Diagnostic Insufficiency in Africa

TOTHEEDITOR—I read with interest and some solace the viewpoint article by Petti et al. [1] and the accompanying editorial commentary [2] published in the 1 February 2006 issue of Clinical Infectious Diseases. Diagnostic insufficiency in Africa, highlighted by both articles, is severely compromising, deep-seated, and unacknowledged problem. Although the “brain drain” problem experienced in Africa with regard to medical doctors, nurses, and pharmacists is largely brought about by emigration, the dearth of clinical scientists is more easily explained by the fact that bachelor degree—level biological scientists are seeking employment in other sectors, including banking, insurance, business, and even the vitally important but low-paying education sector. Professionals who go abroad can return if conditions in their home countries improve or can offer developmental support while based overseas [3]. Professionals who leave the health care sector are lost forever. In many parts of Africa, free medical consultation and even medicine are provided through government support or aid. When free testing services are not simultaneously provided, necessary laboratory tests will not be ordered, even if they are available. The same applies when consultation and drugs are not free but the test costs more than serial chemotherapy. To promote rational practice, there is a need to prioritize subsidies for essential diagnostic tools over curative medicines. There is also a critical need for an assured supply of diagnostic reagents that are maintained at appropriate storage temperature from manufacture until point of use. At present, although a few companies have offices in eastern or southern Africa, most biomedical companies do not operate offices in western Africa, are unwilling to ship there, and do not provide technical support. Pricing of laboratory materials to be used in Africa is higher than it is in the United States or the United Kingdom. Shipping, clearing, and forwarding costs are prohibitive, and heat-susceptible materials are often degraded in the weeks or months that it takes to deliver them. On the other hand, granting agencies commonly provide smaller grants for Africa-based researchers; as a result, equipping a lab to serve diagnostic as well as research needs becomes less feasible. I mention research, because most of the few functional clinical laboratories are only able to perform because of the extra boost they receive from extramural research funding. Diagnostic insufficiency costs lives. For example, despite the findings of recent reports of outbreaks in Africa [4–6], the myth that enterohemorrhagic Escherichia coli infection is a disease of industrialized nations remains. Consequently, in Africa, the recommended presumptive diagnosis of bloody diarrhea remains infection with Shigella species or Entamoeba histolytica, and the treatment regimen for these diseases may lead to potentially fatal sequelae for patients with an enterohemorrhagic E. coli infection. Diagnostic protocols recommended and applied for E. histolytica detection in Africa cannot distinguish the sensu stricto pathogen from its nonpathogenic cousins, which further compounds the problem [7]. Antimicrobials are almost universally prescribed empirically, without supporting information. This is an important contributor to rapidly rising antimicrobial resistance in Africa [8]. Diagnostic insufficiency undermines the confidence that patients who have access to alternative health care forms have in “orthodox” health care systems. Even within the medical establishment, the ability to delineate valuable clinical advances from seemingly spurious claims is also lost, because cure verification is impossible [9]. Therapeutic failure opens myriad questions that can be answered only through laboratory diagnosis. Did the patient fail to recover because the diagnosis was erroneous, because the pathogen was resistant, or because the drug was mere chalk? Diagnostic development could also provide infrastructure that could aid in much-needed preliminarily drug quality assurance, particularly for antimicrobials. The real economic cost of developing diagnostic infrastructure in Africa is likely to be less than what is supposed and will be recouped in savings accrued. Routine antimicrobial susceptibility testing would permit less-expensive antimicrobials to be used more frequently so that the life span of second-line drugs can be conserved, saving the cost of new drug development. Undiagnosed and, therefore, untreated infections are more likely to be transmitted to others who must then be treated. Even when the patient survives, he or she remains sicker for longer and is more likely to be permanently disabled by illness. Diagnostic development will produce savings in all of these areas. Finally, many laboratory tests either can be performed using multiwell plates or require freshly prepared reagents. Such diagnostic tests are less expensive per test if they are used routinely rather than performed rarely. I have consistently found it necessary to justify the pressing need for diagnostic development in Africa, and I thank the authors of the recent articles published in Clinical Infectious Diseases for highlighting this predicament 1, 2]. Potential conflicts of interest. I.N.O. is a consultant to the Alliance for Prudent Use of Antibiotics and a Branco-Weiss Fellow of the Society in Science, Eidgenössische Technische Hochschule Zürich (Swiss Federal Institute of Technology; Zürich, Switzerland), and she has received additional research funding from the National Science Foundation; the Food Standards Agency, United Kingdom; and the Society for General Microbiology.