We need to think of diagnostic capacity beyond crises, says Laura Hallas
On Friday 14 February 2020, the first case of the novel coronavirus, covid-19 was confirmed in Africa—“confirmed” being a crucial word. In the past few weeks, low and middle income countries (LMICs) have rushed to build the capacity needed not only to isolate and treat patients suspected of having covid-19, but also to find them in the first place.
Two weeks ago, only two laboratories on the African continent had the capacity to diagnose coronavirus, raising the concern that there may be more people with covid-19 needing care in LMICs, but that we are missing them. Covid-19 is a pressing reminder that the best hope for effective outbreak control, and everyday care, is for diagnostic capacity to be prioritised before a disease ever makes headlines.
The recent surge in diagnostic capacity has been impressive. Led by the World Health Organization (WHO), Gates Foundation, and a multitude of regional organisations such as the Africa CDC, massive investments have been made to expand testing capacity in Africa. As reported in the Lancet, South Africa’s National Institute of Communicable Diseases and Senegal’s Institut Pasteur were initially the only laboratories on the continent, but by 4 February Ghana, Madagascar, Sierra Leone, and Nigeria were also able to administer testing, with the WHO since claiming capacity has expanded to 11 countries, with more joining the ranks every day.
Going from two facilities responsible for an entire continent to more widespread coverage is no doubt a substantial improvement. Yet even these gains cannot address the more fundamental challenges affecting patients every day.
There is no shortage of information about the current state of diagnostic care in many LMICs. One study of 10 countries in Africa, Asia, and the Caribbean discovered that just 2% of health facilities could perform basic testing such as malaria, HIV, and blood glucose tests. Another study in Uganda found that only 5% of laboratories in and around Kampala met WHO quality standards.
Quality diagnostics that do exist are often extremely costly—a HIV test in one Ghanian programme costs five times the minimum daily wage. In 2013, sub-Saharan Africa’s ratio of pathologists to population was just 10% that of the US’s or UK’s. Many countries have no certified pathologists at all, and one study notes that it will be more than 400 years at current education levels until medical schools in sub-Saharan Africa can fill the gap. These statistics are likely underestimates of the scope of the issue, as data on diagnostic capacity and quality are not routinely gathered.
Thus far, global action on diagnostic capacity has bypassed patients’ everyday needs to focus on epidemic scenarios, as we are seeing with covid-19. The International Health Regulations (IHR) and its subsequent revisions have always emphasised infectious diseases, such as cholera, smallpox, and Ebola. The 2005 IHR and its following 2015 (read: post-Ebola) workbook solidified this by explicitly focusing on the way that infectious disease affects travel and trade. The legacies of SARS, MERS, and Ebola sparked the Global Health Security Agenda, which was constructed to provide more specific guidance to LMICs looking to comply with the IHR. And alongside every meeting, conference, and regulation are parallel influxes of cash from donor countries like the US and UK—money that comes with the implicit goal of keeping disease at bay, keeping it elsewhere.
Experts have made it clear that we need to think of diagnostic capacity beyond crises. We can begin to achieve this goal in several ways. Firstly, national governments can embrace the 2018 Essential Diagnostics List (EDL). Like the Essential Medicines List before it, the EDL recommends quality, cost effective diagnostics for common conditions that mark a valuable starting point for governments to begin their own national list and meet local testing needs.
Secondly, diagnostic care must be made financially viable, both through reimbursement under national universal health schemes, as well as through adequate subsidies in international programmes. Health workforce must be addressed by strengthening education pathways to pathology careers and ensuring that, upon graduation, these doctors and laboratory technicians have adequate working environments.
Finally, public health institutions should continue to support regional quality control initiatives like those run by the Africa CDC to improve disease surveillance. While much work remains, these changes would both strengthen the world’s epidemic preparedness and improve everyday care in LMICs.
Ultimately, the argument for diagnostic capacity building lies with its human costs. When coronavirus testing kits ran out in Wuhan, patients were sent home with inadequate treatment, potentially to their deaths. We see the failures of diagnostic capacity when HIV diagnosis is too expensive in Ghana, TB testing requires days of travel in Tibet, or a Haitian mother cannot manage her diabetes. And then there are the millions of people who live with—and die of—diseases whose names they will never know. This latest epidemic should mark a turning point for these patients.
Laura Hallas is a public health student at the London School of Hygiene and Tropical Medicine. @LauraHallas
Competing interests: None declared.