In November 2017, I got the opportunity to visit the Regional Dermatology Training Center (RDTC) for a second time this year. This time it was by invitation to help set up a teledermatology program for their residency along with my mentor, Carrie Kovarik. She is one of the world’s leaders in the field of teledermatology and I have, by necessity, been building up an expertise during my time in Botswana. Carrie has been working with a company to set up a new telederm platform to provide dermatology care to underserved clinics in Philadelphia. There was a previous application in place which had been successfully improving care but its funding was recently pulled by the AAD.

The new program is called Azova – it works as an application on your phone but also works on a desktop. It is set up like a full medical record platform but can also be used as a simple messaging service, similar to Whatsapp. Basically it offers you the option of getting really simple or getting really complicated based on your telemedicine needs. Carrie wanted to offer this application for use in Tanzania. We were invited to Moshi to introduce the application and help teach the program how to use the technology. Initially, I didn’t quite understand what we would do with a whole week. In my mind, telederm isn’t something that you really need to be face to face to teach, but I am someone that has been working with this kind of technology for most of my life. I often forget what it would be like to see it for the first time.

In Tanzania and Africa in general, smart phone technology is still relatively new. It has been getting more and more common to have a smartphone in the past few years, but not everyone is well versed in how to fully utilize their phones. New applications can be challenging and confusing. Telederm can be a strange concept if you have never been exposed to it. There are many different ways to incorporate telemedicine into a medical practice, but the benefits might not be readily apparent to new users. In the beginning it can just seem like extra work and an added hassle to your work day. So our job was to do more than just teach people how to use a new app. The visit was also about introducing the idea of telederm and trying to get them to buy into the fact that technology can be used to benefit them and their patients. I underestimated what a challenge this could be!

I use so many technological tools for patient care in Botswana that I often take for granted how unique this is. To me it seems so obvious that keeping electronic records of everything would be second nature, that taking photos and storing them would be useful, that standardizing the way patient data is stored and communicated would be critical. I have realized over time that my clinic is the only one that does these types of things in Botswana, even though we are so much smaller than all the other departments (just me as a faculty!). When looking at a robust residency program like the RDTC, I would have assumed that they would have very advanced ways of organizing patient care and communication between physicians. I was surprised to see that data is all stored on paper. They had not been using telemedicine in any organized way, except for pathology. They have a very advanced robotic microscope with a viewing system which they use to sign out difficult cases with a dermatopathologist in Spain. Although they have numerous dermatology residents, advanced diploma in dermato-venereology trainees, and faculty, they end up seeing about an equivalent number of patients to what I see per week in Botswana as one faculty, one medical officer+/- one resident. Which is kind of insane. The only way I am able to keep my head above water managing all these patients is by staying highly organized with technology, keeping track of patient data and communicating closely with all team members.

We faced many unforeseen challenges during the visit. The biggest problem was that the chairman did not inform anyone in the program that he planned to introduce telederm into their practice or that we would be coming that week to teach them about the new Azova application.  This put us in a challenging position because it made us appear like pushy Americans coming in and trying to force our own agendas on them. When in reality we had been invited. We also had nothing to gain from the introduction of telederm into their program – we were just taking on extra work to help them. But one thing you have to learn about global health is that as expats in a foreign country, you are often assumed to be coming to exploit until proven otherwise. I’m guessing this is an unfortunate vestige from the ugly past of colonialism. So we didn’t get much done Monday, except finding out that the Azova application could not be downloaded in Tanzania – eish! Luckily we were able to get that problem fixed rapidly.

Next problem was trying to get all the users logged in. Despite sending out a list of log in names and a generic password – it was near impossible to get people to make the effort to look up their password and attempt logging in on their own. We then sent individual Whatsapp messages to each user to give them their log in information and encourage them to log in.

On Tuesday morning we were given an audience with the whole department. This was our chance to get our message across to everyone at once. The plan was to project our computer desktop on the big screen and walk everyone through how to use the application to create and answer consults. Everyone would have their phones to follow along. Seems easy enough…. Well we didn’t plan for the fact that the internet would be completely non-functional – so slow we couldn’t even pull up the log in page! The residents had not downloaded the application. The ones who had downloaded the app couldn’t figure out how to log in. So we sat there fumbling in front of everyone. Finally someone located a hotspot dongle I could use to access internet….this worked only marginally better. When I finally got logged on, I realized the desktop version of the app was different than the phone app! I had only been using the phone app so again I fumbled around in front of everyone trying to show them how to create a consult.

After the talk, we asked for some feedback. I was surprised at what I heard. One resident said – “It is well known that one cannot make a diagnosis with pictures, why wouldn’t we just see these patients in person.” Good point, but gosh Tanzania is huge and there are few dermatologists, I thought certainly there would be a need for assisting with patient care in rural areas or for figuring out with patients needed to be triaged into their clinic.

Another trainee mentioned that “ I just don’t think it is a good idea to offer this service to non-derm providers because they will want to use our advice to help their patients so they will not need to refer to our clinic.” I was very confused by this comment at first but then I remembered that the RDTC is a for profit hospital. In Botswana, money never comes into play. I help everyone I possibly can and make no money from it….so there is no motivation except to try to find a way to teach dermatology knowledge and provide assistance to as many people and patients as I can. The RDTC, has to make sure they don’t over-train non-derm providers for fear of losing referrals to their center. This really blew my mind! But it is a legitimate real world concern that I had never considered.

Another trainee astutely pointed out, “what is the difference between this and Whatsapp, why can’t we just use that?” I have to admit I completely agree. I think simple is better and I soon realized that the Azova app might be too complicated for the intended audience in Tanzania. In Botswana, I cannot do anything complicated because there are too many providers scattered all over the country and I have no way to train them to use any specific technology. I can only hope to harness something they are already using, which is why I have been using Whatsapp exclusively for teledermatology for the past 2 years and have found it to be a hugely impactful resource. You can read more about my introduction of Whatsapp for teledermatology in Botswana on Penn Medicine’s blog & a recent article from Telemedicine and eHealth. The application is not without its faults but works incredibly well in a resource limited overburdened health system.

Another comment was “How can we ensure the photos used in the application aren’t used against our wishes and published on social media” – another very astute but surprising concern. In my head, I’m thinking – Why in god’s name would that happen?? But I didn’t realize how wary of outsiders the RDTC is due to previous bad encounters. I was told some pretty horrifying stories of people coming to work there and then using patient photographs and information for their own purposes without permission. It was very forward thinking of them to want to make sure the security is clear before they agree to anything.

So our aspirations for a smooth introduction and training pretty much flopped. I got the feeling that most of the program thought that we were in some way profiting from the use of this program. When in reality, it was a difficult for both of us to coordinate flying out there just to try to introduce the program. We had nothing to gain, other than learning more about their program and hopefully building a pathway to collaborate in the future.

Since the visit we have been continuing to struggle by email communication to try to get the program jumpstarted. It is clear that some of the residents are very interested in using the application. The previous graduates now working in remote areas have the most to gain from this program. They work alone with no one to consult when difficult cases come up. A telederm application offers not only a vehicle for assistance with patient care, but also a mechanism for continued engagement in academic discussions and learning. It is our hope that slowly the telederm program will gain support in Tanzania because it has so much potential to improve dermatology care for patients around the country. I hope to be able to give some positive updates soon!

The visit was really a learning experience. Even after 2 years solid of working in a developing country I am still just a beginner in global health. Every country has its unique challenges and you have to be prepared for a tough learning curve when starting any new project. There are always unforeseen challenges and things rarely go as planned – that is what makes global health so exciting but at the same time excruciatingly frustrating!

On a side note, during this trip I visited Arusha for the first time on the way to Moshi. I stayed at the Mount Meru Hotel which appeared to be one of the more upscale hotels in Arusha. I thought it was an excellent property. Beautiful pool area and lush grounds. There were 3 restaurants on site and one served a buffet with local dishes that were excellent. Carrie and I spent one afternoon in Arusha National Park which surrounds Mount Meru. The park is not very dense with game but does offer some spectacular landscapes. You can find colobus monkeys here which I have not seen before in the wild. You can also find thousands of flamingos in Lake Momella. It was a very pleasant place to spend a day but I wouldn’t go out of my way to visit.

In Moshi we stayed at Kilimanjaro Wonders Hotel which is located halfway between Moshi Town and Kilimanjaro Christian Medical Center. It was a quiet hotel with a nice pool and bar area, good internet and spacious rooms. The service was excellent. It was a bit pricey so I am not sure I would have stayed there if I was not visiting for work. My favorite restaurant in Moshi town is Mimosa and I like the Union Café as an afternoon hangout. I got the chance to visit some local bars and clubs this trip with one of the local doctors – this was quite the adventure!! I learned about the local music called Bongo Flava which is awesome!