Audrey N. Schuetz, MD, MPH
A growing number of pathologists and laboratorians are dedicating themselves to building laboratory capacity in the developing world, to improve the lab’s role overseas. Many international institutions, such as the CAP, devote their resources and time to this effort. There are plenty of independent opportunities as well. About a year ago, having completed a medical microbiology fellowship and a clinical and anatomic pathology residency at Emory University Hospital, I traveled to rural Zambia to perform a laboratory assessment.
Discussing the work I performed in Zambia with medical technologists, medical students, and residents has been illuminating. Though philanthropy may not be the primary reason health care professionals pursue health-related professions, a surprisingly large number of them say they would like to donate their time or contribute in some way to the health care crises in developing countries. But the hallmarks of our profession, such as the microbiologist’s expensive automated blood culture instruments and the tissue processing labs of the anatomic pathologist, do not seem to be translatable to resource-limited settings.
Yet we are acutely aware of the importance of laboratory diagnostic services in patient care. The armamentarium of laboratory testing available to the majority of physicians in the U.S. and Canada is often not available to physicians in developing countries. If the peripheral blood count and differential, the CD4 count, or the cerebrospinal fluid culture, which we sometimes take for granted, are not available for the HIV-positive patient in Africa, the physician’s ability to care for the patient may be compromised.
The Masters of Public Health in Global Health that I obtained while I was in medical school led me to explore the possibilities of overseas work for pathologists. After hearing of the ties of my alma mater, Davidson College, with the Mwandi Mission Hospital in Zambia, I contacted my college biology professor, Verna Case, PhD, who has been leading trips to this hospital since 2002. She travels each year with a group of college students to introduce them to issues implicit in the practice of medicine and public health in developing countries. I was invited to accompany the group to conduct a general laboratory assessment and to aid the head of the laboratory, Heath Haamumba, in setting up a microbiology laboratory. This was the first time a pathologist had accompanied this particular group to Zambia.
My prior experience in assessing laboratories in the United States consisted of mock laboratory inspections performed as a pathology resident and the training the CAP offers for inspectors. This prior education was especially helpful in training me to conduct an inspection, but the equipment and state of the laboratory in Zambia were very different from what I had been exposed to during my residency training.
The laboratory in Zambia is part of a larger hospital complex located in the village of Mwandi in the Western Province. This 82-bed hospital employs one full-time physician and, in addition to the laboratory, includes an antiretroviral clinic, maternal and child health clinics, and tuberculosis and infectious diseases wards. Laboratory services include basic chemistry and blood counts, cerebrospinal fluid gram staining, and urine studies. Basic microbiologic culture capabilities were nonexistent. The laboratory serves a catchment area of 30,000 people and is staffed by two technicians. In other words, there are only two people in this region who know how to run a cell count on a peripheral blood or cerebrospinal fluid or who can perform a thin smear for malaria. Their call schedule is very busy.
I was struck most by the degree to which resource limitations dictate which tests the laboratory offers. For instance, though the laboratory offers the bare minimum in chemistry testing (a basic chemistry panel and liver function tests), it is equipped with a recently donated CD4 cell counter that uses electrical resistance detection technology. This donation was a fortunate one because CD4 counts are extremely helpful in this population, of which about 35 percent is HIV-positive. Yet hospitals do not always get to choose the equipment they receive through donation. My role in performing the laboratory assessment was to document and prioritize the laboratory’s issues, so that donating institutions would know precisely what the hospital needed.
My assessment led us to focus on securing energy for basic laboratory functions, such as backup sources of power for the refrigerated blood products and testing kits, which were used daily in the lab. Power outages of up to several hours to days are common, especially during the rainy season. We also set about obtaining normal ranges for the peripheral blood counts and running controls for staining methods on direct patient specimens. In addition, while rounding on the wards with the physician, it became apparent that certain diagnostic tests that were not then offered could be useful to the physicians in their patient workups. For example, we introduced testing for Pneumocystis carinii using a Giemsa stain. HIV viral load testing will soon be offered and will aid the physicians who are treating patients with antiretroviral drugs.
Much of the hospital and laboratory funds are spent on travel to outlying villages, sometimes a three-hour jeep ride away in the bush, to perform voluntary counseling and testing for HIV using rapid immunochromatographic tests. On one trip to a school, the laboratory head remarked how odd it was that so few children were testing positive for HIV, in comparison to his previous experience in that same area. Upon inspecting the HIV test kits, we found that the reagents used for the testing were those of another company. Someone had switched the reagents from a less expensive HIV testing kit, for use with another company’s kit. It was small but important issues such as this that we had to address, and this included training the hospital staff.
One could contribute to global health and development by volunteering for international organizations, such as Doctors Without Borders, or devoting funds or laboratory equipment to organizations, such as Worldwide Lab Improvement Inc. Yes, the job of improving medical care in so many areas appears to be overwhelming, but the best approach seems to be tackling one problem at a time.
Dr. Schuetz is assistant professor of pathology and laboratory medicine and assistant director of the clinical microbiology laboratory, Weill Cornell Medical College and New York Presbyterian Hospital.