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Lymphedema is largely a cutaneous with prevention, they have to look at quality, problem and the gross deformity that causes and consider the poor, women versus men, such severe disfigurement is an example of vulnerability or susceptibility to diseases like skin failure. The World Health Organization infections and cancer, and they also have to concept of "Health for All" includes physical look at good practice. The latter includes the and mental well-being, which means content­ efficacy of treatment, safety issues, the satis­ ment and confidence. In the Proceedings of faction of patients and the cost of therapy. the 10th International Congress of Lymphol­ One has to examine those treatments which Oogy held in Adelaide in 1985, I was are locally available at low cost, many of responsible for coordinating the section of the which may be traditional health systems. Consensus Document devoted to "Goals of In the content of World Health Organi­ Treatment and Criteria of Success or Failure" zation documents, one has to consider (1). The concept of the Greek ideal of beauty "Disability, Impairment and Handicap." In "The Confident Nude" as someone whose this context, one is talking about loss of condition was so improved that no external function. We all know about heart failure, supports were needed and who was confident respiratory failure, liver failure and failure that the condition would not return was of other organs, but in general, noone speaks debated. More recently, as a member of the of skin failure. Most textbooks consider the International Committee on Dermatology, I functions of the skin as protection, con­ have been concerned with the problem that tainment of body fluids, thermoregulation the documents from the World Health and sensing the environment. More recently, Organization concerned with "Health for All" major textbooks (3) have included the impor­ include very little about the skin. A series of tant function of "Display" and contemporary chapters under the heading of "Healthy Skin good management of, for example, a sick for All" (2) have therefore been prepared on child with generalized skin disease in whom behalf of the International League of septicemia, prerenal failure, loss of body Dermatological Societies. These are aimed in temperature are a threat to life, will examine part at providing advice to those who have an the special needs of the child, which will influence on the provision of resources. It include the ability to play. In the case of a takes into account that all Health Care child with severe deformities due to congeni­ professions now have to be more concerned tal lymphedema, there is recognition that in order for the child eventually to achieve its potential, there has to be confidence in *Based on a Plenary Lecture given at the 15th appearance, and probably the most important International Congress of Lymphology held in occasion to effect such confidence will be the Recife, Brazil, September 25-26, 1995. This section of the program was devoted to the problems of first introduction to a new class at school. filariasis in that area and included a course Vulnerability is an important problem. sponsored by the World Health Organization. As I wandered round the streets of Recife, I

Permission granted for single print for individual use. Reproduction not permitted without permission of Journal LYMPHOLOGY 172 noted albinos who have no pigment and are septicemia or malignancy, but this is rare. at risk for ultraviolet irradiation. The many However, one should also take into account albinos in Tanzania where dermatologists are that patients who are disfigured are often trying to provide care for 170,000 of such poor and their social status falls. This has an sufferers, are an example of vulnerability. effect on themselves, their families and on Because they look different, they find their community. One consequence is an themselves in a lower social strata. They are increase in infant mortality and of reduction more exposed to environmental factors and in life expectancy within a community in most die of skin cancer due to the effects of which there are a greater number of the the sun. disabled. Other examples of vulnerability familiar If one addresses the problem of handicap to Dermatologists are the wear and tear in by seeking information from the patients people susceptible to hand dermatitis, and themselves, one finds that it is often the these include the cracks, the abrasions and treatment provided by the physician or infections of the skin so common in the legs surgeon that creates the greatest handicap. of patients with lymphedema. Easy blistering, One should not forget that a prosthesis can be as in epidermolysis bullosa, may also be seen a problem for some people. One should not in edema. Perhaps the most well known forget that bandaging, which so often badly disease in which there is vulnerability is done, can create many more problems and is leprosy. Because of loss of sensation, the always something of a handicap. If one insists hands, the feet and the eyes may be severely that the patient spends much of the day affected, but even in this disease, the making a career of their skin, even, for management has to take into account that instance, simply taking exercise may interfere leprosy is a prototype for stigmatization and with their job potential. rejection by society. There is no disability In the field of Dermatology, the worse than to be unwelcome. Dermatologist has now become much more The measurement of disability can aware of the disfigurement resulting from include assessment of manual dexterity or the inadequate surgery and the creation of bad distance someone can walk. It should be scarring is unacceptable. This, too, needs to realized that someone with sore feet can walk be considered in the management of lymphe­ less distance than someone with no feet at all dema by surgical techniques. One has to who has a good prosthesis. The simple understand that to look good means that one maneuver of cutting toenails may solve a feels good and has greater achievement. In problem of not being able to wear shoes, just the management of patients with lymphe­ as the wearing of glasses may solve the dema by operative versus non-operative handicap of the short-sighted or those who means, one may have to take into account the are aged with failing vision. Other modalities fact that non-operative therapy is prolonged that should be considered are pain and itch, and that skilled masseurs, intermittent and especially important in the case of positive pressure pumps, and even bandages, lymphedema is the problem of odor, which may not be affordable. can be easily remedied in some cases and may When one examines events in life which be the only problem that the patient wishes to are important, going for a job may be one, have treated. getting married will be another, and in terms In contemporary society, resources for of economic potential, being qualified, being the management of illness are most likely to available, competing, and even having be provided if mortality has to be prevented. confidence at an interview has to be taken In the case of chronic disablement, as may into account. If one examines the modalities occur in lymphedema, patients may die from of expressive disability, such as embarrass-

Permission granted for single print for individual use. Reproduction not permitted without permission of Journal LYMPHOLOGY 173 ment, anxiety, confidence or depression, each filariasis. The 5th Report of the WHO Expert of these are amenable to therapy, but one Committee on Filariasis (4) ends with several should also remember that about one-third of recommendations. The first of these is that all patients if asked about their disability, there is an urgent need for studies that will will not admit to any handicap. Enforcing help to determine the public health impor­ treatment on such people may handicap lives tance of lymphatic filariasis in different that otherwise were surprisingly unaffected endemic countries. These should include by their disease. investigations of the psychological and social One of the reasons for insisting on the impact of the disease as well as of economic language of disability is that it is marketable. consequences. This recommendation is Concepts such as the Greek ideal of beauty more-or-less the same as the recommendation which is "The Confident Nude" or of skin made ten years ago for lymphedema in failure, or even recently, the importance of general at the 10th International Congress of healing and repair emphasized by Wound Lymphology in Adelaide, 1985. Healing Societies, creates a language which Dermatologists have found marketable. I REFERENCES have heard three Ministers of Health give excellent talks using the language of wound 1. Casley-Smith, JR. Discussion of the defini­ healing, and so I believe that in managing tion, diagnosis and treatment of lymphoe­ dema (lymphostatic disorder). In Progress in lymphedema, one should use a language Lymphology, X. Proceedings of the Xth which draws attention to the fact that they International Congress of Lymphology, may not be able to walk very far, they may Adelaide, 1985. University of Adelaide Press, not be able to use their hands, they may be 1-16. unwelcome in society, and they may find that 2. Ryan, TJ: Healthy skin for all. Int. J. Dermatol. 33 (1994), 829-835. their treatment is a handicap. One needs to 3. Ryan, TJ: Diseases of the skin. In Oxford make them more welcome in their society, Textbook of Medicine. Wetherall, D, J and they may find that their treatment is a Ledingham, D Warrell (Eds.), Oxford handicap. One needs to help them to be more University Press, 3rd Edition, 1995. 4. Lymphatic Filariasis: The Disease and its confident only if they have lost their Control. Fifth Report of the WHO Expert confidence. One needs to make them more Committee on Filariasis. WHO Technical welcome in their society, only if their Report Series 821: WHO 1992, Geneva. community is isolating them. Nevertheless, "The Confident Nude" is an ideal which Terence J. Ryan, M.D. should be understood in this competitive Department of Dermatology world in which the disfigured can lose a great Churchill Hospital deal. Here in Recife, we are concerned mostly Old Road with lymphedema that is a consequence of Headington, Oxford OX3 7LJ UK

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