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    Taking laboratory medicine for granted



    COVID 19 pandemic is a wakeup call for us to upgrade our diagnostic set up

    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 

    fi ltrate of blood and, as such, could indicate 

    the type and location of illnesses. For many 

    years, urine was the sole fl uid used for the 

    detection of various abnormalities like dia-

    betes, kidney diseases, and pregnancy. It was 

    only in 1874 when the fi rst laboratory of phys-

    iological chemistry in the United States at the 

    Sheffi eld Scientifi c School of Yale University 

    under the direction of Russell H. Chittenden 

    was established. A review of several hospi-

    tals’ records at the beginning of the 20th cen-

    tury 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 signifi cance in care, preven-

    tion, detection, diagnosis, treatment, and suc-

    cessful management of health conditions. 

    The various disciplines that formed the architec-

    ture of the laboratory medicine include clini-

    cal chemistry, immunology, hematology, & 

    microbiology. As the 21st century begins, the 

    laboratory medicine added the cutting edge 

    technologies in its arsenal from the Biotech-

    nology revolution. The technical terms like 

    PCR, RT PCR, FISH, NextGen sequencing, 

    Flow cytometry, Spectroscopy, Chromatogra-

    phy, 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 rig-

    orous 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 analyti-

    cal errors while performing and reporting 

    the diagnostic test. Qualifi ed quality control 

    professionals ensure that the test is being 

    done according to the standard guidelines 

    and practices of the concerned regulators. 

    The signifi cance 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 fi eld in order to save the human pre-

    cious 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

    Before commenting 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-medi-

    cation, mushroom culture medicate shops 

    by the most incompetent people across the 

    valley. The biggest irony is that individuals 

    who are not qualifi ed as medical practitio-

    ners 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 medi-

    cines 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 qualifi cation. 

    This designation prompts him to act like a 

    doctor, thus diminishing and spoiling the 

    role of a noble profession. Without exag-

    geration, it is a common observation that 

    a person who had spent some days with a 

    physician or surgeon collecting appoint-

    ment fee takes the liberty to fi t into the 

    shoes of a Doctor. This mafi a 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 pri-

    vate schools, B.Ed colleges, madrassas and 

    even private hospitals and nursing homes 

    but raising the standards of these insti-

    tutes 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 compro-

    mising 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 innumer-

    able 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 fi nds con-

    siderable 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 fi eld which will benefi t 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 profes-

    sionals as far as the status of our diagnos-

    tics is concerned. A basic molecular biology 

    technique called RT-PCR used for the detec-

    tion 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 impli-

    cations for our quality based treatments. 

    First, the poor person who has to pay a huge 

    sum of money for these tests always fi nds 

    it diffi cult 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 provid-

    ing 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 articu-

    lated 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 cli-

    nicians 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 nation-

    al and international standards. Today, we 

    realized a virus of few nanometers, which 

    in scientifi c 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 fi eld in our set-

    tings 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.

    Imtiyaz Ahmad Bhat, M.Sc, PhD is Senior 

    Resident cum Researcher, Department of 

    Immunology & Molecular Medicine, SKIMS

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