Masindi Road Trip!

Friday, 22 June 2018

I left Mulago Guest House in Kampala around 9:20am this morning with my friend and Masindi driver, Sam, to head to Masindi for the weekend. We stopped by a restaurant on the way to see his daughter who is now out of college and working there. I can’t believe how she has grown up. I remember when Sam had brought me to a school to meet both of his daughters several years ago and they were so much younger. We arrived Masindi safely around 12:45pm. I had called ahead to my friend, Janine, who is Health Education Missionary for the Church of Uganda, and she had lunch waiting for us at the New Court View Hotel. I love staying at this hotel. The food is delicious and the staff is wonderful!

Patrick, KarenBeth, Baluku

We headed over to Masindi Kitara Medical Center (MKMC) after lunch to meet with Patrick and Baluku, the administrative staff, and to meet the new doctor, Dr. Denis Kayumba. It was so nice to catch up with Baluku and Patrick and see how well the Clinic is doing and growing. There are some new staff but also lots of people I know from the years of working with them. Dr. Kayumba and I had a great talk and brainstormed about a variety of different activities he could engage all of the health care professions students who come to rotate at MKMC.

KarenBeth and Dr Denis Kayumba

Besides the students I brought here through Wilkes University, the numbers coming from other Universities has been growing, but most are from MUSC in South Carolina. I agree it is a great learning experience for nursing, physician assistant, medical, pharmacy, physical therapy, public health etc students. Both the medical and non-medical staff are eagerly involved with teaching the students. Tonight at dinner, I got to meet the 3 physician assistant students who have just finished there 4 weeks with MKMC. I’m sure they will return to the states changed for the better with a greater appreciation for the healthcare challenges of Uganda and with a new appreciation for the USA healthcare system.

If you’ve been following me for awhile, you might wonder why is there a new doctor and what happened to Dr. Godson. Well, I need to tell you all about that in detail at a later time but the short answer is that Dr. Godson is now in Binghamton, NY, where I live, getting ready to start an Internal Medicine Residency Program with UHS Hospital. In fact, he told me the other day that his new apartment is only a few minutes away from my home.

Well, it’s getting late and I must sleep now. I’m looking forward to a relaxing day tomorrow I’m this beautiful place. I will share with you the pictures I took of the gardens this afternoon tomorrow. By the way, there was a fierce but short rainstorm this afternoon. Check out the rain in this video. I

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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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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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Potatoes, Patients, Data Collection, and Meetings

Wednesday, 13 June 2018

I slept really well last night and enjoyed getting up a little later and the delicious breakfast at the guest house. I always love the fried potatoes and onions they make in Uganda. They call these “Irish Potatoes” as opposed to the other common potato which is called a “Sweet Potato”. Actually, if someone wants the Irish potatoes which are normal white potatoes, they may say “I’ll have some Irish.” If a Ugandan came to the USA and asked for sweet potatoes they would be in for a big surprise. In Uganda, sweet potatoes aren’t orange and they aren’t very sweet. They look basically like a peeled russet potato and they are gray when cooked. In the USA, sweet potatoes are orange on the inside and are more sweet than the Ugandan version.

Today we planned on spending most of the day recording data from the patient charts but we made a stop by the Neurosurgery ward first, and the head consultant, head Neurosurgeon, insisted we help out on rounds. He was doing teaching rounds this morning, called Major Ward Rounds, and he and the other surgeons have come to rely on Winnie’s expertise in terms of making sure the patients are receiving the drugs that are ordered and making recommendations about antibiotics and other therapies. A Global Health student for Western Canada also joined us for rounds. She is here for her Global Health Program but is interested in pursuing a pharmacy degree so Winnie is going to let her observe. Rounds were quite interesting and I saw very quickly why they rely on Winnie. Many of the patients had drug issues. One major issue is that the Neurosurgery ward has very few drugs. Most of the patients had to send family to purchase their medications at the local pharmacies. And when they can’t afford them, they go without. Winnie always looks at the actual drug products and asks how the patient is taking it. In one instance, the pharmacy labeled the medication envelope (they don’t put the tables in vials as we do in the States) with “phenytoin 250mg – 1X1” but clearly the capsules in the envelope were labeled phenytoin 100mg. The 1X1 means the patient is to take 1 capsule once a day. But, the doctor’s order in the chart read “phenytoin” 300mg OD. This means the doctor wanted the patient to have 300mg which would be 3 capsules of 100mg and these should be taken once daily. How did the pharmacy get it so wrong? Well, probably because most drugs are dispensed by non-Pharmacists. Although a Pharmacist must be the supervisor of the store, they do no need to be present to dispense drugs. Much of the time, non-medically trained people are hired and trained on the job to dispense the drugs. For a country (USA) where you can’t even open a pharmacy if the Pharmacist is not present, this is just a bit scary. It is fortunate the patient didn’t have seizures because he was only taking 1/3 of the required dose. Winnie spoke to the patient’s family member and changed the directions on the envelope and explained the correct dosage. In another situation, Winnie was asked to recommend and dose an antibiotic for an infant, and in another we recommended discontinuation of an antibiotic when infection was no longer present.

We finally made it to the records room and spent a couple of hours collecting data. In the afternoon, we went to the Pharmaceutical Society of Uganda (PSU) offices for an Education Committee Meeting. I was invited to attend to discuss the USA PharmD Program. This committee has been tasked with making a recommendation about whether Uganda should develop a PharmD program and they’ve been talking to Pharmacists trained in these types of programs all over the world. They had a Pharmacist trained in Algeria these who spoke about his program and some others. It was so interesting that despite the common name, these programs all different. I also explained to them about how our Continuing Education programs to maintain our licensure works. They have a requirement that all Pharmacists complete programs yearly but there are not specific numbers of credits or hours right now. Most of the time, they do this as part of the annual general pharmacy meeting of the PSU.

Arthur and KarenBeth

This evening a friend stopped by the guest house to visit. I met Arthur, my regular tour guide of EconestTim Tours and Travel Uganda, back in either 2011 or 2012. He was eating lunch at The New Court View Hotel in Masindi. I sat near him and we started to talk. He told me about his tour company and how he got started. I liked him right away but didn’t have need for a tour guide at that time. I kept his card and reached out to him the next year. Who would have ever guessed that 6 years later we’d would still be working together and developed a friendship. He has taken me and my students on numerous safaris and trips to Jinja. He has great knowledge of all things cultural in Uganda as well as flora and fauna. I highly recommend his tour company. Plus his vehicles are great!!

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Getting Down to Business

Tuesday, 12 June 2018

This morning my day started very early.  Winnie had a meeting with the Executive Director of the Mulago Hospital scheduled for 7am to discuss the severe antimicrobial resistance problem they are having right now and to present some solutions that the Infectious Diseases Institute (IDI) can help with. I was waiting for her promptly at 6:45am but it turns out she got pulled over this morning by the traffic police on a routine check of having the correct and in-date driver’s permit. She had hers but the stop took a long time and when you don’t beat the morning traffic, you get stuck in what’s called a really bad “jam” (traffic jam). It can then take you an hour to go a couple of miles. These routine traffic stops are just one of the regular obstacles people deal with around here.  It is meant to help make the roads safer but ends up delaying everyone.  Anyway, things worked out, as they tend to do, and when we reached the appointment, the Executive Director was just arriving—he probably got stuck in the “jam”, too. He listened to Winnie and my ideas carefully and agreed with the Infection Control procedures we suggested and said to write them up so he could approve them.

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A waterless hand soap station donated by the Duke Neurosurgery Team for a research project.  The sign explains in the local language of the central district, Luganda, the importance of hand washing and infection control.

This will allow IDI to come in and do a full work-up to find the source of contamination, if possible, and stop the spread. This will involve taking cultures from the healthcare practitioners and also swabbing and culturing equipment and beds, etc, on the wards.  They will also perform disinfection procedures.  One basic issue is that the bed linens are not washed and sterilized by the hospital. The patient’s family members have to wash them and re-make the beds. And they certainly aren’t sterilized. Also, something as simple as waterless soap stations or sinks with running water for hand washing in between patients that we take for granted in the USA is something that is not standard in Uganda.  Old facilities just weren’t created with sinks near the patients and even though there are some waterless soap stations on the walls, they were donated from a Duke University project and many of them are now empty. The hospital doesn’t have the funds to make this sustainable.

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Professor Richard Odoi and KarenBeth

We then headed over, through the traffic, to Makerere University Pharmacy School where I was reunited with Professor Richard Odoi. It was so good to see him!  He has been collaborating with me from the beginning and my first research project assessing the water, health and sanitation endeavors of The Water Trust in Masindi, Uganda back in 2011.  We actually started our conversations via email back in early 2010, maybe even 2009.  Anyway, this trip I have brought a memorandum of understanding to formalize our relationship, Binghamton University and Makerere University. He will be taking it to the Dean of the College of Health Sciences for signing.  We also discussed possible next steps in the Pharmaceutical Care Research and hope to develop another project for next summer.

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This is how many of the medical records are filed. No electronic records here!

Finally, we made it back to Mulago Hospital where we spent the rest of the day going through the paper medical records of the neurosurgery patients we need for the Phenytoin Study.  We found many challenges. First, the charts are not organized well but somehow the medical record staff know what they are doing.  They brought out this huge duffle-type bag (white bag in the photo) and it was labeled “neurosurgery”.  But, the charts were just stuffed in there in no particular order. It took about 5 of us to sort through them to find the patients that qualified for our study. They needed to be adults 18 years of age or older, they needed to have had neurosurgery, and they needed to be ordered Phenytoin.

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The large white bag had neurosurgery charts piled in there in no particular order. The pharmacy student standing next to me is Sara, one of Dr. Melanie Nicol’s APPE students who is being precepted by Winnie.

Then we found out that the charts of the patients who had died were kept in a separate location and to pull those, we needed to hunt for an inpatient record number. Unlike in the USA where everyone gets 1 medical record number that stays with them their whole life, these patients get a new number every time they are admitted and old records are not pulled routinely to see what happened to the patient on the previous visit. We had to go to the neurosurgery ward to look through the ledger books to find more patients.  We met with the head nurse, called the “Matron”, and other nurses who dropped everything to help us find the correct ledgers and explained the codes.  We were then told that there may be more charts in the outpatient clinic, so tomorrow morning, the first order of business it to go there to look for more records.  The picture above gives you an idea of what the records room looks like. There are some files on shelves but they are just stuffed in there.  It’s a little bit crazy.  But I have to compliment the medical records staff. They know where to find what they need. It is kind of like my Dad’s old workshop. When you walked in there it looked like a bomb blew up but just ask him where something was, and he knew just where to go get it.

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