Giorgis Okubazgi, an ASCP certified histotechnologist living and working in Ethiopia, and colleagues have published a brief editorial this month in AJCP detailing the current state of histopathology in Ethiopia: https://academic.oup.com/ajcp/article/doi/10.1093/ajcp/aqz144/5581862/. This type of cross-sectional survey of pathology infrastructure is crucial to understanding the gaps that exist in the current service provision models and where resources need to be focused to improve patient care and outcomes. If we just consider the incidence and prevalence of cancer in Ethiopia in a given year, we can start to grasp the magnitude of the problem. It is not fair or just to talk about the “current volume” of any of the 13 pathology laboratories Okubazgi et al reviewed because we can assume (and rightly so based on dozens of other observations in African countries) that, whatever the current volume of these laboratories, it is only a fraction of the population need for services. Consider the 2018 IARC data for Ethiopia, which estimates 67,573 new cancers for Ethiopia per year with 47,954 deaths (71% mortality). Comparing this directly with the US where 1,762,450 new cancers are expected in 2019 with 606,880 deaths (34% mortality), we can see immediately that the mortality differences is horrendous (and must be dealt with immediately) but that the relative rates of cancer seem to be skewed (why so many more cancers in the US?). These numbers for the US work out to about ~5400 cancers per year per 1,000,000 people in the US. Subtracting out skin cancers in Caucasians, assuming Ethiopia will economically improve its healthcare system overtime such that patient access increases, and shooting for a 50% malignant/benign ratio in surgical pathology biopsies of suspect lesions, we can estimate that the total country volume for suspected cancer tissue biopsies will eventually be between 131,146 and 2.5 million. Although that range seems quite vast, it at least provides us with figures to now understand the massive capacity challenges in Ethiopia. Considering there are 13 laboratories currently and equally dividing all that work among them, that would be 10,088 to 192,307 cases per lab per year. Another way to parse this would be by pathologists (again, assume a completely even distribution) for which there are currently 70 in country and 75 trainees. That would be 1873 to 35,714 cases per pathologist per year today or 904 to 17,241 cases per pathologists per year within the next 5 years. Keep in mind that this is JUST for suspected cancer biopsies and does not consider medical disease biopsies, asymptomatic screening tests (such as cervix or colon), obviously benign lesions, or products of conception evaluation. Considerations also have to be included for cytology samples which have been in practice in Ethiopia since 1965 and the role and volume of both forensic and medical autopsies. And, of course, as Okubazgi points out, 54% of these current labs serve only 20% of the population. So, what should surgical pathology services look like in Ethiopia going forward? Despite having three recognized major population concentrations, with a population of over 100 million, multiple populations of more than 1 million people are located in rural/non-urban settings. Only 6 of the current 13 laboratories are located in these areas and some 40 million people live in regions with no access to pathology. There are two solutions (not exclusive) to this type of access challenge which include 1) building additional laboratories and 2) created clear specimen referral networks. Several countries with much smaller populations such as Uganda and Rwanda have either built country-wide referral networks or increased the number of labs and pathologists/technicians to meet the current and projected population needs, respectively. Although neither of these countries has solved every challenge or optimized pathology services perfectly, they have instigated the programs and built value around these solutions which will lead to improved capacity and better patient care. However, for Ethiopia and its West African cousin, Nigeria, the distribution of citizens and size of the population will require a combined approach of both increased numbers of laboratories AND regional and/or national specimen referral networks. For both Nigeria and Ethiopia, there is a spectrum of wealth within the countries which means that robust public and private systems are needed in order to provide access to all citizens. With such a lack of capacity and resources currently in Ethiopia, the time is right for investment in Ethiopia through solid public programs with universal healthcare ideals, diversified private systems, and, most importantly, the opportunity to forge public-private partnerships as the system is being built up. As Paul Kagame has said, “In Africa today, we recognized trade and investment, and not aid, are pillars of development.” The gross domestic product (GDP) per capital in Ethiopia is currently $712; however, Ethiopia has one of the fastest growing economies in the world which means that disposable income and income spent on healthcare for a large cohort of citizens is expanding. By matching both internal and external investors in health, infrastructure, and technology with the sectors of the economy that are either under capacity or expected to grow, Ethiopia is ripe for solving its healthcare challenges, including access to diagnostics, through sustained economic development. This proposition is not without its challenges due to Ethiopia’s current restrictive policies on foreign investment as a non-collaborative endeavor. Despite this situation, there are channels and processes, most of which require local Ethiopian entrepreneurs and/or investing partners, through which powerful investments can be made for the betterment of health and society. It is at this moment when the healthcare infrastructure is under capacity but the economy is growing that Ethiopia needs investments in both public and private sector services so that the result on the far end of this economic boom is NOT a lack of access for the lowest incomed citizens. Nigeria’s boom in GDP and growth in economy happened nearly 30 years ago (with a relatively flat economy now) but those types of investments were not made such that now, the lowest incomed or impoverished citizens of Nigeria are left with essentially zero access to a global fee-for-service healthcare system. Let’s learn from the history of economies on the brink of transformation and not leave a single patient in Ethiopia without the chance for treatments and cure.
-Dan Milner, MD, MSc, spent 10 years at Harvard where he taught pathology, microbiology, and infectious disease. He began working in Africa in 1997 as a medical student and has built an international reputation as an expert in cerebral malaria. In his current role as Chief Medical officer of ASCP, he leads all PEPFAR activities as well as the Partners for Cancer Diagnosis and Treatment in Africa Initiative.