Goats in the Pharmacy School & Ugandan Local Food

6 January 2020

It’s been another busy day and I need to get to bed, but here is a quick post. First of all, I was able to go to the pharmacy school today and meet up with Professor Richard Odoi and the Head of the Pharmacy Program, Dr. Pakoyo Kamba. It was a wonderful reunion. I spent quite a bit of time today working on the details of the pharmaceutical care research project and getting a few new ideas.

I was also able to meet Mark Juba, a 4th year Pharmacy student. He was one of 9 students who were paired up with students of my Complementary and Alternative Medicine elective to do an interview over Whatsapp, a social media chat and phone call app that is widely used all over the world and is my main mode of communication with my Ugandan colleagues. The purpose of the interview was to help the US students understand the role of traditional medicine, mostly herbs and herbal products, in healthcare in Uganda and what Ugandan healthcare professionals think about them. This activity was thoroughly enjoyed by both groups of students. Mark filled in for an extra group of students when something came up for their assigned student. Today Mark and I talked over a classic Ugandan meal of matooke (cooked, mashed green banana- it is not sweet), Irish potatoes (regular white potatoes), rice, greens, and 2 sauces. One was a beef soup sauce and the other was a mixture of beans and g-nuts. G-nuts or ground nuts are similar to peanuts. They are ground and made into a sauce that has a mild peanut butter taste. It was all delicious but way too much food for me to eat!

After lunch I went back to the pharmacy school and was working in the board room and all of a sudden I heard some motion and bleating sounds. I turned around a 2 young goats has just joined me. Some how they found there way into the pharmacy school building and came to visit me. It was pretty hilarious. Dr Kamba had to go around and shoo them out of the building. Someone from a nearby area was probably grazing their goats and these two must have escaped.

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Sunday with Friends in Kampala

5 January 2020

Brunch at the Sheraton Hotel, Kampala

We had an absolutely delicious meal after attending church together. Pictured Left to Right: Mary, Anneth, KarenBeth, Lydia, Eliza (2 years old)

This morning my friend, Lydia, picked me up for church to attend the 9:30am service at All Saints Cathedral, a large Anglican church in Kampala. She had her daughter, Mary, her daughter-law, Anneth, her son James, and her granddaughter, Eliza, with her. This particular service is the contemporary service with uplifting music you dance to and sing your hearts out. There were actually 4 services today; the other ones were: 7:30am (traditional service with holy communion), 11:30am (a mixture of contemporary and traditional) and 3pm (the youth Holy Communion service). They have the words on TV screens around the sanctuary and everything was in English from the Bible reading to the Sermon and songs. They did one song in Luganda but the words were projected and just repeated over and over again and it was easy to catch on, while the singing was happening. I don’t remember all of the words now but it started out with “Ai Mukama”, which I think means The Lord or The Holy One, and then there were 2 other long words that started with “O” and one meant “wide or large” and the other meant “tall or high”, I think. The people made hand motions when these “O” words were sung. To one they put there hands out in front of their belly and pulled them apart as if you were saying “fat or wide” and for the other they either pulled their hands apart vertically, going up, or for some it looked like they were stepping their hand up on top of each other.  I believe the meaning of the song is that God is all powerful and reaches all the ends of the earth to provide for and love us. The church was completely packed and there were people in tents outside the building. This was wonderful to see—the energy was palpable! Back home in the US, this has not been my experience. Another fascinating part of the service was the offering. This is when the gifts to the church and God are collected, meaning money is collected. As with churches back home, people came around with bags to put the money in (most often we use baskets back home). There were 2 bags: one was for the giving of money for their new church building project, which is almost complete after 5 or more years, and the other was an offering of thanks. Lydia said the church also collects tithes, the 10% of our earning we give back to God, but those are usually given in envelopes for record tracking. So, the loose money given in these bags was actually extra, above and beyond the tithe. As if this weren’t generous enough, after the regular offering collection, groups of people came forward to the front of the church with more money they were giving as thanks to God for the blessings given to them. Some of these people were giving thanks for something wonderful that happened during the prior week, such as getting over a sickness or coming through an accident without dying. Then they called up those who had birthdays in January and lots of people came forward to give money to give thanks to God for their birthday and living another year. The December birthdays were also called forward and gave more cash. These gifts were specified as going to the building fund. In the US, many children and some adults celebrate their birthdays with parties and the guests bring gifts, but I never heard of someone giving an extra offering to the church to thanks God for their birthday. This is something that I’m going to seriously consider. The service lasted 2 full hours, although it seemed to go faster than that and those for the next service were coming in as we left so it was pretty crazy getting out of church and leaving the parking area.

We then dropped James off at home and headed to the Kampala Sheraton Hotel for brunch. I have never been there before and it is really lovely. There were very many choices of food on the buffet including made to order stir fry, traditional local Ugandan cuisine, Indian cuisine, grilled chicken, salads, soup, and lots of delicious looking desserts.  We stayed there for hours conversing and enjoying each others company. Eliza was very good, although not too hungry, and at one point Mary took her to get a balloon creation that was a ring and had her forehead painted with a pretty flower. I learned that Mary graduated with a teaching degree recently and is a primary and secondary school biology and chemistry teacher in Mbarara. She is currently on holiday break from school. The school system in Uganda starts in February each year and ends in November, so there is a holiday break for December and January. This is contrary to the US school system which starts in August or September, depending on the state, and goes until May or June. In Uganda, children start primary school at the age of 6 and the first grade is called P1 (for primary 1). In the US, this would be called 1st grade and we generally call the lower grades Elementary school. Primary school goes up to P7 and students take exams at the end of P7 before going into Secondary school. So when a child starts Primary school, they start P1 in February and go to November. The following year they start P2 in February, and so on. After P7, students go into Secondary school which starts with S1, which would be equivalent to 8th grade in the US. Secondary school has 4 grades: S1, S2, S3, S4. So after S4, which when US students are in 11th grade, Uganda students take big exams called the O-level exams. O stands for “Ordinary”. They are about 17 years old at this point and this is the end of basic education. If you want to go on with education and score high enough on your O-level exams, you can go into the A-level grades. “A” stands for Advanced coursework and has 2 levels and is also called Form 6, or grades 12 and 13. During these years, students study only courses that relate to the profession they want to go into. So for a student who intend to be a pharmacist, they will chose science and math courses while a student going into the humanities will not take any science or math. The A-level exam grade determines eligibility for university and in Uganda, the government sponsorships (scholarships) for university are given to those with the highest A-level scores. I was in Uganda awhile back when the A-level scores were released to the public in the NEWSPAPER! So anyone could see what students achieved. If a student desires to be a pharmacist but doesn’t achieve a high A-level score, she may go to training to become a pharmacy technician. Many pharmacy technicians go onto study pharmacy later and from my experience here and back home, they do have an edge up since they have been working in the field as a pharm tech and have gotten to know the drugs and become comfortable speaking with patients.

Lydia’s daughter-in-law, Anneth, is a physician in her 2nd year of the Master of Radiology program at Mulago National Referral Hospital and Makerere University. Her husband, Treasure, is also a physician (they met in school in Tanzania) and is in his 2nd year of the Master of Surgery program, also with Makerere and Mulago. In the US, after medical school, the training is called Residency and does not award an additional degree, such as a Masters, but is required to practice in the discipline you choose. Also, to go to medical school in the US, you much first graduate from university with a bachelors degree and then attend medical school for 4 more years, so a total of 8 years before residency. My son, Christian, graduated from medical school last May and is in his first year of his Neurosurgery Residency. This is one of the longest programs in the US and it will take him 7 years to become a Neurosurgeon. At that point, he would do extra fellowship if he wanted to sub-specialize. The US health professions programs include all of the experiential learning, like seeing patients in the clinics and hospitals, into the university education. While in Uganda, the student graduates from the health professions program at the university and then does a paid Internship for 1 year to be eligible for licensure. At this point in Uganda you can practice as a General Practitioner—going for your Masters is for those who want to specialize. My son was able to come to Uganda last March to complete one of his 4th year medical school clinical rotations. He worked with the Neurosurgeons at Mulago Hospital and with Winnie, my friend and collaborator, who is the Clinical Neurosurgery Pharmacist and lecturer for Makerere Pharmacy School. I’ll close with some of the photos he took during his fantastic visit here! It was a thrill for me to have him work with and meet many of my Ugandan friends!

Gaddafi National Mosque, Kampala

Christian and his tour guide at the top of the Gaddafi National Mosque tower. What a view!

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A Quiet Saturday in Kampala

4 January 2020

It’s been a lovely quiet day. I’ve had time to do laundry and work on both my course preparation for next semester’s classes which begin 21 January as well as work on the pharmaceutical care project protocol.

Through my numerous trips to Uganda, I’ve gotten in the habit of bringing powdered laundry soap and washing my own clothes so that was one of the plans for today. I had checked ahead of time to make sure it was ok to use the clothesline out back and so this morning, I washed and hung out my clothes to dry. By the way, I also always bring clothespins. The day was bright and sunny and hot- very different than the cool weather back in NY. I hung out the clothes then settled down at my computer to work. A few hours later I heard a sound and looked up. It had started to rain, even though it is supposed to be dry season, and the ground was quite wet. In my focus on work, I hadn’t actually heard the start of the rain. I quickly donned a rain hat and went out to grab the clothes off the lines hoping they weren’t too wet. I’m sure I made quite a site- a muzungu* who did her own laundry and then frantically tore the clothes off the line in a rush with a weird looking rain hat. You decide- see the photo.

This is the front of the lower guest house at Mulago Guest House where I’m staying

I’m sure I was quite a site and it makes me laugh to think of it. So once back inside, I spread the clothes out on my bed and hung some on hangars to dry. Fortunately, they were probably already dry when the rain started so they were only damp. Then I want back to work. Later, though, I looked outside and what did I see? The sun!! It had come out and everything was now dry- the lawn, the walkways, and I bet, my clothes- if I had just let them be. I has forgotten that brief rain showers are common in Uganda, even in dry season.

This is the view from the front porch. I believe the building below is a school

This is the side view- you can see part of Kampala in the distance

This is the view to the right of looking straight while on the porch and is a huge new, since 2018, Mulago Women’s Hospital. It seems beautiful but empty, likely due to the fact that patient’s have to pay for services rather than the usual free services at all other Government hospitals

I decided that tonight was the night for me to go to one of my favorite Kampala restaurants. This would be a nice treat after my long day of hard, productive work. Mediterraneo is an Italian restaurant that has a lovely decor, and is like being outside on a covered deck ensconced with green plants. There are some parts that are open to the sky, but I sat under cover this evening. The streets of Kampala are busy, loud, and filled with sounds of cars and boda-boda but when inside Mediterraneo, you can forget you are in the middle of a busy city. Tonight it was pretty busy and the restaurant was filled with the sounds of conversations and enjoyment. The Italian food is very delicious. I found this place on my first trip to Kampala back in 2011 and was so surprised at he quality and availability of such fine cuisine. I have now learned that one will never want for excellent food in Kampala. You name it and you can find any ethic type of food. Now going into the rural areas is a different story…tonight’s meal started with sparkling water, a glass of the house Chianti, and a delicious salad with mozzarella, avocados, tomatoes, greens. This was followed homemade spinach ravioli with tomato sauce rich with lumps of tomatoes. I savored every bite. I’m ending the meal with chocolate moose. Yes, I’m already kind of full, but I just had to go for it. One of my 2020 New Years intentions is to be more mindful of every moment of my life. You know the saying, “you need to stop and smell the roses”. Well tonight I ate very slowly and turned my meal into a greater than 2-hour feast of my senses. (Mostly focused on taste. 😊)

Tomorrow I’m looking forward to attending church with one of my Ugandan friends. She is not related to my pharmacy work but is a Seconday School superintendent and the wife of a physician I met during my Fulbright time in Uganda. It’s always so nice to catch up when I come to Uganda.

*Muzungu is the name used for white people. It is not a derogatory word and is thought to come from Swahili meaning European. If you are out walking around in Uganda and pass by little children, it is common for them to yell out “muzungu” as if a taunt. But this is not meant as name calling – the children are interested to see someone different from themselves.

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Moving Up and Down, All Around Kampala

3 January 2020

Winnie and her Pharmacy

In deep discussion about the appropriate use of Antibiotics

Jamir, Pharmacy Technician

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.

Dauglas, Dr. Godson’s brother and KarenBeth

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.

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First Full Day in Kampala

2 January 2020

I had a wonderful night’s sleep at the Entebbe Airport Guest House and a delicious breakfast of scrambled eggs, bacon, and fresh fruit: the tiny bananas which are so good, watermelon, and papaya. I also had fresh made passion fruit juice. Yum! My friend and regular Kampala driver, Haji, picked me up around 10:30am and we headed to Kampala. There is a new highway which makes the travel much faster. Also, the roads weren’t too busy because a lot of people are still “upcountry” or “in the villages” for the holidays and will start returning today and tomorrow. Just like in the USA, if possible, Ugandans get together with their families and the gathering always includes a feast of their favorite dishes. I’ll talk more about this when I have a Ugandan meal. It only took an hour to get to the Mulago Guest House which is on the grounds of the Mulago National Referral Hospital.. Right now am in the lower house and am the sole occupant which is nice because I have the wifi to myself. But, it is always nice to meet and talk with other guests so maybe some more will join me before I leave. After unpacking and taking a quick nap, Winnie, my friend and collaborator came to pick me up to run errands, the first being the Forex, the foreign exchange, to change my US dollars to Ugandan Shillings, abbreviated UGX. Since I come back and forth regularly to Uganda I always have some UGX which is quite helpful for buying bottled water at the airport and the first night’s hotel stay. The hotel could have taken US dollars but prefers UGX, which I was able to provide. Next we headed to a shopping center, Garden City Mall, to go to the Africell store, which is a Cellular Service, to get my Ugandan phone lines and wifi router fixed. Unfortunately, the lines are still not fixed but hopefully are in the process of being fixed. Then we had to go to a grocery store for water. My students and I always use bottled water in Uganda, even to brush our teeth, so I buy it in bulk. I’ve been told that the water leaves the water sanitation plant clean and perfectly fine to drink but unfortunately the water pipes and infrastructure is not kept up and bacteria inevitably invades the water supply before it comes out of the faucet. One of the things I forgot to mention yesterday was the “smell of Uganda”. As soon as I exit the plane, the air wafts of boiling beans over a wood or charcoal stove, which is the most common mode of cooking here. Even though we were within the jetway, this wonderful aroma penetrated. Winnie and I had a nice dinner at an Indian restaurant and then came back to the guest house for a work session to plan the pharmaceutical care research project we want to start in June. Well, I’m exhausted and need to go to bed. Tomorrow we plan to meet with two of the local private hospitals to interest them in participating in the study. I’ll explain more about that later. Below are pictures of my lovely accommodations at Mulago Guest House.

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Safe Arrival in Uganda!

1 January 2020

Wow-2020! Happy New Year! It’s the start of a new decade and it’s going to be great!! Well I’ve arrived safely to Uganda after a 26hr trip. All went very smoothly with the flights. My seat mate is with the WHO and we had a great conversation. I told him all about my work and he gave me some good ideas going forward. We are planning to meet up this week and talk more. He may be able to connect me to others with similar interests. The only bummer upon arrival is that my Uganda phone lines aren’t working, although my colleague checked on them before I left and put some airtime on them for me. But, I’m grateful for the Wi-Fi at this cute hotel where I’m staying tonight and I’m sure I’ll get things worked out tomorrow. So after a nice hot shower, I’m snug under the mosquito net and ready to get some sleep. Talk to you tomorrow. The pics below are my room at the Entebbe Airport Guest House. I highly recommend this bed and breakfast!.

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Destination: Uganda

31December2019

Merry Christmas and Happy New Year’s Eve!  It’s been quite a long time since I’ve written upon return from my last trip to Uganda in June 2018. That wasn’t my intention but life stateside has been busy for me. The Binghamton University School of Pharmacy and Pharmaceutical Sciences is hopping with 3 classes in now, which is a total of about 230 students, and I’ve been teaching a lot—and enjoying every minute! However, I am thrilled to let you know I am headed back to Uganda today. What a wonderful way to start the new year, and new decade! It is amazing to realize I have now been working with Makerere University School of Pharmacy in Kampala since 2010, by email, and in person since 2011! I will probably take some time to re-visit the past 8.5 years with you via this blog during this trip. The main purpose of this short, 2-week trip is to lay the groundwork for my next research project and put the finishing touches on 2 papers I’m writing with my Ugandan colleagues. It will be a trip packed full with meetings and work sessions and in between those, I will also be busy preparing my teaching materials for the next semester at Binghamton University. Classes start less than 1 week after I return to the States.  For now I’ll say goodbye as my first flight will be boarding soon. I will be arriving in Uganda at 10:30pm their time, which is 2:30pm on New Year’s Day, eastern standard time. I’m looking forward to sharing my journey with you again. Stay tuned to tag along on my adventures!

Elmira Airport, NY

Bags Packed and Ready to Go at the Airport

Gabby in Car

I had to say goodbye to my young pup, Gabby-5 months old and I wanted to share her cuteness with you all. She has brought so much joy to my life! She will be in excellent hands with my husband, to whom she is a constant companion.

Posted in Beginnings, Kampala, My Safari (My Journey/Adventure), Research | Tagged , , , , | 2 Comments