A young child living in Sub-Saharan Africa presents to a rural health care clinic with a one-week history of fevers, night sweats, chills, and malaise. The child’s mother does not know if the child has lost weight in the recent past; when weighed, the child is significantly below the expected weight for her age. No other family members, including other young siblings, report similar symptoms. Physical examination reveals a fever, mild increase in heart and respiratory rates, and enlarged lymph nodes along both sides of her neck. The clinic does not have access to imaging studies, and the only available pathology laboratory tests show that the patient does not have serologic evidence of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) infection or malaria. She is mildly anemic as measured by a manual spun hematocrit. The physician wants to refer the patient to a hospital in a nearby city, but the family does not have sufficient resources.
The physician offers to collect blood for pathology testing and send it to that hospital for testing, but because the hospital requires advance payment for pathology tests, the family again does not have the resources. The physician completes the notes, indicating that the differential diagnosis is broad—including tuberculosis, nontuberculous mycobacterial infection, disseminated fungal infection, Epstein-Barr virus infection (infectious mononucleosis), and malignant lymphoma—and that accurate diagnosis requires pathology investigations, including both microbiology and anatomic pathology. The family leaves the clinic, and the patient is lost to follow-up.
This scenario is played out daily in many countries across the world and illustrates one aspect of the crucial role that pathology has in ensuring effective health care, namely, diagnosis. Despite recent progress in controlling communicable disease, the need for pathology is growing as the burden of noncommunicable diseases increases. There were approximately 14 million new cases of cancer and 8.2 million cancer-related deaths in 2012 (Stewart and Wild 2014), but treating these cases accurately is impossible unless the pathological diagnosis is known. Cancer is predicted to increase by 70 percent by 2032, with more than 60 percent of these new cases in Asia, Central and South America, and Sub-Saharan Africa. Similarly, diagnosing and treating patients with diabetes mellitus—another developing epidemic in low- and middle-income countries (LMICs)—is impossible without the ability to measure the levels of glucose in the blood. The diagnosis and risk stratification of cardiovascular disease requires pathology, for example, to check levels of serum lipids such as cholesterol.
This chapter specifies an essential minimal package of services that should be available in LMICs to provide access to pathology services that are of acceptable quality, affordable, and timely to a majority of the population, especially outside of major cities.
© 2018 International Bank for Reconstruction and Development / The World Bank.