Pathologists hold a key position amongst the medical professionals responsible for cancer management. They, unfortunately, face enormous problems and handicaps in discharging their vital role in the developing countries. This article enumerates many of them, particularly those at the lower end of the socioeconomic spectrum.

Essential Requirements for Efficient Practice

The efficient working of this important specialist does not solely depend upon his or her qualifications, training and competence alone, although these are important. Like most medical specialties, the pathologist is also dependent upon the adequacy of the facilities and infrastructure of his or her work environment.

It has not been determined how many pathologists are required per capita of the population for adequate health care, but the number in developing countries, overall, is clearly inadequate. It has been estimated, for example, that while England has 109 pathologists per million people, Pakistan has only 2.6. Pathologists in Pakistan are clearly overburdened and the quality of their work under these circumstances is bound to suffer. Unfortunately, there are some countries in the world that have no trained pathologists.

Pathologists in most developing countries have little or no access to continuing education programs or to the medical literature and there is often no requirement for licensing or any control over who can practice pathology. This results in widespread “quackery” and a general lowering of confidence in the specialty, making the task of a pathologist to establish credibility a hard one.

Efficient medical technologists, who form the backbone of pathology laboratories, are even harder to find. Many of those presently practicing, particularly in the lower income countries, do not have a basic educational background and have received only “on-the-job” training.

Laboratory instruments are another essential requirement for any pathology practice. In the absence of the capability to produce equipment locally, most machines have to be imported, frequently from second-rate producers, in order to keep costs down. This then raises questions about the accuracy of results. Access to rapid and effective maintenance is also critical. In general, there are inadequate repair facilities and even when equipment is working the power supply is often unreliable, making an already difficult job even harder. Reagents are also often sub-standard. A WHO inter-country workshop to formulate policy regarding quality assurance in the context of diagnostic kits was organized in 2001. Most of the member countries have too limited an infrastructure and insufficient technical expertise to undertake the task of assuring the quality of diagnostic reagents. Only one had a national policy requiring routine assessment of the quality of reagent kits, while laboratories able to monitor quality existed in only two of the seven participating countries.

The handicap under which pathologists work is further compounded by the lack of financial resources and high cost of newer reagents and equipment. Immuno-histochemistry has become a routine element in the assessment of lymph node lesions in high-income countries. However to process a single case the cost is equivalent to some two weeks of the patient’s wages. Since insurance is largely non existent for the poorer people, even if the pathologist has trained technicians and other necessary prerequisites, the diagnosis has to be made on morphology alone – often insufficient to establish a firm diagnosis, or to utilize current classification schemes.

Total Quality Management is the basis of the practice of modern pathology. Accreditation protocols have been developed by the International Standards Organization (ISO) and others. However with a few exceptions, pathologists in poorer countries are outside the purview of such plans. In India, for example, out of about 25,000 laboratories, only a few dozen participate in an accreditation program. The reason is the enormous financial cost, elaborate administrative structure and paperwork required for accreditation. This is beyond the reach of the vast majority of pathologists in countries such as Pakistan.

What can be done to improve the situation?

Given the breadth of problems faced, it is clear that significant improvement will require long-term programs designed to improve professional standards, including technical resources. Training programs and a regulatory framework designed to ensure the achievement of minimal standards are essential. However, a number of steps can be taken by the pathologists themselves with help from outside agencies to alleviate the situation. Very often, a reasonably well-trained pathologist will know best what is needed in the context of local realities.

A variety of educational and training programs could be established, supplemented, or even largely based on telepathology programs which, for this image-based discipline, is likely to lead to a more efficient use of the time available on the part of the teachers. Such systems could also be used to obtain “distance” consultations and second opinions. To ensure that all pathologists meet minimal educational standards, a modified two-tier accreditation system could be devised, the lower tier being appropriate for smaller pathology laboratories able to undertake more routine analysis, thus freeing the more sophisticated laboratories to undertake more detailed analysis when necessary. Minimal guidelines for accurate diagnosis and standard reporting formats, including the classification schemes that will be used for each tumor throughout the country (preferably in line with the most widely used classifications internationally), should, ideally, be agreed upon and adhered to by all laboratories in the country. Such guidelines must recognize the limitations faced by the pathologist in developing countries and avoid unnecessarily exhaustive analysis. Inexpensive sampling techniques such as fine needle aspiration could be used in appropriate circumstances, but criteria defining an adequate sample will need to be created. Lists of “essential” instruments and tests could be drawn up and all pathologists would be required to comply in order for their laboratories to be accredited.

The challenges of overcoming the problems faced by the pathologists in developing countries are many and great. However they must be met if cancer care in developing countries is to improve, for without an accurate diagnosis, precious treatment resources may be squandered, and patients will not receive the treatment they need.

Manzoor Ahmad
Healthways Laboratories
Rawalpindi, Pakistan