By Emily Margosian, assistant editor, January 1, 2021
While the U.S. health care system is far from perfect, many dermatologists and their patients are not struck by the financial burden of a simple biopsy — or even access to sunscreen. With a population of over 56 million, and a ranking among the poorest 15 nations in the world, the practice of medicine in Tanzania looks very different than it does to most American dermatologists.
Despite these challenges, the Regional Dermatology Training Centre (RDTC) in Moshi, Tanzania, has operated for the past 30 years as one of the region’s sole sources of dermatologic care. “The RDTC is known as a dermatologic powerhouse in East Africa,” said Jennifer Adams, MD, assistant professor of dermatology at the University of Nebraska College of Medicine, who visited the Centre early last year. “Similar to what I have experienced in other resource-poor settings, patients travel great distances for dermatologic help due to a shortage of dermatology providers across Sub-Saharan Africa. It was clear that the RDTC is vital to providing excellent training to expand dermatologic access to care for patients across the continent.”
Regional Dermatology Training Centre
- Learn about the RDTC in Tanzania.
According to Connecticut dermatologist Alicia Zalka, MD, the ongoing pandemic only underscores the lessons learned from her visit to the RDTC. “While the journey took place pre-COVID, the fact that we are now in the throes of a worldwide pandemic underscores how diseases with origins outside of the United States still certainly have the potential to impact anyone of us at any time and in any place,” she explained. “It is a global village. I think we must prepare ourselves and not adopt the attitude of ‘that can’t happen to me’. It is our responsibility, especially as physicians, to be aware and well-informed of disease and medicine with a global perspective.”
This month, DermWorld speaks with dermatologists who have had the opportunity to visit the RDTC, as they share the lessons they brought back home.
Established in 1990 as a joint enterprise between the International League of Dermatological Societies (ILDS) and the Tanzanian Ministry of Health, Kilimanjaro Christian Medical Centre (KCMC), the RDTC was built on land provided by the Good Samaritan Foundation in Moshi, the capital of the country’s Kilimanjaro region, most known for its national parks and namesake peak.
The RDTC was co-founded by German dermatologist, Professor Henning Grossman, who served as its first director, and Tanzanian dermatologist Professor John Masenga. Since its inception, the RDTC has operated as a dermatology training, research, and clinical center for the region. Today, the facility includes a pharmaceutical compounding unit, a student hostel, accommodation for visiting teaching faculty, and a histopathology lab. Offered services include dermatosurgery, wound care, radiotherapy, PUVA therapy, and maggot debridement therapy (MDT).
From the beginning, the vision of the RDTC has been two-fold: Provide dermatologic care in an otherwise underserved area, and train local physicians to sustainably bridge the care gap. Its mission is “to produce competent professionals in the field of Dermato-Venereology through training, research, and provision of services to Sub-Saharan African communities through resource mobilization and utilization.” To date, the RDTC has trained more than 290 graduates from 17 African countries in its Advanced Diploma in Dermato-Venerology (ADDV), according to data provided by the International Foundation for Dermatology (IFD), the humanitarian arm of the ILDS.
In addition to working closely with the ILDS, the RDTC also partners with regional and international health care institutions, including the World Health Organization (WHO), and ILDS member societies, which include the American Academy of Dermatology (AAD). In January 2020, several AAD members had the opportunity to visit the center as part of a tropical dermatology course that runs once every six or seven years. Former AAD President David Pariser, MD, has directed the course since 2007. “I’ve been aware of the RDTC for a long time, and it’s amazing what these folks are able to do with so few resources for so many people,” he said. “The Academy supports the RDTC, and this is a chance for dermatologists from North America to see what their support is contributing toward, but more importantly, to learn about diseases that we have all heard about and seldom see — not in textbooks — but from the people actually treating them.”
“I thought the program was amazing,” said Florida dermatologist Anna Chacon, MD. “Throughout my career, I’ve had other opportunities to study tropical medicine, but the RDTC faculty who led the lectures were excellent. I was able to learn a lot about conditions that I wouldn’t necessarily see in general dermatology practice.”
Dr. Adams agreed. “I have always been passionate about tropical and infectious disease dermatology. Most of my work in the field in the past was through tropical medicine connections, but I was thrilled to learn about this course specifically tailored to dermatology based in Tanzania.”
Education and collaboration
During their time at the RDTC, AAD dermatologists were able to attend a series of lectures given by physicians from around the world. Topics included dermatologic disease prevalent in the region, such as Chagas disease, African trypanosomiasis, leishmaniasis, leprosy, lymphatic filariasis, and cutaneous manifestations of HIV and AIDS. “All you could hope for on tropical dermatology,” said Dr. Adams. “The curriculum also emphasized barriers to care, resources available, and advocacy to address disparities.”
Another educational highlight included grand rounds with RDTC patients and providers. “We were all able to examine each patient and discuss their case. I really loved that; it was one of my favorite parts of the trip,” said Dr. Chacon. “We saw a lot of hyperpigmentation and different infectious diseases that are more prevalent in patients with HIV. Another case involved very severe scarring alopecia. It was really valuable to learn how to manage things that I might not commonly see.”
New Hampshire dermatologist Robert Willer, MD, has visited the RDTC twice — once in 2013 and again in 2020. He agreed that the experience of being able to see unique dermatologic cases in person was a major aspect of both trips. “There were around 10 or 12 patients. You walk in the room and there is a RDTC trainee who eloquently presents the patient to you. That was the highlight of the educational experience, to actually see things like elephantiasis and leprosy in person. Generally, these are conditions that you read about in books and learn for the boards but rarely actually see them, if at all, in your career.”
For New Jersey dermatologist Joshua Freedman, MD, MS, the camaraderie forged during the trip was an unexpected surprise. “One of the highlights that I had not anticipated was the opportunity to meet other dermatologists, widely diversified in their ages and geographic locations, brought together by a common interest in global health and expanding their international horizons,” he said. “With all fondness, I can honestly say that I met and learned from numerous colleagues whom I may never have otherwise interacted with, were we not repeatedly compressed together into small vans traveling over long bumpy roads. It was a true delight.”
Albinism education and outreach
In addition to its educational and clinical offerings, the RDTC has also focused on the development of several specific regional initiatives, the most prominent of which is its Program for People with Albinism (PWAs). The program was established in 1993 with the aim of assisting albinism patients with cancer prevention and treatment of complications related to their albinism. According to RDTC data, more than 85% of PWAs in Tanzania develop pre-cancerous lesions before the age of 20 due to lack of education regarding the importance of sun protection.
In an effort to sustainably provide PWAs in Tanzania with quality preventative care, in 2012 the RDTC also launched the Kilimanjaro Sunscreen Care Unit (KSCU) in collaboration with the Tanzania Ministry of Health and Social Welfare. The unit manufactures sunscreen locally (the country’s only sunscreen manufacturer), which is then distributed free of charge to PWAs in Tanzania. “It was impressive touring the RDTC and seeing how they have created their own sunscreen manufacturing facility on-site to provide for their incredible standalone clinic serving those living with albinism,” said Dr. Adams.
During his visit to the KSCU, Dr Willer was struck by the impact that seemingly simple things can make on the lives of albinism patients. “Things that we take for granted, like hats and shoes, can help them so much. Albinism is considered taboo in many parts of Africa, and there can be violence against them. The RDTC is really helping to treat, protect, and educate these people.”
“I spoke with a young girl with albinism via an interpreter and she conveyed the horrors of being albino in Tanzania. She informed us that she is unable to travel after dark and must travel in groups to protect herself from poachers. The thought of poaching humans is unfathomable.”
Virginia dermatologist Keith Robinson, DO, MBA, agreed. “I was surprised to hear that the poaching of albino people still occurs. I spoke with a young girl with albinism via an interpreter and she conveyed the horrors of being albino in Tanzania. She informed us that she is unable to travel after dark and must travel in groups to protect herself from poachers. The thought of poaching humans is unfathomable.”
Dr. Zalka was also moved during her visit with albinism patients at the KSCU. “It was eye-opening to learn how greatly these patients suffer both physically and mentally from oculo-cutaneous albinism. This program greatly impacted my awareness about albinism and how people in other parts of the world are more severely impacted than in the United States.”
The dermatologic care divide: Observations and lessons
While the major disparities faced by dermatology providers and patients in Tanzania were apparent, the adjustments made in order to provide care under challenging conditions offered some valuable lessons, said Dr. Chacon. “One of the African dermatologists mentioned that they don’t do many biopsies, because in Tanzania people have to pay out of pocket for any type of procedure,” she said. “In the United States, we do a lot of biopsies and order a lot of labs, but the physicians at the RDTC are very conscientious about the cost of any work-up they’re doing prior to diagnosing someone. They primarily focus on the clinical exam to narrow down the differential and provide treatment using the most cost-effective tools possible. I think in the U.S. we sometimes lose sight of that, and I think back to that particular lecture often in regard to how we can better maximize the physical exam.”
“In the United States, we do a lot of biopsies and order a lot of labs, but the physicians at the RDTC are very conscientious about the cost of any work-up they’re doing prior to diagnosing someone. They primarily focus on the clinical exam to narrow down the differential and provide treatment using the most cost-effective tools possible. I think in the U.S. we sometimes lose sight of that.”
Dr. Robinson agreed that despite limited access to medication and resources, the style of care provided at the RDTC can offer some lessons to American medicine. “Patients were able to stay at the facility for extended periods of time for treatment and education. Dermatology patients in the U.S. seldom receive the care and personal attention that the patients received at RDTC. Our system is structured to transition patients in and out as quickly as possible, whereas they were geared more toward educating patients and providing them with basic necessities.”
For Dr. Freedman, the visit to the RDTC had a profound impact on his outlook as a dermatologist. “The area is impoverished and access to health care is limited in a way that I have never seen,” he said. “Another serious dermatologic problem which faces this area is podoconiosis, which is almost entirely preventable merely by having shoes. In the U.S. this problem seems almost unimaginable, and yet the numbers affected are quite significant.”
However, despite these challenging observations, the experience offered a renewed perspective on Dr. Freedman’s role as a physician. “As dermatologists practicing in the United States, we have almost certainly all encountered patients where we had to first treat their sense of entitlement before they would allow us to treat their disease — whether that means apologizing profusely if they had to endure some wait time for an appointment, or visit two different pharmacies to obtain medication,” reflected Dr. Freedman. “After that becomes your day-to-day, it is very gratifying to reconnect with an area where doctors are not so heavily commoditized. Where the knowledge and experience physicians strive so hard to come by can actually have the life-changing impact we had always hoped it would way back when we first imagined being a doctor in the first place. The trip to the RDTC exposed me to one more place on the planet where this might be the case.”