Mr Minister, why not hire laboratory scientists in hospitals and diagnostic centres?

During a recent conference, Dr Samant Lal Sen, Health and Family Welfare Minister, said that the operation to root out illegal clinics, diagnostic centres and hospitals, scattered in different areas of Bangladesh, will be strengthened. 

I also read about a month ago that an independent member of parliament requested the Health Minister to appoint graduate pharmacists to all pharmacies in Bangladesh, which the honourable Health Minister supported and promised to take action on. These are all, no doubt, good news. 

In developed countries, when a patient goes to a pharmacy to fill out their prescription containing any new medication, the pharmacist explains to patients how to use the new medicine, how that medicine will work, what the side effects are, etc. A similar practice should take place in Bangladesh, rather than a salesperson giving medical advice. 

There are no real statistics about the number of legal or illegal diagnostic laboratories in Bangladesh; however, as a rough estimate, there are one medical university, 13 government medical colleges, 25 private medical colleges, eight postgraduate institutes, two institutes of health technology, about 3000 hospitals and clinics, and approximately over 18,000 diagnostic centres and health centres all over Bangladesh. 

The numbers of these medical colleges, diagnostic centres, and health centres is increasing rapidly because of the growing population and the increase in new emerging and chronic diseases. Although it's a very rough calculation, the total diagnostic market size is about a billion takas, with an increasing market value of 10% to 15% every year. 

Health care is quite complex in this day and age; modern healthcare is a team effort. Physicians and allied health care workers such as nurses, laboratorians, and pharmacists are all key players in the healthcare system; however, clinical laboratory professionals and the services they provide contribute to maximising the effective delivery of care in today's complex healthcare system. 

Appropriate utilisation of clinical laboratory services enhances the ability of clinicians to make evidence-based diagnostic and therapeutic decisions for their patients, using the optimal level of resources, which minimises overall healthcare expenditure. 

In Bangladesh, till today, laboratories are mostly run by short-term trained or untrained laboratory technologists with minimal or no supervision by medical or clinical (PhD holders in laboratory science) scientists. 

In some laboratories, a junior physician's name may be attached for the purpose of providing a signature on the report to make it valid. This person, however, is also not well trained in laboratory practices and cannot devote significant time to them. As a result, the quality has never been the same as developed countries' laboratory practices. 

As we all know, a wrong laboratory diagnosis can directly lead to the wrong treatment or the wrong management of a patient. As per the Center for Disease Control & Prevention (CDC), USA, over 14 billion lab tests are ordered annually, and 70% of medical decisions depend on laboratory results. That means laboratory professionals play a vital role in healthcare and patient advocacy. 

So, running a well-controlled and quality-assured lab requires well-qualified medically trained or clinically trained laboratory personnel who can monitor the work of laboratory technologists and run quality control and quality assurance metrics to provide accurate and timely diagnosis. 

For ideal patient care, there are a few steps. 

When a sick patient visits a physician, the physician listens to the patient's complaints, observes signs and symptoms and seeks other relevant information by interviewing the patient. Then he analyses all parameters, comes up with one or a few possible diagnoses to rule out those diseases and asks patients to do laboratory tests accordingly. 

The patient then goes to a designated diagnostic laboratory to perform laboratory tests. When the patient comes back to physicians with the laboratory test results, the physician or allied healthcare personnel treat them with appropriate medicine based on the laboratory test results. 

In recent days, Sars CoV-2, dengue, and many other diseases have shown how important an early and accurate diagnosis is in order to manage patients and reduce patient's significant suffering from the disease or even death. 

Apart from other chronic diseases like diabetes, kidney disease, and heart disease, we are seeing new and unknown infectious diseases spread through unknown microorganisms more frequently than ever, especially over the last couple of decades. 

Nipah virus, West Nile virus, H1N1/09 influenza virus, SARS, MERS, Chikungunya, Zika, Ebola, Monkeypox, etc, the list could go on and on. Many of these diseases are still fresh in everyone's mind. 

One thing is for sure — COVID-19 is not the end. We will see more new diseases in the coming days, and this may be due to microbial adaptation and change, human susceptibility to infection, climate and weather, and many other related factors. 

And one thing is common to all of them: viruses cause most of them. 

Whenever a person or a cluster of patients come to the emergency room with an unknown symptom or masked with known symptoms, the first question that comes to the physician's mind is laboratory diagnosis. How can we diagnose this unknown microorganism? 

Management, treatment, and prevention come next. Scientists from around the world have made significant achievements in all areas of medical fields and microbiological diagnosis, including virus, bacteria, parasites, etc. 

Today, we can identify bacteria in 30 seconds after culturing a sample, which took days to weeks a decade ago. The world has advanced in the field of microbial diagnosis using modern tools, and the most notable one is molecular techniques. 

For this reason, China was able to sequence the whole COVID-19 virus genome in 10 days from the first cluster they found in Wuhan province and share their whole genome sequence with the world community.  

Whole genome sequencing can now be done in less than a week. Good laboratories with qualified scientists can not only run commercial tests better; they are also able to develop their in-house PCR test within a week. 

Commercial tests generally take months to assemble their product, because of government policy, regulation, approval, and many other institutional protocols. Implementation of a commercial test in a laboratory can take another few weeks for laboratory validation, training, and implementation. 

Now the question is: why were many developing as well as developed countries able to develop such tests in the shortest possible time? 

The answer is simple: they had the right kind of manpower as well as equipment in their laboratories. One advantage of the western world is that decisions are made quickly to adapt to new demands. 

A couple of decades ago, most of the laboratories in western countries, either in acute care or in public health, were directed and/or supervised by physicians who had an interest in laboratory science. 

Unfortunately, very few of them had hands-on-experience with how to develop a new test or validate, evaluate, and implement a new commercial test. On the other hand, laboratory technicians were also not skilled to do that job either.  They were trained to perform tests under competent supervision. 

So there was a gap between physicians and laboratory technologists and that gap was filled with trained scientists with advanced degrees like a PhD in respective fields. More than 80% of laboratories in the USA now have properly qualified scientists with clinical certifications.  

To be a microbiologist, a PhD scientist should be certified by the American Board of Medical Microbiology (ABMM), a biochemist needs The American Board of Clinical Chemistry (ABCC) certification, while a geneticist needs The American Board of Medical Genetics and Genomics (ABMGG) certification, to name a few. 

There are also similar organisations in other countries. For example,  a microbiologist with a PhD is qualified to sit for the MRCP exam in England and in many other countries. This certifies them to do clinical practice alongside physicians. 

To my knowledge, there are no trained laboratory scientists who can supervise laboratories or  develop new tests when needed in any acute care hospitals or diagnostic laboratories in Bangladesh. 

Nonetheless, Bangladesh produces hundreds of microbiologists, biochemists, and geneticists every year, and many of them are proudly serving the global community. Unfortunately, they have no use in their own country.  

With more trained scientists, more tests would be readily available, no one would be refused tests, no one would be denied access to the hospital for dialysis or need hospital access for a sudden heart attack or stroke. Evidence also shows that in-house developed tests are superior to those expensive commercial tests.

My humble proposal for the Government of the People's Republic of Bangladesh, and especially to the Health Minister, is to consider restructuring the whole diagnostic field of healthcare and create positions for trained laboratory scientists such as microbiologists, biochemists, geneticists, etc. 

At least we should start that by appointing certified MSc or PhD scientists to the public health laboratories, with proper clinical training, at major teaching hospitals, large hospitals, and diagnostic centre laboratories, so that they can serve the country better alongside our physicians and pharmacists. 

They could jointly be a power team to fight against these new emerging diseases as well as keep the quality of the lab as good as in any western country. I also believe this initiative will help to stop illegal diagnostic centres and clinical laboratory practices in Bangladesh.

Dr. Muhammad Morshed, PhD, SCCM, is a Clinical Microbiologist and Program Head, Zoonotic Diseases and Emerging Pathogens, BC Centre for Disease Control, Vancouver and Clinical Professor, Dept. of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada. Email: muhammad.morshed@bccdc.ca

This is the author's own opinion; please note that BCCDC or UBC does not endorse the opinions expressed in this article. 

Disclaimer: The views and opinions expressed in this article are those of the author and do not necessarily reflect the opinions and views of The Business Standard.