A Day Trip To Jinja

15 April 2016

Today is Saturday and we were off to Jinja at about 8:15am.  Arthur, from Econesttim Safaris Uganda, was our tour guide and I highly recommend him. I’ve known Arthur for years now and he is an excellent guide with a wealth of knowledge about the flora and fauna of Uganda.  He is also a super nice guy and my friend.  On our way to Jinja, after driving about 45min out of Kampala, we went to Ssezibwa Falls. This is a beautiful cultural site with a waterfall.  Then we went on to Jinja, the Source of the Nile River, and took a lovely boat ride in a cute wooden boat and went to the reptile zoo and saw snakes, among other animals, and a large Nile Croccodile. We ended our time in Jinja with a delicious lunch at the Gately Restaurant.  After we returned to Kampala through the huge “jam” (they call a traffic jam, a “jam” for short), which made it seem like it took us double the time to get back than to get to Jinja, we stopped by the craft shops once again. Since we have a new member of our team, we needed to let her check out the wonderful goodies for sale.  And, coincidentally, some of us also bought more stuff….

Tomorrow we head to Masindi for our final week in Uganda! 

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Last Day of Work in Kampala

14 April 2017  

It’s been a fantastic week! For this trip, our time in Kampala was the most “up in the air” of the plans I had made but once again, there was plenty of work to get involved with. It was such perfect timing for us to be able to work with the new Clincial Pharmacists at Nakereso Hospital as they embark on the development of Pharmaceutical Care services. All 4 of The Ugandan Pharmacists were a joy to teach and mentor and they are very capable of carrying on this project. As we reminded them everyday, we urge them to continue to be reliable team members and to show up every day to work on their units. The way they will gain the rapport and respect of the nurses, physicians, and other healthcare worker is to be dedicated to the patients and the healthcare team. We got to know Peterson and Aziiz best and I compliment them on their quick learning and dedication to this project. As we head to Masindi on Sunday, we leave them under the capable leadership of Winnie. 

This afternoon over a delicious Mexican lunch at Que Pasa, we met with Daniel, the Regional Director of OneWorld Health, the group that developed and supports Masindi-Kitara Medical Center, our next stop. It was great to get to know him as he is relatively new in this position. We had an opportunity to talk about their new initiatives and brainstorm about ways we can help this week at the clinic. 

In the late afternoon, my friend, Patrick, who is one of the Ugandan pharmacists who came to study with me in the USA stopped by the Mulago Guest House for a brief visit. Our time in Kampala was limited to just this one week and we’ve been keeping so busy I hadn’t had time to talk with him. I’m so glad he swung by. And I got the treat of meeting one of his sons and we had fun taking selfies. 

This evening I went to meet another friend, Dr Mohammed Lamorde, Head of Prevention, Care, and Treatment Programs for the Infectious Diseases Institute, to talk about the possible phenytoin research project that Winnie and I want to do. His specialty is Pharmacokinetics. We had a great planning session for this project but he also offered me a chance to help develop a training program to teach Ugandan Physicians and Pharmacists about Antimicrobial Stewardship – a topic very dear to my heart. Worldwide Antimicrobial Resistance is growing and if we don’t become stewards of the use of our precious antibiotics, we will soon be at risk for going back to the dark ages before antibiotics were available to treat common infections. Many of the bacteria are now able to resist the killing action of our normal antibiotics. Uganda is not immune to this problem and in fact may be in a worse situation than the Western world, as are many developing countries, due to the easy access to antibiotics without prescriptions at community pharmacies. Addressing outpatient antibiotic use at the community pharmacies level eventually needs to be tackled but the first steps involve training medical practitioners in the government clinics and hospitals. I am so thrilled to be asked to be part of this project!!

Now I am on my way to the airport to pick up Dana Manning, Associate Professor at Wilkes University and one of old colleagues. She’s been wanting to join my Uganda project for years but it is only now that her children are older and she is able to try it out. Let me introduce her to you now. 

Dr. Dana Manning

 My name is Dana Manning, and I am an associate professor of pharmacy practice at Wilkes. This is my first trip to Uganda and I am very excited to be part of this experience for many different reasons. I grew up in Rochester NY, and have lived in Northeast Pennsylvania (NEPA) for almost 20 years now. I came to NEPA to be with my husband Brian, who runs a hundred year old vertically-integrated dairy farm that makes the most amazing ice cream and fresh milk. I have three great children – Julia (13), Charlotte (8), and Eddie (5). We have our own farm as well, where we have horses, beef cattle, alpacas, chickens, turkeys, 4 cats, a dog, and a bunny. In addition to my pharmacy career, I am also a registered dietitian and I love all aspects of food – from the production to the politics of it.  

      I have traveled to Europe and Australia in the past, but it has been a long time since I have travelled out of the country. I have spent the last 15 years of my life building my family and my career, and I am now in a part of my career where I an doing a lot of thinking about how I want to grow and contribute to the broader world. I am a person who believes that everyone could use a little more “vitamin P” – perspective, and “vitamin H” – humility. I am grateful for the opportunity to travel to Uganda and be part of an experience with pharmacy students that opens our eyes to challenges and opportunities in the healthcare world as well as in the broader world. I am also very grateful to my amazing husband and to my parents, who are going to keep my busy family and farm running while I am gone!

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Healthcare Challenges at Mulago Hospital & A Meeting at Makerere School of Pharmacy

13 April 2017

This morning, as the rest of the team went to Nakesero Hospital to continue working with the new clinical pharmacists there, I headed off to meet Winnie at Mulago National Referral Hospital for Neurosurgery Rounds.  Winnie has been working in that ward as a Volunteer Clinical Pharmacist for about the past year and has done an amazing job gaining the rapport of the head Consultant physician and the other physicians.  Today I joined her to observe what she has been doing and to try and help with any drug therapy problems that arose.  I immediately saw how much they depend on her for drug information and recommendations.  One of the big challenges in treating patients with head trauma and/or neurosurgery at Mulago Hospital is the lack of drugs, ability to run basic lab tests, and obtain CT scans and MRI’s. The patient’s family often has to go out and purchase the drugs from a community pharmacy and they may have to go to a private hospital and pay to get a CT or MRI.  One of the big problems Winnie has noticed is that at least 3 people per day go into Status Epilepticus despite being on Phenytoin, a standard drug for prophylaxis.  We are working together to develop a research project to see if it is because the patients aren’t achieving adequate drug levels in their blood. In the USA, we would never consider using this drug if we couldn’t get drug levels but here in Uganda, they use it all the time but have never been able to do drug levels.  This is a drug that if adequate levels aren’t achieved, the patient could have a seizure. If the levels are too high, the patient could exhibit signs of toxicity.  We really need to research the issues because when a drug is being used to prevent seizures, we need to know it will do this. Using it, if the levels aren’t being achieved, is just a waste of a precious resource. Of course, if we find the levels are low, that will lead to another project to see why they are low- is it because the dosing isn’t high enough, or the drug is counterfeit or because the patients may have a genetic variance that causes them to more rapidly metabolize the drug…. But, first things first.

After rounding at the Neurosurgery Unit, Winnie and I went back to Nakesero to meet with the rest of the team. They had an excellent day and since the work was done, we decided to go to lunch.  This afternoon, then, while the women students went to do more shopping, the faculty and one of the students went to Makerere University School of Pharmacy to meet with the Head of the Pharmacy Program, Dr. Kamba, and two other faculty I’ve been working with closely- Professor Richard Odoi and Kalidi.  I wanted to introduce them to Erin, the Binghamton Faculty member on this trip with me who is in training to bring future Binghamton pharmacy students. We are also accompanied on this trip by 2 faculty from East Tennessee State University (ETSU) who are looking for opportunities to develop a Global Health project in Uganda.  It was a great meeting. We were able to consider options for possible collaborative research and also learn more about the beginnings of the pharmacy school here which was started by Professor Odoi in 1988.  He said that the first class was only 10 students and that others at the University were skeptical the program would draw many students but it has been extremely successful and is a very popular program today!  The next step in the pharmacy program is to start a Masters of Science in Pharmaceutical Care (Clinical Pharmacy).  I had helped work on the initial concepts for this new curriculum but Dr. Darowan Akajagbor, previously of D’Youville School of Pharmacy in Buffalo, NY had put it altogether during her Carnegie Fellowship in Uganda in 2015. It is making its way through the Curriculum Process at Makerere University and we hope to see the first class in August 2018.

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Clinical Pharmacy Activities & Presentations at Makerere University

12 April 2017

Today was another busy but GREAT day!  We spent the morning at Nakesero Hospital with the new volunteer Clinical Pharmacists seeing patients and participating in their Multidisciplinary Team Meeting. This was a gathering of physicians, nurses, pharmacists, and even a biotechnician. They reviewed patients to make sure the treatments were going well and we had some general discussions about how to improve care. I was really impressed that they have a policy to make sure every patient receives DVT prophylaxis while there in the hospital. A DVT is a blood clot that can develop, usually in the leg veins, when someone is bedridden in the hospital. If that occurs, it can sometime break off in the vein and travel to the lungs where it causes a pulmonary embolus which can kill a person. In the USA we routinely prevent these with medication but most places I’ve worked in Uganda do not do this.  The physicians there were very happy for the input from the pharmacists and even told them to not be shy and to make sure they are interacting with the medical team.

In the afternoon, we went to the Makerere Pharmacy School again and the Wilkes Students did an excellent job presenting on Pharmacy Practice and Education in the USA. They had lots of good questions from the Ugandan students.  Dr. Erin Pauling gave a lecture on Organophosphate Toxicity. This topic was really out of her wheelhouse but with the help of literature and a guideline from one of the newly hired Binghamton University Pharmacy Practice faculty, Dr. Willie Eggleston, a Clinical Toxicologist at the SUNY Poison Center, she was able to develop and deliver the content as if she was the expert.

Finally, our day ended when we stopped by the Uganda Cancer Institute (UCI) to meet up with my old friend, Benjamin. He greeted me with the biggest smile ever and a wonderful hug! I was equally thrilled to see him. He is the Pharmacy Director of the UCI and I’ve known him for the past 4.5 years.  Benjamin is a truly dedicated clinical pharmacist as well as an excellent administrator. He cares for his patients and also has the ability to justify to the Ministry of Health his need for more and better quality oncology drugs.  In fact today, he had to go to Parliament to present his report and convince them to provide the funds for the drugs.  He was successful!

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A New Clinical Pharmacy Program At Nakesero Hospital, Kampala, Uganda

11 April 2017

This week we are fortunate to be spending time helping young Ugandan Pharmacists implement a new Clinical Pharmacy program at Nakesero Hospital. Dr. Erin Pauling and I, with assistance from Dr. Emily Flores, presented a program to teach Pharmaceutical Care Skills to 19 Ugandan Pharmacists at the Pharmaceutical Society of Uganda last Friday.  These Pharmacists have a keen interest in Pharmaceutical Care and have volunteered to start Clinical Pharmacy services at local hospitals. Over the past several years there has been much more interest in developing and implementing pharmaceutical care to help improve safe medication use and patient health outcomes.  Winnie, the Ugandan Pharmacist who I’ve been working closely with over the past couple of years has been volunteering in the Neurosurgical Ward at Mulago Hospital for about the past year and now there are private hospitals in Uganda who are recognizing the critical role a pharmacist can play on the patient care team.  When Winnie told the Medical Director at Nakesero Hospital that she now has 4 trained pharmacists who want to volunteer to start a Clinical Pharmacy program, he said to have them start on Monday (that was yesterday).  This was perfect timing for our trip because not only did we just train them so the skills are fresh, but I have a team of 5 who can help mentor these pharmacists this week as they get off to a running start.  

I had never been to Nakesero Hospital before Monday and boy what a treat to work in such a clean, organized, and patient-friendly hospital.  Unlike many of the government hospitals, the medical charts had all of the documents in the correct order and in specific sections. We were able to quickly find what we were looking for.  Also, the hospital has MEDICATIONS!!! You might wonder why I’m surprised, but significant lack of essential medicines is the government health system is a given. Nakesero is a private institution so patients pay for everything, so we should expect the medications to be there. But it was still a pleasant relief to know that the patients there will not have to leave the hospital to go purchase medications on their own.  We also found the medical and other health professional staff to be interested in our project and receptive to our comments about drug use.  Of course, there are many ways to improve drug use which is to be expected since pharmacists haven’t been routinely reviewing the medication orders for all of the patients, but I think Nakesero will be a great place to start this Clinical Pharmacy initiative. They have the right infrastructure to support it and hopefully when they show improvements in safe medication use, all of the hospitals in the country will want their own Clinical Pharmacists.  I still have a desire to improve drug use in the public sector, but I think that implementing these services in the private sector where there is more support and stability with the medication supply will help us figure out the kind of program that will work for Uganda. Then we can expand it to public hospitals.

This afternoon, Dr. Pauling and I presented a seminar for the Faculty and students at Makerere University School of Pharmacy.  Dr. Pauling discussed Interprofessional Education and Collaboration- the importance of working as a healthcare team to provide excellent patient-centered care.  The faculty were very interested in this concept. Makerere University has been training all healthcare professions students together for their basic science courses for years and they also go on community based education and service (COBES) experiences in the summer where they go to villages and live together for a month and learn and serve at the local clinics.  But, most of these experiences aren’t truly Interprofessional Education because the students are mostly learning alongside each other but not necessarily learning about each other’s roles and how important each is the the healthcare team. I think that when we truly teach the healthcare professions in an interprofessional way, we will no longer have licensed practitioners that are scared to talk to each other because they don’t think the other will listen. We will know each other’s capabilities and appreciate each other’s strengths.  We will want to always work together because this is what is best for patient care.

When I was asked to give a presentation for Makerere Pharmacy Faculty and asked what I should talk about, the answer was “something on Pharmaceutical Care- everyone is interested in that”.  But as I thought about it, I decided to talk about a couple of pharmacy projects that are working in East Africa, rather than focus on the US Healthcare and Pharmacy practices.  Back in 2014 I had the opportunity to go to Eldoret, Kenya with Professor Odoi and Kalidi, another faculty, to see the AMPATH (Academic Model Providing Access to Healthcare) program that Purdue University is participating in at Moi Teaching and Referral Hospital. We learned about their initiative of Revolving Fund Pharmacist and BIGPIC.  A Revolving Fund Pharmacy is a Pharmacy that sells quality medications at a small markup, less than in the community, to supplement when government supplies of essential medication is not available.  This has significantly reduced the times when essential drugs are not available in Eldoret.  I wonder if it could help the problem in Uganda.  The main difference, though, is that in Kenya, patients pay out of pocket for medications at the hospital anyway so if they have to get drugs from a Revolving Fund Pharmacy because the hospital is out of stock, it is not that big of deal that they must pay.  In Uganda, though, all medications received at government facilities are free so having to purchase drugs when the government runs out would not be favorable. But it is actually always happening now and patients have to go to community pharmacies that charge high amounts and sometimes do not have quality products, so perhaps this could be a solution. BIGPIC is an even more interesting. This is a program where community groups are developed for patients with chronic illnesses like high blood pressure and diabetes and the drugs are brought to them so they don’t have to go into the city. Along with this service, medication and disease education is provided to help patients understand how to live their best quality lives.  These groups, though, are also a microfinance program. All of the patients pay a small amount into a pot every time they go to a group meeting. From this pot, they can take loans for small projects to improve their income. For example, maybe someone wants to start an egg selling business and takes a load to purchase chickens.  They must pay this back with interest and the pot of money grows. At the end of the year, the dividends from the interest and the money left in the pot is redistributed to the patients in the groups. This AMPATH program has led to statistically significantly improved blood pressures among the patients.

At the end of the day, I took the students to visit a friend of mine who owns her own pharmacy in town. It was nice to catch up and learn about how different the laws are in Uganda as compared to the USA.

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New Experiences Through Relationships

10 April 2017: A Blog Post By Tristram

When was the last time you tried something new? Was it something out of your daily routine of getting up, eating breakfast, driving the same route to work, coming home, eating dinner, going to bed, and doing it all over again? New experiences can be daunting and challenging. As I think back over of the course of my life, most of my personal growth has come out of new experiences. I remember playing basketball for the first time. Learning a new skill set didn’t come easy, but it taught me a sense of dedication and commitment. Moving away to college was an adjustment, but I learned how to be independent and take care of myself. The last year of pharmacy school has been filled with new experiences. From meeting nationally-recognized pharmacists to watching my sister get married, it’s only fitting to continue the trend by visiting a new place like Uganda! My time here after one week has been nothing short of the best. We have spent time in three different locations: Mbarara, Entebbe, and Kampala. So far, the most rewarding experience has been the relationships that I’ve built. In Mbarara, I was on rounding service with a med. peds. physician from Massachusetts General Hospital. It was fascinating to work with a highly qualified professional. She asked me thought-provoking questions on rounds and pushed me to be the clinical pharmacist on the team. One of the most satisfying aspects of clinical work is being with a physician who values a clinical pharmacist and understands their purpose. More relationships sprouted from my time at the Ugandan Pharmaceutical Student Association (UPSA) symposium in Entebbe. There I met and spoke with two pharmacy students. The one in the black shoes, Benedict, is a student at KIU (Kampala International University). The other, in the brown shoes, is from the University of Rwanda, and he happens to also be a fellow CPFI (Christian Pharmacists Fellowship International) member! The symposium also featured student pharmacists from the Democratic Republic of Congo. The last relationship I’ll touch on is one from Sunday at the Watoto church. After church, I met a younger couple (Emma and Joshua). They are from the United States and are here in Uganda operating an organization that offers a home for special needs children. Wow, what an incredible opportunity to serve a group of people who desperately need our help! I obtained Emma and Josh’s contact information. Ironically, Dr. Bohan had already met Emma the previous day during our visit to the 1,000 Cups of Coffee shop (small world!) After a week’s worth of relationship building, I look forward to what this week holds as we meet new people at Nakasero Hospital in Kampala.

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Palm Sunday in Uganda and Meeting up with Good Friends

9 April 2017

Becky, Gonsha, Emily, Erin, Tristram, Jess

Driving through traffic to church on Sunday Morning

The entrance to Watoto Church

Praise and worship by Video technology in the tent outside the main church

Today was Palm Sunday and the group was able to attend Watoto Church in Kampala. My good friend, Gonsha, who is one of the Ugandan pharmacists who came to the USA to study with me was able to pick us up and take us to her church. The services at Watoto are always joyful and uplifting with lots of music, singing, and dancing. Due to a slightly late arrival, the group had to sit in the tent outside rather than in the main church but there is a TV monitor and the whole service is easily seen and heard.  Afterwards we enjoyed a light lunch and great conversation with Gonsha at the Good Samaritan Canteen which is located right here at the Mulago Guest House where we are staying.

KarenBeth and Kiran

Jess, Becky, and Tristram

Emily and I have the same color and pattern on her pants and my skirt- new purchases from shopping at the craft markets yesterday!

This evening we went to Tamarai, the very delicious Thai restaurant in town. I think we all could eat here many times! When spending time in Uganda, as I have over the past few years, you get to meet all kinds of people whom you might never have met if you stayed in the USA. Well, tonight we had dinner with Kiran, a Professor of Anthropology at Kalamazoo College in Michigan whom I met, with her husband, Russ, back in 2014 when I was here doing my Fulbright work. She and her husband were also here at that time. They had been all set to be placed in Sierra Leone for the Fulbright but due to the Ebola Epidemic, their work was transferred to Uganda.  Since then our paths seem to often pass in Uganda and tonight was another one of those times. She does consulting work with ACODE, (Advocates Coalition for Development and Environment) which is an independent public policy research and advocacy think tank in Uganda.

Well, we have now been in Uganda 1 week and 1 day. The time is rather strange here. Once we get over our jet lag and get engaged in our work here, sometimes it seems as if we’ve been here for a very long time. Our life in the USA seems so far away.  Was it only a week ago that I could brush my teeth with tap water or never have to worry about whether the bathroom will be a traditional toilet (hole in the floor) rather than one with a toilet seat?  You can get used to those things pretty quickly, or at least I have after all of these trips. They are now just part of our normal routine here.  One thing that you do not have to worry about us while we are here is that we are getting enough to eat. The food options in Kampala are many and the restaurants are delicious. Even when we eat Ugandan foods, they are pretty tasty and the plates are piled very high.

Now we are onto a new week- let’s see where it takes us.

 

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