET

At present, there is not only the problem of immigration from developing countries to the Northern Hemisphere but also another type that is little known, yet is causing serious problems. It is the emigration of the farmers, who abandon the countryside and rural areas of poor countries to move to the suburbs of the big metropolises, where they gather, always in increasing numbers, creating potential centres for new epidemics. Some of these frightening suburbs become fertile ground for bacteria, viruses and fungi. Promiscuity and prostitution spread uncontrollably, together with all the relative illnesses.

Why do people want to escape from the southern part of the world, often taking great risks, to come to Europe and to Italy in particular? The Report on Human Development 2004 edited by the United Nation Development Program (UNDP) confirms the rise of poverty for that year. In the developing countries, taking all the countries into consideration, ‘human poverty’, that is deprivation as far as longevity, lack of education, poor health service are concerned, affects about a quarter of that population, while ‘economic poverty’ affects about 2 billion people, about one-third of the world population.

Globalisation certainly offers benefits to some but, at the same time, it relegates and excludes more and more the vast majority of the poor. The report 2003 by the World Bank confirms that over 1 billion 200 million people are trying to survive on less than one dollar a day, and the majority of those doing so, live in countries from which come most of the immigrants who arrive in Europe, USA and Australia.

MIGRATION AND HEALTH

Migration is a stressful experience and consequently dangerous for the health, because it involves not only a complete uprooting from one’s original environment but also the necessity to re-establish oneself in a completely new one. It is for this reason that the safeguarding of the health of the migrants is of strategic importance, also in the light of safeguarding the health of those who risk exclusion.

The problem of ‘Immigration Medicine’ lies in the need to assist people whose condition of health is changing socially and culturally. A lot of attention must be given to facing the reality of immigration, and it is necessary to propose a pact of solidarity among citizens, health workers, public institutions, voluntary workers and the European and International communities to meet the needs of those people who risk being marginalized.

Among the objectives concerning health, it is necessary to repeat that there is an urgent need to reinforce the protection of people who are in a weak position, the needy, those who are somehow disadvantaged and are forced to rely on some assistance. Particular attention must be given to immigrants, nomads and the homeless who, quite often, belong to the first two categories. The departments of dermatology and venereology in hospitals, universities and local surgeries could become centres of preventive medicine for migrants and be of considerable importance in the assistance and the study of these patients. These patients do not normally take advantage of preventive medicine and only use the health service for urgent cases or when the illness has clearly manifested itself, when they can no longer ignore the illness, thus seriously complicating the diagnosis, the type of treatment necessary and the prognosis. The symptoms, which usually force immigrants to seek medical assistance, are lesions on the skin and venereal. This could be an opportunity for the dermatologist, by setting up ‘ad hoc’ services, to treat and study patients who, otherwise, would not be able to use the health system. Furthermore, particular attention has to be paid to clandestine immigrants.

This book shows, once again, the important role our discipline plays in the field of prevention of illness and promotion of health, in particular with the weakest members of the society who risk being marginalized.

This volume will undoubtedly, through the scientific icons of suffering and dermatological knowledge, contribute to the recognition of this new dermatological reality and stimulate further closer examination and scientific debate.

Our thanks go to all authors and collaborators for their precious work.

Aldo Morrone, MD

Jana Hercogova, MD

Torello Lotti, MD

CONTENTS 

Preface

PART 1 • CHAPTERS 1-7

GENERAL MEDICAL AND SOCIO-ECONOMIC ASPECTS OF POVERTY AND MIGRATORY PHENOMENA

Chapter 1 Tropical and Developing Countries

Chapter 2 Geographical, Climatic and Ecological Conditions

Chapter 3 Poverty and Migratory Phenomena: Medical and Socio-Economic Aspects

Chapter 4 Racial and Genetic Factors

Chapter 5 War, Health and Infancy

Chapter 6 Human, Cultural and Environmental Factors

Chapter 7 The Colours of the Human skin

PART 2 • CHAPTERS 8-27

SKIN AND SEXUALLY TRANSMITTED DISEASES OF THE POOREST AND HUMAN MOBILE POPULATIONS

A PRAGMATIC SPECIALISTIC APPROACH TO DIAGNOSIS AND TREATMENT

Chapter 8 Viral Dermatoses

Chapter 9 Bacterial Dermatoses

Chapter 10 Non-Venereal Treponematoses

Chapter 11 Sexually Transmitted Diseases

Chapter 12 Superficial Fungal Infections: An Overview

Chapter 13 Deep Mycosis

Chapter 14 Protozoan Dermatoses

Chapter 15 Helminthic Dermatoses

Chapter 16 Dermatoses Due To Arthropods

Chapter 17 Dermatosis Caused By Malnutrition

Chapter 18 Pigmentary Disorders

Chapter 19 Genodermatoses

Chapter 20 Eczema And Dermatitis

Chapter 21 Maculo-Papulo-Squamous Dermatoses

Chapter 22 Bullous Diseases

Chapter 23 Connective Tissue Disorders

Chapter 24 Urticaria And Drug-Induced Eruptions

Chapter 25 Cutaneous Appendages Disorders

Chapter 26 Benign Cutaneous Neoplasias

Chapter 27 Malignant Cutaneous Neoplasias

 

PART 3 • CHAPTERS 28-31

PECULIAR DERMATOLOGICAL PROBLEMS OF POVERTY AND BIO-ANTHROPOLOGICAL DIVERSITY

APPEAL TO THE INTERNATIONAL DERMATOLOGICAL COMMUNITY

 

Chapter 28 Miscellaneous Dermatoses

Chapter 29 Stop Female Genital Mutilation: Appeal To The International Dermatological Community

Chapter 30 Mobile Populations: A Diagnostic Clue For Difficult Cases

Chapter 31 Main Aims And Scopes Of The “International Dermatology And Human Mobile Population Committee”