ASCP Global Health Fellowship Helps to Expand Laboratory Medicine in Western Africa

Laboratory medicine plays a critical role in the diagnosis and treatment of disease in the United States and other high-income countries around the globe. Yet in many under-resourced countries, laboratory medicine is a neglected part of the healthcare system.

One example is the West African nation of Ghana which has more than 31 million people and approximately 15 neurosurgeons. However, it has no dedicated neuropathologists. While the number of neurosurgeons has increased in all geographic regions over the last decade, there are over 22 million additional needed neurosurgical procedures in low- and middle-income countries (LMICs).¹

Given the relative paucity of neurosurgical specimens and lack of fellowship training, there are no dedicated neuropathologists. Furthermore, there are few pathologists with international fellowship training in neuropathology and even fewer board-certified neuropathologists. That said, recent (2019) and upcoming (August 2022) international neuropathology conferences and the first West African brain bank in Nigeria highlight the growth of the field in the region^.2

To address this situation, Joshua Klonoski, MD, PhD, a neuropathology fellow at the University of Utah Medical School, and professor emeritus and medical director at ARUP Laboratories Cheryl Palmer, MD, flew to Ghana in February to provide neuropathology training to roughly 30 pathologists and pathology trainees at two hospitals in the country. In addition, invited clinical colleagues from the neurosurgery and neurology departments were present. They were supported virtually by an adjunct faculty member from the Utah Office of the Medical Examiner (OME), Andrew Guajardo,MD, (FP/NP), as well as a chief pathology resident, Eric Goold, MD. Their medical outreach was supported by two ASCP Trainee Global Health Fellowships that Drs. Klonoski and Goold received from ASCP. 

ASCP Trainee Global Health Fellowships are intended to offer pathology residents and fellows the opportunity to expand their knowledge and experience by going beyond the training received at their local institutions. It provides exposure to the practice of pathology in a low- to middle-income country setting as part of ASCP’s Partners for Cancer Diagnosis and Treatment in Africa initiative. 

In Ghana, Drs. Klonoski and Palmer performed one month of neuropathology outreach services at Komfo Anokye Teaching Hospital (KATH) in Kumasi and the Korle-Bu Teaching Hospital (KBTH) in Accra. (Kumasi is several hours northwest of the capital city of Accra.) In all, they presented 40 neuropathology instructional and interactive lessons at the two hospitals. 

During their two weeks at each hospital site, they presented educational sessions covering the World Health Organization 2021 brain tumor classification system, neuroautopsy, neuroinfectious disease, neurodegenerative disease, neuromuscular disease, forensic neuropathology, neurodevelopment, and unknown case conferences. Eight brains were examined at four neuroautopsy conferences and 10 case consultations were performed upon request. Meanwhile, Dr. Goold worked remotely to organize 10, one-hour virtual general pathology lectures and develop continuing outreach for KATH and KBTH. Specifically, Ghanian pathologists and trainees continue to have access to morning lectures and a Ghanian trainee will receive funding to spend one month at the University of Utah in the cytopathology division.  

“For pathologists and pathology trainees at KBTH, the outreach was the first of its kind in neuropathology and afforded all the opportunity to have a structured review of neuropathology covering the 2021 WHO Brain Tumour Classification as well as other aspects of neuropathology,” said Afua Abrahams, MBChB, FWACP, FGCPS, Head of the Pathology Department at KBTH, in Accra, Ghana “The brain examination sessions were particularly appreciated; hitherto, brain examination was approached from a purely general pathology point of view. The experience was a much appreciated one.”

A survey of 16 questions, including 12 multiple choice questions and four short answer questions, was used to assess each component and the overall satisfaction of the outreach. The 16 submitted attendee evaluations demonstrated an overall high level of appreciation for the educational sessions, with only the virtual forensic neuroautopsy sessions statistically less appreciated. Pointed formal and informal feedback on the forensic sessions revealed difficulties with electronic access, as well as audio background noise and difficulty visualizing anatomical details on attendee portable devices. Overall, this hints that even live, high-quality distance learning may be limited in future outreach efforts without further consideration and improvement.

Beyond this feedback, one respondent indicated he/she would consider focusing future dissertation research on neurodegenerative disease in Ghana. Several others commented on the utility of molecular updates in the World Health Organization Classification of Tumours of the Central Nervous System, 5th ed. Lyon: International Agency for Research on Cancer, 2021.  

Following his return, Dr. Klonoski said, “We are inspired to continue our outreach in Western Africa. I think our trip has inspired the Ghana programs to start putting a list of consulting pathologists together and realize the potential of their whole slide imagers.”
One concern that he and his mentors have is the state of microscopes and equipment at the two hospitals. “They have no functional multihead scopes for optimal trainee teaching. KATH needs a new autostainer, and KBTH needs a new tissue processor,” he said.

As neurosurgical care and neuropathology expertise continue to grow in need in Western Africa, continued neuropathology outreach will be required. The team asserts that the recent effort in Ghana is an imitable model for future neuropathology outreach. To highlight these efforts and resources for others in neuropathology and the pathology community at large, a platform presentation was delivered at the American Association of Neuropathlogy 2022 meeting in Florida, June 9-12. An abstract has also been submitted to the ASCP 2022 Annual Meeting, Sept. 7-9, in Chicago. A publication is also in process.

ASCP Chief Medical Officer Dan Milner, MD, MSc(Epi), FASCP, reflects on how this outreach serves to fulfill the goals of ASCP’s global health fellowships. “ASCP’s support of these sites offers the unique opportunity for applicants to participate in ongoing research or propose a short-term research project,” he said. 

Resources

1. Mukhopadhyay, S. et al. Neurosurgery JNS, 130,4 (2019), 1142-1148. 

2. Akinyemi RO, Salami A, Akinyemi J, et al. Brain Res Bull. 2019;145:136-141. doi:10.1016/j.brainresbull.2018.08.014

3. WHO Classification of Tumours Editorial Board. World Health Organization Classification of Tumours of the Central Nervous System. 5th ed. Lyon: International Agency for Research on Cancer; 2021.