CEO SUMMARY: On one level, it’s the classic story of volunteerism and help for a developing nation. But on another level, it’s a dramatic demonstration of how new technologies allow two hospital laboratories in St. Louis, Missouri to effectively provide reference laboratory tests and related services to Eritrea, a small country located 12,000 miles from the United States on the Horn of Africa.
SINCE 1996, TWO St. Louis hospital labs have provided reference laboratory testing for physicians in Asmara, Eritrea, halfway around the globe on the Horn of Africa.
This unusual story is a heartwarming example of pathologists and laboratory professionals giving help to a third world country. But there is another, equally interesting, aspect to this story. The weekly reference testing relationship between St. Louis and Asmara demonstrates that clinical laboratories in this country are capable of supporting clinicians anywhere in the world with cost- effective, high-quality laboratory tests.
In St. Louis, laboratories at the Washington University School of Medicine (WUSM) and Barnes-Jewish Hospital provide reference testing, including hematopathology, for the Central Health Laboratory (CHL) in Asmara, the capital city of Eritrea. Champion for this project is Jack Ladenson, Ph.D., Professor of Pathology and Interim Director, Division of Laboratory Medicine at WUSM.
The project is the result of personal relationships and the activities of Pathologists Overseas, an organization founded in 1991 by retired pathologist Heinze Hoenecke, M.D. “Dr. Hoenecke’s vision was to improve and provide affordable clinical lab and pathology services to underserved areas worldwide,” stated Ladenson. “He asked for volunteer pathologists, clinical laboratory scientists, and medical technologists to help. His first project was in Kenya, but activities quickly expanded into Eritrea, St. Lucia, Nepal, Madagascar, Samoa and Bhutan.”
The Asmara–St. Louis connection resulted from the teamwork of Ladenson and Dr. Cesare Manetti, a volunteer pathologist in Kenya. “Dr. Manetti grew up in Eritrea,” recalled Ladenson. “He saw the value of what was done in Kenya and took the idea to Asmara. The project was initiated in 1994.
“I took my first trip in 1996, which was just three years after Eritrea gained its independence after a long civil war,” he continued. “During that war, Eritreans had created a laboratory, surgical suites, a pharmacy plant and other health care services. These were located in a set of container cars in caves in Northern Eritrea. The laboratories set up by Melles Seyoum, now director of the Central Health Laboratory, were an amazing achievement!”
Reference Testing Support
“When we visited Eritrea, we thought we could help them, but how?” observed Ladenson. “To determine the testing needs of the population, we worked closely with the Minister of Health and many local physicians. The decision was to support unrestricted ordering of tests that were clinically relevant to the patient’s condition, essentially allowing Eritrean physicians the same access to laboratory testing as the physicians at Barnes-Jewish Hospital.”
This decision generated a series of tough questions. How would these tests get to St. Louis? What had to happen to guarantee that specimens received in St. Louis were viable for testing?
“Our first mission was to evaluate specimen integrity,” said Ladenson. “Mitchell Scott, Ph.D., Professor of Pathology and Co-director of Clinical Chemistry, tackled this effort. He developed a method to test the stability of specimens. We tested samples at the Barnes-Jewish Hospital laboratory in St. Louis. Those specimens were then sent to Eritrea on cold packs via Federal Express or DHL, where the specimens were unpacked, refrigerated, repacked, and returned to St. Louis for repeat testing.
No Frozen Specimens
“This process allowed us to determine how we could be sure which tests would make the grade,” he added. “Planes fly in and out of Asmara only three or four days per week, so we must consider specimen stability from the time drawn to the potential date we will receive the specimen. Also, we cannot ship frozen specimens. It takes two days for the specimens to reach us and the dry ice available in Eritrea is not dense enough to keep specimens frozen over that transit time.
“Once testing activities commenced, we found some interesting ordering patterns,” said Ladenson. “We provide unrestricted ordering—so long as the test is stable at 4° C. Any test that is available to a patient at Barnes-Jewish Hospital is available to a patient in Eritrea. However, tests for Eritrean patients that are referred to other labs by Barnes-Jewish Hospital must meet the same specific approval criteria as that used for St. Louis patients.
“Very expensive tests are included, as are tests often misinterpreted, and tests that have value in a highly selected group of patients,” he explained. “These types of tests need prior approval by the on-call resident or fellow. Because communication can be difficult, we discourage them from drawing samples until the Central Health Laboratory has consulted us for approval. The highest volume of procedures are thyroid function tests, fertility testing, and lipids. It turns out to be not much different from the United States, but different from what many had predicted.
“During 1998, the first year of testing, we performed about 2,500 tests. Forty percent were thyroid function (T4, T uptake, TSH), 30% were fertility tests (estradiol, FSH, LH, prolactin and progesterone), along with a few hepatitis B and C antibodies, ANA’s and vitamin B12’s. Testing increased through 2001 to almost 6,000 specimens and expanded to include, rheumatoid factors, H-pylori IgG, toxoplasma IgG, PSA’s, testosterone, creatine kinase total and MB, carbamazepine, and some phenobarbitals.
“In Asmara, the Central Health Lab focuses on what they can do with the equipment they have. They send us those tests that require more expertise,” Ladenson noted. “However, I am pleased to say they now do their own lipids and thyroid testing, thanks to Roche Diagnostics, which donated a refurbished Hitachi 717. We don’t do much infectious disease testing like HIV for them because that is supported in Asmara by a variety of grants.”
“When working in a lab in a developing country, it makes you think outside of the box,” mused Ladenson. “You have to resolve issues that never come up in the United States. You develop new ways of solving problems. It is challenging and fun at the same time. It occasionally helps if you are a dinosaur of lab medicine, as you can remember the ‘old testing’ methodologies.
“For patients not living in Asmara, seven regional hospitals have been established around Eritrea. These seven regional hospital labs do basic chemistry and CBC’s. They utilize small chemistry analyzers made in India which are similar to physician office testing analyzers, but on a smaller scale. CBC’s are done on small cell counters donated by Beckman Coulter International. The equipment in the regional hospital labs is correlated with the equipment in the Central Health Lab, which is correlated with equipment in St. Louis,” said Ladenson.
“Numerous companies have donated laboratory equipment for Eritrea. In many cases, these companies followed through to insure the equipment is functional,” noted Ladenson. “Companies that donated equipment or supplies are Becton Dickinson Vacutainer Systems, Comp Pro Med. Inc., Roche Diagnostics Corporation, Dade Behring, Inc, Medical Analysis Systems Inc., Life Scan, Mallinckrodt, Inc., and Radiometer. We’ve also received support from a grant from the United States Agency for International Development (AID).
“We addressed problems with inventory control and the severe shortage of personnel. We developed a system whereby the slope and intercepts are set so results match both the Hitachi in Asmara and the Hitachi in St. Louis. This gives us a reliable way to cross check and confirm that results are within the defined parameters. It also allows us to utilize the same reagents in both the regional hospitals and the Central Health Laboratory,” stated Ladenson.
“Use of the same reagents and supplies makes training and inventory control easier,” he explained. “We find no evidence to suggest that, because of different equipment using the same reagents, testing is compromised in any way. Now we are in the process of working on quality control and patient comparisons.”
Ladenson discussed results reporting. “Once tests are completed in St. Louis, we need to transmit the results. This is not as simple as in the United States. In developing countries, electronic messaging is not as sophisticated as here. We use fax more than e-mail. That’s because we can’t be sure if they received the e-mail. The fax has proved to be more reliable. There is always the phone, but that can become expensive.”
Cost-consciousness is part of the program. “In total, the program costs us between $60,000 and $70,000 per year,” estimated Ladenson. “About one-third of that is shipping costs. This is a real bargain because it provides care to about four million people.”
One interesting aspect of the testing relationship has been the lack of a language barrier. “From our lab, Mitchell Scott has visited Eritria and knows the personnel in the Central Health Laboratory. He has met the two full time Pathologists Overseas volunteers at the Central Lab in Asmara,” he said. “Their names are Gwen Williams and Susan Morin (in Eritrea for one and three years, respectively). Both are medical technologists from the U.S., with previous experience in the Peace Corps. There is no language barrier for the volunteers, as English is used for teaching all courses after fifth grade in Eritrea.”
Ladenson provided details about the volunteer process. “We have learned that it is best that people be willing to spend at least six months on these projects,” he noted. “It provides continuity and allows more to be accomplished.
“Currently we are looking for a clinical microbiologist for at least six months of service. This is a great opportunity for the right person to provide their expertise and knowledge to some Eritreans who are very dedicated to laboratory medicine,” enthused Ladenson.
Little Support Infrastructure
“Things we take for granted in American hospitals do not exist in developing countries like Eritrea,” he noted. “There are no professional bodies that you can call to help with a problem. There are no other consulting pathologists with whom you can discuss your difficult case. There is no real infrastructure for laboratory services like we have here.
“As a result, not only do we provide reference testing, but they use us as a conduit for information. We help with education, consultation, and a variety of things to make them part of our laboratory organization here in St. Louis.
“That said, they set their priorities as to how we can assist,” said Ladenson.
“We always want to work within their range of needs and capabilities. Transplanted technology does not always work. It is important to take time and understand problems unique to their situation. We tend to suggest ways that we can support them and not impose what we think should be done.”
Ladenson’s enthusiasm for the St. Louis–Asmara reference testing relationship is obvious. “I would love to share with others how to set up this type of program. Flexibility, patience, commitment, a clear set of objectives, and a cultural awareness are most important,” he noted.
“There should be a personal or collegial relationship with someone in the chosen location,” continued Ladenson. “That means there is a champion on both sides of the equation. The shipping of specimens, calibration of instruments, consistency of reagents, and many of the clinical aspects of running a laboratory all come into play. Be prepared for delays, setbacks and some frustration, but the rewards are tremendous as you see how such testing benefits patients.”
Doing It Differently
If Ladenson were starting a new reference testing project with another location in the world, he would do a few things differently. “First, we would establish a sample identification system that is more rigid and very specific,” he said. “In Eritrea, people go by one name, not two as we do. They also don’t have unique identifiers, like a social security number. Many don’t know their birth date. With experience, we’ve ‘lightened up’ on accepting the same specimen identification criteria for Eritrea that we have in the U.S. Obviously we clarify as much as possible.
“Also, having a computer from day one would help avoid handwritten communications for test lists and other important information about specimens,” advised Ladenson. “It would make it easier to confirm, by e-mail, the shipment and receipt of specimens.”
Not surprisingly, the laboratory staff at WUSM and Barnes-Jewish Hospital often wonder what happens to the patients in Eritrea. “If an individual is diagnosed with a disease that’s untreatable in Eritrea, one of several things may happen,” stated Ladenson. “Some individuals seek treatment outside the country. Some receive donations of medical therapy from health facilities in various countries. For example, a number of children with leukemia have been treated in Germany at no charge.
Patients Are Grateful
“Even when treatment may not be possible, many Eritrean patients still express gratitude,” he continued. “Because they understand what is wrong with them, they can better prepare for the future.”
THE DARK REPORT observes that, as baby-boomer medical technologists retire, the number of volunteers for these types of international projects will probably increase. Visit Pathologists Overseas, Inc. at http://members.aol. com/pathoverc/-home.html for more information.
For laboratory directors and pathologists, the Asmara–St. Louis reference testing relationship is a powerful demonstration of how rapidly the world is shrinking. It is a reminder that laboratories must think globally, even as they act locally, because the ability of distant laboratories to offer services in any region is becoming easier and easier to do well. In coming years, local competition may come from distant laboratory competitors.
Other Hospital Labs Can Offer Similar Help
“I BELIEVE MOST LARGE HOSPITALS or medical centers could provide similar reference testing services to developing countries, once the logistics are established,” said Jack Ladenson, Ph.D. “But there must be a champion for the program; otherwise it’s forgotten.
“One reward from this program is that our laboratory staff get a sense of volunteerism by working on these specimens,” observed Ladenson, who is Interim Director, Division of Laboratory Medicine at Washington University School of Medicine in St. Louis, Missouri. “Most of our people have never been to Eritrea as a volunteer. Yet they get a great deal of satisfaction from providing patient care across such a long distance.
“Also, by working on these specimens, we get to see diseases that are usually only textbook cases in the United States,” he added. “I am regularly asked by the staff to give lectures on the cases that we see and about the project in general.
“Another way this trans-global project has benefited our daily lab operation is because our laboratory staff has gained a keener understanding about the importance of specimen identification and specimen handling. There is more attention to detail. This pays off with all specimens that we receive in the lab, regardless of whether they come from inside our hospital or halfway around the world from Eritrea.”