This in not an official U.S. Department of State (DOS) blog and the views and information presented are my own and do not represent the Fulbright Program or the DOS.

These are two 3rd year Pharmacy Students working together in class using the newly donated Sanford’s Guides to Antimicrobial Therapy

Today was a frustrating day. I worked at the hospital precepting the 4^th and 3^rd year Makerere University Pharmacy Students as they met with patients as part of the new Pharmaceutical Care Skills Curriculum. It wasn’t frustrating because of the students- they are a joy to work with. I love that they are so interested in learning more about the disease states they are studying from the experiences of their patients. They are also amazingly compassionate with the patients and their caregivers as they listen to the stories about why a person was admitted to Mulago Hospital and as they carefully, and patiently provide information about the drug therapy. These students are really bright and their foundational background in the medical sciences is impressive! They may not have been taught a lot about how to use drugs to treat diseases yet, but they really know their pharmacology. When I asked the 3^rd students yesterday in class if they knew about the drug, Warfarin, which is a common anticoagulant (the most common brand name in the USA is Coumadin©) and which they hadn’t officially studied in classes yet, not only did they know what the drug was but they also knew the mechanism of action. I asked them how they knew this and they could not really recall where this information came from but on further probing, it seems they learned about it during one of their summer experiences in the clinic. The reason I’m surprised is the depth at which they knew about a drug they had yet to study in class, but these students are taught to be self-directed from day 1 in University. The teaching methodology here for all of the students of the medical sciences (nursing, pharmacy, medical school, dental school, etc) is Problem Based Learning (PBL). The students are responsible for working in teams to develop learning objectives for the topic of the week, then they study these topics on their own all week, and then they teach the material to each other at the end of the week. Almost all of their learning is directly from their own efforts of studying. This, along with the fact that most of their final exams are cumulative AND open-ended (as opposed to multiple choice), really helps them to integrate the material deeper into their brains.

Using the recently donated Sanford’s Guide to Antimicrobial Therapy, 4th Year Pharmacy students work on a class exercise

So today, my frustration wasn’t from the interactions with my students. The major lack of drugs and supplies to effectively treat the patients at Mulago Hospital is basically unconscionable. I understand that this is a resource poor environment and the drug supply is not always reliable, but the extent to which this affects patients was clear today. I’m not sure I saw a single patient who was able to receive all of his drugs. In one case, it turned out the supply of a very common drug, omeprazole, which is a drug to prevent acid-secretion in the stomach, had been gone from the hospital for weeks. And, this particular unit had no other drug available as a substitute. One of the things I am trying to work with the students, pharmacy interns, and pharmacists on is their involvement in trying to find alternate therapies for the patients when the primary one the physician ordered isn’t available. Usually there is more than one way to treat a problem, so if one drug is not available, there may be another type of drug that could work. But, for this patient, there was not any other drug for reducing stomach acid and treating ulcer disease- not even a drug from different class of drugs. I was told at the end of the day that the shipment of omeprazole was expected next week, but what if the patient has complications or a bleeding ulcer before then??? The only option in situations like these is for the patient’s caregiver to go and purchase the drug(s) from a community pharmacy. Some patients are able to do this, but many and probably most others, are not able to raise the money to afford this. Also, today I went down to the microbiology lab to learn about their system of culture and sensitivity testing. As an Infectious Disease pharmacist, I am really interested in the appropriate use and choice of antibiotics to treat infection. But, we can’t really know which are the best drugs to use in the patients unless we have an idea of what drugs will usually work for the microorganisms that are causing disease in Kampala, Uganda. The way we usually figure this out in the USA is to create an Antibiogram. This is a compilation of the organisms that are grown from patient specimens in the hospital and the antibiotics that will usually work to treat these organisms, as determined by the lab test called a Culture and Sensitivity (C&S) test. Although these tests are routinely done at Mulago Hospital, it turns out the supply of the antibiotic-impregnated discs is not reliable so not all drugs are usually tested. This means that often, the drug that we must use to treat the infection, because they don’t have many antibiotics to choose from, is not even tested on the C&S. The whole reason for the test is to find out if the drug should work to cure the patient, but if the disc isn’t available and we can’t find out this information, then the process, equipment, and staff time to run the test was just wasted. I must say, though, that the microbiology staff I spoke with today were very helpful and were as frustrated as me by the lack of supplies and equipment to be able to do their job to the best of their abilities.

More 3rd Year pharmacy students work on a class assignment using the new Sanford’s Guide

I am generally an optimistic person yet I know that the work I am trying to do here in Uganda to help improve patient health care through advancement of pharmacy practice will take time and much patience. But, today my resolve was tested. Is it possible that lasting changes in medical practice can be made and result in better patient health outcomes when with every step ahead in improvement in the education of healthcare providers and/or the development of treatment protocols, there are logistical and supply challenges that threaten to push us back to the starting line???

3rd Year Pharmacy Student working with the Sanford’s Guides

Despite the situations I dealt with today, I can’t waiver in my determination to forge ahead with this project. For every difficulty I’ve come across, I have to remember the successes. Today, two patients received better pain control with the input from the students and me. One of these patients was likely saved from a serious adverse effect that could have caused seizures. Several other patients and their caregivers benefited from being able to voice their concerns and receive answers from the team of pharmacy students who were willing to spend time listening and providing advice. The last group of students I worked with today diligently reviewed the patient chart, looked up drug interactions and dosing strategies and adeptly presented the patient to me. After at least an hour of conversation with them, I was done for the day as my feet and voice were worn out. But, I was so pleased that as I left at 6pm, the students said they were headed back to the ward to talk with the patient and gather additional information. These students, along with the others I worked with today, are the new generation of healthcare providers that in the words of Mahatma Gandhi WILL “be the change they wish to see in the world”. All they need is continued encouragement, support, and mentorship. They have everything else it takes- a positive attitude towards learning, determination, compassion, and definitely the intelligence. For this reason and for the Ugandan people, I will persist in this endeavor. I do believe that change is possible- maybe not easy- but possible.