3 January 2020

Winnie and her Pharmacy

My driver, Haji, has a saying when he’s been driving me all over Kampala. He’d say “we’ve been moving up and down and all around” and that is exactly what Winnie and I did today. But let me start at the beginning of the day. I was fortunate to meet with Dauglas, Dr. Godson’s brother here at the Mulago Guest House.

Dr. Godson is a physician who I first met many years ago while working with Masindi Kitara Medical Center in rural Uganda. He is currently a 2nd year internal medicine resident with UHS, which is a local healthcare system back home in Binghamton, NY. He had asked me to bring his brother a few things and we met up today to hand them over. It was nice to talk to Dauglas and learn more about the road system and transportation in Uganda. He is a civil engineer working with the Ministry of Finance overseeing road construction in the country. The Chinese have been very active in building capacity for infrastructure in Uganda and providing workforce. Dauglas’s job is oversight to make sure all of the road projects are coming along. He has to travel the country very frequently to do this interesting work. Fortunately, the Chinese capacity building is paying off and recent projects have been designed and implemented independently by Ugandans. For those unfamiliar with the term, “building capacity”, as I was when I first came to Uganda, it means helping Uganda or any low and middle income economy country (LMIC) to build up their workforce to improve conditions in any sector. So my overall project and work here in Uganda is building capacity for pharmacists to provide pharmaceutical care for the goal of improving safe medication use and ultimately patient health outcomes. My expertise and focus is building capacity by improving and expanding education, particularly in clinical skills and working directly with the patient and the healthcare team. I have worked with pharmacy students as well as pharmacists in Uganda and have also led pharmaceutical care training programs for Ugandan pharmacists in the US. This short 2-week trip to Uganda is for the purpose of developing a research project regarding the implementation of a pilot pharmaceutical care program at 2-3 local hospitals. We want to see if patient outcomes improve when the pharmacist becomes involved with direct patient care working alongside physicians, nurses, and other healthcare providers by the provision of pharmaceutical care. This is a role that has evolved over time in the US and high income economy countries and is in demand because it was shown that pharmacists providing pharmaceutical care can improve patient health outcomes and reduce costs. Examples of patient health outcomes are patients able to leave the hospital early because a pharmacist helped make sure the correct antibiotic was given at the right time, a patient may have a lower risk of recurrent heart attack (myocardial infarction) when a pharmacist makes sure the patient is on all the correct medications that have been shown to reduce subsequent MI, and diabetic patients may develop better blood sugar control with less low blood sugar episodes when the pharmacists works with them to determine the cause of side effects and finds the most appropriate dose of the medication to treat diabetes for a given patient.

Winnie and I had plans to visit a hospital this morning to meet with the head pharmacist to discuss the project but before we could head over to Lubaga Hospital, Winnie got an urgent phone call about a lost key at the pharmacy she supervises. This detour proved to be very interesting for me. While she worked out the key issue, I had the pleasure of talking with the pharmacy technician who does most of the dispensing at the pharmacy. Yes, you heard me correctly. In Uganda, it is pharmacy technicians, and sometimes untrained workers, who dispense and sell drugs. Every pharmacy has to have a supervising pharmacist but that pharmacist doesn’t have to be on the premise for drugs to be sold and in fact, in many cases, the pharmacist only checks in on the pharmacy from time to time and does ordering and such. There are pharmacists who routinely stay at their pharmacies and dispense but it is not required by law. The biggest reason for this is lack of capacity. Until recently, the pharmacy workforce wasn’t large enough to service all of the pharmacies required to serve the needs of the country so pharmacists could supervise more than one pharmacy. The idea initially was the pharmacist would be in one or the other pharmacy during working hours but somehow without appropriate over-site, it evolved into a situation where often pharmacies run without pharmacists. Recently, though, the Pharmaceutical Society of Uganda (PSU) has declared that pharmacists can only supervise 1 pharmacy because the workforce is growing. But old habits die hard and until over-site and accountability is initiated, pharmacists may continue to be absent. I digress…let me get back on track. Jamir, the pharmacy technician, told me that it takes 3 years of college to be trained as a pharmacy technician. Then he applies for licensure but there isn’t an exam as with pharmacists. I asked him what the most expensive drug he had was and this led to a great conversation about drug quality and pricing and appropriate use of antibiotics. At one point I asked him about drug concentration time curves, don’t worry if you have no idea what this is, and I was amazed he had learned about this in school. What I asked him about is pharmacokinetics and related to how fast the drug is absorbed into the body and how high the drug level gets in the blood. This is a concept that all pharmacy students learn but I’ve never heard of an US pharmacy technician knowing this detail about drugs. It is possible this is included in college pharmacy technician curriculum but I have no experience with this. Jamir’s goal is to work as a pharm tech for a year or two to earn the money to go to pharmacy school. He wants to go into the drug industry and develop new drugs. I believe his goal is attainable if he keeps his focus and works towards it. It turns out the most expensive drug is an antibiotic called Cefixime. He had 2 brands in stock, The one manufactured by Torrent in India, cost 6000 shillings ($1.62) for a 200mg capsule while another brand made by Sance in India, cost only 1500 shillings ($0.40) for a 400mg capsule. Wow what a difference! A normal dose might be 400mg a day for 7 days so with one brand a patient might pay 10,500 ($2.80) for the course of treatment while using another brand, a patient might pay 84,000 ($22.68).

Later in the day we went to Lubaga Hospital but were unable to meet with the pharmacist so we made another appointment for next week. We then spent at least a hour at the Africell store trying to fix my phone and wifi router SIM cards. Finally, they are working. At the end of the day, Winnie and I had a nice dinner at Cafe Java’s, a local coffeehouse and food chain, and worked on the project protocol for a few hours. It was a productive day but maybe not exactly in the way I thought it would be when I woke up this morning. And, despite the many times I’ve visited Uganda, this is my 13th trip, I always underestimate the time it will take to get from one place to another. Even though Kampala is not a large city in terms of distance from one end to the other, the roads are poor, there are too many cars on the roads, and the boda-bodas (motorcycle taxis) weave in and out and this all adds up to major traffic congestion. Maybe I’ll time each of the trips next week, but for today, I would guess we were on the road for about 2 hours over the course of the day going “up and down and all around” and only had to cover about 10 miles.