Comment on “What's new in digital and computational pathology 2026: advances in adoption, standards, AI technologies, and clinical integration”
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I read with great interest the review by Sevim et al. [1] on advances in digital and computational pathology, which notes that international adoption remains uneven, with developing countries facing technical, financial, and workforce barriers. I would like to offer a ground-level perspective from Pakistan that shows how early this gap can begin—not as a lag in digital adoption, but as the absence of the basic anatomic pathology infrastructure on which any digital layer must sit. This concern is long-standing: pathologists in Pakistan have described the discipline as one that had to be rescued from a “primitive and outdated” state, constrained by workforce and infrastructure limits [2], and the Lancet series on pathology and laboratory medicine identified workforce, infrastructure, education, and quality assurance as the four foundational barriers in low- and middle-income countries [3].
At Abbasi Shaheed Hospital, a large public-sector teaching hospital in Karachi where I have worked, the pathology laboratory's routine output is weighted heavily toward basic hematology such as complete blood counts, and not all surgical specimens are consistently routed for histopathologic examination—a step that was automatic at the U.S. institutions where I completed clinical electives. I offer this as a personal, institutional observation rather than a measured audit. Published national data indicate that this is not an isolated impression. As of 2023, only 338 histopathologists had passed the fellowship examination in Pakistan, a country of more than 220 million people, and only 18 major histopathology laboratories operate nationally, most concentrated in large cities [4]. Selective rather than routine submission of surgical specimens is also documented: in one teaching hospital series at Lahore General Hospital, 54% of appendectomy specimens were never sent for histopathology [5], and the discarding of gallbladder specimens after cholecystectomy has been described as standard practice in most tertiary care hospitals of Pakistan [6].
These service gaps are reinforced by a workforce and education problem. In a survey of medical students at a Karachi medical school, the leading reasons cited for the low number of graduates entering pathology were lack of general interest (37.4%) and lack of exposure (27.8%), and students perceived pathologists as having little patient interaction, which made the field less attractive [7]. Underfunded, low-visibility laboratories give students few chances to see a functioning pathology service, which in turn sustains the shortage.
A private pathology sector does exist and generally performs to a higher standard, and at least one tertiary center in Karachi has begun piloting whole-slide imaging and telepathology [8]. But because more than half of health spending in Pakistan is out-of-pocket [9], this two-tier structure means diagnostic quality is shaped substantially by a patient's ability to pay. Where pathology does function well, the results are strong—the Karachi Cancer Registry reported that 95.3% of incident cancers registered in 1995–1997 were microscopically verified [10]—underscoring that the constraint is capacity and access, not capability.
I raise this not to diminish the progress Sevim et al. document, but to suggest that "uneven adoption" may understate the true range of the global picture: some settings have not yet reached the starting line. The organizations advancing digital pathology—the College of American Pathologists (CAP), the European Society of Digital and Integrative Pathology (ESDIP), the Digital Pathology Association (DPA) the Asian Society of Digital Pathology (ASDP), the Latin American Society of Digital Pathology (LASDP), and the African Society of Digital Pathology (AFSDP)—could usefully extend their advocacy and capacity-building toward foundational anatomic pathology in low-resource public systems. ASDP is especially relevant, having been founded to serve the diverse needs of Asia and being well positioned to engage South Asia, including Pakistan. Without such foundational investment, the digital transformation this review describes will remain out of reach for many patients.
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