Out of the Pharmacy Classroom and Into Africa

Wednesday, 27 June 2018

It’s been a fantastic trip but it’s time to head home. It was productive and fun in all the right ways and seeing so many friends and colleagues was really special. Here are some pics from my last day.

Eating a delicious meal on the lawn at the Entebbe Airport Guest House with Winnie and her husband, David– the best way to spend my last meal in Uganda!!

Getting to meet Winnie’s parents at their lovely home in Entebbe–what a wonderful treat. They served me a delicious fresh made juice of pineapple and the weird fruit below which is supposed to have anti-cancer activity. It was really good!

Meeting by chance with a current Pharmacist, Babra, whom I taught at Makerere a few years ago and her Pharmacy Intern, Ian, from Kampala International University. I stepped into her store to check out some packaged herbal products. We both remembered each other and I was thrilled when she started to tell me about how she still uses SCHOLAR, a tool to ask patients about their medical condition that she learned from me!

Visiting with Patrick, one of the first Pharmacists that studied with me in the USA.

My last coffee at Cafe Java’s while discussing our current research and planning our next project.

Monday, 25 June 2018

My day got off to an excellent start when I met with Professor Richard Odoi and hewas able to hand me a signed MOU (memorandum of understanding) to formalize the scholarly partnership between Makerere University College of Health Sciences and Binghamton University School of Pharmacy and Pharmaceutical Sciences. Yay!! Although I have been working with Professor and the School of Pharmacy for 7 years, the partnership needed to be sealed with this MOU to make obtaining future research approvals go more smoothly. Speaking of that, we had a great conversation and planned our next project in building capacity for pharmaceutical care to improve patient health and safe medication use.

I also met with Winnie and Kalidi, both pharmacy faculty who are applying for a unique opportunity for a 1-yr fellowship for junior university faculty to jumpstart a research agenda while being mentored by a senior faculty. They are both excellent ideas that would help improve drug use and patient outcomes in Uganda. I won’t reveal them as they are competing for this opportunity with many other faculty.

Later in the afternoon, Gonsha, one of the Ugandan Pharmacists who studied with me in the USA back in 2015 brought me to see her pharmacy and to her new house. The last time I had seen the house it was basically a pile of bricks! She now has basically a compound house with 2 Full and separate living areas. She also has her own medicinal herb garden which was especially interesting since I’m teaching a complementary and alternative medicine course this fall. She showed me all of the herbs she has and explained their uses. We also shared a delicious meal of chicken stew, rice and matooke (mashed banana). Her maid had purchased the chicken at the market today, prepared it, and cooked it. Talk about fresh food!!

Last evening, after returning from Masindi, a friend, Lydia, took me to dinner at a beautiful restaurant in the sky–at least it seemed like we were way high in the sky over Kampala. The view was spectacular but unfortunately with the dim light and only a phone camera, I couldn’t get a photo to express what I was seeing. The hotel and restaurant is actually called The Skyz–a very appropriate name!

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.

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.

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.