May 2, 2016

Since 2011, I’ve been coming to Uganda to help advance pharmacy practice for the purpose of improving safe medication use by for teaching the pharmacy students, pharmacy interns, and pharmacists clinical skills. This is my 9th trip and each one brings me a greater understanding of the challenges the Ugandans face as they strive to improve healthcare.  The issues are so multifactorial that one can get really overwhelmed and depressed just thinking about it. But, I’ve chosen not to do that and instead I try to focus on one piece at a time while keeping in mind the others because they are intertwined.

For example, you might think that if they just had enough drugs, all would be fine. But, no, you have to consider where the drugs come from and if they are actually of quality and not counterfeit or adulterated.

Then you might think, if only the medical doctors were trained better at diagnosis and what to use for treatment. Actually, there has been a lot of money and efforts put towards training medical doctors and I do think it is helping. But, those funding medical training, need to include ALL healthcare workers. Even if the physicians are the best-trained in the world, they won’t make a dent in patient deaths and bad outcomes IF there are no drugs to be dispensed and nurses to administer the drugs.

If there aren’t trained pharmacists to watch over the patient’s whole medication regimen to make sure that the drugs don’t interact and are given in the correct dose for that size patient and take into account their kidney function, then it doesn’t matter if the physician ordered the correct drug for the patient because it might cause a bad reaction with their other drugs or be in a dose that could harm the patient or not work.

Wound infections from trauma, especially boda-boda (motorcycle taxis) accidents are very common. But, antibiotics alone won’t cure the infection. If the absolutely perfect antibiotic is given in the correct dose and doesn’t cause any bad interactions with other drugs, it still won’t work if the nurses aren’t trained or are too few to change the dressing so the wound keeps clean.

Then consider the non-drug or medical issues that interfere with good healthcare like Drug-Supply Chain Management. If the drugs aren’t available in the hospital, they can’t be used to help patients. If the system is computerized and the printer ink or paper runs out and the budget for the month is finished, then within a few days, the whole inventory control can become entirely disorganized. You won’t be able to rely on knowing what is available in which units and soon you are out of stock in one unit and no one knows where to go to find more drug.

These are just a few of the multiple factors that need to be addressed if healthcare is truly going to be improved in Uganda. But another BIG one I want to point out, is that most of the Guidelines for Treatment Protocols are written based off of studies in Western Populations (North American and Europe). The Ugandans (and those in the rest of the developing world) currently rely on these but many of the drugs they recommend aren’t even available here. Or they are so expensive they might as well not be here.  Plus, as we learn more about the human genome we have learned that a person’s genetics may have a lot to say about whether or not a drug will work for them. I’m going out on a limb here, but I daresay, that the African population likely has some differences in genetics to the North American and European populations. So, how do we know our guidelines really will work here in Uganda, Africa?

Throughout our time in Uganda, I have been trying to teach my Wilkes pharmacy students along with the Ugandan pharmacy students and interns, to think out-of-the-box. Don’t immediately judge a patient’s treatment regimen as sub-par just because it may not be what we do in the USA. Look a little deeper and consider what options are available here and consider the fact that they have been using drug regimens that may look “odd” to us but seem to actually be working for them.

An example is the duration of antibiotic therapy. In the USA and Europe, we tend to use longer courses of antibiotics for many infections but here in Uganda, therapy is often much shorter. This is in part due to limited availability of drugs, the expense, and the general thought that patients will not be able to adhere to longer treatments. But, it does appear that most patients do get better. There could potentially be a harm we are unaware of due to the shorter antibiotic courses such as promotion of antimicrobial resistance, but I am not aware of anyone studying this in the developing world. What if there is no induction of resistance but the patients still improve? If this was studied and published, maybe we in the Western World would benefit. Or, if there if resistance being developed or treatment failures greater than we know, then studying this could help to improve care for Ugandans.

I have found that for Ugandans, the concept of “preventative medicine” is new and often unheard of. Most of the poor live a day-to-day existence and are not aware that they should be thinking about what will happen in the future if they don’t treat their high blood pressure with daily medications. But, I think this can be addressed with education. I believe that Ugandans will begin to understand how they can improve their quality and quantity of life with better management of chronic conditions if they are given the right education.

Consider how dismal the outlook for the HIV and AIDS epidemic in Africa was less than 20 years ago. Antiretroviral drugs were not readily available and the disease was rapidly spreading. To get this under control, beside getting drugs to Africa, patients had to be convinced that taking daily medications for the rest of their lives was worth it and they are doing it! And, when treating HIV, it is critical that adherence be 100%. Missing just a few doses of medication can cause the virus to mutate and the patient’s disease state to worsen. And, although there are still challenges in the treatment of HIV in Africa, the outlook has much improved and many patients are living fruitful and quality lives. What great improvements in the health of Ugandans would occur if we could approach the treatment of the newly arising challenge of chronic illnesses like Hypertension, Diabetes, and Heart Disease in Uganda and the developing world in general, the way we tackled the HIV crisis.

If you’ve reached the end of this extremely long post, I hope that you have a better understanding of the many issues affecting health outcomes in Uganda. If you are in a position to do something about this, I urge you to act. All it takes is one step at a time to make forward progress. But, we need to work together and as you tackle your piece of the puzzle, don’t forget about how what you do affects others. Researchers need to work with Clinicians; Clinicians need to consult IT and Business experts; don’t forget to include Educators and Communications experts to convey ideas, etc (you get the idea). Together the puzzle comes together and we see a brighter future.