Advancing Global Health by Empowering the Laboratory Workforce

The global burden of communicable (CD) and non-communicable diseases (NCD) is both complex and expanding. Historically, high income countries tend to allocate a disproportionate portion of their aid, financial and in kind, to address CD. The rapid global spread of the COVID-19 can partly explain why this strategy, namely containment, has been adopted.  

Yet, NCD such as cancer cause more deaths and disabilities annually than infectious ones. The net effects of this asymmetrical attention are unfortunate and are also negatively reflected in laboratory medicine capability and workforce in low-income countries. In recent years, global healthcare leaders have begun to recognize there are opportunities for prevention of all types of diseases and a nondiscriminatory approach would benefit everyone. Kathleen Sebelius, former United States Secretary of Health and Human Services from 2009 to 2014, has been quoted as saying, “Today, the health of Americans and the health of people around the world are more closely linked than ever before… It is critically important that we cooperate with other nations and international organizations to reduce the risks of disease, disability, and premature death throughout the world…No country can protect the health of its citizens alone.” This shift has led to additional funds for NCD in low-income countries and has created more options to advance global health by empowering the laboratory workforce. 

The laboratory is critical for global health 

A well-trained and skillful healthcare workforce, including laboratory medicine, is essential for global health. The World Health Organization (WHO) estimates a projected shortfall of 10 million health workers by 2030, mostly in low- to middle-income countries. In reality, the shortage of pathologists and laboratory medicine professionals is longstanding and has been at a critical level for decades in these countries. In all but five countries in Sub-Saharan Africa, each pathologist serves a population of more than 1 million people. In the other five countries, each pathologist serves 200,000 to 500,000 people. In contrast, each pathologist in the United States or United Kingdom serves less than 20,000 people. This is further exacerbated by the vanishing or nonexistent pipeline for these workers and the growing international migration to high income countries. In 2022, The WHO reported that approximately 15 percent of healthcare workers globally were working outside their country of birth or first professional qualification. It is broadly accepted by public health experts that strengthening laboratory services and systems is essential for advancing global health and for augmenting the ability of a community or a country to respond to chronic and acute health crisis. 

One sad example of how paralyzing a country can be in responding to an acute and large public health crisis without diagnostic laboratory capabilities is in Haiti. On January 12, 2010, the country experienced a deadly 7.0 magnitude earthquake. The Haitian government’s official death count was more than 300,000. The healthcare infrastructures were nonexistent. As a result, hundreds of thousands of Haitians and traveling foreigners who suffered various levels of injuries could not be treated appropriately.  

Fortunately, in the immediate aftermath of the earthquake, there was a brisk influx of international healthcare providers, primarily trauma relief experts, from all around the globe. Unfortunately, it became quickly apparent to these volunteers that full healthcare delivery was limited by the lack of adequate laboratory testing capabilities (e.g., chemistry, microbiology, hematology). Following a request from the Haitian government, the American Society for Clinical Pathology (ASCP) sent four pathologists and a medical technologist to Port-au-Prince, Haiti’s capital, to provide technical and professional support to both local and others medical NGOs. The only functioning laboratory was housed under a 700-square-feet party tent and staffed by both technical and non-technical personnel. All state laboratory analyses were being performed under this poorly ventilated tent using one bench per service (bacteriology, stool, urine, serology, hematology and chemistry) next to each other.  

This was certainly a unique and extreme example of an emergency response system stress test without sufficient laboratory workforce. A more common situation is when a country is trying to address a chronic public health crisis. Botswana is such example where its public health crisis includes a high burden of cervical cancer with about 60 percent of the cervical cancer patients being HIV positive—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 initiated a national cervical cancer prevention program with visual inspection with acetic acid (VIA) and treatment with cryotherapy. This resulted in many Pap exams and resected cervical tissues but also exposed the national shortage of professionals capable of reading the slides. The clinical intervention program to treat women had outstripped the laboratory’s ability to keep up with processing specimens.  

The National Health Laboratory in Gaborone, Botswana urged ASCP to help diagnose thousands of surgical pathology specimens in the laboratory’s backlog. ASCP sent four U.S.-based pathologists to Botswana to read slides for one week. Upon arrival, there were no slides to read. In fact, what they found was a room full of unprocessed tissues. The team of pathologists worked on addressing the actual anatomic pathology service gaps and proposed innovative and sustainable solutions. 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 to provide timely diagnosis and effectively increase the surgical pathology diagnostic capacity of the National Health Laboratory. 

The initial success of this intervention prompted ASCP to expand its footprint with partners to multiple countries, by leveraging technology and human assets through its membership. This is an example of how to increase laboratory capacity in an unconventional way.  

As a result, in 2015, ASCP created “Partners for Cancer Diagnosis and Treatment” to combat cancer in low- and middle-income countries (LMICs). In conjunction with the Obama Administration’s White House and the Clinton Global Initiative, the ASCP initiative was to simply provide rapid cancer diagnosis in Sub-Saharan African countries via telepathology. This effort was coupled with in-country care and treatment, and Rwanda was among the first countries, after Botswana, to see this implementation. There, laboratory equipment and a telepathology system were placed to serve hospitals in the capital and largest city, Kigali, Rwanda. This new setup connected 15 ASCP pathologists who were serving Butaro Hospital to Kanombe at that time. Also, this arrangement ensured that more than 95 percent of all pathology in Rwanda had secondary diagnostic support and consultation. 

Sustainable laboratory services is the goal 

While providing diagnostic expertise is welcome by these countries, sustainability should be the goal by empowering existing laboratory workforce through knowledge sharing. In Ukraine, ASCP worked with the Centers for Disease Control and Prevention (CDC) and sent a team of volunteers to provide technical training to Ukrainian laboratory professionals. Specifically, to train them in expanding their laboratory tests menu to address commonly encountered tests associated with NCD. In Nigeria, ASCP with Bio Ventures for Global Health (BVGH) provided support in the form of expert training in surgical pathology diagnosis of cancers to local pathologists. 

One key barrier to a competent and vibrant laboratory workforce is lack of or limited access to professional development through professional organizations.  In Kenya, 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 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. Providing support empowers local groups to elevate the important role laboratory professionals play in healthcare delivery. 

While there may be distinct physical and cultural borders among countries and communities, humans are one giant organism without these artificial barriers. The recent coronavirus pandemic is a painful reminder. As stated by Former U.S. Secretary of Health and Human Services, Kathleen Sebelius, “…No country can protect the health of its citizens alone…” Advancing global health is tantamount to advancing the survival of the human race. Additionally, advancing global health cannot be achieved without one of the most critical pieces in modern medicine, namely access to high-quality and timely pathology and laboratory diagnostic services. Low-income and middle-income countries have a disproportionately large share of the global burden of disease, both communicable and non-communicable diseases. Yet, they have nonexistent or grossly inadequate laboratory services and resources. Strategies to empower the laboratory workforce in these countries must be multifaceted.