In Partnership with Adventist Health International and Atlas Health Africa,
AZOVA is bringing Teledermatology and Teledermatopathology Services to Malawi, Africa.
Atlas Health Africa is a nonprofit teledermatology group that currently provides free consultations to a network of about 20 hospitals in Africa.
In December 2014, when Travis and I were residents, we pitched the idea to Adventist Health International (AHI). AHI provides administrative and development support for Seventh-day Adventist mission hospitals that span the continents of Africa, Asia and the Americas. To our shock they said “yes...and please start now”. Which candidly, was exhilarating and utterly terrifying.
So why did two dermatology residents have the crazy idea to start a teledermatology consult service in Africa? Because we believe human dignity is universal, not simply a geopolitical term. We saw a real need and felt spiritually called to do something about it.
My grandfather was a founding physician of a mission hospital in Botswana. And it was there that my father was born and raised. I have known since college that I wanted to be involved in international medical work. To treat individual patients, yes, but also hopefully to help change healthcare systems, even if it is only micro-change limited to one specialty or geographic region.
Our goal is simple, to empower clinicians in Africa to provide better dermatologic care. The approach is three-fold: provide teledermatology consults, develop teledermatopathology labs and educate local clinicians in the fundamentals of dermatology.
During medical school, I rotated at a hospital in Central Africa. A boy came in with a large knee mass. Pathology was only accessible through a trip that would require him and his dad to take two weeks off work to travel several days to and from a distant city. Without this trip, there was no way to distinguish whether this was a malignancy likely to metastasize, a cancer unlikely to spread quickly, or perhaps something even more treatable. As such, unless his family made a financially devastating trip for a slim hope of good news, his realistic treatment choice was an amputation and hope for the best.
I found this unacceptable. His case has weighed on me. I have been thrilled to be able to work together with Ashley to offer specialty telemedicine services to rural areas.
The teledermatology consults, which were step one, required minimal expense. We developed a website, which was a good stepping stone. We are now using AZOVA. AZOVA is easy to use, provides greater security for patient privacy and has many more functions than our website did.
After a year of providing teleconsults, and being limited by the lack of pathology resources at essentially every hospital, we received a dermatology humanitarian grant from La Roche-Posay. It helped us build our first teledermatopathology lab at a partnering hospital. Adventist Health International matched the grant dollar for dollar, which combined totaled $20,000. Last November we successfully traveled to Malamulo Hospital in rural Malawi and assembled the lab. Malawi is the third-poorest country in the world by several measures and, to our knowledge, there is no dermatopathologist in the entire country.
Currently, local physicians will send us photos and a history about a challenging dermatology case. This technique is called store and forward since it is not live telemedicine. We will respond with an assessment and plan within 72 hours at most, but normally within 24 hours. The local physician may or may not choose to ask follow up questions. AZOVA makes several things better. It provides greater security for patient privacy. Its organizational tools help keep track of specific cases. It provides dialogue functions where both Travis and I can be essentially texting with local doctors about cases through the AZOVA app. AZOVA makes it easier for doctors in Africa to send us consults and easier for us to respond to them and organize the consults.
Telehealth is the backbone of our program. Our patients and physician colleagues are 9000 miles away. Due to time differences and calling costs, communication via internet is our only realistic option.
AZOVA has astonished me by working with us to customize the interface for our unique needs. AZOVA is sleek, and it fits the workflow on both the requesting and consulting physician's end. I'm used to having to change my workflow to suit the clinical software I'm required to use. This has not been the case at all with AZOVA. My experience with AZOVA has been uniquely satisfying: it works intuitively.
I've especially enjoyed the AZOVA app. I like how easy it is to use and how powerful it is. I like being able to quickly message another physician--as easy as a text message. Messaging is painless, secure and tied to the consult. I prefer to be notified as soon as a consult is requested, so the text message notifications have been perfect for me.
One of our greatest challenges has been poor internet coverage. If the local doctor cannot snap a photo and immediately send off the consult, many will not use the telemedicine service. We do have some doctors who will send us consults from their home computers in the evenings, but many won't. For that reason, most of the doctors use their 3G phones.
A second large hurdle has been the lack of histology services at all of the hospitals. They have the capabilities to do basic blood work, but there are no histology labs to process tissue samples. We addressed that hurdle at one of the hospitals last November, but that is one hospital in a network that spans the continent.
We have seen a spectrum of cases from common entities, such as nummular dermatitis, to rare birds like leucoderma syphiliticum and suppurative keloids. It has been fascinating to see tropical dermatology and many HIV-associated disorders.
Building a teledermatopathology lab in one of the poorest countries in the world for about $20,000 was a struggle, but ultimately an exciting success.
The biggest piece of advice I can give is, go where the local people are also committed to the project. Sustainable change that lasts beyond the humanitarian trip requires that the local community is invested in the project. Just because the local community states that the service, project or equipment would help them, does not mean that they are currently invested in making that a reality today or this year. It may just mean that they intellectually affirm that it would of benefit if present. Or they may even just be being polite and don't think it is a useful or viable idea. Consider having a benchmark to gauge commitment, such as a consistent stream of consults. It may not be a lot, but it is consistent. There is an opportunity cost to time, trips and donations, so prioritize the places that tangibly show commitment, which may not be the place that has the most need.
I would say that anyone can help, but not with anything. Meeting the felt needs of the community, rather than what you as an outsider think is best, is most important. You have to build relationships, evidence humility, and show a long-term commitment before you find the area you are most useful. Despite some small successes that were personally thrilling to us, I think Ashley and I see ourselves at the very early part of this process. We are working and learning.
I would ask the local doctors more often what they think they need and what their priorities are.
Long-term we hope to use the Malamulo lab as a pilot that can be replicated at other hospitals in the network and built upon by other specialties; especially general surgical pathology. This could fundamentally change the healthcare that is available to so many of our fellow men. It will be a process, and I am sure we will make mistakes, but we decided that doing nothing or waiting until we had extensive personal experience treating African histoplasmosis or Buruli ulcers was worse.
We would like to expand these services to other specialties and to new locations, as many potential patients have no alternative. In the future, the ideal would be to lose many of our patients to local physicians as access to specialty training hopefully improves.
Dr. Hamstra practices dermatology and dermatopathology in Coeur d’Alene, Idaho and Spokane, Washington.
Dr. Morrell, a dermatology resident, will be a dermatopathology resident at the University of Massachusetts for 2017-2018.