Two pathologists combine forces to forge a path for global pathology at Stanford and beyond

By Jamie Hansen, Communications Manager

In 2005, Stanford pathologist Dr. Yasodha (Yaso) Natkunam traveled to volunteer her expertise in her home country of Sri Lanka, recently devastated by a tsunami, and discovered that there were almost no pathology labs or working pathologists. The realization that pathology services were scarce-to-nonexistent in many parts of the world catalyzed nearly two decades of Natkunam’s involvement in building capacity for global pathology.

Nearly 15 years later, a young medical student passionate about global health and interested in pathology, Dana Razzano, attended a global health conference excited to network with global pathologists — but found none.  Likewise, when she sought out residencies that would support her twin interests, only one of 18 expressed an interest. During her residency, she worked to create a global health elective, which she did in collaboration with a pathologist, Dr. Omo Aisagbonhi, who was volunteering at a hospital in Mbarara, Uganda. Later, she secured an inaugural global pathology fellowship created by the American Society for Clinical Pathology and traveled to Ethiopia for additional training. Since then, she has become a trailblazer in creating global health pathways for other aspiring pathologists.

 “Pathology serves as the foundation of medicine,” said Razzano, MD, now a clinical instructor of pathology at Stanford. “Most medical practices cannot function without its services. And yet there is a paucity of pathology services in many global settings.”

Now, these two Stanford pathologists have come together with a shared vision to grow their department’s global involvement and training and address the dearth of global pathology services.

Razzano and Natkunum first connected in 2021, when Razzano, a pathology fellow at Stanford, attended a meeting that Natkunam and some colleagues also interested in global engagement were hosting. A spark was lit, and since then, Natkunam has been mentoring and supporting Razzano’s efforts to develop and fund more overseas training and volunteering options for pathologists.

“Yaso is really a leader in creating equity in global pathology service and is just an amazing person overall who has been spearheading the global health effort at Stanford pathology for a while now,” Razzano said. “She saw my interest, took my hand, and pulled me toward this.”

Their goal, Razzano said, is to convert the informal, volunteer efforts of individual Stanford pathologists into a structured program that has the funding and support to offer overseas global health training and career pathways.

“Dana and Yaso are eloquent advocates for the need for global pathology training,” said Dr. Michele Barry, Director of the Stanford Center for Innovation in Global Health. “I believe their efforts can help Stanford become a leader in global pathology.”

The growing need for global pathology

As the global burden of disease shifts, the need for a well-trained global pathology workforce has never been greater or more urgent, say Natkunam and Razzano.

As people around the world live longer and adopt more urban, Westernized lifestyles, they have a greater likelihood of getting life-threatening non-communicable illnesses like cancer and heart disease. The need for pathologists to diagnose these conditions early, while they’re more easily treated, is growing dramatically. And yet, many countries in places like Sub-Saharan Africa have such a low ratio of pathologists that it would take decades if not centuries to meet demand, given current educational capacity, Razzano said. 

With the burden of cancer increasing, “we feel our global value is completely under-represented and under-used,” Natkunam said. Natkunam, MD, PhD, is the Ronald Dorfman Professor of Hematopatholgy, and a faculty fellow at the Stanford Center for Innovation in Global Health. “It’s the lack of trained personnel, the lack of infrastructure that people like Dana, my pathology colleagues, and I are really interested in changing.”

Lack of diagnostic tests and expertise can lead to ineffective treatments and the over-use of antibiotics, among other things. For instance, in parts of the world where tuberculosis is prevalent, physicians often lack the ability to test for the deadly disease. Out of caution, they may treat a range of symptoms as tuberculosis and prescribe antibiotics. This can lead to ineffective treatment and helps contribute to the growing problem of anti-microbial resistance.

“Global health practitioners can arrive in other countries and bring modern and targeted treatments, but how can you know what treatment is needed without first building the ability to test for the specific disease?” Razzano said. 

A lack of training and pathways for global pathology

In the US, interest in global pathology has never been greater, especially among young medical students and residents. And yet, Razzano said, most academic institutions, including Stanford, lack a formalized training program for pathology residents.

Overseas training programs are critical to residents gaining cultural awareness and understanding of the needs of low-resource settings that have different disease profiles and access to medical equipment than high income countries, Natkunam said.

“You can read all about it, and you can look at statistics, but there’s a big difference when you are actually there and don’t have the equipment that is available at Stanford—the things we take for granted” she added.

She recalled an experience during her first visit to Sri Lanka after the 2005 tsunami. While she was volunteering in a makeshift operating room, a surgeon asked for her help diagnosing a tumor he had taken from the cheek of a young, single mother. With no pathology lab available to stain the sample, Natkunam found and adapted a slide meant for malaria testing, air dried it, and took a look at the tumor using a microscope she’d brought with her.

Based on what she saw, she believed the tumor was different from what the surgeon had suspected — one that would require radiotherapy. While the hospital didn’t have the tools needed to confirm her diagnosis, the surgeon decided to send the patient for radiotherapy based on Natkunam’s input. Meanwhile, he sent the sample to Sri Lanka’s central laboratory and later learned that Natkunam’s diagnosis had been correct. By then, the patient had received treatment and was in remission.

“It was a very gratifying experience and showed, I think, that our work doesn’t have to be fancy. We have so much knowledge and training and could do so much good in the world if we had a chance to,” Natkunam said.

Forging a Pathway at Stanford and Beyond

Razzano and Natkunam’s efforts are already gaining traction. In 2019, Natkunum approached the Stanford Center for Innovation in Global Health to request support for sending pathology residents oversees. They were able to send one resident, Dr. Atif Saleem, to Botswana — but the program did not continue because of the pandemic. They plan to resume this partnership as pandemic conditions ease.

“It’s a unique thing to offer pathology residents,” Razzano noted. “Few programs offer funding and travel opportunities for overseas training.”

The timing for such offerings couldn’t be better, she added. “We have a wonderful young generation of pathologists who are connected and aware of the need for pathology services, and many people interviewing for residencies ask about what global health opportunities are provided.”

Beyond Stanford, global pathology is beginning to gain traction as well, with many pathology organizations launching expanded global health initiatives.

Natkunam, Razzano, and many colleagues volunteer their time providing services to low-and-middle-income countries, including for a program developed by the American Society for Clinical Pathology where volunteer pathologists consult to help evaluate digital whole slide images uploaded by labs in several African countries. Razzano has been helping to build a two-year gynecologic and breast pathology fellowship in Ethiopia, which has just recently launched.

“The problem with working like this is, it’s a hobby. You do it on your extra time,” Natkunam said. “There’s a lot of interest, but there is not a set pathway to make this part of a person’s career.”

Razzano and Natkunam hope to see these burgeoning efforts become more formalized. Funding to support part of a person’s time working on global health is the biggest challenge, Natkunam said: “I believe that if we can build a formal global health initiative within the Department of Pathology, there will be a lot of interest among faculty and trainees, and the expertise in our department would certainly allow Stanford to lead in this field.”