Laboratory Medicine Abroad

Doctors Without Borders—it just sounds cool. Not only does the name allude to the organization's purpose of providing medical care abroad, but it also lionizes physicians in a way, suggesting we are capable of transcending boundaries to help those near and far. I always wanted to participate in Doctors Without Borders or a similar international medical program, and I have friends in other subspecialties who seem to have plenty of opportunities to travel abroad on medical relief–type trips. I attributed these opportunities to the fact that interacting with patients on a daily basis lends itself to fieldwork in other countries. As pathologists, we are reliant on resources such equipment, instruments, reagents, and so forth in order to deliver results and render diagnoses. Consequently, our reliance on technology makes providing international support more cumbersome, especially in resource-limited countries, which of course are the ones most in need. Taking on this prohibitory mentality, I sadly resigned myself to a life sans international medical work. Luckily, my view changed once I was asked to participate in a laboratory medicine course for physicians in Sub-Saharan Africa. Under MEPI, African medical schools are strengthening and expanding their curricula. Photo by Richard Lord for Fogarty/NIH In the United States, we are spoiled in that our laboratories, especially in academic settings, have the infrastructure to support a variety of tests at high volumes. Furthermore, the quality of the results are regulated by CLIA and deemed organizations that require validation, verification, internal and external controls, proficiency testing, and much more. However, not all places around the world, particularly in the developing world, are so fortunate. Laboratories in Sub-Saharan Africa have been shown to be substandard and undependable.1,-3 Undoubtedly, the dearth of good, reliable laboratories can have deleterious consequences on health care, encompassing delayed diagnoses, misdiagnoses, avoidable interventions, and other negative effects.3,-6 Fortunately, organizations worldwide, including ASCP, have taken note of the issue and are actively working towards bolstering and improving clinical laboratories in Africa.3 Still, strengthening the quality of laboratories only addresses part of the problem. In areas where laboratories have limited resources and are of low quality, it is understandable that physicians may be wary of the results released. It has been proposed that “physician perception regarding the value of diagnostic testing is potentially a major barrier to laboratory use” in Sub-Saharan Africa.6 Thus, not only is the quality of the laboratories in need of improvement, but training physicians in the fundamentals of laboratory medicine is just as imperative. In some countries, this may require a paradigm shift from reliance on clinical- and intuition-based diagnosis to a more integrative approach that includes laboratory results.3 Therefore, educating physicians in developing countries in clinical laboratory medicine and encouraging them to engage laboratory personnel are critical to improving diagnostics and patient care; I was fortunate enough to participate in a program designed to do just that. I recently returned from Addis Ababa, Ethiopia, where I spent a week helping to teach physicians under the auspices of the Medical Education Partnership Initiative (MEPI), established to increase the number of healthcare workers in sub-Saharan Africa, develop and strengthen medical education in those countries, as well as build an infrastructure for research.7 The program consists of an approximately 14-hour course, originally developed by combining principles from laboratory medicine curriculum for medical students set forth by the Academy of Clinical Laboratory Physicians and Scientists8 with a problem case-based method used at Emory University School of Medicine to teach medical students laboratory medicine.3,9 The course covers the main sections of clinical laboratory medicine (microbiology, chemistry, urinalysis, hematology, coagulation, and blood banking). Each day begins with two hours of lecture, which leads into a 90-minute case-based learning activity done in small groups. These small groups then come together to share teaching points from their respective cases. The course is bookended with pre- and post-course assessments. In years past the program has shown significant improvement in laboratory knowledge as seen in improved scores in the post-course assessment when compared to the pre-course assessment.3 Ultimately, the goal is to improve patient care by educating physicians on how to appropriately utilize laboratory services and, in doing so, elevating laboratory standards. The hospital and laboratory where the program is based have seen many positive developments in the three years since the program's inception. For starters, the laboratory went from 1 star to 4 stars, on a 0- to 5-star scale, in the WHO-Africa regional office (WHO-AFRO) laboratory improvement system, a scheme created to assess quality in laboratories that have yet to meet international laboratory standards.10,11 The microbiology laboratory has started using its automated microbial detection system, which had previously remained untouched and unused. Additionally, the microbiology laboratory is now able to quickly test for Mycobacterium tuberculosis with its newly acquired GeneXpert. And as a blood banker, I am particularly proud to see the advancements in the hospital's blood bank. This past year, the blood bank obtained a freezer and platelet shaker, permitting on-site storage of plasma and platelets, respectively. Moreover, according to the newly-created quality board, highlighting laboratory quality measures, demonstrates that the blood bank is now issuing more packed red blood cells as opposed to whole blood, which was essentially the only product dispensed when the program first started. Whether these improvements are related to the program is hard to measure. However, with improved physician and laboratory engagement, physicians can better advocate for the allocation of funds and resources to the laboratories to maintain and enhance laboratory standards.3 I am very grateful for my experiences in Ethiopia, not only for the relationships I built, but because it opened my eyes to the wide array of opportunities in which to get involved. For instance, ASCP's Partners for Cancer Diagnosis and Treatment in Africa initiative, which seeks to provide patients of Sub-Saharan Africa access to cancer diagnostics, is a wonderful example of how pathologists can integrate themselves into the international arena. Creativity and open mindedness go a long way in creating and finding prospects to support the integration, dissemination, and utilization of pathology and laboratory services, whether that be on a local, national or international level.