Humanitarian dermatology extends its reach

By Emily Margosian, Assistant Editor, September 1, 2022

“When you take a step back and look at why we went into medicine, what is it that drives us?” asked Naurin Ahmad, MD, MPH, FAAD. “Medical mission work not only gives us the chance to practice medicine but reconnect with what motivated us to become physicians in the first place.”

This month, DermWorld talks to dermatologists involved in recent humanitarian relief efforts across the globe and within the United States about what motivates them — and how their work has impacted communities in need.

Assistance for Afghan evacuees

In 2021, several dermatologists took part in evacuation efforts for Afghan refugees escaping the country. “After the fall of Kabul in August 2021, tens of thousands of Afghans converged around the airport hoping for protection and a way to leave the country. People selected for evacuation flew on U.S. military aircraft, and most were eventually taken to Ramstein Air Force Base in Germany,” explained Scott Norton, MD, MPH, MSc, FAAD, who served as a volunteer medical officer on flights transporting Afghan evacuees from Germany to the United States.

From August to December 2021, evacuation efforts from Ramstein to Dulles International Airport in Washington, D.C., were underway. Lt Col Simon Ritchie, MD, FAAD, was responsible for overseeing medical services for Afghan evacuees passing through the base. “I am not normally the commander of the medical forces out here at my base in Germany, but a large portion of it ended up falling to me because I was the chief of the Field Response Team at the time. While I’ve had some opportunities to do humanitarian aid work through the Air Force as a dermatologist in the past, nothing really prepared me for this,” he said. “We were dealing with separated families, people who had been attacked and shot by the Taliban literally hours earlier as they tried to escape to the airport, blunt force trauma injuries, stab injuries, and a lot of old disease that had never been taken care of because a lot of these people came from very poor areas. It’s hard to train for this sort of thing, and it was unexpected that I, a dermatologist, ended up leading this effort. In the end, it worked out well because a lot of the medical issues that we dealt with did fall within the realm of dermatology.”

According to Dr. Ritchie, the base had roughly 48 hours to prepare for the arrival of the first evacuees. “We initially did not have any intention of holding people there for a long period of time because we were simply not equipped for that. The idea was that they would land here as a waystation, get processed through the State Department, and get on a plane to the United States,” he said. “That worked for about the first 12 hours, but then we started hitting a lot of bottlenecks. At my holding area at any given time, I had up to 7,000 Afghan refugees who we were providing care for. We had to source baby formula, bottles, blankets, sleeping bags, and cots. We reached out to the Red Cross, the United Service Organizations, all these different agencies for help.”

Beyond immediate injuries, physicians also had to contend with infectious disease threats from COVID-19 and measles. “We ended up not moving anybody for two months out of concern of infectious disease,” explained Dr. Ritchie. “We had to vaccinate everyone for measles, chickenpox, and COVID. In the end, we had roughly 35,000 travelers come through Ramstein, with thousands there at a time during that three-month period.”

“We were dealing with separated families, people who had been attacked and shot by the Taliban literally hours earlier as they tried to escape to the airport, blunt force trauma injuries, stab injuries, and a lot of old disease that had never been taken care of because a lot of these people came from very poor areas. It’s hard to train for this sort of thing, and it was unexpected that I, a dermatologist, ended up leading this effort.”

During evacuation efforts, there was a need for medical professionals to supervise and provide aid on flights from Europe to the United States. “As we started airlifting Afghan refugees back into the country, it was noted that they were arriving very ill, dehydrated, and incredibly tired,” said Arturo Saavedra, MD, PhD, FAAD, who served on two flights in the fall of 2021 transporting Afghan evacuees to the United States. “As time went by, it became clear that people were getting sicker and sicker, and that we needed medical professionals to fly as we transported people into the country. The Medical Society of Virginia sent out a request for help; I got the email, and 24 hours later I was on a flight. My dad is a Cuban refugee, and the opportunities that this country afforded him and my family are incredibly dear to me. How could you not repay in kind when you have been the direct recipient of such kindness? As a physician, I really felt that moral imperative to help.”

According to Dr. Norton, volunteer medical officers were primarily tasked with addressing any medical emergencies that might occur aboard so that the flights would not be diverted en route from Germany. “In the first 10 days, the evacuees had just escaped a horrific situation, and there were a lot of mental health issues, particularly panic attacks,” he said.

Dr. Saavedra agreed. “When you combine physical exhaustion and potential disease with the incredible emotions of what was happening in their lives, you can imagine that medical symptoms, in addition to emotional distress, synergize in awful ways. I saw things I never thought I’d see and had to learn on the spot how to handle medical emergencies in the context of human devastation.”

According to Dr. Saavedra, while dermatologists might seem like unlikely assets in disaster scenarios, their unique skill sets are often beneficial in times of crisis. “I have practiced dermatology for many years and had to brush up on some important skill sets for immediate response. However, what I learned through this experience is that dermatologists have so much to offer specifically in humanitarian efforts. When you’re on a plane, you have very limited tools, but what you do have is the power of observation and touch, and those are things we practice every day,” he explained. “As dermatologists, we’re experts in visual inspection and the ability to recover cues from the environment, particularly around patients who don’t speak your language and with whom you can’t communicate verbally. This gave me a new perspective on my role as a doctor, and the incredible impact we can have.”

Organizing supplies for Ukrainian first responders

In response to reports of heavy injuries and casualties in Ukraine, several dermatology practices across the United States organized the collection of medical supplies for first responders. In March 2022, New York dermatologist Brian Raphael, MD, FAAD, collaborated with other regional medical practices to gather and distribute supplies. “In the beginning I was working with Dr. Amy Derick in Chicago, who was coordinating a large-scale national effort to send supplies to Ukraine. We ultimately organized a smaller effort here, recruiting local physicians and community members,” said Dr. Raphael. “We have a large Ukrainian population here in upstate New York, and we worked with a local church to get supplies to Poland, and then on to Ukraine.”

According to Dr. Raphael, local dermatology groups and other medical specialties worked together to gather a range of supplies. “We donated all sorts of things: gauze, gloves, sutures, iodine, alcohol pads, and a variety of different medical supplies that first responders and wounded victims in the area would need during the war effort. We expanded what we collected to include anything needed for daily use or personal hygiene because so many victims were now homeless and didn’t have access to day-to-day personal needs.”

A focus on community was a driving force behind the collaboration, said Dr. Raphael. “We try to help our community on both a local and global scale whenever we can. During the pandemic, we donated a lot of supplies to hospitals when they were needed, so this was just another avenue,” he said. “I think this hit close to home for a lot of our staff, who are either married to descendants of Ukrainian immigrants, or are of Ukrainian descent themselves. As dermatologists, there’s a lot more we can do in our practices to help than just our day-to-day medical service.”

Medical aid in Bangladesh

In 2017, a massive humanitarian crisis unfolded in Myanmar as hundreds of thousands of Rohingya were forced to flee after decades of ethnic and religious persecution. By 2018, an estimated 1.1 million Rohingya refugees were residing in camps in adjacent Bangladesh, many lacking access to food, clean water, and medical services. Dr. Ahmad spent five weeks in Bangladesh in the spring of 2018 providing medical care to Rohingya refugees. “I had an ophthalmologist friend who had just returned and told me about her experience and what the needs were there,” explained Dr. Ahmad. “I was born in Bangladesh and immigrated as a young child to the United States. I come from a family of physicians and academics who always emphasized service. I really am one of those physicians who thinks health care is a basic human right.”

Dr. Ahmad was responsible for seeing roughly 50 patients a day, providing direct patient care, and working with interpreters. “The Rohingya people speak a language called Rohingya, which is not common, so very few people can understand it,” she explained. “I’m dually trained in internal medicine and dermatology, and originally went there in the capacity to serve as an internist. When I arrived, however, there had never been a dermatologist in the refugee camp before, so I was pushed from doing basic medical care to primarily surgical and dermatologic care for these patients.”

“I came from a family of physicians and academics who always emphasized service. I really am one of those physicians who thinks health care is a basic human right.”

From a care-delivery standpoint, Dr. Ahmad says an unexpectedly difficult challenge was navigating patients’ severe emotional trauma. “A lot of these patients were victims of physical torture. These were things I had never seen in my prior medical missions. I was prepared to deal with physical trauma — that was the easy part. Dealing with emotional trauma was quite challenging, especially with a language barrier.”

Dr. Ahmad encourages dermatologists interested in medical missions to do their research into the organizations they choose to partner with, and to take time to care for their own mental health afterward. “I can’t stress it enough because it does affect you. We’re not as desensitized as we like to think we are as physicians,” she said. “Understand the patient population that you’re serving and what their needs are. Don’t take part in medical tourism; go to clinics that have continuity of care, versus a pop-up that’s there for a month and gone the next day. It’s important to find an organization that really has their boots on the ground and will be there for the long term.” To learn more about telemedicine opportunities in Bangladesh, visit Medglobal.org.

Dermatology care for underserved populations during the pandemic

Within the United States, a group of dermatologists from the University of Pennsylvania have partnered with a community clinic in Philadelphia to provide a unique model of care to underserved populations during COVID-19. “Puentes de Salud was started by an emergency medicine doctor at Penn who wanted to provide high-quality health care for the undocumented and immigrant populations in the community,” explained Emily Baumrin, MD, FAAD, who serves as faculty director of dermatology involvement at the clinic. “It has since become its own self-sustaining clinic that’s open five days a week, with continued volunteer involvement from University of Pennsylvania sub-specialties, including dermatology. It serves primarily Latino/Latina immigrants, although it will see anyone who doesn’t have insurance.”

Dr. Baumrin initially got involved in the clinic as a volunteer during medical school and developed an interest in caring for traditionally underserved populations in residency. “I speak Spanish, and during residency I took care of an almost 100% Hispanic patient population in Boston, which has a large Puerto Rican and Dominican presence. I saw there was a lot of medical need that was not being met due to cultural or language barriers and social determinants of health,” she said.

According to Dr. Baumrin, the clinic’s unique model has proved to be particularly efficient for delivering dermatologic care, especially amid the challenges caused by the pandemic. “I really think this could serve as a template going forward when subspecialists are involved in community outreach, especially on a volunteer basis when it’s hard to get someone in there frequently,” she said. “The clinic submits all their dermatology cases — easy and difficult — to us at the University of Pennsylvania through the AAD teledermatology platform. We then triage and determine whether that person can be treated via teledermatology or needs to be prioritized at the next in-person clinic.”

Although in-person dermatology service at Puentes de Salud only occurs once a month, this hybrid model has dramatically reduced the waitlist for dermatology care, said Dr. Baumrin. “It’s allowed us to manage an efficient, high-yield clinic which has really become a medical home for the Latino/Latina community in Philadelphia. The patients themselves are incredibly appreciative. A story I hear commonly is, ‘I’ve had this for over a year, and I’ve never been able to see a skin doctor at the other community clinics.’ They’re just so happy to finally be able to see a dermatologist, and it’s through this model that we can offer to have a specialist see them.”

Additional DermWorld Resources