Let’s upgrade lab capacity to meet global standards -Prof. Idris Mohammed
Chief Consultant Physician and Life Fellow of Royal Society of Medicine (UK) Professor Idris Mohammed has observed that that there is urgent need to upgrade the laboratories in Africa to meet International standards.
The latest call by the renowned Chief Consultant Physician comes at the period the West Africa sub-region has been hard-hit by infectious Covid-19 pandemic with its devastating impacts to life, health systems and national economy.
Professor Idris Mohammed delivering the Keynote Address at the Opening Ceremony today.
Delivering Keynote address at second Regional Scientific Conference and Induction of Elected Fellows of West African Postgraduate College of Medical Laboratory Science on Monday 15 November 2021 in Abuja on the topic: “Improving Global Health Security by Strengthening Medical Laboratory Capacity in Africa, Professor Idris Mohammed OON, NNOM, FRCP, FAS
Chief Consultant Physician, Life Fellow, Royal Society of Medicine (UK) said “These multifactorial problems make it imperative to upgrade laboratories in Africa so that their capacity would match those of international standards. These illnesses, and others, know no national or international boundaries, so that an infection anywhere should be considered as infection everywhere. Therefore, laboratory capacity should be as comparable as possible across the world if these infections are to be controlled and pandemics prevented or cut short expeditiously”.
Honourable Minister of Health, Nigeria, Dr. Osagie E. Ehanire 3rd from the right after declaring the Conference open, Prof. King-David Terna Yawe, 1st from right Representative of the Executive Secretary, National Universities Commission & President of West African College of Surgeons.
For Prof. Idris Mohammed “This is no easy matter as it consists of many necessary interventions that are very difficult to accomplish. Firstly, the most critical of these is adequate funding. Assuming the international community can unite in a rare display of equity and responsibility to provide funding for globally uniform capacity laboratories in all continents, rich, middle income or poor; developed, developing or under developed; dictatorships or democracies, executing the project would be equally difficult – some believe it may require a modified “Marshal Plan”. In terms of financing, we are talking about trillions of US Dollars and single-minded cooperation from multi-stakeholder finance institutions such as the International Bank for Reconstruction and Development (World Bank), the World Trade Organization (WTO), United Nations Development Program (UNDP), the International Monetary Fund (IMF), International Finance Corporation (IFC), Multilateral Investment Guaranty Agency (MIGA), International Development Association (IDA) and others”.
According to Prof. Idris Mohammed “Regarding laboratory capacity in Africa, at least three things must happen; (1) the infrastructure must be significantly upgraded and modern equipment installed that would assure performance equivalent to what obtains elsewhere in Europe, America and Asia; (2) As more laboratory scientists are trained and commissioned, the problem of retaining them in the country must be addressed in such manner as to eliminate or drastically reduce “brain drain”; and (3) research, development and innovation must be adopted, encouraged and supported by government in a serious, sustainable and continuous manner”.
Below is the keynote address by Prof. Idris Mohammed:
IMPROVING GLOBAL HEALTH BY STRENGTHENING MEDICAL LABORATORY CAPACITY IN AFRICA
Professor Idris Mohammed, OON, NNOM, MD (Immunol), FRCP, FAS, FWACP, FMCP, FNAMedS, FNAMed, DTH&H
I begin by gratefully acknowledging the honour done to me by the Council of the West African Postgraduate College of Medical Laboratory Science of inviting me to serve as Guest Speaker at this august gathering, as conveyed to me by the Registrar/Secretary General, Dr Godswill Okara. It is not very often that one gets such recognition, for which reason I am extremely grateful to the Council and the entire Membership/Fellowship of the highly esteemed College.
I understand that the West African Postgraduate College of Medical Laboratory Science was established to train specialists and advance the practice of medical laboratory science in the ECOWAS sub-Region, and that this is the second Scientific Conference and induction of newly elected Fellows of the College, the first being the one held in Lagos in 2020 where Foundation Fellows were inducted. I congratulate you for this achievement.
The theme of this Regional Scientific Conference and Induction of Elected fellows is entirely appropriate, considering we are still in the woods with respect to the latest and ongoing pandemic of Covid-19 that has already infected over 245 million people, claiming the lives of over 5 million across the world (1). This new infection emerged suddenly and very little was known about the causative agent, its exact origin, gross and molecular structure, diagnosis or treatment. Initially referred to as new Coronavirus 2019, or nCovid-19, it became recognized as being very similar to the Severe Acute Respiratory Syndrome (SARS CoV) that had been known before.
Invited Guest Speech at the 2nd Regional Scientific Conference and induction of Elected Fellows. International Conference Centre, Garki, Abuja, Nov. 15-17, 2021
This new virus was therefore named SARS CoV-2. It soon became clear that we were dealing with a major new virus with the potential to cause the most serious pandemic since the flu pandemic of 1918. This realization caused panic and a flurry of accusations and counter accusations as to its cause, its origin and what needs to be done to curtail it. Politics naturally took over in the beginning, delaying effective international action by the WHO and other stakeholders in public health that would have limited its impact, particularly on the poor.
Medical laboratory science development
According to Wikipedia, “A medical laboratory scientist (MLS) or clinical laboratory scientist (CLS) or medical technologist (MT) performs diagnostic testing of blood and body fluids in clinical laboratories” (2). The scope of their work spans the receipt of patient specimens and delivery of results “to physicians and other healthcare providers”. It is often based on this that the outcome of therapeutic and other intervention depends, so the methodology and validity of the results must leave no room for any doubts. It is the duty of the laboratory scientist to ensure the quality and accuracy of the results emanating from their laboratories, as well as reproducibility of the results in independent alternative laboratories. The entire actions of these workers are firmly rooted in science, leaving no room for doubt or speculation. In the face of senseless anti-science conspiracy theories currently attending the Covid-19 pandemic, it is imperative that laboratory results are unquestionably accurate. The quality and reproducibility of the results of scientific tests by medical laboratory scientists (3) is largely responsible for curtailing the negative effects of anti-vaxxers, for example.
Medical laboratory scientists play a most important role in medical diagnosis, epidemiology, research and clinical care. They are key in quality scientific medical research and the relatively new discipline of translational medicine that is responsible for driving new treatments, the remarkable results of which have come to define the new revolution in medical and surgical care. In this regard, one must emphasize the concept of multidisciplinary approach to research and the application of its results to clinical care that has moved to a new high level in the 21st Century. No longer is it the sole function or prerogative of one discipline to claim responsibility for managing any situation, be it medical, educational, environmental, agricultural, engineering or even social science and poverty. Modern management science (yes, it is science) demands that actors cooperate with each other in a multidisciplinary effort to tackle the problems of this world. Perhaps one of the most disturbing consequences of denying or neglecting science is environmental pollution and climate change, the combined effects of which are threatening the very future of mankind. World leaders are currently meeting in Glasgow under COP26 to try and reach agreement on reducing carbon emission that would prevent catastrophic temperature rise above 1.5 degrees Celsius and ensure the future of mankind, but the outcome seems uncertain as many countries adopt self-centered and selfish economic interests , in the process denying science.
Just as a concerted multidisciplinary approach is required to address climate and environmental problems, so is such an approach critical to success in addressing health issues. In this regard, all stakeholders with training and mandate in health care – doctors, nurses, pharmacists, medical laboratory scientists, physiotherapists, occupational therapists and public health practitioners of all cadres – must close ranks and work together as one team, working in the interest of the patient, whose health we swore to protect and repair should it falter. There is simply no other way in this age of complex interrelationships between man, nature and the environment. No longer is it relevant or rational that one stakeholder amongst the several in our esteemed profession must be of necessity designated as the leader. That has been the case from time immemorial, and it remains the case in most of the advanced nations that the team MUST be led by a doctor. I hasten to add that the circumstances in most countries even today makes it difficult to effect a sudden change in the system of leadership, but where possible such leadership should by law be open to all in the care team, depending only on individual training, competence and professionalism.
This means that the system of training health professionals must be streamlined and monitored in a peer review style system to ensure maintenance of the highest standards that would assure quality and competence. Unless and until that happens, it would be difficult to justify a sudden unregulated change, particularly in countries where there is shortage of well-qualified persons in the various specialties, laced with godfatherism, “a term primarily used in Nigeria to refer to wealthy and powerful figures who exert political influence behind the scenes while often remaining out of the limelight” (Oxford Dictionary of African Politics, 2019 ). This reality exists in much of West Africa, and unless it is addressed squarely any attempt to harmonize the existing order is doomed from the word ‘go’.
Let us begin by examining the historical developments of laboratory service in one West African country Nigeria. While there are subtle differences between countries in the West African sub-region, the example of one country can serve as representative of the region. Medical laboratory services have a chequered history in Nigeria where there were very few training institutions for producing laboratory technologists, as they then were, that would assist the doctor to arrive at a definitive diagnosis of illnesses suffered by their patients. Those available institutions were not only few but they also trained very low level laboratory assistants and technicians with limited knowledge and experience, and with limited numbers of functional equipment. To compound the problem, any available equipment was outdated, relatively archaic, of low sensitivity and specificity, and did not always give reproducible and reliable results. Thus for quite some time – indeed up to the 1970s – laboratory services in the much of Africa were rudimentary in relative terms, and doctors had to rely more on their clinical acumen to diagnose and treat illnesses, a rather unsatisfactory state of affairs as I am sure you will agree.
Those earlier institutions that attempted to include laboratory services in their teaching were named variously as “schools of hygiene” which produced multipurpose dispensary and laboratory attendants; “schools of health technology” that produced graduates of somewhat higher qualifications and competence, and could provide some laboratory services with variable degrees of accuracy, and who functioned as rural “doctors” as well as laboratory technicians. Relatively more recently, Schools of Medical Laboratory Technology were established which produced “Medical Laboratory Technologists” able to perform more complex laboratory tests with a fairly good degree of accuracy and reproducibility, thus enhancing the quality of the service. That was when awareness increased of the utility and necessity for establishing even better trained and more advanced staff within the discipline of laboratory science, with a view to advancing the service to a higher level. About that time, the products of those schools were referred to as “Medical Laboratory Technologists” – a term that was maintained for several decades, despite vigorous protestations from the medical laboratory practitioners at the time. Originally referred to “Associate Members of the Institute of Medical Laboratory Technologists” (AIMLT) of Nigeria, those who excelled or acquired higher qualifications by research were made “Fellows” of the Institute (FIMLT). An umbrella association was formed to cater for the interests of this cadre of staff.
This brief conceptual history of how medical laboratory services evolved in Nigeria enables us to understand some of the issues that arose, affecting the service over time. Almost unanimously, members of the Association decided that they were in fact “medical laboratory scientists”, not “medical laboratory technologists”, so the vigorous campaign became a whirlwind and sustained pressure was mounted on the powers that be to recognize the discipline as “Medical Laboratory Science”, and its practitioners as “Medical Laboratory Scientists”. An unnecessary counter-campaign was mounted by those who would rather have the status quo maintained – among them (but not exclusively) doctors. I say unnecessary because many of us in the medical profession could not understand the basis for the opposition to a mere change in terminology, for – to all intents and purposes – the practical functions of providing a good laboratory service remain the same whatever terminology was applied. In any event, if sitting by the bench on a stool in a biochemical, haematological, microbiological or immunological laboratory, holding a test tube and using pipettes to mix samples of biological fluids, or grow cultures of microorganisms, perform a test and read the results correctly is not science, then I do not know what science is! Medical laboratory service is a science by any definition, and recognized as such throughout the modern world.
In any event, the change in terminology was eventually agreed, and one hoped that this would have been the end of the matter. But what is the difference between science and technology other than the names? All the instruments or equipment used in the laboratory are the result of technological advances. Without the auto-analyzer, the Coulter S, the cryostat, the centrifuges, the fluorescent microscope, the thermal cycler, the flame photometer, the microtome, the gamma counter, the spectrophotometer, the inverted or electron microscope and a litany of other equipment, how would the laboratory scientists provide the services expected of them to perform? These are produced by research and innovation in modern technology, so how can technology be inferior to science?
The current Medical Laboratory Science Programme consists of Bachelor of Medical Laboratory Science (BMLS) as designed by the Medical laboratory Science Council of Nigeria, established by Law in 2004. Students receive wide ranging training in basic sciences, management and social sciences, general studies, medical laboratory science. The 5-year programme ends with training in hospital settings that exposes the students to the range of routine laboratory tests, and all special areas of Laboratory Science. In year 5 the successful students are broken into four core special areas namely, Medical Microbiology/Parasitology, Chemical Pathology/Immunology, Haematology and Blood Transfusion and Histopathology/Cytopathology. This comprehensive course produces highly qualified laboratory scientists, able to conduct accurate investigations on all samples and report the results. On the other hand, Ghana awards the doctor of medical laboratory science (MLS.D), a 6-year professional training programme. A 4-year Bachelor’s degree is also offered (BMLS), as well as a 3 year programme leading to a diploma in medical laboratory science, the successful candidates referred to as medical laboratory technicians (MLT). In both Ghana and Nigeria, there are thus structured academic programmes for medical laboratory scientists that strongly enhance the quality and reliability of laboratory science practice. I am optimistic that similar programmes exist in other West African countries, just as they are now the norm in the US, UK and several Commonwealth countries. Furthermore, universities now offer laboratory scientists the opportunity to pursue Masters’ and Doctorate degree in most sub-specialties of Laboratory Medicine, so they can aspire to any academic or professional positions, including Vice-Chancellor of a university.
Medical laboratory science has developed to such an enormous extent that the services its practitioners provide to African health practitioners are in most cases superb. Medical laboratory scientists undergo rigorous training in their areas of specialisation, having been admitted on merit. Indeed, many of them could have been admitted to read medicine had they chosen to do so. However, the training may be as rigorous as that in any other discipline, but the duration is similar in every material respect to that for lawyers, engineers, pharmacists, nurses, linguists, physiotherapists, political scientists, historians, architects and many more.
The shorter training has had little effect on the performance of medical laboratory scientists in providing an excellent service to the health sector without which doctors would be constrained, particularly in the area of diagnosis. Therefore, from whatever angle one cares to evaluate it, the scientific and technological perspectives of their work in hospital laboratories, research institutes, drug development and manufacturing, as well as in some private settings are entirely reliable and accurate, providing the most important information to doctors that enables the latter to practice their trade – clinical research, translational action sequel to scientific investigation, prevention and management of disease. Without medical laboratory scientists doctors would be unable to function optimally because they would then have to rely only on their individual clinical acumen, an undesirable and indeed untenable situation in today’s circumstances. Even as new and esoteric investigations are introduced courtesy of the scientific and technological revolution of the last 30 years, African laboratory scientists have not been left behind, and are able to keep pace with the rest of the world, all things being equal. But of course things are not equal.
In this regard, our scientists can diagnose almost any infection with a good degree of accuracy, including such infections as amoebic dysentery, typhoid fever by culture and by the Widal test, HIV infection and its multifarious immunopathologic manifestations by enzyme-linked immunosorbent assay (ELISA) and/or immuno-blotting and measurement of viral particles such as p24 (representing the viral load) by PCR, multi-drug resistant (MDR) tuberculosis, ultra-drug-resistant (XDR) tuberculosis, viral infections such as hepatitis B and C, pneumococcal and meningococcal infections. There are many pneumococcal serotypes causing disease in man, the most worrying being seasonal flu in cold climes, as well as meningitis in Europe and Africa, and our African laboratory scientists are able to isolate and characterize them. Given the right level of support, they can develop the multivalent vaccines used particularly in the elderly to prevent the kind of flu pandemic encountered in 1918. As for meningococcal meningitis, it is now possible to not only diagnose the several sero-groups, but also the clonal sub-types causing particular epidemics. For example, during the largest epidemic of the disease (as determined by the WHO) in Nigeria in 1996 (5), together with the microbiologist scientific officer we were able to determine that the epidemic was caused by meningococcal sero-group A; clonal sub-group III.I that was responsible for the epidemic of the disease that occurred in Niger in 1994.
Where P2 or P3 laboratories are available medical laboratory scientists in West Africa are able to perform all sorts of cultures, grow and maintain cell lines, conduct studies on viral hemorrhagic fevers such as Lassa, Ebola, and any others safely and accurately. They are also capable of undertaking studies in nearly all aspects of molecular biology or biomolecular science. With the advent of Covid-19 African scientists have shown competence and ability to diagnose the viral infection using real time reverse transcriptase PCR. They are also able to conduct reliable studies in genetically sequencing the virus and detect its emerging new variants wherever these first occurred. The fact that Africa is far behind in producing Covid-19 vaccines is not a reflection of laboratory scientific incompetence, but rather a severe shortage of political and financial support. Some are inclined to believe that advanced Western nations are not exactly supportive of African efforts to develop equivalent competence in laboratory investigation. One example cited is the development of the conjugate meningitis vaccine for West Africa. Once the necessary funds were made available, the joint WHO/PATH Meningitis Vaccine Project ignored pleas for awarding the patent acquired for conjugation to an African laboratory to develop the vaccine. This would have provided a fine opportunity for empowering Africa to acquire competence in vaccine development, so that by now we would have been in a position to complement US and European efforts at producing the Covid-19 vaccine.
Clinical chemistry service by medical laboratory scientists provides much valuable information on the content of electrolytes and their balance in the body, allowing the doctor to identify and correct abnormalities arising from many illnesses, not least the very common ones such as diarrhoeal diseases in children and patients with cholera. These tests are also of immense value in the diagnosis and management of diabetes, heart disease, and endocrine disorders such as thyrotoxicosis, Cushing’s disease and Phaeochromocytoma. Laboratory scientists also perform tests that enable doctors diagnose and manage kidney and liver diseases.
There are certain prognostic markers of disease that are not generally known which laboratory scientists reveal by performing appropriate tests, such as “glycosylated (or glycated) Haemoglobin” – HbA1c – that often indicate better control of blood sugar in diabetics on treatment. Alternatively, the laboratory service can provide the doctor with the “International Normalised Ratio” (INR) as a better indicator of disease control. They of course perform the routine haematological profiles of thousands of patients on a daily basis, in the process aiding the diagnosis and severity of anaemia from any cause. The list of tests performed with credit by medical laboratory scientists as a service is long. Suffice it to state that they can perform molecular genetic testing for heritable disorders, and I am certain that when the next generation sequencing (NGS) – an evolving DNA sequencing technology – is eventually perfected, our laboratory scientists will be equal to the task of applying it to help physicians arrive at actionable decisions on eliminating genetic disorders such as sickle cell disease and haemophilia. This is already beginning to show promise, and gene therapy is an exciting new development that is adding to the modern armamentarium of medical interventions to prevent or treat inherited diseases.
Certain viral infections are important in the sense that they can lead to cancer; these include not only the better-known hepatitis B and C viruses which cause liver cancer, but lesser known ones such as the human papilloma virus (HPV) which causes cancer of the cervix in young women. It is important to provide more of the facilities for these tests to enable our laboratory services to detect them early so measures can be taken to prevent their deadly effects. Vaccination for HPV, for example, can serve to prevent cervical cancer, while hepatitis B and C vaccines can prevent infection and cancer of the liver.
A landmark set of services provided by medical laboratory scientists is in the area of immunology, serology and immunohaematology, where there is a wide scope of laboratory testing that is of paramount importance as a service to the practice of medicine, whether in the rural or urban setting. Serological tests are of immense value in diagnosis of a wide variety of diseases and their management, but had been plagued by a lack of sensitivity, specificity and reproducibility, until the so-called monoclonal revolution. Radioimmunoassay and many serologic tests have been used to quantitate drugs, bacterial and viral antigens and circulating immunoglobulins. However, uncertainties arising from the unpredictability and heterogeneity of the immune response meant that immunologists had to be content with whatever antibodies were produced as a sequel to vaccination, which remained more as an art than a science.
Global Health and Medical Laboratory Capacity in Africa
To return to the theme of this year’s Annual Conference of the West African Postgraduate College of Medical Laboratory Science: “Improving Global Health by Strengthening Medical Laboratory Capacity in Africa”, this topic is germane in the context of today’s remarkable progress in science, technology and innovation that are transforming life with unprecedented speed. These developments are taking place mostly in the advanced Western nations, though some countries described as “middle income countries” such as Brazil, Russia, India and China are fast catching up, whilst African nations are far behind. In fairness to ourselves, we need to examine why we are so far behind countries which became independent about the same time as African countries, and were at nearly at the same stage of development and similarly with low income.
With regard to the situation in Africa one can only best discuss the relevant issues from practical knowledge. That means that for me to address them fairly, Nigeria must of necessity be my primary reference country. Over the last 61 years since the country achieved political independence, things had been going topsy-turvy for the first 30 years, which included just over 5 years of civilian rule when progress was considered satisfactory by the international community. The military years post January 15th 1966 coup d’etat began with disturbing uncertainty threatening the corporate existence of the country. However, after another coup in July 1966 some stability was restored by creating 12 states. Subsequently, things became unpredictable with progress in some sectors, retrogression in others. Several years later, as more of the country was broken into states, chaos set in, the cost of government became unbearable and there was little money left for development as the budget balance was routinely stolen by players in all arms of government. This affected development and progress in all sectors, including health care, with laboratory infrastructure among the worst affected. As a result, despite availability of qualified laboratory manpower not much could be done to meet the requirements of routine service, much less conduct sophisticated research and development investigations for new drugs and vaccines.
It is generally believed that Nigerian leaders do not care about the quality of health care or diagnostic services in the country because they are so stupendously rich they can catch the next available plane out of the country and obtain quality care abroad. Incredible as it may sound, some go out for treatment of malaria or suspected typhoid fever, while many others travel out with demonstrably terminal incurable diseases, even when told nothing more could be done by anyone anywhere to cure their illness. Many are reported to have said they would rather be brought back in coffins than stay in the country for care they do not trust. That is the quality of leadership in a country that is otherwise potentially one of the richest in terms of availability of numerous natural resources and eminently bright and trainable manpower. In fairness, a few isolated attempts have been made to upgrade the infrastructure and curtail brain drain, such as the 1985 designation of four teaching hospitals into “Centres of Excellence” in identified fields. The regime of Obasanjo also made an attempt through injection of several billions of Naira to further resuscitate selected tertiary hospitals. However, there is not much evidence of a long-term impact of these interventions. Corruption in Nigeria has become systemic, and it would seem that reversing the trend is more than a Herculean task, best left for our grand children to tackle.
The Nigerian example does not represent the overall situation in West Africa, as I am aware that there are countries in the sub-region with honest, reasonably accountable and competent leadership that made sure the decline in laboratory service was minimal. There are thus a few countries able to undertake esoteric investigations, including vaccine research. Covid-19 vaccine is for example being developed in Dakar, Senegal. In case some might think my view of the Nigerian decline is universal, let me add that there are private initiatives that have enabled some proprietors to establish state of the art laboratories capable of drug and vaccine development and manufacture, such as in Ede which has a “Centre of Excellence” in genomic research.
The need to strengthen laboratory capacity in Africa;
The need to strengthen laboratory service in Africa is predicated on the fact that the world has now become a global village. Before proceeding any further, it is useful to consider how and why development in Africa fell far below that of our independence era counterparts of the 1960s. The best and most quoted example is that of the so-called “Asian Tigers” – in particular Indonesia, Malaysia and Singapore. At the material time when Nigeria attained independence in 1960 the country was at least at par with – or in a few cases even ahead of – the Asian and South American countries, in terms of human resources manpower and economic wherewithal. The comparison between African and Asian nation is one means by which to drive home the need for the developing countries of sub-Saharan Africa to reflect deeply and with serious sense of responsibility on the problems that have prevented the continent from achieving scientific, educational, socio-economic and physical development within the last 40 years. Nigeria attained political independence from Britain in October 1960 while Singapore became independent in 1965.
Whereas Nigeria was adjudged viable in every respect, few people gave Singapore much chance of surviving. Nigeria had a population of about 100 million people at the time, was well endowed with human, agricultural and mineral resources, and was surrounded by much smaller nations in size, population or might: Cameroun to the east (population 5 million); Chad to the northeast (population 3 million); Niger to the north (population 4 million); and Benin Republic to the west (population 2 million), none of which could pose any threat to Nigeria. Singapore, the main British naval base during World War II, on the other hand, was a tiny metropolis (a City-State) with a population of just 1 million mostly Chinese, Malay and Indians, bordered by Indonesia with 100 million people, and Malaya (later Malaysia) whose population was just over 6 million. As the smallest country in Southeast Asia with no demonstrable natural resources, no one gave it any chance of survival as a nation state. Then came Lee Kuan Yew who assumed leadership of the tiny island determined to prove everybody wrong. He summoned like-minded compatriots, and with their help transformed Singapore into a modern “First World” country whose per capita income grew from $400 in 1959 when he became prime minister, to $1,000 at independence in 1965, and to $30,000 within 35 years of independence from Britain. This success – a defining moment for all South Asian counties – was achieved by providing exemplary leadership and embracing scientific and technological research and applying the results to transform the otherwise resource-poor country.
In similar fashion, Malaysians had committed their motivation for success to develop their country through single-minded hard work, relentless pursuit of education (particularly science and technology education) and applying the new knowledge thus generated to advance socio-economic, physical and political development. Good governance ensured respect for human rights, accountability, equality whilst respect for the rule of law generated popular patriotism and commitment to the development of all aspects of societal values. The country witnessed progressive rise in per capita (Gross Domestic Product [GDP]) and other economic dividends, good education and health care, high quality standards of living, physical development and political stability. Malaysia obtained palm oil seeds from us which they had planted and nurtured so diligently that the country became the largest exporter of palm oil in the world and began refining palm oil to produce environmentally friendly non-petroleum energy for automobiles, whilst Nigeria is still unable to produce enough of the crude commodity for human consumption. Today, Nigeria imports palm oil from abroad, paying for it with petro-dollars, and I believe we should be embarrassed.
Although Indonesia has also done well, its development is not as spectacular as that of Malaysia or Singapore. Nevertheless, it is far more developed than almost any country in sub-Saharan Africa. The real impact of scientific research and new knowledge is to be found in India and China, where the applications of research and new knowledge have combined in remarkable fashion with political will, commitment, discipline and good government, to produce the most profound example of what can be achieved in terms of economic power and modern physical development driven by science and technology research. Despite its massive population of about 1.4 billon people, China has achieved such economic transformation that no one in China is hungry. China and India are no longer in the developing Third World – which they left somewhat quietly several years ago – but are challenging the only remaining super power, the United States of America. For a very long time, Indians have provided the technological manpower at the ‘Silicon Valley’ that sustained the ‘dot.com’ companies for decades, providing more of such information and communications technology (ICT) experts than any other country in the world today.
The comparison between sub-Saharan Africa with the Asian countries enables us to understand some of the reasons why we lag so far behind, and what we must do to catch up before it is too late. It is clear that we in Africa must re-examine our approach or response to the challenges posed by poor education, underdevelopment and political instability against the background of poor governance. There is no sustainable alternative to attitudinal change in almost everything we do – or do not do in this regard. We must accept, advertise, fund and apply new educational benchmarks in order to restore quality and manpower development in education, particularly science and technology education, as sine qua non for rapid socio-economic and physical development.
In the last forty years, newly emerging or re-emerging infections have appeared in various parts of the world, compounding the problems faced by all stakeholders in the health care industry (for that is what is has become). These began with the emergence of human immunodeficiency virus (HIV) in 1981 (6), after which others appeared on the scene, the list currently including over 40 infections and accounting for substantial number of all human pathogens (7). Perhaps no single professional group bears the heaviest burden of this development more than the medical laboratory scientists. These are the ones who must work efficiently and in a timely manner to perform the necessary investigations and identity these new or re-emerging diseases. Unless this happens quickly, the world may face horrendous public health emergency. We already have one, currently ongoing, the new Coronavirus-19 (Covid-19; SARS CoV-2). This infection caused by a novel Coronavirus appeared literally out of the blues, catching the entire world, including the WHO by surprise. A debate has been raging on several aspects of this infection that first appeared in late 2019 from a laboratory in Wuhan, China, and rapidly spread across the world becoming a pandemic in little time. The jury is still out on the origin, but there are several other disturbing issues: there was originally no vaccine, no cure, and the world had to rely on non-pharmaceutical action to prevent its spread. A vaccine has now ben developed, and there are some encouraging reports of antiviral drugs promising cure or preventing serious illness.
However, in typical lack of empathy on the part Western nations, they promptly horded all the manufactured vaccines for their people, many of them storing more than twice their needs. Before then, there were serious problems with making tests available to those countries which lacked infrastructure and supplies for testing, most of them in sub-Saharan Africa. They lacked PCR machines and primers for real-time Reverse Transcriptase testing for accurate diagnosis of the infection. This was a major setback as it meant that the prevalence of infection was not even known. Testing is essential for finding infected persons, tracing and isolating their contacts and implementing non-pharmaceutical prevention measures such as social distancing, mask wearing, avoiding congregations in prayer houses, markets and, where necessary, lockdowns. The result is that we did not know the extent of Covid-19 infection in much of Africa, and it took the best part of 6-8 months before PCR testing took off in earnest. Even so, the level of testing remained low in many countries, and remains so today.
Other than SARS-CoV-2 there are a number of emerging and re-emerging infections: Ebola virus disease, Lassa fever, SARS, MERS-CoV, HIV/AIDS, Multidrug resistant Tuberculosis (MDR-TB), extensively resistant Tuberculosis (XDR-TB), Marbug virus, Rift Valley fever, H10N8 influenza, H7N9 influenza, H5N1 influenza, Enterovirus 71, Human monkeypox, Zika virus disease, Hantavirus syndrome, Chikungunya, Anthra bioterrorism, Adenovirus 14, H1N1 influenza, Listeriosis, E coli O157:H7, C. difficille, Cyclosporiosis and measles. Of particular relevance to us in West Africa are HIV/AIDS, Tuberculosis, Lassa virus infection, Ebola virus disease and Covid-19. In addition to their novel nature, these emerging and re-emerging infections have some troubling characteristics. Many of them undergo regular changes in their molecular composition making it very difficult to develop effective vaccines against them. This phenomenon of antigenic variation or “antigenic disguise/mimicry” is common in HIV, the viral haemorrhagic fevers, malaria and Coronaviruses. That is why 40 years on we still do not have an effective vaccine against HIV. The attempts at developing a malaria vaccine antedate those of HIV but it was only weeks ago that it was announced that a malaria vaccine had at last been developed which is only 30% effective.
The need to upgrade laboratory capacity
These multifactorial problems make it imperative to upgrade laboratories in Africa so that their capacity would match those of international standards. These illnesses, and others, know no national or international boundaries, so that an infection anywhere should be considered as infection everywhere. Therefore, laboratory capacity should be as comparable as possible across the world if these infections are to be controlled and pandemics prevented or cut short expeditiously. This is no easy matter as it consists of many necessary interventions that are very difficult to accomplish. Firstly, the most critical of these is adequate funding. Assuming the international community can unite in a rare display of equity and responsibility to provide funding for globally uniform capacity laboratories in all continents, rich, middle income or poor; developed, developing or under developed; dictatorships or democracies, executing the project would be equally difficult – some believe it may require a modified “Marshal Plan”. In terms of financing, we are talking about trillions of US Dollars and single-minded cooperation from multi-stakeholder finance institutions such as the International Bank for Reconstruction and Development (World Bank), the World Trade Organization (WTO), United Nations Development Program (UNDP), the International Monetary Fund (IMF), International Finance Corporation (IFC), Multilateral Investment Guaranty Agency (MIGA), International Development Association (IDA) and others.
Funding cannot be complete without massive input from Philanthropic Organisations such as the Bill and Melinda Gates Foundation (BMGF), the Global Fund (GF), Ford Foundation, Rockefeller Foundation, MacArthur Foundation, Novo Nordisk Foundation, Wellcome Trust, Howard Hughes Medical Institute, African Institute for Health and Development, Centre for Global Health Research, USAID, Japan International Cooperation Agency (JICA), UK Department for International Development (DfID), International Institute for Health promotion, Organisation for Economic Co-operation and Development (OECD), United Nations Population Fund, International Society for Equity in Health, Health Action Partnership International, Global Health Watch, Cochrane Public Health, US Centers for Disease Control and Prevention (CDC). It is perhaps too optimistic to assume that these disparate Bodies and Agencies would all agree to fund global action to ensure equal laboratory capacity in the world. In particular, the actions of Western nations on the Covid-19 vaccine have shown us how much they care for developing nations and their welfare, so we can safely assume that helpful cooperation in action to bailout Africa in the area of laboratory development may prove elusive. However, we must remain hopeful that in the long run the rich countries and organisations funded by them will sooner than later develop higher levels of conscience that would remove or at least minimize inequity and inequality in dealing with African problems.
I have gone so far as to underscore the need for the widest possible assistance and collaboration in developing and upgrading laboratory capacity in Africa because, according to the WHO laboratory services in Africa do not meet even the basic needs of the continent, let alone be rated as equivalent to laboratories in the developed countries of the world (8). This is due largely to inadequate laboratory systems, as exemplified for example by the response to the 2014-2015 outbreak of Ebola Virus Disease (EVD) in West Africa and the findings of the Joint External Evaluation (JEE) which revealed the urgent need to reform and upgrade the quality of laboratory services in the African Region (9). Strengthening laboratory capacity in Africa requires both significant infrastructural upgrading with “state of the art” modern equipment, as well as accelerated structured training to develop adequate numbers of highly qualified and competent human resources for laboratory investigations. Achieving, maintaining and improving accuracy, timeliness and reliability of test results constitute major challenges for health laboratories in Africa. Experience with the Covid-19 pandemic shows that the capacity and integrity of laboratories depend on the accuracy of testing and reporting. Otherwise doubts with serious consequences erode the confidence of stakeholders and the general public.
The Covid-19 pandemic has exposed serious fault lines in country and global health systems. Unfortunately, these fault lines have not been exploited positively in any significant ways. Several weeks after its arrival in Nigeria, the chairman of the Presidential Task Force (PTF) on Covid-19 was so alarmed by the fault lines that he declared publicly that he never knew how bad the health system in Nigeria was until he was appointed to chair the Task Force. Since he doubles as the Secretary to the Government of the Federation, you would expect that something urgent would have been done to address the flaws in the system. It has not yet happened, but instead he seemed to have been made to retract his honest observation. How sad! This pandemic is a wonderful opportunity for African governments to have seized the moment and declared a health emergency that would have enabled them to repair the damage done to the health system by years of neglect. A severe decline had occurred in all levels of health care: primary, secondary and tertiary, leaving the majority of Nigerians without access to affordable quality care at any level. There is no equity, equality, justice or empathy in the system, and it is impossible for anyone with conscience to detail the shortcomings without breaking down; so I refrain. At one stage, a senior government health official described Nigerian hospitals as “mortuaries”, and the flagship tertiary hospital in Abuja as being run by what he called “baby doctors”. It was that bad. The few with power and circumstance – 0.1% of the population of 200 million people – often board the next available flight out of the country whenever they are sick, in what has come to be known as “medical tourism” that costs the country hundreds of millions of US dollars annually. That is more than enough to establish state-of-the-art tertiary hospitals and laboratories in every geo-political region of the country. I am advised that this will not happen because of entrenched self-interests of powerful politicians, their powerful business backers and powerful foreign beneficiaries of the repugnant practice. It is such a great pity because the poor 99% of the people have no voice, while the Nigerian physician who by international practice is the “natural attorney of the poor” is no longer sure where his conscience belongs!
The way forward
Regarding laboratory capacity in Africa, at least three things must happen; (1) the infrastructure must be significantly upgraded and modern equipment installed that would assure performance equivalent to what obtains elsewhere in Europe, America and Asia; (2) As more laboratory scientists are trained and commissioned, the problem of retaining them in the country must be addressed in such manner as to eliminate or drastically reduce “brain drain”; and (3) research, development and innovation must be adopted, encouraged and supported by government in a serious, sustainable and continuous manner.
Infrastructural upgrading of laboratories must be such as to ensure African laboratory scientists can function the way those trained in Africa who migrate to “greener pastures” do – performing with excellence and assured professionalism in foreign countries – simply because of better modern equipment. They often outperform their locally trained, US and EU compatriots. They must have equipment that would facilitate their quest for excellence in such areas as immunochemistry, generating and characterizing substances necessary for high-end research upon which depends progress in modern medicine and science. They want to, for example, be constantly engaged in “high performance liquid chromatography’ (HPLC), and other chromatographic work, so a fully functional column and related chromatography laboratory should be part of the upgrading. Immunohistochemistry, immunofluorescence, radioimmunoassay (and other isotope studies), analytical and preparative ultracentrifugation and preparation of blood and blood products are essential in the modern 21st century world. The full range of spectrophotometers, new generation auto analyzers, fluorescence activated cell sorters (FACS) and other facilities for quality clinical chemistry work should be made available as essential elements of laboratory capacity building. The full range of microbiological investigations should be available in every African country, complemented by histology and cytology services comparable to those elsewhere. Polymerase chain reaction (PCR), genetic sequencing, cell signaling mechanisms and other cancer research facilities are sine qua non.
The problem of brain drain and its associated negative impact on human resources for science laboratory work, and other special disciplines has been discussed for decades in Nigeria, but nothing significant has emerged to suggest that it is getting any better; if anything, it seems to be getting worse as conditions in the country have become more of a “push factor” here and a “pull factor” abroad. It appears there is as yet no end in sight. I happen to believe though that Nigerians and other West Africans should re-examine their conscience on this matter.
As for research and development, Africans must strive to pursue these with greater urgency, will and commitment. This applies more to governments than to the scientific researchers who are ever ready to conduct research but lack the necessary support in terms of research infrastructure, funding and, critically, political commitment. There is no plausible reason why we should remain so far behind. The selfish conduct of the Western powers on the need for equitable and timely distribution of Covid-19 vaccines and medicines is a stark reminder of the need for us to be independent in research for the development of vaccines and drugs for Africa. Yellow fever vaccines were produced in Yaba for West Africa for decades, until the Federal Vaccine Production Laboratories were allowed to run themselves down before our own eyes. Now there are only two possible Covid-19 vaccine developers in Africa, one in Dakar, Senegal, and the other in South Africa. Something must be done by African governments, perhaps under the aegis of the African Union (AU) to build laboratory capacity in the continent and free us from 21st century scientific and technological colonialism.
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