Transfusion Medicine in Africa – SADC Visits Part I (February 24, 2012)

James Kelley, PhD, MD (BWH Clinical Pathology resident)

The Southern African Development Community (SADC) is a group of nations in southern Africa that share information, infrastructure, and trade regulations to spur regional growth and prosperity. Being based in Johannesburg, as the home office of my host organization (Safe Blood for Africa) and the home of the busiest airport on the continent, I toured the national blood services of SADC countries to learn about transfusion medicine in Africa, compare their capabilities in both urban and rural settings, and offer medical/technical advise when appropriate. Such a trip also allowed me the opportunity to teach blood safety to many clinicians, as this is a topic rarely discussed in medical training. Blood safety is particularly important in a region with high levels of transfusion transmitted infections (TTIs) such as HIV, hepatitis, and malaria. The WHO reports that only 43% of national blood services routinely test for these infections.

Lesotho – The Lesotho Blood Transfusion Service (LBTS) is based on a back hallway of a shopping mall in Maseru, their capital city. The main entrance to this shopping center was full of people selling phone cards, live chickens, fruit, lingerie, and tires. The manager of the LTBS is an exceptionally capable woman, who has led numerous improvements in the service including introduction of disease and compatibility testing. Their service collects and dispenses approximately 7,000 units per year from regional centers and blood drives. (For reference, BWH averages 68,000 transfusions per year.) The LTBS does not have a medical director to oversee or consult on operations, which complicates communication with other physicians and advising the Ministry of Health on needs. One striking feature of their blood service is that in the past five years, they have had no transfusion reactions, which occur in >1% of blood transfusion recipients in the US. Upon asking an internist in the hospital about the possibility of under-reporting or lack of awareness regarding reactions, I was told “God was generous to the Basotho people; we are very strong and do not have such troubles.”

Mauritius – The Mauritius Blood Service has impressive human capital with a clinical pathologist at the helm. They have an aggressive and innovative donor recruitment program that helps them deliver 45,000 units per year to an island nation of 1.2 million people. One constraint of working in a sovereign island setting is the isolation. Producing enough critical mass for training laboratory technicians, biomedical engineers to repair equipment, and medical specialists is difficult. For example, there are no clinical hematologists on the island. They also have surveillance programs for TTIs uncommon in the US such as Chikungunya. I was able to deliver their version of grand rounds, which is shared among all specialties, and discuss clinical use of blood.

South Africa (outside of Johannesburg) – I visited the National Bioproducts Institute located outside of Durban, which is the only fractionation facility in the continent. It was interesting to see how plasma is pooled by the thousands of liters and used to produce coagulation factors. I have also visited a rural hospital located in Piet Retif (Mpumalanga) in order to compare with the hospitals in Johannesburg. Again, I was able to discuss and lecture the medical staff on transfusion medicine. They were very concerned about the availability of blood products, which was surprising to me given the highly efficient South African National Blood Service (SANBS) located in Johannesburg. There are difficulties though in a rural setting, as the nearest blood bank to this hospital is a 3 hour round trip, which makes obtaining blood in an emergency difficult.

Swaziland – The Swaziland National Blood Transfusion Service produces 10,000 units per year in amazingly well equipped facilities. King Mswati III, their absolute ruler, has made friends and diplomatic recognition with the Republic of China (Taiwan). In return, they have provided advanced medical facilities including a four-story state of the art building dedicated to the blood service and new ICU facilities across the country. Swaziland lacks though in the human resources capacity to use fully these physical buildings completely. I was able to visit their main service, tertiary referral hospital, provincial hospital, and blood collection drives. Swaziland has one of, if not the, highest HIV prevalence in the world at 35%. They have to limit their blood donors to those under 18 where the prevalence is about 2%. This raises interesting challenges as all collections are at high schools and in donor clubs during the holiday periods.

Next stops … Mozambique, Botswana, and Namibia

Outcomes, HPV status, and Attitudes among American Indians in South Dakota with Head and Neck Cancer

He Sapa Wacipi (Black Hills Powwow)

Our first community event was the Black Hills Powwow, a cultural gathering with dancing, singing, and socializing. I am working closely with the Walking Forward Program, which is a community based participatory research program working to increase cancer cure rates for American Indians. Over the course of three days we administered over 100 surveys and performed 41 head and neck screening exams. 

Grand Entry for the Powwow

My husband setting up the screening booth

Dr. Petereit, a radiation oncologist, and director of the Walking Forward Program and I

A participant and I in the screening booth

My son after all the hard work 

Sunshine Dwojak, MD, MPH
Harvard Program in Otolaryngology

Amputation in Tanzania

I am a general surgery resident at the MGH who recently returned from a two week trip to Tanzania.  I kept a blog while I was there and it can be accesses here.

An American Pathologist in Malawi: Settling into a Rhythm

            It is always just a matter of time for someone to get used to his or her surroundings.  Even far away from home, I’ve come to establish a routine for my days.  The Malawian sun rises around 5:30 AM, seemingly perfectly timed to the cacophony of cawing crows and barking neighborhood dogs.  After enjoying some local breakfast of “Jungle Oats” and coffee, I take the short walk to the College of Medicine and arrive around 8:00 AM.  On most days, the slides and paperwork await.  On other days, there are no cases in our inbox for one reason or another.  There have been a few days where the college has lost water or power (or both), leaving the histology technician helpless to prepare the daily cases.  Even if the cases are ready, we need electricity to power the light in the microscopes and the computers to generate our reports. 

I’ve come to consider these issues to be minor hiccups in the lives of pathologists here.  This is compared to pathology back in Boston, where losing water and power aren’t usually an issue.  However, the routine problems encountered in Malawi are replaced by a slough of other issues that exist in the majority of larger institutions with more equipment, staff and cases (misplaced slides, misplaced paperwork, crashing computer servers, etc.).  It is sobering to see that no institution is perfect, regardless of the size of the facilities.

Cutting surgical specimens with a
Malawian pathology registrar

            I have become used to other aspects of the Malawian department as well.  For example, I have settled into the method of teaching here.  There appears to be much more hands on training in the laboratory in the first years of medical training.  The medical students and rotating residents (called “registrars”) here are eager to learn, both at the grossing bench and the microscope.  I must admit it is quite enjoyable to watch them approach pathology with such enthusiasm. 

            By now, we have completely caught up with the backlogged workload, and are examining specimens that were taken just a few days ago.  Furthermore, my initial shock and awe at the severity of lesions biopsied here have subsided, allowing me to settle into a rhythm of diagnosing cases relatively comfortably.  We, as BWH pathologists, are very fortunate in that we have expertise available back home for unusual cases.  (We already have sent a few cases back to Boston to be looked at by the BWH subspecialty pathology services.)  For this reason, I have been afforded the opportunity to start an interesting teaching collection of rare cases to show my colleagues back home. 

            This has been once-in-a-lifetime experience so far.  I feel that my contribution here in Malawi has been worthwhile up to this point, and I have seen how much I can produce given the limited resources.  Accepting the challenges here and taking this worthwhile experience home will certainly help me overcome any challenges at home. 

Kevin Golden, MD/PhD

PGY-5, Surgical Pathology Fellow