January 23 - What of Implementation?

We visited the Ministry of Health, Makerere School of Public Health (MakSPH), and spoke with Dr. Lukande from Makerere Medical School on the steps and challenges of implementing a decentralized pathology diagnosis.

Ministry of Health

We have passed by this building before - Ministry of Health. As our van rolled in, we noticed a malaria campaign going on at the side of the parking lot. Dr. Acharya can be seen curiously peeking over at what is going on, being heavily involved in the vector surveillance project VectorCam which is being worked on by one of our other CBID (Center for Bioengineering Innovation and Design) teams this year.

It took us awhile to find our way - we first ended up in the room of the commissioner for the NDC before we eventually found our way to the commissioner for NCD (Non-Communicable Disease). Dr. Charles Oyoo was expecting us, and welcomed us into his office. He shared that decentralization was in line with the Ministry’s goals for breast cancer. He alluded to the development of regional cancer centers in Mbarara, Gulu, and Mbale, and shared that the goal was for cancer treatment to be available at regional health centers in the coming future. He also shared with us the general pathway that needs to be followed for us to pilot an intervention, as well as the approval process for the eventual implementation of the intervention. Dr. Oyoo was very helpful and encouraging of our project, and provided us with multiple helpful contacts.

MakSPH

We then found our way to Makerere School of Public Health (MakSPH), where we met with Dr. Waiswa. Dr. Waiswa had helped us tremendously in our first foray into Women’s Health back in August 2022. He has a great breadth and depth of knowledge in maternal health, and has continued to support us even as we narrowed down our project to the field of breast cancer. We exchanged thoughts on possible modes of intervention and he alluded to the HIV’s intervention model as something that we can look at for inspiration. Heavy surveillance and screening was brought to the women with the 90/90/90 goal - 90% screened and treated by 1990. He believes that bringing diagnosis to patients at HC4 (community level) is a good place as hospitals can be ‘overwhelming’ to many of these patients.

The Johns Hopkins group with Dr. Waiswa

Also at MakSPH, Professor Orach came from his meeting later than expected. We only got a short introduction with him. However, he expressed keen interest in working with us for evidence generation in the breast cancer project.

Dr. Lukande

We then made our way to Mulago Guest House, where we finally got to meet with Dr. Lukande who had been mentoring us and connecting us with clinics, hospitals, and pathologists well before we made our second trip to Uganda. Before we spoke of anything else, Dr. Lukande introduced us to the boda-boda culture in Uganda - an effort that organized itself when the government failed to provide the organization for public transport. However, this disorganized organization proves to be chaotic. Many boda riders (as we have witnessed), do not follow rules - running red lights and zipping amongst cars. I would venture to hypothesize that the bulk of Kampala’s traffic jam is caused by Bodas incessantly snaking itself around already slow-moving traffic, especially along the many round-abouts amongst the main roads that cut through the capital city. We have also heard of many Boda-related accidents that have led to lives lost. However, Boda remains a key part of the transport system in Uganda.

A parallel can be drawn for breast cancer pathology, where the destination is the diagnosis for the breast cancer patient. As with riding the Boda, we may not get to that ‘final destination’. Samples can be lost, mixed, or improperly fixed. Along different pathways, there exist challenges that can cause a patient and their healthcare provider to not reach the destination of getting a proper diagnosis.

Biopsy samples used to be transported in wooden blocks through the Posta system. Stamps on a separate block can be seen in the background

We exchanged more thoughts on task-shifting and FNAs. Dr. Lukande shared the successes in task-shifting for Kaposi Sarcoma and punch biopsy in Uganda. We also talked about how the current pathology system is based around tissue biopsy and that cytology is lagging behind. However, with an intervention around FNAC, we can have an impact on the landscape and drive demand for FNA tools. The beauty of FNA is that it requires a standard syringe which is relatively accessible, and an expertise similar to that of blood draw. This is something that can reliably be performed by any senior nurse who has good experience in blood draw with additional training. The challenge, however, is that the current system does not have supplies for the processing of cytology samples. Some of the greatest risks, Dr. Lukande shares, are that of motivation and sustainability. How do we ensure that healthcare workers remain committed and motivated to operate decentralized pathology at a community level? How do we ensure that the supplies are affordable and readily available in a sustainable manner?

Photo with Dr. Lukande after he walked us through the pathology department at Makerere

“Community is the key”

“If you keep questioning, you will find a better and simpler way”

“Think wildly and think weirdly”

Some quotes from Dr. Lukande