Pathology Against the Odds

In this issue of Archives of Pathology & Laboratory Medicine, a special section is devoted to the theme of pathology services in resource-poor nations. It is largely based on a symposium held at the annual meeting of the Canadian Association of Pathologists in Ottawa in July 2008, with additional contributions from other pathologists who actively provide voluntary services in developing countries.Although pathology and laboratory medicine play a crucial and central role in the modern practice of medicine, most of the globe's population do not have access to medical services with a sound basis in laboratory diagnosis. The reasons for this are, for the most part, readily evident—a lack of resources means that expensive equipment, appropriate physical facilities, and trained personnel is simply beyond the reach of many countries in what is sometimes referred to as the “developing world.” This lack of the necessary tools of our trade may frequently be compounded by cultural or political issues as well as geographical and climatologic challenges. As a result, the practice of pathology in many countries poses unfamiliar and at times difficult problems for pathologists trained in resource-rich environments. The availability of laboratory procedures is often limited, and quality control may be lacking for the ones that exist. And where the practice of medicine has been getting by without the benefit of pathology, it may be difficult to change this pattern.Pathologists who are interested in contributing to global health may find it difficult to become involved in a suitable project. Pathologists Overseas, as Dr Hoenecke and colleagues present, is able to act as a matchmaker for pathologists looking for such opportunities, for short or long periods. Many pathologists gradually become highly subspecialized in their practice, but, as Dr Deck points out, this does not have to be an obstacle. His experience demonstrates that pathologists can contribute to the fundamentals of the medical system, through teaching and diagnostic work, even in a war-torn country such as Afghanistan. It should be emphasized, however, that such work can present significant dangers to the participating individuals; several tragic events involving death or kidnapping of journalists and health care workers demonstrate this beyond a doubt. Involvement in projects in such areas requires a great amount of prudence and appreciation of potential risks.It is well recognized that political instability and internal strife are significant determinants of health. Indeed, some resource-poor countries expend a greater portion of their budgets on the military than on health and education. Dr Adeyi describe the situation in Nigeria, where a once strong health care infrastructure has deteriorated while the fundamentals of the economy remain relatively strong. Sri Lanka, another country that has suffered from civil war, has managed to maintain a forensic medical system based on a British and Dutch tradition, albeit severely challenged, as Balachandra, Vadysinghe, and William describe. This is all the more remarkable, as forensic pathology is frequently a neglected specialty and is not practiced at all in many resource-poor countries.Many original observations have been made by those practicing in resource-poor countries—such as the original recognition of the epidemiology of Burkitt lymphoma. Drs Rambau in Tanzania and Roy and Othieno in Uganda describe aggressive forms of breast carcinoma, presenting in young women at an advanced stage. Although the epidemiologic and molecular genetic details of these tumors await further investigation, this appears to be a particularly important health problem in the region and potentially in larger portions of Africa.Although the lack of technical resources remains a serious impediment to the practice of pathology in resource-poor areas, much can be achieved using relatively simple technology. Drs Guggisberg, Okorie, and Khalil describe the use of a mobile fine-needle aspiration unit, which can provide a rapid and reliable diagnosis in many situations. Calhoun et al have developed a lightweight, portable tissue-processing unit that actually allows the production of histologic slides “in the field,” while Dr Hitchcock describes some of the applications of telepathology in areas that do not have full access to laboratory services. Dr Pagni and colleagues, working with the Italian Association of Pathologists, have developed a telepathology approach that they have found to be useful in providing assistance to a medical practice in rural Zambia, a country with next to no pathology services.Health partnerships have a tremendous potential to generate new knowledge. The importance for the personal development of those involved should be emphasized as well. Dr Valerie White describes the experience of investigating cerebral malaria in Malawi—a life-changing experience for those involved and an inspiration for others.It is the hope of those involved in this special section that, although the articles describe many different aspects of involvement in international health projects, some of our readers will find in them an inspiration to seek expression for their own aspirations for international work. We also would like to recognize the numerous pathologists who contribute regularly in this manner, whose work is not featured here. We would like to encourage the sharing of such experiences in the form of publications.We would like to acknowledge the support of Philip Cagle, MD, editor in chief for Archives of Pathology & Laboratory Medicine, in the development of the special section.

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