College of American Pathologists
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Award winners push "luxury" service: pathology

Related article:
Dr. Killeen wins Foundation award

November 2004
Anne Ford

For Danny A. Milner Jr., MD, it’s easy to explain why he has spent much of the last four years working as a pathologist in Malawi—an impoverished African country in which three pathologists serve 10 million citizens. "There are so many people there who need help on many different levels," he says. "Everything you do there helps someone."

Dr. Milner is one of two recipients of the CAP Foundation’s 2004 Humanitarian Grant Award. The award, presented Sept. 18 at the CAP ’04 annual meeting, will allow Dr. Milner and Frank Kiel, MD, JD, MSBA, to fund pathology services in the developing countries of Malawi and Madagascar.

Dr. Milner, anatomic and clinical pathologist and microbiology fellow at Brigham and Women’s Hospital and clinical fellow in pathology at Harvard Medical School, began his work in Malawi four years ago as part of an NIH-funded study of the clinicopathologic correlations of cerebral malaria in children. He has returned every year since, working with the two pathologists in the histopathology department of the University of Malawi College of Medicine to ease the country’s acute shortage of pathology services and to spark interest in pathology among the university’s medical students. In a country with few physicians, pathology is often seen as a luxury. Most of the students, he says, "see clinicians who give out drugs as very beneficial," but they’re "puzzled as to why anyone would want to be a pathologist." The CAP Foundation grant will allow him to stay in Malawi for five months to teach, do case sign-out, assist in research projects, and set up a functional manual for the university’s immunohistochemistry laboratory.

Not surprisingly, he has found many contrasts between his Boston and Malawian patient populations. In Boston, "in general, it’s tumor pathology, and those patients require lots of social services like support groups." In Malawi, malaria and tuberculosis are two of the most frequent diagnoses. "Most of the adults have had malaria several times," he says. "The diseases affect most of the population, so the community itself is the support group." Like many African countries, Malawi’s most pressing medical problem is HIV, with which 30 percent of the population is infected. "There’s not a lot of antiretroviral therapy there, so they end up with really bad TB and really bad Kaposi’s sarcoma," Dr. Milner says. No matter what the diagnosis, the often inadequate sample labeling makes his job more difficult. "For some of the cases you get a chunk of tissue and it says, ’This is from a 25-year-old woman,’ says. "Is it breast? Is it cervical? You just have to figure it out."

Despite the differences between his American and Malawian practices, Dr. Milner has found himself at home in the African country. Originally from rural Alabama, he says he had much more trouble adjusting to the urban bustle of Boston than he did to the more community-oriented culture of Malawi. "The social structure is much more familiar to me," he says. "It wasn’t even an adjustment."

Aside from his work, Dr. Milner found time last year to hold a celebration for the children of a Malawi orphanage. In talking to a Peace Corps volunteer who worked there, he learned that no one knew the orphans’ birthdays or how old they were. He and the volunteer decided the children should have a birthday celebration. "We went and bought two chocolate cakes and a bunch of presents and went out to the orphanage," he says. "They ate as much cake as they could possibly stuff in."

The other award recipient, Dr. Kiel, has already used his grant money to buy a restored TissueTec 2000 tissue processor for the SALFA/ AnaPath Laboratory in Madagascar where he began working in 1999 under the auspices of Pathologists Overseas. Dr. Kiel, clinical professor in the Department of Ophthalmology at the University of Texas Health Science Center at San Antonio, is a retired U.S. Army colonel.

The laboratory serves hospitals and clinics throughout the island, which has a population of about 18 million. "Before this lab was set up, they [the hospitals] didn’t do surgical pathology to any extent," Dr. Kiel says. "Most hospitals had no place to send anything for analysis. So this was a big leap in terms of the sophistication of medical practice." Pathologists Overseas continues to extend support to the laboratory, though it no longer has direct responsibility. For the first three years USAID supplied a grant. The Lutheran Church in Madagascar donates the laboratory’s space and administrative services.

The CAP Foundation grant made it possible for Dr. Kiel to replace its small-capacity and obsolete tissue processor. "The equipment we have, most of it was donated in 1999, and most of it was old when it was donated," he says. In addition, his wife, Ruth Kiel, who accompanies him on his month-long trips to Madagascar, persuaded the publisher Elsevier to donate the new two-volume Rosai and Ackerman Surgical Pathology textbook. The Kiels will deliver the books during their trip to Madagascar this month.

Two Malagasy physicians operate the laboratory. Fifty-four pathologists, through Pathologists Overseas, volunteered to visit the country for a month at a time to train them. "We did not want to set up a strict service-type operation," Dr. Kiel explains. "We wanted to train Malagasy pathologists to take over the lab, and we’ve succeeded." The lab also has a histotechnician, and he has an assistant. There are difficult-to-diagnose tumors of lymph nodes, soft tissue, and eye, and infectious diseases such as schistosomiasis, cysticercosis, and chromoblastomycosis. "Big problems in Madagascar are malaria and tuberculosis," Dr. Kiel says. Enlarged, ruptured malarial spleens occur. "We see a lot of cases in which tuberculosis of the lymph nodes has to be ruled in or ruled out," he adds.

Like Dr. Milner, Dr. Kiel must often explain the importance of pathology services to the country’s physicians. "We typically make one or two visits out to hospitals and clinics where surgery is done, and part of our role is to teach them the role of pathology and how it can help them," he says. "We’ve won over quite a few. We have 65 client hospitals now." He hopes to encourage interest in pathology among students from the University of Antananarivo in Madagascar, who frequently come to the laboratory for training with the five-headed Olympus microscope purchased with the original USAID grant. One student wrote his doctoral thesis in 2002 on the value of pathology consultation in medical care, using statistics from the laboratory.

Much of Dr. Kiel’s work must accommodate a language barrier (for which his wife sometimes provides an interpretive bridge). Most of the physicians speak French, the second language after Malagasy in this former French colony. The lab’s reports, which give diagnoses in both English and French, also include the diagnosis SNOMED code number. "I put that in right at the start," Dr. Kiel says, "to avoid potential diagnosis confusion."

Drs. Milner and Kiel are honored to receive the Foundation grants and look forward to continuing the work to which they have already dedicated so much time and effort. "I went to medical school to help people," says Dr. Milner. With the assistance of the CAP Foundation, he and Dr. Kiel will be able to continue doing just that.

Anne Ford is a writer in Chicago.