Saying Goodbye

 By Alec Helmke, PD4

I write this blog entry from 38,000 ft. I’m somewhere over Quebec, but I still have Uganda on my mind, and my initial feeling is one of deep gratitude. Despite being in the country for just over three weeks, I take many memories home with me. From days spent on the wards to nights spent in the savannah, the trip was truly jam-packed! And my last few days were no different.

As I mentioned briefly in my last post, I was fortunate to watch a traditional Ugandan dance troupe performance. Along with Melanie, we drove to a cultural center in Kampala, where we were treated to a nearly four-hour performance, with dinner and dessert included! The dances were beautiful, and it was interesting to see how the performances differed across regions of the country. With over 50 tribes occupying a space about the size of Minnesota, Uganda possesses striking diversity. In some performances, dancers balanced drums or pots on their heads, somehow failing to drop them as they moved across the stage. In others, the dancers stomped their feet, shouted, and did flips in the air. And in between performances, a Ugandan MC narrated the meaning behind each of the tribes’ dances, pointing out how dance is a form of cultural expression. During the show, I tried some traditional Ugandan foods, including matoke, a mashed banana dish that many locals had encouraged me to taste. I also tried to dance. The MC told us that if we didn’t join the troupe on the stage, then we must be against world peace. So, the blackmail worked, and Melanie has some potentially compromising photos of my dance moves to prove it.

Melanie returned to the United States the following day, but before she left, we jumped on an opportunity to visit a local HIV clinic. There, the director told us about the many amazing programs they offer to Ugandan HIV patients. One of the projects they are focusing on most heavily right now is the provision of HIV post-exposure prophylaxis in community pharmacies. This form of treatment is given to folks who may have been exposed to HIV through unprotected sex and is intended to prevent the user from contracting HIV. The current approach of the clinic outreach is to offer this prophylaxis to young women who visit community pharmacies seeking the morning after pill. Young women are at very high risk of contracting HIV due to the high prevalence of the disease in Uganda, and post exposure prophylaxis is highly effective, so this program promises to greatly benefit the health of the nation.

The clinic also leads a number of other programs centered on marginalized patient populations and harm reduction. The director mentioned how the clinic has earned the trust of LGBTQ and transgender populations, which is very difficult to do in a country where one’s sexual orientation may be punishable by death. The clinic supports needle exchange programs and offers HIV treatment for illicit drug users. They also conduct outreach for communities of sex workers who, like LGBTQ folks and illicit drug users, are at very high risk of contracting HIV. I was deeply impressed by this clinic. Although the clinicians are constrained by socially conservative laws, they continue to act in the best interests of highly marginalized patient groups. In many respects, the care offered at this Ugandan HIV clinic exceeds US standards.

Although Melanie returned home, my rotation continued. I had a wonderful conversation with a Ugandan emergency response pharmacist named Peter. His story was one of diversity and impact. Although a trained pharmacist, Peter is deeply involved in epidemiology, health policy, and disaster preparedness. In fact, he continues to expand his global health skillset in hopes of one day becoming Secretary General of the United Nations! Peter encouraged me to set my sights high like him and do all I can to pursue my global health passion.

During my final weekend in Kampala, I met with a local guide to do a walking tour of the city. Miti, our guide, peppered our walk with tons of information about Ugandan history, including the colonial era, independence, and modern-day politics. We also took in a number of beautiful cultural sites during our tour, including the parliament building, national court, several monuments, and the national mosque, which towered over the city. The view from the top of the mosque’s minaret was simply stunning. From the vantage point, you could clearly see each of the original seven hills that formed the historical city of Kampala. You could also visualize the great growth of Uganda’s capital, which has expanded far beyond the bounds of the original hills. After leaving the mosque, we walked into the largest market in the city, which was an assault on the senses. The vibrant colors of second-hand shirts mixed with the hues of herbs and flowers. The sounds of bargaining meshed with Afrobeats. And the smell of smoke from roasting meats combined with aerosolized peanut powder made me preemptively reach for my Epi-pen. It was certainly no Costco. Seeing the local market was a wonderful experience, as it allowed me to connect more closely to the lives of average Ugandans. I was glad to have the chance to explore Kampala a bit more as well because—although my walk to the hospital in the morning was beautiful—it definitely did not encompass the entire scope of one of Africa’s largest cities.

My final week in Uganda was spent at Kiruddu Hospital, which is about a 45-minute drive from the Infectious Disease Institute. Opened in 2016, Kiruddu is a newer public hospital designed to provide internal medicine services to Kampala’s lower income population. For several specialties—including cardiology, burns and plastic surgery, and dialysis—Kiruddu is the national referral hospital, implying that it offers the highest-level care in the whole country. In this new hospital, I shadowed several pharmacists. Abert showed me how pharmacists verify orders and communicate with physicians, and his keen eye helped him detect several medication errors during my shift. Saviour oversaw the central pharmacy, meaning he managed the medical supplies for the entire hospital, which is a truly imposing task. The scale of his work became clearly apparent when the hospital received an order for two months of supplies. Trucks dropped off literal tons of medications and materials that filled the pharmacy and spilled into the driveway of the hospital administration building. I helped to inventory the products—which had been shipped from the national medical repository—and got quite the workout as I moved boxes. Next, Immaculate instructed me in how the hospital conducts antibiotic stewardship for the burns unit. She let me tour the lab and showed me the antibiogram, a tool that clinicians use to select which antibiotics will be most useful to treat certain bacteria. Finally, a pharmacy rotation would not be complete without shadowing in a dispensing pharmacy. On my last day at Kiruddu, I spent time with Mr. Kiseka, who showed me how medications are distributed to patients and how dispenses are recorded in their hospital software.

On my daily drives to Kiruddu, I was surprised to hear some songs that I never thought I’d hear outside of the United States. The clinicians I was riding with loved listening to the same classic country songs that my grandparents would play over their radio: Clint Black, Don Williams, Dolly Parton, and Kenny Rogers. When I asked them how they came to like this quintessentially American music, they told me they appreciated the slow melodies, which differ greatly from upbeat, energetic Afrobeats. And I understand why these healthcare professionals may have needed some relaxing music in their lives as, much like the United States, Uganda struggles with severe staffing challenges. In fact, a strike of pharmacy interns had led to Kiruddu pharmacies operating at 1/6 capacity. To help cover for the shortage, one of the pharmacists I shadowed was even working on an entirely volunteer basis. He knew the hospital needed support and that the strike threatened to harm patients, so he stepped up to cover the gap, which deeply impressed me.

And this pharmacist’s dedication will be something I take home with me to the United States. As I look back, I can clearly visualize the challenges that afflict the pharmacy profession in Uganda. On a daily basis, pharmacists struggle with drug shortages and staffing constraints that prevent them from working at the top of their license. Patients suffer from these systemic issues too, as, in many resource-limited healthcare facilities, they are unable to receive optimal healthcare. However, Ugandan pharmacists show up every day, working long hours, sometimes for free, to serve their patients. And, using their skills and experience, they do all they can to offer the best possible care. As I mentioned in my second blog post, the problems we face in healthcare here in the States are not that different than those they face in Uganda. So, I want to confront these problems with the same steadfast dedication as the pharmacists and other healthcare professionals I met at the Infectious Disease Institute, Mulago, the HIV clinic, and Kiruddu. It’s the same dedication I saw in a local pharmacy student I met for a brief conversation as well. Despite the nascency of oncology pharmacy in Uganda, he was committed to making an impact in this space and to offering patients the pharmacy services they deserve to ensure the safety and effectiveness of their chemotherapy regimens.

Although I say goodbye to Uganda, I leave with a great sense of gratitude for my experience. I offer heartfelt thanks to all who supported this experience, especially my preceptor Melanie. And I also leave Uganda with a sense of motivation. Motivation to be like the pharmacists I met abroad and to dedicate myself to the service of my patients despite the challenges I will surely face.

It was a pleasure to share my experience with you all in this blog, and I sincerely hope that future pharmacy students follow my lead to Uganda so that we won’t have to wait too long for new content. Thanks for reading!

Poverty and Ignorance

 

                                            

By Alec Helmke, PD4

I’m wrapping up week two in Uganda, and there are many updates to share! As I alluded to in my last post, I was fortunate to spend this last weekend on safari in Northwest Uganda. Along with several other US medical trainees, we left far too early in the morning on Friday for the long trek to Murchison National Park. My eyes struggled to stay open as we lurched over speed bumps along the Ugandan highways. Along the way, we stopped at the national rhino sanctuary, where we travelled with a guide to see the herds in their natural habitat. “A safe distance away” seemed a bit too close, and I certainly didn’t feel comforted when the guide pointed out how the rhino was sharpening its horn. I was more comforted to hear, however, that after local extinction in the 1980s, rhinos had been very successful following their reintroduction. Local conservationists were especially excited following the recent birth of a male rhino to a mother imported from the United States and a father from Kenya. They named him “Obama.”

That was only the first stop of many on a jam-packed and frequently tiresome journey. We arose early in the morning for game drives, during which our guide would point out the many unique animals I had previously only seen in zoos. Among the most thrilling sightings for us were giraffes, water buffalo, hippos, antelope, and even the elusive lions. Travelling in the safari van—with the top open to ensure a panoramic view and to enjoy the fresh savannah breezes—was a surreal experience. As the sun set on our nighttime game drives—although I knew The Lion King is based on Tanzania and Kenya rather than Uganda—I still couldn’t help playing “Circle of Life” over an over again in my head. But, to save you all the trouble of reading more (when we all know pictures are worth a thousand words), I’ll include some photos of the many animals we saw during our game drive experiences.

During the weekend, we spent some time on the Victoria Nile, which connects Lake Victoria to the Lake Albert delta. The watersheds from both lakes feed into the Nile River, which winds its way North into South Sudan, Sudan, and finally, Egypt. The first day we arrived, we viewed the waterfall for which Murchison Park is named. As the most powerful cataract in the world, Murchison Falls was an awe-inspiring sight, and the spray from the falls certainly felt nice to cool down in the Ugandan heat! We also viewed the falls from below. Moving upstream from the park in a barge, we saw many aquatic animals, including massive African alligators, before arriving at the base of the falls. We even got to enjoy a Nile on the Nile, that is, a Nile brand beer while floating on the river.

Although the game drives were undoubtedly beautiful, they took a serious toll on my sleep schedule. In fact, I had to laugh when the manager of our hotel described how beautiful the grounds of the property were. I knew that, leaving before sunrise and returning by sunset, I’d never get to see the hotel in daylight! We ended our trip with chimpanzee tracking in a nearby forest and sighted several of the agile climbers high up in the trees before hopping in the van to return to Kampala.

But I do work here too! This week has been spent shadowing pharmacists in the Infectious Disease Institute (IDI)—an NGO located within Mulago that cares for patients with communicable diseases including HIV and TB. I met with John, a regulatory pharmacist, early in the week and learned from him the incredible effort that must go into study administration. Viewing a text of biblical proportions on his shelf, I asked him what it was for. He explained that the book consisted of protocols and regulatory documents for just one clinical trial. Although I have been able to gain limited experience with clinical research, it still astounded me that hundreds of pages of protocols were required to create a single 15-page study. I also learned that regulatory pharmacists are highly focused on education. In his role, John is tasked with imparting information to researchers and explaining the intricacies of study protocols to other healthcare professionals. It suits him well because John was actually a teacher before he started his pharmacy career.

On Tuesday and Wednesday, I joined Arnold in the IDI pharmacy. This pharmacy reminded me of the retail pharmacies you’d find in the United States—except the drugs you encounter are a bit different. In the IDI pharmacy, they stock a variety of HIV and TB medications, along with a smattering of medicines used to treat other conditions. These medications are provided entirely free to IDI patients, which is critically important, as almost all medicines in Uganda are paid for out-of-pocket. Considering this, if medications were not offered for free, many patients simply wouldn’t be able to take them.

During my experience, Mike, another one of the pharmacists in the department, commented:

“The two biggest problems with healthcare in this country are poverty and ignorance,” he stated.

Mike’s comment struck me in its verisimilitude, not just for Uganda, but across the world. Here in Uganda, and throughout sub-Saharan Africa, infectious disease burden is remarkably high. HIV, TB, malaria, and diarrheal diseases kill millions each year. Poorer local governments frequently lack the financial resources to respond to these concerns with public health interventions such as widespread vaccine and prophylaxis distribution, parasite control, and sanitation. And many poorer patients—having to purchase treatments and medical supplies out-of-pocket—tend to avoid care until it’s too late.

Yet, poverty isn’t limited to sub-Saharan Africa. The United States—despite possessing the largest GDP in the world—still faces concerns of inequity. And for many of the conditions listed above, poor and marginalized patients are at high risk. For example, TB in the United States is particularly common among patients experiencing homelessness and among incarcerated individuals. Recent research even quantified poverty as the fourth most deadly disease in the United States.[i]

Mike continued to explain how ignorance can kill. He mentioned that millions of people in Uganda lack an understanding of the risks posed by infectious disease. Some individuals who receive mosquito nets choose to use these nets for fishing, failing to recognize that mosquito-borne malaria may lead to serious morbidity. Similarly, folks with HIV often fail to realize the risks of stopping treatment, even when they feel well. Particularly in Uganda—where AIDS is so stigmatized as to be called by a different name (ISS)—patients may disregard their medications and appointments to avoid the shame of being recognized as HIV positive.

Again, ignorance isn’t a problem specific to Uganda. For many healthcare workers, what immediately comes to mind are vaccine skeptics, who fail to recognize the risks they face by choosing not to receive immunizations. I wonder if—given a chance to see the amount of detail that goes into clinical trial design like I saw with John—these folks would be less hesitant about vaccines. Another example pharmacists love to mention is antibiotic resistance. Like the HIV patients in Uganda, many patients with infections in the United States may stop taking antibiotics as soon as they feel better rather than continuing for the entire recommended course. In doing so, some particularly hardy germs may survive the medication’s onslaught and return later as drug-resistant bacteria. Our healthcare system is rapidly exhausting our supply of antibiotics to treat these superbugs, so patient education is crucial to keep us from running out for good.

Poverty and ignorance are the greatest healthcare challenges in sub-Saharan Africa, the United States, and across the globe. And I hope to use the tools I am learning here in Uganda to fight back against these killers. To address poverty, I will follow in IDI’s footsteps by making it my goal to expand patient access to vital, low-cost medications. And to address ignorance, like I mentioned in my last post, I must become an adept educator. Hopefully my fourth year will be great practice!

It’s hard to believe that the next week will already be my last. However, I’m excited to continue my learning next week in a new hospital, Kiruddu, where I will be rotating with several clinical pharmacists. Although there is so much more to share—including dancing alongside a traditional Ugandan troupe and an enlightening visit to an HIV prevention clinic—I’ll sign off for now!

 

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[i] Brady, D., Kohler, U., & Zheng, H. (2023). Novel Estimates of Mortality Associated With Poverty in the US. JAMA Internal Medicine, 183(6), 618-619.

Meet Alec Helmke, PD4

 

I’m Alec, and I’m a now-fourth-year pharmacy student currently on rotation with Dr. Melanie Nicol in Uganda. After a COVID-related hiatus, this APPE rotation is now being offered again, so I’m privileged to be able to participate as well as excited to share a few brief snapshots of my experience. Let’s dive right in!

Only a couple of days after my arrival in Uganda, another student living in the Minnesota House asked me: “What has been your biggest surprise since arriving in Uganda?” Still jet-lagged from the 18-hour, transatlantic flight, I offered the only paltry responses my brain could muster. For one, I was surprised by my living quarters. As I mentioned, I am living at the Minnesota House, which is offered to visiting students, faculty, and researchers connected to the University. When I opened the door to my bedroom for the first time, I nearly ran smack into the bed. My room—"the closet” as many in the house affectionally call it—was perhaps smaller than I anticipated! But more pleasantly, the house surprised me with its beautiful front deck, from which I spotted a vibrantly colorful Ross’s turaco within the first few days. With such unique beauty so close at hand on the breezy front porch, I am glad to trade away a few extra feet of living space.

I was surprised too, I commented, by the differences I had discovered between Uganda, home, and some of the other foreign countries I have visited. After spending Memorial Day weekend with family in Northern Wisconsin, I was thrilled to find the mosquitoes are much smaller here—even though Ugandan mosquitoes’ malarial punch is not something to take for granted. I also kept finding myself walking towards the driver’s side of local taxis, as Ugandan vehicles are driven from the right side, per British custom. Finally, although there is great food nearly everywhere, the widespread availability of cheap, delicious food here has been a very welcome discovery.

It wasn’t until my first day rounding with the infectious disease team at Mulago Hospital—the largest public hospital in Uganda’s capital of Kampala—that being surprised took on a new meaning. As I shadowed the local physicians caring for patients with cryptococcal meningitis and tuberculosis—two comorbidities commonly associated with severe HIV—one of the doctors looked up from his chart and turned to me.

“If a patient is taking PISA, would they need metronidazole?”

“Uhhh,” I stammered. “Let me check.”

Quickly checking on a friend’s phone, I refreshed my infectious disease knowledge, which had collected a semester’s worth of mental dust. Recently having learned that piperacillin-tazobactam was referred to as “PISA” in Uganda, I found that this common antibiotic’s broad spectrum covers the anaerobic bacteria for which metronidazole is indicated. After imparting this information to the doctor, he caught me off guard yet again:

“What about ornidazole?” He asked.

“What?”

“Ornidazole,” he repeated. “O-R-N-I-D-A-Z-O-L-E.”

I returned to the online spectrum I found, but to no avail. I had never heard of this mystery drug, and it was not listed in the online resource either. Slightly ashamed, I Googled the medication and saw that it is in the same class as metronidazole and kills the same types of bacteria. However, the drug is not even available in the United States. I explained to the doctor that this medication is not much different than metronidazole, so unless he wanted to treat a parasitic infection, piperacillin-tazobactam should be sufficient.

My first surprise at this moment was the doctor’s confidence in my abilities. To him, my white coat and identity as a fourth-year pharmacy student meant I could be trusted to provide reliable information about medications. After years of being expected to learn, I was now expected to apply and share the knowledge—a truly daunting task. Second, I was surprised with the depth of knowledge one must obtain to be an effective clinical pharmacist. Although the pharmacist board exam emphasizes the top 200 medications as the most important drugs to understand, this is different than practice. On hospital rounds or in the pharmacy, it seems the most important medication is the one right in front of you, whether it is in the top 200 or is not even used in the United States.

Although I was able to muster a reasonable answer to the physician’s questions, our brief discussion was a reminder of the challenges that lie ahead in my year of rotations. It will be a year of growth and learning, that’s for sure, but also a year during which I will face uncertainty and will be expected to apply knowledge rather than to simply memorize information. I look forward to building my clinical acumen so that the trust providers and patients have in me is not misplaced. And I can think of no better place to begin my APPE experience than Uganda. Here, I am immersed in the unfamiliar—exposed every day to new medicines, new places, and a new culture. I hope that, by the end of this rotation, I will learn to thrive in this environment, and I will be better prepared to meet the new challenges offered in each of my upcoming rotations.

Over the next few days, I will finish rounding with the infectious disease team. I will also embark on a much-anticipated safari to Murchison National Park in Northwest Uganda. So, I certainly will not lack in content for future blog entries, but, for today, I’ll sign off!