Pathology: Functionality in Resource-Poor Settings

The burden of morbidity and mortality is heaviest in resource-poor settings. Although the causes involve derivatives of poverty and much can be explained by using the 3 Delays Model (Table) the medical reasons for health disparity cannot be ignored. Health care issues in much of the world could be remedied in large part by improvements in patient education and availability of transportation, but the medical services need to be available, affordable, and appropriate. For optimal improvement in medical services, morbidity and mortality data must be accurate. Unfortunately, this is not the case. Vital statistics are not recorded in most of the world. Millions (billions?) of public health dollars are allocated based on estimates of the causes of mortality and morbidity. How accurate are these data? We don't know, because the necessary validation studies have not been done. Pathologists have a responsibility in this arena, as we have long been the definitive diagnosticians as to disease burden, causes of death, and the discovery of new diseases. When public policy is directing health care efforts, pathology should be actively involved by providing these data.We, as a profession, have been relatively late to the global health care table. One reason for poor pathology integration into public health policy decisions is the alarmingly low numbers of pathologists working in the same resource-poor settings from which data is needed. For example, in western Kenya there are only two pathologists in the greater Kisumu area—with a population of ∼4 million, nearly that of the US state of Alabama (which has ∼70 pathologists on faculty at just one institution!).1 Without pathology services, not only are the clinicians handicapped in providing optimal disease-specific care to their patients, but true health statistics are lacking (because of limited use of the autopsy and little laboratory or tissue diagnosis). It would be extremely difficult to improve, for instance, cancer-related morbidity and mortality in Africa without the utility of pathologic-specific tissue diagnosis, grading, and our otherwise routine immunophenotyping and molecular phenotyping.There is an international focus to reduce maternal and child mortality; the Millennium Development Goals numbers 4 and 5 directly address this, with the estimate that these 2 goals are the least likely to be met by the 2015 deadline.2 It seems self-evident that in order to improve maternal and infant health, one needs to know what are the specific diseases and causes of death! These data are just not being recorded. The statistics presented for rates and causes of maternal and infant mortality are based on surveys and interviews, not on autopsy or laboratory data. The tool most often touted as the best available is the World Health Organization's “verbal autopsy.” 3 The verbal autopsy is a set of well-defined questions addressed to a household member some time after a death in the family, via an interview by a nonmedical (but trained) individual, and evaluated by either clinicians or computer algorithms to designate the most probable cause of death. I may be naïve, but this method to diagnose a cause of death came as a total surprise to me, and this has been used and championed for more than 2 decades! It will be no surprise to readers that there has not been a pathologic validation of the verbal autopsy, nor were any pathologists involved in the formulation of the verbal autopsy questionnaire. Pathologists and pathology societies have not participated in this critically important health care issue, one in which we are uniquely qualified to address. The time has come for our participation (see a related discussion in Fligner et al4).Clearly, the best documentation of cause of death would be a complete autopsy performed by an experienced autopsy pathologist. Unfortunately, autopsy pathology is nearly a lost art even in rich countries. With rates now at less than 10% of all hospital deaths in the United States,5 our professional competency and the training of our residents suffers. Too frequently clinicians and public health officials rely on the clinical diagnosis for cause of death, or that written on the death certificate in studies, despite a published unacceptably high error rate. Many studies have shown a 30% to 60% discrepancy between the clinical diagnosis and the autopsy diagnosis,6–20 this even in resource-flush settings with optimal radiologic and laboratory services to facilitate diagnosis. One can be sure that the discrepancy rate in resource-poor settings is equally unacceptably high, if not higher. As we try to improve international health and decrease preventable morbidity and mortality, we ought to know what we are dealing with in terms of true burden of disease.A huge obstacle to improving the quality of mortality and morbidity statistics in resource-poor settings is the paucity of pathology and laboratory professionals. Anatomic pathology services are nearly nonexistent in much of the world, and if this is going to improve we must prioritize pathology education and training. The problem is not an easy fix, as one must address both supply and demand. The improvement in pathology services comes with the demand from the clinicians.21 With clinical demand, hospital administrators and health ministers will allocate resources, and there will be improvement in services. With increased demand comes respect for the profession, and this stimulates interest in medical students. How do we increase demand and interest from our clinical colleagues?First, funding institutions that support research on disease-specific entities in resource-poor areas should not fund these “pillars of excellence” without improving the services—especially laboratory services—for the population, who will not benefit from these pillars because they do not meet the “inclusion criteria” (they do not have the disease du jour). For this I urge that a percentage of the overhead of studies go to improve pathology and laboratory services on site, which are generally exploited by the funded studies for their expertise, or coerced to focus time and energy on the research instead of the needs of the population.Second, those of us who work on such projects, or who go on medical missions, or are invited speakers to underserved areas, need to make an effort to offer to give lectures to the clinicians about the utility of pathology services. I make a point of talking to obstetricians and pediatricians whenever I can, wherever I am, to teach about the importance of, for example, placental pathology in their clinical practice. The goal is to stimulate interest in pathology services and to promote specimen submission. This often encourages interaction between the clinician and the pathologist—leading to better clinical care and improved pathologist job satisfaction.In addition to speaking with clinicians, we as a profession need to be more active in medical school education, especially in countries with a desperate need for more pathology specialists. Giving a lecture to medical students highlights the critical service we provide in health care and shows the specialty as a challenging and interesting option for them to consider pursuing. Pathology is not optimally presented to medical students as a career option. We need to improve the respect for pathology among medical students as well as within all clinical fields.Third, we must make a concerted effort to encourage pathologists from poor countries to attend continuing medical education courses. Continued education improves practice, which ultimately benefits patients and clinicians and improves public health data. We in the United States usually attend many such courses over our career, often combining vacation with the course! How often have any of us seen pathologists from poor countries at these courses? Almost never, I am sure. Why? Pathologists from Ethiopia make the equivalent of $300 US monthly, and those from Cuba make less than $100. It is unreasonable to expect that any of them can afford to attend the conferences we take for granted. To remedy this, many institutions offer online continuing medical education courses free or at low cost. Although this is a start, I believe these are not as effective as in-person attendance at a meeting. Internet services are not available or are not reliable in many locations that the online courses are not used. The group courses, in which interaction, communication, and collaboration can be fostered, I believe should be encouraged. Many pathologists work in isolation, and the face time at “real” meetings is likely as valuable as the content of the meetings. Isolation in a specialty breeds career dissatisfaction and poor work ethic. By supporting these pathologists to attend courses, we improve their sense of pride and importance in their profession. As I heard at the continuing medical education course in Ethiopia, “This is the first time I felt part of a professional group.” I do think the face-to-face physical presence is very important, and our organizations should provide courses in country for pathologists as well as the online variety. Full scholarships, including travel, food, and lodging, should be included for as many pathologists with limited funds as affordable in all continuing medical education courses offered from rich countries.I also believe that pathology training programs should support their residents in training to do rotations in underserved areas. These programs should be a required part of their training. My observations in 5 countries in sub-Saharan Africa (Ethiopia, Kenya, Tanzania, South Africa, and Ghana) found a wealth of pathologies we have little experience with in the United States (infectious diseases, maternal mortality, pediatric diseases and mortality, advanced malignancies), all of which provide opportunities for learning and research. Autopsy experience and training, especially, would be vastly improved by such a rotation. Faculty should be encouraged to participate as well, and their international work should be considered “work” or “productivity” and be included as such in their schedule. This in-country work is much preferred over inviting pathologists to come here. There is no sense in having pathologists come to the United States to see how, for example, soft tissue tumors are worked up if, when they go home, even routine hematoxylin-eosin pathology is a challenge. For the cost of bringing 1 physician from Africa to the United States for a 2- to 3-month stay, one could easily send 3 American physicians to Africa for a 3-month stay each, and there would be the funds for them to bring, set up, and leave some needed laboratory equipment!In my travels in East Africa I have been impressed by some institutions that are supported by “sister” hospitals/departments in the US (for example, Moi Teaching Hospital in Eldoret, Kenya, and its partnership with Indiana University, Bloomington, Indiana). The disparity among hospitals with partners/benefactors and those without is stark and unfair to the populations served. My suggestion is not that this support be stopped, but that we somehow provide the needy population more universally. One idea would be that benefactors elect to provide support on a larger geographic scale—perhaps each benevolent institution would support all regional or university hospitals in a country by ensuring that some specified minimal basic services are available at all hospitals, and the specialized services divided among them based on facilities already in place. I strongly advocate that basic laboratory and anatomic pathology services be available in all hospitals that offer surgery and inpatient care. If a benefactor would adapt this philosophy, then instead of providing state-of-the-art care for a single disease or diagnosis in 1 or 2 hospitals in sub-Saharan Africa, the benefactor could make a bigger impact on the population's health, I argue, by deciding to improve a minimum collection of services in all university hospitals (for example, improving obstetric care, pediatrics, and adult infectious care) in one country (and I would push for improving pathology services in parallel with the clinical services). There is currently a focus on noncommunicable diseases among the poor—which includes cancers. Care cannot be improved if cancer cannot be diagnosed (because there are no pathology services available) by type and grade or staged (because of poor radiology services as well). These aspects of integrated and improved medical care have been too long ignored in favor of clinical care of specific communicable diseases.Last, we should pay more attention to the training and upkeep of pathology laboratories, pathology assistants, and technicians worldwide. So much of my personal experience working in east Africa has been thwarted by the lack of available trained and committed histotechnologists, equipment shortages and breakdowns (without service contracts or available parts, service professionals, etc), and the on-hand supply and quality of the consumables. Again, it makes no sense having the demand for pathology services increased in an institution if there is no formalin, no processor, and no histotechnologist available to meet the demand.There are many more challenges and more ideas to meet them then I have addressed here.22 I urge all readers to consider our role as a profession and our duty as physicians to take a seat at the global health table. This edition highlights some of the lectures from the first-ever Harvard Medical School continuing medical education course held in sub-Saharan Africa. There were more than 60 pathologists who attended, most on full scholarship (including travel and housing), from many African nations, Europe, Latin America, and the United States. The faculty consisted of dedicated academic pathologists who came on their own dollars and lectured through illness, jet lag, and personal family tragedies. We include herein just a sampling of these lectures, with the humbling thanks to all and especially to the participants whose interaction made the event bidirectionally inspirational.I am deeply appreciative and humbled by the faculty and the participants at the course. The faculty included Kamran Badizadegan, MD (former Director of Pediatric Pathology and Associate in Gastrointestinal Pathology, Massachusetts General Hospital); Ronald C. Kaschula (Emeritus Associate Professor of Paediatric Pathology, University of Cape Town); Eugene Jerome Mark, MD (Director of Autopsy and Pulmonary Pathology, Massachusetts General Hospital); David C. Wilbur, MD (former Director of Cytopathology, Massachusetts General Hospital); Michael Wilson, MD (Director, Department of Pathology and Laboratory Services, Denver Health); Melesachew Mulatu Yeshi, MD (Anatomic Pathologist, Department of Pathology, Black Lion Hospital, Addis Ababa, Ethiopia, and Mekelle University, Mekelle, Ethiopia); and contributions by Adriana Dionigi Corben, MD (Assistant Attending Pathologist, Department of Pathology, Memorial Sloan Kettering Cancer Center); Melinda Lerwill, MD, and Elena Brachtel, MD (Department of Pathology, Massachusetts General Hospital); Teklu Bekele MD (Pathologist, Addis Ababa, Ethiopia); Corinne Fligner, MD, (Chief, University of Washington Medical Center Autopsy/Decedent Affairs Service, Adjunct Professor of Pathology); and Shabin Nanji, MD (Assistant Professor, Department of Laboratory Medicine and Pathobiology, University of Toronto, Canada).

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