February 14, 2008
Roy Colven: To Africa and back, battling AIDS
Dr. Roy Colven is a UW associate professor of medicine, director of the dermatology residency program, and section head for dermatology at Harborview Medical Center. He is also a leader in a global medical movement called telemedicine, which relies on electronic transfer of medical information via e-mail, the Internet and teleconferencing for medical consultations, examinations or procedures.
Colven’s expertise is in HIV-related skin disorders and teledermatology. In 2004, he received a Fulbright Award to set up a long-distance consulting program based in Cape Town, South Africa, where he established teledermatology sites in underserved areas across South Africa — regions with a high prevalence of HIV infection and only one dermatologist per 4 million people.
Q. What led you to pursue a career in medicine?
A. My interest in medicine began while I was traveling between high school and college. Probably the single greatest thing my father did for me was to quit his secure job with IBM. He had a boat and was living in Honolulu at the time, and my sister had just finished college, so we set sail from Honolulu to New Zealand.
We traveled for two years. It took about a year to get to New Zealand with all the stops, and I met a lot of people along the way — physical therapists and other health professionals who were traveling and taking their skills with them. A psychologist I met on this trip first suggested medical school to me. He told me you can travel wherever you want with your skills — they’re practical, you’re always going to have sick patients, and it’s going to be independent of economy. It turned out he and his wife were to become my future inlaws. I met my wife along the way, and we’ve been together for more than 20 years. My father-in-law was my first mentor in medicine.
Q. How did you become interested in HIV-related skin diseases?
A. I started medical school at UW in 1983. The first identified cases of HIV were in 1981. So what HIV was about was just emerging as I started medical school. It [the AIDS pandemic] has always been fascinating to me at a number of levels — medically, socially, globally. And my interest didn’t wane as I got into dermatology because there are a lot of skin manifestations related to HIV. It’s an immune organ, so when the immune system goes off, a lot of things happen to the skin.
Q. How did your work eventually take you to Africa?
A. In 1996 I was working at Harborview’s Madison (HIV) Clinic. That was the year protease inhibitors (which prevent viral replication) came out — a big piece of what made anti-retroviral therapy really effective. Everyone was optimistic. An issue of Newsweek magazine from that December showed these drugs on the cover and read “The End of AIDS?” So everyone was thinking, ‘we got it — we got this thing licked.’
And patients were definitely improving. I had three clinics a week and, in a couple of years, it went down to two clinics. Then by the time I went to South Africa in 2004, it was down to one clinic — and even that one clinic was more or less like my general dermatology clinic. At the same time, we were hearing reports out of sub-Saharan Africa that HIV was devastating this region. It was Ground Zero there. I had never been to Africa before and I was very interested in seeing the impact of HIV in Africa. Also because I’d met my wife traveling, we were committed to taking a sabbatical to live and work abroad as a family. By this time we had two school-age children.
Q. Why Cape Town?
A. I hadn’t really thought about South Africa much because I thought it was too developed — I really wanted to see what was going on in rural, underdeveloped sub-Saharan Africa, like in Tanzania or Ghana. But Neil Prose, a mentor in dermatology from Duke, suggested the University of Cape Town, so I contacted the head of the department and, literally, within hours she e-mailed me back and invited me to come. I then realized that South Africa has the largest population of HIV-infected people, and at the same time has relatively robust information and communication technology in most parts of the country, a situation that was ripe for telemedicine to have an impact.
My family and I arrived in Cape Town in August 2004 with a Fulbright Scholarship and a Puget Sound Partners for Global Health grant and, with colleagues in Cape Town, I started setting up a telederm network. Eventually, we stretched out the network to seven sites across South Africa’s most underserved regions, and by November 2004 we started getting our first cases at the sites.
Q. Describe how the teledermatology system worked.
A. Most of the sites had general practitioners, and a couple had nurses only. These providers would e-mail me clinical information about patients, their histories, and photo attachments of skin conditions. I would return a response on average within three to four days. Often, I would attach relevant articles from the medical literature with the responses. What was amazing was the referring providers tripled their diagnostic acumen after as few as nine consultations in terms of concordance with the specialist’s telediagnosis.
There are 47 million people in South Africa. The majority of them are in the public health sector, and about 20 percent of them are HIV positive. Add to that the fact that there are 11 dermatologists working in the public health sector and you realize there’s no way one or two people doing teledermatology are going to make a big dent in the skin disease burden there. The sustainable impact, however, is going to be in training the general practitioners and nurses to be better skin care providers.
Q. What have you been doing in teledermatology since you returned from South Africa?
A. Last year, I gave a talk on HIV dermatology for an I-TECH (International Training and Education Center on HIV/AIDS) clinical series to a class here of two students, a class in Jamaica of 30 students, and a class in Nairobi of about 60 students. It was an extraordinary experience. It was a case-based interactive lecture in real time (in Seattle and Jamaica), that included Web streaming audio with a PowerPoint presentation. I did the same talk for I-TECH late last year, this time broadcast live to India, Kenya and Barbados. Most of the audience were health practitioners and, collectively, they got every case right — even some of the tough ones — because this is what they see.
During this lecture, I was talking about a really severe drug reaction in which most of the skin peels away, and I said ‘this is how we handled it in Cape Town, and this is how we handled it in Seattle, how about those of you out there?’ And someone from India said they use banana leaves to apply to the patient’s skin as a non-stick dressing, and I thought what a brilliant idea. It’s cheap, it’s available, and it’s what works.
Because of this collective talent in the remote sites, we decided to pilot Dermatology Virtual Office Hours, which includes texting, audio, and still images of patients that the practitioners in remote sites sent — either for educational purposes or because they needed some help. We put together a presentation and held a roundtable, case-based conference that I facilitated. A few weeks ago, we broadcast from 9 to 10 p.m. in Seattle so we were in real time in Nairobi and Namibia. This was right after the Kenyan elections, so we weren’t sure if the Kenyan folks could be there. But they showed up despite the protests and vuiolence.
On Feb. 21, we will hold a second Virtual Office Hours with cases from India and the Caribbean.
Q. Will teledermatology take you back to Africa?
A. It already has — virtually. I also hope to visit these sites in person, not only for myself and my family to experience these areas, but also to personally meet the providers and students I interact with. Though telemedicine can extend one’s expertise across huge distances, it’s still about people, not technology, and this personal connection helpsto sustain remote health providers’ interest in using technology this way.
Roy Colven will present “Imagery and Interpretation in International Medicine at the Mini-Medical School at 7 p.m. Tuesday, Feb. 26, in Hogness Auditorium, Health Sciences Center.
