Lab Voices

Ann Nelson Interview (Part II)

• Pathologists Overseas • Season 1 • Episode 6

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Dr. Ann Nelson is a pathologist who is a member of the working group here at Pathologists Overseas. She has had a long career in global health. Dr. Nelson completed medical school in Mexico and served as a chief of the pathology laboratory for the International AIDS Project (Projet SIDA) in Kinshasa. This is part II of her story in global health and pathology. 

Tim:

Hello and welcome to the Lab Voices podcast from Pathologists Overseas. This is Tim Amukele, president at Pathologists Overseas, and I am pleased to introduce our guest today, Dr. Ann Nelson. Dr. Nelson is a pathologist who is a member of the working group here at Pathologists Overseas and has had a long career in international work that started right in the beginning. She grew up in Southern California, completed medical school in Mexico, and served as a chief of the pathology laboratory for the International AIDS Project in Kinshasa, Zaire. She will share this and much more in today's podcast. Hi Ann.

Ann:

Hi Tim. How are you today?

Tim:

Hey, I'm good. Alright, so Ann, welcome to the second hour of your interview with Pathologist Overseas. We are excited to have you here again.

Ann:

Thank you.

Tim:

Yeah, last time, we talked about your experience from growing up until you went to work at AFIP and you were in Kinshasa, for a number of years, and we left right when you and your son were essentially airlifted out of Kinshasa.

Ann:

Correct.

Tim:

As things were falling apart there, so let's go from there. How did things proceed? Where did you arrive in the US and how did you go from there?

Ann:

So, I got back, end of September, October of 1991.

Tim:

Mm-hmm.

Ann:

So, we were all shellshocked at that point, but I had a job at the Armed Forces Institute, and I just went back and worked and continued working on, HIV/AIDS pathology, doing more US cases, of course, since I wasn't in Kinshasa. I had some of my material that I brought with me and we continued to work on, tuberculosis and diarrheal disease and placenta, and the large collections I brought with me, pap smears. So there were a few more papers and things written. Then, I started doing a lot more with, US cases and creating teaching sets with the material that was at the AFIP, both from Africa and from the military hospitals and VAs that were seeing a lot of HIV. So that was in the early nineties.

Tim:

Yeah. And how old was your son when you got back?

Ann:

Two and a half.

Tim:

Oh, wow. And how did he acclimate back to life in the US? I guess he hadn't really started talking, or maybe he had just started talking, but he must have been in French.

Ann:

He was speaking mostly French, but by the time he was 18 months, he knew a hundred words or something.

Tim:

Wow.

Ann:

Cause he knew French and Lingala and he talked all the time. Now he doesn't talk very much. He's much, much shyer now. But, no, he was fine. What was funny is we eventually got him into a pre-kindergarten school and one of the ladies there was Swiss, so she spoke French, but there was a girl who was six months older than he was.

Tim:

Yeah.

Ann:

Who was French. And her parents were sending her there to learn English. And so she said, Eric, we're in America now we have to speak English. So he stopped speaking French.

Tim:

Wow, that's amazing. Peer pressure.

Ann:

Yeah. Extreme peer pressure. I mean, he still knew it, but he lost some of his French.

Tim:

Oh, okay. I kind of wanna get a sense of how you stayed involved in global health in the bridge between, you know, having a young child and kind of getting set up again in the US between that and the Fulbright, how did you stay involved?

Ann:

So, all the Projet SIDA people; we were still writing some papers. I did some chapters on tuberculosis. So I kept the contacts that I'd had, around HIV stuff. And then global pathology I did mostly through different IAP meetings, which are every other year. International Academy of Pathology was founded in 1907. And they would rotate around. So that was how I kept doing global health stuff.

Tim:

Okay.

Ann:

In 2004, I was asked to organize a course on global pathology in Brisbane, Australia. So, when I organize those kinds of sessions, I've tried to pick somebody from each continent to come and talk. Because I think you can't just have all the same Americans and Europeans. You need to hear from local people talking about what they knew.

Tim:

Yeah.

Ann:

So I stayed active academically through meetings and doing some travel

Tim:

Mm-hmm. Yeah. I was reading somewhere that you've presented or taught in every continent except Antarctica.

Ann:

Yes. Yeah. Yeah. I think I'm up to about 24, 25 countries.

Tim:

That's awesome.

Ann:

Yeah, and it's fun because you go and you're part of the local people. And some places I've been to several times. Bolivia, I've been back to three times because I can lecture in Spanish.

Tim:

Yes, exactly. Which is not a common skillset for Americans.

Ann:

No. So networking with people, you sort of feel like you're keeping up with what's going on.

Tim:

Yeah. So, tell me about the Fulbright. What gave you the idea to apply for it? How were things lined up in your personal life so you could actually travel?

Ann:

Well, my son graduated from high school in 2007.

Tim:

Okay. See, this matters. Yeah. Uhhuh.

Ann:

And that was about the time the AFIP was told they were gonna close in five years. And so I was well, what am I gonna do? And somebody said, why don't you apply for a Fulbright? You know, I didn't think about Fulbrights at my age. I started thinking about it and went online and looked at what was available. And there was a research Fulbright, for HIV/ AIDS in Africa.

Tim:

Tell us about the Fulbrights. How do those work?

Ann:

So, if you're like a graduate student level, there's research level and then there's a little more advanced research like sabbatical type stuff.

Tim:

Okay. Uhhuh.

Ann:

If you're already working and then there's fulbrights that are shorter term, that are full professors and you go and spend three months teaching somewhere. I just looked for the HIV/ AIDS one.

Tim:

Mm-hmm.

Ann:

I applied and I got a letter saying that my scientific proposal had been accepted, but it wasn't funded. And so apparently Professor Nelson Sewankambo who at the time was the dean of the medical school at Makerere, and Roger Glass, who was head of Fogerty, made some phone calls and then I was funded. Because he said the people in the embassy didn't get what's a pathologist gonna do, but they explained to them that it was really desperately needed.

Tim:

Yeah, absolutely. Why did the embassy have a role? Just explain how it works.

Ann:

Because Fulbright is linked with the Department of State. And so when you go over, you're under the auspices of the Secretary of State. And it's affiliated And the embassy is responsible for me, and I have to abide by their rules and things.

Tim:

Okay. Right

Ann:

So because I was a government employee and at the time I was working for the Veterans Administration, I could take six months leave without pay, without losing any of my retirement or health benefits.

Tim:

Oh, I see. So your Fulbright ended up being six months?

Ann:

Six months. So I first went out for four months to Uganda, so it was October into part of February. So, I did the first half of my Fulbright, and then I came home.

Tim:

And how did it work, in terms of your salary?

Ann:

I got a grant that basically paid my airfare and room and board, but I did not earn a salary.

Tim:

Okay. Okay.

Ann:

And so I came back and worked for a few months and earned some money and then went back. Part of it had to do with weather and different things. So I, when I went back, I spent some time in Tanzania. Then Robert Lukande, along with Dr. Colebunders from Antwerp tropical Medicine and Dr. Yuka Manabe who is Hopkins. But she was at the time at infectious Disease Institute. We developed some proposals to do autopsies. What were people with HIV dying of? So, we got some funding to do that. And when I was going to Uganda, Robert Lukande and I wrote a grant to Novartis. And they had small grants and so I think we got like$80,000.

Tim:

Oh, that's exciting.

Ann:

That I could use to create teaching material on HIV, but it was helping to set up the laboratory. We actually used some of the money to paint the lab and clean up the cutting rooms and buy cameras and computers and the microscope. So, we were able to buy a lot of useful things, to use in the fulbright.

Tim:

Yeah. Yeah. That's great. That's great. So tell me, you've been involved with different organizations. You've mentioned IAP. I want you to talk about what your involvement to the local organizations has been and how important that is.

Ann:

I think that one of the first international pathology groups was the Southern African division of the International Academy of Pathology.

Tim:

Okay.

Ann:

And then there was a West African Francophone division that came out of the French division. So In the early nineties, the pathologists in East Central, like a lot of the old British Commonwealth countries wanted to organize regional conferences. So, the British division and the South African division of the IAP did a survey to see who had pathology departments, were they training people, what kind of equipment, what was their caseload? So, it was a big capacity survey that was done in those countries. And then out of that grew, let's have regional meetings every couple of years, and they would rotate to the member states.

Tim:

Okay.

Ann:

So, it took a while to build up a cadre of doctors who were graduated from schools in Africa. And at first, they would go to France, or the UK or to the US and get their training with the idea of coming back to Africa, but that didn't always work out so well because people didn't wanna go back. And so there was an effort to create teaching within the medical schools on the continent of African pathologists and with African faculty.

Tim:

Mm-hmm.

Ann:

So, that was evolving around the time that APECSA started.

Tim:

Okay. And tell us what APECSA is again?

Ann:

Association of Pathologists of East, Central and Southern Africa.

Tim:

Okay.

Ann:

And it's former British commonwealth countries for the most part. There's the West African division of the IAP, the Anglophone, which was formed in about 2005 or 2006, and that's still part of the International Academy of Pathology. But the West African, the Francophone Division, which is Francophone West Africa and parts of Central Africa was there, but the French hadn't been actively supporting them for a while, so they sort of started having meetings together. So that's one group. Then, the other group that I mentioned, AORTIC or the African Organization for Research and Teaching in Cancer, was actually around in the eighties, they had a few meetings

Tim:

And was it primarily a pathology group or was it

Ann:

No, oncologist and pathologist. It was a multidisciplinary group.

Tim:

Okay.

Ann:

And then after the West African division started, then the East African division of the IAP was formed by Ahmed Kalebi. He became secretariat, and then he worked with a lot of the same people from APECSA and from that grew the idea to create a college. Well, they were trying to create academies of medicine in East, Central, and Southern Africa. So, the College of Pathology was formed around that time.

Tim:

Okay. So, I wanna talk about two specific projects that I know you've been involved in. Now, I want the autopsy project that you alluded to earlier. And then, the paper that you guys published about pathologists capacity in Africa, and I just wanted you to talk about both of those in whichever order you'd like.

Ann:

Okay. Couple months before I did my Fulbright, Sebastian Lucas, and Ephata Kaya and I put together a symposium in Dar and we got a little bit of money from the World Health Organization and then other money that Sebastian was able to get through teaching funds he has. And we brought maybe a dozen or so pathology leaders from around the continent. And we met in Dar es Salaam for several days to talk about, how could we do more together. There were several of the people that we'd known and worked with who were at the hundredth anniversary of the IAP in Montreal in 2006. And so that's when we tried to create a consortium of African pathologists to help each other out and share information and that kind of stuff. So we put this together and one of the things that came out of that meeting is we said there hasn't been a survey of pathology capacity done since the one Sebastian did 15 years earlier.

Tim:

Right.

Ann:

So, we put together a survey and I think Ahmed made one of those survey documents.

Tim:

Right.

Ann:

You could just go in and fill out the information. And, The American Society of Clinical Pathology helped fund translating it into Spanish, French, and Portuguese.

Tim:

Okay.

Ann:

So, we had various lists of pathologists from the different divisions and from, a bunch of different ways we could get emails. And we sent out several hundred emails to pathologists all over the continent. And you know how surveys go, you get 10 or 15%.

Tim:

Yeah, that's actually that's a pretty good return rate, usually it's lower.

Ann:

Yeah. But it was people you knew and you asked them, and then if there were meetings we'd tell people about it and say, please go on. But it took about, four years of networking, calling people, sending emails. It took a long time and it's not so easy. And we wanted to know as much as possible what the data was. So, we collected where was the department, the countries, the individual medical schools, how many pathologists did they have? How many technicians, what was their caseload? A lot of detailed questions, but also did they do oncology in their hospitals? Did they have radiation? Did they have chemotherapy? So, we asked as broad of questions as we could, and the ones that answered right away, we tried to go back and update as much as possible. I think Angola was one of the hardest countries to get.

Tim:

Yeah. As a person who was on the other end of it, who was reading the paper, I thought it was- I don't wanna say ground breaking, but it just became instant classic paper. You know?

Ann:

Foundational.

Tim:

Yes. Foundational. That's the word. Yes. Thank you.

Ann:

Yeah. No, and you know, we've tried to repeat it, but people don't answer.

Tim:

Yeah, yeah. It's hard.

Ann:

I had no grant money, nothing. I just did it because I felt it was important to do.

Tim:

Yeah. It is important to do. Yeah. That's great. So, tell me about the autopsy work.

Ann:

So, yeah, that sort of went on from 2006 until 2016 when it was published. Um, but most of the data collection was done in the first five years. But anyhow my Fulbright objective was define HIV pathology in Uganda. What is it now? How has it evolved? How can adding the ability to do special stains to find organisms help? But you have to have clinical buy-in when you're trying to do studies. And so I would sit in the cafeteria at Makerere and whenever Muzungu came in...

Tim:

What's a Muzungu?

Ann:

Which is a white person. So somebody who was there, not, not a local person visiting, I would talk to him and say, what are you doing? How can pathology help? What do we need to do to be of service to you and how can we work?

Tim:

I just wanna make a point of what you've just said cause it's so important. A lot of times, people don't rely on pathologists, the way where they would in the US or in the UK or somewhere in the west because they're used to not having them. So they're used to doing without. So, I think making people aware that the service is available is a great thing.

Ann:

And then making the service functional. You know, it has to be rapid and reliable.

Tim:

Exactly. Yeah.

Ann:

So, the idea started when I was doing my Fulbright, but we got grant money and continued it. I think there's been four or five papers written out of that, an original survey of autopsies in Africa, and then our descriptive autopsies. And then what they did later in the study was do minimally invasive tissue sampling. So using large bore needles, but they do ultrasound and the clinician would collect the specimens, and then somebody in the path department would go and do a standard autopsy. And then, comparing the results to see how well it did.

Tim:

How well did it do? Because it seems like it's the kind of thing that would be really practical.

Ann:

If you get an answer, it's likely to be correct, but you miss a lot of things by not doing a full autopsy..

Tim:

Okay, I see. Yeah.

Ann:

It's a lot better than just a verbal autopsy. But, you're still missing a lot of things, right? By not doing, and you may get TB, but you don't know, is it disseminated TB? Is there other things going on? What's the insight to changes that are going on that you don't do? And, because I'm always talking to people, one of the people I met when I was in Uganda was a lady named Leona Ayers, who was doing cancer related projects in Africa, lymphoma related is what she got started with. And so she put me on a grant to help set up immunohistochemistry at the University of Nairobi and to do teaching. So, after my Fulbright, maybe 2010, 11 and 12, I was going to Kenya to work on this immunohistochemistry and teaching HIV related cancers at the medical school in Nairobi. So, that was one of the spinoffs from the Fulbright.

Tim:

Yeah.

Ann:

And then, another one, and this is sort of, if you wait long enough, maybe something will happen is I have been teaching the pathology of medical microbiology at Duke University going back 15 years maybe.

Tim:

Oh wow.

Ann:

I did for a long time. And then, when Dr. Reller retired, they didn't have that fellowship anymore, but I would go down and they always said, we work at Kilimanjaro Christian Medical Center, and we really wanna know in these big fever studies, what do people die of that we weren't able to work up.

Tim:

Right.

Ann:

And so we tried getting autopsies in different grants. And then finally in 2016, they got funding to do autopsies. But, it ended up that a lot of the people that had autopsies weren't enrolled in the study because they came in and died. Or the people in the study who died, died at home. They did them with the minimally invasive techniques as well, but they weren't part of the fever study for the most part.

Tim:

Okay.

Ann:

So, that's the most recent grant and project I've been involved with. But, you know, over the years I've gone to meetings and I've done things and I would say half of what I've done has been on my own dollar.

Tim:

Yeah. Yeah. It's, it's worth pointing out. Yeah. Cause it's been given by your own interest. Yeah.

Ann:

Yeah. So, I keep working, I'm working part-time now. I keep working and, you know, a percentage of that money, which can be a write off on taxes, but it's still money out of my pocket that I use to travel to go to the different meetings in Africa, or even some of the travel I did going back to Uganda to work with Robert, I did on my own dollar.

Tim:

Okay. So I was gonna ask you if you plan to remain in global health now that you're retired or semi-retired. Well, you're retired, but you're still working.

Ann:

Yeah, I'm working part-time as a consultant. You know, I'm still on the calls with the project at KCMC. Kilimanjaro Christian Medical Center by-

Tim:

In Tanzania. Mm-hmm.

Ann:

The Impala, the International Pathology Group that became African Society for Advancing Pathology, ASAP.

Tim:

Mm-hmm.

Ann:

Has a mentoring group and I've remained as part of the mentoring group.

Tim:

Right. And you were one of the founders of that group. Of course. Of ASAP.

Ann:

Yeah. Back in 2014. And, it's different leaders from pathology around the country and it's a group that has a board and they meet, but they really don't have a lot of funding or anything. So, but it's helping people stay connected and share resources. And the mentoring group, we give people information about meetings that are coming up. Bursaries. And that kind of thing. And then if they need help, they're writing about breast cancer, well talk to Shaheen or talk to this person. So Right. Like that creating a database for them to use for mentors.

Tim:

That's very practical. It makes a lot of sense. So, you have a unique perspective cuz unlike many other people who do volunteer work, who sort of do short term missions type thing.

Ann:

Yeah.

Tim:

You were actually working in the DRC before it was the DRC, back when it was Zaire. You were working there and you were there for five years. And then you've had this long ongoing relationship where you were working with Africans and working on the continent in different capacities. What's your view? Just take the long view of how things were, say 20, 30 years ago and how they are now in terms of the staffing and just the level of work. What is your view?

Ann:

You know, going back when I was in Kinshasa, Professor Kalengayi was, you know, he was sort of a unique leader, pathology leader, and developed people and did research. So, he was doing things a little different than a lot of other people were doing. He was academically very strong, but a lot of places weren't. People would just come and do their work. They'd spend their time out in their private labs in order to make enough money to send their kids to school. And so, there were a lot of factors impeding good pathology practice.

Tim:

Mm-hmm.

Ann:

A lot of it was just lack of enough people. But I think in the last 20 years, the number of training programs and the number of trainees is probably close to doubled. And a lot of them, I think I told you, they call me Mama. The mama.

Tim:

Yeah.

Ann:

And so now I was telling some of the people at the meeting we had in South Africa last fall, I said, you don't need a mother anymore. Now I'm the grandmother. So, you're the parents and I can help you with your grandchildren. You're the one who was raising your children now.

Tim:

Yes, yes, yes. And so, I think that says that

Ann:

now us ex-patriots can be there to help, help people get grant money. But it should no longer be our responsibility. It should be the Africans who carry the responsibility.

Tim:

Right.

Ann:

And the more you do, the more you're able to do and the more confidence you get. And so I think that's where the future's going. I think going forward, it may be more that we go to learn. And bring skill sets in. But not to manage the projects.

Tim:

Right. Exactly. That's great.

Ann:

And that's sort of, where I see it should go going forward. But anyhow, this is sort of an end note. I gave a talk at the funeral of Dr. Connor, who was my mentor.

Tim:

Okay. Yes, yes, yes, I know that. Yeah. Uhhuh.

Ann:

And he and Kalengayi died within a couple weeks of each other. But what I said in the last paragraph, it is said that a great teacher inspires. Dr. Connor inspired me to do infectious disease, pathology, global health, to mentor the next generation and have a passion for learning and culture and people. My goal when I heard his first lecture was to be like him. And so the seed that was planted in me 40 years.

Tim:

Yeah.

Ann:

Ago. It was my responsibility to carry it on.

Tim:

Yeah. And you have, it's wonderful.

Ann:

Yeah. Yeah. But I've always said if you wait for somebody to offer you something, you may never get it.

Tim:

Yeah, exactly.

Ann:

Or if you wait for somebody else to pay again, you know, what are you willing to invest to get where you wanna be.

Tim:

Yeah, yeah, yeah.

Ann:

So anyhow.

Tim:

All right, Ann, this was lovely. I think how that we have what to figure out.

Ann:

We have way too much.

Tim:

But no, it's great. It's better to have way too much, and then, you know, you can trim.

Ann:

Yeah. Well that was another thing Dr. Connor said. He said the hardest thing to learn is what not to say without losing the story.

Tim:

Right. Right. Yeah, exactly. That was Dr. Ann Nelson. Thank you for listening to the Lab Voices podcast. I'm your host, Tim Amukele. To find out more about Pathologists Overseas and our projects, visit www.pathologistsoverseas.com. And follow us on social media. Podcast edited and produced by Taylor Harris. Theme music by Tim Amukele. Do you or someone you know have an interesting story to share that would be great for our podcast? Send us their name and email address at admin@pathologistoverseas.com. and you might hear it on the Lab Voices podcast.