Editorial Manager(tm) for Cutis Manuscript Draft Manuscript Number: 9--105 Title: The role of a dermatologist on military humanitarian missions Article Type: Special Features Corresponding Author: Dr Elizabeth K Satter, MD/MPH Corresponding Author's Institution: US Navy First Author: Elizabeth K Satter, MD/MPH Order of Authors: Elizabeth K Satter, MD/MPH Abstract: Recently the U.S. military in conjunction with allied military services and nongovernmental organizations have embarked on various humanitarian missions to underserved areas worldwide. These missions illustrate what interoperability between nations can accomplish. As a dermatologist, you encounter many conditions rarely seen in developed countries and learn to practice general dermatology with limited resources in austere environments.
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April 28, 2009
Melissa Steiger
Editor, Cutis
(Submitted electronically)
Dear Ms. Steiger:
Enclosed please find a manuscript entitled, “The role of a dermatologist on
military humanitarian missions”, which I would like to submit as a Special Feature article
for Cutis.
The article reviews military’s involvement in joint humanitarian missions and the
role of the dermatologist.
Thank you for your consideration of this article for inclusion into Cutis. I look
forward to hearing from you with possible editorial improvements.
Word count: Abstract 56 words, main text 1557 words, two tables 216 words and 5
pictures
With best regards,
Elizabeth K. Satter, M.D.
(Submitted electronically)
Cover Letter
The role of a dermatologist on military humanitarian missions
Elizabeth K. Satter, MD/MPH
Departments of Dermatology and Dermatopathology
Naval Medical Center
34520 Bob Wilson Drive Suite 300
San Diego, CA 92134-2300
619-532-9702
The views expressed in this article are those of the author and do not reflect the official policy or
position of the Department of the Navy, Department of Defense, or the United States
Government.
The author reports no conflict of interest, and there was no financial support.
Word count: Abstract 56 words, main text 1557 words, two tables 216 words and 5 pictures
*Title Page
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The role of a dermatologist on military humanitarian missions
Abstract
Recently the U.S. military in conjunction with allied military services and
nongovernmental organizations have embarked on various humanitarian missions to
underserved areas worldwide. These missions illustrate what interoperability between
nations can accomplish. As a dermatologist, you encounter many conditions rarely seen
in developed countries and learn to practice general dermatology with limited resources
in austere environments.
Continuing America's longstanding tradition of helping those in need, the U.S.
military has begun to focus on creating stronger partnerships with underprivileged areas
worldwide. To accomplish this goal, recently the military has embarked on various
humanitarian civic assistance missions to multiple countries in the Asian Pacific and
Oceania regions, as well as in the Caribbean and Latin America.
The idea of employing military personnel to undertake humanitarian and
peacekeeping projects is not new. In fact, the United States is the world's largest
contributor of military aid.1 In 2006 alone, the U.S. military participated in
approximately 556 humanitarian projects in 99 countries to include providing daily ration
packages to displaced personnel, responding to multiple natural disasters and re-initiated
proactive large scale humanitarian civic assistance missions.1 The latter missions utilized
hospital ships, as well as Navy gray hulled vessels to deliver health care on a large scale
basis. Hospital ships are unique platforms in that they serve as self-contained floating
*Manuscript (should not include ANY author information)Click here to download Manuscript (should not include ANY author information): HA Cutis final with abstract.doc
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health care systems. Currently the Navy has two hospital ships, the USNS Mercy (T-AH
19) and USNS Comfort (T-AH 20), run by the Military Sealift Command’s civil service
mariners. Originally oil supertankers, these 894-foot ships were converted to hospital
ships in the late 1980s. (Figure 1) Although designed to provide emergency, on-site care
for deployed U.S. combatant forces, they are also used to lend humanitarian aid and assist
in disaster relief. Each ship holds approximately 1000 hospital and support staff, and has
a 50-bed receiving area, 1000 hospital beds, 12 standard operating rooms and 100 critical
care beds. The ships have a full radiology department inclusive of computed axial
tomography, physical therapy, optometry, dental, a well-stocked pharmacy and complete
laboratory with a pathology department and blood bank.
These humanitarian missions serve as a coordinated joint effort between various
U.S. military services, allied military members and nongovernmental organizations who
work in conjunction with the host nation’s health care members. (Table 1) The missions
are designed to build bridges between foreign nations and form partnerships with a
common goal of improving health care in these regions illustrating what interoperability
between nations can accomplish. The medical complement includes a robust medical
team composed of various subspecialties that provide a range of services ashore, as well
as aboard the ship. The services offered include public health training, medicine (e.g.
internal medicine, neonatology, pediatrics, dermatology, infectious disease, cardiology,
nephrology, and preventive medicine) and surgery (e.g. general surgery, plastic surgery,
pediatric surgery, urology, otolaryngology, gynecology, ophthalmology and orthopedics),
in addition to providing dental, optometry, and veterinary services. Another component
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of the mission is to help revive the region’s infrastructure by utilizing the military’s
mobile construction battalion units.
Although these missions provide much needed health care to the regions served,
various obstacles can be encountered such as maintaining impartiality regarding assorted
political issues, overcoming language barriers, and recognizing and respecting the local
customs, beliefs and traditional medicine. 2
Additional logistic problems include
obtaining access to remote areas and identifying appropriate health care issues that can be
addressed during the short stay. The benefit of utilizing the military is that they can
provide diverse resources and technical expertise, and have the ability to move
equipment, supplies and people quickly and effectively through various modes of
transportation.
In addition to medical care onboard the ships, small contingents are sent to
remote, austere locations onshore. The small groups, referred to as Medical and Dental
Civil Action Projects (MEDCAPs) are composed of 30-100 personnel who offer basic
medical, dental, optometry care to adults, and children, perform minor surgical
procedures, as well as provide vaccines, medications and vitamins. Typically, each
MEDCAP stays in one location up to a few days utilizing tents, school houses, or existing
health care facilities. Approximately 1000 people are seen each day; some have common
illnesses or serious medical issues, while others simply come out of curiosity.
The main issues underlying the majority of health care problems were lack of
clean water, inadequate sanitation, and poverty. It was essential for providers to be aware
of endemic medical conditions not only to avoid misdiagnoses, but also to recognize
potentially fatal conditions. In many areas, the local people live by subsistence farming,
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or make less than 2-dollars a day. 3
Often the total caloric intake was adequate, but
protein consumption was insufficient; therefore, it was not uncommon to see children
with reddish hair, distended abdomens and dry flaky skin, thereby showing signs of
kwashiorkor. In other children, the total caloric needs were not met, and marasmus was
more common. Vitamin deficiencies were also seen. Occasionally a child presented at a
MEDCAP for other medical problems, but then complained of difficulties seeing at night
and dry eyes; thus showing the first signs of vitamin A deficiency. If a provider failed to
recognize this condition, not only was the child at increased risk for infection with
potential increased mortality if they contracted measles, but permanent blindness could
ensue.
The last nutritional issue encountered was goiter, which was attributed to a low
iodine diet and increased consumption of goitrogenic foods such as cassava. Cassava, a
starchy tuber, is a main staple in many developing countries. Although it provides a good
source of calories, it is low in protein and contains thiocyanate that interferes with
accumulation of thyroidal iodide, and results in elevated thyroid stimulating hormone and
thyroid gland enlargement. 4
Most patients were euthyroid, but had a markedly enlarged
thyroid; however, thyrotoxicosis or Graves disease were also encountered.
Although the majority of patients seen had general medical or surgical problems,
a variety of dermatologic conditions were also encountered (Table 2). Since resources are
limited, lesional morphology and clinical acumen are the main means of diagnosis.
Undoubtedly, infections were the most common dermatologic ailment. The frequency
and type of infection varied, but overall impetigo, abscesses, scabies and superficial
fungal infections were most common. Many cases of impetigo or abscesses in young
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children occurred because of poor hygiene and chronic persistent scabies infections. The
main problem treating scabies was that in many areas up to 10 people shared a one-
bedroom dwelling; hence, unless the entire family was treated, the infection simply
recurred. Moreover, even if the entire household was treated, often extended family
members were infected, which simply perpetuated the infectious cycle. Other problems
encountered were difficultly in communicating the permethrin treatment regimen, and
lack of clean water to remove the medication.
Tinea versicolor was by far the most frequent superficial fungal infection
encountered; yet, it was rarely treated because of its high recurrence rate and relative low
morbidity. Tinea corporis and capitis were also seen, but less frequently. In Papua New
Guinea, many indigenous people had tinea imbricata (Figure 2), which is hypothesized to
occur as a result of a genetic predisposition combined with poor hygiene, environmental
conditions, nutritional status, and an altered immune system.5 Other tropical infections
rarely seen stateside, but common in the South Pacific, were yaws (Figure 3) and
leprosy.
The most common infection that had the highest morbidity and mortality was
tuberculosis. According to the World Health Organization (WHO), nearly 2 billion
people, one third of the world's population, has been exposed to Mycobacterium
tuberculosis. 6
In 2007, 9.27 million new cases were identified, and most were in
developing countries. Despite the WHO’s efforts to increase the number of Direct
Observed Therapy Short-course (DOTS) programs that provide free anti-tuberculosis
medications, less than 25% of TB patients are enrolled in these programs.6 Another
weaknesses of the program is only adults can receive medications, since children are
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considered less infectious. Moreover, the diagnostic testing required to obtain the
medications is not free, and is often beyond the means of the patient, and frequently the
clinics run out of medications. Therefore, many people with tuberculosis go untreated; in
fact, we frequently saw emaciated patients with chronic untreated tuberculosis,
previously referred to as consumption. Scrofuloderma (Figure 4) was also common, and
occasionally primary cutaneous TB or a Potts abscess was seen (Figure 5).
Dermatologic conditions other than infections were also seen, but less frequently.
Many dermatologic conditions were chronic and require long-term medications;
therefore, since medications routinely used stateside are often unavailable and/or beyond
the patient’s means, knowledge of what is locally obtainable was essential. Sometimes
education was the only service that could be rendered. Constraints also occurred when
medications were dispensed for acute conditions. For example, often there was difficulty
in translating the instructions for taking medications because of language barriers
secondary to multiple regional dialects. Additionally, many people did not have
electricity; consequently, medications that require refrigeration could not be dispensed.
Lastly, since the incidence of glucose-6-phosphate dehydrogenase deficiency is increased
in some regions and there is no means to test for this condition, all patients were
considered at risk; therefore, medications associated with hemolysis were restricted.
The last role of the dermatologist during these missions was to perform minor
surgical procedures and to identify neglected cutaneous malignancies requiring general
surgery. Since most minor surgeries occurred out in the field in less than optimal
conditions with no diagnostic capabilities and limited follow-up, careful selection of the
cases was warranted.
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In conclusion, it has been a privilege to participate in several military
humanitarian missions. The missions are rewarding on many levels; not only do you help
people in desperate need of medical care, you also see conditions rarely encountered
stateside, and learn to practice general dermatology with limited resources in austere
environments.
For those who would like further information on these missions please visit the websites
for the USNS Comfort and USNS Mercy, and/or Pacific Partnership 2008 and
Continuing Promise 2009. Civilians, interested in participating in future U.S. military
humanitarian and civic assistance missions, should contact affiliated nongovernmental
organizations to learn more.
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Figure Captions
Figure 1: USNS Mercy
Figure 2: A classic case of tinea imbricata with multiple adjacent concentric plaques
Figure 3: Annular lesions of secondary yaws
Figure 4: Scrofuloderma
Figure 5: Potts abscess lower left back
Table 1: Examples of participant on prior humanitarian assistance missions
Table 2: Dermatologic conditions encountered on prior humanitarian missions
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Table 1
Examples of participant on prior humanitarian assistance missions
US military services: Air Force, Army, Navy and Public health service
Allied military members: Australia, Bangladesh, Canada, Chile, India, Indonesia, Japan,
Malaysia, New Zealand, Papua New Guinea, Philippines, Portugal, Republic of Korea,
Singapore, Spain
Nongovernmental organizations: e.g. Aloha Medical Mission, East Meets West
foundation, Operation Smile, Project HOPE, International Relief Team, Save the
Children, Tzu Chi Foundation, University of California Pre-dental Society
Table 2
Dermatologic conditions encountered on prior humanitarian missions
Routine infections: impetigo, abscesses, scabies, chicken pox, varicella zoster,
molluscum, herpes, tinea (capitis versicolor, corporis), HIV
Tropical disease (South East Asia): Dengue, lymphatic filariasis (LF), leprosy, yaws,
tinea imbricata, white piedra, deep fungal infections, Buruli ulcers, tuberculosis (primary
cutaneous, scrofuloderma, Potts syndrome).
Tropical diseases (Latin America): Chagas disease, leishmaniasis, onchocerciasis
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Autoimmune and Inflammatory disorders: Lupus, scleroderma, vesiculobullous
disorders, psoriasis, eczema, contact dermatitis, lichen amyloidosis, acne, hidradenitis
suppurativa, vitiligo, alopecia areata
Genetic and congenial disorders: Neurofibromatosis type I, ichthyosis, ectodermal
dysplasia, nevus of Ito and Ota, Proteus syndrome, Klippel-Trenaunay syndrome, Kindler
syndrome, multiple familial trichoepithelioma, hemangiomas, vascular malformations,
epidermal nevi, xeroderma pigmentosa
Congenital defects: cleft palate and lip, clubbed feet, congenital heart disease
Malnutrition: Marasmus, kwashiorkor, night blindness/ xeroderma
Neoplasms: BCC, SCC, adnexal tumors, melanoma
Trauma: Burns from kerosene stoves, cuts from machetes, bullet wounds
Minor surgeries performed: Incision and drainage of abscesses, removal of epidermal
cysts, ganglion cysts, lipomas, fibroepithelial polyps, limited cutaneous malignancies.
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References
1. America.gov. U.S. Military Humanitarian efforts planned for 99 nations.
Available at (http://www.america.gov/st/washfile-
english/2006/July/20060712172520berehellek0.4737207.html). Accessed April
14, 2009.
2. Ritchie EC and Mott RL. Military Humanitarian Assistance: The Pitfalls and
Promise of Good Intentions. Chapter 25 In Beam TL and Sparacino LR, eds.
Military medical ethics. Vol 2 Washington, DC: Office of the Surgeon General at
TMM Publications Borden Institute Walter Reed Army Medical Center 2003:
805-830.
3. Davis KD, Douglas T, Kuncir E. Pacific Partnership 2008: US Navy Fellows
provide humanitarian assistance in Southeast Asia. Bull Am Coll Surg. 2009; 94:
15-23.
4. Chandra AK, Mukhopadhyay S, Lahari D, Tripathy S. Goitrogenic content of
Indian cyanogenic plant foods & their in vitro anti-thyroidal activity. Indian J
Med Res 2004; 119: 180-185.
5. Satter, EK. Tina Imbricata. Cutis. 2009;83: 188-191.
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6. Who report 2009-Global tuberculous control. Available at
www.who.int/tb/publications/global_report/2009/key_points. Accessed April 14,
2009.
Figure 1:USNS MercyClick here to download high resolution image
Figure 2: A classic case of tinea imbricata with multiple adjaceClick here to download high resolution image
Figure 3: Annular lesions of secondary yawsClick here to download high resolution image
Figure 4: ScrofulodermaClick here to download high resolution image
Figure 5: Potts abscess lower left backClick here to download high resolution image
