CPD for Pharmacy Interns & A Busy Day!

Thursday, 21 June 2018

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Pharmacy Interns, The Principle Pharmacist of Mulago Hospital, The University of Minnesota Crew and KarenBeth

Greetings! Sorry for the lack of a blog post last evening. I went out to dinner with friends and got back to the Mulago Guest House very late. When I sat down to write, I was falling asleep so I decided not to post. I wondered if anyone would notice and sure enough, today one of the Pharmacy Interns mentioned that he missed my blog last night! So, let me not disappoint today. 🙂

 

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Sara and Prosperity talk about Pharmaceutical Care

It’s been a great day! I was able to attend the weekly CPD (continuing professional development) program for the pharmacy interns training in Kampala today. It was held at the Makerere University Medical School of the campus of Mulago Hospital. This time it wasn’t me and my students presenting but Dr. Melanie Nicol’s students, Sara and Kunkun, and her Global Health Fellow, Prosperity. It was so nice to sit back and listen to them and look around to see how engaged the interns were.  They were speaking on the Pharmaceutical Care process and how to identify Drug Therapy Problems.

Afterwards we took a large group photo on the lawn.  I also enjoyed meeting up with Derrick and Noah and two other interns I haven’t seen in awhile, Paul and Mark.

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Mark, KarenBeth, Noah, Derrick

It is so exciting that they are all really interested in pharmaceutical care and clinical pharmacy. They want to use their skills to make a difference in the health of their patients.  But the challenges are numerous. Even if you review a patient’s chart or meet with them to determine what drug therapy is best, the drugs are often not available. As I’ve mentioned before, the “free” government health care, really isn’t so “free” when patients have to go purchase their own drugs or go without.  At least they do not have to pay for the consultations with the physicians. All of the doctor visits are free.  But for surgery, the patients need to go and purchase all of the supplies—everything from the sutures, to the bandages and gauze, to the bone wax, as in neurosurgery, and even to the intravenous (IV) morphine they will need for pain relief as part of the surgical procedure or in the immediate post-op period.  After that, the strongest pain medicine they get is Tramadol.  And this is quite a large expense for Ugandans!

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Winnie, Kunkun, Prosperity, Sara, Mercy and Eva (the latter two are from IDI-Infectious Diseases Institute) (Pictured left to right). This is one of the nice cabanas at Mulago Guest House

Today we also said goodbye to the University of Minnesota students. They fly back to the USA tonight but Prosperity gets to stay on for another month, I believe.

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Sam Opio and KarenBeth

I also met with the Secretary of PSU, Sam Opio, this afternoon. (Pharmaceutical Society of Uganda) We’ve been working together for years and today we discussed potential next steps in our capacity building research to advance pharmacy practice in Uganda.  I’ll share more about this as the project proposal comes together. Needless to say, I left this meeting super excited for the future!!

This afternoon I met up with a friend for lunch, Daniel Hernandez and his wife, Julie and their adorable 9mo old baby girl. Daniel used to work for OneWorld Health, the NGO from the USA that is the parent organization for the Masinidi-Kitara Medical Center. It was great to catch up.

Afterwards I walked to two new craft shops that I haven’t been to before, but was told about recently. One of them called Good Glass makes beautiful glassware from old wine bottles and the other was a clothing shop, Kampala Fair, where they had numerous dresses made from African fabrics. They also make hand-crocheted rugs from African fabrics.  I just love the bright colors—they make me smile!

 

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Does the Medication Brand Really Matter?

Tuesday, 19 June 2018

Does the Medication Brand Really Matter? When practicing as a Pharmacist in the USA, I would tell you that most of the time the manufacturer doesn’t matter. There are some drugs are called “narrow therapeutic drugs” which means just a slight difference in the amount of drug in a given product could change the way it works in the human body and for these drugs, we usually recommend that a patient always gets the same brand. For example, levothyroxine is synthetic thyroid hormone that patients have to take if their thyroid doesn’t work or was surgically removed. Synthroid and Levoxyl are examples of two products that both contain levothyroxine. Both are equally good, but if you start with one brand, it is generally recommended you stay with that specific brand.

When a drug first comes to market, it was developed and made by one manufacturer. This unique product is usually pretty expensive when it is first available. After 17 years, though, the patent expires and other manufacturers can apply for the right to create a generic version and market it, at least this is the process in the USA. This product is almost exactly the same and it costs way less. The USA Food and Drug Administration (FDA) tests it and if it meets pre-specified criteria, they give it an AB rating which means a Pharmacist can dispense the generic version, even if the prescriber wrote a brand name product on the prescription. The only exception is if the prescriber specified “brand necessary” but this rarely happens. Health insurance helps the majority of Americans pay for their medications and they usually won’t pay for a brand name product if an AB generic is a available and so the patients usually ask for generic drugs to keep the costs low.

The opposite occurs in Uganda, and likely in other developing countries. Contrary to what you’d think, patients who have little money are willing to pay more for drugs that are produced in countries with a reputable pharmaceutical industry such as anywhere in Europe, Canada, or the USA because brands from certain countries are thought to be of poor quality. For example, unless a patient is very poor, he or she will not purchase drugs made in India. The story on the street is that drugs from India just don’t work. I was told about this problem way back when I first started coming to Uganda. The issue is so prevalent it comes up over and over. The other day, I had a very interesting conversation with Noah and Derrick, the Ugandan Pharmacy Interns. Derrick was telling me how he is having problems with many of his patients coming to the pharmacy asking for a specific country brand of a drug that doesn’t exist. For example, he said someone was asking for the UK brand of Clexane. The actual drug in Clexane is Enoxaparin and it is made in France. There is no such thing as Enoxaparin made by a UK manufacturer. He tries to explain but patients are just adamant about purchasing the UK brand because of the UK’s good reputation. They don’t quite get the concept that not all drugs are made by every manufacturer. I believe this was the patient who actually left his pharmacy to go find another pharmacy that could sell him the UK brand of Clexane. He said that sometimes patients will refuse to purchase a lower cost drug product because of the poor brand and instead will spend more money on an expensive brand from Europe but will not be able to afford the whole amount so they only buy a few tablets. But, “an expensive drug you can’t afford is useless” Derrick profoundly stated. Instead of taking the whole course of an antibiotic, they prefer to take a partial course of an expensive drug. This practice can worsen the antibiotic resistance problem that Uganda has. And a person may only take a medication for high blood pressure for part of the month because they don’t want to purchase the full supply of drug from India. This will not prevent the complications of high blood pressure like stroke and cardiovascular disease.

Derrick and Noah were suggesting that a marketing campaign to the public to explain and dispel the myths of certain drug product brands may be necessary. “So, you think the products from India are OK. I mean you would purchase them for yourself and your mother?” I asked them. Well, that brought on giggles. No, they both admitted they wouldn’t purchase them. Obviously there is either truth to the fact that the Indian drugs (just using India as my example because that is what I’ve been told) OR even the health care professionals are prone to peer pressure and “the word on the street”. If you asked 100 USA Pharmacists if they use generic drugs for themselves and their family, you would probably get almost 100% of them to say “yes!”, at least most of the time. (Exception is those narrow therapeutic index drugs.) I can use this to support my recommendation to patients to spend less money on drugs by buying the generics. But, here in Uganda, if the healthcare professionals won’t use those drugs themselves, how can we possibly convince our patients it is right to do so. This is truly a dilemma because Derrick is right—taking only part of a prescribed drug regimen could do more harm than good.

The only thing I can think of is for the National Drug Authority (NDA), equivalent to the FDA, to engage in more drug testing and to make these results available to at least healthcare professionals, if not the public to dispel the “talk on the street”. Noah is currently finishing up his NDA rotation as an Intern and he explained to me that when a drug manufacturer first applies to have their drug product registered in Uganda, they need to provide documentation of all of the quality testing and the NDA conducts its own tests of the actual tablets and then compares the results. If they match, the product is approved. For every subsequent order than comes into Uganda, the documentation is reviewed and compared. It is let into the Uganda drug supply if the documents are fine. There is no further NDA testing unless physicians petition the NDA in instances of major concerns about a drug product and from my conversations, this happens rarely. Until something is done, this problem won’t be solved. This is just one more challenge to overcome to improve the health of Ugandans.

I didn’t take any photos today but let me leave you with one of the snack I had last week. This shows two of my favorite Ugandan foods: samosas and g-nuts. G-nuts are “ground nuts” which are roasted like peanuts but much better. They pack a nice crunch. Samosas are meat or veggies in a pastry. I’ve had them in the States but these are better- crispier.

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Neurosurgery Morning Report, Data Collection and a Surprise Visit from an Old Friend

Monday, 18 June 18

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The Pharmacy Crew of the Neurosurgery Ward: Kunkun, Issac, Sara, Prosperity, Miriam, Dr. Bohan (left to right)

It’s been a busy but wonderful day here in Kampala! We started this morning by attending the Neurosurgery Morning Report. Winnie and I were going to head to the chart room to collect more data but she was called to the Neurosurgery Ward so we could help consult on a few patients. The meeting was in the small room in the photo and it was filled with physicians, medical interns, medical residents, nurses, pharmacists, pharmacy interns, pharmacy students, and even a physiotherapist (same as a physical therapist)—a true interprofessional team! Afterwards we went into the unit to see one particular patient whom we’d been asked to review regarding his multiple anticonvulsants and antibiotics. I worked with Issac, a 3rd year Makerere Pharmacy student and Miriam, a pharmacy intern, along with the University of Minnesota pharmacy students, Sara and KunKun and their preceptor, Prosperity, and Winnie.  We made our recommendations directly to the head Neurosurgeon who was very receptive and thankful.

Winnie and I then headed to the medical records room and spent the rest of the day in the patient charts.  By 4pm we were both starving so we headed to a very crowded and yummy cafe called Cafe Javas.  Back at the guest house a couple of hours later, I was just getting ready to get on my computer to accomplish some work when I received a phone call that Gonsha, my good friend, was here in the parking lot.  Gonsha is one of the  pharmacists who came to the USA in 2015 to complete a short-term experiential Pharmaceutical Care training course. We ended up talking for hours out on the lawn. The sun went down and we continued talking. It actually got quite cool as the night drew near, especially because there is a nice breeze. It hasn’t rained here for a few days and most folks seem to think the dry season has set in. I think the weather has been beautiful. In fact, right now it is hotter in Binghamton, NY (93F) than it will get in Uganda on most days. It is usually in the high 70’s or low 80’s.

IMG_1676Yesterday the monkeys were going crazy on the lawn as I sat and watched them from one of the cabanas while I enjoyed one of the truly delicious Cokes they have here. Yes, it is definitely different and better than the Coke’s in the USA. IMG_1673

They kept getting closer and closer so I finally had to get up and leave. Monkey’s here are kind of like squirrels or rabbits—a normal event.

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Return to Kampala and Meeting up with Friends

Sunday, 17 June 2018

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We have just reached Kampala! (Winnie and KarenBeth)

It’s been a very nice, relaxing weekend away in Mbarara! Winnie and I had a great time catching up with Dr. Susie Crowe and her team and learning all about their work with the Mbarara Pharmacy students. One of the first things they did was to teach the students pharmaceutical care skills such as teaching them how to give an immunization, how to do a fingerstick to check someone’s blood glucose, and how to take a Blood Pressure.  We were told the students were very engaged in these activities.  Check out their blog for some nice pictures.

As we headed back to Kampala, I took the following photos to give you an idea of the countryside near Mbarara.  It is a bit more hilly here.

This evening, back at the Mulago Guest House, I had some old students of mine from Mbarara come a visit—Noah and Derrick! These were the two who were responsible for getting me to come down to Mbarara University of Science and Technology (MUST) back in November 2016.  They are now Interns in Kampala and are doing quite well. After hugs and greetings, we jumped into our conversation as if we’d never been apart.  They are both also working at community pharmacies now to make a little money when they don’t have to be at their internship sites. This is pretty important because although Interns are paid, both of them are interning in government sites and the government is well-known for delaying their pay by months at a time.  They know that they will eventually get their back pay, but it is kind of hard to cover living expenses without a regular income.  In the USA, “internship” is done by pharmacy students within the university curriculum. We have students do experiential rotations for learning during the last year of pharmacy school and our students are paying tuition for this opportunity.  In Uganda, and much of the world, the pharmacy internship occurs after university. These students finished up their education in May/June 2017 and started internship around Sept/Oct 2017. They will then finish this September and will prepare to take their registration exam to officially become a pharmacist before the end of the year. They are paid for this experience but it is because they are depended on for work and to fill a position. In the USA, pharmacy students on rotation are extra and they are not called “staff”; although they may accomplish work for their sites, their role is to learn to be a pharmacist under the direct tutelage of pharmacist preceptor. This is a pharmacist who acts as both a supervisor and an educator but most of all they are a role model and mentor for the student.

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Noah, Derrick, and KarenBeth

Anyway, Noah and Derrick and I talked about many things but I want to focus on an interesting project in which they’ve become engaged.  They have both been interested in Information and Communications Technology (ICT) for quite a while. Basically, in addition to pharmacy, they love computer technology.  They, along with some friends, have conceived an innovation that mobile phone technology could be used to improve infant and maternal care for pregnant mothers. They saw a healthcare need:  many pregnant women don’t get the appropriate prenatal care because of lack of funds to pay for the services and they don’t know how to eat or how important it is to prevent malaria while pregnant or even when to go to the clinic to be checked during pregnancy. These challenges lead to greater mortality in pregnant women and infants.  Noah and Derrick said to themselves: “What if women could get advice about how to take care of themselves and their unborn baby through the use of a mobile phone, whom just about everyone has these days in the developing world? And what if they could save money ahead of time that would be set aside to be used for the prenatal visits and baby kits for safe delivery in a healthcare facility?” This led them to develop a plan to create a mobile phone app to address just these things.  They are still in the process of development but are much closer than when I last saw them. They have even found a mobile phone company interested and guiding them in the process. Check out their website, Wazazi Mother Care LTD, for more information!  Noah and Derrick are truly passionate about using their skills to improve health. These gentlemen are the type of caring leaders Uganda needs more of. Keep up your good work, stay positive, and great things will happen!

 

 

 

 

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Saturday in Mbarara

Saturday, 16 June 2018

Today we actually got to sleep in and have a nice relaxing breakfast at Acacia Hotel in Mbarara. The meal included fried potatoes and onions, sautéed fresh tomatoes, Spanish omelette, a sausage which is like an American Hot Dog, fresh squeezed passion fruit juice, fresh pineapple, and fresh papaya. As you can see, I’m not suffering in the food department. Fruit is especially delicious here! We decide to head downtown to shop today. Winnie and I met up with Katrice, one of the ETSU pharmacy students and went to town to meet up with Dr. Susie Crowe, the faculty member from ETSU.

By the time we got down there it was time for lunch. We had a delicious meal at a restaurant called Havana. I had tilapia which is a local fish from Lake Victoria. It was delicious! Afterwards we walked around and finally ended up at a dress shop where clothes are made to fit your body with beautiful African fabric. The tailor was quite talented and I wished I could have been in Mbarara longer to be able to have something made for me. Maybe next time… We finally called it a day and headed back to the hotel. All in all we’ve had a nice respite from our work in Kampala it we are looking forward to heading back there tomorrow and getting back to the research on Monday.

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Road Trip to Mbarara

Friday, 15 June 2018

This morning around 8:30am, Winnie and I got on the road with Haji, our driver, to head to Mbarara—a town about 150 miles southwest of Kampala. It took us about 5 hours and we had a couple of interesting stops along the way.  We stopped by The Equator to use the bathroom. I’ve been there so many times that I forgot to get the obligatory picture with the Equator sign—I may try to get one on the way back.  This is an area where the Equator crosses Uganda and has lots of craft shops.  The bathroom facility was quite nice- a normal toilet that flushed! Later in the day we stopped by a petrol station with a clean bathroom, but of the “traditional” kind—check out the pictures below. We also stopped by a roadside vegetable stand. The veggies looked so fresh and delicious I got the craving to buy some and start cooking.

We arrived safely around 1:30pm and checked in to the Acacia Hotel. IMG_1649We met up with a friend from East Tennessee University (ETSU) and her pharmacy students. She has been here almost a month and her students joined her a couple of weeks ago. It was nice to hear about how they are rounding everyday and enjoying working with Mbarara University of Science and Technology (MUST) students and pharmacy interns.  Unfortunately, the hospital situation with a severe lack of drugs is the same, if not even worse here in Mbarara. We shared a delicious late lunch at this lovely hotel.  I’ll share a bunch of photos and let them do the rest of the talking tonight.

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Data Collection & Dinner with a Friend

Thursday, 14 June 2018

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KarenBeth and Linda at Cafesserie in Kampala, Uganda at Acacia Mall

When I woke up this morning and pulled back the curtain, it was bright and sunny outside. By the time I had gotten ready to go down for breakfast, it was pouring down rain. It was actually really loud.  Needless to say, I needed to wait this one out, since I happened to be lucky enough to still be in my room when the rain shower hit.  My colleague, Winnie, was walking across the hospital complex when the skies broke loose and had to quickly find a building to duck into.  This is a pretty common phenomena here and I knew it would soon pass. Sure enough, 10min later, the skies were clearing and the rain had stopped and I headed out to breakfast. But, I forgot how slippery the red dirt roads can be in the rain. The red dirt seems impossibly hard and packed down when it is dry but just pour on some water and it turns into a gooey and slippery mess. When I’m back home, I’m constantly on the look-out for just the right pair of shoes to wear in this type of weather so I don’t slip down the hill. But, alas, short of wearing spiked shoes, I don’t think there is much out there that won’t succumb to the slippery roads.  I just had to walk gingerly and take my time.  Even if walking on pavement, you have to be careful because the slight layer of red dust turns into to a slick mess. You can equate it to “black ice” for those who live in snowy areas. For those who don’t, that is when the black macadam roads get covered with such a thin sheet of frozen water—ice—that you can still see the black road through it. It is easy to slip on because it doesn’t appear icy.  Anyway, I made it to breakfast and then hiked through this red gunk to the hospital. By the time I got there, my shoes were caked with red goo. I haven’t looked yet, but I bet my legs were probably spattered with red mud all day.  The order of business for the day was chart review and data collection.  We’d already gone through a few before, but today that is all we did—chart after chart—we collected the information required for the study.  I forgot how tedious it is to look through paper charts. And in Uganda, probably in much of the developing world, the charts are not well-organized and are often missing pages and information that we need.  But, we just do our best to make sense of it.  At first I tried to sort through the chart to find the beginning and then work my way though the pages in order but that was way too time consuming. Then I realized I just needed to start with whatever was the first page in the chart and note down the info. I’ll recreate the correct order after the fact.

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P

Finally we needed to call it quits for the day. We walked back to the Guest House and had a cup of coffee. Then Winnie headed her way, and I started back to my room to get some work done. But on the way, I noticed two newcomers to the Mulago Guest House sitting at a table on the lawn.  I had run into them as they arrived last night. I ended up sitting and talking with the gentleman and his daughter for probably 1.5 hours. It was a delightful conversation in a beautiful setting. After the rain this morning, it turned out to be a gorgeous day.  Finally I got ready to meet up with a friend at a nice cafe at local mall.  Linda was one of the first students I taught at Makerere University School of Pharmacy back in Fall 2014.  She was a 4th year student then and was quite interested, and still is, in clinical pharmacy. We’ve kept in touch over these years as I have kept in touch with a number of the Ugandan pharmacy students.  Their enthusiasm and desire to learn and gain skills to help improve their healthcare system is one of the major motivators that keeps me going in this work.  She’s doing quite well now but not able to pursue a strictly clinical position at the moment. She has a couple of jobs, as does almost every Ugandan, and one of them is working for a drug company. She helps develop marketing materials for them—she showed me some pocket cards she developed to help pharmacists remember how to counsel / educate patients about their drug therapy and she included the 3 Prime Questions! I was thrilled—this is clear evidence she has kept up with what I taught her and is teaching others today!  (for non-pharmacists, the 3 Prime Questions is just a method of helping us remember what we need to ask the patient and what we need to inform the patient about their new medications.)  It was so nice to catch up but eventually I went into “teaching mode” and taught her about evidence-based medicine and calculating the Number Needed to Treat (NNT) to determine how clinically relevant statistically significant findings are in clinical drug trials.  For those who are not in the healthcare field, don’t even worry about understanding that. Linda- so sorry if that is not what you were expecting when we met tonight, but know that I really enjoyed talking with you.  Just hang in there…your next step towards becoming a clinical pharmacist will show up when you least expect it. I’m really proud of your accomplishments and enjoyed our conversation. Plus, my pizza was totally delicious!!

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Pizza Funghi (Mushroom Pizza)- DELICIOUS!!!

 

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