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!

Anniversaries and Milestones

By Melanie Nicol

And that's a wrap on the 2019 Uganda APPE!  Everyone made it back safely to the U.S. and students have already settled into their next rotations. This was my third offering of this APPE. Every year I've learned so much. Since it's a research elective, I have a lot of flexibility in how I implement the rotation. Therefore I've been given the room to try some creative projects.

With Winnie Nambatya, one of the fantastic Ugandan preceptors
we worked with this month.
Front: An and Melanie M
Back: Joe, Melanie N, Winnie

In the hope that there may be some other APPE preceptors of research electives looking for some ideas, I wanted to share one new assignment I tried this year that worked fantastically well. Each of the students were given a topic. These topics had been chosen based on conversations I've had with Ugandan practitioners and researchers as being related to some sort of ongoing or anticipated problem or unmet need in Uganda. Here are the examples from this year:
          1) Is there a role for pharmacogenomics in Sub-Saharan Africa to improve patient care.
          2) With the rollout of dolutegravir in Uganda, what is known about incidence of dolutegravir-related IRIS
          3) As availability of flucytosine in Uganda may increase in future, is there a role for therapeutic drug monitoring of antifungals in resource-limited settings.

Students were asked to do a literature review on their topic. Based on what they found in the literature, coupled with observations from their experiences in different settings throughout their rotations, they were to design a research study to address the research question they were assigned. In addition to sharing their results in a presentation at the end of the rotation, they were asked to prepare a specific aims statement.

I didn't know how well this was going to work but the students hit this assignment out of the park. All three of them proposed studies that I think have potential to be implemented.  In pharmacy school, students learn how to critique research studies. But how to identify a research problem, and then design a study to address that research problem requires an entire different level of thinking that most people (including myself) don't develop until years of training in graduate and post-graduate programs. Likewise,writing specific aims page can be a daunting task. They are only one page in length but they require precise writing and an impeccable flow of logic- they are intended to convince a grant reviewer or funder that your study adequately addresses a significant problem. Writing a compelling specific aims page is an invaluable skill as a researcher. In short, feedback from the students suggests that both myself and the students got a lot out of it. The students shared that the project forced them to think in a way that they weren't used to thinking. Mission Accomplished!

So now I turn my thought to next year of the APPE. Since Prosperity has graduated and I will no longer have her help in precepting this rotation,  I have been thinking a lot about timing and capacity. Over the next few months, I'll be thinking a lot about: What is optimal timing of the rotation; What is the optimal number of students? What is the right balance between clinical and research activities? How can I better integrate research projects into the rotation?

In other news, my career is approaching a significant milestone. Just last week I submitted (what I hope is) the final draft of my dossier for promotion and tenure. Over the next year, various levels (External Peers, Department, College, Provost, Board of Regents) will be reviewing this package to determine whether I meet the requirements for tenure at my University. Preparing this dossier has taken a significant amount of energy and attention from me, not only in putting the document together, but moreso in ensuring that I had the publications, grants, and evidence of quality teaching and service to include in the document. Needless to say, I am very much looking forward to an upcoming weeklong vacation I will be spending with my family in Ohio.

While preparing the dossier, I spent a lot of time reflecting on my past contributions. The entire point of the dossier is to explain your scholarship and why it's important. This summer, my goal is to re-shift my focus to be forward-thinking again. Although there are lots of data to collect and papers to write from our current projects, I've already started planning my next grant applications. It's exciting and exhausting to get back into grant writing!

While this summer/fall there are grants I am working on (an internal grant, an R03, and a co-I on a P01), I have also started planning for my first R01! For those of you not in research/academia, R01s are the quintessential backbone of NIH research funding. I'm not exaggerating when I say it will take me 6 months - 1 year to write this. My task for this fall is to nail down my specific aims (see above). I've been reflecting recently about how my different lines of research may fit together into one grant application. How can I leverage my partnerships in Uganda? What new collaborations should I be pursuing? What preliminary data do I still need to obtain to make this application competitive. I don't know these answers, but I'm excited to dig in this summer. More later!

Uganda has a lot going for it...but I miss this face when I'm away..
Happy Adoption Anniversary Sadie!

The "other Melanie's" final reflection

Post by Melanie Mahoney, PD4

That’s a wrap! Today marks our very last day in Uganda. This experience has taught me so much in so many ways. I have grown and become more confident in my clinical knowledge through rounding with different pharmacists, medical officers, and specialists. I have developed my presentation skills with a journal club, case presentation, and final project presentation. I have expanded my knowledge and understanding of research through interactions with the cryptococcal meningitis research team and development of my own research project proposal. My personal project focused on flucytosine therapeutic drug monitoring in the treatment of cryptococcal meningitis.

Beyond all the official, structured learning, I also think this was a time of personal growth for me. Leaving for Uganda I was a bit nervous about being so far away from my husband, family, and friends for 5 weeks. I love to travel but this was a different kind of trip that I knew would challenge me. I was really surprised that I never got homesick. I appreciated the opportunity to completely immerse myself in my learning here and set everything else aside for a few weeks. While the past few years of pharmacy school have been rewarding, this time has also been very stressful and overwhelming. I tend to “say yes” to everything and sometimes over-involve myself in work, volunteering, training, and other activities. The past five weeks have allowed me to “reset” and mentally prepare for my professional future. I have seen how productive I can be when I am fully committed to one experience.

I have also loved learning and hanging out with my classmates on this trip. It has been really helpful to share this experience with such wonderful people who are also passionate about global health and willing to discuss and reflect on our learning together. We have also been fortunate enough to share in some fun excursions from the safari at Murchison Falls to white water rafting on the Nile to countless trips to Acacia Mall for ice cream! After spending almost every waking moment with Joe and An, I’m sure I will miss them when we get back to the US and go on to different rotations.

Delicious gelato from Acacia Mall

I want to thank all the pharmacists, pharmacy technicians, medical officers, specialists, and students who taught us so much over the past five weeks. I know we all appreciate you taking the time to engage in our learning by asking us questions, describing patient cases, and patiently explaining the reasons behind certain differences in healthcare practice. As I wrap up my final thoughts on this experience, I am moved by how my perceptions of healthcare, and especially healthcare in a resource limited setting, have changed. I really loved exploring the differences between healthcare in the US and Uganda and learning why certain things are done the way they are here. I was surprised to see families bring in their own sheets for the hospital beds and help in caring for their loved one by preparing food at the bedside and cleaning out catheter bags. We learned about cultural differences and the shortage of healthcare professionals that cause family to be so involved in care. I was shocked to learn that most pharmacists are only at their pharmacies for fewer than ten hours per week and that pharmacy technicians are usually the ones checking prescriptions and providing patient education. We learned that pharmacy technicians actually have an advanced level of education in Uganda that prepares them for work similar to a community pharmacist in the United States. If I could bring one message back to share with others it would be that it is so important to seek understanding before seeking a solution based on preconceived expectations. This applies not only to experiences abroad but also within the United States. The US is a country of such vast diversity that it’s important to realize how our unique experiences can lead to different viewpoints and that this can become emphasized and more important to accept and understand in a stressful healthcare setting.

This experience has been so impactful for my professional development. This rotation has allowed me to learn more about infectious diseases and global health, two of my major areas of interest in pharmacy. I am looking forward to applying to residency programs this fall and will hopefully find a position where I can then move on to a second year infectious disease residency. In the end, I want to work in a setting where I can use infectious disease knowledge and my passion for continuously learning and public health to improve patients’ lives.

 

Melanie, An, and Joe on the
Nile River Boat Tour

Melanie, Joe, and An White Water Rafting

An's Final Reflection

Post by An Le, PD4

I still can’t believe 5 weeks in Uganda is almost over. Everyday, I am thankful for having this incredible learning opportunity to kick-off my last year of pharmacy school.

Looking back to our rotations at the Infectious Disease Institute, Nakasero Hospital, Kirrudu Hospital, and community pharmacy, the entire experience provided me different activities to apply and gain more research and clinical knowledge. At the beginning of the rotation, one of the most challenging parts for me was to have a better understanding of the pharmacists’ roles in Uganda. However, through our visits and conversations with different health professionals, we started to recognize the similarities and differences of the health system and the roles of pharmacists between Uganda and the United States. The main difference in the pharmacists’ roles is the majority of pharmacists in Uganda tends to be more involved in the supervising role instead of directly interacting with patients. I would also want to say that the hospitality of the health professionals in Uganda contributed to our positive experience. At each institution, the health professionals were so willing to teach us how care is provided here in Uganda, yet, they were also very eager to learn about the U.S. health system.

To wrap up this rotation, I got to spend the last couple days at the Neurology unit with patients who have traumatic brain injury and other brain-related conditions. Here, I got to work along side with a pharmacist, Winnie, who has worked so hard to let other health professionals understand the roles of pharmacists in clinical pharmacy. Following her was such a rewarding experience, as she taught me so much on how to approach each patient case and how to work effectively with the care team. She always made sure that I learned something new while being with her. We had a small debrief at the end of the day, so we could go over the important points we saw during rounds. These conversations were very helpful, as they helped me solidify the acquired information during rounds.

Throughout my time in Uganda, a couple things that surprised me the most is the numbers of research studies being conducted and the motivation of using evidence-based resources and recommendations in spite of being in the resource-limited settings. During one of my conversations with Winnie, my assumption about the practice completely changed when she told another Ugandan pharmacy student that pharmacists in Uganda have to use research literature as evidence when making recommendations to other health professionals. When I reviewed the literature for my proposed project on pharmacogenomics in sub-Saharan Africa, I was amazed by the number of initiatives and projects that have been invested in genomic studies.

An, Melanie, and Joe present to pharmacy staff at Nakasero Hospital

Joe, Melanie, and I also had an opportunity to give a presentation on minimizing dispensing errors and proper handling, storage, and dispensing of hazardous medications to the pharmacy staff at Nakasero Hospital. While preparing for this presentation, I realized that we started becoming more aware of the cultural settings to ensure the presented information is appropriate and beneficial for the staff at the hospital.  We talked about what the hazardous medications the hospital currently has on the formulary and other work flow at the pharmacy, so that we could select the information that would be applicable.

View from Speke Resort

Through our journal club presentations, case presentations, and literature review for our final project, this rotation really helped me improve my research skills and understand what it takes to successfully work in research field. Prosperity once told me that “Research is always connected to each other. You have to look at other studies to understand what other questions that still need to be answered”. Indeed, there are still a lot of research questions out there that need to be answered to improve patient care and treatment outcomes. I’m hoping that one day I will get to work in a position where I can combine both research and clinical aspect, so I can provide patient care from a different perspective. I believe the clinical knowledge will help me understand what research questions need to be answered to promote better health outcomes.

I will definitely miss the hospitality of the Ugandans, the beauty of the Ugandan wildlife, the wonderful matooke, and the completely different timing schedule. I’m hoping that one day, I’ll get to come back to this country and work along side with other professionals within the research area to improve patients’ health services and treatment outcomes.

Joe's Final Reflection

Post by Joe Corbino, PD4

            It’s hard to believe that I only have two nights left in Kampala before I begin the journey back to Minnesota for the remainder of my APPE rotations. These past four weeks have been full of exciting new experiences that both humbled and challenged me mentally, emotionally and physically.

            Over the past several days I have been able to conclude my clinical experience by attending a variety of rounds at Nakasero Hospital. As both An and Melanie have mentioned previously, Nakasero is a private hospital that resembles what we see in America much more than average healthcare throughout Uganda. I have been surprised by the shear number of malaria cases involving individuals from foreign countries. This reiterates a very important point, always remember to take your daily prophylaxis while in an endemic area! It has also been interesting to see the types of bacterial infections that have infected individuals in the intensive care unit. During my time three individuals developed blood infections with a bacterium named Acinetobacter baumannii, which was resistant to about every antibiotic available in the hospital. As medical professionals, especially future pharmacists interested in infectious diseases, we were worried about what that meant for antibiotic resistant infections in the near future! Nakasero has also given me the opportunity to converse with a variety of healthcare specialists, such as a cardiologist, nephrologist, and geriatrician. Both the clinical and personal conversations with these individuals has led me to have a greater appreciation for the compassionate care that they give to patients and the passion they have for their careers.

            Our final Saturday was spent relaxing at Speke Resort on the edge of Lake Victoria. Even with the overcast sky for most of the late morning and early afternoon, we enjoyed an Olympic size swimming pool mostly to ourselves in what felt like a totally different part of the world. The sun finally decided to come out in the late afternoon, which made a walk on the shores of Lake Victoria a perfect end to a lazy day. An added bonus to remember this great day was that we all are currently sporting some major sun burns.

An, Joe, and Melanie at Lake Victoria

            Due to this being a rotation with research emphasis, we were all assigned the task  to perform a literature review and design a research study on a particular topic. My topic was investigating the effect of an antiretroviral drug, dolutegravir, and the consequences it may pose to individuals initiating treatment during various stages of HIV/AIDS. If this is something that sounds interesting to you, I would be more than happy to talk your ear off as it is all I have been reading about for the past four weeks. Our final presentations were given this afternoon and we all feel a huge weight lifted off our shoulders!

            I feel extremely fortunate that the University of Minnesota has connections here in Uganda. The plethora of clinical and research activities that I have been able to witness firsthand have truly been life changing. I feel that my experiences over the past five weeks will impact my career for the rest of my life. I learned to have greater appreciation for all of the resources that we have available to use in America, not just medical. All of the institutions I have been immersed in have been able to provide comprehensive care even with limited resources.

            I am still surprised with how quickly I became comfortable in Uganda. I was expecting there to be an adjustment period where I would feel like a complete outsider. With the help of both individuals at the Minnesota House and healthcare professionals, I was able to quickly overcome any uncertainties about my place in this country. With only a few days left I am not ready to leave. I still find myself constantly surprised by the circumstances that people find themselves dealing with. Even with so little they find ways to live their lives to the fullest while rarely complaining. If anything, this is the lesson that I want to share with people when I return. We need to appreciate what we have in front of us and try to make the most out of it rather than wishing for more.

           

Kampala neighborhood

This rotation has constantly been making me question where my future in pharmacy is headed. I entered the rotation set on completing two years of residency specializing in infectious diseases and becoming a practitioner. Two weeks into the rotation I realized how much I enjoyed the process of research and thought that pursuing a PhD or fellowship may be a better option. Over the past few days my thoughts have changed once again! I have now even began to consider the possibility of completing additional public health degrees and working at a more global level to impact as many lives as possible through policy, research and public health campaigns. The bottom line is that this rotation has made me appreciate that there is so much more to healthcare than what I have been exposed to in the United States. I have a passion for improving the lives of people, especially thus suffering from infectious disease such as HIV/AIDS. I am more confident than ever that this passion and drive will allow me to find careers that work best for me in the future.

Lake Victoria

            We have several activities planned over our final two days, which is sure to make the time pass at lighting speed. With a presentation scheduled for early Wednesday morning and a last-minute info sheet added to our schedule the learning never ends! I look forward to the moments of reflection over the next several days and weeks. Thank you to everyone that has been following my journey in Uganda for the past month as it has been truly life changing.