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 (UHC) 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.
Alongside infrastructure and equipment, the authors say that the insufficient numbers of pathologists is 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 130,000 patients. To reach staffing levels similar to the UK or USA, the authors say that China needs an estimated additional 70,000 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.
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.
The authors call on all nations to develop national strategic laboratory plans to deliver at least a basic level of tests.
“There is an urgent need for nations to recognise that lack of access to adequate pathology and laboratory medicine services is a critical gap in health systems in resource-limited settings; without immediate and sustained intervention, this gap will only widen disparities between low and high income countries” says Dr Shahin Sayed, Aga Khan University Hospital, Nairobi, Kenya and Secretary General of the College of Pathologists of East Central and Southern Africa.