Out of the Pharmacy Classroom and Into Africa

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.

May 1, 2016

Wilkes students and Arthur, our tour guide

 Morning came early today- we had to rise at about 5:30am to get ready for our early morning game drive. We were all surprised at how cold it was when we started out.  This was especially so because not only was the weather cool, but the top of the Safari jeep was open and the wind whipped through the vehicle.  But as soon as we started seeing the animals, the cold was less prominent on our minds.   

 We saw tons of the Ugandan Kob, an antelope which is also the National amimal.  We saw Forest and Cape buffalo, many birds, and LIONS!!  The first group of lions we saw was way in the distance and then we saw another group a tad bit closer.  Both those groups could be seen only with the ranger guide’s binoculars. But then we saw lions up in a Cactus tree!! I couldn’t get a good picture but we could see them with our own eyes, especially the tails hanging down and wagging.  Then one of the further group of lions ambled over to the ones in the tree and climbed up to join them!  

  Later we were able to see another group of 3 lions up really close.  It was close enough to get a decent picture with my iPhone.  I have some even better ones, though, with my camera. When we got back we had a huge “American” type breakfast. The food is great here. After only a couple of hours of free time, which I used to re-pack my suitcases for the flight tomorrow, we ate another up yummy meal- lunch.  I was hardly hungry enough to eat it, but of course I did.  

 In the afternoon we took a double-decker boat ride on the Kazinga Chanel, a natural body of water than connects 2 lakes, Lake George and Lake Edward. We hit the jackpot on the boat ride in terms of Amimal sightings. We saw many, many Cape Buffalo in the water surrounded by numerous species of birds, and  even more hippos all over the place.  We saw 2 crocodile and a huge old elephant that let us take his picture from many angles for about 15 – 20 minutes before he decided to go on the land and we had to head back.  Most of the hippos were in the water laying on top of each other but we also saw some on land- how huge they are!  We even saw adorable baby hippos.  It’s hard to think about how dangerous they are when they look so cute.  We passed by a native fishing village and were horrified to see 2 teenage boys swimming in the water where we had just seen crocodiles and hippos. When I asked the ranger guide about how safe this was he said that he didn’t recommend it and it was 10% safe. We all took this to mean a 90% chance of a bad outcome.  We agreed those weren’t good odds.  The fishermen were getting their boats ready to go out for the night.  Apparently their routine is to fish all night long and come back in the morning.  They have long narrow wooden boats and I don’t know how they would be able to see, but I suppose they fish by moonlight. Tilapia and catfish are the main fish they catch.  

 Now we are back at the beautiful lodge relaxing and some are swimming in the pool. Tomorrow morning we head to Lake Mboro National Park for another game drive then onto the airport for our flight home. 

April 30, 2016

All ready to go- some luggage on the roof

The inside of the vehicle is really roomy but you can’t tell because we have so much “stuff”

We finally got a tarp to cover up the luggage and protect from the rains

The Rwenzori Moutains in the distance

The scenery and landscape along this drive south was very different than in other parts of Uganda. There were more trees and forests along the way and it was also much hillier. At one point the hills had lots of huge rocks on them.  As we got near Fort Portal and beyond we could see the Rwenzori Mountains in the distance- it was beautiful!  We all tried to get pictures but they just can’t do the real scenery justice.

  Then as we entered Queen Elizabeth National Park, we started to see animals, even though we weren’t officially on a game drive yet.  You have to drive about an hour into the park to get to the Mweya Lodge, which by the way is also beautiful.  We finally arrived at the lodge at 5pm- so a 10hour day of driving. All we had to do was relax but I’m sure Arthur is tired out.  The students were really impressed to be able to already see some animals- a Uganda Kob (an antelope), and a bunch of Elephants, including a baby one, and to see the accommodations here.  Right now they are relaxing by the pool and in the pool. Dinner is a 7pm and then tomorrow morning we will rise really early for a morning game drive. 

We saw a small herd of elephants cross the road in front of the vehicle

The view from our hotel room!

April 27, 2016: A Blog Post by Casey

 One of the Ugandan Pharmacists that Dr. Bohan brought to the USA to teach last summer, Gonsha, owns 2 pharmacies in Kampala. A few weeks ago we ventured out to visit one of her pharmacies. Makenzie and Kassi went one day and Lauren and I went the next. Upon arrival we were introduced to the staff and received a tour. Medications are arranged by disease state here, which we found very interesting. Back home medications are arranged in alphabetical order. Another thing we found interesting is that a pharmacist does not need to be present at all times in the pharmacy; as long as there is a pharmacy technician in the pharmacy to dispense medications the pharmacy can operate. I’ve been working in a community pharmacy for 3 years now and I’ve only seen my pharmacist leave the pharmacy to go to the bathroom, and they were never gone for very long.

 When patients come into the pharmacy they do not need a prescription to pick up medications. They simply tell the technician or pharmacist what medication they want, the amount they want and pay for it out of pocket. There is no limit on the amount of medication they can receive. However, a big limiting factor here is the price-most patients have to pay for prescriptions out of pocket. Back home then would never fly. Here if a pharmacy turns a patient away because they do not have a prescription the patient will just leave and walk to the next closest pharmacy in order to receive their medications. Gonsha actually told us about only 3% of patients come into the pharmacy with a prescription. (mind blown AND disturbed)

 While we were at the pharmacy Lauren and I did blood pressure screenings. The patients could understand English but couldn’t understand us because of our American accent so Gonsha had to help translate for us. We talked to them about the importance of taking their chronic hypertensive medication. Many patients here stop their anti-hypertensive medication(s) once their blood pressure is controlled. Makenzie and Kassi counseled a patient on how to correctly take their omeprazole. The patient came in complaining of stomach ulcers and stated he was taking his omeprazole three times a day. They explained to him how he only needs to take his medication once a day and if he is having problems he should go see his doctor.