Out-of-the-Box Thinking: A Q&A with Dr. Laura Warner

By Molly Strzelecki - April 04, 2022

Out-of-the-Box Thinking: A Q&A with Dr. Laura Warner
Dr. Laura WarnerBefore she became the deputy director of operations at San Juan Basin Public Health in Durango, Colorado, Laura Warner, MD, worked with the nonprofit African Strategies for Advancing Pathology (ASAP) while doing her practicum project for her master’s degree in public health. During her time with ASAP, Dr. Warner helped develop the “Lab-in-a-Box” concept for laboratories in Sub-Saharan Africa. She published a paper on her findings of the process, Lab-in-a-Box: A Guide to Building Anatomic Pathology Networks in Resource-Limited Settings, in the January 2017 issue of the American Journal for Clinical Pathology. Her research was also picked up by the World Health Organization’s book, WHO list of priority medical devices for cancer management. Here, Dr. Warner shares her insight on lab-in-a-box and why it is critical to promoting better global health.

Critical Values (CV): For those who don’t know, what is lab-in-a-box,
and how/where is it typically used?
Laura Warner (LW): Lab-in-a-box is a concept that looks at the essential elements and cost estimates of a network of anatomic technology lab really targeted for resource-limited areas. The goal is to enable the rapid upscale of anatomic pathology capacity in resource-limited areas, along with increasing the quality of pathology services and cost efficiency. It’s a grand goal, but it’s meant to jump-start the process of how a network of laboratories would be built.

The hope is that these laboratories are in resource-limited areas, and in this case specifically Sub-Saharan Africa. An independent organization or a government might recognize the need for increased capacity in anatomic pathology, and want to build a network of labs from the ground up, so they could pick up this lab-in-a-box idea and have some guidelines around what are the essential components of creating a network like that.

Over the last several decades, through a lot of public health initiatives, we’ve been really successful at reducing the disease burden from communicable diseases. Infectious diseases used to be the bulk of the disease burden in resource-limited areas.

The global disease burden, again, particularly in resource-limited areas, is really shifting to noncommunicable diseases, which are what we’re primarily faced with in higher-income areas. With noncommunicable diseases, cancers are an important component of that. However, even though we can anticipate an increase in the demand for pathology services, which of course support diagnosis and treatment of cancers, resource-limited areas oftentimes don’t have the supply of pathology services to meet the demands of that growing disease burden of noncommunicable health issues. With the shift in disease burden, it’s important to try and get on the front end of that to build infrastructure as the demand for services continues to grow.

CV: Tell us about the research findings discussed in your paper.
LW: From the broader advocacy perspective, it’s a pretty daunting idea to build a network of laboratories that would be able to serve entire countries. It’s hard to know where to start, so the idea of lab-in-a-box was really just to start somewhere with one central location that lays out, at a very detailed level, what are the consumables you would need in a particular type of laboratory? What are the utilities that would be necessary to keep the lab going? We discussed workforce requirements with whole networks. In the paper I looked at three different types of labs that would be in a network like this. And again, the idea is to provide a starting point, so if an organization or government wanted to tackle something like this they have a place to start.

Since there are cost estimates included in the lab-in-a-box, another potential use is for economists to do modeling about what the cost would be of any one component of the network or the entire network itself. So, from the perspective of bringing a very complex problem into more manageable pieces, an economist could at least provide cost estimates. You can understand what kind of workforce, what sort of staffing would we need? What would the equipment requirements be, so that it’s a little bit more within reach to actually move to this really necessary resource.

CV: You mentioned three different types of laboratories in this type of network. What are those types?
LW: The idea is to have a local, regional and national level laboratory for a network being implemented in an entire country. That primary local level is where any routine pathology services would begin, in the community setting. The next higher tier would be a district or regional level, and would potentially be located in a hospital rather than a community. They would also do specimen collection and processing, but also would have additional capabilities not available at the primary level. The second level would receive referrals from the first level. Finally, the national level would really encompass all the different activities of a pretty advanced laboratory— specimen collection and processing, but also technical assistance and support for the lower levels, maybe even activities as complex as tumor boards or incorporating new technologies into pathology service or providing telepathology services to those regional and local levels of laboratories.

CV: What are some of the challenges you see in implementing lab-in-a-box?
LW: The big takeaway for me was the only way that really high-quality pathology services can be delivered on a large scale is to have the entire network, those three tiers I discussed. You’re going to need a little bit of all of those things. It’s impossible to have a fully functioning network in an instant, so you have to think about what you do first in order to at least get you part of the way.

There are also a lot of other challenges that come along with the idea that this would be implemented in a resource-limited setting, so something that’s simple in a high-income area such as access to reliable clean water or maybe Internet, those utilities might not always be reliable as in some other areas of the world.

The other aspect to consider is workforce. Yes, we can create brick-and-mortar laboratories. We can stock them with supplies and big, fancy machines, but if the workforce isn’t in place, and they’re not highly trained to use all the equipment and provide services to colleagues and patients, it won’t be successful.

So there are a lot of components in a lab-in-a-box that each take additional work, additional planning.

Molly Strzelecki

ASCP Director of Communications + Editor of Critical Values