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Dermatology in
Public Health
Environments
A Comprehensive Textbook
Renan Rangel Bonamigo
Editor
André Avelino Costa Beber
Clarice Gabardo Ritter
Renata Heck
Associate Editors
Second Edition

123
Dermatology in Public Health
Environments
Renan Rangel Bonamigo
Editor

Dermatology in Public
Health Environments
A Comprehensive Textbook

Second Edition

Associate Editors
André Avelino Costa Beber
Clarice Gabardo Ritter
Renata Heck
Editor
Renan Rangel Bonamigo
Dermatology Service
Federal University of Rio Grande do Sul/HCPA and Santa Casa de Misericórdia
Porto Alegre, Rio Grande do Sul, Brazil

Associate Editors
Andre Avelino Costa Beber
Hospital Universitario de Santa Maria
Dermatology Service
UFSM—Federal University of Santa Maria
Santa Maria, Brazil
Clarice Gabardo Ritter
Dermatology Department of Nossa Senhora da
Conceição Hospital and Santa Casa de Misericórdia
Porto Alegre, Brazil
Renata Heck
Dermatology Service of Hospital de Clínicas de Porto Alegre
Porto Alegre, Rio Grande do Sul
Brazil

ISBN 978-3-031-13504-0    ISBN 978-3-031-13505-7 (eBook)

https://doi.org/10.1007/978-3-031-13505-7

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher,
whether the whole or part of the material is concerned, specifically the rights of translation,
reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any
other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
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To the students, who make us learn every day.
To patients who would be clinically and psychologically well,
if it were not for the living conditions imposed by the economic
circuit.
To Ademar Bonamigo, in memoriam.
Renan Rangel Bonamigo

I dedicate this book to its readers. To medical students, resident

physicians, public health professionals, and everyone who
seeks constant improvement. I dedicate it to those who, even in
the most adverse situations, seek to offer the best possible
medicine to their patients.
André Beber

I dedicate the merits of this book to all the teachers who inspire
and teach us in the service of alleviating the suffering of skin
diseases. To my teachers, especially Dr. Renan Bonamigo, who
is an example of ethics, competence, and humanism.
Clarice Gabardo Ritter

I dedicate this work to all the patients who have crossed my

path over these years of public health, teaching in practice a
real medicine that goes far beyond theory.
I dedicate this especially to my daughter Lívia, a source of
inestimable love.
Renata Heck
Preface

The second edition of Dermatology in Public Health Environments highlights

the vitality of this topic in the context of the health of populations, globally.
Clinical chapters have been updated and new ones have been added, com-
plementing the consultation work for students and professionals. In a special
section, the chapters on the history of dermatology, dermatological educa-
tion, and hospital dermatology combine with the previous ones to facilitate
the search for specific syntheses of these areas, sometimes difficult to find in
the current literature.
Editors and co-editors hope that the book will help those who study and
work with dermatology in their daily lives, as well as those who experience
the need to obtain specific information about an emerging problem.
We are convinced that Dermatology should focus not only on the cutane-
ous disease, but on the social, economic, and cultural context in which
patients are inserted and which relate to the main dermatoses. The purpose of
this book to help its readers to consider this reality in the management of
dermatoses and in the relationship with their patients.
Co-editors: André Avelino Costa Beber, Clarice Ritter, Renata Heck

Porto Alegre, Rio Grande do Sul, Brazil Renan Rangel Bonamigo

vii
Acknowledgements

To the authors and co-authors of each chapter, for the quality of the texts and
dedication to the project of this book.
To the co-editors, my friends from many journeys, for their essential inter-
ventions in the quest to improve the quality of this work.
To Daniela, Francisco, and Pedro, for the love and support.
Renan Rangel Bonamigo

At the end of a work of this magnitude, there are many thanks. I start by
thanking Dr. Renan Bonamigo, who trusted me to be an associate editor. I
thank all my teachers, who prepared me to be qualified for this task. I thank
all the authors, who dedicated time and knowledge to write such an exquisite
work. Thanks to fellow dermatologists, residents, students, and patients who
push me to improve every day.
I would also like to thank my family, parents, siblings, and especially
Rejane, Pedro, and Maria Clara for their support, patience, and love.
André Beber

I thank all the patients, that many of them can benefit from the rich content
of this book.
Clarice Gabardo Ritter

The biggest thanks go to all the authors involved in donating their time and
experience to spread knowledge throughout this work.
I thank Professor Renan Rangel Bonamigo, for all the teachings shared
freely over the years, and for being a constant example of academicism and
kindness.
Renata Heck

ix
Contents

Part I Dermatology in Public Health

1 
Setting Priorities in Public Health Dermatology������������������������    3
João Luiz Bastos, Rodrigo Pereira Duquia,
and Jeovany Martínez-Mesa
2 
International Public Health Strategies in Dermatology ������������    9
Antonio Carlos Gerbase, Natane Tenedini Lopes,
and Charifa Zemouri
3 
The User of the Public Service in Dermatology��������������������������   31
Heitor de Sá Gonçalves, Maria Araci de Andrade Pontes,
and Gerson Oliveira Penna
4 Impact of Preventive Campaigns in Dermatology:
A Brazilian Experience������������������������������������������������������������������   41
Maria Leide Wand-Del-Rey de Oliveira

Part II Dermatologic Diseases in Public Health:

Cutaneous Infectious

5 Hanseniasis ������������������������������������������������������������������������������������   67

Letícia Maria Eidt
6 Tuberculosis������������������������������������������������������������������������������������   95
Josemir Belo dos Santos, Iana Costa Freitas de Oliveira,
Maria de Fátima Medeiros Brito,
Matilde Campos Carrera, Virgínia Paiva Parisio,
and Vanessa Lucília Silveira de Medeiros
7 Other Mycobacterioses������������������������������������������������������������������ 131
Josemir Belo dos Santos, Cláudia Elise Ferraz,
Jéssica Guido de Araújo, Márcia Helena de Oliveira,
Perla Gomes da Silva,
and Vanessa Lucília Silveira de Medeiros
8 Sexually Transmitted Diseases������������������������������������������������������ 159
Walter Belda Jr

xi
xii Contents

9 Bacterial Infections������������������������������������������������������������������������ 183

Giancarlo Bessa
10 Viral Infections������������������������������������������������������������������������������ 203
Andre Avelino Costa Beber, Ana Maria Benvegnú,
Daniela da Pieve, Lia Natália Diehl Dallazem,
and Luis Felipe Teixeira Neumaier
11 Fungal Infections���������������������������������������������������������������������������� 293
Raíssa Londero Chemello, Rafaella Daboit Castagna,
Taciana Cappelletti, Juliana Mazzoleni Stramari,
Carolina Borques da Silva, and Larissa Reghelin Comazzetto
12 Parasitic
 and Protozoal Infections������������������������������������������������ 339
Carolina Talhari and Bernardo Gontijo
13 Congenital Syphilis������������������������������������������������������������������������ 361
Rafaela Caroline Clarinda Melo, Mauricio Obal Colvero,
and Renan Rangel Bonamigo

Part III Dermatologic Diseases in Public Health: Neoplasias

14 Precursor
 Lesions of Skin Cancer������������������������������������������������ 371
Majoriê Mergen Segatto
15 Basal Cell Carcinoma�������������������������������������������������������������������� 397
Wagner Bertolini, Roberto Gomes Tarlé, Luciano José Biasi,
and Guilherme Augusto Gadens
16 Squamous Cell Carcinoma������������������������������������������������������������ 413
Roberto Gomes Tarlé, Wagner Bertolini, Luciano José Biasi,
and Guilherme Augusto Gadens
17 Melanoma �������������������������������������������������������������������������������������� 429
Thaís Corsetti Grazziotin, Louise Lovatto, Felice Riccardi,
Antônio Dal Pizzol, and Alexei Peter dos Santos
18 Cutaneous
 T-Cell Lymphoma and Other
Lymphoproliferative Dermatological Diseases���������������������������� 461
Lisia Martins Nudelmann Lavinsky
and Renan Rangel Bonamigo

Part IV Dermatologic Diseases in Public Health:

Inflammatory and Autoimmune Diseases

19 Eczemas������������������������������������������������������������������������������������������ 487
Rosana Lazzarini, Mariana de Figueiredo da Silva Hafner,
Vanessa Barreto Rocha, and Daniel Lorenzini
20 Psoriasis������������������������������������������������������������������������������������������ 519
André Vicente Esteves de Carvalho
and Leandro Linhares Leite
Contents xiii

21 Seborrheic Dermatitis�������������������������������������������������������������������� 537

Juliano de Avelar Breunig
22 Lichen Planus �������������������������������������������������������������������������������� 559
Paulo Ricardo Martins Souza, Leticia Dupont,
and Daniele Damares Rodrigues de Souza
23 Acne Vulgaris���������������������������������������������������������������������������������� 569
Marina de Almeida Delatti, Caroline Cabrelon Castellan,
Adilson Costa, and Marcel dos Santos
24 Hidradenitis������������������������������������������������������������������������������������ 589
Magda Blessmann Weber, Clarice Gabardo Ritter,
Gabriela Garbin, Sindy Natália Balconi,
and Gustavo Andreazza Laporte
25 Rosacea�������������������������������������������������������������������������������������������� 603
Renan Rangel Bonamigo, Wagner Bertolini,
Fabiana Bazanella de Oliveira,
and Sérgio Ivan Torres Dornelles
26 Vitiligo �������������������������������������������������������������������������������������������� 621
Gerson Dellatorre, Vinícius Medeiros Fava,
and Caio Cesar Silva de Castro
27 Autoimmune Bullous Dermatoses������������������������������������������������ 647
Hiram Larangeira de Almeida Jr. and Renata Heck
28 Cutaneous Vasculitides������������������������������������������������������������������ 657
Lucas Samuel Perinazzo Pauvels, Bruna Ues,
Rafaela Baesso Reddig, Leandro Rüdiger Pastore,
and Andre Avelino Costa Beber
29 Aphthae ������������������������������������������������������������������������������������������ 713
Juliana Dumêt Fernandes and Marcello Menta S. Nico
30 Neutrophilic Dermatosis���������������������������������������������������������������� 719
Renata Heck, Bianca Nogueira Lopes, Tamires Ferri Macedo,
and Cláudia Ana Modesti
31 Adverse Drug Reactions���������������������������������������������������������������� 749
Paulo Ricardo Criado

Part V Dermatologic Diseases in Public Health:

Skin Diseases and Environment

32 Cold and Heat�������������������������������������������������������������������������������� 809

Clarissa Barlem Hohmann and Renan Rangel Bonamigo
33 
Solar Radiation and Photodermatoses���������������������������������������� 827
Tania F. Cestari, Marcel de Almeida Dornelles,
and Sérgio Ivan Torres Dornelles
xiv Contents

34 Dermatoses by Plants�������������������������������������������������������������������� 845

Maria Antonieta Scherrer and Vanessa Barreto Rocha
35 Skin
 Lesions Caused by Venomous Animals�������������������������������� 875
Vidal Haddad Jr.
36 Occupational Dermatosis�������������������������������������������������������������� 883
Alice de Oliveira de Avelar Alchorne,
Maurício Mota de Avelar Alchorne,
Maria Laura de Avelar Alchorne Trivelin,
and Stefano de Avelar Alchorne Trivelin
37 Air
 Pollution and the Skin Health������������������������������������������������ 899
Adriano Heemann Pereira Neto, Leandro Linhares Leite,
Samanta Daiana De Rossi, and Renan Rangel Bonamigo

Part VI Dermatologic Diseases in Public Health:

Vital Cycle and Dermatology

38 Skin
 Diseases and Pregnancy�������������������������������������������������������� 929
Julia Costa Beber Nunes and Gilvan Ferreira Alves
39 Neonatal Dermatosis���������������������������������������������������������������������� 947
Ana Elisa Kiszewski and Juliana Tosetto Santin
40 Cutaneous
 Aging and Dermatosis in Geriatric Patients������������ 967
Letícia Maria Eidt

Part VII Skin Manifestations of Major Diseases in Public Health

41 Diabetes Mellitus���������������������������������������������������������������������������� 1005

Karen Regina Rosso Schons and Andre Avelino Costa Beber
42 Diseases of Thyroid������������������������������������������������������������������������ 1025
Sérgio Ivan Torres Dornelles, Anelise Damiani da Silva Citrin,
Camila Boff, and Renan Rangel Bonamigo
43 Dyslipidemias��������������������������������������������������������������������������������� 1041
Cristiane Almeida Soares Cattani and Renata Heck
44 Nutritional
 Disorder, Morbidly Obese, and Post-Bariatric ������ 1053
Ana Paula Dornelles Manzoni and Vanessa Santos Cunha
45 Renal Failure���������������������������������������������������������������������������������� 1105
Andrea Nicola, Lídice Dufrechou, and Alejandra Larre Borges
46 Connective Tissue Diseases������������������������������������������������������������ 1129
Jesus Rodriguez Santamaria, Jayana Marcela Doro Dionizio,
and Maira Mitsue Mukai
47 Smoking,
 Alcoholism, and Use of Illicit Drugs���������������������������� 1153
Renan Rangel Bonamigo, Catiussa Brutti, Taciana Cappelletti,
Rodrigo Pereira Duquia, and Mauro W. Keiserman
Contents xv

48 
Skin Manifestations Associated with HIV/AIDS������������������������ 1169
Márcia S. Zampese, Gabriela Czarnobay Garbin, Lucas
Samuel Perinazzo Pauvels, and Luciana Pavan Antonioli
49  uman T-Cell Lymphotropic Virus Type-1
H
(HTLV-1) Infection in Dermatology �������������������������������������������� 1259
Achiléa Lisboa Bittencourt
50 Liver Diseases �������������������������������������������������������������������������������� 1285
Gislaine Silveira Olm
51 Transplant Recipients�������������������������������������������������������������������� 1299
Lídice Dufrechou and Alejandra Larre Borges
52 Skin Manifestations of Major Diseases in Public
Health Psychiatric Diseases���������������������������������������������������������� 1325
Cecilia Cassal, Nathalia Hoffmann Guarda Aguzzoli,
and Ygor Ferrão
53 Paraneoplasias�������������������������������������������������������������������������������� 1349
Fernanda Razera, Maisa Aparecida Matico Utsumi Okada,
and Renan Rangel Bonamigo

Part VIII Emerging Issues of Dermatology in Public Health

54 Ethnicity and Dermatology ���������������������������������������������������������� 1385

Lia Dias Pinheiro Dantas, Juliana Catucci Boza,
and Juliano Peruzzo
55 
Skin Disorders in Transgender Patients�������������������������������������� 1405
Marcio Soares Serra and Felipe Aguinaga
56 
Dermatosis in Conflict Zones and Disaster Areas���������������������� 1413
Rosana Buffon
57 Dermatology and Sports���������������������������������������������������������������� 1429
Renato Marchiori Bakos, Kátia Sheylla Malta Purim,
Antonio Macedo D’Acri, and Helena Reich Camasmie
58 
Photoprotection and the Environment���������������������������������������� 1439
Kátia Sheylla Malta Purim, Ana Claúdia Kapp Titski,
Incare Correa de Jesus, and Neiva Leite
59 Human Skin Bank�������������������������������������������������������������������������� 1459
Eduardo Mainieri Chem, Luana Pretto,
Aline Francielle Damo Souza, Angelo Syrillo Pretto Neto,
Suyan Gehlm Ribeiro dos Santos, and Carla Zanatelli
60 Marketing Influence on Body Image Perception:
A Bioethical Perspective���������������������������������������������������������������� 1465
João Batista Blessmann Weber, Daiane Oliveira Hausen,
and Tatiana Quarti Irigaray
xvi Contents

61 Quality
 of Life in Dermatology���������������������������������������������������� 1477
Magda Blessmann Weber, Mariele Bevilaqua,
Rebeca Kollar Vieira da Silva, and Gustavo Bottene Ribolli
62 Vaccines
 and the Prevention of Dermatologic Diseases�������������� 1501
Giancarlo Bessa
63 Dermatoscopy
 in the Public Health Environment���������������������� 1521
Alejandra Larre Borges, Sofía Nicoletti, Lídice Dufrechou,
and Andrea Nicola Centanni
64 Teledermatology ���������������������������������������������������������������������������� 1555
Daniel Holthausen Nunes

Part IX Signs and Symptoms of Skin Diseases

in Public Health—A Practical Guide to Management

65 Pigmented Lesions ������������������������������������������������������������������������ 1565

José Carlos Santos Mariante and Gabriela Fortes Escobar
66 Purpura������������������������������������������������������������������������������������������ 1587
Renata Heck, Larissa Rodrigues Leopoldo, Simone Perazzoli,
and Natane Tenedini Lopes
67 Pruritus ������������������������������������������������������������������������������������������ 1607
Magda Blessmann Weber, Fernanda Oliveira Camozzato,
and Júlia Kanaan Recuero
68 Prurigo�������������������������������������������������������������������������������������������� 1637
Daniel Lorenzini, Fabiane Kumagai Lorenzini,
Karen Reetz Muller, and Sabrina Dequi Sanvido
69 Ulcers
 Legs and Lymphedema������������������������������������������������������ 1651
Luciana Patrícia Fernandes Abbade and Hélio Amante Miot
70 Urticaria������������������������������������������������������������������������������������������ 1673
Roberta Fachini Jardim Criado and Paulo Ricardo Criado
71 Erythema Nodosum ���������������������������������������������������������������������� 1709
Débora Sarzi Sartori, Lara Mombelli,
and Natalia Sarzi Sartori
72 Rash������������������������������������������������������������������������������������������������ 1719
Isadora da Rosa Hoefel, Marina Resener de Moraes,
and Barbara Hartung Lovato
73 Alopecia������������������������������������������������������������������������������������������ 1757
Giselle Martins, Isabella Doche, Laura Antoniazzi Freitag,
Mariya Miteva, and Patricia Damasco
74 Stains ���������������������������������������������������������������������������������������������� 1789
Roberta Castilhos da Silva, Mariele Bevilaqua,
and Juliana Tosetto Santin
Contents xvii

75 Xerosis �������������������������������������������������������������������������������������������� 1827

Clarice Gabardo Ritter
76 Hyperhidrosis �������������������������������������������������������������������������������� 1839
Doris Hexsel and Fernanda Oliveira Camozzato
77 Nail Diseases ���������������������������������������������������������������������������������� 1857
Renan Minotto, Liliam Dalla Corte, Thaís Millán,
and Bianca Coelho Furtado
78 
Metatarsalgia, Calluses, and Callosities of the Feet�������������������� 1877
Silvio Maffi

Part X Dermatological Biopsy and Major

Histopathological Patterns

79 Skin Biopsy ������������������������������������������������������������������������������������ 1901

Wagner Bertolini, Greice Spindler Chaves,
Marcos Noronha Frey, and Fernando Eibs Cafrune
80 
Major Histopathological Patterns in Dermatology�������������������� 1911
Martín Sangueza, Ana Letícia Boff, and Laura Luzzatto

Part XI Multidisciplinary Team and Dermatological Care

81 Dermatological Assistance in the Primary Health Care:

A Brazilian Nursing Approach ���������������������������������������������������� 1975
Erica Rosalba Mallmann Duarte, Dagmar Elaine Kaiser,
Doris Baratz Menegon, Silvete Maria Brandão Schneider,
Alcindo Antônio Ferla, and Gimerson Erick Ferreira
82 Care Wounds: Dressings���������������������������������������������������������������� 1995
Heloísa Cristina Quatrini Carvalho Passos Guimarães,
Sidinéia Raquel Bazalia Bassoli,
Regina Maldonado Pozenato Bernardo,
and Marcos da Cunha Lopes Virmond
83 Physical Therapy in Leprosy�������������������������������������������������������� 2009
Susilene Maria Tonelli Nardi,
Lúcia Helena Soares Camargo Marciano, Tatiani Marques,
and Cristina Maria da Paz Quaggio
84  sychological Approaches in Treating Patients
P
with Dermatological Diseases�������������������������������������������������������� 2043
Luciana Castoldi, Fernanda Torres de Carvalho,
Daniel Boianovsky Kveller,
Caroline dos Santos Mendes de Oliveira,
and Tanara Vogel Pinheiro
xviii Contents

Part XII Special Chapters

85 Dermatological
 Education in Public Health:
The Teaching of Dermatology ������������������������������������������������������ 2057
Renata Ferreira Magalhães, Andrea Eloy da Costa França,
and Paulo Eduardo Neves Ferreira Velho
86 Hospital
 Dermatology: The Role of Dermatologists
in Hospital Settings������������������������������������������������������������������������ 2075
Iago Gonçalves Ferreira, Magda Blessmann Weber,
Clarice Ritter, and Renan Rangel Bonamigo
87 Brief
 History of Dermatology (Pandemics Included) ���������������� 2105
Iago Gonçalves Ferreira, Magda Blessmann Weber,
and Renan Rangel Bonamigo

Index�������������������������������������������������������������������������������������������������������� 2157
 Part I
Dermatology in Public Health
 Setting Priorities in Public Health
Dermatology
João Luiz Bastos, Rodrigo Pereira Duquia,
and Jeovany Martínez-Mesa
Key Points
• A public health approach to dermatology
emphasizes issues that are frequent, severely
impact collectivities, and for which effective
remedies are available.
• “Magnitude” refers to the frequency of health
problems within populations or, at least, some
of their specific subgroups. The underlying
idea is that health conditions with higher fre-
quencies should be prioritized
• The impact of health problems on collectivities is
frequently known as “transcendence.” The higher
their burden, the higher they should be ranked.
• The extent to which scientific knowledge and
resources (be they human, material, financial
etc.) are available to tackle health problems
corresponds to “vulnerability.” Vulnerable
health issues need to be tackled first, meaning
that we should prioritize problems for which
effective solutions are available.
• Taken together, magnitude, transcendence,
and vulnerability should be used to set priori-
ties in public health dermatology.
J. L. Bastos (*)
Department of Public Health, Federal University of
Santa Catarina, Florianópolis, Santa Catarina, Brazil
R. P. Duquia
Dermatology Unit, Federal University of Health
Sciences of Porto Alegre, Porto Alegre, Brazil
J. Martínez-Mesa
School of Medicine, IMED, Passo Fundo, Brazil
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
R. Rangel Bonamigo (ed.), Dermatology in Public Health Environments,
https://doi.org/10.1007/978-3-031-13505-7_1
1
• Setting priorities according to the criteria
mentioned above is key to offering high-­
quality care to all populations.
Introduction
A public health approach to dermatology is only
seen as important when health policy develop-
ment or health service planning is the focus of
attention. Such an approach is not commonly
regarded as of utmost importance when clinical
care is to be provided to patients, however. In
fact, the clinical and population perspectives to
dermatology are often taught by distinct faculties
of physicians or surgeons whose scopes of action
do not seem to show a high degree of overlap.
The end result is that these perspectives seem to
be disconnected from each other, even though
they are complementary and, if mastered, greatly
contribute to the provision of quality care to all
populations.
Our primary goal in this chapter is to give
salience to the intersections between the popula-
tion and individual perspectives in dermatology,
taking the concept of “public health problem” as
the main point of departure. By giving meaning
to the terms “public health” and “epidemiology,”
we present a set of technical criteria on which to
base the definition of priorities in public health
dermatology: “magnitude,” “transcendence,” and
“vulnerability.” While we recognize that these
3
4 J. L. Bastos et al.
are not exhaustive criteria on their own—that is,
social, political, economic, and historical con-
cerns are also taken into account in the process of
setting priorities—we do believe that they have
good potential to reconcile population and indi-
vidual perspectives and to help bring the patient
back to the center of attention.
The chapter goes on to discuss causes of
health problems among populations and
­individuals, drawing from widely known publi-
cations and authors in the field of public health.
An underlying assumption is that what underlies
health issues in populations is different from
what determines health-related problems among
individuals—the classic distinction between
“sick individuals and sick populations,” as origi-
nally proposed by Rose in 1985. Such a distinc-
tion is needed, because the extent to which a
health issue may be tackled by population or
individual measures also helps to set priorities in
public health dermatology. Next, some dermato-
logic problems are presented and discussed in
light of the aforementioned criteria (i.e., magni-
tude, transcendence, and vulnerability) in order
to clarify that some health problems may be
important from a public health perspective, pre-
cisely because they are to be easily treated in the
clinical realm. The idea is to demonstrate that by
being conditions that are easily treated, such
problems fulfill one of the three criteria to be
considered a public health priority (i.e., vulnera-
bility). Thus, both individual and population
approaches are depicted as complementary, when
the main goal is to provide high-quality care to
all populations.
The text that follows is divided into four dis-
tinct subsections. The first, “Setting Priorities,”
reviews the following topics: public health, epi-
demiology, public health problems, and determi-
nants of health and disease among populations
and individuals. A subsection named “Practical
Applications” brings examples of health issues to
illustrate the application of the population and
individual perspectives. A list of terms or jargon
is included under the heading “Glossary.” Finally,
interested readers are presented with three sup-
plementary bibliographic references that offer
additional thoughts and opportunity for further
learning.
Setting Priorities
Public health has been defined in multiple ways
over the past 100 years. It is mostly concerned
with the application of knowledge to the organi-
zation of health care systems and health care ser-
vices, as well as to factors that drive population
patterns of health to control disease occurrence
through continued surveillance and population-­
level interventions. One of the most famous defi-
nitions of public health dates back to the 1920s
and was set forth by Charles-Edward Amory
Winslow, a North American bacteriologist, pub-
lic health expert, and professor at Yale University.
According to Winslow [1], “public health is the
science and the art of preventing disease, pro-
longing life, and promoting physical health and
efficiency through organized community efforts
for the sanitation of the environment, the control
of community infections, the education of the
individual in principles of personal hygiene, the
organization of medical and nursing service for
the early diagnosis and preventive treatment of
disease, and the development of the social
machinery which will ensure to every individual
in the community a standard of living adequate
for the maintenance of health.”
As one important branch of public health, epi-
demiology aims to help public health achieve its
own goals. Whether epidemiology has lost
momentum in serving public health is a matter of
controversy, and interested readers are referred to
two specific publications for further discussions
on this topic [2, 3]. Epidemiology is nevertheless
thought to be the cornerstone of public health, lit-
erally meaning “the study of health issues within
and between populations,” given that its etymol-
ogy derives from the three Greek word roots
“epi” (upon or among, in English), “demos”
(people or population), and “logos” (study or
scrutiny), clearly suggesting that epidemiology
encompasses a population-based approach, not
an individual one. According to Gordis [4], a late
1 Setting Priorities in Public Health Dermatology
North American epidemiologist, epidemiology
“is the study of how disease is distributed in pop-
ulations and the factors that influence or deter-
mine this distribution.” Other definitions of
epidemiology may be found elsewhere [5, 6].
Indeed, we argue that most public health
scholars would easily agree with our view that
epidemiology is about frequency, distribution,
and causes of health problems in a given
­population. By frequency, we mean the extent to
which a population is affected by a certain health
condition. For example, if 20 out of 1000 city
residents have diabetes, the prevalence of this
health condition would equal 20/1000 or 2.0%.
While the overall frequency of diabetes would be
2.0%, some groups within this population could
present higher rates of such a chronic condition.
Suppose that there were 600 women in this city
and that 15 of them had diabetes; the prevalence
of diabetes among women would then amount to
2.5% (15/600), whereas the prevalence of diabe-
tes among men would equal to 5/400 or 1.3%.
When we compare the frequency of diabetes
among different population subgroups, we are, in
fact, analyzing its distribution within the popula-
tion. Relatedly, when we study factors that poten-
tially underlie or are responsible for the
emergence of diabetes within a specific popula-
tion, we are investigating the causes or determi-
nants of the health problem in question.
Hence, it should be clear that what public
health and epidemiology have in common is that
both aim at addressing health problems in the
context of populations: they either base their
actions on “community efforts,” as Winslow
accurately acknowledged, or take “population”
as the reference to study health profiles, follow-
ing Gordis’s conceptualization. Not all health
problems are accorded the same level of priority,
however, and therefore do not warrant similar
efforts toward their prevention, control, or treat-
ment. When it comes to setting priorities, the
notion of “public health problem” becomes par-
ticularly important, and it is to this concept that
we now turn. What becomes a priority and is
effectively addressed is dependent upon several
factors and their complex interrelationships.
5
Political, social, economic, and historical con-
cerns play an important part in this process. For
instance, the concept of “neglected tropical dis-
eases” was primarily coined to increase public
awareness of some infectious diseases that are
frequent in marginalized populations of the
Americas, Asia, and Africa, but do not receive
adequate treatment and sufficient research fund-
ing [7], i.e., they are not prioritized. Paradoxically,
these are diseases for which reliable and efficient
public health and individual measures are often
available, but which lack timely and adequate
treatment or prevention due, in part, to less power
and restricted access to resources faced by mar-
ginalized populations and countries around the
world. In other words, neglected tropical diseases
technically fit the criteria of a public health prob-
lem, even though political, economic, and power
relations among and within countries contribute
to their long-standing persistence in the most vul-
nerable populations across the world.
What, then, should we take into consideration
to set priorities in public health (dermatology)?
As argued in the previous paragraph, this ques-
tion is far from settled, although we believe that
the three following concepts are particularly use-
ful in setting public health agendas and defining
priorities. “Magnitude,” as is commonly referred
to by scholars in the public health field, pertains
to the frequency of health problems in popula-
tions and their subgroups. According to this con-
cept, the higher the frequency of a health
condition, the stronger the need to characterize it
as a public health problem. Hypertension, for
instance, is a widespread disease whose preva-
lence rates reach up to 40–50% in many popula-
tions worldwide. In contrast, the frequency of all
types of cancer tends to be very low in the gen-
eral population. If we considered only magni-
tude, we would therefore conclude that
hypertension is a public health problem, while
many types of cancer are not. “High magnitude”
is not the only attribute in classifying a health
condition as a public health problem, though. An
interesting example is the microcephaly epidemic
associated with Zika virus infection described in
Brazil and some other countries in the recent
6 J. L. Bastos et al.
years [8]. In absolute numbers, microcephaly
cases attributed to Zika infection are perhaps
insignificant, but ethically unacceptable, espe-
cially due to their burden on health services, col-
lectivities, families, and individuals. This
example leads us to the discussion of a second
criterion to define a public health problem:
“transcendence.”
Along with magnitude, “transcendence” is a
criterion on which to build a list of public health
priorities. Transcendence refers to the impact of
each health condition on individuals, collectivi-
ties, and societies as a whole. In the previous
example of microcephaly and Zika virus infec-
tion, the high impact of this condition on indi-
viduals, families, and the whole society suggests
it should be considered a public health problem.
As one extra example, take the case of dental car-
ies. As well as causing pain, discomfort, and
negatively influencing social interactions, dental
caries is associated with absence from work and
school, in addition to posing a great burden on
dental health services because of treatment
demands. Cancers are also burdensome, in that
quality of life is often severely diminished among
those with some type of cancer and the associated
costs of treatment are expressively high.
Following this criterion, Zika virus-related
microcephaly, cancers, and dental caries would
be public health problems, whereas mild health
conditions with low impact on individuals/fami-
lies/societies, such as sunburn, would not.
The third concept commonly used to set pri-
orities is “vulnerability.” Such a term is some-
what misleading, because vulnerability is
frequently attributed to individuals or specific
population groups subjected to processes of mar-
ginalization and social exclusion. When setting
public health priorities, however, vulnerability
refers to availability of knowledge and resources
to efficiently tackle a specific health issue: in this
case, vulnerability refers to the extent to which a
health condition is “vulnerable” to change
through the application of existing knowledge
and available resources. This means that only
those problems for which effective measures of
prevention, control, or treatment exist should be
prioritized. In other words, we should spend
resources and time on problems that cannot be
dealt with given the available knowledge.
Returning to the topic of microcephaly and Zika
virus infection, the control of the vector, the
Aedes aegypti mosquito, is key to combating dis-
ease transmission. This could be achieved
through the implementation of strategies at mul-
tiple levels: states, communities, and individuals
could all be engaged in actions to reduce mos-
quito breeding and disease transmission, includ-
ing measures related to improved sanitation,
early detection of cases, and adequate treatment
of affected mothers and newborns. By acting on
these levels, Zika virus infection and related
cases of microcephaly would reduce. Another
example is iron deficiency, which is controllable
through community and individual actions based
on the available knowledge and resources.
According to the concept of vulnerability, iron
deficiency and Zika virus infection should thus
be regarded as public health problems. Rothstein
[9] contends that any health condition should be
treated as a public health problem “when govern-
ment action is more efficient or more likely to
produce an effective intervention,” as compared
to individual measures, to address the problem.
The distinction between problems that may be
dealt with at the population level and those issues
that are amenable to individual action brings us
to one final clarification: drivers of health prob-
lems in populations are often different from
determinants of diseases among individuals.
As Rose [10] rightfully pointed out in 1985,
the potential causes of diseases among individual
cases will likely differ from the determinants of
health issues among populations. To fully under-
stand this idea, let us consider a brief example.
Suppose an epidemiologist carries out an investi-
gation to ascertain whether fluoridation of public
water supplies is associated with fewer dental
caries among children and adolescents. If the
whole population under study is homogeneously
exposed to water fluoridation, the investigator
will not be able to demonstrate that caries levels
1 Setting Priorities in Public Health Dermatology
vary according to access to fluoridated water, i.e.,
regardless of varying caries levels among groups
of children and adolescents, the entire population
is exposed to fluoridated water. Rather, the study
of this specific population will easily point out
that dental caries may, in fact, be linked to indi-
vidual characteristics (sugar consumption, tooth
brushing, use of dental floss etc.) owing to the
fact that these health-related behaviors vary a lot
from individual to individual within the popula-
tion. However, if the same investigator decides to
compare this highly exposed population with
another one, whose levels of fluoride exposure
are lower, fluoridation of drinking water could be
identified as a protective factor for dental caries.
Therefore, depending on the groups being com-
pared and the level of analysis (populations or
individuals), investigators may identify different
sets of causes or protective factors for dental car-
ies. In the case under consideration, sugar con-
sumption, tooth brushing, and use of dental floss
would be individual determinants of caries.
Fluoridation of water supplies would be a poten-
tial protective factor for dental caries according
to a population perspective, on the other hand.
Following Rothstein’s argument outlined above,
if water fluoridation happens to be more effective
in addressing dental caries, this health condition
should be considered a public health problem.
As we finish this subsection, we could argue
that, broadly speaking, a public health problem
is any health condition that presents magnitude,
transcendence, and vulnerability; yet we could
also add that public health problems are those
which are more likely to change in response to
population measures. It is important to note,
however, that population measures will most
likely be based on scientific knowledge of what
causes diseases among populations rather than
individuals (e.g., a public health measure to pre-
vent dental caries would focus on water fluori-
dation rather than on individual behaviors).
There are exceptions to these criteria, of course,
and other factors may play an important role in
setting priorities. We nevertheless believe that
the aforementioned criteria are fundamentally
7
important, as they bring people’s lives and soci-
etal impacts to the fore, while not restricting
public health problems to those whose expres-
sions are fundamentally biological, physiologi-
cal, biochemical, or organic. In fact, our
conceptualization of public health problems
may include not only health states, diseases, and
their biological expressions, but also their popu-
lation determinants or related processes.
According to this definition, lack of sanitation
(which has profound health impacts) would also
fit the criteria of a public health problem, and
why shouldn’t it?
Practical Applications
Several diseases or health states/processes in der-
matology could be deemed public health prob-
lems. Such health conditions could be ranked
from those highly lethal (e.g., cutaneous mela-
noma) to those with mild clinical expression
(e.g., capitis pediculosis). One of the most sig-
nificant and stigmatizing dermatological diseases
is hanseniasis. Even though hanseniasis is a treat-
able infectious disease, it is still highly prevalent
in many populations, especially those in develop-
ing countries [7]. Hanseniasis also negatively
impacts affected individuals, including granulo-
mas of the nerves, skin, and eyes. These granulo-
mas may result in loss of sensation and eventual
limb amputations. Taken together, these charac-
teristics help us define hanseniasis as a public
health problem. Dermatologists are trained to
diagnose and treat affected individuals.
Nevertheless, whenever dermatologists face a
public health problem, such as hanseniasis, the
individual approach to the case should be com-
bined with the population-based approach to the
problem, as we argued above. In these cases, the
reasons that turn the disease in question into a
public health problem must be discussed and
considered in the course of treatment and devel-
opment of strategies to face it from an individual
and community perspective.
8 J. L. Bastos et al.
We believe that medical training which com-
bines population and individual perspectives to
address health issues is on the horizon. Once this
is achieved, we shall successfully counteract
important and persistent problems in many coun-
tries, especially those that remain inexplicably
high in the most marginalized populations of the
world.
Glossary
• Causes, drivers, or determinants (of diseases
or health states/processes): any factor, condi-
tion, or process that is responsible for changes
or specific states in a particular health
outcome.
• Distribution (of diseases or health states/pro-
cesses): frequency of a health condition
according to personal, spatial, or temporal
characteristics.
• Epidemiology: the study of frequency, distri-
bution, and the causes that determine health
problems in human populations.
• Frequency (of diseases or health states/pro-
cesses): number of affected individuals rela-
tive to a specific population or group.
• Magnitude: extent to which a given health
condition is frequent in a given population.
• Prevalence: refers to a simple mathematical
calculation whereby the number of affected
individuals is divided by the total population
in question.
• Public health problem: any health condition
showing magnitude, transcendence, and vul-
nerability. It is important to note that, accord-
ing to this chapter, other criteria are also
commonly used to define public health prob-
lems, including social, historical, economic,
and political concerns.
• Public health: “[…] the science and the art of
preventing disease, prolonging life, and pro-
moting physical health and efficiency through
organized community efforts for the sanitation
of the environment, the control of community
infections, the education of the individual in
principles of personal hygiene, the organiza-
tion of medical and nursing service for the
early diagnosis and preventive treatment of
disease, and the development of the social
machinery which will ensure to every indi-
vidual in the community a standard of living
adequate for the maintenance of health” [1].
• Transcendence: extent to which a health con-
dition impacts individuals, families, and
societies.
• Vulnerability: extent to which a health issue is
vulnerable to change. In other words, vulner-
ability refers to availability of knowledge and
resources to counteract any health issue.
References
1. Winslow CE. The untilled fields of public health.
Science. 1920;51(1306):23–33.
2. Nedel FB, Bastos JL. Whither social determinants of
health? Rev Saude Publica. 2020;54:15.
3. Shy CM. The failure of academic epidemiol-
ogy: witness for the prosecution. Am J Epidemiol.
1997;145(6):479–84.
4. Gordis L. Epidemiology. Philadelphia: Elsevier/
Saunders; 2014.
5. Bonita R, Beaglehole R, Kjellström T. Basic epide-
miology. Geneva: World Health Organization; 2007.
6. Porta MS, Greenland S, Hernán M, Silva IDS, Last
JM. A dictionary of epidemiology. New York: Oxford
University Press; 2014.
7. Feasey N, Wansbrough-Jones M, Mabey DC,
Solomon AW. Neglected tropical diseases. Br Med
Bull. 2010;93:179–200.
8. Franca GV, Schuler-Faccini L, Oliveira WK,
Henriques CM, Carmo EH, Pedi VD, et al. Congenital
Zika virus syndrome in Brazil: a case series of the first
1501 livebirths with complete investigation. Lancet.
2016;388(10047):891–7.
9. Rothstein MA. Rethinking the meaning of public
health. J Law Med Ethics. 2002;30(2):144–9.
10. Rose G. Sick individuals and sick populations. Int J
Epidemiol. 2001;30(3):427–32.
Further Reading
As a resource for further learning, we recommend the fol-
lowing bibliographic references to interested readers:
Fletcher RH, Fletcher SW, Fletcher GS. Clinical epide-
miology: the essentials. Philadelphia: Wolters Kluwer/
Lippincott Williams & Wilkins Health; 2014.
Keyes KM, Galea S. Epidemiology matters: a new intro-
duction to methodological foundations. New York:
Oxford University Press; 2014.
Rothman KJ, Greenland S, Lash TL. Modern epidemiol-
ogy. Philadelphia: Wolters Kluwer Health/Lippincott
Williams & Wilkins; 2008.
 International Public Health
Strategies in Dermatology
2
Antonio Carlos Gerbase, Natane Tenedini Lopes,
and Charifa Zemouri

Abbreviations MB Multibacillary
MDA Mass drug administration
3TC Lamivudine MDT Multidrug therapy
AIDS Acquired immunodeficiency NTDs Neglected tropical diseases
syndrome PB Paucibacillary
APOC African Program for Onchocerciasis PLHIV People living with HIV
Control PWID People who inject drugs
ART Antiretroviral therapy STI Sexually transmitted infections
ATV/r Atazanavir/ritonavir TDF Tenofovir
COVID Coronavirus infection disease WHA World Health Assembly
EFV Efavirenz WHO World Health Organization
G2D Grade 2 disability
GPELF Global Program to Eliminate
Lymphatic Filariasis
GRADE Grading of Recommendations Introduction
Assessment Development and
Evaluation Structured strategies to tackle skin diseases and
HIV Human immunodeficiency virus related infections (e.g., sexually transmitted
HPV Human papillomavirus infections) are necessary to provide a frame-
IDEA Dignity and Economic Advancement work and direct actions against their burden.
ILEP International Federation of Anti-­ Usually this is not perceived at the clinical care
Leprosy Associations level, the curative branch of the strategies
LF Lymphatic filariasis where most resources are used. However, for
LPV/r Lopinavir/ritonavir professionals working at ministries of health
and other leading institutions, and who are
A. C. Gerbase (*) responsible for a comprehensive response, an
Geneva, Switzerland organized strategic approach is fundamental.
N. T. Lopes On the other hand, health professionals on the
Departamento de Dermatologia, Ambulatório de front line must understand the general issues of
Dermatologia Sanitária, Porto Alegre, Brazil the strategic interventions in order to under-
C. Zemouri stand their role and strengthen the effectiveness
Academic Center Dentistry Amsterdam (ACTA), of their actions.
Preventive Dentistry, Amsterdam, The Netherlands

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 9

R. Rangel Bonamigo (ed.), Dermatology in Public Health Environments,
https://doi.org/10.1007/978-3-031-13505-7_2
10
Strategies to treat skin diseases and related
infection at an international level give directions
to national strategies, which encompass not only
provision of care and preventive measures but
also interventions dealing with structural, envi-
ronmental, cultural, and financial issues.
The WHO is the health agency of the United
Nations system [1]. At an international level, the
WHO is the leading organization that, reacting to
the global health situation and to regional and
country requests, develops, updates, advocates,
and disseminates international public health
strategies and, subsequently, the norms, stan-
dards, and guidelines needed for their implemen-
tation. Established in 1948, it was until the end of
the 1980s the only institution leading interna-
tional health strategies on a global level. During
the past decades, other international foundations
(e.g., Gates Foundation) and bilateral national
agencies (from countries such as Germany,
Sweden, United States, and United Kingdom)
increased their role in international public health
strategic interventions and frequently directly
channeled resources to countries (e.g., PEPFAR).
Nonetheless, the WHO is the only international
public health institution that is accountable and
responds to virtually all countries. Moreover, to
improve the way strategies are conducted and
norms are set, the use of standard procedures has
been developed in the past decade, including the
use of the GRADE system for guideline develop-
ment [2].
International strategies are developed by the
WHO secretariat in close collaboration with the
scientific community and member states. The
duration of a typical WHO global strategy ranges
from 5 to 10 years, although shorter or longer
examples exist. The first global strategy in the
modern use of the term was the Global Strategy
on AIDS, developed by the Global Program on
AIDS in 1991. Once a global strategy is formu-
lated, member countries evaluate its implementa-
tion and efforts are made to measure its impact.
When the new strategy is developed, a consulta-
tion process is established, the drafts are widely
circulated, regional and global meetings are con-
ducted, and, finally, the strategy is presented for
approval by the World Health Assembly (WHA),
A. C. Gerbase et al.
the main governing body of the WHO [3].
Countries approve and are committed to its
implementation.
Once the strategies are approved by the
WHA, specific guidelines are needed to support
their implementation. The process to develop
WHO guidelines follows the GRADE system,
whose main characteristics are prioritization of
problems; establishment of panels, developed
from questions; systematic review of evidence;
evidence summary; evaluation of outcomes;
overall quality of evidence; evaluation of bene-
fits/harms; strength of recommendation and
implementation and evaluation of the guide-
lines; strict evaluation of evidence; participation
of final consumers; and evaluation of quality.
The guidelines using the GRADE method are
strictly based on the available scientific evi-
dence [2].
This chapter reviews the main WHO strategies
related to skin diseases and related infections
whose prevalence, incidence, and significant
population burden permits them to be considered
of public health importance.
State of the Art
 HO Strategies Related
W
to Dermatology
Sexually Transmitted Infections
Key Point Summary
• The 2016–2021 strategy plan to end STI epi-
demics as a major public health concern tar-
gets the 90:90:90 reduction of the global STI
prevalence and national human papillomavi-
rus vaccine coverage.
• Standardized protocols and guidance that are
people-centered are needed to reach the tar-
gets as defined during the 69th WHA.
• Interventions are mainly focused on preven-
tion, management of asymptomatic patients,
reaching sex partners and treatment, access
to STI services of adequate quality, reduce
vulnerability and risks, and meet the needs
of the general population with appropriate
services.
2 International Public Health Strategies in Dermatology
Rationale
STIs result in a high burden of morbidity, mortal-
ity, quality of life, sexual and reproductive health,
and newborn and child health. STIs facilitate the
sexual transmission of HIV and increase the risk
of some cancers through cellular changes. It is
estimated that 357 million new cases of curable
STIs (Fig. 2.1), Neisseria gonorrhea, Treponema
pallidum, Trichomonas vaginalis, and Chlamydia
trachomatis, occur every year among people
aged 15–49 years. The prevalence of some viral
STIs is similarly high as a result of herpes sim-
plex type 2 virus (HSV-2) and HPV. This chapter
focuses primarily on three infections, N. gonor-
rhea, T. pallidum, and HPV, which require imme-
diate action for their control (see Boxes 2.1, 2.3,
and 2.4).
Fig. 2.1 New cases of curable STIs: annual estimate
11
Box 2.1 Milestones for 2020
• 70% of countries have STI surveillance
system in place
• 70% of countries screen at least 95% of
pregnant women for HIV and/or
syphilis
• 70% of key population for HIV have
access to a full range of services relevant
to STI and HIV, including condoms
• 70% of countries provide STI services
• 70% of countries deliver HPV vaccines
• 90% national coverage of HPV
vaccines
• 70% of countries report on AMR in N.
gonorrhoeae
12
Targets
The WHO developed a global strategy plan for
2016–2021 on STIs, responding to requests by
member states [4]. The goal is to end STI epidem-
ics as major public health concerns. The WHO’s
vision is to have zero new infections, zero STI-
related complications and deaths, and zero dis-
crimination and a world with free and easy access
to STI prevention and treatment services, result-
ing in individuals being able to live long and
healthy lives. A 90:90:90 target for 2030 is set up
to reach 90% reduction of T. pallidum (syphilis)
incidence globally, 90% global reduction in N.
gonorrhea, and sustainment of 90% national cov-
erage of HPV vaccination in national immuniza-
tion programs. Furthermore, the WHO has set up
milestones for this strategy by 2020 (see Box 2.1).
For syphilis, there is a separate strategy and tar-
get. Syphilis in pregnancy leads to more than
300,000 fetal and neonatal deaths each year with
215,000 infants at increased risk for early death.
The new strategy has set up a goal of 50 or fewer
cases of congenital syphilis per 100,000 live births
in 80% of the countries. To eliminate mother-to-
child transmission, all pregnant women should be
screened for syphilis and HIV simultaneously.
Strategies
To reach the targets, there is a need to improve
universal health coverage with improved quality
health interventions and services, reduced costs,
and financial protection for those in need of the
services (see Fig. 2.2). The public health
approach should focus on a standardized proto-
col and guidance, people-centered services,
focus on equity, community participation,
involvement of affected individuals, ensuring
free or affordable services, and focus on popula-
tion-based national plans. The first strategic step
is for countries to acquire knowledge of their
STI epidemic and to implement a tailored
response; therefore, they need strategic infor-
mation for advocacy and investments. Next,
understanding the epidemics includes knowing
where, how, and among whom new infections
occur and identifying factors to facilitate access
to appropriate services. Finally, national STI
surveillance is needed to monitor infections
among the populations and improve the strate-
gies and interventions.
A. C. Gerbase et al.
All persons should receive STI services they
require, which should be of adequate quality.
Countries should promote an enabling environ-
ment which includes policies and laws that pro-
mote human rights and gender equality. They
should also reduce vulnerability and risk and meet
the needs of the general population with appropri-
ate services. Specifically, men and boys should be
addressed, since they have often been overlooked
in STI control. Countries should therefore engage
and link with communities and partners and
strengthen the health systems to ensure access to
quality vaccines, diagnostics, medicines, and other
commodities. To achieve this goal, persons should
receive the STI services they need without experi-
encing financial hardship. Innovative financing
and new funding approaches, financial risk protec-
tion, reduced prices and costs, and improved effi-
ciency strategies should be implemented.
Interventions
People should receive the full range of STI ser-
vices they require. Therefore, countries need to
define a set of core interventions. The following
intervention areas should be covered:
• Prevent STI transmission and acquisition
• Achieve early diagnosis of STI and linkage to
treatment
• Manage asymptomatic patients
• Reach sex partners and offer them treatment
• Maximum impact interventions include elimi-
nation of mother-to-child transmission of
syphilis and HIV; HPV and hepatitis B virus
vaccination; control the spread of antimicro-
bial resistance of gonococcals
• Ensure quality of care by strengthening pre-
vention, diagnosis, treatment, and care; inte-
grated services and programs; quality
assurance and improvement of programs
The main intervention is to prevent STI trans-
mission and acquisition. Countries need innova-
tion for acceleration by optimizing STI
prevention, diagnostics, medication, and treat-
ment regimens, but also by using existing tools
more efficiently and adapting them for different
populations, settings, or purposes. The current
intervention recommendations for STIs are sum-
marized in Boxes 2.2, 2.3 and 2.4.
2 International Public Health Strategies in Dermatology 13

Fig. 2.2 Outline of the draft global health sector strategy on STI, 2016–2021
14
Box 2.2 Chlamydia
Chlamydia accounts for 131 million STIs
annually and is an important cause of infer-
tility in women of reproductive age. It
appears often as a coinfection with gonor-
rhea. The rate of infection is increasing in
adolescents. However, the best strategy is
yet to be defined. The WHO STI guideline
(2016) recommends the following treat-
ments [5].
Uncomplicated genital chlamydia:
• Azithromycin 1 g orally as a single
dose
• Doxycycline 100 mg orally twice a
day for 7 days
Or one of these alternatives:
• Tetracycline 500 mg orally four
times a day for 7 days
• Erythromycin 500 mg orally twice a
day for 7 days
• Ofloxacin 200–400 mg orally twice a
day for 7 days
Anorectal chlamydial infection:
• Doxycycline 100 mg orally twice a
day for 7 days over azithromycin 1 g
orally as a single dose
Genital chlamydial infection in pregnant
women:
• The WHO STI guideline recom-
mends treatment with azithromycin
over erythromycin
• The WHO STI guideline suggests
treatment with azithromycin over
amoxicillin
• The WHO STI guideline suggests
treatment with amoxicillin over
erythromycin
A. C. Gerbase et al.
Dosages:
• Azithromycin 1 g orally as a single
dose
• Amoxicillin 500 mg orally three
times a day for 7 days
• Erythromycin 500 mg orally twice a
day for 7 days
Lymphogranuloma venereum:
The WHO STI guideline suggests treat-
ment with doxycycline 100 mg orally
twice daily for 21 days over azithromy-
cin 1 g orally, weekly for 3 weeks.
Ophthalmia neonatorum:
The WHO STI guideline recom-
mends treatment with azithromycin
20 mg/kg/day orally, one dose daily
for 3 days, over erythromycin 50 mg/
kg/day orally, in four divided doses
daily for 14 days.
Box 2.3 Gonorrhea
Gonorrhea is one of the most common STIs
worldwide and has a significant effect on
morbidity and mortality. Together with
chlamydia, it is one of the main causes of
infertility in women of reproductive age.
Gonorrhea has developed resistance to
almost all medicines used for its treatment,
which raises the prospect of untreatable
gonococcal infection. Its spread and impact
should therefore be controlled alongside
systematic reporting and monitoring of
antimicrobial resistance.
The WHO STI guideline (2016) recom-
mends the following treatments [6]. The
local AMR data should determine the
choice of therapy.
2 International Public Health Strategies in Dermatology
Genital and anorectal gonococcal
infection:
Dual therapy (one of the following)
• Ceftriaxone 250 mg intramuscu-
lar (IM) as a single dose PLUS
azithromycin 1 g orally as a single
dose
• Cefixime 400 mg orally as a sin-
gle dose PLUS azithromycin 1 g
orally as a single dose
Single therapy (one of the following)
• Ceftriaxone 250 mg IM as a sin-
gle dose
• Cefixime 400 mg orally as a sin-
gle dose
• Spectinomycin 2 g IM as a single
dose
Oropharyngeal gonococcal infection:
Dual therapy (one of the following)
• Ceftriaxone 250 mg IM as a sin-
gle dose PLUS azithromycin 1 g
orally as a single dose
• Cefixime 400 mg orally as a sin-
gle dose PLUS azithromycin 1 g
orally as a single dose
Single therapy
• Ceftriaxone 250 mg IM as single
dose
Gonococcal ophthalmia neonatorum:
One of following
• Ceftriaxone 50 mg/kg (maximum
150 mg) IM as a single dose
• Kanamycin 25 mg/kg (maximum
75 mg) IM as a single dose
• Spectinomycin 25 mg/kg (maxi-
mum 75 mg) IM as a single dose
15
Box 2.4 Syphilis [7]
Recommendations
EARLY SYPHILIS (primary, secondary, or latent
syphilis of not more than 2 years’ duration)
 Adults and adolescents
In adults and adolescents with early syphilis, the
STI WHO guideline recommends benzathine
penicillin G 2.4 million units once
intramuscularly over no treatment
Remarks: This recommendation also applies to
pregnant women, people living with HIV, people
who are immunocompromised, and people at
high risk of transmitting and acquiring STIs
In adults and adolescents with early syphilis, the
STI WHO guideline suggests using benzathine
penicillin G 2.4 million units once
intramuscularly over procaine penicillin G 1.2
million units 10–14 days intramuscularly
When benzathine or procaine penicillin cannot be
used (e.g., due to penicillin allergy) or not
available, the STI WHO guideline suggests using
doxycycline 100 mg twice daily orally for 14 days
or ceftriaxone 1 g intramuscularly once daily for
10–14 days or azithromycin 2 g once orally
Remarks: Doxycycline is preferred over
ceftriaxone because of its lower cost and oral
administration. Azithromycin is an option only
when susceptibility to azithromycin is confirmed
and resistance can be monitored. This
recommendation also applies to people living
with HIV, people who are immunocompromised,
or people at high risk of transmitting and
acquiring STIs. If the stage of syphilis is
unknown, recommendations for persons with late
syphilis should be followed
 Pregnant women
In pregnant women with early syphilis, the WHO
STI panel suggests using benzathine penicillin G
2.4 million units once intramuscularly over
procaine penicillin 1.2 million units
intramuscularly once daily for 10 days
When benzathine or procaine penicillin cannot be
used (e.g., due to penicillin allergy) or not
available, the STI WHO guideline suggests using
erythromycin 500 mg orally four times daily for
14 days or ceftriaxone 1 g intramuscularly once
daily for 10–14 days or azithromycin 2 g once
orally
Remarks: Azithromycin is an option only when
susceptibility to azithromycin is confirmed and
resistance can be monitored. Erythromycin and
azithromycin do not cross the placental barrier
completely; therefore, treatment of the baby soon
after delivery is necessary (see recommendations
for congenital syphilis). Ceftriaxone is an
expensive option and is injectable. Doxycycline
should not be used in pregnant women
16
LATE SYPHILIS (infection of more than 2 years’
duration without evidence of treponemal
infection)
 Adults and adolescents
In adults and adolescents with late syphilis or
unknown stage of syphilis, the STI WHO
guideline recommends benzathine penicillin G
2.4 million units intramuscularly once weekly for
three consecutive weeks over no treatment
Remarks: This recommendation also applies to
people living with HIV, people who are
immunocompromised, or people at high risk of
transmitting and acquiring STIs
In adults and adolescents with late syphilis or
unknown stage of syphilis, the STI WHO
guideline suggests benzathine penicillin G 2.4
million units intramuscularly once weekly for
three consecutive weeks over procaine penicillin
1.2 million units once a day for 20 days
When benzathine or procaine penicillin cannot be
used (e.g., due to penicillin allergy) or not
available, the STI WHO guideline suggests using
doxycycline 100 mg twice daily orally for
30 days
Remarks: This recommendation also applies to
people living with HIV, people who are
immunocompromised, or people at high risk of
transmitting and acquiring STIs. Doxycycline
should not be used in pregnant women (see
recommendation for pregnant women)
 Pregnant women
In pregnant women with late syphilis or unknown
stage of syphilis, the WHO STI guideline suggests
benzathine penicillin G 2.4 million units
intramuscularly once weekly for three consecutive
weeks over procaine penicillin 1.2 million units
intramuscularly once a day for 20 days
When benzathine or procaine penicillin cannot be
used (e.g., due to penicillin allergy) or not
available, the STI WHO guideline suggests using
erythromycin 500 mg orally four times daily for
30 days
Remarks: Erythromycin does not cross the
placental barrier completely; therefore, treatment
of the baby soon after delivery is necessary (see
recommendations for congenital syphilis).
Doxycycline should not be used in pregnant
women
Infants
Infants with confirmed congenital syphilis
(symptomatic or microbiological evidence) and
infants who are clinically normal, but mother
with syphilis was not treated, inadequately
treated, or treated with non-penicillin
A. C. Gerbase et al.
In infants with confirmed congenital syphilis or
infants who are clinically normal, but the mother
with syphilis was not treated, inadequately
treated, or treated with non-penicillin, the WHO
STI guideline suggests aqueous benzyl penicillin
or procaine penicillin
Dosages:
• Aqueous benzyl penicillin 100,000–150,000 U/
kg/day intravenously for 10–15 days
• Procaine penicillin 50,000 U/kg/day single
dose intramuscularly for 10–15 days
Remarks: If an experienced venipuncturist is
available, aqueous benzyl penicillin may be
preferred over intramuscular injections of
procaine penicillin
Infants who are clinically normal and the mother
had syphilis and was adequately treated with no
signs of reinfection
In infants who are clinically normal and the
mother had syphilis and was adequately treated
with no signs of reinfection, the WHO STI
guideline suggests close monitoring of the infant
over treatment
Remarks: The risk of transmission of syphilis to
the fetus depends on a number of factors,
including titers and stage of infection, and
therefore this recommendation is conditional. If
treatment is provided, procaine penicillin
50,000 U/kg/day as a single dose intramuscularly
for 10–15 days is an option
Neglected Tropical Diseases
Key Point Summary
• Vector-borne infectious protozoa causing der-
mal complications such as lymphatic filariasis
(LF) and leishmaniasis are to be targeted for
elimination.
• Since the start of mass drug administration
(MDA) for LF, the transmission has dropped
and resulted in economic benefits. However,
adverse events in the case of double infection
by the Loa loa worm should be considered for
revised local treatment and control strategies.
• The WHO strategy for LF is to interrupt trans-
mission and target 70% of countries verified
as free of LF by 2020, 30% under post surveil-
lance, and full coverage and access to basic
care for lymphedema. As for leishmaniasis,
prevention and control with adequate diagnos-
tic tools and vaccines are essential.
2 International Public Health Strategies in Dermatology
• The intervention and prevention strategies set
up by the WHO for both protozoal infections
overlap with regard to interrupting the chain
of transmission, monitoring the burden of dis-
ease, vector control of sandflies and mosqui-
toes, environmental management and
protection, and control of animal reservoirs.
Neglected tropical diseases (NTDs) are preva-
lent in 149 tropical and subtropical countries and
affect more than 1 billion people annually. NTDs
cover the following vector-borne infectious dis-
eases: Chagas disease; dengue and chikungunya;
dracunculiasis; human African trypanosomiasis;
leishmaniasis; LF; and onchocerciasis. Other
diseases such as buruli ulcer, echinococcosis,
­ timori, and is transmitted by mosquitoes infected
endemic treponematoses, food-borne trematodia-
ses, leprosy, rabies, schistosomiasis, taeniasis,
and trachoma are airborne, zoonotic, or transmit-
ted vertically. This subsection highlights the
vector-­borne infectious diseases that cause der-
mal manifestations: leishmaniasis and LF.
Rationale
Leishmaniasis manifests in three forms: visceral,
mucocutaneous, and the most common form, cuta-
neous leishmaniasis, caused by the protozoa
Fig. 2.3 Prevalence of Leishmaniasis (2013)
17
Leishmania transmitted by phlebotomine sandflies
[8]. An estimated 900,000 to 1.3 million new cases
and 20,000–30,000 deaths occur annually and
affect the poorest people on earth. The disease is
associated with malnutrition, population displace-
ment, poor housing, a weak immune system, and
lack of financial resources. Cutaneous leishmania-
sis causes skin lesions, mainly ulcers, leaving life-
long scars and serious disability. Mucocutaneous
leishmaniasis leads to partial or total destruction of
the nose, mouth, and throat membranes.
LF, a painful and profoundly disfiguring dis-
ease, commonly known as elephantiasis, is
caused by the thread-like nematode worms
Wuchereria bancrofti, Brugia malayi, and Brugia
with microfilariae. More than 1.1 billion people
in 55 countries worldwide, wherefrom 80% occur
in African countries such as Angola, Cameroon,
and Mozambique, are at risk for acquiring LF
and require preventive chemotherapy to stop the
spread. Furthermore, an estimated 25 million
men suffer from genital disease and 15 million
are afflicted with lymphedema by this infection.
Eliminating LF prevents unnecessary suffering
and stigma while contributing to the reduction of
poverty [9] (Figs. 2.3 and 2.4).
18
Fig. 2.4 Prevalence of LF (2014)
Strategy
Effective control of NTDs in general can be
achieved when several public health approaches
are combined. The WHA adopted a resolution
with strategies to target the elimination of many
diseases and eradication of at least two diseases
by 2020. The WHA66.12 resolution calls on
Member States to intensify and integrate mea-
sures and plan investments to improve the health
and social well-being of affected populations
[10].
The WHO Director-General requests to sus-
tain the leadership of the WHO in the drive to
overcome NTDs. The WHO control on leishman-
iasis and LF involves supporting national control
programs; raising awareness and advocacy of the
global burden; development of evidence-based
policy guidelines, strategies, and standards for
prevention and control; monitoring implementa-
tion; technical support to Member States; and
promoting research on effective leishmaniasis
control as well as diagnostic tools and vaccines.
In addition, the WHO strategy for LF is based on
two key components: annual treatment of all eli-
A. C. Gerbase et al.
gible people in an endemic area and alleviating
the suffering caused by LF through increased
morbidity management and disability prevention
activities. Since the start of mass treatment, the
transmission of LF in at-risk populations has
fallen by 43% and the economic benefit is esti-
mated at US$ 24 billion.
The Global Program to Eliminate Lymphatic
Filariasis (GPELF), started in 2000 and continu-
ing until 2020, delivers mass drug administration
(MDA) in LF endemic countries. The new strat-
egy includes a protocol for stopping MDA and
post-MDA surveillance. The programmatic steps
taken to interrupt transmission are: (1) mapping
geographical distribution of LF; (2) MDA; (3)
surveillance; and (4) verification of elimination.
The 2020 target for LF is to reach 70% of coun-
tries verified as free of LF and 30% under post
surveillance, and full geographical coverage and
access to basic care for lymphedema in all coun-
tries. Moreover, the WHO calls for integrating
national programs to eliminate LF and onchocer-
ciasis within the African Program for
Onchocerciasis Control (APOC).
2 International Public Health Strategies in Dermatology
Interventions
To control and prevent leishmaniasis and LF, a
combination of intervention strategies is required
which targets the host, parasite, and vector, and
sometimes also the animal reservoir [11, 12]. The
key strategies for both infections are to reduce the
prevalence of the disease and prevent disabilities
and death by early diagnosis and case manage-
ment. Early detection and treatment [13] of cases
reduces the transmission and monitors the spread
and burden of disease. For LF [14], morbidity,
management and disability prevention are required,
alongside continuous access to care for LF patients
with lymphedema to prevent disease progression to
advanced stages. Simple measures of hygiene, skin
care, exercise, and elevation of affected limbs in LF
help to prevent further progression.
Vector control is a key factor in reducing
transmission and breaking the chain by control-
ling sandflies and mosquitoes. Methods such as
insecticide sprays, insecticide nets, environmen-
tal management, and personal protection are to
be used. Regarding the control of animal reser-
voirs, a complex intervention should be tailored
to the local situation [15].
The treatment for LF is continued by MDA by
expanding the coverage in nonparticipating coun-
tries and preventive chemotherapy for all LF
endemic countries [16]. LF prevention is treated
annually with a single dose of 400 mg albenda-
zole with either 150–200 μg/kg ivermectin or
6 mg/kg, or annual preventive chemotherapy with
diethylcarbamazine. However, coinfection with
the Loa loa worm should be taken into consider-
ation because of the adverse effect in ingesting
ivermectin. The extensive treatment recommen-
dations for various types of leishmaniasis are
available at the following web page: http://www.
who.int/leishmaniasis/research/978924129496_
pp67_71.pdf?ua=1.
Partnership and collaboration with various
stakeholders and other vector-borne disease con-
trol programs should be implemented together
with education of the community and behavioral
change interventions that are locally tailored.
Furthermore, the financial burden should be low-
ered to make treatment and surgery possible for
hydrocele or episodes of adenolymphangitis.
19
HIV and AIDS
Key Points Summary
• HIV Global Health Strategy for 2016–2020
is a priority for WHO and is based on accel-
erating actions and fast-tracking their
responses
• WHO goal for HIV is the end of AIDS epi-
demic as a public health threat by 2030
• The Strategy 2020 global targets are: reduce
new HIV infections and HIV-related deaths to
fewer than 500,000 each and zero new infec-
tions among infants
• The five Strategic Directions are: information
for action; interventions for impact; delivering
for equity; financing for sustainability; and
innovation for acceleration
• Unless intensified action occurs (hence the
importance of fast-tracking), the HIV epidem-
ics will see a rebound with current constant
coverage
In May 2014, the 67th World Health Assembly
requested a new strategy in the post-2015 devel-
opment agenda whereby HIV continued to be a
priority for the WHO [17]. The global health sec-
tor strategy on HIV/AIDS achieved 2015 targets
of more than 15 million people on antiretroviral
therapy (ART), with an estimated 7.8 million
HIV-related deaths and 30 million new HIV
infections averted since 2000. The 2030 Agenda
for Sustainable Development adopted by the
United Nations General Assembly in 2015 tar-
geted the end of the AIDS epidemic by 2030. The
WHO set forth to establish a new Global Health
Strategy for HIV for 2016–2021, appraised dur-
ing the 69th Health World Assembly in 2016
[18]. Full implementation of the draft strategy
will contribute to the achievement of other sus-
tainable development goals.
Global Health Sector Strategy on HIV,
2016–2021
Understanding that the actual steady state
response will see a rebound in new HIV infec-
tions and related deaths, emphasis is laid on the
need to fast-track the response to actions to pre-
vent this rebound, outlining countries and WHO
tasks to reach those goals [19]. The 2016–2021
20 A. C. Gerbase et al.

strategy is based on five strategic directions to estimates that an accelerated testing and treat-
guide actions in achieving 2020 targets and goals ment effort would:
(Fig. 2.5). Modeling undertaken by UNAIDS

Fig. 2.5 Outline of the draft global health sector strategy on HIV, 2016–2021
2 International Public Health Strategies in Dermatology
Fig. 2.6 Projections for decline in HIV-related deaths
• Avert 28 million HIV infections between 2015
and 2030
• Avert 21 million AIDS-related deaths between
2015 and 2030 (Fig. 2.6)
• Avoid US$ 24,000 million of additional costs
for HIV treatment
• Enable countries to reap a 15-fold return on
their HIV investments
Strategic Direction 1: Information for Focused
Action (What Is the Situation?)
Focuses on the need to understand the HIV epi-
demic and response as a basis for advocacy, politi-
cal commitment, and national planning as well as
resource mobilization and allocation and program
improvement. WHO guidelines recommend
adoption of 50 national indicators [20] (see sug-
gested readings, “Global Health Sector Strategy
on HIV, 2016–2021”), of which the following 10
are for global monitoring (Fig. 2.7) (Box 2.5).
Strategic Direction 2: Interventions for Impact
(What Services Should Be Delivered?)
Addresses the first dimension of universal health
coverage by describing the essential package of
21
high-impact interventions that need to be deliv-
ered along the continuum of HIV services.
The following interventions should be
included in an HIV prevention package:
• Male and female condoms
• Harm reduction for people who inject drugs
• ART-based prevention
• Vertical transmission prevention
• Voluntary male circumcision
• Injection and blood safety
• Behavioral change interventions
• Prevention and management of gender-based
and sexual violence
HIV testing should be expanded, focusing on
populations carrying the highest risk for HIV
infection and transmission, with appropriate
counseling and links to care. This is needed for
the expansion of ART therapy [21, 22] to achieve
the 90% people living with HIV (PLHIV) treat-
ment goal (see Box 2.5 for first-line therapy regi-
mens). Besides expanding ART, action should be
taken to prevent and manage coinfections such as
tuberculosis, hepatitis B and C, and HIV drug
22
Fig. 2.7 Key indicators for monitoring the HIV response across the continuum of HIV services and including the HIV
care cascade
resistance. Chronic care for PLHIV should be
person-centered.
Box 2.5 First-Line Regimens (Adults and
Adolescents)
• Pre-exposure prophylaxis (PrEP): Teno-
fovir (TDF)
• Post-exposure prophylaxis (PEP):
TDF + lamivudine (3TC) (+lopinavir/
ritonavir or atazanavir/ritonavir if
possible)
• ART Therapy: TDF + 3TC + dolutegra-
vir (DTG)
• Alternative ART first-line treatment:
TDF + 3TC + EFV 400 mg
Strategic Direction 3: Delivering for Equity
(How Can These Services Be Delivered?)
Addresses the second dimension of universal
health coverage by identifying the best methods
for delivering the continuum of HIV services to
A. C. Gerbase et al.
different populations and in different locations.
Special focus should be fixed on addressing key
populations (at increased risk of HIV regardless
of the local epidemic context): men who have sex
with men, people who inject drugs, people in
prison and other closed settings, sex workers, and
transgender persons.
Strategies for achieving equity include decen-
tralization of care, differentiated care (based on
stage of HIV disease, stability of treatment, and
special care needs), linking HIV with tuberculosis
services, community engagement and task shifting,
and providing chronic care for PLHIV. Countries
should also end policies and practices that rein-
force stigmatization and discrimination.
Strategic Direction 4: Financing
for Sustainability (How Can the Costs
of Delivering the Package of Services
Be Covered?)
Addresses the third dimension of universal health
coverage by identifying innovative models and
2 International Public Health Strategies in Dermatology 23

approaches for financing HIV responses and rosy strategy focused on reducing leprosy-­
reducing costs without incurring financial hard- related disabilities
ship: essential HIV services should be provided • 2016–2020 WHO Global Leprosy Strategy
free of charge. Reducing costs also mean improv- focuses on promoting early diagnosis to
ing efficiency of service delivery, such as decen- reduce leprosy burden
tralization, service linkage, and task shifting. • The Strategy 2020 targets are: zero new chil-
Other strategies include fostering generic compe- dren diagnosed with leprosy and visible defor-
tition on ART drugs, applying pro-access terms mities, <1 per million newly diagnosed
of the Medicines Patent Pool, and appropriate use leprosy patients with visible deformities; and
of the provisions in the Agreements on Trade-­ zero countries with legislation allowing dis-
Related Aspects of Intellectual Property Rights crimination on leprosy
regarding flexibilities to protect public health. • The Program five key operational strategies are:
However, it is acknowledged that investments focus on early detection; increased detection
in HIV will need to grow if long-term control of and coverage; universal contacts screening; uni-
the epidemic is to be achieved; therefore, coun- form leprosy treatment; and interventions
tries need to develop strong investment cases for against stigma and discrimination
HIV.
Leprosy, also known as Hansen’s disease, is a
Strategic Direction 5: Innovation chronic infectious disease caused by
for Acceleration (How Can the Trajectory Mycobacterium leprae that mainly affects the
of the Response Be Changed?) skin and the peripheral nerves. It occurs at all
Identifies those areas where there are major gaps ages ranging from early infancy to elderly [23]. It
in knowledge and technologies, and where inno- is curable, but if left untreated almost always pro-
vation is required so that actions can be acceler- gresses to permanent damage with a disabling
ated and 2020 and 2030 targets achieved. and stigmatizing condition [24]. Although it was
Research and innovation provide the tools and considered eliminated as a public health problem
knowledge that can change the trajectory of the globally in 2000 (defined by the WHO as preva-
HIV response. Innovation is also required to use lence less than 1 per 10,000 population), it still
existing tools more efficiently and to adapt them occurs in more than 120 countries with more than
for different populations. 200,000 new cases reported every year [25].
Key areas for innovation are: optimizing HIV The global leprosy strategy for 2016–2020
prevention; optimizing HIV testing and diagnos- reinforced early detection to reduce the burden of
tics; optimizing HIV medicines and treatment leprosy, while accelerating actions toward the
regimens; and optimizing service delivery. vision of a leprosy-free world [26]. The strategy
general overview, its three pillars, and their core
Strategy Implementation areas of interventions are displayed in Fig. 2.8.
Finally, effective implementation of this strategy There were five key strategic operational
depends on collaboration between all involved changes in the 2016–2020 plan along with target
parties, in which the WHO plays an important indicators:
convening role. Monitoring and evaluation are
done at global and regional/country level goals 1. Focus on early detection to prevent disabili-
(Fig. 2.6), while applying WHO results-based ties, with special focus on children. The target
management and UNAIDS accountability was zero disabilities among new pediatric
frameworks. patients (<15 years of age) by 2020. For coun-
tries that do not detect grade 2 disability
Leprosy (G2D) among pediatric patients, the target
Key Points Summary would be zero pediatric cases.
• Once leprosy was eliminated as a public health 2. Increased detection, coverage, and access to
problem globally in 2000, WHO global lep- treatment for high-risk groups and marginal-
24
Fig. 2.8 WHO 2016–2020 Global Leprosy Strategy Overview
ized populations. The target was an incidence
of G2D of less than 1 per million population.
3. National plans to ensure screening of all close
contacts. The target was to have all household
contacts screened.
4. Promote steps toward the use of shorter and
uniform treatment regimens for all types of
leprosy.
A. C. Gerbase et al.
5. Incorporate specific interventions against
stigma and discrimination due to leprosy. The
target was zero countries with legislation allow-
ing discrimination on the basis of leprosy.
This was implemented and advocated by many
countries, and by the end of 2019, leprosy had
shown gradual and consistent reduction in preva-
2 International Public Health Strategies in Dermatology
Fig. 2.9 Leprosy geographical distribution of cases
lence and new cases of all WHO regions (Americas,
African, Eastern Mediterranean, Europe, South-
East Asia, and Western Pacific), including new
child cases rate. For the first time, the number of
new child cases (<15 years) was <15.000. Also,
the presence of G2D globally at the time of diag-
nosis had decreased in almost all regions. The
global number of new cases decreased by 6506,
compared to the previous year [25].
Although substantial progress has been made,
the three main targets of the program: zero new
child cases with G2D; reduction of new G2D cases
to <1 case per million population; and zero coun-
tries with laws or legislation that allow discrimina-
tion on the basis of leprosy; were only partially
achieved. A number of 370 new cases of children
with G2D leprosy were still detected in 2019; there
are still 127 laws in 22 countries allowing discrimi-
nation against leprosy; and the rate of new G2D
cases was 1.36 per million population—this goal
will probably be achieved by the end of 2020 [25].
Child cases indirectly indicate ongoing trans-
mission since it reveals an active circulation of
bacillus, continued transmission, and lack of dis-
ease control by the health care system [27]. G2D
indicates a delayed detection, perhaps because
the poor awareness of the community or the dif-
ficult access to health care. That is why these are
important parameters on leprosy control.
25
Besides, while some countries reported 0 new
cases, Brazil, India, and Indonesia reported more
than 10.000 cases. The geographical distribution
of cases is presented in Fig. 2.9 [28]. These three
countries together with Democratic Republic of
the Congo and Ethiopia were also responsible for
75% of new child cases with G2D.
The number of new leprosy cases has continued
to decline along the past 10 years, but by a slow rate
of 1% per year. Hence, WHO launched the “Ending
the neglect to attain the Sustainable Development
Goals—a road map for neglected tropical diseases
2021–2030.” This document is a new guide (the
first one was published in 2012) to definitely pre-
vent, control, or eliminate 20 diseases. One of the
goals is to eliminate leprosy (interruption of trans-
mission) by 2030. The targets are: 120 countries
with zero autochthonous cases; the number of new
cases reduced to about 63.000; the rate of new G2D
cases to be reduced to 0.12 per million population;
and the rate of detection of new child cases to be
reduced to 0.77 per million child population. Three
critical actions are presented by WHO in its latest
document to reach these targets [29]:
1. Update country guidelines to include use of
single-dose rifampicin for post-exposure pro-
phylaxis for contacts; advance research on
new preventive approaches.
26
2. Continue investment into diagnostics for dis-
ease and infection. Develop surveillance strate-
gies, systems, and guidelines for case-finding
and treatment. Ensure resources for validation.
3. Ensure medicines supply, including access to
multidrug therapy, single-dose rifampicin,
and second-line treatments and medicines to
treat reactions. Monitor adverse events (phar-
macovigilance) and resistance.
This will require innovation of countries,
companies, and leaderships. And some have been
done. WHO provides free anti-leprosy medicine
(shown in Box 2.6) to more than 90 countries and
ensures uninterrupted supplies of MDT. Also,
technology has been developed to facilitate
detection and breaking down transmission: the
Novartis Foundation has invested in a molecular
diagnostic test for leprosy [30].
Box 2.6 Adult MDT regimen
– PB: 6 months MB: 12 months
Monthly Rifampicin Rifampicin
600 mg 600 mg + clofazimine
300 mg
Daily Dapsone Dapsone
100 mg 100 mg + clofazimine
50 mg
Also, to facilitate engagement for the end of
leprosy, a coalition was created in 2018 by gov-
ernments, civilians, organizations, and donor
agencies. The Global Partnership for Zero
Leprosy includes Novartis, WHO (as an
observer), the International Federation of Anti-
Leprosy Associations (ILEP), the Sasakawa
Memorial Health Foundation, the International
Association for Integration, Dignity and
Economic Advancement (IDEA), and the national
leprosy programs of Brazil and Ethiopia [6].
Their purpose is to “facilitate alignment of the
leprosy community and to accelerate effective
collaborative action toward the goal of zero lep-
rosy.” During the COVID-19 pandemic of the
year of 2020, for example, the partnership helped
to identify and establish the leprosy community’s
challenges and face it. Their action framework is
stated in Fig. 2.10.
A. C. Gerbase et al.
 kin Diseases in Primary Care
S
Key Points Summary
• Some nongovernmental organizations, such as
the International Society of Dermatology,
have developed public health task forces and
programs to promote skin health.
• Although the WHO has no specific public
health strategies for general skin diseases in
primary care, it has issued simple and practi-
cal clinical guidelines in the Integrated Man-
agement of Adolescent and Adult Illness
(IMAI) for such diseases.
The International Society of Dermatology sets
the task force “Skin Care for All: Community
Dermatology” [31] to promote general skin
health, stating that public health strategies have
not been sufficiently inclusive of skin care. The
program focuses on low-cost interventions, rely-
ing on self-help and low technology, while edu-
cating a workforce for skin care among primary
care health workers, nurses, and physicians,
facilitating delivery of skin care to those in need.
The task force is responsible for the creation of
the Regional Dermatology Training Centre in
Tanzania, with several dermatology graduates
serving in Sub-Saharan Africa; and a 1-day train-
ing course for health center personnel in Mali for
recognition and management of the three most
commonest skin conditions: impetigo, superficial
fungus, and scabies. It also emphasizes the “look
good feel good factor” concept in advocating
skin care and promotes social marketing such as
“Natural is Beautiful” to prevent the use of
creams containing harmful agents.
While the WHO has not developed public health
strategies for general skin diseases as seen in pri-
mary care (aside from specific diseases with an
important burden such as leprosy), it has issued the
IMAI in 2004, with interim guidelines for primary
care workers on the diagnosis and treatment of sev-
eral skin diseases and conditions (see suggested
readings, “Skin Diseases in Primary Care”). These
guidelines are based on several algorithms for eas-
ily defining the type of skin problem (e.g., lump,
itching lesion, patch, infected lesion) and tables for
prompt diagnosis or classification of each type of
problem along with its specific management (see
Table 2.1 for an example). They should be vali-
dated in primary care intervention studies.
2 International Public Health Strategies in Dermatology 27

Fig. 2.10 Action framework for zero leprosy

Table 2.1 Use this table if lesion red, tender, warm, pus, or crusts (infected skin lesion—consider this in all skin
lesions)

Adapted from Integrated Management of Adolescent and Adult Illness. WHO; 2004
28
Future Perspectives
The WHO will continue to be a leading public
health organization at international level. Its
importance depends on the capability of the
Director General to mobilize financial and human
resources and to continue to deliver high-level
strategies and products for its member countries.
The use of the GRADE methodology to develop
international guidelines has been questioned as
too strict and expensive. A challenge to be faced
is to maintain the present high scientific standard
of developing a modified and user-friendly meth-
odology. The impact of COVID19 pandemic
global control on other WHO activities is too
early to be assessed.
STIs, especially syphilis, will decrease in inci-
dence and prevalence, but will continue to be a
major public health concern. The reasons for this
include the lack of affordable tests to identify
asymptomatic infections, difficulties in reaching
sexual partners, and weak health systems not pro-
viding extended access to STI services of ade-
quate quality to all in need.
The WHO strategy will contribute to interrupt
the transmission of LF and the targets will be
probably reached (70% of countries verified as
free of LF by 2020, 30% under post surveillance
and full coverage and access to basic care for
lymphedema). Leishmaniasis will be more diffi-
cult to eliminate, as the diagnostic tools and vac-
cines are yet to reach optimal performance.
The WHO goal for HIV, the end of AIDS as a
public health threat by 2030, probably will not be
reached because the present international envi-
ronment is not intensifying actions as required
and, as is mentioned in the strategy, necessary
innovations are still not in the pipeline.
Furthermore, it is unclear on how the COVID19
pandemic will impact global health priorities.
Considering that leprosy was eliminated as a
public health problem globally, the WHO global
leprosy strategy focuses on reducing leprosy-
related disabilities. This will be more difficult
given the fact that disabilities are not always
related to active disease. Moreover, it will be dif-
ficult to reach the ambitious target of zero new
children diagnosed with leprosy and visible defor-
A. C. Gerbase et al.
mities. The strategy focuses on early detection,
increased detection and coverage, universal con-
tacts screening, uniform leprosy treatment, and
interventions against stigma and discrimination.
Most of the strategies rely on coverage and quality
of health systems, which are not performing opti-
mally at this stage in the most affected countries.
In relation to skin diseases, a global strategy is
needed, targeting primary health care, using sim-
ple and practical quality clinical guidelines.
These guidelines, based on IMAI work, need to
be further developed and field-tested before wide
dissemination. A discussion on the role of derma-
tologists at different levels of health systems
needs to be conducted with the participation of
specialists, universities, and public health
authorities.
References
1. The global Guardian of public health. WHO; 2016.
http://www.who.int/about/what-we-do/global-guard-
ian-public-health/en/. Assessed Aug 2016.
2. WHO handbook for guideline development.
2012. http://www.who.int/kms/handbook_2nd_
ed.pdf?ua=1. Assessed Aug 2016.
3. WHO Governing bodies site. http://apps.who.int/gb/
gov/. Assessed Aug 2016.
4. World Health Organization. Draft global health sec-
tor strategies sexually transmitted infections, 2016–
2021; Sixty-ninth World Health Assembly. 2016.
http://apps.who.int/gb/ebwha/pdf_files/WHA69/
A69_33-en.pdf?ua=1.
5. World Health Organization. WHO guidelines for the
treatment of Chlamydia trachomatis. 2016. http://
www.who.int/reproductivehealth/publications/rtis/
chlamydia-treatment-guidelines/en/.
6. World Health Organization. WHO guidelines for the
treatment of Neisseria gonorrhoeae. 2016. http://
www.who.int/reproductivehealth/publications/rtis/
gonorrhoea-treatment-guidelines/en/.
7. World Health Organization. WHO guidelines for the
treatment of Neisseria gonorrhoeae. 2016 (in press).
8. World Health Organization. Leishmaniasis fact sheet.
2016. http://www.who.int/mediacentre/factsheets/
fs375/en/.
9. World Health Organization. Global health observa-
tory data, situation and trends. 2016. http://www.who.
int/gho/neglected_diseases/leishmaniasis/en/.
10. World Health Assembly. Sixty-sixth world health
assembly, agenda item 16.2 Neglected tropical dis-
eases. 2013. http://www.who.int/neglected_diseases/
mediacentre/WHA_66.12_Eng.pdf?ua=1.
2 International Public Health Strategies in Dermatology
11. World Health Organization. Integrating national
programmes to eliminate lymphatic filariasis
and onchocerciasis; strategic and technical advi-
sory group for neglected tropical diseases sub-
group on disease-specific indicators, 7–8 February
2015. 2015. http://apps.who.int/iris/bitstr
eam/10665/246190/1/9789241511148-eng.pdf?ua=1.
12. World Health Organization. Control of the leish-
maniases; report of a meeting of the WHO expert
committee on the control of Leishmaniases, Geneva,
22–26 March 2010. 2010. http://apps.who.int/iris/
bitstream/10665/44412/1/WHO_TRS_949_eng.
pdf?ua=1.
13. World Health Organization. Recommended treatment
regimen for Leishmaniasis. 2016. http://www.who.
int/leishmaniasis/research/978924129496_pp67_71.
pdf?ua=1.
14. World Health Organization. Weekly epidemiological
record; 17 September 2010; World Health Organization;
2010; Global programme to eliminate Lymphatic
Filariasis, progress report 2000–2009 and strategic
plan 2010–2020. 2010. http://apps.who.int/iris/bitstr
eam/10665/44473/1/9789241500722_eng.pdf.
15. World Health Organization. Lymphatic filariasis
fact sheet. 2016. http://www.who.int/mediacentre/
factsheets/fs102/en/.
16. Global programme to eliminate lymphatic filariasis.
http://www.who.int/wer/2010/wer8538a.pdf?ua=1.
17. Summary records of the Sixty Seventh World Health
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(document WHA67/2013/rec/3).
18. Draft global health sector strategies, HIV 2016–2021,
22 April 2016. Sixty-ninth world health assembly.
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the AIDS epidemic by 2030, see www.unaids.org/
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Understanding_fasttrack_en.pdf.
20. Global AIDS response progress reporting 2013—
Construction of core indicators for monitoring the
2011 UN political declaration on HIV/AIDS.
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ommendations for a public health approach, 2nd ed.
WHO; 2016.
22. Consolidated Guidelines on HIV testing Services;
5Cs: consent, confidentiality, counselling, correct
results and connection. WHO; 2015.
23. World Health Organization. Leprosy (Hansen’s
disease). https://www.who.int/health-topics/
leprosy#tab=tab_1. Accessed 4 Oct 2020.
24. Rodrigues Júnior IA, Gresta LT, Noviello MLM,
Cartelle CT, Lyon S, Arantes RME. Leprosy classifi-
cation methods: a comparative study in a referral cen-
ter in Brazil. Int J Infect Dis. 2016;45:118–22. https://
doi.org/10.1016/j.ijid.2016.02.018.
29
25. World Health Organization. Global leprosy (Hansen
disease) update, 2019: time to step-up prevention
initiatives. https://www.who.int/publications/i/item/
who-wer9536. Accessed 4 Oct 2020.
26. World Health Organization. Global leprosy strategy.
Accelerating towards a leprosy-free world. World
Health Organization, Regional Office for South-East
Asia; 2016.
27. Fischer M. Leprosy—an overview of clinical fea-
tures, diagnosis, and treatment. J Dtsch Dermatol
Ges. 2017;15(8):801–27. https://doi.org/10.1111/
ddg.13301.
28. World Health Organization. Ending the neglect to attain
the sustainable development goals: a road map for
neglected tropical diseases 2021–2030. Geneva; 2020.
29. Global partnership for zero leprosy. https://zerole-
prosy.org/about-the-partnership/. Accessed 3 Nov
2020.
30. Global Health progress. Collaborating for a sustain-
able future. https://globalhealthprogress.org/collabo-
ration/leprosy-drug-donation/. Accessed 3 Nov 2020.
31. Ryan TJ, Ersser SJ, Fuller LC. The public health
intervention of skin care for all: community dermatol-
ogy. In: Maddock J, editor. Public health—social and
behavioral health. InTech; 2012. p. 523–36.
Further Reading
Global Health Sector Strategy on HIV,
2016–2021
Consolidated Guidelines on the use of antiretroviral drugs
for treating and preventing HIV infection; recommen-
dations for a public health approach, 2nd ed. WHO
2016.
Consolidated Strategic information Guidelines; for HIV
in the health sector—WHO, May 2015.
Global AIDS response progress reporting 2013—con-
struction of core indicators for monitoring the 2011
UN political declaration on HIV/AIDS.
Leprosy
WHO Regional Office for South-East Asia Leprosy
Programme. http://www.searo.who.int/entity/leprosy/
en/
Skin Diseases in Primary Care
World Health Organization. Integrated management of
adolescent and adult illness. Geneva: World Health
Organization; 2004.
 The User of the Public Service
in Dermatology
3
Heitor de Sá Gonçalves, Maria Araci de Andrade Pontes,
and Gerson Oliveira Penna

Abbreviations • Nosological profile in dermatology depends

on many variables such as gender, age, socio-
AIDS Acquired Immunodeficiency Disease economic status, and access to health services,
Syndrome among others.
Covid 19 Coronavirus infectious disease 2019 • Health professionals should be able to observe
DALYs Disability-Adjusted Life Years and recognize symptoms of the cutaneous
GBD Global Burden of Disease complaints more prevalent in the population
NHS National Health System they care for.
SBD Brazilian Society of Dermatology
UHS Unified Health System (in portu-
guese: Sistema Único de Saúde or Introduction
SUS)
Skin problems are one of the main reasons why
people seek medical care, and one of the leading
Key Points
causes of global disease burden, affecting mil-
• Skin diseases are responsible for approxi- lions of people worldwide. In fact, dermatologi-
mately one-quarter of medical appointments cal diseases are the fourth most frequent cause of
in primary care. all human disease, affecting some 1.9 billion
• Patients with cutaneous problems experience a people at any time, almost one third of the world’s
reduction in their quality of life that often goes population [1]. It is therefore a leading reason for
seeking medical help in all societies. In the
beyond other non-dermatological conditions.
United States, 85 million Americans (i.e., 1 in 4
• Social and demographic characteristics of the
individuals of all ages) were seen by a physician
population using public dermatology services
for at least 1 skin disease in 2013 [2].
are essential to direct and plan public health
A study conducted in Sweden, with a random
policies.
sample of 8000 individuals, assessed the impact
of skin conditions on the quality of life of this
H. de Sá Gonçalves (*) · M. A. de Andrade Pontes population, from an epidemiological perspective.
Centro de Dermatologia Dona Libânia, The subjects were aged between 20–84 years and
Fortaleza, Brazil 20.5% reported skin problems and/or the use of
G. O. Penna topical medications, with a higher frequency
Fundação Osvaldo Cruz–Brasilia, Brasilia, Brazil among women [3].
e-mail: gpenna@gpenna.net

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 31

R. Rangel Bonamigo (ed.), Dermatology in Public Health Environments,
https://doi.org/10.1007/978-3-031-13505-7_3
32
Another survey, conducted in France, evalu-
ated the prevalence, management and impact of
dermatological diseases, from the patient’s point
of view. Of a total of 25,441 subjects, 18,137
(71.3%) returned the questionnaire. Of these,
86.8% reported at least one skin problem from
birth, and 43.2% mentioned a skin disease in the
previous 24 months. For 28.7% of the respon-
dents, their dermatological problem had impaired
their quality of life [4].
The importance of the skin’s health is under-
estimated, due to the chronic nature and low
lethality of most cutaneous diseases, which
results in those not being considered important
health problems by those who formulate public
policies [5] However, skin conditions can be pre-
cursors to considerable physical and psychologi-
cal deficiencies, making them a public health
problem of great magnitude. Important examples
of these situations can be cited, such as: leprosy,
psoriasis, vitiligo, melasma, lupus, urticaria,
atopic dermatitis, and skin cancer, especially
melanoma [6–8]. The prevalence of suicidal ide-
ation is high in several skin diseases, especially
in patients with psoriasis, atopic dermatitis, and
acne [9]
Moreover, frequently, dermatologic manifes-
tations are indicative of or associated with sys-
temic diseases, where the skin changes can be the
first sign of a medical condition, or part of a mul-
tisystem disease, like systemic lupus, sarcoid-
osis, neoplasias, and AIDS, for example [10], and
more recently, the heterogeneous and complex
spectrum of cutaneous manifestations observed
in patients with Covid 19 [11].
Skin diseases place a huge burden on global
health. The costs and prevalence of skin disease
are comparable with or exceed other diseases
with significant public health concerns, such as
cardiovascular disease and diabetes [12]. Global
disability and mortality due to skin disease has
been investigated by the Global Burden of
Disease (GBD) 2013 Study, a collaboration of
more than 1000 experts worldwide, aiming to
create a systematic, quantified, and internally
consistent source of health information.
According to this study, skin and subcutaneous
diseases were the 18th leading cause of global
H. de Sá Gonçalves et al.
DALYs (disability-adjusted life years).
Excluding mortality, skin diseases were the
fourth leading cause of disability worldwide,
expressed in years lost due to disability. Skin
diseases arranged in order of decreasing global
DALYs are as follows: dermatitis (atopic, con-
tact, seborrheic), acne vulgaris, urticaria, psori-
asis, viral skin diseases, fungal skin diseases,
scabies, melanoma, pyoderma, cellulitis, kerati-
nocyte carcinoma, decubitus ulcer, and alopecia
areata [13, 14].
Patients with cutaneous complaints experi-
ence a reduction in their quality of life that often
goes beyond other non-dermatological condi-
tions, including restricted mobility, intense pruri-
tus, and physical and psychological discomfort;
the physical characteristics of the diseases related
to contagion and deformity may even lead to the
social segregation of individuals. Such restric-
tions undermine the activities of daily life and
have a great impact on the patients’ sense of well-­
being [12, 13].
Although skin problems are common in the
population, there is little information on the pro-
file of users of public dermatology health ser-
vices. Data on the dermatological care provided
in public health services are critically important
to identify and monitor the impact of dermato-
logical diseases on the health of the population,
as well as the user profile of those afflicted, with
a view to planning the treatment, prevention, and
promotion of such maladies, especially among
the most vulnerable population groups [5].
Health Services
The World Health Organization defines a health
system as a network of organizations, people, and
actions whose primary objective is to promote,
restore, or maintain health [14]. This includes the
public, private, and voluntary bodies that contrib-
ute to the delivery of essential health services,
working to fulfill the mission of guaranteeing a
healthy population. The responsibility of the pub-
lic health in each country lies with specific agen-
cies at different levels of management (municipal,
state, federal, and international).
Another random document with
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through hatred, and in order that he whom he attempted to accuse
might suffer death, or bodily injury, or the loss of his property; he
shall be delivered over into the power of him he accused, that he
may himself suffer the penalty which he endeavored to inflict upon
an innocent person.
Where anyone states that he is in the possession of any fact
which should be brought to the notice of the king, and should be, at
the time, in the place where the court was sojourning, he shall
straightway reveal all that he knows, or shall communicate it to the
ears of the king through the agency of some reliable person. If,
however, at the time, the king should be at a distance, and the said
party should believe that information in his possession relating to the
accusation of another, ought to be sent to the king by the hands of a
messenger, he must draw up a letter, and in it set forth plainly what
he wishes to say concerning the alleged guilt of the accused; and he
must do this in the presence of him whom he has selected to convey
the information to the king. And, in order that he may not be able to
deny the aforesaid communication, three witnesses, known to be
men of respectable character, must, in the presence of one another,
affix their seals or signatures to said letter.
FLAVIUS CHINTASVINTUS KING.
VI. How Kings should Practice the Duties of Mercy.
Whenever a supplication is made to us on behalf of those who
have been implicated in any crime against our majesty, we willingly
give attention to such appeals, and exercise the prerogative of mercy
when it is consistent with our power. We must, however, refuse to
interfere when a crime of this kind has been committed against the
nation and our country. Yet, if a prince should desire to be merciful to
persons of such wicked character, he shall have the right to do so,
with the approval of the ecclesiastics and the principal officers of the
court.

VII. He Alone shall be Considered Guilty who Committed the

Crime.
 Punishment for all crimes shall be visited upon the authors of the
same; and a father shall suffer no penalty on account of his son; nor
a son on account of his father; nor a wife on account of her husband;
nor a husband on account of his wife; nor a brother on account of his
brother; nor one neighbor on account of another; nor any person on
account of a relative; but he alone shall be adjudged to be guilty who
is responsible for the offence, and the crime shall die with him who
committed it. Neither successors nor heirs shall, under any
circumstances, be placed in jeopardy on account of the acts of their
parents.
 TITLE II. CONCERNING MALEFACTORS AND THEIR ADVISERS, AND
POISONERS.

I. Where a Freeborn Man Consults with a Soothsayer Concerning the

Health, or the Death of Another.
II. Concerning Poisoners.
III. Concerning Malefactors and their Advisers.
IV. Concerning Those who are Guilty of Acts of Witchcraft, or any Injury,
towards Men, Animals, or any kind of Property whatsoever.

FLAVIUS CHINTASVINTUS, KING.

I. Where a Freeborn Man Consults with a Soothsayer
Concerning the Health, or the Death of Another.
Whoever plots the death of the king or any of his subjects, and,
with a view to the execution of such a crime, consults diviners,
augurs, or soothsayers; should he be freeborn, he shall be scourged,
and be condemned to perpetual slavery in the public service, after
the confiscation of all his property, or he shall be delivered up as a
slave to anyone whom the king may select; and those who have
given him advice shall undergo the same penalty. And if any children
should be implicated in the crime of their parents, they shall be
punished in like manner. But if said children should be innocent, they
shall not be degraded in rank, and shall enjoy full and undisturbed
possession of all the property which their parents have lost. Slaves
who are implicated in such offences shall be tortured in various
ways, sold, and transported beyond sea; as the vengeance of the
law does not excuse those who have voluntarily participated in such
infamous proceedings.
FLAVIUS CHINTASVINTUS, KING.
II. Concerning Poisoners.
Different kinds of crimes should be punished in different ways;
and, in the first place, freemen or slaves who are guilty of preparing,
or administering poison shall be punished in like manner; as for
instance, if they should give poisoned drink to anyone and he should
die in consequence; in such a case those who are guilty shall be put
continuously to the torture, and be punished by the most ignominious
of deaths. But if he who drank the poison should escape with his life,
the party who administered it shall be given up into his power, to be
disposed of absolutely as he may desire.
FLAVIUS CHINTASVINTUS, KING.
III. Concerning Malefactors and their Advisers.
Enchanters, and invokers of tempests, who, by their incantations,
bring hail-storms upon vineyards and fields of grain; or those who
disturb the minds of men by the invocation of demons, or celebrate
nocturnal sacrifices to devils, summoning them to their presence by
infamous rites; all such persons detected, or found guilty of such
offences by any judge, agent, or superintendent of the locality where
these acts were committed, shall be publicly scourged with two
hundred lashes; shall be scalped; and shall be dragged by force
through ten villages of the neighborhood, as a warning to others.
And the judge, lest, hereafter, the aforesaid persons may again
indulge in such practices, shall place them in confinement, and see
that they are provided with clothing and food, to deprive them of an
opportunity of inflicting further injury; or he may lay the matter before
the king, to be disposed of at his royal pleasure. Those who are
convicted of having given advice to such persons, shall each receive
two hundred lashes in the assembly of the people, in order that all
who have aided in the commission of such a crime may not go
unpunished.
FLAVIUS CHINTASVINTUS, KING.
IV. Concerning Those who are Guilty of Acts of Witchcraft, or
any Injury towards Men, Animals, or any kind of Property
whatsoever.
We decree, by the present law, that if any freeman or slave, of
either sex, should attempt to employ, or should employ, witchcraft,
charms, or incantations of any kind with intent to strike dumb, maim,
or kill, either men or animals; or injure anything movable; or should
practice said arts to the detriment of crops, vineyards, or trees; he
shall suffer in person and property the same damage he endeavored
to inflict upon others.[34]
 TITLE III. CONCERNING ABORTION.

I. Concerning Those who Administer Drugs for the Production of Abortion.

II. Where a Freeborn Man Causes a Freeborn Woman to Abort.
III. Where a Freeborn Woman Causes another Freeborn Woman to Abort.
IV. Where a Freeborn Man Produces Abortion upon a Slave.
V. Where a Slave Produces Abortion upon a Freeborn Woman.
VI. Where a Slave Produces Abortion upon a Female Slave.
VII. Concerning Those who Kill their Children before, or after, they are Born.

ANCIENT LAW.
I. Concerning Those who Administer Drugs for the
Production of Abortion.
If anyone should administer a potion to a pregnant woman to
produce abortion, and the child should die in consequence, the
woman who took such a potion, if she is a slave, shall receive two
hundred lashes, and if she is freeborn, she shall lose her rank, and
shall be given as a slave to whomever we may select.
ANCIENT LAW.
II. Where a Freeborn Man Causes a Freeborn Woman to
Abort.
If anyone should cause a freeborn woman to abort by a blow, or
by any other means, and she should die from the injury, he shall be
punished for homicide. But if only an abortion should be produced in
consequence, and the woman should be in no wise injured; where a
freeman is known to have committed this act upon a freewoman, and
the child should be fully formed, he shall pay two hundred solidi;
otherwise, he shall pay a hundred solidi, by way of satisfaction.
ANCIENT LAW.
III. Where a Freeborn Woman Causes another Freeborn
Woman to Abort.
Where a freeborn woman, either by violence or by any other
means, causes another freeborn woman to abort, whether, or not,
she should be seriously injured as a result of said act, she shall
undergo the same penalty provided in the cases of freeborn men.
ANCIENT LAW.
IV. Where a Freeborn Man Produces Abortion upon a Slave.
Where a freeborn man produces abortion upon a female slave,
he shall be compelled to pay twenty solidi to the master of the slave.
ANCIENT LAW.
V. Where a Slave Produces Abortion upon a Freeborn
Woman.
Where a slave produces abortion upon a freeborn woman, he
shall receive two hundred lashes in public, and shall be delivered up
as a slave to said woman.
ANCIENT LAW.
VI. Where a Slave Produces Abortion upon a Female Slave.
Where a male slave produces abortion upon a female slave, he
shall be compelled to pay ten solidi to her master, and, in addition,
shall receive two hundred lashes.
FLAVIUS CHINTASVINTUS, KING.
VII. Concerning Those who Kill their Children before, or after,
they are Born.
No depravity is greater than that which characterizes those who,
unmindful of their parental duties, wilfully deprive their children of life;
and, as this crime is said to be increasing throughout the provinces
of our kingdom and as men as well as women are said to be guilty of
it; therefore, by way of correcting such license, we hereby decree
that if either a freewoman or a slave should kill her child before, or
after its birth; or should take any potion for the purpose of producing
abortion; or should use any other means of putting an end to the life
of her child; the judge of the province or district, as soon as he is
advised of the fact, shall at once condemn the author of the crime to
execution in public; or, should he desire to spare her life, he shall at
once cause her eyesight to be completely destroyed; and if it should
be proved that her husband either ordered, or permitted the
commission of this crime, he shall suffer the same penalty.[35]
TITLE IV. CONCERNING INJURIES, WOUNDS, AND MUTILATIONS INFLICTED
UPON MEN.

I. Concerning the Injury of Freemen and Slaves.

II. Concerning Insolent Persons and their Acts.
III. Concerning the Law of Retaliation, and the Amount to be Paid in Lieu of
the Enforcement of said Law.
IV. Where a Person Deprives a Traveller of his Liberty, against the Will of the
Latter, and with Intent to do him Injury.
V. He who Violates the Law by Inflicting Injury upon Another, shall undergo
the same Punishment which he Himself Inflicted.
VI. He shall not be Considered Guilty who Struck Another, when the Latter
was about to Strike Him.
VII. Where a Slave Insults a Freeborn Person.
VIII. Where one Freeborn Person Strikes Another.
IX. Where the Slave of Another is Mutilated by a Freeborn Person.
X. Where a Slave Strikes a Freeborn Person.
XI. Where One Slave Mutilates Another Slave.

I. Concerning the Injury of Freemen and Slaves.

Where one freeborn person strikes another any kind of a blow
upon the head, he shall pay five solidi for a bruise, ten solidi if the
skin be broken, twenty solidi for a wound extending to the bone, and
a hundred solidi where a bone is broken. If a freeborn man should
commit any of the above named acts upon the slave of another, he
shall pay half of the above named penalties, according to the degree
of his offence. If one slave should strike another, as above stated, he
shall pay a third part of the above penalties, proportionate to his
offence, and shall receive fifty lashes. If a slave, however, should
wound a freeborn person, he shall pay the largest sum hereinbefore
mentioned, which is exacted from freeborn persons for assaults
upon slaves, and shall receive seventy lashes. If the master should
not be willing to give satisfaction for the acts of his slave, he must
surrender him on account of his crime.

II. Concerning Insolent Persons and their Acts.

If anyone with a drawn sword, or armed with any kind of weapon,
should insolently enter the house of another, with the design of killing
the master of the same, and should be himself killed, no one shall be
held responsible for his death; but if he who entered said house
should kill anyone, he shall be put to death at once. But if he should
not commit any crime, he must at once give satisfaction, according
to law, for any injury resulting from his act. And if he who entered the
house of another by violence, should steal anything there, he shall
be compelled to pay elevenfold the value of what he carried away.
And if he should not have the means to pay the amount due, he shall
be given up to serve as a slave; and if no damage should result from
his violent entrance into the house, and he should not steal anything
therefrom; for the mere fact of his forcible entry, he shall be
compelled to pay ten solidi and shall receive a hundred lashes in
public; and if he should not be possessed of said sum, he shall
receive two hundred lashes. If any other freeborn persons, who were
not under his orders or subject to him, or under his protection, should
enter with him into the house; all of them, as giving consent to a
high-handed and illegal act, shall undergo similar condemnation and
penalties. If they should not have the property wherewith to render
satisfaction, each one of them shall receive a hundred and fifty
lashes; but they shall not lose the right to testify in court. But if they
were under the protection, or in the service of the aggressor, and it is
proved that he ordered them to commit the act of violence, or that
they participated in it with him, the patron alone shall be held liable
for all damage committed, as well as for the penalty; for they were
not guilty who only carried out the orders of their superior. If a slave
should commit such an act of violence without the knowledge of his
master, he shall receive two hundred lashes, and shall be compelled
to restore whatever he carried away. If, however, the slave acted
with the knowledge of his master, the latter must give satisfaction for
his act, as has been hereinbefore provided in the cases of freeborn
persons.
FLAVIUS CHINTASVINTUS, KING.
III. Concerning the Law of Retaliation, and the Amount to be
Paid in Lieu of the Enforcement of said Law.
The bloody rashness of some persons must be legally revenged
by even the most severe penalties; for when anyone fears that he
will suffer for what he has done, he is liable to abstain from the
commission of crime. Therefore, if any freeborn person should dare
to shave the head of another; or should mark, or scar him by
violence inflicted either upon his face, or upon any other part of his
body, by the use of a scourge, a whip, or any weapon; or, by
maliciously dragging him upon the ground, should soil or defile him;
or should maim him in any part of his limbs; or should restrain him of
his liberty, by placing him in jail, or in any other place of confinement;
or should order him to be imprisoned by others; or to be kept in
custody and sold as a slave; having been apprehended by the judge,
the same person shall receive by way of retaliation, whatever he
inflicted, or attempted to inflict, upon another. And if he who suffered
from his violence, or endured insult through his agency, should
desire to receive pecuniary compensation from the culprit, he shall
be entitled to recover such a sum as he may estimate will
compensate him for the injuries he has sustained. We forbid,
however, retaliation to be made for a blow with the fist or with the
foot, or for any stroke upon the head; lest, when the retaliation is
inflicted, a greater or more dangerous injury may result.
Where an aggressor commits such acts without causing any
injury to the limbs, for a slap, he shall receive ten lashes; for a blow
with the fist, or a kick, he shall receive twenty lashes; for a stroke on
the head, if the blood should not flow, thirty lashes. And if he by
whom the injury was produced, or who is said to have instigated it,
where the act was not deliberately committed, but was the result of a
sudden quarrel, should prove that it was caused by the fault of
another, and against his own will, and, in the affray, an eye should
have been lost, he shall pay a hundred solidi as a penalty. But if it
should appear that the party injured can still see with the damaged
eye, he may accept a pound of gold from the aggressor, by way of
compensation. Where anyone is struck on the nose, and it should be
entirely destroyed, the culprit shall pay a hundred solidi. If the blow
upon the nose should be of such a character as to lay open the
nostrils, the judge shall impose a penalty according to the deformity
produced; and we decree that the same rule shall apply to injuries
done to the lips and to the ears. A hundred solidi shall be paid for
any injury to the loins. Whoever cuts off the hand of another entirely,
or injures it with a blow so that the party cannot make use of it, shall
pay a hundred solidi by way of reparation for such injury. Fifty solidi
shall be paid for the loss of the thumb; for that of the forefinger, forty
solidi; for that of the middle finger, thirty; for that of the fourth, twenty;
for that of the fifth finger, ten solidi. Similar sums also shall be
exacted for injuries inflicted upon the feet. For every tooth lost by
violence, twelve solidi shall be paid. Whoever breaks the leg of
another, and the latter thereby is rendered lame, shall pay him a
pound of gold; and all the provisions above stated in regard to such
injuries, shall apply where the rights of freemen are involved. But if a
slave should commit any of the unlawful acts hereinbefore specified,
or should he only shave the head of a freeman, he shall be delivered
up into the power of the latter to be dealt with according to his
pleasure. If, on the other hand, a freeborn person should shave the
head of a slave belonging to another, or should give orders to shave
the head of a peasant, he shall pay his master ten solidi. Where the
slave is of superior rank, the offender shall not only be forced to pay
the aforesaid sum of ten solidi to his master, but shall also receive a
hundred lashes. If he has maimed the slave in any part of his body,
or has ordered another to mutilate him, he shall receive two hundred
lashes; and shall be compelled to give to the master of said slave,
another of equal value to the one he has injured, by way of
satisfaction. And if any freedman should commit any of the crimes
hereinbefore specified against any freeman; for the reason that he
was of inferior rank, not only shall the violence he committed be
visited also upon him, but he shall, in addition, receive a hundred
lashes with the scourge. And if a person born free should injure a
freedman in any of the ways hereinbefore mentioned, he shall pay
the third part of the amount for which freeborn persons are liable. If
one slave should mutilate another without the knowledge of his
master, or should shave his head, he shall undergo the same injury
which he has inflicted, and shall receive a hundred lashes in public.
If a slave, without the knowledge of his master, should seize and
confine a freeborn person, he shall receive two hundred lashes in
public. But where a slave commits any of these acts, with the
consent of his master, the master only shall undergo the penalty, and
pay the damages which are prescribed by this law in the case of
freeborn persons. Where a freeborn person imprisons the slave of
another who is innocent, he shall pay three solidi to his master. If
one slave should imprison another, without the consent of the latter’s
master, he shall receive a hundred lashes. Where the slave
committed the act, with the knowledge of his master, the master of
said slave shall be compelled to pay three solidi. If any freeborn man
shall detain the innocent slave of another in custody, day or night, or
should cause him to be detained by another, he shall pay to the
master of the said slave, for every day that he is thus restrained of
his liberty, three solidi, and for every night an equal sum; and if the
innocent slave is proved to have been thus imprisoned by the said
freeman for several days, the latter shall be compelled to pay to the
master the same sum of three solidi for every single day and night
during which said slave was imprisoned. Any freeman who shall
strike the slave of another with a whip, or scourge, or any kind of
weapon, in such a way as to cause the blood to flow, or a bruise to
appear, shall pay to the master of the slave one solidus for every
blow inflicted; or, if serious injury should result, by which he who was
struck was either killed or maimed, the offender shall pay for such an
act, whatever sum the court, in its judgment, shall deem proper.
Where one slave commits an assault upon another slave, the judge
shall determine, according to the nature of the injury, the amount of
the sum to be paid by the slave, or his master; which sum shall be
equal to half that paid by a freeman under similar circumstances,
and the slave shall receive a hundred lashes, in addition, for his
insolence. All the provisions of this law shall apply to the cases of
men as well as to those of women, in order that the questions left to
the discretion of the judge by this and other laws, may be quickly
decided.
If a judge, influenced by friendship, or corrupted by a bribe,
should not dispose of a case in an equitable manner, or should
neglect to at once impose a penalty, he shall be deprived of his
judicial power for the future, and shall be compelled by the bishop, or
the governor, to render satisfaction out of his own property, to an
amount which said bishop or governor shall determine, to him to
whom he refused to do justice; in order that he, who voluntarily
refused to redress the wrongs of another, may be forced to undergo
the loss of his own possessions.
ANCIENT LAW.
IV. Where a Person Deprives a Traveller of his Liberty,
against the Will of the Latter, and with Intent to do him Injury.
If anyone, while on a journey, should be unlawfully restrained of
his liberty by another, and no indebtedness should exist between
them, he who has been so restrained shall be entitled to five solidi
for the injury he has undergone; and if the offender should not have
such a sum, he shall receive fifty lashes. But if one party should be
indebted to another, and should refuse to pay the debt, the creditor
may, without inflicting any injury upon him, bring him before the
judge of the district, and the latter shall make such an order as he
thinks to be just. Where a slave commits such an act, without the
order of his master, he shall receive a hundred lashes. But if he
should have done this under the direction of his master, said master
shall be liable for the payment of the sum hereinbefore mentioned.
FLAVIUS CHINTASVINTUS, KING.
V. He who Violates the Law by Inflicting Injury upon Another,
shall undergo the same Punishment which he Himself Inflicted.
It is no less a fault to be ignorant of the laws than, knowing them,
to commit crimes. Wherefore, whoever, up to this time, or hereafter,
has perpetrated, or shall perpetrate, any act forbidden by law, and
shall either declare that he was ignorant of the law, or shall plot to
carry out any act that shall enure to the injury or danger of anyone,
alleging, at the same time, that such act is not prohibited by law, and
that for this reason he cannot be held liable for its commission, and
should such person be convicted, he shall at once undergo the same
dangers, ignominy, tortures, suffering, or pecuniary loss, which he
inflicted, or attempted to inflict, upon another; shall receive, in
addition, a hundred lashes in public, and shall be scalped, as a mark
of perpetual infamy.[36]
FLAVIUS CHINTASVINTUS, KING.
 VI. He shall not be Considered Guilty who Struck Another,
when the Latter was about to Strike Him.
It is no crime to resist another, where the violence of the attacking
party is manifest. Whoever, therefore, should recklessly attempt to
strike, or should strike, another with a whip, or sword, or with any
weapon whatsoever, and the offender should then be so wounded by
the party whom he attacks that he dies, such death shall not be
considered homicide, nor shall he be liable to any reproach who
struck the fatal blow; because it is more proper for a living person to
defend himself against an angry man, than to be revenged after his
own death. And whoever, in anger, draws a sword against anyone,
even though he should not strike him, shall be forced, on account of
his insolence, to give ten solidi to him whom he thus threatened.
FLAVIUS RECESVINTUS, KING.
VII. Where a Slave Insults a Freeborn Person.
No slave, however respectable he may be, shall act insolently,
arrogantly, or seditiously, towards a person of noble and illustrious
lineage; and, should one be guilty of such conduct, he shall be
sentenced by the judge to receive forty lashes with the scourge. A
slave of inferior position shall be punished with fifty lashes with the
scourge. Where a person of exalted rank first provokes the slave of
another, and is insulted in consequence, he must attribute it to his
own bad behavior; since, as he was forgetful of honor and patience,
he only received what he deserved.
ANCIENT LAW.
VIII. Where One Freeborn Person Strikes Another.
If one freeborn person should inflict a wound upon another, and
the wounded person should die at once, the attacking party shall be
punished for homicide; and if he who was wounded should not die
immediately, the aggressor must either be confined in prison, or
released on bail. Should the person who was wounded escape with
his life, he who injured him must pay him twenty solidi, on account of
the attack alone; and, if he should not have that sum, he shall
receive two hundred lashes in public, and, in addition to this, he shall
be compelled to pay such damages, for the wound he inflicted, as
may be assessed by the judges.
ANCIENT LAW.
IX. Where the Slave of Another is Mutilated by a Freeborn
Person.
If any freeman should voluntarily mutilate the slave of another, he
shall be compelled to give at once to his master, another slave of
equal value; and he shall retain the one that was injured, to be cared
for at his expense until he is cured. And if he should afterwards
recover, the person who inflicted the wound shall pay such an
amount in damages as may seem just to the court. And should he,
afterwards, be restored to his master, safe and sound, said master
shall receive him again as his slave. The aggressor, on account of
the boldness of his act, inasmuch as he did not commit murder, but
only ventured to wound the slave of another, shall pay ten solidi to
his master.

X. Where a Slave Strikes a Freeborn Person.

If a slave, without the order of his master, should strike a freeborn
person, and the latter should die at once, from the effect of the blow,
the slave shall be punished for homicide; but if the wounded person
should not die immediately, the slave shall be imprisoned; and if he
who was wounded should recover, his assailant shall receive two
hundred lashes. The master, if he should wish to do so, may pay, in
satisfaction of the injury, whatever sum may be assessed by the
court; and, if he should refuse to do this, the slave shall be given to
the party injured, in satisfaction for his crime.

XI. Where One Slave Mutilates Another Slave.

Where one slave inflicts mutilation upon another, he shall receive
a hundred lashes, in addition to the pecuniary satisfaction due for the
wound; and if, as a result of said wound, the other should be partially
disabled, the judge shall estimate how much his value has been
diminished in consequence. If his master should refuse to accept the
sum thus estimated, as satisfaction, he shall be entitled to receive
the price of the slave who was injured, or one of equal value, from
him whose slave committed the attack; and said master shall retain
the mutilated slave as his own. We decree that this law shall also
apply to female slaves.
 TITLE V. CONCERNING HOMICIDE.

I. Where One Kills Another without Knowing it.

II. Where One Kills Another without Seeing Him.
III. Where One, being Pushed, Kills Another.
IV. Where One, Seeking to Strike Another, Kills a Third Person.
V. Where One is Killed while Interfering in a Quarrel.
VI. Where One, Intending to Inflict a Slight Injury, Kills Another.
VII. Where One, in Sport, or Recklessly, Kills Another.
VIII. Where One Kills Another through Immoderate Punishment.
IX. Where a Freeman Kills a Slave by Accident.
X. Where a Slave Kills a Freeman by Accident.
XI. Where One Man Intentionally Kills Another.
XII. No Master shall Kill his Slave without Good Reason; and Where One
Freeman Kills Another.
XIII. No One shall Deprive a Male or Female Slave of a Limb.
XIV. Any Person may bring an Accusation of Homicide.
XV. Both Relatives and Strangers have a Right to Accuse a Person of
Homicide.
XVI. Where a Homicide Takes Refuge in a Church.
XVII. Concerning Parricides, and the Disposition of their Property.
XVIII. Concerning Those who Kill Others Related to Them by Blood.
XIX. Where One Blood Relative is Accidentally Killed by Another.
XX. Where One Slave Kills Another by Accident.
XXI. Concerning Those who Destroy their Souls by Perjury.

FLAVIUS RECESVINTUS, KING.

I. Where One Kills Another without Knowing it.
Whoever kills another ignorantly and unintentionally, if he has
cherished no animosity against him, is not guilty of murder according
to the Word of God; for it is not just that he should suffer the penalty
of homicide who committed the act against his will.
FLAVIUS CHINTASVINTUS, KING.
II. Where One Kills Another without Seeing Him.
If one man should kill another, either standing, coming, or
passing by, not being aware of his presence at the time, where no
cause of enmity had previously existed between them, and he who
committed the homicide shall declare that he did it involuntarily, and
shall be able to prove this in court, he shall depart in safety.
FLAVIUS RECESVINTUS, KING.
III. Where One, being Pushed, Kills Another.
If anyone, either by accident, or by being pushed in any way, or
by rushing headlong upon another, should kill him, he shall not be
liable to the penalties of homicide. But if one man should push
another, and, impelled by that push, the latter should kill a third party,
and he who gave the push did so without malice, he shall pay a fine
of a pound of gold, because he neglected to avoid the commission of
an injury.
THE GLORIOUS FLAVIUS RECESVINTUS, KING.
IV. Where One, Seeking to Strike Another, Kills a Third
Person.
Whenever, in a quarrel, anyone, while endeavoring to strike his
adversary, unwillingly kills a third person, a legal investigation must
be made to determine who originated the quarrel; and if it should be
found that he was guilty who was first struck at, then he who stirred
up the strife, although he escaped the blow, yet, because it is
apparent that he was the cause of the homicide, shall pay a fine of a
hundred golden solidi. He who struck the blow shall pay fifty solidi to
the nearest relatives of the person who was killed. Thus both pay a
penalty; one, because he intentionally gave an opportunity for the
commission of homicide; the other, because he unintentionally
committed said homicide.
FLAVIUS RECESVINTUS, KING.
V. Where One is Killed while Interfering in a Quarrel.
If any freeman should interfere in a quarrel for the purpose of
making peace, and should be killed in consequence, and he who
struck him shall be able to prove, either by his own oath, or by the
testimony of respectable witnesses, that the act was not committed
intentionally, because the party who struck the fatal blow did not wish
to commit assault or homicide upon the person who was killed, he
shall pay a pound of gold to the relatives of the person who lost his
life; and, in like manner, if any wound was inflicted under similar
circumstances, the person who inflicted it shall pay a third part of the
aforesaid sum; for the reason that the death of him who interfered for
the purpose of making peace should not be unavenged.
FLAVIUS RECESVINTUS, KING.
VI. Where One, Intending to Inflict a Slight Injury, Kills
Another.
Where anyone, attempting to commit an injury, gives a kick, or a
blow with the fist, or commits any other violent act, and death should
result, the guilty party shall be punished for homicide.
VII. Where One, in Sport, or Recklessly, Kills Another.
Whoever incautiously, or recklessly, or in sport, or in a crowd,
unintentionally, by a fatal blow, strikes or kills anyone; because no
malicious intention or desire to injure existed, shall incur no infamy
for having committed an assault or homicide, even though he should
be convicted by oath, or by the testimony of witnesses; nor shall he
be liable to punishment by death, because he did not kill the person
intentionally. But, for the reason that he struck the fatal blow without
due caution, and did not attempt to avoid an accident, he shall pay a
pound of gold to the nearest relatives of the deceased, and shall
receive fifty lashes with the scourge.
FLAVIUS RECESVINTUS, KING.
VIII. Where One Kills Another through Immoderate
Punishment.
If it should happen that a scholar, or any person under the
patronage, or in the service of another, while undergoing moderate
corporeal punishment, inflicted by his teacher, patron, or master,
should die as a result of the same; and that he who inflicted the
punishment entertained neither hatred or malice toward him whom
he killed; he shall neither be rendered infamous, nor punished on
account of the homicide; for the reason that it is said in the Holy
Word of God that he shall be unhappy, who does not inflict
punishment.
FLAVIUS RECESVINTUS, KING.
IX. Where a Freeman Kills a Slave by Accident.
If a freeman should kill a slave not intentionally, but by accident,
he shall be compelled to pay to the master of the slave one-half of
the amount which has been provided by way of reparation in the
case of freeborn persons, under similar circumstances.
FLAVIUS RECESVINTUS, KING.
X. Where a Slave Kills a Freeman by Accident.
If a slave should kill a freeborn person not intentionally, but
accidentally, he shall pay the same sum which a former law has
provided in the case of other freeborn persons. But if the master
should be unwilling to pay said sum for his slave, the latter must, at
once, be given up to justice.
ANCIENT LAW.
XI. Where One Man Intentionally Kills Another.
Every man who kills another intentionally, and not by accident, is
liable to punishment for homicide.
FLAVIUS CHINTASVINTUS, KING.
XII. No Master shall Kill his Slave without Good Reason; and
Where One Freeman Kills Another.
If anyone who is guilty of crime, or of giving wicked counsel to
another, cannot escape punishment, how much more liable is he
who deliberately and maliciously commits homicide? For this reason,
as very frequently, through the excesses of cruel masters, slaves are
deprived of their lives, without having committed any crime; it is
proper that this license should be entirely abolished by means of the
following law, which shall be hereafter observed by all, to wit: that no
master or mistress shall deprive either their own slaves, or the
slaves of others, of life, without an order of court. But if such a slave