Ann Senga (not her real name), an 18 year-old from Turkana County has been feeling unusually tired during the day and has had low-grade fevers, night sweats and a recent swelling in her neck.
Her household chores, like fetching water from the nearby stream that she usually finds effortless, now leaves her dizzy and unstable. Her mother first takes her to a renowned traditional healer in the community, who prescribes a mixture of herbs to cure the ailments. She dutifully takes the herbs but sees no improvement. Her next stop is the nearby health centre, where she’s given antimalarial drugs and multivitamins.
After a week, her condition is still worsening and she finally travels to the only public hospital, a 85km drive on unpaved, muddy roads. When she finally arrives, she learns that the necessary laboratory and radiology tests cannot be performed because the laboratory reagent stocks are out, the next supply of reagents is uncertain and the X- ray equipment has been broken down for the past three months.
Four months later, upon securing a small loan from the village self-help group, mother and daughter finally make their way to Nairobi for testing only to be informed that she has advanced Hodgkin disease, which would require intensive chemotherapy. However, given the delay in diagnosis, the prognosis is extremely poor.
Unfortunately, lack of access to diagnostics leading to delay in diagnosis of potentially curable diseases is a typical scenario in many regions especially in the low and middle-income countries (LMICs) in the sub-Saharan Africa region.
Fractured health systems make access to accurate, cost effective and timely diagnosis unattainable. The lack of diagnostic capabilities in many LMICs in sub-Saharan Africa region is certainly no secret to patients like Ann Senga and their families. This is due to the fact that the health systems and infrastructure for LMICs has suffered from many years of neglect, lack of serious investment and a heavy burden of non-communicable diseases.
In addition, the recent Covid-19 pandemic has brought the shocking lack of diagnostic capabilities at the forefront of public health and has spared no health system, revealing old and ignored fault lines within the entire healthcare landscape. Across both high-income countries (HIC) and low- and middle-income countries (LMICs) a common failure has emerged; access to accurate and timely diagnosis.
Notably, different approaches have been deployed in the management of Covid-19 cases and they vary from country to country, with varied success in controlling local epidemics. Widespread viral testing has been much more available in some countries than others. In developed countries such as the United States, tests have been in limited supply, with testing prioritised to hospitalised patients, healthcare workers, and contacts of known cases of Covid-19.
Lessons are being learnt during this period and the most important one is the value of readily available and prompt diagnostic testing. Without the ability to accurately and quickly diagnose cases of Covid-19, patients in sub-Saharan Africa are becoming increasingly vulnerable.
In Africa and much of the global South there are few diagnosed cases of Covid-19 patients, but public health experts question whether this is due to a low incidence of the disease or the lack of available diagnostic testing.
As per the latest statistics from Kenya’s Ministry of Health, there was still inadequate testing, with the country having only tested just over 100,000 Kenyans against a population of 53 million by the second week of June.
In Malawi, one of the poorest countries in Africa with a population of 18 million people and with one of the highest HIV rates in the world, a recent survey conducted for the Lancet Commission on Diagnostics, shows that only 20percent of the population have access to diagnostics within a two-hour journey.
In Haiti, in the Caribbean, only 257 of the 11 million people had been tested for Covid-19. In countries where the social distancing is not feasible for the poor, the lack of a diagnosis and subsequent quarantine can have devastating financial and social effects.
Perhaps, some of the most vulnerable populations within these LMIC’s are those like Ann Senga who have oncological diseases, cancer, HIV, or tuberculosis, or are immunocompromised, but due to limitations in the diagnostics equipment and workforce, must travel to the same central locations where diagnosis or treatment of Covid-19 patients is ongoing.
With regards to oncological diagnoses in sub-Saharan Africa, there is only one anatomical pathologist per million populations, compared to about 44 per million patients in the United States. In China, it is estimated that there are only 7.4 anatomical pathologists per million population. This is according to (unpublished data,) Chinese Society of Pathology, 2015.
During this pandemic, there is a great need for policymakers in health to ensure that they strike a balance between the health response to Covid-19 with the need for continuous delivery of other health services such as cardiovascular diseases, cancer, HIV, diabetes, respiratory illnesses like TB and other critical healthcare services amongst the entire population.
This is solely because for patients in LMICs with cancer, HIV or tuberculosis, a four-month delay can be a death sentence. Therefore, as the Covid-19 pandemic forces us to rapidly reconstruct our health care systems, and as we make national and global decisions about investments in pandemic preparedness and health system strengthening, let us not forget patients like Ann Senga. She represents our most vulnerable population. Health equity and health security both start with diagnostics!
Dr Sayed is Associate Professor and Consultant Pathologist, Aga Khan University Medical College. Dr Meara is Kletjian Professor of Global Surgery and Director, Program in Global Surgery and Social Change, Harvard Medical School. Dr Jean Wilguens Lartigue MD and Dr Alexis Bowder MD are both Paul Farmer Global Surgery Fellows, Program in Global Surgery and Social Change Harvard Medical School.