An ASCP Volunteer’s Experience Abroad

I volunteered in April 2019 in Tanzania at the Kilimanjaro Christian Medical Center. I was there specifically to teach breast mastectomy grossing. There are two pathologists at KCMC, Dr. Mremi and Dr. Patrick, but finding time in their schedule to work with them proved to be the biggest challenge. The pathologists have many responsibilities outside of just looking at slides. Dr. Alex Mremi is the head of the department, but he also teaches at the medical school and meets with medical students. The pathologists at KCMC perform autopsies, including the forensic autopsies that would normally be sent to a medical examiner or coroner’s office in the United States. Dr. Mremi was pulled away one day to do an autopsy and two other days to go to court to discuss autopsy findings. One of the days Dr. Mremi also performed an FNA, where he was not only preparing the slides, but procuring the specimen from the patient himself.

In the end I was able to go over one mastectomy case with each pathologist, but I had hoped to discuss my case study examples and talk to them about the differences in our grossing techniques in greater detail. When the pathologists were busy I would go over grossing techniques of the less complex specimens with the lab aides that perform grossing. Unfortunately the lab aides have responsibilities as accessioner, histotech, grossing aide, transcriptionist, etc. They do it all, so it was equally difficult to find time in their busy schedule. In addition to scheduling conflicts, there was also the issue of ventilation in the gross room. Because there is a window fan, but not proper ventilation, whoever is grossing could only be in the gross room for a limited amount of time before formalin exposure would be too much. I did bring a formalin 3m mask that was donated by a colleague of mine with some replacement cartridges that I hope they will implement into their routine.

In retrospect I wish I had known how difficult it would be to schedule my grossing time with both the pathologists and the lab aides. It takes a forceful and persistent personality to wrangle people into the gross room when they are bogged down with their other work. I wish I had known about this blog before my trip to Tanzania because this seems to have been previously stated by PAs. I would also recommend that the PA make sure to have all their transportation arrangements and initial appointments at the hospital set up in advance because you will essentially be dropped in a place with no Wi-Fi. I made sure to arrange all of this with the help of Alpa Pandya, Dr. Milner’s assistant, who was incredibly helpful. If you are able to exchange money in advance or schedule a trip to the bank with your airport driver this will be very helpful. The day I arrived was a Sunday so banks were closed. It was somewhat of a challenge to find a restaurant or local transportation that would take US dollars. I would recommend getting your visa before your trip because this may prove difficult to accomplish at the airport upon arrival. Be sure to get all the recommended vaccines and anti-malarial medicine if necessary in the area you are travelling. I was very surprised to see no mosquitos at all during my entire trip and find out that malaria is nearly eradicated in the Kilimanjaro region. I also had my clothing sprayed with an anti-bug spray that may have helped keep flies away from me. I would recommend people learn basic phrases (hello, thank you, please, etc.) in the language of the country they are visiting to be more respectful of the local people. Language apps such as Duolingo or Babel are a great help.

I recommend that if a PA is volunteering in a low resourced setting they find out exactly what would be most beneficial to the pathology department in that setting. Since my trip was more focused on breast mastectomy grossing I brought Lester, breast diagrams, templates, inking diagrams, breast protocols and procedures from my hospital, as well as multiple case examples. Some of which I laminated in advance so they could be used again and again in this setting. If I were to volunteer again I would try to set up a more concrete schedule in advance with exact times blocked out to discuss techniques, be in the gross room or give presentations. I am incredibly grateful I got to have this experience, I only wish I was able to make more of an impact. I hope that more PAs will continue to volunteer and that pathologists will participate in the telepathology volunteer roles to free up more time for the few pathologists in these low resource environments. Thank you again to ASCP, Dr. Milner and Alpa for this opportunity!

-Faith Fletcher is a Pathologists Assistant at Henry Ford Hospital in Detroit, Michigan.

Global Health Narratives Interview Series: Meet Dr. Kumarasen Cooper.

Kumarasen Cooper, MD, PhD completed his medical training from his home country in South Africa and his PhD at Oxford. He now works as a surgical pathologist at the University of Pennsylvania and is responsible for leading the initiative to engage the pathology department in the Botswana-UPenn partnership through the Perelman School of Medicine Center for Global Health. He has over 260 publications and has lectured in 5 continents. Despite this busy schedule, Dr. Cooper devotes two separate months of the year to work in Botswana’s only academic pathology department, where he pours his energy into helping the department advance.

I met Dr. Cooper through email when I heard about the work he was doing in Africa. He generously agreed to come visit my department to give an excellent Grand Rounds lecture on his experiences working in Global Pathology, and he led a much-appreciated resident slide session of unusual and difficult cases from his work in Botswana. Humility and grace envelop Dr. Cooper despite his brilliant accomplishments. He also proved to be incredibly generous with a refusal of his speaker honorarium, in exchange for an agreement that we would collect pathology textbooks to send to the under-supplied residency program in Botswana. I’m excited to share the inspiring work that he does through the Botswana-UPenn partnership with all of you today, as I think this program could be used as a model for all institutes to involve their pathology departments in global health opportunities.

Q: What began your interest in global health?

A: I was born, raised, and completed my medical training in South Africa. I spent 15 years working as a Pathologist and served as the Chair of Pathology in Johannesburg until I was recruited to the US to work as Vice-Chair at the University of Vermont. I knew when I left Africa that I would always come back, and that I could use what I learned abroad to give back in some way. I wasn’t sure in what form that would take at the time, but I knew there was work that still needed to be done. This was also influenced by my visits to the pathology departments in many different countries over the years…I was able to gain a sense of the ‘haves and have-nots’, and so developed a strong feeling that I needed to give back.

Q: How did you hear about the Botswana-University of Pennsylvania (BUP) partnership and was pathology an active part in that already?

A: When I first discovered the partnership, I thought that this may be an avenue for me to participate in global pathology. At the time, the pathology department was not involved in any of the ongoing BUP projects, though other clinical departments at UPenn were. After my initial assessment of the Botswana pathology department and its resources in April of 2016, I was able to identify ways that I could help. Together with the Director of BUP, I approached the Chairman of my department with the proposal, and we started the pathology partnership program in October of that year. Since then, I travel to Botswana twice a year for one month at a time, and each time I take 1-2 residents from UPenn along with me.

Q: Can you describe the pathology department in Botswana?

A: To serve a population of just over 2 million people, Botswana has only one academic pathology department, a College of the University of Botswana (UB) School of Medicine, which consists of six pathologists who are all from other countries. There are currently no Botswana pathologists working in the department. There are about six technicians working in the laboratory, all of whom were trained internationally. The laboratory receives around 7,000 surgical specimens yearly, plus cytology, and autopsy. They work with an extremely limited panel of immunostains that are not routinely used but are spared for the rare case that cannot be diagnosed with morphology alone.

The residency program is still very new. There are six residents in the program at the present time, and the program is designed so that they will spend the first two years in Botswana and then they will continue their final years of training in South Africa. I look forward with anticipation to the first Botswana trained pathologists in the country.

Q: What is your role when visiting Botswana?

A: We try to help with everything we can. I sign out cases with the residents during the time I am there, and I teach the residents using these cases every day. The UPenn residents that I bring with me are eager to teach as well, so they deliver didactics regularly also. We all participate in tumor boards and the FNA clinic. We each take on projects that we can partner with them to tackle…things like improving turnaround time, quality improvement, and SOP preparations.  We also work on developing academic programs, grossing templates and manuals (A UPenn pathology PA spent two weeks working in Botswana on this project), synoptic reports, cancer guidelines…anything they need I try to help them with.

Q: How are the UPenn pathology residents given credit in their home program to join you?

A: As of this year, the BUP pathology program is now offered as one of the official electives that residents are allowed to choose from. They are able to use elective time and their travel expenses are paid for by a resident travel grant.

Q: In your role as supervisor of the UPenn residents, what do you see the residents gaining from the experience?

A: The residents that have come with me to Botswana are very compassionate and are eager to contribute in any way they can. Experiencing pathology in Botswana, where people are trying to achieve so much with so little resources, it makes the UPenn residents even more grateful for all of the resources they have available to them. They also have the opportunity to not only learn from the unusual cases that present in Botswana, but also the opportunity to contribute their own unique set of skills – some have focused on teaching autopsy technique, others give enthusiastic  and detailed lectures, and one gave a talk about successful study techniques. [For more information about the resident experience, one can read more about it in the UPenn blog here: https://pathology.med.upenn.edu/department/blogs/residency-matters/penns-pathology-residency-program-reaches-botswana]

Q: How do you see the BUP pathology partnership affecting the trainees in Botswana? What changes have you seen since you started working with them?

A: The residents in Botswana really appreciate the partnership that we have formed.  I have seen the residents develop so much since working with them. At first, they were reserved and now they actually request lectures on topics they feel they could improve on. They are still very humble and respectful, but I have encouraged them to be advocates for themselves. They have really embraced their program and I’m very proud of them. We have a deep appreciation for each other and are proud of what we have achieved together.

We’ve also started hosting Botswana residents at UPenn for a one month rotation so they have the opportunity to supplement their training even further. We fly them to the US, house them, and include them in our residency training program for the month. They have the opportunity to sit in on sign-outs, shadow grossing and autopsy, attend conferences, and be exposed to the advanced testing that we routinely perform in the US.

Q: How do you see the pathology partnership growing in years to come?A: I’m currently helping them find placements in South Africa or possibly partnering with private laboratories to help expose the residents to a greater diversity and volume of cases. As the program continues to grow, we look forward to seeing the fruits of the partnership for many years to come.


-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.

Not Starbucks but the DMV

I merrily wait in line at Starbucks for my iced cappuccino with soy milk, pay $5+ for $0.25 worth of goods poured into my $14.00 souvenir mug, and walk out the door with my head held high, joyous with the privileges of conspicuous consumption. My server was super-cheery and the brief exchange we had was so pleasant—they really love me!  I need that high because I am off to the Department of Motor Vehicles (DMV) for a driving-related task and know–just know–that there will be an incredibly long line at the end of which sits a disgruntled government employee who doesn’t care if I show up or not. Their motivation to help us is non-existent. “Why would anyone ever work here?” I ask, sipping my delicious beverage.

Today, a doctor called someone in the United States (US) and told them the biopsy taken from their leg earlier this week has come back as invasive cancer. A bit distraught and nervous, the patient called up a nationally recognized cancer center, from which they only live a few miles, and on the end of the line is a caring, pleasant voice who informs them they can be seen today! The valet parking is gorgeous, the building is gleaming with glass and steel, and every face they see as they journey from check-in to clinic is smiling, compassionate, and sincere. Their nurse and then doctor are both genuine people with their patient’s best interest in mind, and they carefully and completely explain what has been found, what needs to be done, and how they are going to get through all of this together. As they depart, the receptionist grabs them for a brief moment to return their private insurance card and waves at them as they depart, adding, “We will see you soon!”

Today, someone in Africa went back to the hospital—an 8-hour journey from their home—where their biopsy was performed a month ago, hoping to get the result. After several people searched multiple offices and inquired with several people, the result is found and brought to them, a single piece of paper. Payment is required before they can receive the biopsy results. They have brought money with them, which they gathered from three neighbors, their brother, and by selling some chickens, and pays for the report. They read the report and, at the bottom, notices that it says additional testing is needed. Confused, they ask for help and a pathologist comes to find them. Respectfully, the pathologist explains that additional testing is needed, which is not available in the hospital despite the pathologist’s strong desire to have it, but they can send the biopsy to a lab elsewhere to do the testing which will cost about 3 times what they just paid for the primary report. They happen to have enough and pay the amount requested. The report will be back in about a month. Two months later, they have returned to the hospital for the 4th time and the report is now available. The testing that was done simply confirms that the primary diagnosis is accurate. They go to the oncology clinic on the same campus and sit in the waiting area with 3 dozen other people. They sleep at the clinic overnight outside with about a dozen people. The following afternoon, they are finally seen and the oncologist reviews the report. He notes that if the patient had come to the clinic as soon as they had the biopsy result three months ago, a simple surgery would have cured them of this lesion. But now, because they waited so long, there is only chemotherapy available which is expensive and, the oncologist reports, doesn’t actually work very well for this tumor.

Before you shed a tear for this terrible situation (while I sip my cappuccino and a nurse begins someone’s chemotherapy in a shiny, brightly lit, and expansively windowed infusion unit not far away), we have to ask ourselves what is really going on? First and foremost, this is an allegory to make a few points but the situation is repeated over and over again every day in the US and Africa. However, as a simple, superficial explanation, the person with cancer in the US is receiving their cancer therapy from Starbucks and the person in Africa had to go to the DMV.

Cancer care in the United States is almost entirely in the private sector, dispersed among the 1500 cancer treatment facilities, of which 70 are comprehensive cancer centers.[i] Based on the US population, the expected cancer rate, 100% detection, and 240 working days for a given cancer center, there are on average only 5 new patients per day per cancer center. Is that why one can often get that appointment right away in a major cancer center or is it really a concierge customer service effort? A standard private insurance plan for which I pay, for example, $250 per month and my employer pays $1300 per month is accepted by cancer centers and results in small co-pays for multiple appointments, which can be covered with a Flexible Spending Account (FSA) or Health Savings Account (HSA). On insurance statements after appointments, some of the services received cost thousands of dollars but the patient portion was only, say, a hundred dollars, again, which may be paid with FSA/HSA. It’s so great that we have insurance because the insurance company is bearing the brunt of costs. But are they?

In the United States, 79% of facilities providing health care are private, a mix of non-profit and for-profit.[ii] But 64% of all healthcare in the United States is paid for by the US government through Medicare, Medicaid, the Veterans Administration (VA) system, and Children’s Health Insurance Program (CHIP).[iii],[iv] Since almost every cancer care facility is private (or, stated another way, “not free”), that means that for every one of us at the cancer center getting treatment, for which we and our employer are paying through insurance, there are two people getting the same treatment at the same high-level quality of care for which the government is paying. Those other deductions from our paychecks for Medicare and Medicaid (which everyone pays, regardless of how old, as long as they are employed and regardless of their own health insurance plan) are going towards the 64% coverage. The point is not that the US healthcare system is expensive. The point is that there is a lot of revenue and resource being put into the healthcare system and, thus, there is a high-quality product or experience that is available.

If we look at any low GINI index country and compare their GDP with the US GPD and compare their spending on healthcare as a % of GDP, we don’t even need to do the math to see that there is very little money per person available in the system for any type of healthcare. The challenge in low-resourced settings (by which it is meant low-resourced patients in low-resources locations) is both a lack of funding available to provide healthcare services along with a lack of “stuff” to provide those services. We can invoke the law of supply and demand to try and argue that the people can rise up and demand more healthcare facilities and “someone” will meet that supply. In the US, this results in the Starbucks model. In a low-resourced setting who has the incentive to meet that supply? Where does the government get the money from to create such a system? What private corporation is going to start a healthcare program that provides universal coverage regardless of what you can pay?

The answer is really quite simple. This model of healthcare is insufficient for cancer and isn’t going to work for all patients. Moreover, the Starbucks model is not really applicable, sustainable, nor equitable. When we go to Starbucks for their coffee, to some degree, our choice of Starbucks is because of the a) flavor of the coffee, b) cost of the coffee, c) perception of the coffee, and/or d) convenience of the coffee. We could always choose Dunkin’, Peet’s, Tim Horton’s (maybe let’s not go there for this analogy), or Green Mountain coffee at a different location. There is variation in pricing and convenience. There is variation in the condiments we can use to doctor our coffee. An economy and series of markets exist which allow Starbucks to gather resources from dozens of other companies to provide your coffee. But, ultimately, we are all buying coffee which has caffeine which has a desired effect. We can go to a free AA meeting or to a soup kitchen and get some pretty basic coffee if we don’t have the money to pay. The point is we have choices and we can pay a high price, a low price, or no price and we get coffee.

The Starbucks model does work for a certain sector of the population but not everyone. Since vast majority of cancer care in the US is private, the Starbucks model falls down because we don’t actually have any free options as a society and “low-cost healthcare” is not typically appealing to most Americans with cancer because they have their mortality at stake (no one wants cancer nor does anyone want to die from cancer). In fact, desperation in the face of cancer is what makes the US one of the only places in the developed world where people go bankrupt trying to be treated for cancer. The ultimate inequity is that cancer care is “pay to play” in the US and there essentially aren’t safety nets for any populations that can’t pay (homeless) or are living below a certain income threshold (i.e., the ~10% of Americans without healthcare plus a large percentage with insufficient insurance).[v]

Please remember, these are human beings and they didn’t choose to get cancer (there is no demand for cancer… there is only demand for cancer care!). Since they didn’t have a choice in the disease they have to be burdened with, why is there an expectation that they should pay for the treatment? Moreover, if a patient has a stage I cancer, easily surgically removed and cured vs. a Stage III cancer requiring months of various therapies at a very high cost, how do we ethically explain an increased cost for a worst state of disease? It’s really an inverse quality spectrum and we make patients pay more for getting a lot less. We pay for insurance in case we ever do get cancer (or other major disease). It’s a risk reduction or risk aversion pre-payment. Like we do with our car or our house or our boat. Those last three things we choose to have (and are luxuries). We don’t get to choose to have health. It’s just an inherent part of being human so holding someone accountable for it because they didn’t have the resources to “prepare for the worst” is really the wrong attitude. Our healthcare system isn’t perfect but there are gaps that could be easily filled if resources are allocated efficiently to meet the whole populations needs—that’s the benefit of having a large resource supply into the system. We just have to find the operational efficiency to make the costs work.

However, when we remove the luxuries of insurance, Medicare, and Medicaid and other payments systems from the health sector or, worse, simply assume the government’s role is to provide healthcare 100% free to all citizens in a resource-limited or resource-constrained setting, we suddenly have an untenable situation. The economy and tax-base are not there to create the resources. We find overworked, underpaid, and undersupplied medical staff working in crowded conditions. For single entity care (e.g., HIV, tuberculosis, malaria), vertical programs have made great strides in combatting these diseases even in some of the poorest countries in the world. But cancer is anything but simple with the complexity of cross-discipline collaboration, spectrum of disease, range of treatments, and inherent costs creating huge gaps in the delivery of cancer care. Economic and physical infrastructure for the provision of care is what is needed to meet this challenge. Our current Starbucks model in the US would be extremely difficult to replicate in a low-resourced setting due to the lack of infrastructure. However, when this infrastructure is assessed, planned for, and implemented, cancer care can be delivered in these settings at a significantly lower cost per patient. Adding infrastructure implementation high-quality private facilities and public-private partnerships creates a way forward to pump resources into the system and insure that no patient is left behind. To round out this allegory, AAA locations (a commercial car-servicing company) in various parts of the US allow one to renew your driver’s license with them, rather than the DMV. I did this once, it was VERY fast, friendly, and efficient. This type of public-private partnership worked for me and I believe it will work for cancer if we are willing to try.

References

[i] NCI-designated Cancer Center. https://en.wikipedia.org/wiki/NCI-designated_Cancer_Center  Retrieved May 21, 2019.

[ii]  “Fast Facts on US Hospitals”. Aha.org. Retrieved December 1, 2016.

[iii] Himmelstein DU, Woolhandler S (March 2016). “The Current and Projected Taxpayer Shares of US Health Costs”. American Journal of Public Health. 106 (3): 449–52. doi:10.2105/AJPH.2015.302997. PMC 4880216. PMID 26794173. Government’s share of overall health spending was 64% of national health expenditures in 2013

[iv] ^ Leonard K (January 22, 2016). “Could Universal Health Care Save U.S. Taxpayers Money?”. U.S. News & World Report. Retrieved July 12, 2016.

[v] https://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/

milner-small

-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.

Global Health Narratives Interview Series: Meet Nichole Baker

Nichole Baker, PA, works at Mercy Regional Medical Center in Durango, Colorado as a Pathologists Assistant. Nichole started working as a volunteer with Mbarara University of Science Technology (MUST) in 2017 through the existing partnership with Massachusetts General Hospital Pathology department– she responded to an advertisement looking for pathology volunteers that Dr. Drucilla Roberts had placed in a pathology journal. She decided to visit the laboratory and see in what ways she could help. In total, she has visited three times, and in that time, has accomplished incredible things! What was particularly impressive to me is that Nichole single-handedly solved a very complex problem in the MUST laboratory. In fact, it was this same problem that many people (including myself!), had attempted to solve and could not find the means to do so! Not only did she implement a solution to the problem, but she did it in just two weeks!

Read on to hear from Nichole about her experience making positive changes in her global community. I guarantee you will be inspired by her work, her enthusiasm, and her can-do attitude!

Q: Nichole, I know that you recently returned from Uganda, and you were able to team up with the pathology staff at MUST to make some major changes and implemented a solution to a major problem. Can you tell me about your project?

A: It started with realizing from my two prior visits to the anatomic pathology lab at MUST that the laboratory had a faulty internal tracking system for cases. This had two consequences: The first is that the case turn-around time has been very difficult to track. This even results in occasional cases being lost entirely. The second is that there is no repository of cases to be able to easily conduct research.

What I decided to do was build a free computer program that could accession the cases, track them, generate a pathology report, and give a report of turn-around-time. Not having a computer science background myself, I contacted a friend who connected me with a software engineer in Denver, Colorado. He helped guide me in what would be feasible to accomplish and helped me find a pro-bono programmer based in Belize named Maurice, who had some background in healthcare IT. We started building the system less than a month away from my departure to Uganda.

My goal was to work with the laboratory staff to build a program based around their needs, for which I needed to be there in person to clearly identify – I set out on my third trip in March 2019, this time for two weeks. Maurice and I built a cloud-based tracking program and every day, we would try it out in the laboratory. Day by day, issues would arise, such as the need to add a sign-out function, general localization changes, or adding a timestamp for a particular function. Fortunately for me, Maurice and I had a substantial time difference which really worked to our advantage. I would try the system out during the day and then email Maurice a report that he would just be waking up to. He was able to work in Belize while we were asleep in Uganda, and when I returned to the lab the next day, the program had been updated with the changes. This allowed for rapid progress and the pathology staff grew more and more excited to use the system as it improved. So, day by day, we made the program better and better.

Q: What were some of the unique challenges that you faced when implementing the program?

A: Originally, we had planned to use a laptop with boosted RAM to act as a local server, but the network in the hospital wasn’t functioning as needed. On-site we realized we’d need to shift to an internet server and to do so we had to improve the internet access in the laboratory in order to run the program –this was difficult because IT progress can be slow in Uganda.

Another example that is unique to this setting is the difficulty we had in generating unique patient identifiers in the registration system. In the US, two patient identifiers are required for each sample, and that is easy to obtain because everyone knows their date of birth. In Uganda, things are not as clear and straightforward. We might only have the village they live in, or a phone number. We had to look to see what items were most consistently reported and use those.

Image 1. Sample patient intake page. Patients can be uniquely identified and stored for future visits.
Image 2. Sample case information page. All aspects of the case can be stored and easily retrieved, including IHC performed, and diagnosis codes.

Q: How are you financing the data storage and internet?

A: All fees and costs associated with the program were raised by a small charity organization I started in 2017 called “Path of Logic” which has 501c3 status, making any donations tax deductible. With the funds raised, a shared laboratory laptop was purchased. We are using a cloud-based system that charges based on storage space. Right now, the storage need is low because reports are stored as PDFs, but we may need to expand in the future. The internet connection is also a low expense, as it’s simply a backup modem that’s used when the university internet is not functioning.

Q: It’s now been two months since you rolled out the program in the lab. What results have you seen from that?

A: Once we got going, we have been able to identify where the delays were in processing the cases. After I returned back to the US, Maurice and I continued to work on small issues remotely, such as single vs. double click preferences and those sorts of things.

So far, 421 cases have been registered in the system. The average turnaround time is 12.5 days. We still have a lot of work to go, but this is the first we’ve been able to track this number. Many of the cases that were started in the weeks following my departure were not signed out, but as the team sees the value in the system, the more accurate that average will be, allowing adjustments to be made accordingly. 

We also added in the ability to assign ICD codes to the final diagnosis to allow for a way to categorize the cases to make the diagnosis searchable. Now we are going to be able to generate epidemiological data. This feature is not yet in use by the pathology team, but we are hopeful that as the system becomes more routine, this will be the next step to incorporate.

Image 3. Sample Final Pathology Report, stored as a PDF.

Q: What future impact do you think this program might have?

A: In addition to being able to easily track cases, build pathology reports, generate icd codes for researching cases more easily, we also hope that this will eventually result in increased funding for pathology services in Uganda. Right now, the money allocated from the Ugandan Ministry of Health is going towards HIV, malaria, and cancer treatment – but not for diagnostics. The Department of Education allows some funds for Pathology, but only about 30% of what is needed. Part of the reason why is that until now, there has been no way to quantify the number of cancer cases. With our program, we will be able to generate that data to show real numbers when lobbying for increased funds.


-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.

Global Health Narratives Interview Series: Meet Dr. Drucilla Roberts

Drucilla Roberts, MD is a perinatal pathologist and a faculty member at Massachusetts General Hospital (Boston, Massachusetts). I found out about her work in global pathology when I spent time in a Ugandan laboratory she has been working in for about a decade. We didn’t meet there, but since then, I’ve read everything she has written about global pathology – she has published a wealth of knowledge on the topic. I recently spoke with her on the phone to find that she is incredibly kind, humble, and a true luminary. Read on to understand the needs of global pathology better and learn how you can get involved!

Q: Dr. Roberts, I’m curious to know how you got started in global health.

A: I have always wanted to give back to the continent–both my daughters and my husband are from Africa and I spent time in the early part of my career working in research under the Women and Infants Transmission Study (WITS) that studied the congenital transmission of HIV. I decided that I would find a way to volunteer my time as a pathologist while my family and I were in Ethiopia. I went to a teaching hospital and offered to volunteer my services–I made contacts and soon enough, I was giving lectures. And that’s how it all started! Since that humble beginning I have given three courses in sub Saharan Africa on the anatomic pathology of women and children. It is a privilege to teach in Africa and I hope to continue to do so.

Soon I was contacted by people working in perinatal global health that had heard I was working in Africa and recruited me to help with their projects in Botswana, Kenya, Tanzania, and Uganda. One main objective for me to become involved in research projects in Africa was to improve pathology capacity. For the last ten years, the majority of the work that I have done has revolved around capacity building.

Due to the nature of my work as a perinatal pathologist, many opportunities have arisen to work with populations internationally due to the abundance of research and volunteer roles that exist. I am often contacted to consult on perinatal and autopsy cases, and my subspecialty expertise has presented a perfect opportunity to provide mentorship.

Q: What are some improvements that you have seen in that time?

A: Generally, in medical academic institutions in East Africa, departments are split between the hospital and the university creating a competition for resources and energy between teaching and service work. Often service work suffers due to the discordant provision of resources. When I first started working there, I saw a very long turnaround time for cases due to issues beyond the lab’s control (e.g. supply chain problems and faculty disruptions). I’ve been fortunate to witness these institutions begin to prioritize patient care and create avenues to decreasing turnaround time. It’s been very rewarding for me to help support these efforts. Many exciting things have happened—an example from Mbarrara—when I first arrived, there was one broken microscope that the resident used, and one microscope that the chief pathologist used. There was no immunohistochemistry, and no cameras for photographing slides. Now, there is a multiheaded scope, multiple individual microscopes (that work!), and a microscope camera. There is power backup so equipment still runs when the power goes out (a common occurrence across the continent), an adequately equipped histology lab, and most recently a case tracking system! [More to come about this tracking system in a future interview with an amazing pathology PA–Nichole Baker.] The histology staff have received additional training and mentorship. The pathology residents have increased from one to four and have also received additional training, mentorship, and have access to subspecialist consult services from MGH when needed. The pathologists and residents can send MGH pathology case photos via email or blocks by courier and together we come up with a diagnosis. When on site immunohistochemistry was introduced, it was a huge advance! [Author’s note: I remember the effect this had when I was working in the lab in Mbararra–the clinicians used to ask the pathologist “Is it lymphoma?”, now after IHC they ask “Which type of lymphoma?”]

Q: What are some of the main problems to improving pathology services in Africa right now?

A: One of the biggest problems is that there are not enough pathologists. You can help improve things in individual labs to a point, but for long term there has to be more pathologists working in Africa. For example, the laboratory in Mbarrara went an entire year without a senior staff pathologist with a senior resident essentially running the department. Often the renumeration for the pathologists (residents and faculty) in government hospitals is so low that they take on second jobs in the private sector. One of the things that we in pathology need to focus on is building systems and influencing healthcare management policy across the continent. Recruitment of pathology residents, teaching, training, and continued medical education all need to be prioritized. [Authors note: Dr. Roberts has written extensively about the need for pathology services in Africa – for anyone interested in this topic, there are two key articles she authored that are a must read: “Pathology Functionality in Resource-Poor Settings” and “Improving Diagnostic Pathology Capacity for Global Cancer Care”. Another that she co-authored is crucial for understanding the seriousness and scope of the problem, “Improvement of pathology in sub-Saharan Africa”.]

Q: What can readers of this article do? Is there a way to volunteer and get involved?

A: Yes! Many pathologists volunteer, from fresh graduates to retired pathologists. Some come for just a few weeks, but some stay six months, or even a year. Volunteering to teach, train and do service work goes a long way to filling needs in these institutions. One major thing that pathologists can contribute in addition to service work is mentorship and teaching. It has an enormous impact on the trainees when they can benefit from an experienced pathologist, not only from signing out cases, but also having a role model and mentor. African pathologists often do not get the benefits that we take for granted -the value of attending conferences, continuing medical education, and interacting with our peers.

Research is another avenue in which it is possible to get involved – there are endless opportunities. For example, any tumor that you can imagine has probably not yet been fully characterized in Sub-Saharan Africa. In Mbarrara, the residents do a research project as part of their graduation requirement and many have paired up with volunteer Pathologist mentors. Some have published their work. Currently the MGH is sponsoring two projects with residents in Mbarara – MSI in colorectal tumors and TMPRSS2-ERG in prostate cancers. In addition to resident projects, I have several research projects in Ghana, Kenya, and Tanzania involving either placenta or autopsy studies. For example, we are looking at the effects of HIV infected mothers and placental health and how that relates to the child’s morbidity and mortality outcomes. My other projects are focused on studying the effects of poor air quality on placental health (many women use indoor stoves without proper ventilation) and similarly the placental effects of exposure to high concentration of pesticides (often lacking government regulation). To combat the infrequent performance of medical autopsies, and therefore lack of mortality data, I’m involved in a study that is exploring the use of minimally invasive autopsies and validating that data against a full autopsy. For all of these projects I engage and include local pathologists for training and mentoring in academic pathology.

The volunteers get a lot out of their service too – they see extremely interesting cases that are rarely seen in the US, and they have increased feelings of self-worth because they are really valued. It’s a very rewarding experience for all.

Another way to get involved is to advocate for global health partnerships in your home department, especially if you are in an academic center. Speak with the leadership to discuss getting involved globally, develop a budget, and advance opportunities for outreach. Make a global pathology contact and maintain continuity – offer support and help them advocate for pathology in their hospital, local government, and ministries of health.

Q: Your attention and focus could be used to serve in many areas; why focus on global health?

A: We are so fortunate in the USA that we can get a diagnosis that can guide treatment – when most of the world cannot! We should aim for equipoise, so there is a better chance for people to get the proper treatment with the right diagnosis. It really is not an unattainable task. It’s easy to get caught up in your own challenges here, but there are bigger challenges out there. If you go, you will see. You have to just go!


-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.

Global Health Narratives Interview Series: Meet Dr. Ann Marie Nelson

Ann Marie Nelson, MD has been a long-time hero of mine from afar. If you don’t know who she is and what she has done, then after reading this interview – you will see why! She is brilliant, selfless, kind hearted, and is simply an inspiration!

Dr. Nelson is an anatomic and clinical pathologist with more than 30 years’ experience in global infectious disease pathology and is committed to improving health care by promoting timely and accurate diagnoses, especially in parts of the world where resources are limited. She is currently Infectious Disease Pathology Consultant at the Joint Pathology Center and Professor of Pathology (visiting) at Duke University. The focus of her work has been in HIV/AIDS pathology in the US and in sub-Saharan Africa. Currently she works on educational projects and capacity building in anatomic pathology, and linking anatomic pathology to ongoing clinical and epidemiologic research. She is a founding member of InPaLa (International Pathology and Laboratory Medicine), ASAP (African Strategies for Advancing Pathology) and serves as co-chair of the subcommittee on education for the ASCP Partners in Pathology initiative.

Recently, I had the good fortune of meeting her in person and we sat down to talk about her amazing life and career, and what she continues to do to contribute to the world.

Q: Your entire career has been focused on improving the lives of others, through helping people get the care they need by improving access, education, and opportunity. What inspired you to pursue a career in global health in the first place especially as it relates to working through pathology?

A: I’ve always had a desire to travel even since I was young – I thought I wanted to do something involving travelling – something like photography. When I was older, I worked as a medical technician and the pathologist I worked under advised me to pursue medical school. It was Vietnam war time though, so the odds of going to medical school were 30:1 in California – but an opportunity arose to go to medical school in Guadalajara, Mexico. I did, and this was my first time living outside of the country. While there, I would participate in medical outreach projects orchestrated by the medical school to serve the rural community members. Naturally, since I was a Med Tech, I would run the laboratory point-of-care diagnostics for the outreach. We would screen for parasites for example, and this got me interested in infectious diseases.

I thought at first, I would pursue pediatrics, but pathology drew me in. In 1979, I took a course in ‘Parasites for Medical Technicians’ and met the folks in Tropical Medicine at UCLA.  I met Dr. Marietta Voge, who had written a book in Parasitology, and she became a mentor to me. Also, at the course, there was a pathologist named Dr. Daniel Connor, from the AFIP [Armed Forces Institute of Pathology], who was the editor of the ‘Atlas of Pathology of Tropical and Extraordinary Diseases’.  He gave a lecture on his fascinating work which took place all around the world, but at length in Uganda, and this was the inspiration for me.  I thought “that’s what I want to do!”. Dr. Connor would become like a father figure to me, and to this day my son calls him Grandpa. He has always been an important supporter and mentor throughout my career.

Fast forward, I finished my residency training in pathology and had the opportunity to spend four months at the AFIP working with the Infectious disease pathology department. A few months later, they invited me to take a job with them – which I did.

One of the hospitals in Africa that the AFIP supported was the Karawa hospital in the Ubangi territory in the former Zaire. I worked for a few months in the hospital there. While there, I met an African physician who had just returned from completing his master’s in public health at Tulane University. His name is Sambe Duale – I am now married to him. [She said this point with a smile and we both giggled at how charming this story was!]

Towards the end of my work at Karawa, I was asked to help bring pathology services to Kinshasa in a collaboration with the NIH, CDC, and the Tropical Medicine Institute of Antwerp to work on Project SIDA [the first project on AIDS in Africa]. I began working with Jim [James] Curran, Tom Quinn, and Peter Piot, who were some of the people leading the project. I worked at the Medical School in the Department of Pathology from the fall of 1986, and continued to work there until 1991 when we were evacuated out [by the US government due to the civil unrest that brought violence to the capital].

After that, I continued to work in infectious disease pathology in the US, waiting for my son to graduate from high school before considering working abroad again. In that time, I continued to be heavily involved in IAP [International Academy of Pathology], working to organize meetings, and contributing to building educational systems. I have given world-wide lectures in at least 23 countries, in all continents except for Antarctica. I retired from full time practice in 2015.

After my son graduated from high school, I decided to work in Africa again on a Fulbright in Tanzania and Uganda. Professor Nelson Sewankambo, who was the head of Makerere University College of Health Sciences, invited me to mentor the young pathologists at Makerere University. Robert Lukande was one of them – he is now Chair of the pathology department there. We worked and wrote several papers together, focusing on AIDS and autopsy. I gave lectures to multiple departments, mentored staff, and made connections. I went and built partnerships with everyone I could. You have to just go and talk to people, and ask them “What can we do?”

Q: You worked to conduct a landmark survey of African pathologists to determine the status of pathology resources in Sub-Saharan Africa. What were some of the key findings and how did you collect all this data?

A: The idea for the survey came when I was in Victoria Falls, South Africa for a pathology conference, when I was speaking with Martin Hale. The realization that most of the conference presenters were foreign pathologists, not African pathologists, struck us. We who had been working in Africa knew the answer as to why – there weren’t enough African pathologists. But there wasn’t any data, nobody knew how bad the situation really was. The idea evolved over the next decade, Dan Milner helped to put together an on-line survey that was translated into French and Portuguese.  When we finished the survey in 2014, there were less than 800 pathologists in Sub-Saharan Africa. The question then became, why aren’t there more African pathologists? How do you advocate for this to improve?

The data was largely based on person to person connections. We had to reach out individually, involving people who spoke multiple languages, made phone calls, sent emails…we worked for hundreds and hundreds of hours. You have to really just get out on the street and talk to people.

This was the starting point so that we could measure improvement. We are now working to update the survey and measure the progress that’s been made.

Q: I’ve heard you have the nickname “Mama” in and outside of Africa. How did this come about?

A: In 2006, it was the 100th anniversary of the IAP, and there was a pathologist from Nigeria who I had known, and he unofficially crowned me the “Mother of African Pathologists.” It stuck because people still refer to me as “Mama.” [Dr. Nelson told this story with a warm smile, and it was clear that this designation is an honor for her – I can easily tell that it is her kind soul and motherly nature that make people feel trust in her – “Mama” is absolutely a perfect fit.]


-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.

A Pathologists’ Assistant Abroad

Jennison Hartong, MLS(ASCP)CM, PA(ASCP)CM, is a Pathologists’ Assistant who recently went to Ethiopia to teach grossing techniques. The editors of Lablogatory asked her a few questions about her experiences.

Lablogatory: How’d you get involved with ASCP’s Center for Global Health?

Jennison: Dr. Milner, Chief Medical Officer of ASCP, initially reached out to one of the pathologists at M.D. Anderson to inquire if any Pathologists’ Assistants (PAs) would be interested in attending a workshop in Nigeria. I reached out and expressed my interest in teaching grossing techniques rather than public speaking (not one of my strengths). Dr. Milner then told me about this opportunity in Ethiopia where pathologists were requesting advanced, gross training in lymph node dissections on breast and colon specimens. I immediately jumped at the opportunity to help in this way.

L: What were your motivations for going?

J: Whether with basic health needs or more complex areas like cancer treatments, I’ve always wanted to use my education and experience to help others and impact lives in areas around the world where certain aspects of healthcare may not be accessible. Before becoming a PA, I was a medical technologist and was always interested in working with Doctors Without Borders, however, I did not have the years of experience to apply. I decided to go to PA school and was disappointed to learn that Doctors Without Borders does not utilize PAs. I figured that dream would have to be accomplished another way, which was why I was so eager to work with the ASCP and their global health initiatives.

Another motivation for going on this trip was experiencing the work and organizational skills required for making a trip like this successful. I am currently finishing my second master’s degree in public health with a focus in health policy and management. I was very interested in learning everything I could about planning programs to help developing countries as well as being able to network with like-minded health professionals.

L: What did you hope to accomplish while you were there?

J: My main goal of this trip was to help advance Ethiopian residents and pathologists in certain grossing techniques. More specifically, I aimed to assist with lymph node dissections and, as it turned out, how to locate and sample the radial margin in colon cancer cases.  I also wanted to experience a different culture than my own, step out of my comfort zone and challenge myself as a PA by teaching others. At the end of this experience, I can say that this trip was definitely a life changing experience and one I am extremely grateful for.

Image 1. Jennison (black scrubs) training residents from St. Paul Hospital to locate radial margins on colorectal cancer cases.

L: What did you learn about lab medicine in Ethiopia?

J: During my week in Addis Ababa, I quickly realized that it was up to me to make this trip as successful as possible. Never before in my professional career were all the decisions up to me, and at first, it was slightly uncomfortable. I was worried I would come across as too bossy or even condescending. However, after meeting Eshetu Lemma, the ASCP local representative, along with the other participants and experiencing their kindness and eagerness to learn, I was newly determined to make this trip an absolutely positive experience for everyone. I made some changes to the training sessions and after the first day, the rest of the week ran smoothly. I learned a lot about how lab medicine is practiced in Ethiopia. I learned that, in the case of a power outage, you carefully set your blade down and wait it out. I learned that resources like aprons and sleeves are not thrown away unless completely used up. I learned that due to cassette shortages, tissue submission is done quite thoughtfully- more so than in the United States. I learned that the overwhelming majority of cancer cases are presented at stage 4 due to issues surrounding resources, fear, myths, and lack of cancer education. But most importantly, I learned that the labs in Addis Ababa, Ethiopia, are doing an amazing job with the resources they are given and are eager for opportunities to positively impact patient care.

L: Is what you learned there applicable to your work in the States?

J: I’ll take what I learned there and incorporate it into my work here in the States. I’ve gained confidence in my ability as a health professional and reignited my passion to help others.

To put it simply, this trip has been life changing. It has allowed me to experience and accomplish a lifelong dream for which I am forever grateful. I’m hopeful that my future holds more opportunities to serve other communities and help strengthen cancer programs in developing countries.

Image 2. View from St. Paul Hospital.

-Jennison Hartong, MLS(ASCP)CM, PA(ASCP)CM is a board certified Pathologists’ Assistant, specializing in surgical and gross pathology working mainly in oncology cases. Before attending graduate school, she worked as a Medical Laboratory Scientist (MLS) at Lurie Children’s Hospital of Chicago, Illinois. Upon graduating, Jennison started working at Memorial Sloan Kettering Cancer Center. In 2018, she relocated to Houston and currently works at M. D. Anderson Cancer Center in Houston, Texas. In May of 2019, Jennison will graduate with a second Master’s in public health with a focus in health policy and management from New York Medical College. She plans to use her extensive lab experience and newfound knowledge of public health to help bring basic healthcare to communities that would otherwise not have access to these necessities.