Pathology Practice in a Resource-Poor Setting Mwanza, Tanzania Peter F. Rambau, MD N Practicing pathology in a resource-poor setting presents many challenges that are unfamiliar to pathologists in developed countries. Typically, the number of pathologists in a resource-poor country is small, even as a percentage of the total medical workforce. Although pathology should play a central role in the delivery of appropriate health care to the patient, this role is often hidden and not well recognized by patients, clinical colleagues, or other stakeholders, such as administrators and politicians. The public tends to think of the pathologist as the ‘‘Doctor of the Dead.’’ The financial rewards are also small. Conse- quently, it is difficult to recruit physicians into pathology. The lack of human and material resources allocated to pathology leads inevitably to a large gap in health care for many patients, with an unmeasured negative effect, at both the individual and societal levels. Correct management of the patient, even when available, is not administered because of the lack of pathologic information. Surgery may be performed without the benefit of preoperative or postoperative pathologic confirmation of the diagnosis, let alone identification of important prognostic informa- tion. The pathologist plays a key role as an educator in developing countries to medical students, allied health professionals, and medical colleagues and is, therefore, called upon to provide many hours of teaching. The pathologist is uniquely qualified to provide knowledge and understanding regarding the diseases in the region where he or she practices. Although many of these challenges are universal, they are perhaps nowhere more acute than in resource-poor settings. (Arch Pathol Lab Med. 2011;135:191–193) T he United Republic of Tanzania is a sub-Saharan country that measures about 945 000 km 2 , with a population of 39 459 000, according to the World Health Organization estimate for 2008. The country was formed in 1964 as a union between the former Tanganyika and the islands of Zanzibar. Tanganyika gained its independence from the United Kingdom in 1961 and Zanzibar from the Sultan of Oman in 1964. Initially, the political system was that of a one-party state with a socialist ideology. In recent years, multiparty elections have been held, and there has been a gradual process of economic change in a stable political environment. Since independence, Tanzania has worked hard to establish and improve its health care system. Initially, all health services were offered free of charge. A change in policy, instituted in 1995, required individuals to contribute to the cost of their care, excluding certain groups, such as children younger than 5 years of age, pregnant mothers, and the elderly, as well as patients suffering from chronic diseases, such as diabetes, tuberculosis, and AIDS. Tanzania has 22 regions, organized in 5 zones and 121 districts. The physician to population ratio is 1:23 000, one of the lowest in the world and lower than in the neighboring countries. Health services are stratified, starting with the local dispensary, progressing through health centers, district hospitals, regional hospitals, and at the highest level, referral hospitals. Specialized care is generally only delivered at the referral hospitals, and that is where most specialist physicians work, including pathologists. Training of physicians and the education of medical students occur principally in the referral hospitals. Forensic medical services are primarily organized at the referral hospitals, although some forensic services are also available— although strictly not permitted—at the regional and district levels by medical officers and assistant medical officers. The territory is vast, and transportation is frequently difficult; consequently, referrals of forensic cases to centers with facilities and trained personnel tend to occur infrequently. DISEASE BURDEN IN TANZANIA AND THE LAKE ZONE Although communicable diseases, including zoonotic diseases, remain the major cause of morbidity and mortality in Tanzania, 1,2 chronic diseases, such as diabetes, heart disease, and cancer, are also important and increasing in frequency. 3 Malnutrition contributes signif- icantly to morbidity and mortality in infants and children. Human immunodeficiency virus continues to spread, although the levels are not as high as in many other African countries. 4 Cancer of the cervix is the leading malignancy in women in Tanzania, as in most other African countries, 5 and has been shown to have a high prevalence among women who are positive for human immunodeficiency Accepted for publication March 16, 2009. From the Department of Pathology, Weil Bugando University College of Health Sciences, Mwanza, Tanzania. The author has no relevant financial interest in the products or companies described in this article. Presented in part at the Pathology in Developing Countries Symposium at the annual meeting of the Canadian Association of Pathologist, Ottawa, Ontario, Canada, July 14 2008. Reprints: Peter F. Rambau, MD, Department of Pathology, Weil Bugando University College of Health Sciences, Box 1464, Mwanza, 00255 Tanzania (e-mail: ra1972tz@yahoo.com or prambau@bugando. ac.tz). Arch Pathol Lab Med—Vol 135, February 2011 Pathology in Mwanza—Rambau 191