Taking laboratory medicine for granted

The history of lab medicine can be traced back to the earliest times when the urine was used for the detection of pregnancy by Sumerians and Babylonians in 400 BC, and later Hippocrates (460–355 BC) described the characteristics and colors of urine from his patients for the diagnosis of long-standing kidney disease. Galen (129–200 AD) wrote and taught that urine was a filtrate of blood and, as such, could indicate the type and location of illnesses. For many years, urine was the sole fluid used for the detection of various abnormalities like diabetes, kidney diseases, and pregnancy. It was only in 1874 when the first laboratory of physiological chemistry in the United States at the Sheffield Scientific School of Yale University under the direction of Russell H. Chittenden was established. A review of several hospitals’ records at the beginning of the 20th century indicated that urine testing was being done on most patients even if there were no indications. The famous names which can be attributed to the clinical laboratory medicine are Folin, Benedict, Garrod, Koch, Van Slyke, and Ehrlich. The laboratory medicine, thus, became an integral part of the health care system with its significance in care, prevention, detection, diagnosis, treatment, and successful management of health conditions. The various disciplines that formed the architecture of the laboratory medicine include clinical chemistry, immunology, hematology, & microbiology. As the 21st century begins, the laboratory medicine added the cutting edge technologies in its arsenal from the Biotechnology revolution. The technical terms like PCR, RT PCR, FISH, NextGen sequencing, Flow cytometry, Spectroscopy, Chromatography, Microarray, CRISPR CAS Gene editing, and Hybridizations techniques have become common jargons. Thanks to their utility from diagnosis to the management of diseases.

For a procedure to be scientifically sound and to put it into practice, the rigorous analysis of its quality is mandatory. The laboratory medicine, in fact, has the robust mechanism of quality control as it deals with the management of public health.  There is no scope of deliberate introduction of pre-analytical, analytical or post analytical errors while performing and reporting the diagnostic test. Qualified quality control professionals ensure that the test is being done according to the standard guidelines and practices of the concerned regulators. The significance of quality control can be gauged by the fact that each diagnostic laboratory has an internal quality system and to have an international accreditation has to participate in the  external quality assessment schemes like EQAS, RIQAS, etc  The reputed hospitals and diagnostic labs across the globe are registered with these companies to provide the quality based investigations A constant vigilance by the designated experts in every part of the world are always on toes to check any malpractice in this field in order to save the human precious lives. But with all these checks and balances errors can still occur and every test needs to be clinically correlated before starting the treatment regimen for better patient care. In brief, the clinical diagnosis in conjunction with laboratory medicine is the backbone of modern health care system.

Kashmir Scenario

Beforecommenting on the evolution, standards, and prospectus of laboratory medicine, it won’t be out of place to describe the pathetic condition in terms of self-medication, mushroom culture  medicate shops by the most incompetent people across the valley. The biggest irony is that individuals who are not qualified as medical practitioners are prescribing medicines as well as treating the patients in these pharmacies.   People might have observed, an individual selling the rice or other items in one shop and the same person is prescribing medicines in the next shop. In Kashmir, there is a unique culture of labeling an employee working in health department as Doctor Sahab irrespective of his qualification. This designation prompts him to act like a doctor, thus diminishing and spoiling the role of a noble profession. Without exaggeration, it is a common observation that a person who had spent some days with a physician or surgeon collecting appointment fee takes the liberty to fit into the shoes of a Doctor. This mafia is taking a heavy toll on our common masses by either mismanagement of patients or sometimes leading to mortality of patients which remains unnoticed. These individuals have ruined the health care system and it is the responsibility of the government to hold such individuals accountable according to the rule of law. And as individuals, we must not let our diseased condition get exploited by these quacks.

In Kashmir, as is the case with the global system, laboratory medicine is practiced in private and public sector settings.  First, let us understand the functioning of the private diagnostic labs.   We always follow people blindly without spending time in critical analysis and proper planning and it seems this problem lies in our genetic makeup. Although, we have invested a lot of money and time in establishing the private schools, B.Ed colleges, madrassas and even private hospitals and nursing homes but raising the standards of these institutes has been a lackadaisical affair. The same pattern is being followed in the case of laboratory medicine as a vast number of diagnostic labs have been established in every nook and corner of the valley by people immediately after obtaining D. MLT or B.Sc MLT courses. There is genuine need of providing lab facilities to the general population but not at the cost of compromising the health of an individual. If the private diagnostic labs don’t work under the ambit of internal and external quality control systems, then, they are, surely, the source of employment for lab professionals but don’t serve the purpose to mitigate the sufferings of patients. Among the innumerable private labs throughout the length and breadth of valley, few labs are doing routine and advanced tests as per the prescribed standards. Most of the labs turn blind eye to the quality system, thus one finds considerable variation in their testing. There is somewhat inverse relationship between quantity and quality. When the quantity of a particular service increases, it becomes all the more necessary for the regulatory bodies like the paramedical council of our UT and other associated health bodies to gear up and make it compulsory that the rules and regulations are followed in letter and spirit. This is the only way to maintain the standards and try to catch up the latest advances in this field which will benefit the common man at present and in the future.

Due to the paucity of standard advanced private diagnostic labs, labs associated with the Government hospitals, in general, and the laboratory medicine of our only tertiary centre SKIMS, in particular, is the only hope for any kind of quality basic and advanced diagnostics for better patient care. It is noteworthy that the quality control systems for basic investigations in the Government sector are to some extent satisfactory but there are miles to go as far as advanced investigations are concerned. COVID 19 pandemic has been an eye opener for our administrators as well as the health professionals as far as the status of our diagnostics is concerned. A basic molecular biology technique called RT-PCR used for the detection of SARS CORONAVIRUS 2 and also for the detection of various abnormalities for around 30 years in most of the centers was only available at 2 centers of our valley. From this, one can imagine the status of high end techniques in most of the colleges and universities. It would be inappropriate not to mention that  at our tertiary care center some advanced diagnostic tests like RT PCR, Flow Cytometry, FISH, and other genetic abnormalities are being performed, but the huge quantum of these advanced diagnostics tests goes to the labs located outside J&K. The practice of sending these tests to outside labs has two huge implications for our quality based treatments. First, the poor person who has to pay a huge sum of money for these tests always finds it difficult to arrange the money and the cost is unbearable to the common masses. Second, the time to get the test report from these labs usually takes 15-20 days and this duration make a huge difference in providing the proper treatment.

To summarize, when the world is busy in single-cell sequencing, CAR T cell therapy, antigen discoveries, microchip technology, we are yet to standardize and validate the basic techniques in our own settings. The critical question to be raised time and again is why we are lagging behind in establishing these facilities. Do we lack the well-trained staff, infrastructure, funds, a well articulated health policy or will and determination to provide the world class lab facilities? The answer could be we lack bit of everything. So, in order to revive the laboratory set up, we should learn a lesson from this pandemic and accept that our priorities with regard to health are misplaced. We have taken the laboratory medicine for granted and our clinicians who are at the helm of the medical institutions have to work with missionary zeal to uplift the standards of our diagnostic labs and bring them at par with the national and international standards. Today, we realized a virus of few nanometers, which in scientific terms has not the distinction of being called cell, has brought down the highly evolved species that is Homo sapiens to his knees.

Tail Piece: I don’t believe in critics but the pain in my heart made me express my emotions. I request everyone to please play his part in improving this field in our settings so that we may provide some relief to the common masses and in turn get a better reward in this world and in the hereafter.