Becoming a pharmacist in Malawi

Jezman#1The Hamilton FHT has been involved with the World University Services of Canada (WUSC) and the Leave for Change program for a few years now. As you may recall from this blog, all that started when Jay Graydon (CFO at Hamilton FHT) went to St. Joseph’s hospital and help their finance department. The following year more people got involved and the next year even more. Helping out people in Malawi, Botswana, and other countries in Africa. Jay had spoken to me after his trip and discussed areas where my skills may be of help. The following winter I was on my way to Malawi and St. Joseph’s hospital to help at the pharmacy department. During my stay I worked mostly with Jezman Vallan a pharmacy technician and Sister Mary. It was the hope of Sister Mercy, the administrator of the hospital to eventually get a pharmacist as the hospital is in great need for such a professional. This was something that she had expressed during my visit but nothing more. Almost 10 months later, to my surprise, I receive an e-mail from Jezman indicating that he had been accepted to the pharmacy program of Rhodes University in South Africa. The program was starting in 2 weeks and unfortunately was unable to attend due to lack of money. Opportunities like this do not come often is ever in the life of a Malawian. This desire to improve himself, the goal of becoming a pharmacist and helping out his community resonated with several of us pharmacists but also other Hamilton FHT staff members and family members. Within these 2 weeks after getting the initial request we were able to collect sufficient funds to send Jezman to Rhodes University in January 2014.

Since then, Jezman has been performing very well and will be completing the second year of his 4-year program in November. He is very focused, he is smart, has good marks and is eager to apply his newly acquired knowledge to his setting of St. Joseph’s hospital. During the break between the second and third year he will be returning to Uguludi to work at the hospital.

Jezman_in_labHowever, for him to be able to actually go back to Rhodes University for his 3rd year, he will need our help. Each year, Jezman needs about $12,500 CDN for the bare requirements to go to school.  Obviously, this is not something that I can do on my own but as a group I think that we can do it as some of us have done it for the last 2 years. Since the start of this project some people have retired making their ability to contribute very difficult. We need some other donors to participate otherwise Jezman will not be able to complete his program. Because we are partnering with WUSC a charitable organization, you will be able to get a tax receipt for your donation which correspond to approximately 40% of the amount donated. The administrative fee for WUSC is 12% which is very low and I make sure personally that all donations make their way directly to Rhodes University. Jezman has a work bond with St. Joseph’s hospital and he will be working as a pharmacist for the first 6 years after graduation as repayment for his educational expenses.

Please donate

Select the category “General”. In the message box, indicate that this donation is related to the project “Jezman Vallan – Pharmacy School, Rhodes University”.

Thank you very much for all of your help.

Antony

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Diabetes Clinic

I have spent last Tuesday morning at the diabetes clinic. It is estimated that 5% of the adult population of Malawi has diabetes. The diabetes clinic runs once per month and this morning about 40 people were present. The armamentarium of medication available to the clinicians is very limited, metformin, glyburide, and insulin (beef and pork) either regular or lente. Very few people are on insulin. None of the patients that I have seen today, although in Canada several of them would be candidates for insulin. Several people presented with peripheral neuropathy of different stages.

There was more similarities than differences as to how the clinic was run. Patients arrive at 6:30 am (so before their first meal of the day) to get their fasting blood glucose measured. No one had their own glucometers. In fact, there are barely enough supplies to get the glucometer of the clinic working. People’s blood pressure was taken, their feet checked then a discussion with the clinician about lifestyle modifications mostly nutritional counselling, they have plenty of exercise as most people walk several kilometers per day. No personal transportation to speak of. Nutrition is a challenge. Their diet is very heavy in starches. The main staple of Malawian diet is nsima which is dish of cornmeal cooked with water to dough-like consistency. Potatoes and rice play also a significant role. Little protein (very expensive) and some fruits and vegetables which are locally grown. Being overweight is sometimes seen as a sign of health. Some women are proud to be heavy, it shows to the world that they do not have HIV. There are campaigns to shift that way of thinking and promote more healthy weights. Their relationship with food is very different. If you have been deprived of food or starving in the past you may be more likely to over eat when you have a chance to do so.

Surprisingly (or may be not), very few people with type 2 diabetes at the clinic today were overweight, only one exception. Adherence to therapy is a big problem in view of the price of medications. Some people have a drug plan call MASM but no governmental support here. Today the president of the Diabetes Association of Malawi was speaking to the patients at the beginning of the clinic. He is trying to have diabetes medications covered by the government the same way that antiretroviral agents for HIV/AIDS are covered. One big gap is the lack of access to lab work monitoring. A1c is not monitored and treatment decisions are based on that single blood glucose reading on the morning of the clinic which operates once a month. Very difficult to manage people that way and expect any success at preventing complications. Not surprising to see so many people with peripheral neuropathy. And this was assessed crudely with the point of a pen. Whatever works in a pinch. As to nephropathy, who knows, kidney function is not monitored. Too expensive. As to retinopathy, people are asked if they have any problem with their vision, no retinal exam, not even an eye chart. Even is retinopathy was diagnosed, no fancy laser treatment or intra-ocular injection to curb the progression of complications. So much more could be done with more resources…  I am no sure if Canadians truly appreciate how fortunate they are.

Back to Africa

A lot has happened since my last blog entry. This is the first opportunity that I have had to upload any material to this blog. Even in the large town of Limbe connectivity has been a struggle. I have been using an Internet Hotspot (free Wi-Fi) in the lobby of the hotel. Unfortunately, the Internet has been down for the last 6 days.

Jezman has been attending pharmacy school at Rhodes University. He started in February, has completed his first term successfully and is presently in his second term. We have been communicating regularly over Skype. Jezman is discovering a brand new world full of promises and opportunities.

A new pharmacy technician has now been hired at St. Joseph’s hospital. His name is Thoko. He is 23 y.o. a just recently graduated. This is his first job. Before that he was working with his dad at their family farm. Working on a farm in Malawi is hard work. Only rich people can afford a plow and an animal to pull it. Thoko’s family is not rich so all the labor is done by hand. Turning the soil and all field work is done with simple hand tools.

Jezman was my main contact at St. Joseph hospital so after his departure not much progress has happened at the pharmacy. Checking emails is not part of the usual activities and communication has been difficult. The internet at the hospital is patchy at best, often down all together, for days at a time.

Since I had been working all along on further developing the Inventory management software for St. Joseph’s hospital, I wanted to make sure that it could be fully implemented. To accomplish that I decided to go back to Nguludi and St.Joseph’s hospital. I was fortunate to have my second application to the Leave for change program accepted and have an opportunity to finish the project that I had started a bit more than one year ago.

I have been back to Malawi since Aug 25th. I was able to fly directly to Blantyre which is the town next to Limbe where I will be staying the 3 weeks of my stay. I was greeted by Sister Mary whom I had worked with last year and one of the drivers that I had come to know at my last visit. Very warm welcome and nice to see familiar, happy, faces.

The next day was my start at the hospital. Nothing had changed since my last time, almost as if I had left just for the weekend. Nothing except for the fact that the pharmacy is now down to only one working computer, my old laptop. Jezman had informed me of the state of affairs over the winter. A few months ago, at the Hamilton Family Health Team, we were in the process of changing our computers. In the past, we had donated the older computers to charitable organizations. So this time, I asked for setting aside 14 computers to be donated to St. Joseph’s hospital. Sending them to Malawi has been a challenge. I have contacted DHL (the courier company) and they were kind enough to provide shipping at a discounted price. Unfortunately, I have been trying for over 6 weeks to ship the computer at no avail. For the first 4 weeks my contact at DHL was away in India. She had left instructions for someone to follow-up with me but they never did. Now from Africa, I am trying to coordinate the shipment and I am afraid that it will not happen. I will keep my fingers crossed.

I am been working with Sister Mary and Thoko at fine tuning the software as they are bringing good points for improvements. We did a full inventory count, down to the last single tablet. Many of the inventory items are pretty fast to count, the quantity being zero. This is probable the caser for 1/2 the items on their inventory. I am pleased with our progress so far and things are looking like they will be working well. Every one here is excited about the possibilities that will become available from a management point of view. The process will also be faster for the staff at the pharmacy. So far a win win for every one. 

On a lighter note, I have had the chance to rub elbows with the Malawian National soccer team which are staying at the same hotel as I am. They won against Benin a couple of weeks ago and they are playing Ethiopia on Sept 10th. The stadium is close to where I am staying. I am hoping to get a chance to see the game. I have not watched any soccer games since my departure from Canada. I am in withdrawal. My team (Manchester United) apparently is doing poorly, maybe I am not missing much.

Something extraordinary…

There are events in your life that remain in your memory forever. Situations where people distinguished themselves in a way that is extraordinary. I had the privilege to witness such an event this week.

While I was in Malawi, I worked very closely with Jezman, a pharmacy technician, and Sister Mary. There are no pharmacist at St. Joseph’s Hospital. In fact, most hospitals in Malawi do not have a pharmacist.Wages being more attractive as a community pharmacist, it is very difficult for hospital to retain or hire a pharmacist.

Sister Mercy, the executive director of the hospital, has great aspirations for Jezman. She sees his potential and encouraged him to pursue his studies and become a pharmacist. Jezman is a bright young man, hard working, and striving to be the best that he can be. Jezman applied to the pharmacy school at Rhodes University in South Africa. He got accepted. But Jezman’s dreams may be only that…dreams. Jezman cannot afford his dream. Jezman found a buyer for his old clunker but this only made a dent in gathering the funds that he needs. As a last ditch effort, Jezman reached out to me. It was now January 8th 2014. Jezman needs his tuition paid by Friday Jan 17th. At first glance, the task seemed impossible and the likelihood to be of any help to Jezman in a significant way was pretty dismal. This is when something extraordinary happened. True generosity. The belief in helping people help themselves.  Teaching a man to fish.The pharmacists of the Hamilton Family Health Team, Jay Graydon our CFO, who went to St. Joseph’s hospital in 2012  and a relative of mine got together and managed to gather the funds necessary to send Jezman on his way to South Africa, to pharmacy school. We are still a long way from having the funds to cover all the 4 years of Jezman’s program but we are close to having enough to cover the first 2 years. Jezman was so excited, he could not sleep a wink the night after I announced the news to him.

You to can also help make Jezman’s dream a reality. Help a hospital and a community.

https://secure.e2rm.com/registrant/startup.aspx?eventid=138540

Last night in Limbe

Today was my last day of work at St. Joseph Mission Hospital in Nguludi.  So much to do and so little time. In the other hand a single person can have a significant impact over a short stay. My main task before coming was to implement an electronic inventory system for their pharmacy. This was what the hospital had identified as a need. After my briefing session on arrival, I discovered that the initial thought of inviting a pharmacist had germinated from a need with their palliative care unit and their difficulty in securing morphine supplies. I was not sure how I would go about that since morphine is provided at a deep discount to hospitals (12.5 % of the cost) by the government and supplied from the national provider are limited.  The physician of the hospital, the clinicians at the palliative care unit, the staff at the pharmacy department all identified the need for acquiring more morphine but had limited expectations as far as potential success in acquiring supplies. In Malawi the strong analgesic of choice is morphine with the liquid form being the most readily available. Here at St.Joseph Mission Hospital it is the only form available. When asking one of the clinicians at the palliative care unit how they managed patients over night, I was told that “We double the dose before going to bed.” Not very effective to last the night, I would suspect. “And if we run out of morphine, we use acetaminophen or ibuprofen, sometimes we have acetaminophen with codeine but not always”. So everywhere I went, the Phamaceutical Supplier in Limbe (which happened to be just across my hotel), the Malanje Mission Hospital, the Malanje District Hospital, I asked about how to get morphine. In Limbe, I have learned that you can get morphine but only one supplier in the country has stocks. Since the government supplies morphine at a deep discount their is no incentive or market for the private suppliers. But their was one potential source that could import morphine from outside the country albeit at a much higher price, but there was some hope. With sufficient finances i could get morphine, even long-acting morphine. At Mulanje Mission Hospital, a sister hospital of St. Joseph’s, they have a significant donor and they had a whole 4 liters of liquid morphine just sitting on the shelf. So the possibility was there but the chance of being successful was slim in the long-term due to financial constraints. I was a bit discouraged and started to feel the same desperation as the people at St. Joseph’s. This was until 2 days ago. At lunchtime, a met a pharmacist from France who was working with the organization Medecins Sans Frontieres. Start to talk to him, what he was doing. He told me about his work and most what he did revolved around the provision of antiretroviral agents and that they were moving away from lopinavir/ritonavir based regimens to atazanavir/ritonavir and that they were doing some training about that next month. In passing I inquire about possible source of supply for morphine. To my surprise, they also provide free morphine as HIV is not their only target area but also cancer and palliative care. Not only they can provide liquid morphine but also long-acting morphine, and tramadol which is one of the only other strong analgesic available. The only request that he had was for the hospital to supply him with estimated quantities that they would need and they would supply them for free, and over the long term. In addition, he said that they usually had good quantities in stock. A goal that sounded improbable to reached was accomplished. A basic need to provide palliative care patients access to medications to relief their suffering.

Malawi in pictures

Extreme car pooling, The whole nun congregation in the back of the truck.

Extreme car pooling, the whole nun congregation in the back of the truck.

Food market

Food market

Mount Mulanje is a granite inselberg in southern Malawi, Africa. At 3,000 meters (9,824 feet) high, it is one of the largest inselbergs in the world as well as the tallest peak in south-central Africa. Inselbergs are isolated stands of hard igneous rock which have been left standing isolated on level plains, formed because their rock mass resisted erosion while the plains around them did not.

Mount Mulanje is a granite inselberg in southern Malawi, Africa. At 3,000 meters (9,824 feet) high, it is one of the largest inselbergs in the world as well as the tallest peak in south-central Africa. Inselbergs are isolated stands of hard igneous rock which have been left standing isolated on level plains, formed because their rock mass resisted erosion while the plains around them did not.

Pineapple on the side of the road. It is served peeled with the leaves used as a handle. Very delicous. $0.15

Pineapple on the side of the road. It is served peeled with the leaves used as a handle. Very delicious. $0.15

Everywhere along the roads you see people walking or biking. Many more people using those mode of transportation than using motor vehicule.

Everywhere along the roads you see people walking or biking. Many more people using those mode of transportation than using motor vehicule. Also you can see the corn on the right side of the picture. It is grown everywhere and is a major component of their diet.

Airtel is one of the local cell phone company. MAny people use a cell phone in the cities. Everyone seems to have one in their hand

The old and the new. Airtel is one of the local cell phone companies. Many people use a cell phone in the cities. Everyone seems to have one in their hand

One of the borders between Malawi and Mozambique. People can cross freely but motor vehicles are inspected. During the war in Mozambique, Malawi accepted many refugees and the relations between the two countries are very good.

Mount Mulanje

Mount Mulanje

Macademian nut plantation

Macademian nuts plantation

The very OU T patient department at the Nguludi Hospital

The very OUT patient department at the Nguludi Hospital

The ambulance. The backis a plain flat bed.

The ambulance. The back is a plain flat bed.

The Stadium where the National soccer team plays

The Stadium where the National soccer team plays

Other part of the StadiumBye the way, Paul, the nickname for Liverpool FC here in Malawi is Looserpool. Just thought I would bring you a bit of the local flavor.

Other part of the Stadium
By the way, Paul, the nickname for Liverpool FC here in Malawi is Looserpool. Just thought I would give you a bit of the local flavor.

During my first week, it was very rainy. The is a side road in a village. It is hard to appreciate the condition on the picture but just let say that if we did not have a 4 wheel drive vehicle we would not have been able to use that road.

During my first week, it was very rainy. The is a side road in a village. It is hard to appreciate the condition on the picture but just let say that if we did not have a 4 wheel drive vehicle we would not have been able to use that road.

At another border between Malawi and Mozambique.

At another section of the border between Malawi and Mozambique on the road from Lilongwe to Blantyre.

Typical Countryside landscape.

Typical Countryside landscape.

The state of Pharmacy in Malawi

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According to the local newspapers there is a drug crisis in Malawi. There is a 95% shortage of medications which they define as hospitals and pharmacies having only 5% of their needed inventory. Not only funds to buy medications is an issue but also the suppliers do not have sufficient stocks to distribute even if one has the funds to purchase them. The picture on the left and in the middle, at the top, depicts the extend of the variety of medications that is available at the outpatient pharmacy of the hospital in Nguludi. Malaria, TB, HIV are the most common medical conditions seen at the hospital. There are only a few people presenting with CVD but remember the the life expectancy is only about 46 y.o. The only oral medication available for diabetes is metformin and insulin. Insulin is a challenge with the problems with refrigeration and frequent power outages. For pain, there is basically only acetaminophen, ibuprofen, and oral short-acting morphine. There was tramadol at some point but there has been no supplies available for a while. Morphine is available from the government at a very subsidized cost (the hospital pays 12.5% of the actual cost) but availability from the central supplier is patchy.

The actual process of dispensing medications is very different from what we are use to. At Nguludi there is no pharmacist but they have a pharmacy technician which is more than most hospitals can say. A clerck dispenses the medication in the outpatient pharmacy, she is all by herself and may be seeing 40 -60 patients a day. There is no checking process in place. The medication are provided in small plastic bags (see picture top right) which has pictogram for morning lunch supper and bedtime under which she indicates the number of tablets to be taken and for how many days someone needs to take their medication. In the city you can get most medications without a prescription with possibly the exception of antibiotics and morphine. Physicians are very rare to actually prescribe medications and only very basic ones are available. When locals get a fever they assume that it is malaria and treat themselves for it. If it does not get better than it most be another infection of some sort and then seek medical attention. Very few diagnostic procedures are available so that when people have cancer it is detected very late.

I have heard today that sometimes people bring medication as donations but it sometimes remains untouched due to unfamiliarity with them. A lesson to be learned. If you ever consider volunteering as a pharmacist and consider bringing medications there is a good document from the WHO which addressed best practices. Do not bring samples being one of them. If bringing medication bring some that the people will be familiar with and that they have on their national formulary, etc.

Yesterday, there was a child seizing on a ward, and a nurse arrived flying in the pharmacy to know how to dilute it so she could administer it. No reference books available in the pharmacy, no access to the Internet on a regular basis, no package inserts in with the actual medication,…

Today there was another child who had swallowed a coin which got stuck in his throat. They started operating on him to remove the coin but the power ran out, so the child had to be woken up and transferred to the larger district hospital.