Scott A. Norton, M.D., M.P.H., M.Sc., is Chief of Dermatology at Children’s National Medical Center and a Professor of Dermatology and Pediatrics at the George Washington University. He is additionally on the academic faculty at Georgetown University and Howard University. Dr Norton was Chief of Dermatology at Walter Reed Army Medical Center for many years and retired as a Colonel from the US Army. He has clinical privileges at the National Institutes of Health and Walter Reed National Military Medical Center and serves as a frequent consultant in Dermatology and in Tropical Medicine to the State Department, Peace Corps, and CDC.
In addition to Dermatology, Dr Norton’s academic interests are in Tropical Medicine, Infectious Diseases, and Global Health. He has additional certification in Tropical Medicine and Traveler’s Health from the American Society of Tropical Medicine & Hygiene. Other interests include ethnobotany (traditional uses of plants) and medical anthropology. While with the federal government, his overseas medical experiences included duties in Zambia, Egypt, Ghana, Mauritania, Senegal, Haiti, Jamaica, Guyana, Bolivia, Peru, Marshall Islands, Fiji, Palau, Federated States of Micronesia, and the Philippines, where he worked on clinical, educational, and public health projects, including many humanitarian assistance and disaster relief operations.
When asked about his global health interest, Dr. Norton clarifies, “Actually, I feel that I am interested in ecology, which derives from the Greek oikos, meaning ‘house.’ So ecology is ‘the study of the house,’” adding, “it’s about knowing what is around you.” A desire to understand the world as a systematic structure has driven Dr. Norton’s passion for biology since his time as an undergraduate, and led him to conduct field research in plant-animal coevolution, working on a Fulbright Scholarship in New Zealand.
“I was a field biologist before going into medicine,” describes Dr. Norton, “I wanted to look at the interactions between plants and animals, animals and animals, parasites and animals at a population level.” His understanding of the system within which we, as human beings and animals, exit, is at the core of his approach to clinical dermatology, and a key factor in his medical expertise. “You have to be interested in everything to be a good ecologist and I think in medicine one can retain or maintain that view of the world as a system,” elaborates Dr. Norton, “in that regard, you have to look at disease or health as the complex interaction of many things.”
In global health, often operating in micro communities and unique climates, understanding the system surrounding the patient is critical to understanding their proper care. “When looking at the health of a population, it is important to know the topography, the climate, the geography, the economy,” sums Dr. Norton, “it’s the genetic, the cultural, the habitual: the manner of cooking and traditional diet. There is nothing outside of the realm of consideration when you look at it that way.”
This systems perspective, ingrained in Dr. Norton before he even began his medical training, has informed his research, academics, and life since then. His Fulbright research led him to complete a Masters of Science with Distinctive Honors from Victoria University in Wellington, New Zealand. He then returned to Tulane University for degrees in medicine and public health, where he was selected for Alpha Omega Alpha and Delta Omega, the medical and public health equivalents of Phi Beta Kappa.
However, his biological foundation stayed with him, and led Dr. Norton to dermatology and infectious diseases. “In a sophisticated metropolitan area, people think of dermatology as acne, and warts, and dandruff,” suggests Dr. Norton, “but when you’re working in overcrowded, impoverished areas, practically every child has skin disease.” Frequently, dermatology and infectious diseases go hand-in-hand. “Things like head lice, various superficial skin infections, a lot of contact dermatitis, scabies, ringworm, and common bacterial infections, insect bites getting infected; evidence of that can be seen in every child either active or inactive,” describes Dr. Norton. And “while it’s not always mortality,” he adds, “it is quality of life and longevity.”
Recalling his early experiences in global health, Dr. Norton remembers, “When I would visit a given community somewhere, people used to say, ‘what’s a dermatologist doing here?’ and I would say, ‘let’s find out.’” “We would go out into the community, and 90% of the population would come in for some dermatological issue,” he adds. “Everyone has skin disease because of things like crowding, hygiene, clothing, the social customs,” he suggests, circling back to his systems approach. Good healthcare for Dr. Norton requires understanding the patient’s internal as well as external environment.
Following medical school, Dr. Norton completed his residency in dermatology at the Fitzsimons Army Medical Center. A Colonel in the US Army, one of Dr. Norton’s first assignments found him in the Middle East as a flight surgeon. “Leishmaniasis hit soldiers in concentrated areas” he recalls, “we had lots of outbreaks.” Once again, solving the problem required understanding the operating environment. “You had to think about the soil, and the water, and the behaviors of the soldiers and the local people there,” describes Dr. Norton. It’s about “looking at health from an ecosystem standpoint, how maintaining the ecosystem is essential to human health,” he summarizes.
So, for his patients with leishmaniasis, while “there is a role for someone who knows what parasite drugs to use,” says Dr. Norton, “that’s after the fact. Knowing the behavioral risk factors that all lead to an individual becoming susceptible and gaining the disease comes first.” And while these cases in the military barracks were controlled, similar cases can be a matter of life or death in many rural communities dependent on the manual labor of family members.
Dr. Norton fleshes out the dire implications of many dermatological diseases, “Let’s say you have an individual in an agrarian community who gets some kind of disabling infection. That’s a mouth that isn’t contributing. Let’s say the main person in the family can’t farm. That’s going to impact the entire community and family.” Not only are these diseases disruptive for the individuals and families they affect, but in order to avoid them, entire communities will displace themselves, disrupting established economies. “Diseases like river blindness and African sleeping sickness in west and equatorial Africa have caused entire communities to move en mass from one location to another because the consequences of getting these disease could be miserable or fatal,” describes Dr. Norton. While many international diseases are measured in mortality rates, Dr. Norton and his systems perspective are attuned to the fact that mortality rates alone often mischaracterize the potential threat of a given disease. When an entire community is being displaced by the threat of disease, deaths occur indirectly, futures are altered, and stability is disrupted. These factors are not represented in mortality metrics.
His initial experience in the Middle East sparked a lifelong passion for Dr. Norton, “I have been very interested in infectious diseases of the skin,” he describes, “and I have been very fortunate to work on a number of international projects as a clinician and a public health officer, as well as several projects here in the U.S.” His first long-term international assignment was in Zambia. “Back around 1990, Zambia was a country in south central Africa, formerly Northern Rhodesia. I went there relatively early in the HIV response, and I worked for the US health service on an HIV project there,” recalls Dr. Norton. Much to his surprise, Dr. Norton ended up with more responsibility than expected, “the guy who ran the clinical HIV program in the country took off once I arrived because he had not had a vacation for several years. It was the first time he had the opportunity to rest and I was suddenly thrust into a new situation, making a lot of clinical decisions in the developing world,” Dr. Norton remembers.
Despite the daunting task, Dr. Norton stepped up, drawing on his foundational systems perspective. “Spending time in Zambia at the national hospital helped me see a health system, not just the diseases,” he recalls. His dermatology training served him well, “HIV really starts off as a skin disease. Nearly all HIV presentations in the developing world start as some kind of skin disease. Maybe not all, but really most,” describes Dr. Norton. With his skill set, Dr. Norton was able to hit the ground running, quickly appreciating the many factors at play within the HIV crisis. “Understanding the referral patterns in a developing country, and becoming aware of the inequities in healthcare from social and economic parameters was very powerful,” recalls Dr. Norton.
Despite serving as the HIV clinical care coordinator at the national hospital essentially alone, Dr. Norton was still able to find time to explore the surrounding area. “I had the chance to travel around and combine one of the things that makes being abroad exciting on a personal level: traveling to different African countries on the weekend. I got to see some amazing things like Victoria Falls, and some big game and the Zambezi river,” recollects Dr. Norton. Always on his mind, however, is the ecosystem, “These are just absolutely fascinating places from their ethnology, to the plants and animals, the flora and fauna and so remote, not just geographically but also culturally from the bustle of the big city,” he characteristically adds.
Another memorable trip for Dr. Norton is his time spent in the Philippines following the volcanic eruption of Mount Pinatubo. “It was a volcano on the main island,” recalls Dr. Norton, “it had a tremendously powerful eruption in the early 1990s.” While the eruption itself was catastrophic, what followed was even worse. “The cities were blanketed with volcanic ash and follow by these typhoon like storms that liquified that ash and basically created a liquid concrete. Villages were buried up to 25 feet, displacing huge populations,” describes Dr. Norton “I was part of one of the US government relief teams that went there when the acute disaster was over but civil society needed to be restored, especially in the rural areas, getting farmers back on their land, and getting the local life revived,” he adds. To do this required traveling into some of the remotest areas of the Philippines.
Always interested in the ecosystem and the genetics of populations, getting the chance to meet these indigenous communities was unique for Dr. Norton. “I spent a day with a veteran public health worker and we went into the mountains where there is an indigenous group that predates the genetically asian Philippines. The women file their teeth into points as a sign of beauty and they look totally unlike the more asian or mixed asian filipino people,” he remembers. “Being up there with this community was a rare opportunity.”
On the restoration team was a public health veterinarian. Ostensibly strange, his presence on the team turned out to be very lucky. Due to the importance of livestock to the local economy as well as the cultural practices, the veterinarian played a crucial role in rebuilding these communities. “What was interesting for me,” recalls Dr. Norton, “was to see how useful the veterinary was. He was invited into their homes and was able to support the families right there.” This was an important lesson, one to which Dr. Norton was very receptive. “Since then,” he remarks, “I have always hoped that I would have public health veterinarians on my team. They are able to see and interpret things medical providers just cannot see. Their eyes are trained in a different perspective.”
While the Philippines was in a state of natural disaster, many of the places Dr. Norton has travelled to have been in a state of “complex emergency,” or, “a natural disaster that is coupled with a human disaster,” he describes. “Many of the countries that I went to were in a state of man made disaster: civil war, uprisings, enslavements of other peoples, genocides,” Dr. Norton adds. Addressing the health problems within these states often requires addressing the political and economic issues as well, making any substantial change very difficult if not impossible. Ever optimistic however, Dr. Norton perseveres in what he can change, “once I was in a country where they had an attempted coup while I was there. It put a damper on our ability to go out and explore the country, but we were able to continue our relief efforts.”
Experiences like this have taught Dr. Norton the root of many large-scale health crises, such as famine, are frequently the result of an inability to distribute existing resources due to failed infrastructure or active conflict. Luckily, as a dermatologist, Dr. Norton is able to operate without much equipment. This means he can maximize impact even when the tools are taken away. And while “many of those decisions to bring a dermatologist satisfied US political interests,” admits Dr. Norton, “I am proud of the fact that some of these (government) agencies knew that a dermatologist would be able to provide more photons of good.”
The ability to operate without many extras has enabled Dr. Norton to travel to and be a part of many remote relief efforts. Experiencing these communities which he would never have the opportunity to engage with independently has left a lasting impact on Dr. Norton, and is one of the highlights of his global health work. The aforementioned trip to the Philippines was one such experience, as was his trip to a series of remote islands in Fiji. While there, Dr. Norton had the privilege to participate in the traditional kava ceremony, native to communities in Western Oceania.
“The people retained their traditional kava for a couple hours, discussing important things like how the fishing was on the reef on their island before we were permitted to discuss the medical and health concerns that brought us to the village,” recalls Dr. Norton. “We would sit down, cross our legs, have this bowl of kava that was provided ritually,” he says, adding, “to an outsider it seemed very ceremonial, like a Japanese tea ceremony or communion in a church.” Participating in the tradition, helped make sure the external support Dr. Norton and his team were providing was be symbiotic with the existing communal practices and expectations. The experience also left a strong impression on Dr. Norton: “these practices go back hundreds of thousands of years, and to participate in something like that I thought that was very powerful.”
However, not all rare opportunities are good ones. While providing relief efforts in Bolivia, Dr. Norton and his team found themselves stranded on a sandbar in the middle of the Amazon River. “I was working with the Bolivian Navy,” begins Dr. Norton. “We were in a tug boat going up these water ways to villages that are visited twice a year by the Bolivian government providing resources. Our boat went aground on this sandbar, and the water was receding,” he recalls, “we were stuck for two and a half days.”
Another Navy boat came to help, but in order to dislodge the bottom of Dr. Norton’s boat, all able-bodied riders had to get into the murky water, no knowing what was underfoot or nearby. “Fortunately, we didn’t see any anacondas in the river–we were in this kind of river where there were dozens of caymans and anacondas–but we had to walk across and see the carcasses of these animals on either side of this trail on the swamp,” he describes, “if a cayman had been there that would have been it.”
To make matters worse, two young Bolivian soldiers were holding tightly on a rope used to move the stuck raft. The boat suddenly gave way, and in a freak accident, both soldiers lost a few fingers on their hands. With no surgeon onboard, and much too far from one to save their appendages, the young men permanently lost those fingers. Dr. Norton tells this story with sadness and retrospection. “It was the kind of thing you would not want to do twice,” he concludes.
However, the majority of his experiences have been both eye-opening and fulfilling. It is these opportunities which remind Dr. Norton of the power of human connection and the importance of global health outreach. Traveling all over the world has expanded Dr. Norton’s existing systems understanding, familiarizing him with ecosystems all over the world. While this was hazardous in the Amazon, it has also been stunningly beautiful. Dr. Norton recalls one trip to Alaska, “we were there shortly after the summer solstice, and the sun shone about 23 hours a day.” “It was just so otherworldly to us,” he recalls, “we could see brown bears and caribou and all sorts of wildlife.”
All of these experiences, both good and bad, have served to reinforce Dr. Norton’s foundational perspective. “Human health really is dependent on other living elements in the environment,” he concludes. Moving forward, Dr. Norton aims to share as much of his wealth of experience and knowledge with the burgeoning generation of physicians and global health providers as possible. This educational outreach is essential to Dr. Norton. “Whenever I travel somewhere, I almost always require that I take one or two residents with me,” he says, “I feel very strongly that there is so much energy and enthusiasm, and it is so rare for the young person who has such little experience to be able to go out and see healthcare in action in the rest of the world where medication is not the only issue.”
It’s about imparting an appreciation for the system within which we exist, “it’s infrastructure, clean water, legal issues, laws that protect marginalized populations, and laws that will protect the environment,” describes Dr. Norton. At the end of the day, this understanding is about preventative care, “all these factors can be viewed as only one step removed from human health care. You can far better serve a population by, for example, controlling deforestation, than treating the diseases that arise after the ecosystem has been disrupted and exposed the human population to all new sorts of disease and exposing the farm animals and exposing the crops,” advocates Dr. Norton. A systems perspective enables providers to see a potential threat and work to address it before it destroys lives and livelihoods.
Dr. Norton is currently aiming to develop a fellowship in public health dermatology between Children’s and a local university, hoping to prepare younger physicians to provide and lead global health initiatives. “I think the most important thing is to determine the best way to use the human capital we have, meaning the people and their energy and ideas, in ways that will help the target population or benefit the world,” says Dr. Norton, “but in ways which also benefit and enrich the lives of these individuals.” “What we don’t want to do,” he adds, “is to produce a ‘parachute in’ tendency,” citing the importance of global health outreach which aims to cure, not merely treat. “We want people who understand the complexities, the one health of the whole thing,” Dr. Norton summarizes, concluding: “Maintaining the ecosystem is essential to human health.”