At the national rural health conference in Perth this week, Dr Sam Prince – a doctor, entrepreneur and philanthropist – talked about the goal of the One Disease at a Time foundation “to take out scabies”, to use mass treatment programs to eradicate the infection from Aboriginal communities. (Update: you can watch his full presentation here).
The presentation sparked much subsequent discussion. Professor Lesley Barclay, who is Director of the University Centre for Rural Health in northern NSW for the University of Sydney and previously worked in the NT, was among those questioning whether communities would be better served by a public health approach that would not only help tackle scabies but bring other benefits.
Professor Lesley Barclay writes:
When health problems arise in a community or a group of people, the natural response of many is to look for a medical solution.
But this approach does not always yield the greatest health dividends or the wisest use of health resources.
Sometimes the best approach is to look for a public health solution – to look for interventions that tackle the root causes of poor health, rather than fixing the symptoms through medical treatments.
At the national rural health conference in Perth this week, the difference between these two approaches was starkly outlined during discussions about how to tackle scabies, an infectious disease caused by mites that burrow under the skin.
A solution was proposed that built on inspiration from a spectacularly successful program – the Australian Donovanosis Eradiction Project – which dealt with an uncommon sexually transmitted infection. This was treated effectively and eradicated with the introduction of a new antibiotic.
However, scabies eradication represents a much greater challenge. Donovanosis is a disease very unlike scabies and its rapid elimination represents an exception rather than the rule.
Scabies is highly infectious and is caught through skin contact with an infected person or their bedding or clothing. It causes itching and often infection where the skin has been broken with subsequent infections causing more serious problems.
It is widespread and common in remote Indigenous communities, and is a symptom of the poor infrastructure afforded these communities – inadequate housing, overcrowding, poor health knowledge and literacy and lack of access to water – or the necessary facilities for washing.
The opening session of the conference heard from a doctor, entrepreneur and philanthropist, Dr Sam Prince, whose One Disease at a Time foundation has set a goal of eliminating scabies from Australia by eradicating the disease though drug treatment.
While scabies needs to be treated with creams or drugs, it is the re-infection and cyclical nature of this that starts early in life, often as a baby, that is common in remote Aboriginal communities – but unusual in the rest of Australia.
The treatment alone will not result in long-term eradication in individual communities, due to the significant mobility of Aboriginal people in the Top End and elsewhere. The continued existence of scabies is an indicator of social disadvantage and it will persist, despite medical treatment, until people have access to the basic essentials for health.
The evidence tells us that prevention of scabies consists of washing clothes in hot water or using a clothes drier and heat to kill the mites. In houses where our beds are our own and not shared, and clothes and bedding are frequently changed, scabies is rare. In Aboriginal communities with overcrowded housing and few washing machines and driers, early infection and reinfection is common.
It was suggested at this conference that we treat the whole community with a drug to kill the mite. In fact this is being undertaken in one place in the Top End currently.
However treating a disease that is caused by poorer living conditions with a potent medication is a challenging concept.
Clean drinkable water, facilities for washing and a capacity to wash clothes and live in ways that do not transmit disease is a taken for granted luxury by most Australians. If scabies occurs in a city or a country town though contact with an infected person it is treated and goes away because we have access to basic services and housing that minimises spread.
Why should remote Aboriginal Australia be different and continue to experience overcrowded houses, poor plumbing, unpalatable water and poor access to washing machines?
Clean palatable water that is fluoridated not only keeps our skins clean but also prevents dental disease and minimises the need to drink other fluids such as soft drinks associated with obesity. Remote and rural water supplies are almost never fluoridated. This is despite of high rates of dental disease and the minimal dental care available and the implications of dental disease on other aspects of health eg chronic disease.
Why are we considering eradicating a one disease, scabies, when we could achieve so much more in Aboriginal Australia by going direct to the heart of the matter?
If housing and infrastructure were comparable, we would not have this disease in epidemic proportions, we could also minimise dental disease and treat any scabies that remains with conventional strategies.
The new housing going in to the Northern Territory needs to have infrastructure such as clean palatable water and the capacity to wash clothes and bedding as crucial to this work – they are not additions.
In most parts of Australia, housing in cites or towns will not be permitted by councils or shires unless supply of water or sewage is available. Not in remote Australia.
As revealed recently by the ABC, even normal building standards are not mandated in NT remote communities. This would be unthinkable in mainstream Australian towns.
Not only do we not apply conventional building standards, we are going to treat a whole community with medication to get rid of a mite that causes disease that exists because of these inequitable living conditions.
The real challenge is to find the mechanism that puts in place the one solution to many diseases, including scabies, in remote Aboriginal communities – clean water and healthy housing.
We should be focusing on promoting good health, rather than just treating single diseases.
• Lesley Barclay began working in the NT in remote communities in the early 2000s, taking up a 5 year appointment of Health Services Development in Darwin. In 2009 she began her role as professor and Director of the University Centre for Rural Health in northern NSW for the University of Sydney. She is still leading an NHMRC study on maternal infant health in the NT, working in two remote communities. This will continue until 2012.