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!