Virtual Dermatology Education

After travel-related restrictions resulting from the COVID-19 pandemic, we established a virtual educational exchange program between dermatologists in the public sector in Tajikistan and experts in Kathmandu, Nepal at the DI Skin Health and Referral Center. Every week, providers from various clinics and hospitals in Tajikistan met with their colleagues in Nepal virtually to present complex cases, exchange ideas, learn about new evidence-based approaches to treatment with the goal of improving the quality of care for patients, particularly those from lower socioeconomic backgrounds.

This educational exchange program has served as a model for other training programs which can be sustained over the long term and enhance provider knowledge level, leading to improvements in quality of care and better patient outcomes.

This program was supported with a grant from the International Foundation for Dermatology.

Establishing Disease Registries

In Tajikistan, PASHA is working with the Ministry of Health and physician leaders to establish disease registries for patients with eye disease and other conditions. Our team is providing technical support and education to local physicians on use of computer software. We are also providing information technology support for these activities. With the introduction of registries, a patient can visit different facilities and have his or her information accessible to different physicians who can add to the registry. This increases coordination and communication among physicians, which could lead to improved patient care outcomes.

Data from the disease registries will also help Ministry of Health officials, public health professionals, and researchers collect more accurate data on common disease trends and design intervention programs. Recognizing that diseases of the eye and skin are linked to other chronic conditions such as diabetes, we are working with primary care physicians and internists to establish a registry for diabetes patients and to document the complications of diabetes such as diabetic retinopathy.

Language Education for Healthcare Staff

In Tajikistan, most medical education takes place in Russian and only recently has there been a move towards incorporating English-based medical education in medical school curricula. As a former Soviet country, most Tajiks speak Russian as a second language and not English. This includes many physicians and other healthcare providers.

In order to provide physicians and other healthcare professionals with the opportunity to more easily access the international medical literature, to communicate with colleagues from other countries, to participate in academic exchanges, and to attend international conferences, PASHA has designed and implemented English language courses for skin care and eye care providers. These classes take place at the hospital several evenings after working hours, making them easily accessible to providers who are interested in learning English. The number of participants per course is kept limited, in order to ensure that trainees can get the most out of the classes.

Advancing Skin Care for Children in Nepal

In the summer of 2016, PASHA established an ongoing collaboration between the Society for Pediatric Dermatology and DI Skin Hospital and Referral Center in Kathmandu. With support from Health Volunteers Overseas, an educational exchange was established, whereby specialists in pediatric skin disease from the United States travel to Nepal several times a year to exchange ideas with Nepali experts, provide training to residents, and support patient care activities. This ongoing collaboration, which continues to this date, has enhanced the level of knowledge for dermatologists in Nepal and better prepared them to provide care for children with skin disease in the community.

Bringing Teledermatology to Tajikistan

Telemedicine technology and in particular, teledermatology is a modern solution for connecting patients from more distant or remote areas to medical care. Telemedicine technology has a lot of potential in Tajikistan given that the majority of the country is made up of mountainous terrain and traveling to the capital city of Dushanbe can be difficult especially in the winter when weather conditions are poor.  In January 2017, with a grant from the American Academy of Dermatology, we introduced store and forward teledermatology for the first time in Tajikistan. The idea behind this initiative was to allow referring dermatologists from different parts of Tajikistan to consult the most experienced dermatologists in the capital using telemedicine. The PASHA team, working with local leaders, provided the technology and training in the use of software and hardware, taking advantage of Google Drive as a free program that is easy to use and secure. Thus far, more than 200 patients have received care using this portal and with new support from the American Academy of Dermatology, the project is currently undergoing expansion and is being incorporated into resident teaching.

Introducing Low Cost Treatments for Lower Extremity Wounds

Lower extremity wounds are a major source of disability in patients as they can cause a lot of pain and make it hard for patients to walk. Although lower extremity wounds are very common, treatments can be difficult for patients to access because of the costs involved and the extended period of time that treatments are required. One treatment for lower extremity ulcers is the Unna boot, but these pre-manufactured boots can cost more than 10 US Dollars for a one week treatment course. This makes Unna boots unaffordable to many people especially in low- and middle-income countries.

PASHA recently introduced a program for local physicians and nurses across Tajikistan, training them to locally source Unna boots using ingredients that are readily available at local pharmacies. This program, which was modeled on a similar project implemented in Kenya, allows local pharmacies and health facilities to produce these boots at under 2 US Dollars.

PASHA has held workshops across Tajikistan for physicians in all three oblasts (Khatlon, Sughd, Gorno Badakhshan) and the Region of Republican Subordination, training dermatologists, family medicine physicians, surgeons, and nursing staff on the methods of preparation and use of Unna Boots. Thus far, more than 100 providers across Tajikistan have been trained in this method and the local public pharmacies are working to make these boots available to patients at rates that are affordable to most Tajiks.



Bringing Cataract Surgery to People in Tajikistan

Building Capacity for High Quality, Low Cost Cataract Surgical Services in Tajikistan

According the World Health Organization, nearly 39 million people around the world are blind and another 285 million suffer from some form of visual impairment. Ninety percent of blind and visually impaired individuals live in low-income settings. It is estimated that 80% of blindness and visual impairment is treatable with surgical or medical interventions. The leading cause of blindness worldwide is cataract. Cataract results in decreased economic productivity, as the afflicted individual is unable to work and earn wages. In many parts of the world, where families live as cohesive units, the presence of cataract in a family member often places a burden on the entire family. Children frequently miss school and adults leave work to take care of a visually impaired family member with cataract.

Cataract surgery is a highly effective medical intervention, yet more advanced surgical procedures require equipment that can be too costly to purchase and maintain. In the last decade, however, a highly advanced and cutting edge method of cataract extraction known as manual small-incision cataract surgery (MSICS) has been introduced. This procedure does not require expensive machinery, can be performed at a fraction of the cost of other surgical models, takes less time to perform, and is easier to master. India and Nepal have been highly successful in reducing the burden of cataract blindness using MSICS techniques.

In conjunction with the Ministry of Health and Social Protection of Tajikistan and the Tilganga Institute of Ophthalmolgy, we have designed training programs in MSICS for surgeons in Tajikistan. Thus far, four surgeons, including one from the Eastern region of Gorno Badakhshan Autonomous Oblast, have received hands-on MSIC training in Nepal. Collectively, these trainees have provided surgery to more than 4000 individuals. This training has made high quality cataract surgery significantly more affordable by substantially lowering the out of pocket costs to patients and families. We are also involved in closely monitoring surgical outcomes as well as surgical proficiency in the trainee surgeons.

Supporting Teledermatology Programs in Nepal

Although skin diseases do not commonly lead to death, if untreated they can cause difficulty working, require frequent medical attention, and result in disfigurement and social isolation. In Nepal, access to dermatologists is limited especially in rural villages.

PASHA has worked with Community Health Education Services by Tele-health (CHEST), a Nepali NGO, to support capacity-building for teledermatology with the goal of helping rural villagers receive care for dermatologic ailments. This project involved developing the facilities and integrating the necessary technology so that rural patients can receive dermatology services via live video conference with medical professionals in the capital city of Kathmandu. Currently, the pilot village of Gerkhutaar in the Nuwokot district has been equipped with computer access and intranet connection, and which are both being housed by a local community facility to which patients can come and be connected with a physician once a week. PASHA has supported CHEST in re-establishing the infrastructure for teledermatology and other telehealth services in this village after the devastating earthquake in April of 2015. Part of this effort has focused on rebuilding the destroyed heath facilities in the village where patients received medical care.

This program also bolsters community engagement, as the video streaming facilities will be run and organized by local Nepali volunteers. Thus, there is no need for a medical professional or healthcare provider to serve as the middleman in the rural village, because community volunteers can be trained to use the technology and create schedules to organize patient visits. Plans for the near future include optimizing the technology and infrastructure of the facilities at the pilot village and eventually scaling the project to be expanded to villages in other districts in Nepal.

Increasing Access to Medical Information for Skin Care Providers

Providing high quality medical care requires accessing the latest medical literature.  That is why PASHA has worked in conjunction with the American Academy of Dermatology to translate and disseminate educational material for skin care providers across Tajikistan.  To build on this project, we are currently working with local dermatologists to develop clinical guidelines that can be adapted to Tajikistan and used for the treatment of common skin conditions.