Introduction
In 2003 the kind of population called Human Mobile Population (HMP), which includes migrants, asylum seekers, refugees, migrant workers and travellers, was more than one billion.
Considering the dangerous health conditions of this population and after a quick overview of what is happening in nearby countries and everywhere else in the world, we can explain why in the next few years more and more people will flood Europe, North America, Australia and other developed countries and why we will have to be able to manage this phenomenon in terms of public health.
We believe that the dermatologists can prevent disability and infections of the skin, contribute to reduce the incidence of leprosy, cutaneous tuberculosis, scabies, and improve prevention and management of skin cancer and HIV/AIDS as well as other Sexually Transmitted Diseases (STD)(1).
Recognizing the overwhelming evidence of the close relationship between poverty and poor health, and the responsibility of health systems to improve the health of the needy, the World Health Organization (WHO) Regional Office far Europe has gathered and analysed information on action taken in Member States to reduce poverty and improve the health of the poor populations. A collection of case studies, entitled Health Systems confront Poverty (2), was published last year. One of these case studies describes the innovative type of activity in the field of Migration, Poverty and Health of the Department of Preventive Medicine of Migration, Tourism and Tropical Dermatology (Dept.) at San Gallicano Institute - IRCCS in Rome (Italy), whose activities are in the spirit of the HMPC's aims.
The Department is actually one of the Collaborating Centres of WHO - European Office for Investment for Health and Development. During the activity of the Department over many years, a new model to reduce the number of people suffering from dermatological and/or other diseases was developed. In fact a network of public institutions and private organizations was established, working with disadvantaged people at many different levels: medical, social, psychological, anthropological, educational and occupational.
Probably this method is not very new because some doctors, already two centuries ago, were quite sensitive to the needs of their patients, being aware at the same time of the essence of their culture, tradition and emotions. However, nowadays the situation of the National Health Systems is structurally different, and we have also to consider the new economical and demographic aspect of today's world, situation that makes a holistic approach to the people's health very difficult and expensive. Nevertheless this model offered us, at least in our case, the possibility to help and to treat more efficiently many different kinds of distressed people without a strong impact in terms of expenditure for the Italian National Health System (INHS). We, as well as the authors of the publication "Health Systems confront Poverty ", are of the opinion that this model is not only ethically valid, but also practically and economically convenient, and that there is evidence that our experience is worth being repeated in as many situations as possible, also in the interest of public health.
Main fields of action
Immigrants
In the last 20 years 60,528 illegal and clandestine immigrants, coming from 146 different countries, made their first visit to the Department. 25,421 (42%) were females, 10% were children and the number of both is increasing with time. In 2003 26.3% immigrants were from Africa (in 1985-91, 73%, in 1992-94, 48%), 14.4% from Central and South America (in 1985-91, 7%, in 1992-94, 22%), 20.9% from Asia (in 1985-91, 12%, in 1992-94, 21%), 38.4% from eastern Europe (in 1985-91, 8% and in 1992-94, 19%). Altogether 79% of the immigrants observed were under 40 years old, but it is interesting to notice the slow increase of elderly immigrants over 60, who in our cases exceeded 11 %. In addition to these foreign patients, the percentage of Italian patients attending the Dept. has increased from 5% in 1985, to 25% at the beginning of 2004. This group is composed mainly of homeless (90%) and elderly people (10%). This phenomenon may in part be explained by the increase of the percentage of Italians (14.7%) who are under the poverty threshold. They have difficult access to the INHS and to the social and health care network, where complete coverage of their needs by the INHS is not fully available to them. These people come to the Dept. for all kinds of help, especially social and also for simple practices, such as intramuscular injections of drugs. The main diseases observed were the following: dermatological diseases (25.6%), infectious diseases (23.7%), digestive and intestinal diseases (12.2%), chest diseases (11.1%), orthopedic and traumatic diseases (10.7%), diseases of the genito-urinary tract (9.1%), HIV/AIDS infection (5.5%), psychiatric diseases (1.3%). No diseases were observed in 0.8% of cases.
Homeless
In Italy, homelessness has become a major problem with serious social, economic, and ethical consequences, and the homeless are estimated between 170,000 and 250,000. Since 1998 a medical Observatory has been established in the Dept, in collaboration with the Municipality of Rome and without any further expenditure for the INHS, for monitoring the health conditions of the resident, immigrant and nomadic homeless people (HP) in the metropolitan area of Rome.
3,162 people were visited (178 nomads and 305 refugees) representing 30% of HP in Rome, mainly young adult males (73.4%). 31.9% were Italian, 42% from non European countries. The most frequent countries of origin were Romania, Poland, Bosnia, Ukraine, Morocco, Moldavia, Iran, Tunisia, Albania, Iraq, Egypt. The commonest dermatological diseases observed were scabies, pediculosis, mycoses and bacterial infections.
Gypsies
Between 4 and 5 thousands gypsies live in Rome, divided into about 50 communities.
We visited 4,941 gypsies between 1996 and 2003 and observed a high prevalence of odontoiatric diseases (50.3%), skin diseases (24.4% scabies, 20.1% pediculosis, 9.6% tinea capitis, 8.9% tinea corporis), traumatic diseases (10.2%) and gastroenterological diseases (6.2% gastritis and duodenitis, 6.1 % liver diseases).
We observed also an increasing trend regarding alcohol and drug abuse by gypsies in Rome (about 500 with opioid addiction and about 700 with cocain/crack addiction).
In this case the cooperation between public health care structures and private organizations encouraged the active participation of gypsies in the management of their health and allowed the INHS to treat these people without any further expenditure.
Victims of prostitution trade
The women victims of prostitution trade in Western Europe are about 500,000.
As detected by Interpol, the profit from sex trade is about 7-8 billion euros per year and the income per year for each prostitute is about 150,000-180,000 euros.
In Italy the number of these women is about 50,000 coming mainly from China, Nigeria, Albania, Romania, Ukraine, for more than 9 million Italian clients.
From 1 st January 1998 to 1 st April 2003, 3,937 foreign prostitutes were registered for first medical examination in our Dept. The majority of them (98.8%) were un-documented or with an expired tourist residence permit.
The main diseases observed were the following: infectious diseases, mainly syphilis, tuberculosis and HIV/AIDS (32.7%), dermatological diseases, mainly burns (14.4%), gynaecological diseases, mainly STD (14.1%), orthopedic and traumatic diseases (13.2%), psychiatric diseases (11.3%), digestive and intestinal diseases (7.7%), other chest diseases (6.6%). Moreover we observed many cases of Female Genital Mutilation (FGM) with a prevalence of 43.2% among the women coming from endemic countries.
Although several health prevention campaigns in all European countries have been carried out in order to protect prostitutes and their clients, and even though in Europe laws that protect victims of prostitution trade exist, we need further interventions aiming at improving the protection of undocumented migrant women and at reducing the incidence of STD in young people.
Abandoned children and adolescents
In Italy, while the immigrant population has doubled during the last l0 years, for minors this has happened in just 4 years and their number now probably represents a fifth of the immigrant population.
In 2003 the number of foreign children in Italy was about 320,000 and more than 49% of them was born in Italy, which is now the oldest Nation in the world with 24.5% of people over 60 years of age.
For the first time in the history of humanity, the number of people over 60 will exceed, in 2050, the number of children under 14, with very important economic and social consequences related to this demographic lack of balance.
We visited 1,137 foreign minors in the last three years (401 from East-Europe, 185 from Latin-America, 156 from Asia and 140 from Africa), 255 of them had the double nationality, 50% of them were under 14 and 37% of them were abandoned. In our experience the health conditions of foreign minors in Italy is still worse than that of the Italian minors and there are not sufficient epidemiological and clinical studies on this subject.
The number of foreign minors in Italy increased by 5.0% in the last three years and this encouraging trend will be carefully preserved because we cannot hope in an unexpected improvement of the Italian (or European) people fertility rate. For these reasons we have to encourage a growth of the fertility rate among Italians and migrants too, but most of all we have to promote the entrance of new immigrants (to Italy as well as to Europe) and we have to improve their rapid integration in the new social, economic, occupational and educational context.
Refugees/asylum seekers and victims of torture
During the last five years we visited in our Dept. 924 refugees/asylum seekers from 39 different countries, most of them from Kurdistan and from Iraq. 82.5% were males with a mean age of 25 years, in 78% of the cases with a high educational level and in more than 60% of cases we observed signs of torture. The recognition of the status of refugee concerned only 30.1% of the cases; the absence of any work or economical support was the main problem for our patients, 31.7% of them were homeless and the main dermatological conditions observed were similar to the above mentioned diseases related to the homeless condition. The victims of torture represented 51% of the cases and most of them showed symptoms of depression and anxiety, panic attacks or agoraphobia. Poor sleep patterns are almost universal but are not usually revealed by the patients spontaneously.
In our experience the basic health needs of refugees/asylum seekers are broadly similar to those of the other migrants, and although symptoms of psychological distress are more frequent than those observed in the other patients, they do not necessarily signify mental illness. Poverty and social exclusion have a negative impact on health and time, patience, and a welcoming approach will break down many barriers, especially visiting the victims of torture.
Female Genital Mutilations
Female Genital Mutilation (FGM) is a condition that, while originating in distant countries and regions, is frequently observable in our country due to the continuous flow of people from the African continent, particularly Egypt, the Horn of Africa and Sudan sub-Saharan Africa. While being frequently practiced by people of the Islamic religion, it is also observed among Christian populations, animists and Jews (Ethiopian Falashas).
The WHO has classified FGM in 4 types:
Type 1. Excision of the prepuce, with removal of all or part of the clitoris.
Type 2. Excision of the clitoris, with removal of all or part of the labia minora.
Type 3. Excision of all or part of the external genitalia and narrowing of the vaginal opening ( infibulation ).
Type 4. Unclassified: includes perforation, penetration or incision of the clitoris and/or labia; stretching of the clitoris and/or labia; cauterization by burning the clitoris and surrounding tissue; scraping of the tissue surrounding the vaginal opening ( angurya cuts ) or incision of the vagina ( gishira cuts ); introduction of corrosive substances or herbs into the vagina to cause bleeding in under to close or tighten it; and any other procedure falling under the definition of FGM.
The complications observed are serious, both physical (haemorrhagic shock, vaginal fistulae, keloids, dermoid cysts) and psycho-sexual. A specially created law prohibits the practice being carried out in Italy.
In the last 20 years we examined 249 women affected by FGM (121 type 1, according to WHO classification, 69 type 2 and 59 type 3), coming from 13 different countries (Somalia, Egypt, Ethiopia, Eritrea, Nigeria, Sudan, Chad, Mali, Burkina Faso, Sierra Leone, Camerun, Niger, Senegal).
Immigrants and food
The presence of foreigners from different continents is by now structural within the Italian community, with an age distribution that becomes more and more ample, in which the people over 60 years old and the children under 14 are more represented than before. Moreover the last group of age is often born in Italy where the feeding habits are different from those of their parents.
We have to underline the fact that, together with the mother tongue, the feeding habit is one of the fundamental characteristics of the cultural identity of each population. In fact many studies carried out on the phenomenon of migration in Italy show that everybody feels very strongly the need to keep alive customs and traditions belonging to his/her own ethnic group, above all in the field of feeding and gastronomy.
On the other hand food is one of the factors recognised as fundamental for the maintenance of an ideal condition of health, so much so that one of the strategic lines of all the health studies concerns the digestive and metabolic diseases, with special regards to intestinal diseases, liver diseases, diabetes and obesity. It is well know in fact that many pathological conditions are related for example to incorrect feeding. Among these we find some types of tumours, type 2 diabetes, cardiovascular and ischemic diseases, arthrosis, osteoporosis, biliary lithiasis, dental caries and other iron and iodine deficiency diseases.
For these reasons we have developed in our Dept. a service with a specific aim: to investigate the feeding habits of the populations of immigrants who attend our hospital; to find out whether there may be any possible connection with the diseases related to feeding habits, and to propose and develop specific guide-lines for all public health services, and in particular a specific campaign of nutritional education to be carried out by trans-cultural operators, involving a multidisciplinary team: doctors, nurses, linguistic and cultural mediators, nutritionists, psychologists, sociologists and opinion leaders of the community.
We interwieved in 2002-2003 182 patients coming from 35 different countries (39% from Eastern Europe, 11% from North Africa and Middle East, 15% from Central and South Africa, 28% from Central and South America, 7% from Far East) in order to study their feeding habits and the anthropological and cultural aspects of nutrition. We observed in about 50% of patients the presence of malnutrition, that was successfully treated by nutritionists working at our Department.
Social, psychological, anthropological assistance and linguistic-cultural mediation
For long the belief has survived that the term 'health' could be properly defined by the expression ‘absence of disease', ‘well being', not being ill. Nowadays we have realised that health is not simply this and WHO felt bound to define health as ‘implementation for all human beings, women and men, of their whole potential in terms of physical, psychic, cultural and religious faculties'. This accounts for the inconceivability of defining 'healthy' people obliged to live abroad, in a foreign land, far from their families, devoid of friendship and love, without resources and a job.
To attend to the migrants therefore does not mean to take care only of their body, although most of them address the Department with requests centred on their 'ill' body.
In the last 20 years 60,528 immigrants coming from 146 different countries were observed from linguistic-cultural mediators.
Several kinds of demands have been specified: ‘clear' demands; demands concerning psycho-somatic problems; demands raising an unconscious psychological problem; demands for social help; demands for legal help.
In order to meet these different demands a particular attention is given to the patients' reception, organised by linguistic-cultural mediators with the supervision of the Social worker, and offered to the people addressing the service. The aim is both to refer people to the correct operators on the grounds of their needs and to meet cognitive requirements. For the latter reason patients are asked to answer a questionnaire useful for collecting data which can later be processed for further research and surveys.
The work of social secretariat concerns decoding and clarifying regulations in force in Italy and involves a network activity to keep in touch with the different organisations dealing with a same person, in order to be able, if necessary, to refer the person to the right institution.
Also differentiated are the psychological and medical activities of the Department service:
• 234 patients were followed by the psychologists or the psychiatrists from 2000 to 2003;
• analysis of the demand and, if necessary, assistance of person or families asking for psychiatric help was done;
• advice was given to the other Dept. operators on situations and cases at risk;
• all the Dept. operators are involved in a study group that meets every other week to discuss and check the work done, in order both to improve the service and to function as a referring and advice point for other institutions working on similar socially complex situations.
Within the Department is a medical-anthropological Counselling Service, specially aimed at detecting and taking care of cultural disadvantage as a risk of onset of diseases.
The Service avails of the help of anthropologists from Università “ La Sapienza ”, Rome.
Clinical, epidemiological and teaching activities in Ethiopia
During the last five years we started a clinical activity in Africa, namely in Ethiopia. The particulars of this activity in respect of 2003 are as follows:
1) We opened a dermatological department in the regional hospital of Quihà - Makallè (Tigray Region). This centre, accessible daily, provides for the local population dermatological consultations and necessary prescriptions, treatment for out-patients and, for some dangerous health conditions, hospitalization. Last year we visited and treated 1,217 patients, on whom we performed 118 skin biopsies that were histologically examined at San Gallicano hospital and the results of which were sent by e-mail to the Quhià hospital in addition to the necessary suggestions concerning treatment. We provided the patient with all the necessary information to facilitate his/her understanding of his/her disease, particularly in order to assure compliance of the patient to treatment and to make them accept preventive behavioural habits; and, as a result, to minimize the worsening progression of the disease and to prevent transmission of some contagious diseases. Therefore, minimization of costs can be achieved by making sure that the patient has in fact started medical treatment and is taking the preventive measures suggested. Such activity is possible with the contribution of a monthly paid local nurse whom we have trained in regard to assistance in this dermatological clinical duty. The local nurse has undergone a theoretical and practical course on how to obtain clear digital clinical images that are sent to San Gallicano hospital via the WEB. This last didactical task, which is not necessarily associated with medical assistance, is important mainly for three factors:
• a. In absence of the above mentioned activities of the local nurse, the patient could not be adequately diagnosed nor treated due to the lack of proper expertise.
• b. The filing of images from these diseases, more than just being a diagnostic tool for distant doctors, also becomes an essential tool to instruct other native health care workers who can treat some of these dermatological diseases. Therefore, we should encourage and propagate any initiatives taken of their own accord by the local health care workers within the local community ("self- empowerment") .
• c. In addition to instructing local medical workers, the filing of 1,993 clinical images, has proven useful to teach European medical doctors in the field of tropical dermatology and other infectious diseases of the skin. In fact, we have so far used such images to offer a course in the San Gallicano Hospital to train our medical doctors in this field. All the principal clinical, sociological and cultural case histories of patients in our Dermatological department in Tigray, have been stored in a computer data base by nine Italian medical doctors (dermatologists, surgeons and infective and tropical diseases specialists) who have participated in the medical missions in Tigray.
2) Prior to the activities of the medical doctors, the house had been made comfortable by being equipped with a refrigerator, beds and beddings, pots and pants, cutlery.
3) In the last year we suggested, outlined and discussed the development of a social and medical support programme for the Orphanage of Wukro, which hosts 200 orphan children from parents who died of AIDS or from the most recent war between Ethiopia and Eritrea. We have considered improving and extending our medical and social activities in Tigray against infectious and dermatological diseases (AIDS, tuberculosis, leprosy) and have provided preventive education and rehabilitation programmes for many years in Ethiopia and Eritrea.
Discussion and conclusions
The WHO's document "Health Systems Confront Poverty" acknowledges that poverty in Europe is multidimensional and is linked not only to material deprivation but also to low educational achievement, poor health, vulnerability and exposure to environmental and occupational risks, as well as voicelessness and powerlessness. Furthermore, it recognizes that poverty deprives individuals of the freedom to satisfy basic needs and rights. This might include freedom to achieve sufficient nutrition (food security), to obtain remedies for treatable illnesses, or to enjoy clean water or sanitary facilities. This lack of freedom prevents individuals from fulfilling their potentialities, thus leading to a great loss for society and hampering development. Poverty might also be the source of stigmatization within subgroups of our societies, within national borders and among countries - both rich and poor. Finally, the WHO's publication confirms that the impact of poverty might be unequally distributed among the poor and that it can have different impacts according, for example, to gender and age group (3).
We have to remember that the same "European" aspects of the poverty, described above, are valid for the all Developing Countries (DC) and they are more and more described in many articles and documents (4-13).
In our experience we could identify twelve global public health priorities that should be carried out by Dermatologists in the world:
1) Skin activities in developing and developed world should be integrated into the general health system based on primary health care and not only supported by secondary and tertiary care, as outlined at the Alma Ata conference, but also by political, social and economical interventions aimed at reducing poverty (14, 15).
2) To promote prevention activities around the world aimed at obtaining a reduction of some accidents, especially burns, or other culture-related dermatological injuries (e. g. cupping, coining, scraping, branding, FGM).
3) To reduce the practice of FGM in Sub-Saharan countries and to improve of care by proper education of health care providers (guide-lines) and prevention of new cases by women's education in developed countries (16).
4) To improve the health of the skin of women in the world reducing the gap existing in many different geographical areas of developing and developed countries (where we still observe many unacceptable health differences between men and women).
5) Provide increased and results-based financial and technical resources to scale up access to prevention, care and sustained treatment, including effective low cost treatment (using generic drugs), in the poorest countries suffering from HIV/AIDS, Malaria, Tuberculosis, Leprosy, Scabies and STD.
6) Ensure men, women and adolescents to have universal and equitable access to and promote the use of a comprehensive range of high quality, range, accessible and reliable skin care services.
7) Combat stigma and discrimination of disadvantaged people living in the poorest countries or in the big western metropolis.
8) Request the Global Commission on International Migration to take into account in its work the goal of “healthy skin for all”.
9) Improve and harmonize surveillance systems, in line with international standards, to track and monitor some skin diseases that could be a beacon to find the essential global health priorities: leprosy, skin cancer, scabies, cutaneous tuberculosis, ulcers, diabetic and madura foot, HIV/AIDS.
10) Monitoring and control of environmental hazards which pose a threat to human health, including potentially toxic chemicals, radiation, harmful consumer goods and biological agents.
11) To improve the quality of lire of many people suffering from disability.
12) Control and reduce the air and water pollution in order to better protect the skin from many irritants and allergens.
The title of the last WHO Report was: "Shaping the future" (17), but the future public health policies around the world will need to take under careful consideration the above mentioned global public health priorities and the impossibility to "shape the future" if we shall not include among our top priorities "a healthy skin for all” , particularly in the countries where the level of poverty is still unaccept able.
References
1) Chi-Keong ONG & Terence J. Ryan "Healthy skin for all", Oxford 1998.
2) D. Manfellotto "From misinformation and ignorance to recognition and care: immigrants and homeless in Rome, Italy" in E. Ziglio, R. Barbosa, Y. Charpak, S. Turner "Health Systems Confront Poverty" Public Health Case Studies No.5; Regional Office for Europe, World Health Organization, Copenhagen 2003.
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