ASCP’s Inaugural Global Health Trainee Fellowship – My Experience in Addis Ababa, Ethiopia

ASCP has led the way in bringing pathology and laboratory medicine to the forefront of the discussion about global health. Through their many international partnerships, they have been working to bring high quality pathology services to patient populations in need worldwide.

In an effort to engage and enrich the next generation of pathologists, ASCP created the Global Health Trainee Fellowship in which those in a residency or fellowship (in the US or Canada) have the opportunity to apply for a minimum of a four-week rotation at one of ASCP’s global partner sites. This serves as an opportunity for trainees to gain hands-on laboratory medicine experience in low resource settings and to broaden their knowledge of pathology outside of the scope found in the typical western demographic. As a recipient of the inaugural American Society of Clinical Pathology Global Health Trainee Fellowship, I chose to go to Addis Ababa, Ethiopia for the month of December 2018. I knew that laboratory services were actively advancing, and I hoped that this would help me understand the challenges faced by an expanding laboratory working with constrained resources. Ethiopian people are known to be warm-natured, welcoming, and hospitable. Reputable also for their love of good food and coffee (both of which are near and dear to my own heart!), I knew I would be heading to a vibrant community of kindred spirits.

Ethiopia

Known as the birthplace of humanity, Ethiopia is a country that is rich in culture, ancient traditions, and beautiful scenery. In the last 100 years, Ethiopians have faced attempts at invasion and occupation, severe famine, drought, ongoing water shortages, and challenges most in the western world would never need to even think about. Despite these challenges, Ethiopia has shown to be a resilient nation, constantly moving forward, and is now considered to be the fastest growing economy in East Africa.¹

Ethiopia’s Cancer Problem

Worldwide, cancer incidence is increasing each year. Developing countries are no exception; not only do they bear the burden of communicable diseases; they are also faced with an increase in non-communicable diseases, creating a ‘double burden of disease’. One estimate of the growing cancer epidemic in Ethiopia demonstrated that death from cancer accounts for nearly 6% of total national mortality with 80% of reported cases diagnosed at advanced stages.² The Ethiopian Federal Ministry of Health has composed a national cancer control plan to address the growing threat of cancer. In it, issues such as lack of expertise on cancer diagnosis and treatment as well as lack of diagnostic and treatment facilities are cited as major obstacles to achieving cancer control. Addressing these factors is an enormous task, as there are currently only approximately 40 pathologists in Ethiopia to serve a population of over 100 million.³ Training enough pathologists in sub-Saharan Africa at the current rate of matriculation is a major barrier to developing a rapid solution. It is estimated that it would take over 400 years to match the number of pathologists to the population to reflect the ratio found in the USA or UK.⁴ Therefore, those in higher resource settings have a unique opportunity to help close this gap by joining in the effort to improve access to pathology services.

My work with ASCP in Ethiopia

In Ethiopia, ASCP has partnered with the two largest hospitals – Black Lion and St. Paul’s Hospital Millennial Medical College (SPHMMC). They are working to improve the quality management systems, introduce immunohistochemistry into the testing menu, and provide mentorship.

I had the privilege of spending a month with the remarkable anatomic pathology team at St. Paul’s; here, there is an impressive staff of pathologists, a residency program, a busy fine needle aspiration biopsy (FNAB) clinic, and a histopathology laboratory. They average around 600 surgical specimens monthly and perform between 40-50 fine needle aspiration biopsies daily. This volume will only increase in the future, as a major cancer treatment center is in construction now. I was fortunate to attend daily sign-outs where I saw innumerable cases of tuberculosis- and HIV-related pathology, massive thyroid goiters and malignancies, breast lesions that were sampled by both FNAB and surgical methods, and a spectrum of tumors with the majority presenting in advanced stage. I was so impressed by the diagnostic ability of both the pathologists and the residents, and they were eager to share and teach the cases that were rare to me. This was very valuable to me as a third-year resident, as I do not see nearly as many infectious disease related specimens and was exposed to an abundance of very advanced cases with unusual presentations. In addition to these sign-outs, I had the opportunity to help with frozen section diagnostics, which was quite challenging, but an extremely rewarding experience.

One of my favorite experiences was working with the talented and committed laboratory staff. I had the pleasure of working with George Okbazgi, the anatomic laboratory manager, and Eshetu Lemme, the ASCP local representative – both of whom are extremely passionate about quality standards in the laboratory. We accomplished many things together, including conducting a thorough mock inspection of the cytopathology department that concluded with a detailed written report, and plan for improvements. We also went through all the laboratory standard operating procedures as well as the AP quality manual – we spent many hours going through these documents revising and editing, identifying missing portions, and comparing to current laboratory procedures. This was tedious work, but fortunately, we had an abundance of delicious Ethiopian coffee to carry us through!

I reached out to the residents and attendings to see where else I could be of use. I was excited that they asked for my help with editing and revising several research reports, proposals, and grant applications. I was delighted with this task because, in my residency, we’ve had ample opportunity to participate in research and I’ve been fortunate enough to receive training in manuscript writing. This was an area that the team at St. Paul’s felt that they could improve, so it was a fantastic opportunity for me to be able to share the benefits of my training.

I’m excited that my departure from the lab back to the US did not mark the end of the relationship, as I was asked by the department to be involved in their endeavor to develop a fellowship program in gynecologic pathology – which will make this the first pathology fellowship program for the nation! I am thrilled to be a partner in such a monumental venture and hope that this will be the first of many long-term collaborative projects with the wonderful pathology group at St. Paul’s.

Conclusion

My time in Ethiopia was time truly well spent – together, we were able to make significant gains in improving the quality of the laboratory, engaging in research, and began laying the foundation for future collaborations.

I highly encourage all residents and fellows to apply to participate in this trainee fellowship with ASCP. It is an invaluable opportunity to exchange knowledge, build new collegial relationships, and help develop solutions to problems unique to these settings. And for the pathologists out of training, ASCP offers many ways to get involved in global health – please visit the ASCP Center for Global Health Website for more information about the changes they are making worldwide and how you can play a role: https://www.ascp.org/content/get-involved/center-for-global-health

References

1. Ethiopia Overview. World Bank. http://www.worldbank.org/en/country/ethiopia/overview. Accessed January 7, 2019.
2. Federal Ministry of Heatlh Ethiopia. National Cancer Control Plan of Ethiopia. 2015.
3. Adesina A, Chumba D, Nelson AM, et al. Improvement of pathology in sub-Saharan Africa. Lancet Oncol. 2013;14(4):e152-e157. doi:10.1016/S1470-2045(12)70598-3
4. Wilson ML, Fleming KA, Kuti MA, Looi LM, Lago N, Ru K. Access to pathology and laboratory medicine services: a crucial gap. The Lancet. 2018;391(10133):1927-1938.

-Dana Razzano, MD is a Chief Resident in her third year in anatomic and clinical pathology at New York Medical College at Westchester Medical Center and will be starting her fellowship in Cytopathology at Yale University in 2020. She was a top 5 honoree in ASCP’s Forty Under 40 2018 and was named to The Pathologist’s Power List of 2018. Follow Dr. Razzano on twitter @Dr_DR_Cells.