Wednesday, May 4, 2016

Pathology in Rwanda: Waiting for Installation

 Isaac H. Solomon, MD, PhD
 Fellow in Infectious Disease and Molecular Microbiology at Brigham and Women's Hospital

In two weeks you can learn a lot about a place.  It's enough time to learn the basic layout of a city (Kigali), where to find cheap bottled water and delicious food, and to visit a genocide memorial.  Two weeks is enough time to learn a few key words in Kinyarwanda such as "murakoze" (thank you) and "mzungu" (someone with white skin; literally translated as someone who roams around aimlessly), and to make some new friends.  Oh right, it's also enough time to teach a little pathology. 

During my two-week visit to Rwanda, I spent a majority of my time interacting with the dozen or so pathology residents who left their various locations around the country to assemble at the University Central Hospital of Kigali (CHUK).  Through a combination of lectures, slides, and writing assignments, we covered a variety of topics including implementation of standardized synoptic reports, histopathological features of infections, and scientific writing.  We also made some progress in reducing the backlog of cases, which were accumulating due to the combination of a broken tissue processor, requiring samples to be sent to another lab prior to the preparation of slides, and limited pathologists available for interpretation.

A reoccurring theme during our review of cases was the limitations of hematoxylin and eosin staining, which is easily overcome at BWH.  In many cases, "special stains" or immunohistochemical stains could have definitively proven a diagnosis or provided additional clinically actionable information.  Either type of ancillary study could be performed in a matter of hours by the available personnel with the equipment on site.  Instead, these tests required sending of material to another lab due to lack of reagents, taking days to weeks to receive the final results.  In the case of a tumor diagnosis this is less than ideal; in the case of an acute infection it is often futile. 

When you first walk into the building housing the pathology lab, you notice a crate taking up a large portion of the hallway with a label that reads "New machine (cryostat) waiting for installation."   In the adjacent room, a shiny metal workbench awaiting ventilation duct hookups is labeled "Grossing station to be installed." I was at first excited that CHUK had received this upgraded equipment, until being informed that the machines had been sitting there for years with no imminent plans for installation.  Struggling to figure out why equipment goes unused, unfixed, or underutilized and why relatively inexpensive reagents cannot be obtained, I was forced to conclude that not everything can be learned in two weeks, but at least it’s a start.

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