Volunteering on the Front Lines of Global Health

Following a very hard workout at the gym, JK (not a real patient’s initial) has been experiencing difficulty breathing. This sadly is not the first time she has noticed she is running out of air with physical activity. In fact, it has gotten worse over the past month and it is associated with facial pressure and nasal congestion. JK is an avid 28-year-old crossfitter who is in excellent physical shape. Three months prior, she contracted coronavirus and was very ill. Now, she was wondering whether her symptoms represent the dreaded “long COVID” she has read about in the news. Then again, the Spring season is here, and it could also be her allergy. Without improvement over the following weeks, JK made an appointment to see her primary care physician.

She was seen by an otolaryngologist who discovered there were nasal polyps. Imaging studies were remarkable for an enhancing destructive sinonasal mass with extension into her orbits. The mass was biopsied and tissues were sent to a pathologist for histological investigation. The microscopic assessment revealed occasional respiratory-type epithelial islands within a spindled cell proliferation. The diagnosis of biphenotypic sinonasal sarcoma was established following characteristic immunoreactivity to S100, SMA, EMA, and PAX3. The diagnosis was further confirmed with molecular analysis showing t(2;4)(q35;q31.1): PAX3::MAML3 fusion. 

JK underwent definitive surgical resection accompanied by radiation. Though the rate of local recurrence is high, this entity is considered rarely to be life-limiting.

Navigating the healthcare divide
 

This scenario is not uncommon in high income countries, but atypical anywhere else. The level of healthcare infrastructure, advanced diagnostic technology, and personnel training (clinicians, radiologists, pathologists and laboratory professionals) needed to arrive at the correct diagnosis followed by timely therapeutic intervention are nonexistent in many parts of the world. 

In many low-to-middle income countries, the number of people per pathologist can be greater than 5 million. Comparatively, in high income countries like the United States, this number drops to less than 20,000. The disparity is projected to deepen with growing international migration. In 2022, the World Health Organization estimated that approximately 15 percent of healthcare workers globally were working outside their country of birth or first professional qualification.

Most of you are likely familiar with the statement that 70–80 percent of clinical decisions depend on laboratory testing. And it is true that the vast majority of established clinical guidelines aimed at establishing or managing a clinical condition require laboratory testing. So how do healthcare providers perform the seemingly impossible task of caring for the sick with limited pathology and laboratory medicine services? How are clinical decisions being made in low-to-middle income countries? How do these countries address acute and chronic public health needs? 

Rebuilding Haiti
 

In January 12, 2010, at 16:53, Haiti experienced a large-scale earthquake. The initial shock registered a magnitude of 7.0, followed by numerous aftershocks of magnitudes up to 5.9. The already weakened infrastructures were reduced to shambles – including hospitals, clinics, and laboratories. The Haitian government’s official death count was more than 300,000. But hundreds of thousands of survivors suffered various levels of injuries and some were displaced. The ensuing chaos included a large public health crisis.

In the immediate hours and days following the earthquake, the country witnessed a brisk influx of international healthcare providers from around the globe. Understandably, in the acute phase the teams of volunteers consisted of trauma relief experts. These volunteers were mainly from high income countries where they are accustomed to the full armamentarium of modern western medicine, including laboratory testing capabilities. On the ground, it quickly became apparent that medical relief – even in this acute setting – required access to laboratory services, such as chemistry, microbiology or hematology. 

Six months after the disaster, the American Society for Clinical Pathology (ASCP) sent four pathologists and a medical laboratory scientist to Port-au-Prince, Haiti’s capital, to help restore and improve the clinical laboratory capabilities in the country. Upon arrival, the ASCP team quickly made contact with local government figures, local public health leaders, and non-governmental organizations (NGOs) to strategize on possible intervention. 

The situation was dire. The only working laboratory was housed under a 700 square feet tent that was supposed to be temporary, but after six months it was still there. The laboratory consisted of both technical and non-technical personnel. All state laboratory analyses were performed under this poorly ventilated tent using one bench per service – bacteriology, stool, urine, serology, hematology, and chemistry – next to each other. The vast majority of the tests were performed manually (for example, small hematology analyzer) and using antiquated methods. Non-laboratory personnel, including other emergency relief team members, were in and out of the tent constantly, bringing specimens.

The ASCP volunteers worked with Haitian laboratory professionals to develop strategies for short-term solutions and to propose recommendations for long-term rehabilitation of a struggling laboratory system. The short-term interventions comprised dealing with the acute surge in needs of laboratory services while the laboratory system capability was diminished. Other short-term interventions included improving laboratory workflow, implementing quality assurance and best practices, and providing technical training. The long term strategies spanned training on laboratory management, expanding test menus to cover both communicable and non-communicable diseases, widening the pipeline to recruit laboratory professionals, and working to develop a laboratory accreditation system. Lastly, ASCP and its partners agreed to work on acquiring updated technologies and laboratory equipment along with appropriate maintenance plans and training.

Tackling healthcare challenges in Botswana
 

As a low-income country, it is not surprising that Haiti’s laboratory infrastructure was underdeveloped and ill-prepared to adequately respond in the aftermath of the earthquake. However, a country’s financial means do not always translate to having a functioning national laboratory system. 

Despite being one of the richest countries in Africa – thanks to its diamond and beef industries – Botswana struggled to provide laboratory diagnostic services. The country’s public health crisis includes a high burden of cervical cancer with circa 60 percent of the cervical cancer patients being HIV positive. At one point, Botswana had the second highest prevalence of HIV/AIDS worldwide, with 24 percent of its adult population affected. Notably, women with HIV/AIDS are four to five times as likely to develop cervical cancer. 

Through initiatives by its Ministry of Health and various strategic partnerships, Botswana had initiated a national cervical cancer prevention program with visual inspection with acetic acid (VIA) and treatment with cryotherapy. This resulted in a large number of Pap exams and resected cervical tissues, which exposed the national shortage of professionals to read the slides. In other words, the clinical intervention program to treat women outstripped the laboratory’s ability to keep up with processing specimens. 

The Botswana government’s National Health Laboratory in Gaborone urged pathologists from ASCP to visit and help diagnose 2,000 surgical pathology specimens in the laboratory’s backlog. The understanding was that all tissues were already processed and diagnostic slides were waiting to be seen under the microscope. ASCP sent four US pathologists to Botswana to read slides for one week. Unfortunately, the actual laboratory needs were not clearly communicated to ASCP and it quickly became apparent that there were no slides to read; in fact, there was a room full of tissues in buckets labelled with patients’ names. 

The ASCP team readjusted the mission, worked directly to address the anatomic pathology service gaps and proposed innovative solutions to use automated tissue processing. A three-pronged strategy was outlined to remedy the concerns in the laboratory and develop a sustainable solution for diagnosing disease through key partnerships. This included installing all relevant laboratory equipment and training laboratory professionals to ensure a long-term solution. In addition, ASCP provided diagnostic support via telepathology with a view to reducing turnaround times and increasing the surgical pathology diagnostic capacity of the National Health Laboratory.

Expanding ASCP’s footprint
 

The success in Haiti and Botswana fueled ASCP’s expansion into other countries, driven by the need to respond to the often overlooked crisis of non-communicable diseases in Sub-Saharan Africa. ASCP also possessed the human asset because its members largely include board-certified pathologists and laboratory professionals that are eager to offer their time and expertise pro bono to advance global health.

So, in 2015, ASCP launched the “Partners for Cancer Diagnosis and Treatment” initiative to combat cancer in low- and middle-income countries in Africa and elsewhere around the world. In conjunction with the White House (Obama administration) and the Clinton Global Initiative, the new and ambitious ASCP initiative aimed to provide rapid cancer diagnosis in Sub-Saharan African countries via telepathology. This effort was to be coupled with in-country care and treatment. To kickstart this effort, ASCP conducted a feasibility assessment to identify countries that could immediately benefit from the initiative.

Rwanda emerged as a suitable site during early implementation, thanks to ASCP’s prior work in this country and its strong partnership with Partners in Health (PIH), which had a significant presence there. The fact that Rwanda was likely a difficult site – both in terms of how remote the first targeted hospital was and the lack of robust infrastructure – delivered a welcome challenge, giving everyone a glance of potential obstacles in future installations. In Rwanda, laboratory equipment and a telepathology system were placed to serve hospitals in the capital and largest city, Kigali. This new setup connected the 15 ASCP pathologists that were serving Butaro Hospital in the northern part of the country and Kanombe Hospital, close to Kigali, at that time. Also, this arrangement ensured that more than 95 percent of all pathology in Rwanda had secondary diagnostic support and consultation.

Empowering local professionals
 

Often, the required support may be as simple as providing technical training through knowledge sharing. The United States government – through the President’s Emergency Plan for AIDS Relief (PEPFAR) – has a long history of providing Ukraine with life-saving HIV medications and services. The focus of these US funds has been primarily on HIV and AIDS. However, like any other country, Ukraine has an underlying health crisis with non-communicable diseases with and without association to HIV. ASCP, working with the Centers for Disease Control and Prevention (CDC), sent a team of volunteers to provide technical training to Ukrainian laboratory professionals; specifically, to train in expanding their laboratory tests menu to address commonly encountered tests associated with non-communicable diseases. In Nigeria, ASCP partnered with Bio Ventures for Global Health (BVGH) to provide expert training in surgical pathology diagnosis of cancers to local pathologists.

In resource-limited countries, technical and non-technical support are critical. The latter can be in the form of mentorship. One key barrier to a competent and vibrant laboratory workforce is the lack of or limited access to professional development through professional organizations. In Kenya, for example, ASCP worked to support burgeoning local professional societies, such as the Association of Kenya Medical Laboratory Scientific Officers, by helping with meetings planning and logistical expertise. Similarly, in the Ivory Coast, ASCP supported and sponsored the country’s first laboratory week of Association Ivoirienne de Biologie Technique in 2014. These local organizations’ core mission and goals tend to align perfectly with their counterparts in high income countries. Broadly speaking, their mission is to provide excellence in education, certification, and advocacy on behalf of the patients, pathologists, and laboratory professionals. By providing support, local groups are empowered to elevate the important role laboratory professionals play in healthcare delivery.

Now, imagine our patient JK was situated in a resource-limited country. In fact, there are millions and millions of JKs in need of access to modern diagnostic laboratory services and medicine. For many patients across the globe, this is their lived reality. The number of preventable deaths is staggering. So how would a sick JK, in one of these countries, receive care? The short answer is that a large proportion of individuals do not get diagnosed and treated. Subsequently, many die before they even get to see a healthcare provider or before their specimens are evaluated by pathology. The overall cancer mortality rate in Africa is nearly 80 percent – a stark contrast to outcomes in high income countries. Nonetheless, many do get some care. How?

Practical solutions in resource-limited settings
 

Local ingenuity often surprises volunteers. Local folks can be extremely resourceful, innovative, and creative in achieving the impossible with limited resources. For example, during our time in Botswana, we noticed histotechnologists using the tips of pen covers to advance tissues. In Haiti, they recycled all disposable glass and worked around the time when electricity was available. In Ukraine, when international funds are provided solely for communicable diseases like HIV, pathologists and laboratory professionals find ways to use these resources to address their country’s other main public health crisis: non-communicable diseases. 

The reality is that a huge portion of healthcare delivery in these countries flows from non-profit NGOs like ASCP and PIH, and international monetary and non-monetary donations. These organizations help fill the gap in diagnostic capabilities – with or without local government coordination. But is this a sustainable solution?

The answer is “no.” The problem is dynamic with continuous augmented complexity and size. The world population is increasing and aging, leading to increased needs for laboratory services. Geopolitical instability threatens the contributions of NGOs. The disparity between the haves and have-nots is widening, with unfair economic forces and international migration of a skilled laboratory workforce. The pipeline for competent healthcare workers to enter into the laboratory workforce is shrinking for a variety of reasons, but mainly vanishing access to proper education and training. To provide care for the sick in places that have limited pathology and laboratory medicine services, dynamic and multifaceted approaches are needed.

The humanitarian efforts by NGOs that provide resources and lend expertise have to continue in conjunction with the goal of sustainability. This goal can be achieved through mentorship of local professional pathology societies, like in Ivory Coast, and by guiding them to international certification designed to increase the overall quality of laboratory medicine. Organizations like ASCP and the College of American Pathologists can make significant contributions by providing access to their educational portfolios and creating opportunities for knowledge exchange. More importantly, international and local entities need to avoid competition among themselves, fostering strategic partnerships with the shared goal of advancing global health. Lastly, leveraging existing technology, such as telepathology and artificial intelligence, can markedly close the disparity gap between high and low income countries by leveling the playing field for cancer diagnosis.