Pathology is the cornerstone of modern medicine, ensuring that patients are correctly diagnosed and given an appropriate treatment. However, a new Series in The Lancet highlights how common presumptive treatment – treatment without a confirmed diagnosis – is likely to be in many low- and middle – income countries (LMICs) as a result of a serious shortage of pathologists, laboratory services, and basic medical tests.
The authors warn of the impact on patient care with patients poorly diagnosed or given inappropriate treatments, and of the wider impact on health systems in LMICs if already scarce resources are wasted, ultimately threatening progress on universal health coverage and the sustainable development goals (SDGs).
Pathology services are central to the detection, treatment, and monitoring of infectious diseases. In addition, many non-communicable diseases (such as diabetes) cannot be detected or diagnosed on the basis of clinical history or physical examination alone. Other diseases, such as cancer, require pathology services not only for detection and diagnosis but also for the specific classification and staging that is needed to guide treatment and help determine prognosis. Non-communicable diseases such as diabetes and cancer are now responsible for 7 out of 10 deaths worldwide, with rates fast accelerating in LMICs.
“In Europe or the USA, we take for granted that if you see your doctor with symptoms of liver disease, you will be diagnosed based on a blood test, and given the correct treatment. Similarly, we wouldn’t dream of diagnosing breast cancer without performing a biopsy. But, in far too many countries around the world, diagnosis and treatment can be based on no more than a well-educated guess,” says Dr Kenneth Fleming, lead author of the Series, National Cancer Institute and University of Oxford, UK.
Pathology services include a set of medical specialties – such as biochemistry, microbiology, hematology, histopathology – that, along with imaging, represent the breadth of diagnostic testing that is needed to support all health care. Pathology also includes autopsies and forensic pathology to determine the cause of death.
Alongside infrastructure and equipment, the authors say that the insufficient numbers of pathologists are a major issue. Based on available evidence, and supplemented by a survey of over 250 pathologists in LMICs, the authors of the Series estimate the number of pathologists in sub-Saharan Africa at one per 1 million patients – a ratio roughly 50 times lower than that of high-income countries. In China, the rate is estimated at lower than one per 130000 patients. To reach staffing levels similar to the UK or USA, the authors say that China needs an estimated additional 70000 pathologists.
Training and education is also an issue – in 2015, only 2% of the physician trainees in the USA were pursuing postgraduate training in pathology. The situation is particularly challenging in LMICs. With current rates of education and training, it might take more than 400 years to match the pathologists-to-population ratio of sub-Saharan Africa to that of the USA or UK.
Professor Michael Wilson, Series author, Denver Health Medical Center, Colorado, USA says: “Our research has identified four key barriers which must be addressed, to ensure that pathology and laboratory medicine service delivery is optimal in resource-limited settings: insufficient human resources and workforce capacity; inadequate education and training; inadequate infrastructure; and insufficient quality, standards, and accreditation.”
Additionally, there is the issue of cost. While point-of-care testing could prove promising for many diseases such as tuberculosis, it is more expensive than laboratory testing. Professor Susan Horton, Series author, University of Waterloo, Canada notes: “Economic studies are essential to determine whether point-of-care testing is affordable, cost-effective, and an appropriate component of a well-functioning pathology system in resource-limited settings. New diagnostic tests will be most relevant if they and their accompanying new treatments are within the financial reach of patients in low and middle-income countries”
“In many low and middle-income countries, diagnostic tests, such as blood tests are not funded by public insurance. A patient’s choice is then whether to spend a few dollars on a drug that might work, or on a diagnostic test. Understandably most people would take a risk and choose the drug. With rising rates of non-communicable diseases, health systems will need to prioritize and fund pathology services to ensure scarce resources are not wasted on inappropriate treatments,” says Dr Fleming
The authors call on all nations to develop national strategic laboratory plans to deliver at least a basic level of tests. “We recommend that all countries should allocate at least 4% of their healthcare budget to pathology and laboratory medicine,” says Professor Horton.
“Relying on out-of-pocket expenditures for diagnostics, leads to risks to health. Unless we have access to quality pathology services at all levels of care, achieving the year 2030 target of the SDGs, including universal health coverage will simply not occur.”