We had a very large caseload of run-of-the-mill infections and the pathology of poverty – malnutrition, tremendously advanced cancers, all kinds of things. It’s a hospital that covers the full spectrum of human pathology, from zero to 18 years of age.  I could see cancer, or I could see tremendously infected patients because they hadn’t eaten properly ever in their lives
Miguel Reyes-Múgica (Mexico and USA)

  More quotes on International Perspective

A number of people have experience of working in different countries and cultures, and this collection of conversations offers some insights into the working conditions, disease profiles and pathology practices in a variety of settings in the US, UK, Africa and South America.  In much of the developing world, where resources for health are extremely limited, there are no pathologists working locally. 

For many years St Thomas’ hospital in London ran a postal service, started by Michael Hutt in the 1970s, providing diagnostic histopathology for mission hospitals abroad, particularly in Africa. Sebastian Lucas took over the service on Hutt’s retirement and this allowed him to develop his expertise and passion for infectious diseases: “I saw loads of things I had never seen before; things that don't happen in Britain; wonderful parasites that simply don't happen anywhere else.” 

This experience was invaluable when he came to work on HIV and AIDS internationally: in Africa and the West, the disease profile was very different.

I saw loads of things I had never seen before; things that don't happen in BritainMiguel Reyes-Múgica and Francisco González-Crussí who trained in Mexico, and Kumarasen Cooper, who trained in South Africa, also comment on the fact that what they experienced in these countries was “the pathology of poverty”, which meant largely infectious disease.  All are now practising in the United States where diseases of affluence, such as heart disease, diabetes and cancer, predominate. 

A further factor in treating the diseases of poverty is that for a variety of reasons -- not just cost -- people often don’t present until the condition is far advanced.

There are other differences between continents that affect the practice of pathology.  In Africa, where services are thin on the ground, there is little scope for specialisation, as both Richard Hewlett and Dhiren Govender point out.  Hewlett, almost the only neuropathologist practising on the continent, had to train in the UK and USA, and has the found the lack of resources for specialist services hugely frustrating.

While ethical standards often reflect different cultures and attitudes to death, increasing globalisation and international cooperation – given a huge boost by new communication technologies – are encouraging uniformity.  A number of interviewees discuss the pros and cons of this trend to ever tighter controls. 

Sebastian Lucas, for example, talks about his participation in groundbreaking work on HIV, AIDS and TB in Uganda and Cote d’Ivoire in the late 1980s and early 1990s which, he points out, would no longer be possible under current rules governing patient consent.

The sharing and exchange of information among pathologists internationally has also thrown up the vital importance of consistent classification of diseases.  Elaine Jaffe, for example, talks about the varying classification of lymphomas in different countries, and how WHO was involved in setting a universal standard.

Key interviewees: 
Sebastian Lucas, Richard Hewlett, Miguel Reyes-Múgica, Francisco González-Crussí, Kumarasen Cooper, Derrick Pounder, Juan Rosai

See also:
History of Pathology, Legislation and Regulation

 

QUOTES

Sebastian LucasThe [pathology] specimens would come in by post. Surgeons in mission hospitals all over the place – but particularly Uganda, Kenya, Zaire as it was then, Rwanda, all central Africa, Tanzania, and Sierra Leone, just lots of places – would send in these specimens. They'd do operations, put their specimen in formalin, let it fix, then pack it up, usually in the used ends of surgical gloves which are very good containers, water-tight, tie off the ends with a piece of cotton or simply tie a knot in it like a balloon, put it in an envelope. Post office didn't give a damn; they didn't leak very often!
 - Sebastian Lucas (UK)

Kumarasen Cooper[The future of pathology?] It’s difficult to predict where we’re going, it really is, bearing in mind the global perspective, and the disparities between countries in how we practise pathology.  In Africa they’re having difficulty getting basic stains; in the United States it’s whether you should do the super-stain or not. You cannot say that these disparities don’t affect all of us – this is a global village. So where do we go from here?  I really don’t know.
 - Kumarasen Cooper (South Africa and USA)

Dhiren GovenderWe knew what the experience was [with nephroblastoma] in the US and Europe. Those were first world scenarios, and we wanted to see what was happening in the third world, and we are largely third world here. If you are in Cape Town and Johannesburg you think it's the first world, but if you go 10 kilometres outside the city you will see a developing country. The majority of patients referred to King Edward Hospital in Durban, over 70%, were rural, and we wanted to see: is there anything different? One of the things we found was not about the science; it was purely about socio-economics.
 - Dhiren Govender (South Africa)

Among pathologists at the moment we don't have sub-specialities like you would have in the UK...  Here everyone trains as a generalist... If we had to go to the sub-speciality stage, the numbers required would double or even treble...  I can't justify that in terms of my department, because I'm fee-for-service, so it's the money that we make that is used to pay the salaries. Now, if we don't make enough money, we can't employ.
 - Dhiren Govender (South Africa)

Miguel Reyes-MúgicaWe had a very large caseload of run-of-the-mill infections and the pathology of poverty – malnutrition, tremendously advanced cancers, all kinds of things. It’s a hospital that covers the full spectrum of human pathology, from zero to 18 years of age.  I could see cancer, or I could see tremendously infected patients because they hadn’t eaten properly ever in their lives. So I was exposed to a massive amount of paediatric human pathology in the four years that I spent there... Some people were well-off, but they came to that hospital because it was the most advanced paediatric hospital in the country.  But most of what I saw was pathology that is exacerbated by the lack of resources. People with advanced cancers, for example, were sent -- people that, had they been seen a year before, would never have presented with these tumours...invading their whole anatomy.
 - Miguel Reyes-Múgica (Mexico and USA)

Dhiren Govender[Fetal alcohol syndrome] is a big problem, because of some of the labour practices that we had in the Western Cape. In the past wine farmers, the vineyards, used to pay their staff by giving them wine instead of salaries... Now you can't get away with it, because we have a labour relations act which governs how employers treat their employees. But [the 'tot system'] is one of the roots of the alcohol problem. The Western Cape, where the vineyards are, has one of the highest prevalence of fetal alcohol syndrome, I believe, and the reason is socio-economic and a legacy of the past.
 - Dhiren Govender (South Africa)

Francisco Gonzáles-CrussíIt was the pathology of poverty, where I was working.  It was a hospital for the indigent, and I remember seeing so many patients, or autopsies of patients, with hepatic amoebic abscess -- something that one does not see in North America, unless it be in immigrants. And tuberculosis, which also had largely been eradicated from the industrialised countries -- it was very common in Mexico at that time. So amoebic abscess, pulmonary tuberculosis and such things, I saw there, and I didn't see when I came here!
 - Francisco Gonzáles-Crussí (Mexico and USA)

There are no articles in this category. If subcategories display on this page, they may have articles.

Copyright © 2019 | Conversations with Pathologists. All Rights Reserved. Design by MK Digital

Please publish modules in offcanvas position.