Small acts translate into big changes in Haiti. So when Partners In Health staff members receive the keys to a new laboratory in April, it will be more than a simple transaction.
The opening of Mirebalais Reference Laboratory for Diagnostic and Research means that thousands of patients every year will receive highly accurate diagnoses and the quality care they need. It means more Haitian lab technicians will receive advanced training in their fields. And it means more original research will be conducted to expand the existing body of knowledge on infectious and chronic diseases worldwide.
Zanmi Lasante, as PIH is known in Haiti, broke ground last spring on the two-story, 15,800-square-foot building opposite University Hospital and anticipates that construction will be completed this April, just weeks from the three-year anniversary of the hospital’s opening. The facility—built in partnership with Build Health International, a Massachusetts-based construction company, and Haiti’s Ministry of Public Health and Population—will eventually house a range of services and become a hub for PIH’s network of clinics throughout the Central Plateau and the lower Artibonite.
The reference laboratory will open in phases over its first year, with priority going to pathology services. This section of the lab will open in June and primarily focus on the preparation and analysis of tissue biopsies for cancer diagnoses. The Biosafety Level 3 (BSL-3) section, which typically deals with airborne infectious disease, is scheduled to open at the end of this year and will aid in the diagnosis of tuberculosis (TB) and multidrug-resistant tuberculosis (MDR-TB). The remaining sections will be phased in over time and include serology, microbiology, parasitology, chemistry, and hematology.
“Technologies are available today in the world to provide better and highly accurate diagnostic capacity, but people don’t have access to them,” says Daniel Orozco, PIH’s director of laboratory services and a globetrotting microbiologist who spent the last 18 years with Doctors Without Borders and FIND Diagnostics. “Our aim is to bring those technologies closer to patients and clinicians and to strengthen the overall diagnostic capacity in the PIH-supported laboratory network in Haiti.”
A national model
Painter Edel Quittere prepares to work in a second floor conference room at the new reference lab. Photo by Liz Cherchia/Build Health International
The reference laboratory is the only public facility of its kind in the region. Private laboratories exist, Orozco says, but they charge high fees and are mainly located in Port-au-Prince—factors that make such services inaccessible to many Haitians, who make less than $1 per day.
University Hospital currently houses three small laboratories that serve the in-patient department, women’s health, and the outpatient clinic. These labs often lack necessary resources, use obsolete technologies, and face constant stock-outs and frustrations when instruments malfunction or can’t be fixed.
These problems surfaced once the labs began operating at full capacity. As the number of patients seeking care grew and the complexity of their cases magnified, the labs struggled to keep up through existing “stuff, space, and staff.” The new laboratory will completely change that scenario, allowing PIH to offer more advanced and appropriate treatment options to a greater number of patients.
The responsibility of having everyone on the same page and up to international lab standards falls on the shoulders of Orozco and his lab team in Boston, and PIH leaders—such as lab network coordinator Betty Alexandre—and their partners in the Haitian government. Together, they see the reference laboratory as an opportunity to consolidate diagnostics at University Hospital under one roof and provide referral and research capacity to the national health system.
Establishing a network of labs requires precision. The reference laboratory and its network of PIH labs will need to establish protocols and procedures required by national and international standards, including uniform documentation, data management, biosafety, quality assurance, training, and a regular supply chain across all locations. This is a constant process and, through step-by-step quality improvement, Orozco hopes the lab will meet accreditation standards set by international organizations, such as the International Organization for Standardization, as proof as its solid work.
“How we are going to reach that,” Orozco says, “is by starting today.”
Once fully functioning, the reference laboratory will house ambitious technology upgrades, expanding testing capacity, and surveillance and research projects. It will also serve as a training grounds for pathology residents—much as University Hospital is for Haiti’s future doctors and nurses. And it will be a hub of continuing education for PIH lab staff, and a home for regional seminars uniting PIH staff with partners in the Haitian government.
Pathology as priority
The nearly finished reference lab sits across from University Hospital in Mirebalais. Photo by Caitlin Candee/Build Health International
Together with PIH leaders in Haiti, Orozco and his lab team identified as a top priority the opening of the lab’s anatomic pathology department. There are less than 10 pathologists in all of Haiti, and only one works in the public sector. Right now, University Hospital doctors remove a sample of potentially cancerous tissue from patients. Through a unique collaboration with Brigham and Women’s Hospital, Dana Farber Cancer Institute, and Newton-Wellesley Hospital, pathologists analyze patient biopsies on a pro-bono basis and provide a diagnosis that is sent back to Haiti, where PIH clinicians begin treatment.
In 2011, PIH’s oncology team in Haiti sent 90 biopsies for diagnosis. That number has grown exponentially each year, to the point that surgeons performed nearly 1,600 in 2015 alone.
Before University Hospital opened, patients had little access to a proper pathology diagnosis. They now are directly linked to some of the best pathologists in the United States, but still wait weeks for a proper diagnosis. With the new lab’s opening, the pathology team will achieve similar diagnostic standards as in the United States, where patients typically wait a maximum of seven days for the same information. The difference can be a matter of life or death.
“For cancer patients in particular, the diagnostic component of care is critical,” says Lauren Greenberg, PIH’s oncology program associate. “For most cancers, you cannot begin to treat with chemotherapy until you have a pathology diagnosis.”
Lengthy waiting periods also mean that patients simply don’t return for their results. It’s a big challenge for Greenberg and the entire oncology staff. “If we can improve our lab,” she says, “we can decrease the wait time for these diagnoses and decrease our loss to follow-up.” And get patients on treatment much quicker.
With pathology services opening, reference laboratory technicians will start processing biopsies performed by surgeons just meters away at University Hospital. Through collaboration with Boston-based partners, technicians will be trained to slice and transfer tissue samples to microscope slides for diagnosis by a pathologist. The goal is to have all biopsies prepared, processed, and diagnosed in Haiti.
By December, the BSL-3 section of the lab will open and technicians will be trained to process sputum samples for the diagnosis of TB and MDR-TB, as well as monitor how effective therapy has been for patients.
Properly identifying TB strains is key to treatment and the prevention of drug resistance. If patients are infected with a TB strain that is susceptible to common antibiotics, they can be put on the right treatment and their case properly managed, eventually leading to a cure. If patients are misdiagnosed, then they could be taking medication that doesn’t kill the bacteria, but makes it more resistant. Resistant TB strains require months of daily injections and a cocktail of antibiotics that could cause debilitating side effects.
Clinicians often have to wait weeks or months to appropriately diagnose a TB or MDR-TB case. But new technologies exist that can shrink that time to a few days or even hours. “It’s challenging, but it’s not impossible to do in Haiti,” Orozco says.
Other parts of the lab will be phased in gradually, with the microbiology section next in line. There, lab technicians will analyze blood, urine, stool, and other cultures, which are essential in providing more accurate and targeted therapies for children and adults with deadly diseases.
Diagnosis of infectious diseases—including HIV, hepatitis, meningitis, cholera, Zika, or chikungunya—will be possible in this new facility, as well as the monitoring of treatment for HIV-positive patients on antiretroviral therapy.
This array of advanced diagnostics simply hasn’t been possible before in Mirebalais. Having such a wealth of laboratory expertise within a stone’s throw is a clinician’s dream.
"When you have a lab with the capacity to do tests that meet physicians' needs," Alexandre says, "you improve the system of care."