I had the pleasure of talking recently with Danny Milner, Jr., MD, MSc(Epi), who serves as the Chief Medical Officer of ASCP. He has worked to improve diagnostic access and improve laboratory medicine services in low- and middle-income countries [LMICs] his entire career. I recently read his book for which he served as editor for titled “Global Health and Pathology.” This highly informative compilation of articles written by the foremost experts in the field is a MUST READ for anyone interested in global health! You can order your copy here: https://www.elsevier.com/books/global-health-and-pathology-an-issue-of-the-clinics-in-laboratory-medicine/milner/978-0-323-58158-5.
After reading the book, I hoped to learn more about Dr. Milner and how he became a leader in global health and pathology. Below you will find his fascinating narrative of his career and his reflections on the importance of providing high quality pathology services worldwide.
Q: Dr. Milner, I’m curious to know where your service in global health began and how your career in pathology has intersected with that?
A: Truly, many events occurred that were serendipitous in shaping my career and life. I grew up very poor in a rural community in Alabama, in an area known as the “black-belt” of the southern states due to the rich black soil found there. This area was home to many of the relocated former slaves after the end of the civil war and is now home to a 50/50 mix of Caucasian and African-American members of the community.
Towards the end of high school, I was awarded a scholarship for high achievement and a scholarship geared to support healthcare careers. At the award ceremony, a person giving me an unrelated award knew of my scholarship for pre-med and said to me and the crowd, “go become a doctor”. When I was in college, I worked as a nurse’s assistant for a physician and became interested initially in primary care . After some careful consideration, I decided to embark on a path that would take me to medical school, finishing my pre-med requisites and graduating in three years. I was accepted to the MD/PhD program at the University of Birmingham [UofB] wanting to do my PhD in Medicinal Chemistry. Unfortunately, this particular PhD wasn’t allowed, so I decided to pursue a MD only.
In medical school, I decided to slow down my fast track through school– so I applied to a post-sophomore fellowship in Pathology and at the same time applied for a summer program offered by UofB that entailed working in a clinic in The Gambia. This would be the first time that I had traveled outside the United States. I first went to Africa, with my fellowship to follow on my return.
In The Gambia, I lived in a compound with 12 people in an extremely rural area with no running water or electricity. I spent four weeks working in a clinic with a Gambian doctor, seeing patients without the use of diagnostics. I was traumatized by the extreme suffering of the patients we saw. My take away from the experience was the idea that it would have been so much easier to help had there been any sort of diagnostics available – a malaria smear, a microscope, anything that could have helped us do a better job than we were doing.
When I returned from Africa, I started my post-sophomore fellowship and my first rotation was autopsy. There was a neuropathologist there named Angelica Oviedo, and she had just gotten back from Malawi. Hearing about my recent trip to The Gambia, she encouraged me to pursue more work in global health. She put me in contact with Terrie Taylor – who is an internal medical physician who has been working in Africa since 1986. It was in the 1990’s and she had just started a cerebral malaria autopsy study which would become the largest study on this topic in the world.
This post-sophomore fellowship really inspired me to pursue pathology. I was thrilled to be offered a position at the Brigham and Women’s in Massachusetts for pathology residency. I finished medical school by spending time in Germany and then under the supervision of Terrie Taylor in Malawi working on the cerebral malaria autopsy study. I continued to work with her for thirteen years following this.
In residency, it was a natural fit for me to gravitate towards all things related to global health which meant a focus on infectious diseases. I continued to work in Africa and traveled there 4-5 times during residency, scrounging together any time and any money that I could to try to help. It was during my second time in Malawi, around 2001, that I was surprised to find that all the cases crossing the surgical pathology bench were cancer – there was nothing but cancer, and it was often very advanced. This was 15 years before the WHO resolution on cancer. I was suddenly very interested in this aspect of care. Up until this point, I was heavily focused in infectious disease, and how this related to oncology, but now I wanted to really focus on cancer. I was not encouraged by my elders to try and tackle this because they said, “they are all going to die anyway.”
Fast forward, I finish a fellowship in Microbiology and am joining the Brigham as faculty to work in infectious disease pathology. During this time, I continue to go to Malawi and I am continuously signing out cancer cases for Africa. This was tragic since there was no intervention at that time, and every case was essentially a death sentence. The first oncologist did not arrive in Malawi until somewhere around 2008-2009.
During my time at the Brigham, Partners in Health [PIH] began sending tissue biopsy cases to us to diagnose. Every year, the cases increased more and more. Because cancer started to become the majority, PIH decided to strategize the best way to meet this need. Larry Shulman, the lead for PIH based at Dana-Farber in Boston, reached out to me to build a pathology laboratory in Haiti, but since that idea was quickly followed by an epidemic of cholera, it was decided to build a pathology lab in Rwanda instead – this was in 2011. After a massive effort entailing equipment installation, capacity building, infrastructure, and staff training, Butaro Cancer Center officially opened 6 months later. With the help of a few other volunteers, we continued to run the lab remotely using static image telepathology. In 2016, a full-time local pathologist took over the lab and ASCP brought in whole-slide telepathology services. In 2015, I met Blair Holladay in person for the first time. He shared his vision for ASCP to expand their global outreach and we had a healthy discussion about the details of making it happen. Blair asked me to volunteer to become part of the team, and I worked together with ASCP to launch the Partners for Cancer Diagnosis and Treatment in Africa Initiative. The project grew and ASCP reached out to recruit me to work as the Chief Medical Officer and lead the global health team. I was excited to have the opportunity to work in global health full time.
Q: Why is pathology the essential cornerstone of global health?
A: First, you should consider how important the laboratory is in medicine. An often-quoted study says approximately 70% of the clinical decision making is based on laboratory results. In certain subspecialties of medicine, like surgery or oncology, these clinicians are nearly 100% dependent on the laboratory for delivering care. In fields like psychiatry, it is going to be much less dependent on the laboratory. Even so, it is reasonable to say that almost all medical decisions are best informed by high quality laboratory results.
Starting with that statement, the laboratory is what allows clinicians in certain fields to function. In the field of cancer, which is a major problem in LMICs, you cannot treat the patient without a diagnosis – and the diagnosis must come from the laboratory.
Q: Historically, pathology hasn’t always been associated with creating global health solutions. Why do you think that is now that we know it is an essential component of building health systems?
A: It’s a general challenge in global health that pathologists haven’t been involved as much as they could be. This could be due to multiple reasons. The need for pathologists to serve in low- and middle-income countries hasn’t traditionally been recognized. This may be due to a disconnect in understanding our potential to make an impact. We, like surgeons and radiologists, require electricity, supplies, and resources in order to volunteer in very remote settings worldwide. This is unlike clinicians and emergency medical doctors for instance, that can see patients without extensive resources available – they are more readily available to serve in small, remote communities. An exception would be the use of cytology which can, with very limited resources, be extremely effective even in remote areas. However, as a specialty, pathologists are typically able to serve in larger cities in LMICs and, there, have an enormous impact. So, there are plenty of opportunities for pathologists to practice their specialty in improving global health and make an impact.
It may also be that people and their families have concerns about their safety, or they don’t have the support of their institution in terms of time, or they may not feel they have a connection to a potential site. The desire may be there but there are perceived obstacles.
ASCP works to create relationships and facilitate connections, as well as allay fears for safety concerns. We also offer institutional support, for example, we provide a letter of explanation and support for our Trainee Global Health Fellows. We try to bridge the gaps for people to feel that they have the ability and are empowered to volunteer, remove the barriers to participation, and make it as easy as possible for people to do so.
-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.