Tired Traveler Travel Tips

When I was considering the Chief Medical Officer role at ASCP, there was significant travel on the table. Prior to ASCP, I was already a seasoned traveler, having been to every continent except Antarctica. I had a few travel tricks up my sleeve. However, the nearly 2 weeks per month that I find myself out of the ASCP offices have evolved my travel skills from seasoned to ninja. For your enjoyment, here are some of my best tips.

Join and explore a loyalty program. We all have frequent flyer miles with one or more airlines; however, consistent use of a single airline or group of airlines (Star Alliance, Sky Team, etc) will rapidly add up and provides perks and benefits you may have to research a bit. Most importantly, don’t get discouraged by one bad flight and switch! They are called loyalty programs for a reason. In addition to upgrades, lounge access, early boarding, and free premium snacks, perks like premium economy for the same price as economy make a huge difference as planes seats get tighter.

Book economy, fly business. Economy non-refundable tickets are the least expensive typically, especially when booked on a Tuesday. If you’re booking a common business commuter flight (Chicago to NYC, Boston to DC), make sure you’re staying over a Saturday and watch prices to book effectively over time. Typically, business customers book last minute (paying highest prices) so prices are lower when booked very early; however, commuter flights are often packed with business travelers so booking early may not always be cheapest. When you get to the airport, ask if upgrades to business are available when you check in but be patient! Booking the upgrade at the gate desk is often significantly cheaper. Set a limit for yourself. “I won’t upgrade unless the cost is less than $XXX.” This will keep your personal budgeting in check and not let your exhaustion or irritation with your last economy leg lead to something rash. 

Plan ahead. If you’re planning a vacation, especially a long flight (not a typical business flight), research prices way ahead of time and watch them for some time. There are websites into which you can load your favorite flights and received pricing alerts. Even if you’re a business traveler (for example, attending conferences), you’ll likely know the dates early and be able to do the same. The earliest flights of the day are often the cheapest but remember the opportunity cost to you of having to get up extra early (especially if hauling little ones!).

Carry on. Don’t check a bag. There are exceptions but, for the most part, don’t check a bag. Consider the laundry services at your hotel or access to laundry machines. When you are packing, lay everything out and ask yourself, “Am I going to die if this is not with me?” If the answer is “no,” move to the “maybe” pile. If you’re bringing gifts, carry them in a reusable sack as your personal item. Speaking of reusable sacks, organizing your back pack with a few of these means you can pull out “computer” or “clothes” or “other” quickly and replace them easily (it’s like file folders). If you are going on a big trip and just can’t do without a checked bag, try to fly direct and/or make sure you have a full one hour (domestic) or two hour (international) layover between flights— both will increase the likelihood of your luggage arriving. If you are a business traveler, INVEST in a very good carryon bag. Because carryon luggage at the low end of the scale is assumed to never be checked, one bad flight can destroy it. 

Toiletries. I know you have a strict beauty regiment with 12 products you can’t live without but consider lightening your load when possible. All hotels provide basic toiletries and there are stores everywhere (clearly, if you’re vacationing or working very remotely, there may be limitations, but remember context and consider the essentials). Most large format toiletries have to be checked and that’s adding challenges you don’t need. Some of my pro-travel colleagues who MUST have their complete hygiene system check bags but always use the suggestions I mention above about checked bag security. A clever, lovely friend of mine once said (when I asked why she was wearing only mascara in the middle of Africa), “If I just have this one thing I do every morning, I feel normal.” Sound advice.

Security. There is general anxiety about going through security but there doesn’t have to be. First, it’s for your safety and, unless you are a criminal or a terrorist, the security people are there for your protection and they are quite nice. Second, if you get TSA pre-check, know the drill. Nothing infuriates fellow travelers like a confused passenger in the TSA pre-check line disrobing and regurgitating the contents of their bag into a bin. If you’re not TSA pre-check, be ready to remove coats, shoes, laptop, belt, all pocket contents, and sunglasses. You can do all of that during your 10 + minute waiting in line. You should not do it when you get to the table—that’s why the line is so long. Third, when you travel internationally, the rules are always different but the security agents are still just human beings doing their job. Politeness and paying attention will make all the difference. Fourth, some of us are more likely to experience friction with security because of the way we look, our clothes, or even our perceived attitude. It’s not right, it’s not fair, and it’s annoying… but we know this and can prepare for it. Displaying courtesy and politeness at all points in the airport will get you through security quickly. If you happen to have a difficult experience, I encourage you to send a strongly worded, formal letter later (you can write it on your smartphone on the plane… just don’t send it until you are back home). There is no point in ruining your trip over someone else’s potential unfounded fear or ignorance. Lastly, I understand the world is liberated (being liberated) and we all think we have the freedom to do as we wish l; however, showing up to a security check point drunk or stoned or reeking of pot will get you heavily screened and searched. The rest of us enjoy the show but not the delays.

Boarding. The bin above your seat is not assigned to you. The space under the seat in front of you is. The bin above your seat is determined to be full by the crew, not by you. Other peoples’ bags are going to touch yours. The crew can and will place your bag correctly in the overhead bin. When you find your seat, quickly store your bags and sit quietly with your seatbelt unfastened and your hands in your lap. Don’t pull out your laptop. Don’t have 5 things in your hands and in the seat pocket. Your personal item under the seat in front of you should contain anything you’ll need during the flight. Organize yourself at home before you depart—not while the rest of the plane is trying to board. People will like you. The crew will like you. 

Seat selection. If you know you get up frequently to use the restroom normally, book an aisle seat. If you pass out on airplanes at takeoff and wake up at landing, book a window seat. If you are in a middle seat (someone has to be), it’s frustrating but it does not entitle you to more space than the people on either side of you. Booking early and checking in early is the best way to score a window or an aisle. We are all trapped on the same plane and courtesy wins the day. If you are rude or discourteous, the crew will notice and you will have a miserable flight.

Jet lag. It happens. It’s terrible. It can take you out for a day or more of your trip. There are apps and websites that explain how to avoid, reduce, or beat jet lag. But each person’s physiology is different and these remedies may fail. Common chemicals used include melatonin and caffeine. You’ll have to find your own way of coping but, for fun, here is mine. First, sleep when it’s dark and stay awake when it’s light. Avoid napping during the day. Second, if you are on an overnight flight to an earlier time zone (US to Europe), do your best to sleep on the plane. I don’t recommend drugging yourself but earplugs and an eye mask can do the trick. Lastly, the first night you are in your final destination and about 1.5 hours before bed, run a hot bath and drink a very cold beverage (beer is my preferred coolant but anything cold, with calories, and no caffeine will work). Turn the AC down to a low setting so the room is chilly (even if it’s winter).The hot bath relaxes your muscles, shifts your blood flow, and tells your brain to cool down your body. The cold liquid helps do this. Why? We are naturally diurnal and our bodies are warmer when we are awake than when we are asleep (and the switch is related to light cycles and perceived time of day). After the bath, don bathrobe or towel and sit in the cool room for 15 to 30 minutes so your body dries with water on it (more cooling effect!). Now that you are chilled, crawl in bed and sleep. As I said, this works for me and it may not work for you. And, of course, it requires a bathtub.

Consumption. Drink plenty of water. Deep vein thromboses are no laughing matter. Being well hydrated and getting up to use the restroom a few times is actually good for you. Don’t drink tea or coffee on an airplane (google it to see why). If you’re on an international flight and the alcohol is free, pretend you’re at your grandmother’s house. A glass of wine or a cocktail are fine but becoming inebriated will do you no favors. It can also cause you to sleep when you shouldn’t and it dehydrates you. Make your own choices about eating food on the airplane. It’s often hit or miss so my decisions are made in real-time.

Here’s some self-explanatory one-liners to wrap up:

  1. Wear comfortable, slip on shoes
  2. Loose fitting pants (with belt)
  3. Leave you giant pillow at home
  4. Headphones! No exceptions
  5. Ziplock bags to organize electronics
  6. Always have a pen
  7. Seats are for people, not bags
  8. Understand time zones in advance
  9. Learn “Hello” and “Thank you” in the local language
  10. Carry at least two universal travel adapters
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 Dr. Blair Holladay

In my short career in pathology, I’ve had the opportunity to meet some amazing laboratory medicine specialists working in global health. I’ve been curious to know their personal stories of how they got involved in global pathology and their suggestions of how we can also contribute.

In my first article for Lablogatory, I detailed my recent experience participating in ASCP’s Trainee Global Health Fellowship in Addis Ababa, Ethiopia. It was incredibly exciting, and I was thrilled to be involved with what ASCP is accomplishing there. I thought it would be fascinating to hear from the CEO and the driving force behind the global health initiatives at ASCP – Dr. Blair Holladay. He was kind enough to reserve some time for me to interview him. I felt inspired after talking with him, and even more excited about the future of pathology in leading the way to success in global health! In the following, I share our conversation. I hope it will also leave you inspired to go out and change the world!

Dr. Holladay during a recent trip to Tanzania with ASCP.

Q: Dr. Holladay, how did you get started working in global health through laboratory medicine?

A: Beginning in the late-1980’s while working as a professor at the Medial University of South Carolina in Charleston, I directed a clinical trials cancer research center focused on developing better diagnostic test methods with the goal of improving access. My interest was focused on creating innovative pathways to diagnostics for people who don’t currently have access to testing, including those in developing countries. We sought alternative diagnostic methods, such as molecular biomarkers, that could act as screening tools and as targets for drug therapies.

Through the course of this work, what became interesting to me is that I found that a lot of low- and middle-income countries didn’t have an essential toolkit for population screening and were seeking to mirror the US in their broad test menus. This goal is realistically impossible, and unnecessary. This led me to the next step in my global health career, which was to work with companies around the world to develop alternative screening techniques and diagnostics that are more feasible to be used in low- and middle-income countries. To try to apply the same tests used in the US around the world is not possible and not helpful. You cannot retrofit a square test into a round hole — meaning that every country, every culture, every population, will have unique epidemiological issues and different access to healthcare. Considering this, I worked to develop individual diagnostic tool kits for each country – for each unique population, each unique financial setting, in order to bring the best diagnostics to populations without access. It is important to bear in mind that any test is better than no test. 

Q: How did you start working with ASCP and expanding the global health initiatives?

A: I started working as the Vice President for Scientific Activities for ASCP in 2005, but in the early 2000’s, ASCP’s global outreach was limited to only as distant as Canada. We worked to expand our outreach around the globe, with a strategy to look at where the need was the greatest, and next to focus on individual opportunities where the yield would be the greatest. This was, in our opinion, in Sub-Saharan Africa. We first started working with a [U.S. President’s Emergency Plan for AIDS Relief] PEPFAR grant to provide access to testing for HIV. With infectious disease, namely HIV, being the most problematic issue at the time, we focused our work to build capacity and infrastructure around this epidemic – our goal was to train the trainer, build a self-sustaining diagnostic system, and move on to the next country and do it all again. This was very successful until we ran into the next big problem – cancer. Suddenly people were living longer and developing cancer and other non-communicable diseases [NCDs]. One memory stands out – It was around 2012-13, while serving as ASCP’s CEO and working  with the Clinton Global Initiative,  I remember visiting Botswana where I walked into the main hospital ward to find beds upon beds full of women, laying there dying of cancer, while their young children sat on the floor around them.  The waiting areas were also full of children and their grandmothers, while their mothers were either dying or had already died of cervical cancer. We, at ASCP, realized then that we needed to do something about this growing epidemic, and we realized the need to focus on creating strategies for the prevention and intervention of NCDs.

As we set forth, one problem that we discovered was that the World Health Organization had undervalued malignancy as a global health threat – largely because the cancers were going undiagnosed and the cancer registries to generate data were anemic to non-existent. Realizing the urgency of the situation, we began working with the US federal government and other groups to enhance diagnostic access.

In 2014, I met with the Obama administration to urge them to place value on developing outreach to address cancer and other non-communicable diseases in low- and middle-income countries, particularly in Sub-Saharan Africa. Emphasizing the urgency that because NCDs are the inevitably worsening epidemic in Africa, with a population approaching 1 billion, 800 million people or more who had little to no access to diagnostics and were clearly at risk for developing cancer. This will serve to threaten their rapidly growing economies and the ability for their economies to continue to grow.

The Obama administration agreed to let ASCP work with them to develop a program for the prevention, diagnosis, and treatment of NCDs in Africa. I was able to also garner the support of the Clinton Foundation and we brought in significant partners (such as Paul Farmer with Partners in Health) with cohorts such as the pharmaceutical industry, diagnostic industry, people in the public health sector, and key members in Pathology. ASCP proposed the Partners for Cancer Diagnosis and Treatment in Africa initiative and together we launched this program from the White House in October of 2015.

This was the first time that any pathology association had ever launched a large-scale initiative of this kind to bring pathology and laboratory medicine to the forefront of the global health solution.

We began our work by partnering with the ministries of health in each country to establish disease registries. We forged a partnership with the World Health Organization and the Center for Global Health at the NIH to develop pathology-led early detection testing so that early intervention strategies could then be developed.

The Partners Initiative has grown into a 150-million-dollar operation run through the ASCP Center for Global Health which functions to first survey the disease prevalence in the country, next to build pathology and laboratory medicine capacity with the help of technology and pharmaceutical vendors, and to supplement the diagnostics with alliances with the interventionalists who can provide appropriate treatment.

Q: What about sustainability? How will these systems stay in place when ASCP leaves?

A: Before ASCP launches to build capacity and create the necessary partnerships for treatment, we ensure that there is government buy-in for long term sustainability. There is a ten-year exit strategy for each site – we aim to create turn-key facilities, where we can walk away and begin work in the next country. We do this by requiring each country to contractually prioritize diagnostics and develop a plan to financially sustain these systems. They must train enough laboratory and medical staff to run the facilities – and they must have a plan to train and retain pathologists to do the work.

We’ve also focused on the prevention of diseases and invested in a lot of education and training to teach the population about preventive medicine. We also support vaccination programs that lead to prevention of NCDs. For instance, in Rwanda, one hundred percent of the girls there have been vaccinated against HPV – a rate not seen even in the US. We’ve also had great success in dispersing laboratories throughout the country and the government has responded to support this by increasing the training of laboratory medicine specialists to nearly a 1000-fold increase since when ASCP first began working there.

Q: What are some ways laboratory members can contribute their skills to this cause?

A: Anyone that is willing to volunteer time is welcomed and needed, and there are opportunities available no matter your specialty. We try to match each person to their specific interest.

  • On the clinical side, we have many opportunities to volunteer with our PEPFAR initiatives around the world working in the microbiology and infectious disease space.
  • Much of our telepathology diagnostics are provided by our board-certified Anatomic Pathologist members that take time to remotely review cases.
  • We need the help of forensic specialists, for example in Puerto Rico, where we are working to go through the back-log of victims from the 2018 hurricane.
  • For residents and fellows, we have the ASCP Trainee Global Health Fellowship where they have the opportunity to spend a month at one of our global partner sites.
  • We’ve also started a Global Health Ideation Challenge that is an opportunity for anyone to contribute solutions to challenges uniquely faced by low- and middle-income countries.
  • There’s also ample opportunity for anyone to help us with our global education initiatives. We need people to work with institutions to help with educating and training laboratory members, build curriculums, and develop educational systems.

Q: Why is Global Health something that Pathology as a field needs to prioritize?

A: All you have to do is look at the world’s population – 80% of the population lives in developing countries. These are all our brothers and sisters and they deserve the same access to care and the same standard of care as we do in the US. At ASCP, we fervently believe health care for is a universal right.  How can we stand by and let children die of preventable diseases?

The Obama administration had initially raised the point that we in the US have our own health related issues to deal with – and they queried the incentives to prioritize the health of those in sub-Saharan Africa. I explained that if you consider that the US is currently the largest distributor of global aid – and that a threat such as the enormous burden that uncontrolled NCDs will place on the fast-growing economies of sub-Saharan Africa – then you must consider this situation a priority.

The US National Security Council shared these concerns and recognized that if even if only one of the booming African economies crumbles under the looming healthcare crisis, it is our economy that is ultimately affected.  We will be the ones to pay the price.

One must realize that the world is fluent – we are all connected now, and we work not only for altruism but also to ensure global health security. 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.

We cannot turn our backs on our brothers and sisters in other countries who are just like us, who just want the same access to healthcare that we have. We must have the life-cycle of our patients in mind when we offer diagnostic testing – how sad it would be to treat a young woman’s HIV infection for example, only to the let her die of cervical cancer in her thirties. We at ASCP believe it is a fundamental fiduciary responsibility to provide access to healthcare – and is part of why our members join us.

What was the reason that we went into medicine in the first place? Wasn’t it to help patients? We have the obligation to help not only our local population of patients, but also all those around the world. The work is difficult, but immensely rewarding. We can help make a difference in a big way, we just need to TAKE ACTION.

-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.

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

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

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

Ethiopia

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

Ethiopia’s Cancer Problem

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

My work with ASCP in Ethiopia

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

SPHMMC-Future Cardiac and Cancer Center

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

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

George Okbazgi and I discussing laboratory quality improvement plans (over coffee, of course!)

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

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

The wonderful pathology team at St. Paul’s!
(From left to right):
Back Row: Drs. Addishiwot Tadesse; Aisha Jibril; Dawit Solomon; Eyerusalem Fekade; Amanuel Yeneneh.
Middle Row: Drs. Eskindir Redwan; Nebiat Zerabruk; Melat Debebe; Hewan Hailemariam; Mersha Mekonnen; Menal Hassen.
Front Row: Drs. Taye Jemberu; Dana Razzano; Samrawit Goshu; Abinet Admas.
Pathologists and Residents missing from photo: Drs. Bereket Berhane (Chairperson); Mesfin Asefa (Program Director); Zewditu Chayalew; Selamawit Tadesse; Kirubel Girma; Tsion Betremariam; Zemen Asmare; Mahlet Guu’sh; Tadesse Musie; Azeb Gezahegn; and Ashenafi Getachew.

Conclusion

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

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

References

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

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

Solutions, Not Resolutions

The turn of the year is a quasi-inspiring time for many people who attempt to change something about themselves or their situation with “New Year’s Resolutions.” When my friends and I were heading to brunch on New Year’s Day in southern California, there were many people running (alone or in groups) which I hadn’t seen before and my one thought was, “How long will that last?” When I returned to Chicago after the holidays, I dusted off my gym membership card and logged some treadmill time—my one thought was, “I hope this lasts!” But we are all too familiar with the breaking of these resolutions by most of us, and the ultimate regret we feel in the latter part of the year when our hopes and dreams of thinness/money/power/rare pokemon/fame have been dashed by the collision with our actual lives and the limited time we have to get done what needs to be done. Fortunately, we are human beings and we are allowed to be disappointed with ourselves over this (or these) tiny failings as long as our life trajectory is heading the way we want*. Then there are those handful of people that each of us will ultimately know who stick to their resolution and shed the weight, get a new job, or (hopefully with increasing numbers!) quit smoking! And we are more inspired by their actual doing of these things than by our lack of resolve.

As individuals, this trivial annual mindset is acceptable and even entertaining. But as a society, empty promises and feigned changes are simply unacceptable. To certain things, we must as a society—and as individuals in that society—commit. Recycling, for example, is a strategy that is both an economic and environmental boon. But as of January 2018, our major “solution” for plastics (especially from the West) that was China has now ended. Other nations willing to take these recyclables stopped their acceptance as well towards the end of 2018. What can we do to solve (not resolve) this situation permanently? Each country should consider first the role of plastics in their society and perhaps, like many African nations, simply ban the product(s). Secondly, encouraging personal recycling and reuse of plastics, for example through water filters to refill plastic bottles or fees on reusable grocery bags, can minimize impact. But, ultimately, each nation needs a sustainable recycling plan that represents a balance of production and utilization, creating a negative plastic total impact (i.e., no new plastic created).

In pathology, the theme of recycling is very important for any laboratory but can have major benefits for laboratories in developing nations. Formalin, xylene, alcohol, and paraffin (the four principle reagents for pathology processing), can be recycled using devices or process plans that can have minimal capital costs to set up. Consider that a given country may have shipping challenges such that an order placed today for 10 gallons of neutral buffered formalin may take 6 weeks to 6 months to arrive and cost 3 to 5 times the price in another country. In that setting, recycling formalin is clearly a superior approach and extrapolates to xylene and alcohol. Process approaches to paraffin (e.g., collecting waste paraffin from trimming and lids, using minimized mold sizes, lateral flow to minimize contamination) can optimize the use of the wax and reduce costs.  As these four reagents represent core elements to the process, efficient utilization, reuse, and management can keep costs low and processes running. But the laboratory must commit to this process and adhere to it every moment of every day to change patient’s outcomes for the better.

Similarly, core histology equipment (unlike many clinical laboratory machines) is almost indestructible when properly managed and maintained. Laboratories in developed nations may replace this equipment when it is several years to a decade old when the equipment may have another decade (or sometimes two) left of life. Decisions to replace functional equipment are left to the individual laboratory; however, once this process occurs, functional equipment should not be left to collect dust and should be moved to a new location where it can be of value. Every laboratory considering the replacement of older equipment must ask the question, “What is the remaining functional life of this device?” If that number is many years or the often stated 70%, a plan for donation of the equipment is highly suggested.  It is this philosophy that inspired the ASCP Center for Global Health program along with many other groups to actively seek out donated, functional equipment and transfer it to nations and colleagues who desperately need it to maintain their pathology services (Do you have equipment for donation? Email us!). This is especially important because the perceived demand for histology equipment in many low-income countries is so low that manufacturers and distributors refuse to become involved with the equipment (especially with trade and tariff barriers standing in the way). But, in truth, the demand is the same per population as in any other country with at least one high volume, functional pathology laboratory needed for every 1 to 3 million people (depending on population age structure and clinical utilization).

As we begin a new year together, reflecting on what we did (and didn’t) do in 2018 and what we can (and should) do in 2019 is an iterative process that can guide us through many decisions. I hope that everyone reading this blog takes a few moments (or even an hour if you can spare it!) to delve into 2018 and really plan for 2019 with true solutions in mind for any challenges you identify. And, lastly, always take some time every day to think outside yourself and even your laboratory to others in your local community or in foreign lands. Consider what little (and big) things you can do that may improve the life of just one person other than yourself and commit to those things.

*If your life trajectory is not going the way you want, consider performing a personal SWOT (strengths, weaknesses, opportunities, threats) analysis and think outside the box about where you are and where you want to be. Don’t be afraid to make life changes or new life choices that give you a better piece of mind and stronger sense of self and self-awareness. A room full of happy people who are self-aware and emotionally intelligent can solve problems at light speed because their personal issues (good or bad) don’t get in the way. So, for 2019, I strongly encourage everyone to consider really solving (not resolving) the problems you perceive in your life so that we can all work together to solve (not resolve) the challenges we face as a society moving into the next decade.

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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.

The Best Laid Plans: A “Trial by Fire”

From around 2009 to 2016, I worked very closely with a USA-trained surgeon, Dr. Brian Camazine of Earthwide Surgical Foundation, who visits Nigerian Christian Hospital in Aba, Nigeria for one month every quarter. He performs between 200 to 300 surgeries, which produce 40 to 60 surgical pathology specimens each visit.  Dr. Camazine has invested time, energy, and money into training local Nigerians in surgical skills, acquiring surgical and medical supplies to support his patient population, and following up all of his patients with Skype clinics after he returns.

My role in Dr. Camazine’s activities was to receive the surgical pathology samples, process them, and return results for him as quickly as possible. When Dr. Camazine contacted me, there was no pathology laboratory at NCH. Dr. Camazine uses a heavily subsidized model for all of the services provided at NCH such that a patient may pay ~$200 for a surgery (complete care including pathology) that would have cost them $2,000 to $4000 elsewhere in Nigeria. My hospital at the time had an ongoing project of a similar fashion with several sites in Africa but the costs of that program were growing. Dr. Camazine agreed to pay a fee of $25 per sample to my hospital to offset the technical costs of our laboratory processing the samples, and I provided all diagnostic results pro bono. Dr. Camazine was only charging patients $20 per case for pathology; thus, he subsidized the service further.

I had many long and difficult discussions with Dr. Camazine about this program and how we needed to focus on a sustainable solution that did not involve transport to the US for processing for many reasons including (but not limited to): a) danger and difficulty with sending tissue, b) long turnaround time because of shipping delays, c) chain of custody and requisition challenges, and d) capacity building in pathology. We kept at it with this long-term plan in mind but, as I departed my hospital to join ASCP in 2016, a drastic decision had to be made because I would no longer be able to shepherd this service. Dr. Camazine reached out locally to Nigerian laboratories and was fortunate to meet Dr. Chidi Onwuka from the Department of Histopathology at the University of Uyo Teaching Hospital. Brian and Chidi came to a feasible financial arrangement and, with the closeness of the laboratory, Chidi can return results to Brian in about 1 week (Meet Chidi and read Brian’s Blog here). This was a great success for Brian and Chidi because it represented moving from a non-sustainable, bridging program (i.e., what I had set up with Brian) to a permanent solution with the local laboratory. For over two years, Chidi has provided high quality service with quick turnaround time and massively improved the patient care journey for NCH patients.

On June 27th, 2018, however, that complete pathology solution came to a screeching halt when a fire swept through the laboratory and destroyed all of the equipment and reagents. The laboratory in question had just been completely updated with 40 Million Naira (~$115,000 USD) worth of equipment and upgrades, but it was all lost. Dr. Chidi reached out to Brian, myself, and many others with an urgent request to help him get a replacement laboratory up and running. After so much success, it was heartbreaking to hear such a loss had occurred.

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The ASCP Partners for Cancer Diagnosis and Treatment in Africa Initiative was launched in 2015 with a goal of bringing 100% access to cancer diagnostics services to all patients. Although the population of patients Brian cares for and Chidi diagnoses are within Africa and within the scope of the Partners Initiative, at the time of the fire, there were at least 10 laboratory projects (including equipment, training, IHC, telepathology, etc.) in process through the Partners project. We were seemingly “at capacity” to help. What could we do? Although we have ASCP member volunteers that donate equipment, we have a waiting list of labs wanting to receive the equipment. Although Brian and Chidi are my colleagues and friends, the distribution of global health resources, assistance, and capacity should always be done with equity. As part of the Partners Initiative, ASCP Center for Global Health acquires equipment (typically through donation which means donor requirements of the local countries) and covers shipping costs to move the equipment to the recipient sites but we had not yet formalized this process. But, for Chidi, I simply didn’t have the equipment available to send.

Then, I received a WhatsApp message from Chidi on August 3rd with a small bit of good news. He had located a microtome in the USA that he could purchase; however, he did not have sufficient funds to ship the equipment. Now, finally, ASCP could help him! But it was not quite that easy!

ASCP staff member Dr. Debby Basu got the microtome in the USA to Chidi in Nigeria. This was not an easy task. Debby faced two major challenges for organizing Chidi’s shipment. First, she had to establish key templates and tools necessary to facilitate donation. Although we have several sets of donated equipment that are to be shipped from ASCP to other sites, Chidi’s microtome was the first actual piece of equipment that would go with our new shipping agent. As this was our first shipment with Bollore, she first had to work with Bollore to determine what documentation ASCP was responsible for providing. She then developed the in-house documents, templates and tools needed to facilitate shipment using Bollore’s services (e.g. commercial invoice, packing list, Shipper’s Letter of Instructions (SLI) Form (customs information), donor letters, etc.). She served as the liaison between the original vendor, recipient and shipper to make sure that donation and shipping documentation was consistent, and that information was clear and available to all parties. The second challenge was understanding the complex international shipping guidelines for exporting scientific instruments and goods on US side and importing donation on receiving end. To address this on the domestic side, she worked closely with the shipper directly to clarify domestic customs guidelines specific to the context of the items being shipped and ensure customs documentation was completed appropriately. On the Nigerian side, she connected Chidi to Bollore’s Nigeria-based shipping team to establish a local point of contact for him. She then coordinated with both the US-based and Nigeria-based shipping teams to clarify country-specific importation requirements and provide Chidi with necessary documentation to ensure smooth receipt of instrument. It had been ASCP’s intention to use Bollore for the donation program but Chidi’s emergency pushed our agenda forward and Debby was able to race into action to make the process go. Now, Chidi has his microtome (and is replacing his other equipment) and ASCP’s shipping donation program has its process finalized for the next series of donations.

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ASCP is so grateful to all of our members and member volunteers who have made the Partners Initiative a functional and impactful global health program. We are careful in our assessments, planning, and development of implementation plans with each of our sites and their leadership. However, terrible things happen unexpectantly. We hope that ASCP can always be a light in the dark when all others have gone out.

 

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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.

Innovative Diagnostics for the Developing World

My last two posts have focused on the WHO Essential Diagnostics List (EDL). The EDL, modeled after the Essential Medicines List, is meant to serve as a model guide for countries to use in the development of laboratory services for diagnosis, treatment, and monitoring of common diseases. The EDL is meant to be tailored to an individual nations disease burden, and India is on track to be the first country with a country-specific EDL. I think this is a tremendous step forward for the field of laboratory medicine worldwide, but I do wonder how this will roll out Low or Middle Income Countries (LMIC). How we will got from a list (actually a draft of a list) to real-time diagnostics in the developing world? Let’s take a step back and look at what access to laboratory testing really looks like, and then discuss some innovative diagnostics that might help increase access to useful diagnostics.

In the US, we have many labs tests available – so much so that laboratory utilization has become a very real area of study with groups like Choosing Wisely, PLUGS, and Preventing Overdiagnosis dedicated to helping guide appropriate use of in-vitro diagnostics (IVDs). The US has over 250,000 accredited laboratories, and 18,000 clinical pathologists. That’s about 5.7 pathologists per 100,000 people. In contrast, the continent of Africa has about 1 million people per pathologist, and some African countries have over 5 million people per pathologist. It’s difficult to find a number of laboratories in LMICS, because many are mom and pop type shops that aren’t registered with the Ministry/Department of Health. Test menus are often limited to cell counts and rapid testing, and proficiency testing or quality control is not practiced.

Challenges to building laboratory capacity in LMICs are environment, economics, and education. Environmental challenges include extreme temperatures, limited electricity, and limited access to water. Some point of care options that might be able to work in these environments just aren’t affordable. Many people in LMICS make around $2 USD a day and a $10 iStat/Piccolo/your favorite POC chemistry device cartridge is just out of reach especially if the testing needs to be repeated frequently for monitoring disease progression. Lastly, education remains a challenge as laboratory medicine including not not only technical skills but also the use and interpretation of lab tests is not frequently taught in LMICS.

However, there are many different innovative diagnostics being debuted or in development with these challenges in mind. There are definitely trends in the area of new diagnostics for the developing world. The most distinctive trends are: smartphone imaging, smartphone spectrophotometers, transdermal testing, and paper based sample collection. In my next few posts, I’ll take us through examples of each of these, and I’ll start now with smartphone imaging.

Smartphone imaging is essentially using light boxes, cameras, or apps, to turn a smartphone into an imaging device. Smartphones are even being used as simple ultrasounds! A smartphone microscope can be useful in diagnosing tropical infectious diseases. A good example is the LoaScope, developed by the Fletcher Lab at UC Berkeley. Dr. Daniel Fletcher is known as the “father of the cell phone microscope”. The LoaScope is a mobile phone based microscopy platform plus an app-based algorithm for the detection of L. Loa. The device is elegantly simple: a 3D printed case with a rest of the mobile phone. The case contains a USB port, bluetooth controller board, and LED array, and a carriage for a capillary slide. Blood is introduced to the capillary slide and imaged by the phone. A 5 sec video is captured by the phone, and then analyzed via app that uses a algorithm based on the the wiggling motion of the loa worm. The algorithm actually distinguishes the movement of blood cells as the loa worms move between them! The interpretation of the video lets the user know if the parasite is present or not present. Another bonus the device is that a georeference is captured with every video, which is great for epidemiological studies. In 2017, the LoaScope was used by the NIAID to testing over 16,000 subjects in Cameroon. Because of the LoaScope, over 15,000 subjects were successfully treated with ivermectin without serious complications.

There are some key elements to the LoaScope that are common across the new, innovative diagnostics for the developing world. First, the 3D printed case. 3D printing seems to really be helping this field jump ahead by decreasing the costs associated with creating the physical structure of the devices. Secondly, the device does not require special specimen preparation, nor does it need reagents. Lastly, a simple read-out is a available to the user in real time.

In summary, the EDL is great for telling us what test are, well, essential. Innovative diagnostics are going to help us get to those hard-to-reach places. I look forward to continuing to investigate these with you!

 

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Sarah Riley, PhD, DABCC, is an Assistant Professor of Pediatrics and Pathology and Immunology at Washington University in St. Louis School of Medicine. She is passionate about bringing the lab out of the basement and into the forefront of global health.  

A Response to “Offline: Why has global health forgotten cancer?”

I read with great interest Richard Horton’s comment, “Offline: Why has global health forgotten cancer?” ASCP applauds his bringing light to this issue and his strong call to action for both the global health community and governments to take up the challenge of dealing with cancer. There is no doubt that the world needs a “Global Fund for Cancer” or the “President’s Emergency Plan for Cancer.” There is no question on what those funds could be spent—

prevention, screening, diagnosis, and treatment of cancer has been well worked out in high-income countries (HIC). There is definitely a question of how best to spend those funds, what is the most effective approach in a given population, and what special circumstances exist in a population that must be considered. We thank him for shouting about this and being so direct and for using the Lancet as a platform for this important message.

We would like to clarify, however, that Richard is certainly not the first person to shout this call (and hopefully he will not be the last!). Please review the 17 references below; one of the earliest was authored by pathologists and appeared in Lancet in 2012.  In addition, the three most recent were from a Lancet Series. When I was in Malawi working in a diagnostic laboratory in 2000, more than 75% of what I saw was cancer. Although, at the time, a lot of cases found their etiology in untreated HIV. My senior colleagues told me I was wasting my time because there was “no way to treat cancer in Africa.” As I continued to visit Malawi over the next 15 years, the percentage of cases that were cancers increased. The HIV-related cancers decreased. Lung cancer never crossed the scope because there were no resources to biopsy or resect patients; yet, lung cancer was a leading cause of death in cancer registries. Today, the limited oncologists in Blantyre are overwhelmed by breast cancer cases. A similar story is found in Butaro, Rwanda and Mirebalais, Haiti.

But in all three places, patients can access a diagnosis because pathology services have been installed, bolstered, or maintained through commitments of NGOs, academic institutions, and governments. More importantly, they have access to treatment because oncologists and oncology nurses have joined the fight against cancer in global health in these units. There are many organizations in the United States and around the world that focus on cancer in low- and middle-income (LMIC) countries including (but not limited to) ASCP, PIH, UICC, ACS, CHAI, BVGH, ICCP, ICCR, NIH, APECSA, ASLM, ASCO, and, yes, the WHO. Do all of these organizations need more resources to make their missions more effective? Absolutely! Do more organizations need to join the fight? Absolutely! But, even with limited resources, huge progress can be made for individuals and populations.

In his comment, Richard points out two arguments used to explain why global health has forgotten cancer. The first is that cancer is not a statistical priority in LMICs. This is actually untrue. Advances in treatment for communicable diseases, especially HIV, have “unmasked” cancer in every one of these nations with clear evidence that many are preventable, many are curable, and many require palliative care. Mortality in Africa from cancer reaches 80% compared with only 35% for all cancers in the US. We clearly have a goal to focus on in mortality reduction with measurable targets. The WHO has announced a cancer resolution at the World Health Assembly. National Cancer Control Plans have been written for most LMICs. The stage is set for any one or all LMICs to develop, build, and expand cancer centers of excellence with people in and out of those countries eager to help. What is missing is not desire or resolve. What is missing is funding. And in this challenge, we find an actual barrier for advancing cancer care. Many organizations are drunk with funding for infectious diseases. They have no experience with cancer and no capacity to tackle it. If funding were suddenly diverted from these communicable disease organizations (CDO) to NCD organizations that could deal with cancer, many CDOs would have to close their doors. And millions would suffer at the loss of infrastructure and capacity that these organizations have created. But THAT is the ultimate barrier—the assumption that we have to divert funding. We don’t need to move funding from one program to another. We must find creative ways to finance cancer for every patient everywhere around the world.

Richard second points out that global health people tout “building systems” rather than focusing on specific cancer types (e.g., breast or cervix) as an excuse to not start cancer care. However, this is not accurate because a) health systems ARE needed to treat cancer and b) it is impossible to treat a single entity cancer and maintain an ethical program. For example, focusing on breast cancer or cervical cancer “first” or “only” is highly unethical because all the tools for those cancers also allow one to partially move a non-breast/non-cervical cancer patient through the system (the main difference being the chemotherapy types used). I do not disagree with the concept of “you have to start somewhere” but, if we think back to HIV and malaria, there is a precedent for why this is a flawed approach. HIV was a single test that diagnosed a single disease but the pre-test probability was high (since very few things looked like HIV at the height of the epidemic). RDTs for malaria were a single test that diagnosed a single disease but the pre-test probability was medium (many things look like malaria that are not). But we focused on HIV diagnosis and treatment and we focused on malaria diagnosis and treatment. Now we have HIV patients who are doing great—and getting cancer. We have malaria patients that are doing great with RDTs and ACTs—but any child with a fever of another cause probably dies. If you ask anyone with an understanding of biology or epidemiology to look at the history of the HIV epidemic or malaria in the modern age, they would all predict these findings. It’s not an epiphany…it was deliberate ignorance. Building systems is hard but it IS the answer. So, I 100% disagree with Richard that treating a single cancer will have an impact beyond those few patients that benefit from that disease. Do those patients with a specific cancer deserve treatment? Of course! But so do patients with all cancers. So, the answer IS still systems.

In order to treat cancer, clinicians must have a pathological diagnosis. For example, if clinicians decided that they would by assumption treat all women with Stage 4 breast cancer in Peru (with positive lymph nodes on palpation), 20% of patients would actually have tuberculosis. But a % of the patients will also have metastasis from other tumor types (such as lymphoma, benign lesions, and soft tissue tumors). If we provide chemotherapy for invasive ductal carcinoma and a pathology service to biopsy the patients to prove the diagnosis, what do we do with those that don’t actually have invasive ductal cancer? How is that ethical? Once we expand our breast tumor regiment to cover all tumors that MAY occur in the breast, now we must treat patients that have those tumors in other locations, otherwise we are in an ethical nightmare.

At the heart of this issue is the pathological diagnosis. There is no treatment without a pathological diagnosis and, once you have the ability to make a pathological diagnosis, there is not justifiable excuse for not treating patients who present with any cancer. The curse of a tissue biopsy processed for histology is that it is one test with, literally, thousands of possible results. Remember HIV and Malaria? They are each one test with one actionable result. A histology slide can present thousands of actionable results! So, no, it is not possible within an ethical construct of healthcare or within a paradigm of equity to focus on one cancer. We can deploy thousands of oncologists and nurses across LMICs with truckloads of every chemotherapy known to humankind and there would be NO IMPACT—absolutely none—unless every patient was pathologically diagnosed before treatment was begun. Surgeons could enter a country and remove every breast with a lump in it—the number of women with inappropriate surgical treatment would result in criminal charges. Pathology is the central tool for diagnosing cancer and creating an appropriate treatment plan, but it is also a single tool that can diagnose EVERY cancer so we must be able to fulfill every appropriate treatment plan.

It is for this reason that PIH with assistance from Dana-Farber Cancer Institute and Brigham and Women’s Hospital began diagnosing and treating patients in Haiti, Lesotho, and Rwanda in 2005 with cancer. By 2011, the trickle of patients that would find their way to PIH clinics had become a flood. It was now necessary to not only build pathology laboratories in countries that could handle the volume and range of diagnoses but also import nurses and oncologists to formulate and run programs. Before the pathology laboratory was built in Butaro, Rwanda, patients may have waited for up to 6 months (if ever) to receive a result which may have been incomplete or inaccurate due to the limitation of staffing. In Butaro today, after the construction of a laboratory, training of staff, addition of immunohistochemistry, installation of telepathology, and residence of a permanent Rwandan pathologist, the turnaround time is < 72 hours. There are other success stories like this but these systems need to be replicated within country and in other countries at a rate of at least one cancer treatment center per 5 million people or less. And, as Richard rightly points out, these centers need to have resources to treat every patient.

ASCP has been in the global health arena working with PEPFAR since its inception. In 2015, ASCP launched Partners for Cancer Diagnosis and Treatment in Africa (including Haiti) which was built on the premise that telepathology would be a key tool to diagnose patients more rapidly and accurate in LMICs. Butaro, Rwanda was the first site to receive telepathology with ASCP but there were many examples of other labs with telepathology in place prior to that; however, the bulk of them were focused on single-entity or research-based programs. The ASCP program starts with the premise that the site where telepathology is placed plans to treat all cancers that are diagnosed. Thus, ASCP requires that a system for cancer care is at least planned or in process. So, the old adage, “you have to start somewhere” is great but, for cancer, that first start must be the provision of pathology services. The ethical framework that follows will require that all cancer move into the realm of treatment.

Again, ASCP thanks Richard Horton for bringing this issue up with the Lancet audience and ASCP hopes that we, all shouting together, can move the needle much further along towards funding for cancer across the systems spectrum.

References

  1. Horton S, Sullivan R, Flanigan J, Fleming KA, Kuti MA, Looi LM, Pai SA, Lawler M. Delivering modern, high-quality, affordable pathology and laboratory medicine to low-income and middle-income countries: a call to action. Lancet. 2018 May 12;391(10133):1953-1964. doi: 10.1016/S0140-6736(18)30460-4. Epub 2018 Mar 15. Review. PubMed PMID: 29550030.
  2. Sayed S, Cherniak W, Lawler M, Tan SY, El Sadr W, Wolf N, Silkensen S, Brand N, Looi LM, Pai SA, Wilson ML, Milner D, Flanigan J, Fleming KA. Improving pathology and laboratory medicine in low-income and middle-income countries: roadmap to solutions. Lancet. 2018 May 12;391(10133):1939-1952. doi: 10.1016/S0140-6736(18)30459-8. Epub 2018 Mar 15. Review. PubMed PMID: 29550027.
  3. Wilson ML, Fleming KA, Kuti MA, Looi LM, Lago N, Ru K. Access to pathology and laboratory medicine services: a crucial gap. Lancet. 2018 May 12;391(10133):1927-1938. doi: 10.1016/S0140-6736(18)30458-6. Epub 2018 Mar 15. Review. PubMed PMID: 29550029.
  4. Sayed S, Cherniak W, Lawler M, Tan SY, El Sadr W, Wolf N, Silkensen S, Brand N, Looi LM, Pai SA, Wilson ML, Milner D, Flanigan J, Fleming KA. Improving pathology and laboratory medicine in low-income and middle-income countries: roadmap to solutions. Lancet. 2018 May 12;391(10133):1939-1952. doi: 10.1016/S0140-6736(18)30459-8. Epub 2018 Mar 15. Review. PubMed PMID: 29550027.
  5. Milner DA Jr. Pathology: Central and Essential. Clin Lab Med. 2018 Mar;38(1):xv-xvi. doi: 10.1016/j.cll.2017.11.001. Epub 2017 Dec 12. PubMed PMID: 29412893.
  6. Milner DA Jr. Global Health and Pathology. Clin Lab Med. 2018 Mar;38(1):i. doi: 10.1016/S0272-2712(17)30139-7. Epub 2018 Feb 3. PubMed PMID: 29412888.
  7. Orozco JD, Greenberg LA, Desai IK, Anglade F, Ruhangaza D, Johnson M, Ivers LC, Milner DA Jr, Farmer PE. Building Laboratory Capacity to Strengthen Health Systems: The Partners In Health Experience. Clin Lab Med. 2018 Mar;38(1):101-117. doi: 10.1016/j.cll.2017.10.008. Epub 2017 Dec 28. Review. PubMed PMID: 29412874.
  8. Milner DA Jr, Holladay EB. Laboratories as the Core for Health Systems Building. Clin Lab Med. 2018 Mar;38(1):1-9. doi: 10.1016/j.cll.2017.10.001. Epub 2017 Dec 1. Review. PubMed PMID: 29412873.
  9. Dayton V, Nguyen CK, Van TT, Thanh NV, To TV, Hung NP, Dung NN, Milner DA Jr. Evaluation of Opportunities to Improve Hematopathology Diagnosis for Vietnam Pathologists. Am J Clin Pathol. 2017 Nov 20;148(6):529-537. doi: 10.1093/ajcp/aqx108. PubMed PMID: 29140404.
  10. Mpunga T, Hedt-Gauthier BL, Tapela N, Nshimiyimana I, Muvugabigwi G, Pritchett N, Greenberg L, Benewe O, Shulman DS, Pepoon JR, Shulman LN, Milner DA Jr. Implementation and Validation of Telepathology Triage at Cancer Referral Center in Rural Rwanda. J Glob Oncol. 2016 Jan 20;2(2):76-82. doi: 10.1200/JGO.2015.002162. eCollection 2016 Apr. PubMed PMID: 28717686; PubMed Central PMCID: PMC5495446.
  11. Sayed S, Lukande R, Fleming KA. Providing Pathology Support in Low-Income Countries. J Glob Oncol. 2015 Sep 23;1(1):3-6. doi: 10.1200/JGO.2015.000943. eCollection 2015 Oct. PubMed PMID: 28804765; PubMed Central PMCID: PMC5551652.
  12. Nelson AM, Milner DA, Rebbeck TR, Iliyasu Y. Oncologic Care and Pathology Resources in Africa: Survey and Recommendations. J Clin Oncol. 2016 Jan 1;34(1):20-6. doi: 10.1200/JCO.2015.61.9767. Epub 2015 Nov 17. Review. PubMed PMID: 26578619.
  13. Mpunga T, Tapela N, Hedt-Gauthier BL, Milner D, Nshimiyimana I, Muvugabigwi G, Moore M, Shulman DS, Pepoon JR, Shulman LN. Diagnosis of cancer in rural Rwanda: early outcomes of a phased approach to implement anatomic pathology services in resource-limited settings. Am J Clin Pathol. 2014 Oct;142(4):541-5. doi: 10.1309/AJCPYPDES6Z8ELEY. PubMed PMID: 25239422.
  14. Mtonga P, Masamba L, Milner D, Shulman LN, Nyirenda R, Mwafulirwa K. Biopsy case mix and diagnostic yield at a Malawian central hospital. Malawi Med J. 2013 Sep;25(3):62-4. PubMed PMID: 24358421; PubMed Central PMCID: PMC3859990.
  15. Berezowska S, Tomoka T, Kamiza S, Milner DA Jr, Langer R. Surgical pathology in sub-Saharan Africa–volunteering in Malawi. Virchows Arch. 2012 Apr;460(4):363-70. doi: 10.1007/s00428-012-1217-z. Epub 2012 Mar 10. PubMed PMID: 22407448.
  16. Roberts DJ, Wilson ML, Nelson AM, Adesina AM, Fleming KA, Milner D, Guarner J, Rebbeck TR, Castle P, Lucas S. The good news about cancer in developing countries–pathology answers the call. Lancet. 2012 Feb 25;379(9817):712. doi: 10.1016/S0140-6736(12)60306-7. PubMed PMID: 22364759.
  17. Carlson JW, Lyon E, Walton D, Foo WC, Sievers AC, Shulman LN, Farmer P, Nosé V, Milner DA Jr. Partners in pathology: a collaborative model to bring pathology to resource poor settings. Am J Surg Pathol. 2010 Jan;34(1):118-23. doi: 10.1097/PAS.0b013e3181c17fe6. PubMed PMID: 19898229.

 

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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.