During our last week in Uganda I happened to notice that my flight information was a bit different than everyone else’s. Accidentally, I booked my flight an entire 24 hours after my entire group. Although my family was encouraging me to “bite the bullet” and pay the price to change my flight, inside I knew I wanted that extra day in Uganda. I wanted to soak in every last minute in the country, even if it meant mostly in silence by myself.
I made it home on Tuesday, just in time for Thanksgiving. With every family member and friend I’ve seen the first question has been “well, how was it?!” I’ve been struggling because there is not one word, or two words, or ten words (or 100 words) to truly represent the magnitude of this trip.
Landing in the US and driving home from Newark airport with snow on the ground I immediately missed the weather in Uganda. As the drivers around us gave my dad and I the “New Jersey hello” (if you’re from NJ you know exactly what I’m referring to), I missed the warmth and benevolence of the Ugandan people. I missed seeing adorable children left and right waving and jumping up and down. Lastly, when I made it home to my refrigerator, I missed the fresh fruit juices (I may or may not have drank 2-3/day).
Compared to the other countries I’ve been to, there was not one moment during this trip that I felt unsafe or anxious. I believe Ugandans have truly been the happiest and most welcoming of people I’ve ever encountered. My time spent in Uganda has left me more humble. It has taught me to find joy in the little things, like the children whose day was made by finding the perfect stick to play with. It has taught me to relax a bit; not everything has to be so precise and rushed in our lives.
In terms of healthcare, it’s so admirable how eager everyone in Uganda was to learn. With every presentation given there were people fully engaged and curious. It seemed everyone truly valued education of any sort and honestly wanted to expand their minds and their practices. Sometimes it seems as though many people in the US are just going through the motions and are only often driven by money rather than the knowledge or skill. There have been times where I myself have been guilty of this. This trip has helped me better appreciate the education I am getting and have gotten and the good that I will be doing with it in my future.
Before I go on and go on forever, I wanted to end this reflection by giving thanks to those most deserving. Thank you to Winnie and David, your hospitality was beyond words and I’m so happy we were able to spend the most time with you two. Thank you to ALL of the Makerere University students and faculty we’ve met, I hope you all stay in touch! Thank you to Janine, your work is so commendable I wish we could have joined you in Masindi longer than we did! Thank you to the fellow Wilkes pharmacy travelers, I hope this trip has brought us all closer (and thank you for letting me serenade you all with ‘Hey Jude’). Last but not least, thank you to Dr. Dana Manning and Dr. Stacy Prelewicz. You two went ABOVE and beyond enduring lots of time, effort, and stress to give us an incredible, phenomenal, sensational journey.
I will forever advocate for this APPE rotation because I will always promote the importance of global health to health care professionals (and future professionals) and I want other students to feel these indescribable feelings accompanied with this once in a lifetime experience.
The last two days we have gotten the opportunity to experience the Masindi-Kitara Medical Center (MKMC) that, like the other places we’ve visited, has it’s own unique features. While Wilkes University pharmacy program has had an extensive relationship with MKMC in the past, this year we were given the opportunity for just a short two day visit. Although, MKMC will be hosting the drug shop owner health training that we are running with Janine’s help this Thursday. This clinic is now sponsored by and partnered with an organization in the United States called OneWorld Health. They work to build sustainable health facilities to provide care to patients that’s affordable and appropriate. Year round they have United States physicians and health care workers, including students and residents, to help fill the gaps but also to help train the healthcare workers of Uganda to achieve improvements in global health. Patients at these facilities must pay for services, which then helps employ the physicians and staff.
Yesterday, on our first day at MKMC those from OneWorld Health and also the Ugandan staff welcomed us during the morning service. As a Christian facility they start off every morning with this small service that includes prayer but also announcements. I do not consider myself a religious person therefore I usually find myself a bit uncomfortable in this type of setting. The service was much more than praising and thanking god. One of the physicians gave an inspirational spiritual talk about what is it to be kind and help others whenever you are capable and with any and all capacity. The words he spoke were beautiful and touching for me personally and I actually truly enjoyed hearing him speak such words before starting a “work day.” The optimism, faith, and altruism of the Ugandan people shines brighter with each day I spend in this country.
Following the services we had the ability to round with the doctors throughout the two wards, the maternity ward and the general ward. On the first day we met a young woman who was in labor. We all spoke about the tolerance she displayed to her labor pains. She tossed and turned a bit but we barely heard a peep or groan out of her (these patients are not receiving epidurals of any such for the pain as they do in the US). Her beautiful baby girl was born about 1 hour after we left yesterday (rats), but luckily we were able to check in on them today.
Today we rounded on a mother whom had preeclampsia upon admission last night, which is a potentially dangerous complication of pregnancy caused by high blood pressure in the mother. She birthed her child but her blood pressure was still fluctuating a bit despite being on anti-hypertensives. Our team was able to help correctly dose her anti-hypertensives where now, her Nifedipine IR will be given three times daily with the conclusion that her original twice daily dosing schedule was not sustaining control long enough. Therefore explaining her need for additional pushes of Hydralazine.
Patients in the general ward could range anywhere from neonates to geriatrics and we were able to see a bit of both and some in between. They spoke of some of the most common cases they see within their facility and two of those we were able to see were patients with Malaria and patients with H.pylori. Uganda has one of the highest rates of malaria in the world and it is not uncommon for residents of the country to contract the disease at least once (often times more than) in their lifetime.
In the general ward today a few of us rounded on our own before the doctors were ready to begin. Dr. Manning, Autumn, Mike, and I came across a 2.5-month-old baby who had stopped breastfeeding due to respiratory symptoms such as coughing and trouble breathing. We could see in his chart that they were suspecting pneumonia. He was started on Ceftriaxone, Gentamicin, Hydrocortisone (all IV), as well as IV fluids and oxygen. The first thing we asked ourselves, why did they start Gentamicin and why hydrocortisone? The double antibiotic coverage wasn’t necessary and the hydrocortisone did not seem indicated. The second action we took was to calculate the doses of each medication based off the baby’s weight. The good news was nothing was overdosed, but some of the doses seemed a bit off with some room for improvement. Later during rounds, the physician from OneWorld Health supported our thoughts and recommended discontinuing the gentamicin and hydrocortisone. The baby’s oxygen was increased which improved his O2 sat and they put in an order to have an x-ray done to definitely diagnose pneumonia.
In comparison to some of the other clinics and hospitals in Kampala that were government-run, my first impression was that this clinic was beautiful. The facility was tidy and clean. The patient charts were written fairly neat and in a decently organized chronological manner. The patients seemed comfortable and so did their accompanying family members. Despite these obvious physical differences I noticed some gaps and room for improvement. For example, the clinic only had one working ECG machine and one working ultra sound machine. There was also, like the other facilities, no clinical pharmacist or input from pharmacy in patient care which could be very beneficial to patients such as the scenario mentioned above. I admire the achievements they’ve made and continue to make but I truly believe the value of a clinical pharmacist could drive quality patient care even further.
During rounds we took turns escaping in small groups to the lab just to get a taste of what was happening behind the scenes of diagnosing. The lab technician was so wonderful and kind he took us through step-by-step of all his work he was doing. We were able to look at blood smears to identify malaria, we watched him prepare renal tests (SCr, BUN/Urea, and Uric Acid), and also testing plasma for hepatitis B. With the funding of OneWorld Health via machinery and lab equipment they are able to perform just about every basic/vital test we know in the US. Challenges come with low stock of things such as reagents from their suppliers within the country. My time spent in the lab really brought me back to Microbiology and Analytical chemistry during my undergrad career at Kutztown University and also to pharmaceutics lab with Dr. Jacobs during pharmacy school. It’s been 3 years since I’ve used a pipet (YIKES)!
Blood smear of mild malaria
Blood smear of severe malaria
The above images are of blood smears the first being of mild malaria and the second being severe malaria!
While saying our goodbyes to one of the physicians, Dr. Dan, he expressed his desire to have a conversation with all of us about pharmacy practice in the United States. To our surprise he really was not fully informed on our role as pharmacists. He was shocked to hear that a pharmacist must be present in the pharmacy AT ALL TIMES in order to help patients, receive prescriptions, and dispense medications. This is a huge difference from Uganda. In fact, often times the pharmacist is not in the store and it is their technicians and other employees (whom may or may not have accurate medical training), are present in the pharmacy and are dispensing the medications and making recommendations (hence recommendations during our little experiment yesterday). He then posed what I thought was such an interesting question; “do you think the people of Africa do not treat as many chronic conditions as you do in the US (ie diabetes, hypertension, thyroid disorders, etc), because we are healthier or because we just don’t know we are sick?”
I’m sure most people would assume “that’s easy, it’s because they don’t know they are sick due to limited healthcare access.” This may or may not be true. Although many of our patients from the blood pressure screening had very high readings, we’ve made personal observations about diseases such as diabetes, which does not seem nearly as prevalent in Uganda as it does at home. Fruits, vegetables, and home cooked meals in general are much more common and are staples of their diet whereas in The States, buying fast food is much cheaper than whole foods. Some food for thought (pun intended).
It’s really great to see the execution in patient care this clinic upholds when it all works well (most of the time)! I’m hoping these next (and last) 5 days go by veryyyyyy slowly (although I’m really missing my dog son Oliver)! Thanks for reading and happy Tuesday!
One of the things that I personally have been enjoying about Uganda is the relaxed atmosphere- especially when it comes to being on time and scheduling. If you know me, you know that at home I almost always stick to a schedule and I am always on time. Since being in Uganda, I haven’t looked at the schedule once; I wake up and ~go with the flow~
Our morning’s plan changed, as originally we were supposed to wake up and head to Mulago hospital for rounds but instead our morning started out at the Makerere University because the Dean of the pharmacy school was eager to meet all of us!
Upon arrival to the University a pharmacy student had stopped us all to talk. The conversation started with him asking, “what have you found to be the biggest differences between the hospitals in Uganda compared to the United States?” Naturally, one of us had answered about electronics; we have computers and automated systems everywhere, whereas in Uganda everything is done on paper and therefore things may seem less organized and often times untraceable if papers become damaged or lost. The student went on to express his fears about Uganda following into our countries footsteps in the future and electronics becoming emotional barriers between the physician and patients. I think many if not all of us were taken back and a bit defensive when he expressed these feelings. I appreciate the value that this student held in maintaining close patient-clinician relationships although I had to politely disagree. I feel with our advanced systems we are able to stay organized enough to know even more so about our patients using electronic medical records than others may realize.
Our conversation spun off into a more lengthy conversation involving a nearby professor about continuing to bring Wilkes students to Uganda but also to begin bringing the students from Uganda to Wilkes University. We all came to a common conclusion that the biggest issue is cost. I could not get this conversation off my mind the entire day. For those of you who don’t know, our University does not fund this rotation. We’ve all found a way to afford this trip by working our tails off in our internships while also thoroughly completing our 40 hrs/week unpaid APPE rotations, or by taking out an extra loan (ya know, because we all don’t have enough of those already right)?
I’ve been so stuck on this conversation because I don’t think everyone sees the value behind what funding could provide in a program such as this one. We have been identifying similarities, but there are also many differences, especially between a first and third world country’s healthcare system. The Dean at Makerere University had mentioned the increased motivation he notices in many students following our visits each year where we educate them about our system, practice or teach clinical skills, and present lectures. The exact phrase he had used was that we “inspire them to be better.” If we have had that impact on such students in the small time we have spent directly with them (and them on us!!!), then who is to say we can’t have an immense influence on each other if they are also given the opportunity to come to the United States to see pharmacy and medical practice first hand.
Maybe some of you are thinking, “Why does Rubi feel so strongly about this? Is it that important for others to learn about or from our system hands-on?” My answer is YES. We’re not just here to lend a helping-hand and improve our teaching skills. We are here to make a difference in underdeveloped health system and therefore improve global health, even if it is one step at a time. International travel plays a huge role within our economies and travel is often accompanied by the spread of new or recurrent infectious diseases. This affects EVERYBODY, rich, poor, young, old, far, and wide.
As Americans, we have the power to be leaders in promoting worldwide comprehensive identification and preventative techniques for infectious disease. What is the easiest step to take in perfecting a system such as this? Education. This is a huge part of our trip. Another way? Philanthropy. Moving forward, we all plan to keep this discussion going to hopefully implement a plan to help fund the future of this rotation for American and Ugandan pharmacy students.
In the afternoon we stopped by the Mulago pediatric ward to follow-up on some of our patients. For my group, we followed up on our patient with end stage renal disease who previously had uncontrolled hypertension despite being prescribed five anti-hypertensive medications. The good news, his blood pressures seemed controlled today after our group’s recommendation. The concerning news; the patient’s initial empiric antibiotic therapy (for an unknown infection) with Linezolid was stopped when he became afebrile. Soon after, his fevers returned where he was started on Meropenem. This is where as pharmacy students we questioned, why? Often times in Uganda, because the cost of antibiotics such as Linezolid are too expensive, the patient is not kept on this therapy for the recommended course of treatment, but instead until their fever has subsided. If the fever returns, then they resume the antibiotics, often times trying a new one, with the idea in mind that the first antibiotic had failed. This was a teaching moment. By doing this, we are increasing the risk of antibiotic resistance, which is an issue in Uganda. Increased antibiotic resistance=increased chance of “super bugs”=increased spread of disease=increased risk of global spread of disease!
Following this we went to visit a community pharmacy! Some similarities I had noticed; The clinical consultations and services the pharmacist may provide patients is not compensated, inventory is strongly based on demand, if a patient needs a drug that is out of stock the pharmacy will order it for them ASAP, and this pharmacy (like some in the US) organized their liquid and topical medications separate from other oral formulations. Some major differences I had noticed; the pharmacy operates on a cash basis only, herbal medications are dispensed and compounded very often, nurses and clinical officers are employees within the pharmacy as well, medications tend to be brand name only and only some brands are reputable, many medications do not require a prescription, and the other employees within the pharmacy have the ability to make substitutions for medications indicated on the prescription without the pharmacist’s authorization.
The most heart-warming part the visit was the long detailed story told by the pharmacist Gonsha. This woman went above the “above and beyond” for a patient in order to make sure he received the appropriate and best treatment. This patient would often come into her pharmacy looking for antibiotics but would not share why. She continued to follow-up with this patient trying to learn more about him and his conditions. It was when he came in with an amputated leg that he finally shared with her that he believed the amputation was due to a diabetes complication. She continued to check his blood sugars for months, which never revealed diabetes. One day she noticed the patient had extreme pallor (an indicator of severe anemia) and when she had expressed her concern he finally revealed that he had a wound on his groin that was so deep his bone and blood vessels were visible to the naked eye. He also revealed that he’s unable to seek medical treatment because it was unaffordable, which is why he had been treating himself with antibiotics and gauze for all this time.
Gonsha created flyers and shared his story all over town and created a donation box at her pharmacy. With this money she personally took the patient to receive proper treatment at Kiruddu; everything from a blood transfusion, effective antibiotics, biopsies, and more. The deep wound was actually a tumor and the patient has since went from losing one liter of blood a day to only 10 millilters (for my non-medical readers, THIS IS HUGE).
Had she not this put in this care and dedication this patient stood zero chance of being alive today. I know I have been lucky enough to work with a pharmacist in my job who would give an arm and a leg for a patient and I wish to practice this way myself. It was amazing to see that this is a common trait seen in many if not in most of those in my future profession despite the country they practice in.
Gonsha spoke to a few of us about her time she had spent in the United States learning about pharmacy. We talked to her about major differences between the systems per usual but what stuck out to me was that she was unable to mention what she deemed as a negative aspect to her experience in the US. She mentioned that in the hospital they would assign her to work on a maximum of four patients at a time. At first she felt that we did not know what taking on a lot of patients felt like as an American pharmacist. She then continued to explain that she learned by taking on only a few patients at a time she noticed that in the United States we not only focus on the patient’s acute issues but also strive to improve and correct the patients chronic conditions as well. “You really look at the patient as a whole, and I really appreciated that.”
Thank you to those who took the time to read and happy Friday!!!!
Hey everybody! My name is Rubi Mink and I am one of the seven pharmacy students traveling to Uganda from Wilkes University. I will be graduating in May of 2019 with a Doctorate of Pharmacy, as well as a minor in Spanish. Following graduation I hope to pursue a PGY-1 Residency in clinical pharmacy, more specifically one that is focused towards ambulatory care and outpatient services. I love the idea of building personal relationships with patients and having the ability to really take my time with each patient giving them my undivided attention!
I’ve been looking forward to traveling to Uganda for this APPE rotation since I was a P1 student. My advisor at the time was the creator of the rotation and the way she spoke about the country, the people, and the experience as a whole sounded so incredible I knew it had to be something I experienced for myself. Since then, I had followed her blog reading anxiously about her experience every year while patiently waiting my turn.
One of my true passions is traveling. There is nothing I love more than exploring new countries and taking on a new culture full-force. In the last three years I have traveled to Colombia, Costa Rica, Guatemala, Israel, and Thailand. For two of those trips I was able to participate in volunteer work that allowed me to utilize my pharmacy knowledge and patient-care skills in order to help the underserved. Both of those trips were life-changing.
What makes me most excited to travel to Uganda? I’m excited to share what I currently know in a completely foreign healthcare system. I am even more excited to learn about what I don’t know about the healthcare system but also about the way of life of the Ugandan people. This will be my first trip within a bigger group of friends, and it will be the longest time I will have spent over seas. I’m eager to learn more about everybody on a personal level but also to learn more about myself. I think as always, I may struggle with jet lag so my fingers are crossed that I will have a quick transition!
I think this Global Health rotation in Uganda is such an amazing opportunity offered to pharmacy students. I think traveling to different countries in general always helps with personal growth. It opens your eyes to the world and you get to see first-hand how others live differently than you; suddenly your problems are put into perspective of the bigger picture in life. Also, the importance of Global Health has a greater impact than most people think. Although one may believe they cannot have a big influence on the world, I think trips such as this one have the ability to show students differently.