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WhatsApp is Changing Dermatology Care in Botswana

Innovation in health care doesn’t always have to mean new or expensive. It’s often the smart repurposing of something in front of us that can help fix a problem cheaply and adequately. They’re called “frugal innovations,” and they have a long history in low-resource settings – from the vinegar test to screen for cervical cancer to tapping into unused TV frequencies to deliver internet to clinics in Africa.

A more recent example that has been flying under the radar in Botswana is the use of the smartphone application WhatsApp. The popular text-messaging app, which boasts over one billion users a month throughout the world today, is reshaping the delivery of dermatology care in a place that has just one dermatologist in the public sector.

Her name is Victoria Williams, MD, and when she arrived Gaborone, the country’s capital, two years ago, a big obstacle she faced was the poor line of communication and coordination of care with providers treating patients across a country that’s roughly the size of France and has two million people. Appointments to see her were being booked with too few clinical details, and the severity of people’s conditions weren’t always being prioritized. Acne cases were being seen in a week’s time, where people with skin cancers sometimes had to wait three months. Language barriers also slowed coordination.

She needed a better system.


Victoria Williams, MD, and her patient Wendy Ramatuanyana

“The reason I started using WhatsApp was because I urgently needed a way to communicate with other providers that was simple and realistic,” said Williams, who works for the Ministry of Health of Botswana and is part of the Botswana-UPenn Partnership (BUP). “There was no way for me to get an audience with all the providers, so I had to utilize something that they were already using. WhatsApp was the perfect solution because it doesn't require any new training – and it is free.”

WhatsApp is a text messaging app that can send texts, images, and videos in an encrypted, secure message. It has been around since 2009, and was scooped up by Facebook five years later. Now, people around the world send 55 billion messages and 4.5 billion photos every day. It’s different than regular text messaging in that it doesn’t require a cellular tower or a data plan to send or receive messages. It only needs the internet. A person can jump on a public internet connection, and all their messages will download.

More and more people in Botswana have smartphones, but minutes are precious, so they don’t always pick up the phone, and they might only check their email or text messages once a week, Williams said. Providers are also extremely busy and resistant to putting in extra time to learn about a new application. That’s what makes WhatsApp the perfect health care tool there. While general use of the app hasn’t quite caught on in the United States, many people in other countries like Botswana rely on it as a primary source of communication.

“It makes the turnaround time quicker than any other form of telemedicine in lower resource areas we have experienced,” said Carrie Kovarik, MD, an associate professor of Dermatology in Penn’s Perelman School of Medicine.

For more than 10 years Kovarik and the BUP have worked to bring a slew of telemedicine techniques to the country: better landline access, internet for web consultations, computers to upload records and images, and telederm mobile apps, to name a few. All of those efforts have had their successes, but WhatsApp by far has made one of the bigger impacts thanks to Williams’ grassroots effort to integrate the app into clinical care.

“Over the years, we’ve struggled to create something that is easy enough, at their fingertips, fits easily into the workflow, is cheap, and that people will actually take up and use, especially in developing countries,” Kovarik said. “Over time, we have realized it needs to be on people’s – both providers’ and patients’ – personal phones, where it’s ready to go.”

Physicians can snap a photo of a skin condition and send it along to Williams, who can then recommend a course of action or begin to coordinate care for those who need other specialists, like a surgeon or oncologist. Williams recently had a patient with a massive malignant peripheral nerve sheath tumor on his neck.

“I could use WhatsApp to not only get him booked to see a head and neck surgeon within two weeks, but I could also get him set up with a date for the head and neck multidisciplinary conference, so all the different physicians that would need to be involved could weigh in on the best course of management,” Williams said.

Before, time was set aside to review cases like this via email, creating weeks-long back logs, often with poor quality photos and incomplete information. And getting someone on the phone was extremely difficult. WhatsApp, on the other hand, is checked two to three times a day, if not more, by people.

Williams recalled another patient with acral lentiginous melanoma described in the clinic notes as just a “foot sore.” But a photo of the melanoma sent via the app let her know that the patient needed to be seen urgently. She has scores of other examples in which the app enabled her to provide higher-quality care – many of which she and Kovarik shared in a letter to the editor they wrote in the journal Telemedicine and e-Health last year.

The app also allows patients to reach out directly to ask questions about complicated care instructions and share photos of their conditions to determine if they need urgent care. It’s also helping to teach nurses and physicians dermatology skills they may not otherwise learn, preparing them for the next time a case comes through the door.

WhatsApp, however, is not without its challenges. It’s considered very secure – just as secure as any health app in the United States used by providers, Kovarik said. But that’s where the problem lies. Several governments, including Britain, have considered banning it because it’s nearly impossible to monitor potential terrorists’ threats and communication on the app, which has been linked to past attacks.

Ensuring patient privacy is also a concern. There are no standard procedures for photo consenting patients in Botswana, so it’s very difficult to know if they are being consented before pictures are taken and sent. How to protect patient data and control over who can access them are issues that need to be addressed, Kovarik and Williams wrote in the journal. Still, they agree the advantages of the app outweigh the disadvantages.

“You come to a point where you need to provide the best medical care for these patients, and you need to use the best resources and things that you have at your disposal to get them the answers and treatment they need,” Kovarik said. “So, you evaluate everything that you have. Right now, with this app, it’s a good decision that is helping more patients in a big way.”

Williams added, “It has helped critically ill patients get into clinic sooner, decreased wait times by keeping people who don't need to see dermatologists out of the clinic, and saved patients lots of travel time by allowing their local doctors to treat them whenever possible.”

She plans to more closely study the WhatsApp data to determine its impact.

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