Global Health Narratives – An Interview Series Summary

2019 marked a very special year for me as I had the incredible opportunity to interview some of the most remarkable laboratory medicine specialists in the field of Pathology about their involvement in global health. Although their roles ranged from everything between medical technician, to PA, to medical student, to practicing pathologist, to the CEO of a major pathology organization, they all had one thing in common – they actively take the time to better their global community and contribute to improving pathology services in resource limited settings.

Now that the year is winding to a close, I’d like to take the opportunity to highlight all of these wonderful efforts and hopefully inspire you to take similar initiatives where applicable to your abilities and interest. Read on for a summary of each interview.

Dr. Kumarasen Cooper not only volunteers bi-annually in Botswana’s only academic pathology department as a way to give back to his native Africa, he has also worked to create an opportunity for residents at UPenn pathology to be involved too. Because of his efforts, the UPenn residents can accompany him and work together on the departments’ shared initiatives using official institutional elective time. This is a rare opportunity in pathology training, and is a model of how academic institutions can engage their trainees in global health initiatives.

Julie Papango, a medical technologist, has worked with Doctors without Borders/ Médecins Sans Frontières (MSF) to bring laboratory medicine to the world’s most remote places. She was one of MSF’s very few volunteers with laboratory experience and therefore has played a crucial role in projects ranging from addressing the infectious disease outbreaks in a Sudanese refugee camp, to helping the Cambodian Ministry of Health to improve their national tuberculosis detection program.

Dr. Ann Nelson is an expert in infectious disease pathology and has worked in many parts of Africa for more than 30 years. 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 finds ways to be helpful in any new setting by just showing an open and willing attitude. “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?” With this approach, she’s been able to find countless ways to contribute her expertise to the world. She’s also spent innumerable hours in studying and publishing the issues affecting pathology services in Africa. Notably, she worked to conduct a landmark survey of African pathologists to determine the status of pathology resources in Sub-Saharan Africa.

Dr. Blair Holladay and Dr. Dan Milner have worked in global health most of their professional careers and now lead the American Society for Clinical Pathology’s efforts in improving laboratories worldwide. They are working with governments and local agencies to make sustainable changes in the neglected pathology and laboratory medicine landscape in low and middle income countries (LMICs). They are responding to the urgent need to improve pathology services to address the rapid increase in global non-communicable disease (NCD) incidence. As Dr. Holladay points out “Compared to the scale of the HIV crisis, NCDs are the health threat that gone unchecked, will go far beyond in affecting huge proportions of the global population.” In response to addressing this problem, Dr. Milner points out that the lab is the cornerstone to the solution: “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.”

Dr. Constantine Kanakis is a medical student who decided to be an active part of the community of Sint Maarten while living there attending medical school. The community was facing multiple mosquito-borne infectious disease epidemics that includes Zika virus. In response, Dr. Kanakis took a service-learning elective course in medical school that focused on community outreach. He led the way to create an outreach program that has now been incorporated into the nation’s Ministry of Health Collective Prevention Services program. Dr. Kanakis encourages everyone to “Start by looking around at your immediate surroundings and take an assessment of the issues affecting the community. Anyone can do this, whether you are a physician, scientist, or a community member.”

Dr. Adebowale Adeniran, a cytopathologist, frequently works with the USCAP group “Friends of Africa” in which he speaks at the annual meetings, is involved in the group planning activities, and participates in educational initiatives and conferences in Africa. He encourages all academic institutions to engage in global health, stating “Academic institutions in the US can offer ways of enhancing training opportunities for African pathologists and trainees by offering short- or long-term exchange programs. This helps to bridge the gap between practiced based learning in resource limited vs. US institutions.”

Nichole Baker is a pathologist’s assistant that heard of a lab in Uganda that needed outside pathology help due to being severely understaffed. So Nichole decided to go visit the lab and see where she could help. One of the main issues was that the lab lacked an electronic medical record (EMR) system and keeping track of cases and patient reports was a real challenge. With no background in computer science, Nichole resourcefully reached out to her personal network to find someone that could help her build a free EMR and now the laboratory can track specimens, issue electronic reports, and has reduced their turnaround time as a result.

Dr. Drucilla Roberts is one of the world experts in perinatal pathology and has been working in Africa for over ten years with a focus on capacity building. Besides offering her surgical subspecialty expertise, she is also partnering with local pathologists to participate in ground breaking research on topics specific to low resource settings. She’s written widely on the need for pathology services in Africa. She says that one of the biggest problems in improving pathology services in Africa 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.” Dr. Roberts actively engages in solving this problem by helping train African pathology residents and by recruiting other pathologists to do the same.

Dr. Von Samedi, a cytopathologist, has worked with ASCP’s Center for Global Health at their partner sites all around the world. Dr. Samedi started working with ASCP as a resident, using his unique ability to speak French and Creole to assist ASCP in Haiti following the devastating 2010 earthquake. He has since worked on improving laboratory services in a vast array of ways, with everything from mentoring and local laboratorian training to running workshops on HIV related testing services. Volunteering gives Dr. Samedi a sense of purpose and he states that he “also benefits from interacting with my global colleagues and learning from them.”

There are so many more laboratory medicine specialists working in global health that I would have loved to feature on Lablogatory – but there are so many that I cannot capture all of their stories to share here. I hope that you have gained a snapshot of the potential ways that you can get involved, the possibilities are truly endless!

If you’ve been following this series, know that I am extremely grateful for your time and attention to this important matter. This will be my last post with Lablogatory for the time being, as I will be taking a break from writing to welcome my first child into the world! Wish me luck! J

If you want to find out more about volunteering in global pathology efforts, please visit my webpage that I have written in collaboration with Dr. Jerad Gardner: https://pathinfo.fandom.com/wiki/Global_Health_Opportunities_for_Pathologists

Please also take a moment to fill out this survey (https://www.surveymonkey.com/r/K7YK8LW) so that we can learn more about your interest and experience in global health and you can enter to win a global pathology prize pack!

-Dana Razzano, MD is a former Chief Resident in her fourth 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 is passionate about global health and bringing pathology and laboratory medicine services to low and middle income countries. She was a top 5 honoree in ASCP’s Forty Under 40 in 2018 and was named to The Pathologist’s Power List of 2018 and 2019. Follow Dr. Razzano on twitter @Dr_DR_Cells.

Recognizing Disruptive Innovation in Global Health

One of the challenges of providing healthcare to patients of any type is “staying current” or “keeping up with the literature.” This can be especially challenging in the diagnostics laboratory where novel or unique approaches to a given test or test method or disease may show early promise but have no clinical utility, be too expensive, or not actually significantly change work-flow and/or patient value to justify implementation. On the other hand, sometimes a technology or test which is in development or approval can be so anticipated that clinicians and laboratorians are frustrated that it is not yet available.

In global health, there is a different problem that is encountered every day. There are technologies and tests that are approved, have documented clinical utility, and add great value to patients but they are simply not available because of supply chain, cost, administration, or geography. In such situations, the practitioners in these settings face extreme frustration—especially with stock-outs—and can become jaded and non-dependent on laboratory testing as part of care. This latter issue is a major challenge in cancer care where cancer diagnoses are required before treatment can begin; yet, in a large number of countries, access to cancer diagnostics routinely is not available. It is to that end that ASCP along with a whole host of NGO, industry, academic, and government partners are making great efforts to improve cancer care in each part of the continuum.

In this environment, however, disruptive innovations are, in fact, much easier to recognize as forthcoming. In the early 2000’s when I was working and traveling in Malawi, our project had a landline in the hospital to call the landline at the doctor’s house for issues overnight with patients. This required 24-hour nurses to be physically in the ward, tied to the phone and the patients. Landlines were expensive to install, had a very long waiting list to be installed, and, for the most part, the majority of the population in the country had never had a phone line in their dwelling. By the mid-2000’s, our project had one or more cellphones (as did the nurses) and communications through texting were nearly constant (especially since it was less expensive than making a phone call). By 2010, cell phones were ubiquitous in Malawi (and almost everywhere else in Africa) and there was no demand for landlines. Although this is a commonly used example, consider the adoption of cellular telephones and now smartphones in the US compared with Africa. There was push back, denial, avoidance, and even refusal to use them because there was an existing, well established system of landline communication.  If you want to install cable television and internet in your home as late as 2016, you were often required to bundle with a landline. The point is that the adoption pattern was significantly different because there was a pre-existing competitor with the new technology although—clearly—the new technology was superior.

Now consider a woman of 35 years who has a breast mass on mammogram in downtown Boston today. She will likely have an imaging study with immediate ultrasound and fine needle aspiration and/or core biopsy subsequent. A pathological diagnosis will be issued within 3 to 4 business days (or sooner) which includes a histological diagnosis along with hormone receptor status and Her2 staining. She will see a clinician likely within a week for a positive cancer diagnosis and a treatment plan will be decided upon and executed. If we consider a similar woman in downtown Nairobi, Kampala, or Lagos, they may, in fact, have a similar experience because of the recent efforts globally to improve cancer awareness, diagnosis, and treatment. There may be some delays (reports may take several weeks), potential stock-outs, etc. but, in these major cities, the services might exist. They are likely, however, provided in private clinics, will cost a premium, and may or may not have any guarantees about quality.

The reality, however, is that the vast majority of women in the US or Europe who present with breast cancer do so at a very early stage because of active screening programs which include mammography. The vast majority of women in low- and middle-income countries (LMICs) present with later staged disease because of lack of screening. The latter group of women, however, often live in rural conditions and/or poverty conditions such that seeking care for a breast mass (of any size) will require them to spend time and money to travel to one of the major cities and attempt to access services. With this situation, many of these cancers are detected by the health system at a late stage where curative therapy windows have been missed.

Onto these observations let’s now overlay access to a test for a breast mass that can be performed on a fine needle aspiration biopsy and resulted in ~4 hours which will provide a diagnosis of cancer (or benign) along with prognostic features directing treatment. If we consider the woman in Boston, we may see such a test providing an incremental improvement in care because billing systems, litigation fears, compliance requirements, or accreditation standards still include routine histology and immunohistochemistry to be performed on a tissue biopsy. To some degree, the test may be rejected because it is adding a cost over the standard costs without adding value (other than speed) to the results. However, for the woman in the rural village who likely has access to a community health worker, access to such a test could mean that she starts oral therapy the same day she has the health visit without ever having to leave her village. We have now removed the journey to a clinic that can performed a biopsy, the costs associated with that travel, the time lost while traveling and waiting for a result, and removed the risk that this is not breast cancer—which would mean all the time and money were wasted. For this woman, enormous value is created for her with a test that is performed same day with immediate results.

This concept of point-of-care (POC) cancer diagnostics would arguable meet resistance in the US or European system because of competition with existing systems and other issues as mentioned previously. In an LMIC setting, as there may be no competition, such an innovation would sweep the system and become standard of care—almost regardless of cost. This last bit is very important because traditional systems for performing histology and IHC are complex, costly, and require multiple highly trained individuals to get a quality result. If that process costs $75 to $100 US dollars (to the health system) to provide and, for the individual patient, $10s to $100s of dollar for the travel, lodging, and lost wages, the cost of such a test could, in a stable, high-income country (HIC) market, fetch a hefty price. However, if such a test is priced at $25 to $50 USD (half the cost of the current system excluding the travel), the immediate replacement of the old system with this new system for the given indication must and will occur. This uptake is amplified in an LMIC when the POC test moves to the patient in a geographically distributed process. Breast cancer is an obvious target for such an approach because the tumors are easily accessible, the disease is quite common globally, and the primary therapies are very inexpensive. Could such a test have an impact in an LMICs for bone marrow-based, lung, bladder, colon, prostate, liver, kidney, or soft tissue tumors? The answer to that question lies in the availability of therapy, incidence of disease, and access to radiological equipment rather than availability of the actual POC device. That is, once you have a POC test for one cancer, creating a subsequent POC test for another cancer is a surmountable technical hurdle. But will such a test be able to have an impact because of the alignment of the other factors? It is likely that as you are reading this sentence, you have thought of a few yourself but there are certain cancers where you are likely thinking, “not possible”.

For breast cancer, two such POC approaches are coming down the pipeline. The first is the Cepheid GeneXpert Breast STRAT4 assay which measures quantitative RNA (qRNA) for ESR1, PGR, ERBB2, and MKi67. These four assays are surrogates for standard immunohistochemical staining for ER, PR, Her2, and Ki-67, respectively. In a series of published and in press feasibility and validation studies, the qRNA assay is essentially equivalent to IHC. There are nearly a dozen studies of this new testing cartridge using formalin-fixed, paraffin embedded (FFPE) tissue throughout Africa where the test is being compared to standard IHC. However, in at least one site, the test is being performed directly on FNA material. The second test is from the laboratory of Dr. Sara Sukumar at Johns Hopkins which uses a set of DNA methylation markers that can separate benign from malignant disease on FNA using only 10 markers. By combining these two approaches (benign vs. malignant followed by STRAT4 for positive tumors), a diagnosis of malignant breast disease with prognostic factors for treatment could be obtained in less than 4 hours.

Let’s jump forward to the point in time when both of these POCs are available (or, in fact, any POC for cancer is available). How would they change the approach to breast or other cancer in an LMIC? Because both tests require only an FNA of a mass and because tumors of the breast and other organs today are often late staged, community health workers could be trained to evaluate patients with masses, perform the sampling, and run the test in a remote village. Regardless of stage, starting a breast cancer patient on estrogen receptor antagonists can provide palliative relief or pre-surgical treatment. As a population down stages—which occurs as community health workers begin routine screening—the testing can triage benign and malignant disease at a fraction of the cost for both the system and the patient. Based on population epidemiology, nearly exact costs for these services can be predicted for a population and stock outs can be avoided. Corollary note: Only for those cancers for which you HAVE a POC.

How would these tests change the approach to breast cancer in an HIC? There would likely be resistance at many levels but, eventually, the relatively low cost and the increased patient value would allow the tests to replace or displace standard diagnostics. Without complete replacement, there could, at a minimum, be multimodality redundancy which increases quality. However, the tests would find purchase within the system because in some settings their cost and added value would make any other choice impossible.

For both settings, we can now add other market entrants, other tests for other cancers, and a generalize increased in cancer awareness in the community, all of which would increase demand, improve morbidity and mortality, but decrease costs. Such a situation would be highly valued by the patients and, therefore, is the most important eventuality as this disruption ensues. Recognizing forthcoming change is sometimes hard and sometimes easy; however, accepting and embracing forthcoming change in healthcare can lead to best outcomes for our patients—the central mission of ASCP.

Dr. Milner has no financial disclosures regarding this blog post and has received no fiscal or in-kind support from any entity, named or otherwise, that involves this blog post.

References

  1. Wu NC, Wong W, Ho KE, Chu VC, Rizo A, Davenport S, Kelly D, Makar R, Jassem J, Duchnowska R, Biernat W, Radecka B, Fujita T, Klein JL, Stonecypher M, Ohta S, Juhl H, Weidler JM, Bates M, Press MF. Comparison of central laboratory assessments of ER, PR, HER2, and Ki67 by IHC/FISH and the corresponding mRNAs (ESR1, PGR, ERBB2, and MKi67) by RT-qPCR on an automated, broadly deployed diagnostic platform. Breast Cancer Res Treat. 2018 Nov;172(2):327-338.
  2. Wasserman BE, Carvajal-Hausdorf DE, Ho K, Wong W, Wu N, Chu VC, Lai EW, Weidler JM, Bates M, Neumeister V, Rimm DL. High concordance of a closed-system, RT-qPCR breast cancer assay for HER2 mRNA, compared to clinically determined immunohistochemistry, fluorescence in situ hybridization, and quantitative immunofluorescence. Lab Invest. 2017 Dec;97(12):1521-1526.
  3. Downs BM, Mercado-Rodriguez C, Cimino-Mathews A, Chen C, Yuan JP, Van Den Berg E, Cope LM, Schmitt F, Tse GM, Ali SZ, Meir-Levi D, Sood R, Li J, Richardson AL,  Mosunjac MB, Rizzo M, Tulac S, Kocmond KJ, de Guzman T, Lai EW, Rhees B, Bates M, Wolff AC, Gabrielson E, Harvey SC, Umbricht CB, Visvanathan K, Fackler MJ, Sukumar S. DNA Methylation Markers for Breast Cancer Detection in the Developing  World. Clin Cancer Res. 2019 Nov 1;25(21):6357-6367.

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-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 Dr. Von G. Samedi

Von G. Samedi, MD, PhD, is a cytopathologist at the University of Colorado in Denver, CO. I had the pleasure of meeting Dr. Samedi as a result of the thoughtful introduction facilitated by Dr. Melissa Upton, who thought we should talk given our shared interest in global pathology.

I learned that Dr. Samedi is originally from Haiti and completed his MD, PhD, and pathology training in the US. He has always been interested in global health as part of his personal and professional passion and has spent the last decade dedicating his expertise to improving pathology services in low resource settings. It was readily apparent to me that Dr. Samedi’s approach to the world’s healthcare issues is based in the fact that he views these as shared problems – ones that he can and does help solve. This mindset is reflected in the way he lives his life – admirably contributing to society in any way that he possibly can. I was eager to hear of the opportunities he’s found in order to contribute, so that I might learn and share with all of you the ways that we can all get involved. Read on to discover the inspiring story of someone who has persisted in finding ways to give to the world through service!

Q: When did you first get started working in global health through pathology?

A: I started working with ASCP when I was a 4th year pathology resident in 2010 when they called me to assist their project in Haiti, which was in response to the tremendous damage caused from the earthquake. I had signed up as a potential volunteer on their website prior to this and they reached out to me seeing that I had language proficiency in both French and Creole. I spent 21 days working with them and my residency program allowed me to count this time as an outside elective. Their main goal was to work with the Haiti’s national public health laboratory (Laboratoire National de Santé Publique) and its various national and international partners to set up and run a laboratory in this acute disaster situation, and the hands-on experience I gained in doing this was well worth my program elective time.

After this, ASCP requested that I continue to volunteer with them and since then, I have been working on pathology and laboratory medicine improvement projects at their partner sites all over the world.

Q: Can you tell me about your experiences volunteering with ASCP’s global health initiatives?

A: Working with ASCP at their global partner sites has allowed me to volunteer in a variety of ways which is unique to the needs of each situation. Every trip has been different. In Botswana, I helped process and read the cervical biopsy specimens that had accumulated as a result of a government program to address the high incidence of cervical cancer. The biopsy program was successful except that there weren’t enough pathologists to give results from the tissue samples – so the government reached out to ASCP to help fill the gap in care. In Ukraine, I worked with laboratorians and clinicians in which I helped conduct a workshop on HIV related testing services. In the Ivory Coast, I worked as a part of a mentorship program to assist a newly formed pathology organization gain functional independence. In Rwanda, the project was focused on bringing telepathology services into the laboratory. In Kenya, I worked with ASCP to offer support to the local pathology association. I’ve also returned to Haiti since 2010 and now we’ve shifted away from disaster management and focused on local laboratorian training with the goal of achieving sustainability.

Q: Why do you volunteer to improve global pathology services?

A: Historically, pathology and global health are not thought of as connected, yet without pathology, there is no practice of modern medicine. It is the same anywhere in the world as it is in the US, you must have a functioning pathology laboratory in order to effectively deliver health care. Once you understand this, you understand the need that exists in low- and middle-income countries where there is ample opportunity to serve and give back. Doing so gives me a sense of purpose and it is not just a one-way relationship, as I also benefit from interacting with my global colleagues and learning from them. What I have seen my colleagues do with so few resources is impressive and inspiring.

Q: How do you fit volunteering into your schedule?

A: My volunteering experiences have ranged anywhere between 3 to 21 days. I prioritize this work and have been fortunate to work for departments that support it, often allowing me to use professional time and vacation time to work on these projects.

Q: What advice would you give someone new to engaging in global health?

A: The key is to focus on building relationships for the long term. Be patient, flexible, and realize that what you want to accomplish may not happen in the first or even the second visit. Sometimes things just don’t go as planned and you have to keep working and go with the flow. If anyone in laboratory medicine is looking for volunteering opportunities, reach out to ASCP and volunteer to get involved – you can travel to their partner sites, volunteer to read cases through their telepathology program, or serve on ASCP’s global health committees. There’s a way for everyone and anyone working in laboratory medicine to get involved, no matter what your specialty and capacity to serve is.

-Dana Razzano, MD is a former Chief Resident in her fourth 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 is passionate about global health and bringing pathology and laboratory medicine services to low and middle income countries. She was a top 5 honoree in ASCP’s Forty Under 40 in 2018 and was named to The Pathologist’s Power List of 2018 and 2019. Follow Dr. Razzano on twitter @Dr_DR_Cells.

Global Health Narratives Interview Series: Meet Dr. Constantine E. Kanakis.

Constantine E. Kanakis, MSc, LS(ASCP)CM is a board certified Medical Laboratory Scientist and is a newly minted MD. Any pathology program director reading this should pay close attention, since he is currently completing the Pathology Match for July 2020 and you would be lucky to have him in your program. Constantine has done incredible work in the field of pathology already, and was recognized in the prestigious ASCP 40 Under Forty award program in 2017 and he was recognized as a Top Ten medical student with the ASCP Academic Achievement Award in the same year.It was his passion for working to better his community that earned him these, and I can only imagine what else he will do in his career. I came across his work through reading his ASCP Lablogatory blog contributions, to which he has contributed insightful and quality material for years. His work in global health particularly stands out as what he has been able to accomplish in such a short time and while in medical school is really spectacular. If you want to know how to get engaged in your community and make a tremendous impact in the world, read on, you will surely be inspired to do so after reading this!

Q: Can you tell me about your background and what led you into Pathology for your career choice?

A: I received my undergraduate and masters in Chicago studying molecular biology, political science, bioethics, and medical laboratory science. I’ve worked in various laboratory roles for the last ten years, mostly in blood bank and hematology. After some time, I decided to return to pursuing a more advanced career in medicine and go to medical school and was naturally drawn to pathology from having worked extensively in the lab.

Public health was always something I was interested in, but didn’t know how to get involved. This changed when I had an opportunity to take a service-learning elective course in medical school focused on community outreach. We were prompted to choose a project to focus on, and since Zika virus was such a heightened threat to the community of Sint Maarten in 2015-2016, as well as the region at-large, I decided to focus my efforts there. I organized an effort to reach out to the community and help educate them on Zika prevention/infection through speaking at town hall meetings, health drives, and by creating vector control projects in the field. Together with a team, we developed school-based task forces to educate children so they would bring the information home to their parents and siblings. This arm of the project was mirrored after the recycling initiative in the 90’s that was targeted at US school children to bring recycling programs into the home. Recycling started in schools and it was effective in changing the home culture. Our Zika education based program was so successful that the Sint Maarten Ministry of Health adopted it as an official outreach program as part of their Collective Prevention Services. And was even touted as a success by representatives at the 2016 Global Health Security Agenda session in Miami.

I also married this community outreach project to the Zika virus research that I was involved in with my medical school. We used commercially available antibody kits and I both wrote the SOPs and ran testing alongside other team members in the laboratory.

With my background in public health, research, and working in the laboratory as a technologist, Pathology is a career that will allow me to engage in all of these things. Pathology is a perfect career for focusing on global health due to its ability to intervene on behalf of the population in a data driven way. Rather than helping one person at a time, I can help entire demographics through epidemiologic based interventions. 

Constantine Kanakis (center right, first row) and the team in the fight against mosquito borne diseases.

Q: Why do you think medical students should get involved in global or public health?

A: Getting involved in solving the problems in your community enriches your education in a way that solely reading about issues cannot. When you are actively engaged in the solution, the problem becomes more than just something you are reading and learning about in the text. Not only does this enhance your education and understanding, but it also gives you the benefit of being part of your community in a meaningful way. There are so many preventable issues to focus on – in the US and abroad.

Q: How can someone get started in serving their community?

A: Start by looking around at your immediate surroundings and take an assessment of the issues affecting the community. Anyone can do this, whether you are a physician, scientist, or a community member. The first step is to collect data to define the issue and narrow your target. Next is to plan an intervention; start small and organize or join a group working on the issue and just get involved. You will be surprised at how quickly things can develop. And don’t be afraid of failure—taking setbacks are critical in a continuing process of reevaluating and readjusting your project!

Q: Now that you have finished with medical school, what is next for you and where do you see for your future?

A: In between residency program interviews this month, I will be flying to Sint Maarten to deliver a TEDx talk about the rapid evolution of medicine and how we can prepare for the changing landscape. [You can view the talk here: https://vimeo.com/365844585 (skip ahead to 5:00 to jump straight to Constantine’s presentation)].

Next I’m planning to present an abstract in the next Caribbean Center for Disaster Medicine conference. With hurricanes threatening the Caribbean islands and in particular Sint Maarten which was hit in 2016, there’s been a lot of energy centered around disaster preparedness. My focus is on making sure the planning efforts including blood bank and other lab services are ready in the case of a major disaster.

In the future, as a pathology resident and beyond, I want to continue to work in both my local US setting and abroad. In the US, there are many public health issues that need to be focused on. For example, there’s been a record resurgence in preventable infectious diseases due to the anti-vaccination movement. There are also people suffering from Hepatitis C related cirrhosis who aren’t aware that Hepatitis C is curable. There are many educational campaigns for issues like this that can change lives, and pathologists are the ones that can fulfill that role as health educators.

My wife is a RN, has a master’s of nursing science (MSN), is a certified nurse leader (CNL), and is finishing her Doctorate of nursing practice (DNP) in advanced public health with a focus on vulnerable populations and disaster planning, has been an excellent partner and resource for community outreach all along and we hope to focus on these issues throughout our careers. It’s exciting to think of all the possible ways we can help make our community better!

Constantine Kanakis delivering a recent TEDx talk.

-Dana Razzano, MD is a former Chief Resident in her fourth 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 is passionate about global health and bringing pathology and laboratory medicine services to low and middle income countries. She was a top 5 honoree in ASCP’s Forty Under 40 in 2018 and was named to The Pathologist’s Power List of 2018 and 2019. Follow Dr. Razzano on twitter @Dr_DR_Cells.

Pathology in Ethiopia: Here is the Data… What Do We Do?

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.

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-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 Julie SG. Papango

Julie SG. Papango, MLS(ASCPi)CM is a medical technologist currently working in Albany Medical Center in Albany, NY. She was born and raised in the Philippines, where she trained as a medical technologist. I had the pleasure of talking with Julie recently as I had read about her extensive work in global health through Doctors Without Borders which was highlighted by ASCP when they designated her as a Top 5 honoree of the prestigious 40 under Forty recognition program in 2019.

I was impressed by the extent of her work before talking with her, but after digging in and hearing the details, I was entirely blown away and fell nearly speechless. Julie is truly the bravest person I have ever met. She has spent years of her life serving in some of the world’s most difficult places and has done so seeking no reward. One can only imagine the kind of daily challenges that would arise working in these conditions. Not only that, but Julie has done all of this while transitioning as a person of transgender experience. Knowing that in some countries this has been met by death, Julie chose to serve those in desperate need anyway. Take a moment to really digest that. Her bravery and dedication to humanity goes beyond anything most of us will ever hope to parallel.

I hope you enjoy reading about her contributions to the world and are left inspired to make your own contributions too!

Q: What made you interested in global health and how did you have the idea to work with Doctors Without Borders?

A: After graduating as a medical technologist in 2003, I had a very vague idea about working in global health inspired by what I had seen portrayed in movies. My ideas were almost romantic as I pictured myself working with people in need. I heard of Doctors Without Borders around 2005 and thought this might be a good avenue to work through. The idea became more solidified in mid-2007 when I heard a former colleague of mine speak about his experiences working with them around the world. I was so inspired by his impact and realized that I could make my dream a reality. I immediately applied and went through their lengthy interview process and was accepted in December 2007. Although I was matched to a project early the next year, I was not able to go as I stayed back to take care of my mother who had become very ill at the same time. Once she became stable, I re-volunteered and went through the process again and finally started out in my first project in 2009.

Q: Can you tell me about your time working with Doctors Without Borders?

A: The first project I was matched to was in the Kampong Cham province in Cambodia. I spent one year and two months there to help the Ministry of Health improve their tuberculosis detection program and set up a lab for diagnosis with bacterial liquid culture. This was challenging because there were no public laboratories performing these tests at the time and we started from scratch. I worked to train the local workforce to function as medical technologists and to take over and expand the project. At the time, it was challenging for Doctors Without Borders to fulfill their mission to improve the laboratory services because there are not a lot of medical laboratory technicians working as volunteers. Many laboratory members just don’t realize there is a real need and opportunity to work in this capacity. I was originally supposed to stay only for six months but extended my stay because they weren’t able to find a replacement for me for another eight months.

After this, I returned home for a short time when I was then contacted to work in a town called Arua in Uganda in 2010. Admittedly, I was scared to go to Uganda because there had been open hostility towards the LGBT community there, and an activist of homosexual orientation had been killed in his own home there recently. I am a person of transgender experience so this was frightening for me. But I decided to push forward because there was an increasing incidence of HIV/AIDS and the laboratories that were in existence needed serious quality improvement to properly perform testing. For six months, I served as a laboratory supervisor and worked to bring the testing standards up to par.

My next time working with Doctors Without Borders was in October of 2012 when I spent six months working in an extremely remote setting of Papua New Guinea. I spent my time there on the island of Bougainville which hosted only 6 non-native persons in the entire town of Buin where I worked. Transportation across the island was a full twelve-hour trip, which meant crossing numerous rivers and very rough roads. The project focused on maternal and child health, and I was there to help improve the laboratory which was manned by just one technician, who had received the entirety of his training on-the-job without a formal degree. When I arrived, the lab looked like nothing more than a stock room. I spent two weeks alone just cleaning! Eventually, we were able to set up a basic functioning laboratory offering rapid testing for HIV, HCV, syphilis, as well as microscopy, blood counts, and basic transfusion services.

After this, in August of 2013, I was recruited to work in South Sudan for an emergency project. Sudan had split into two countries in 2011 and there was conflict in the Nuba mountain border area over oil land ownership. This created a refugee crisis which resulted in 60,000 refugees rapidly fleeing the area and were forced to live in camps. There were major issues with child mortality due to malnutrition, cholera, meningitis, and malaria. Doctors Without Borders was in the camp and set up a tent that served as part hospital, part living quarters for us working there. The living quarter capacity was meant for just 6 people as there was already a team there, but out of necessity was shared among 30. This situation was challenging, as food and water were very limited – for a camp population of this size, there were only three water points in the entire makeshift facility. Working in this setting is known among the volunteers as the “true litmus test” due to its extreme challenges. My role there was to set up the tent in which we would run the laboratory, help train local staff, and to set up the point of care and basic blood testing for transfusion services. With a break in between, I spent a total of almost two months in the camp working on this project before returning home for a month or two. After this, I returned to work again in South Sudan because there was a need to verify the accuracy and quality of the testing that was being performed in the refugee camp. There were many issues with transporting the specimens to referral labs, and we wanted to analyze if these samples were being handled appropriately to yield reliable results. This is one of the frustrating things about working in these situations, nothing is done perfectly, and you have to find a way to make it work. I was scheduled to work there for four months but after month three, all non-essential Doctors Without Borders staff had to be evacuated out due to a civil war that broke out and made the region too dangerous.

I was then supposed to go to Ethiopia to spend a month working on a primary care health project. I was delayed because of a visa issue pertaining to the fact that I was transgender. The difference between how I appeared on the outside as female and what my passport showed as male was an issue. Eventually, after returning to the embassy every day for a week, I was denied a visa. I was given an invalid reason and I knew that this was just a power-play and was really due to the fact that I was of transgender experience. Eventually, after more paperwork and delay, I made it through the process and worked in Ethiopia for a month to perform a quality analysis on the basic laboratory testing and ensure an adequate chain of supplies that had been initiated by Doctors Without Borders before passing it on to the Ministry of Health. Being there for only a month was frustrating because there were still more gaps to fill, and there was only so much I could do. This is just the reality of the situation and you have to accept that it is not always perfect.

After settling in back home in the Philippines for a short time, I felt that I wanted to return to Cambodia to continue the work that I had started there. So, in March of 2013, I went back to work in the laboratory that I had helped start. This time the laboratory had expanded to other sites where more advanced tuberculosis testing was being done and the government was increasing the support for the labs. I worked in quality improvement and helped to create a network for transporting specimens to larger referral laboratories. At the end of my stay in November 2015, we were able to finish the project, donate all of the equipment that had been provided by Doctors Without Borders, and hand the reigns over to the Ministry of Health. I decided at this time that I would look to stay in the country and worked as a private citizen in a developmental aid project, which was aimed to improve the country’s diagnostic microbiology services. There I found the organization called Diagnostic Microbiology Development Program. This was an interesting shift from the humanitarian aid work that I had done with Doctors Without Borders since it focused more on sustainability rather than immediate intervention in a crisis.

Q: What brought you to the US?

A: Over the years of volunteering abroad, I have had countless challenges when I am crossing a border and the fact that my external appearance of a woman does not match the gender marker that is designated on my passport. I decided that it had come time to go through the process of rectifying this situation and so I applied for a visa to work in the US with the eventual goal to change my gender marker on my passport. I moved to the US in 2016 and have been working as medical technologist in Albany since.

Q: I know that working in global health can sometimes be equally as challenging as it is rewarding, and you have certainly faced your fair share of challenges. What would you say to those wondering if they have what it takes to contribute?

A: I encourage people to go out of their comfort zones and look at what you can give, and just give it. It can be scary, but we have a responsibility to the global world to share what we are privileged to have. For me, being a person of transgender experience, labels are assigned to me that this is not the “right type” of work for me, that I might be more suited for the fashion and beauty industry for instance. This is like any stereotype that puts people in boxes based off race, gender, religion, or sexual orientation. This box should not be the reality, and at the end of the day, we must realize that we are not boxes and we are all just human beyond labels. I encourage everyone to break the glass ceiling, get out of their comfort zones and look for ways to share what you have with the world.

-Dana Razzano, MD is a former Chief Resident in her fourth 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 is passionate about global health and bringing pathology and laboratory medicine services to low and middle income countries. She was a top 5 honoree in ASCP’s Forty Under 40 in 2018 and was named to The Pathologist’s Power List of 2018 and 2019. Follow Dr. Razzano on twitter @Dr_DR_Cells.

The NEXT Storm in Puerto Rico

In 2017, Puerto Rico had a very challenging year with both Hurricane Irma and Maria bombarding its shores. Just last month, Puerto Rico was spared a hit from Dorian. However, a major storm (of sorts) will be hitting Puerto Rico on September 30, 2019, regardless of what the weather says. On that day, the Section 2005 of the Affordable Care Act expires which provided PR with $5.4 Billion in Medicaid funding (from July 1, 2011 to September 30, 2019). If it were any other state of the United States, the expiration of this relief funding would not be such a challenge because of the current matching programs afforded to those states by the federal government. However, PR is unique in that it is only provided a block grant (i.e., a set amount of money) and that block grant is significantly lower than what other states get overall. Based on current estimations of costs in PR, the block grant funding will be exhausted by March 2020. At that point (well after hurricane season), PR will have to cover all costs for Medicaid for its citizens 100%. Why is that a problem?

In order to understand this, we have to look at PR’s healthcare system (removing the stress, strain, and destruction on the system delivered by Irma and Maria) in its base state. The public health care system in PR was privatized and now includes forced managed care participation. Of the 3 million citizens living in PR (which is on the decline), more than half are covered by Medicaid. The Medicaid eligibility limits in PR are much lower than other states ($6,600 in PR vs. $17,236) and with other states ability to expand coverage to 138% of the poverty line, PR can not go above 40% of the poverty line. This leaves a significant portion of the population ineligible. The cost of living in PR is actually higher than many mainland states while the average income is much lower. The per enrollee Medicaid benefit in PR is $2,144 compared with the lowest mainland state ($3,342) and the median state ($6,763) for projected 2020 budgets. If PR were afforded the same system of delegating funds from Medicaid to its enrolled citizens (i.e., matching based on income), the Medicaid matching rate would be 83%; however, because of the block grant the effective matching rate is between 15 and 20% for PR. Reimbursements for equivalent services in the mainland US are significant less in PR (for example, as low as $10 to a physician for an office visit). Unlike other mainland states, a US federal act (PROMESA) created an oversight board (FOMB) to manage the island’s finances and one of the main tools of the FOMB to control costs in PR has been to deeply cut Medicaid spending. 

Given that situation, it should not be surprising that prior to the 2017 crisis, healthcare professionals were leaving PR in large numbers and that trend increased after 2018. In an effort to stem this exodus, Act 14-2017 was enacted (February of 2017) which reduced certain physicians’ income tax in PR to 4% (down from 33%). This act went into effect in April of 2017 but data show physicians continue to leave, evidence that physicians value ability to care for their patients (i.e., resources to provide quality care) over their own income. Jennifer Gonzalez-Colon, the resident commissioner for PR (the only representative to Congress with limited voting rights and a marginalized role) introduced the Puerto Rico Integrity in Medicare Advantage Act in September of 2018 to stabilized Medicaid payments in PR following Maria (as an amendment to XVIII of the Social Security Act), which would have improved payments including to physician providers. The Act died in when the 115th Congress concluded in 2019 having never been enacted.

PR’s Medicaid program is, thus, in a crisis situation which will either need to be resolved before March 2020 or will result in potentially increased challenges (i.e., assuming additional healthcare professionals leave the island). With an already aging healthcare professional population (i.e., young professionals leave) and an aging population of patients, an enormous storm that has been brewing for years will be unleashed in the spring. The solution is for those controlling the healthcare finances of the island to create equitable systems of payment to support the US citizens of PR.

References

  1. Urban Institute Report – PR HC Infrastructure
  2. Revitalize Puerto Rico
  3. Judith Solomon on PR’s Medicaid Program
  4. Rick Shinto on Ending PR’s Health Care Crisis
  5. Caribbean Business June 2018 PR challenges
  6. Puerto Rico – Medicaid.gov
  7. Finding Health Insurance in PR
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-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.