While in graduate school, before I knew anything about laboratory medicine or pathology, I served as a translator for a medical team in Haiti. The team traveled from village to village setting up temporary clinics that consisted of little more than several chairs set up for the physicians and patients. A makeshift pharmacy of donated medications – NSAIDs, vitamins, basic broad-coverage antibiotics, mostly – set up in the corner completed the clinic. While translating for patients, hearing their complaints, and hearing the physician attempt a diagnosis based on clinical signs, I was profoundly struck by how the lack of laboratory diagnostics complicated establishing a diagnosis. It was this poignant awareness that led me to the field of laboratory medicine and clinical chemistry.
Laboratory medicine is a vital part of public health. It is important for detection of disease in individuals and populations. Laboratory tests are also important for detection of environmental toxins such as lead. As we laboratory professionals know well, for a lab test to be useful is has to be available and accurate. For most of the United States, this is not a problem. There are 18,000 pathologists in the U.S. – around 5.7 per 100,000 people – plus clinical laboratory scientists such as clinical chemists and microbiologists. There are over 250,000 accredited clinical laboratories.
However, in the developing world, there is a severe shortage of both quality laboratories and laboratory professionals. For example, all sub-Saharan countries, except Botswana and South Africa, have less than one pathologist for every 500,000 people. Haiti, a country of over 1 million, has only 7 pathologists. Diagnostic testing is offered by the occasional network of unregistered laboratories, operating without regulatory oversight. A survey of 954 labs in Kampala, Uganda, revealed 688 unregistered labs completely unknown to the Ministry of Health. Lack of professional direction and oversight might contribute to poor quality tests, misguided use of tests, and faulty interpretation of results. In fact, the WHO estimates 80% of suspected malaria cases are treated without confirmatory test results, in part due to lack of availability and in part due to physician mistrust of inadequate testing.
Because the gap is so big, it’s easy for me to tell you about the differences in access to quality lab testing in the developing world compared to the US. But it would be remiss of me to not mention the public health burden here at home, and how expansion of laboratory programs within our own boarders could help alleviate the problem. For instance, could a lead screening program have caught the lead exposure in Flint, Michigan earlier?
Global health – a healthy global population – needs quality laboratories and dedicated laboratory professionals both at home and abroad. It’s our responsibility to stay abreast of the issues, to stay active in advancing the field, and to educate those in healthcare, public health, and policy formation about what labs can do. This blog will explore applications of laboratory medicine to global health. Stay tuned!
-Sarah Brown, PhD, DABCC, is an Assistant Professor of Pediatrics and Pathology and Immunology at Washington University in St. Louis School of Medicine. She is passionate about bringing the lab out of the basement and into the forefront of global health.
Lablogatory 
While I agree with your article in principle, I think the reality of lab education and practice in the US is woefully inadequate. Global health is important and lab medicine can be a big part of solutions. If the world looks to the US health system as a standard of care, we are not the optimal model.
I love the sentence under your pic, Dr. Brown- “She is passionate about bringing the lab out of the basement and into the forefront of global health.” We need you, the world needs people like you and your enthusiasm. I wish you success! You and others trying to change healthcare ( even people like Zdoggmd) are an inspiration and give hope to old curmudgeons like me that change will happen in the US healthcare system.
Schools in the US who offer medical technology are closing. There are no real hospital based programs anymore. There are not enough techs to teach and work. Virtual labs are used now instead of actual hands on practice. Some techs graduate never even having touched a patient. Older techs are retiring in droves. Hospital administrators have no clue what lab does, what lab personnel go through for training or what even our credentials mean. Lab medicine is being taken over by more automation, without regard to professional judgement based on education and experience. CMS has decided that nurses are qualified to run and /or direct lab services. You do not need advanced science classes to push buttons. Clinical lab scientists, microbiologists and clinical chemists are dying breeds. Every other facet of medicine has been directed to more patient satisfaction, while lab techs have become more and more marginalized to the patient experience. We don’t collect specimens in big hospitals. We don’t have patient contact. We are not allowed to interact with physicians ( too much work to do). Labs are mostly out of sight in basements. We aren’t even part of the hospital tours for new employees.
Public health labs do a great service for the country. Financial constraints limit their scope of testing and ability to pay qualified personnel. I agree that they should be emphasized more in the US. With the emergence of new resistant pathogens, ever vigilance for bioterrorism, population studies, vector transmitted disease and environmental threats (lead in Flint, MI) there are a myriad of uses for public health labs. But they are usually underfunded and understaffed. Results may take days to weeks and not be relevant to patient care by the time they are received.
Laboratory clinical scientists ( Technologists, technicians, specialists, etc.) are not considered part of the health care team in the US anymore – especially in the large hospitals. I have been in this field for 38 years. I have seen tremendous change in the profession – some good and some bad. I have worked in small, medium and large top rated modern hospitals, public health clinics, university settings, and small private physician practices in both urban and rural environments.
The current state of healthcare in the US cannot continue. We are no longer really in the business of treating patients, we have all become about generating revenue to perpetuate this bloated system we call healthcare in the US. We as a country can’t sustain the level of healthcare spending. Everybody knows it. There are so many medical professions that exist today, that did not exist 40 years ago. Some examples are coders, the entire ICD industry, IT, computer manufacturers, electronic medical record techs and dedicated companies, health information specialists, compliance personnel,wellness specialists, numerous case managers ( not nursing), patient satisfaction personnel and all the survey companies, and numerous safety specialists. Labs have to specialized personnel for middleware,LIS and EMR interactions. These are just a few of the new jobs in healthcare. All of these people must get paid from the money generated from actual direct patient care (remember it is all about patient care). It is no wonder that costs are spiraling out of control in this country. Everyone wants and deserves wages commensurate with their training and experience.
Payers now pay based on patient satisfaction. Insurance companies are pulling out of Obamacare markets because they cannot afford the losses. Premiums simply cannot keep up. Remember insurance companies pay their numerous employees also. People forget healthcare is an industry in this country. An industry that includes for profit and nonprofit entities. All of this has forced medical practices to consolidate to save costs. There are very few single primary care physicians in practice anymore. The actual healthcare providers who bill for services have to have numerous fee schedules to bill Medicare/Medicaid, the many contracted insurance companies, PPO, HMO, private pay and indigent patients. There are different fee schedules for inpatient and outpatient care. We have let all of this become so complex and be bound by so many complex regulations that direct patient care has suffered.
To get back to the lab – It is oft said that 70% of all medical decisions are made based on lab results. As qualified trained laboratory professionals are pushed out of the profession, more and more automation will prevail. Globally, that may not be in the realm of possibilities for poorer countries. Old diseases like malaria will continue. Antibiotic resistance will spread because of lack of testing. New pathogens may not be discovered in a timely manner. Labs on a chip are often touted as an answer for poor countries. Reliance strictly on technology without educating personnel to really make use of the information provided may result in disaster. I do not know the answers to these problems. I only hope that globally, the healthcare labs and systems of the world do not follow the convoluted path that we have taken in the United States.
Thank you for your excellent comments! I agree with you that Lab Medicine in the US is facing challenges that must be addressed. I plan to discuss some of these issues in future posts…maybe I’ll address them a little sooner rather than later! It’s so important that laboratory professionals understand and advocate for their value to the healthcare system.
Thank you for taking the time to write this article. It is so unfortunate that countries with the most urgent need for Pathologists and proper laboratories are the ones with the fewest resources. Countless people are dying from treatable illness simply because a physician never got the opportunity to diagnose and treat. Awareness is possibly the strongest tool we have to combat this and it’s professionals like you who are leading the way!