Can the ASLM Conference reinvigorate laboratory medicine in Nigeria?

As someone who advocates strongly for diagnostic development in Africa, where else would I be in early December but in Cape Town for the third conference of the African Society for Laboratory Medicine (ASLM 2016)?  I am a member as well as a follower of this Society’s activities, closely watching its challenges and successes.  ASLM has turned out to be one of the best of my unfolding dreams.  In this dream, hard work produced results, professionals saved lives, institutions have been built, careers have been nurtured and very visible and tangible progress has been made.

After ASLM’s conference in 2012, I was full of accolades for the work accomplished in its first year, and actually boasted that laboratory medicine has matured in Africa. At the time, accreditation was rare outside South Africa but an impressive number of diagnostic laboratories had begun Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA).  In my excitement, I presumed we had reached our pinnacle.  Now I almost cringe to admit how naïve I was and how low my standards were.

Today, dozens of labs are internationally accredited, over 30 outside South Africa.  And not just reference labs – some countries can boast of more than one accredited district lab.  The progress made in the five short years of the society’s existence is phenomenal.  The conference presentations on quality assurance chronicled this progress and were forward-thinking about the challenges ahead.  One distinct characteristic of this ASLM meeting, as the ones before, is that the biennial meeting is not a space to chronicle problems, but to solve them.

In addition to its essential focus on laboratory quality, presentations and exhibits featured development in the field, including the excellent progress that has been made towards early HIV testing.  Testing newborns for HIV is technically more difficult than screening everyone else. Current testing protocols make it possible to place an HIV-positive patient of any age who had no idea of his or her status on antiretroviral therapy within hours – even in a remote rural area.  As unbelievable as it might be to the naysayers, testing has comfortably settled at the point-of-care.  Today’s technologies are faster, more robust and easier to perform.  And impressive progress has been made towards moving to routine viral load testing as the new Gold standard for care.  Indeed one of the ASLM Best Practice Awards went to the National Viral Load laboratory in Uganda for its impressively rapid scale-up and roll-out in this area.

In departure from years past, when laboratory excellence in Africa was almost entirely focused on HIV, this year’s ASLM Conference pushed boundaries by focusing on global health threats more generally, exploring the problem of antimicrobial resistance – a foremost frontier for diagnostic development – and taking a long hard look at non-communicable diseases such as cancers and diabetes, questioning how best the laboratory should support these.

With the tremendous progress that has been made in Africa, two important challenges have kept me thinking deeply about how Nigeria might scale our own laboratory medicine roadblocks and deliver what we owe our patients.

The first is a simple problem of roll out, which has gone better in some countries than others.  Compared to regional neighbours, as a whole, we in West Africa have the fewest functional quality laboratories and the weakest links between the laboratory and the clinic.  It is not enough to have technologies, caregivers must be able to order the relevant tests and use them to better a patient’s care.  While we are improving at a rapid rate, this does not happen for many patients on the continent and for most in Nigeria.  We don’t have enough labs, we don’t use the ones we have to capacity, investments in labs are far below need, laboratory professionals are not well integrated with each other and other health care workers, patients and many health care providers have a limited appreciation of what laboratories can do for care.

A second problem is that, even though there has been significant progress in quality in HIV testing laboratories, more HIV labs need to participate in existing programs and the message of quality has yet to make a mark on much of the rest of Nigeria’s diagnostic empire.  Twenty labs from seven countries received awards for accreditation at this year’s ASLM award ceremony, not a single one was from Nigeria.  The number of accredited labs in Nigeria continues to be in the single digits and enrolment in SLIPTA is dismal.  Continent-wide, the category with the fewest accreditations was microbiology, my own field and the one that is expressly needed to address the antimicrobial resistance epidemic which we currently find ourselves battling.

So, the end of such a great meeting was bitter-sweet for me.  In spite of so much progress in so short a time, the students who accompanied me to the meeting said that the closing award ceremony had really showcased Nigeria’s individuals rather than its labs.  In 2012, when my students were not yet qualified to join ASLM,  I had made exactly the same remark.  Like them, my eyes dampened as Professor Oyewale Tomori, our Nigerian Academy of Science President and a true champion of laboratory medicine in Nigeria, Africa and the world made his characteristically thought-provoking and funny acceptance speech as he took the Lifetime Achievement Award.  In it, he generously said that the award was for all of us but I could not help but think that in some countries, institutions could lay claim to a piece but it would be individual colleagues in Nigeria that had made the greatest contributions to our continent’s laboratory medicine.  Earlier in the meeting, Professor Tomori had suggested that we no longer need to build capacity in Africa,  we already have it.  We just need to enable it.  This is certainly food for Nigerian thought.

Iruka Okeke