In this guest editorial, Muhammad Shahid Yousuf discusses the disparities in health provision in the Middle East.

Saudi Arabia is the largest country of the Arabian Peninsula with a population of 23.6 million, 80% of whom live in urban centres [1].The past decade has seen a significant surge in the incidence of skin disease in Saudi Arabia, with almost 20% of children between the ages of 6 and 18 suffering from eczema [2]. The symptoms of eczema, including itching, dryness, blistering and bleeding, can cause significant distress to patients and be a signifier of other conditions, such as ulceration of the lower limb. The sharp rise in eczema incidence is possibly due to environmental changes, including higher pollution levels and an increase in food allergies.

Many kinds of drug, including homeopathic and herbal medications, are freely available over-the-counter in Saudi Arabia. Similarly, all consultations and medications are free for Saudi citizens in government hospitals and eczema medicines are easily available. Unfortunately, however, many primary care services are not well organised and management programmes targeting chronic disease are often ineffective due to poor professional skills - this results in misdiagnosis or mismanagement of major chronic conditions [3].

The incidence of eczema across the country is inconsistent. One study carried out in Eastern Province found that dermatitis/eczema were the most frequent dermatoses (19.6%), with atopic dermatitis constituting 36% of eczemas [4]. However, contrary to these findings, patients in the north-western region of Hail, where the majority of people work in agriculture and follow traditional values and beliefs, demonstrated a low prevalence of atopic eczema (8.25 %) [5].

There is a growing body of opinion that the hygiene hypothesis, which argues that by preventing disease in childhood we are impeding the immune system's ability to respond to disease, could be responsible or these variations. In areas of the country with better access to healthcare, patients have usually been more exposed to antibiotics and medication from an early age.

Whatever the causes, it would be a positive step if dermatology provision across the country were to become more consistent. Like many other countries, Saudi Arabia suffers from a lack of co-ordination in its health care system. The primary care service is particularly inconsistent - many doctors are not experienced in treating skin diseases and in most cases use high-potency steroid preparations because patients and parents want quick results.

The majority of the patients distrust local GPs and bypass the primary care altogether to get a specialist dermatological consultation in a secondary care hospitals. Unfortunately, this causes long waiting lists and large numbers of patients simply rely on private dermatologists or use over-the-counter medicines.
 
Another problem is that hospital dermatologists are well qualified but are not supported by specialist nurses with the necessary interpersonal skills to demonstrate how patients should apply topical preparations or tailor information to patients' specific needs. This lack of nurses has been recognised in our dermatology department and since last year we have been arranging training in the supportive care of skin disease.
 
Whether it is to do with pollution, denser populations or the reckless use of antibiotics, there is no doubt that there is a disparity in the prevalence of skin conditions across Saudi Arabia. This is not helped by under-developed primary health services in some areas. It is only by ensuring that everyone has access to similar levels of treatment that higher rates of eczema in Saudi Arabia can begin to be managed.

See the author's case report on managing childhood eczema by clicking here.


Author details

Dr Muhammad Shahid Yousuf, Specialist Paediatric and Neonatology, Ministry of Health, Saudi Arabia

REFERENCES

1. Demographic Survey. Kingdom of Saudi Arabia, Central Department of Statistics, Riyadh, 2006.
2. Significant rise in childhood eczema across the Mideast. Khaleej Times 2004. Available at: http://www.khaleejtimes.com
3. Siddiqui S, Ogbeide D, Karim A, Al-Khalifa I. Hypertension control in a community centre at Riyadh, Saudi Arabia. Saudi Med J 2001; 22: 49-5.
4. Ruiz RG, Kemeny DM, Price JF. Higher risk of infantile atopic dermatitis from maternal atopy than from paternal atopy. Clin Exp Allergy 1992; 22(8): 762-6.
5. Parthasaradh, A, Al Gufai AF. The pattern of skin diseases in Hail Region Saudi Arabia. Ann Saudi Med 1998; 18(6): 558-61.