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Will a public health or a medical approach work best for scabies?

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.

Comments 4

  1. Melissa Sweet says:

    Dr Andrew White, a paediatrician and senior lecturer at the James Cook University School of Medicine in Townsville, has asked for these comments to be posted on his behalf:

    1. Of course we should not promote only medical solutions. Improving access to school, education, appropriate housing etc must be a given as well as whatever medical treatment is proposed. We must not think of these things as mutually exclusive.

    2. Unfortunately Australia has a very poor record in improving local economic and social circumstances, infrastructure and housing so these solutions while most important realistically will not be achieved quickly.

    3. Scabies is extremely uncomfortable, causes significant pain and suffering and has been linked to longer term health problems, so it is not an insignificant problem. If you and your family suffered from frequent scabies and skin infections and you were offered a community medication program which might dramatically reduce your families discomfort in months would you be keen to consider this option? Has anyone asked people in Aboriginal communities if they would support such a program?

    4. For programs to work and be sustained in the longer term in Indigenous communities, we should advocate for community involvement in planning and implementation and that the programs support local employment and provide training etc. So even a very “medical’ program being implemented may assist in improvements in (non medical) community development. If a program was introduced evaluation could include not just rates of scabies and skin infections and sequelae but more general measures such as school attendance, absences from work, general well being, and rates of depression.

    5. And incidentally how much did the focused medical program for trachoma which provided community azithromycin contribute to the eradication of donovanosis?

    6. We should be focusing on promoting good health, rather than just treating single diseases but where there is evidence that benefit outweighs risk, treatment is available, a program is achievable and communities are involved and support the program, why not do both.

  2. Melissa Sweet says:

    Glenn Salkeld, professor of public health at the University of Sydney, asked me to post this comment on his behalf:

    Today I was walking along University Avenue in Toronto, past the many hospitals, health facilities and organizations that provide patient care, research and teaching in this city.

    What I saw on the front of some buildings and billboards were simple messages – “We can conquer cancer”, “Let’s end childhood obesity”. Simple messages that belie the complexity of the problem and possible solutions.

    I’m sure the complexity is not lost of the people who work inside these buildings. Perhaps the simple messages are meant to appeal to a public that wants hope and benefactors who want action and solutions. But if ending obesity was so simple, don’t you think we would have done it by now?

    So when I read about Sam Prince’s call for “One Disease at a time”‚ and to”take out scabies”‚ I wonder how this addresses a far more complex problem, one that points to inadequate housing, sanitation and social infrastructure in remote Aboriginal communities.

    I am sure that the complexity of the problem is not lost on any of the experienced members of the Board for One Disease at a Time. But if you knock off one disease through drug treatment without addressing some of the underlying causes of that disease, in particular the social determinants of disease, then surely that leaves the door open for competing causes of illness to step in and fill the breach.

    If tackling one problem at a time is a call for action and for support, then let’s broaden our notion of the problem. As Lesley Barclay says, “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”.

    Perhaps also there is a challenge is to appeal to our corporate friends and supporters to donate their time and money towards tackling health problems rather than single diseases.

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conflicts of interest
death and dying
diabetes
digital technology
disabilities
e-health
emergency departments and care
Equally Well
euthanasia
evidence-based issues
general practice
genetics
health & medical marketing
health and medical education
health and medical research
Health Care Homes
health ethics
health financing and costs
health reform
health regulation
health workforce
HIV/AIDS
hospitals
HRT
infectious diseases
influenza
international medical graduates
journal articles
LGBTIQ
medical marijuana
Medicare Locals
men's health
mental health
MyHospitals website
National Commission of Audit 2014
National Health Performance Authority
naturopathy
NDIS
NHMRC
non communicable diseases
nurses and nursing
oral health
organ transplants
out of pocket costs
pain
palliative care
paramedics
pathology
Pharmaceutical Benefits Scheme
pharmaceutical industry
pharmacy
Pregnancy and childbirth
primary health care
Primary Health Networks
private health insurance
quality and safety of health care
rural and remote health
screening
sexual health
social media and healthcare
suicide
surgery
swine flu
telehealth
tests
TGA
trauma
women's health
youth health
Indigenous health
#CTG10
#NTRC
Acknowledgement
cultural safety
Indigenous education
Lowitja Institute
NT Intervention
social and emotional wellbeing
Uluru Statement
WA community closures
News about Croakey
PIJ Commissions 2021
Public health and population health
#PreventiveHealthStrategy
#UnmetNeedsinPublicHealth
air pollution
alcohol
consumer health matters
COVIDwrap
environmental health
Fetal Alcohol Spectrum Disorders (FASD)
food and nutrition
gambling
Government 2.0
gun control
health communications
health impact assessment
Health in All Policies
health inequalities
health literacy
human rights
illicit drugs
injuries
legal issues
marriage equality
Media Doctor Australia
media-related issues
nanny state
National Preventive Health Agency
obesity
occupational health
physical activity
plain packaging
prevention
public health
public interest journalism
road safety
sport
sugar tax
tobacco control
transport
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violence
Web 2.0
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Royal Commission
Social determinants of health
discrimination
education
housing
justice
Justice Reinvestment
NBN
Newstart
poverty
racism
social policy
Summer reading 2020-2021
Tasmanian election 2021
Testing Croakey News category 1
The Croakey Archives
#cripcroakey
#HealthEquity16
#HealthMatters
#IHMayDay (all years)
#IHMayDay 2014
#IHMayDay15
#IHMayday16
#IHMayDay17
#IHMayDay18
#LoveRural 2014
Croakey Conference News Service 2013 – 2019
2013 conferences
Australian Centre for Health Services Innovation Forum 2013
Australian Health Promotion Association Conference 2013
Closing the Credibility Gap 2013
CRANAplus Conference 2013
FASD Conference 2013
Health Workforce Australia 2013
International Health Literacy Network Conference 2013
NACCHO Summit 2013
National Rural Health Conference 2013
Oceania EcoHealth Symposium 2013
PHAA conference 2013
2014 conferences
#IPCHIV14
AIDA Conference 2014
Congress Lowitja 2014
CRANAplus conference 2014
Cultural Solutions - Healing Foundation forum 2014
Lowitja Institute Continuous Quality Improvement conference 2014
National Suicide Prevention Conference 2014
Racism and children/youth health symposium 2014
Rural & Remote Health Scientific Symposium 2014
2015 conferences
#CPHCEforum
#CRANAplus15
#HSR15
#NRHC15
#OTCC15
Population Health Congress 2015
2016 conferences
#AHHAsim16
#AHMRC16
#ANROWS2016
#ATSISPEP
#AusCanIndigenousWellness
#cphce2016
#CPHCEforum16
#CRANAplus2016
#IAMRA2016
#LowitjaConf2016
#PreventObesity16
#TowardsRecovery
#VMIAC16
#WearablesCEH
#WICC2016
2017 conferences