Improving access to diagnostic testing in conflict-affected areas: what is needed?

Many of us read or learn little about conflicts other than those with high media visibility, such as the ongoing conflict in Ukraine, and yet, depending on the definition used, there are up to 110 ongoing conflicts around the world [1]. These conflicts, along with “…persecution … violence, human rights violations and events seriously disturbing public order…” lead to an estimated 103 million persons being forcibly displaced as of September 2022, including 53.1 million internally displaced persons and 32.5 million refugees [2]. Forced migration is often multidirectional, and can involve travel over large distances, both of which result in the health impact of conflict being observed over a wide area. Because of the locations of current conflicts, most refugee populations (69%) live in neighboring countries, 74% of which are LMICs and 22% are least developed countries – countries where health systems struggle to accommodate an influx of patients needing care, potentially destabilizing and overwhelming fragile health systems [2].

As shown in Table 1, health care systems in conflict-affected settings experience conditions that adversely affect their ability to provide services [3]. The sum effect of these conditions is that health care systems in conflict areas often cease functioning except at a basic level [4], and access to even that level of care is reduced. Access to diagnostic testing, which is heavily dependent on workforce, infrastructure, and supply chains, also is reduced [5].

Once conflict occurs in an area, what can be done to mitigate the effects on health care systems and especially on diagnostic testing? A first step is to assess what capacity remains and how well it continues to function. In this issue, Markby and colleagues describe the use of two World Health Organization laboratory assessment tools for assessing laboratory capacity in conflict-affected, low-resource settings [8]. These tools are designed to assess the management, operations, and quality programs of laboratories [8]. It might be argued that these tools are too complicated, and therefore not appropriate for laboratories in conflict settings, where only minimal laboratory testing capacity may exist, but focusing on the management and operations of laboratories provides a good understanding of the overall ability of a laboratory to generate timely, accurate test results. Moreover, these tools are standardized and have been used for a number of years in different settings. This experience makes it simpler to deploy trained teams to assess laboratories, allows for establishment of performance benchmarks, and enables managers to track their performance over time. Most importantly, these tools were originally developed to assess the performance of laboratories in low-resource settings.

Understanding the operational capacity of laboratories is a critical step in providing access to diagnostic services, but what other tools or processes should be available to help laboratories provide the testing needed for patient care? Although new technology is not the sole solution to providing access to diagnostic testing in low-resource settings, much of the diagnostic technology used outside of conflict settings is not adaptable to the needs of health care workers who work in conflict settings. The desired characteristics of diagnostic platforms for use in conflict settings are shown in Table 2. There is a need for more research and development in this area, and for manufacturers to develop and support platforms with these characteristics [9].

Development of new diagnostic platforms, as well as the assays to run on those platforms, requires decisions about what tests to offer due to the finite number of different tests that can be performed in a particular setting. Although the scope of testing could vary from site to site, depending on local disease burden, there is evidence that a basic set of tests are common in most settings [10]. In addition, the World Health Organization Essential Diagnostics List (EDL) provides additional information as to which tests should be considered for use in most settings [11]. Although the EDL is not tailored for conflict settings, it was developed as a guidance to countries to provide a core set of tests that are broadly applicable across many health care settings. The EDL can and has been refined for use in individual countries, and it could be adapted to help guide development of diagnostics platforms for use in conflict settings.

These three steps towards better provision of diagnostic services in conflict settings, namely assessing the state of laboratories, developing appropriate technology for use in these settings, and basing that technology on existing knowledge of essential tests, are all important. Yet there is much we still need to learn about how to improve diagnostics in conflict settings, including better ways to ensure test quality over time in settings where External Quality Assurance programs (and even controls) are unavailable, establishing rapid education and training protocols that are appropriate for workers in conflict settings, developing ways to handle patient data and enable that data to accompany patients as they move from area to area, and developing tiered, integrated diagnostic systems that would allow for clinically-relevant near patient testing within conflict settings but allow specimens to transported to more stable settings for a broader scope of testing as necessary. Conducting this type of research in conflict settings is difficult and dangerous, and there is very little precedent for research in diagnostics in these settings [12, 13]. For this reason, the paper by Markby and colleagues, as original research, is exceptional.