Pharmaceutical Journal Vol 263 No 7066 p582-583
October 9, 1999 Special Feature

Pharmacy education

E-mails from Grahamstown

By Claire Anderson, PhD, MCPP

Claire Anderson, PhD, MCPP, director of pharmacy practice and social pharmacy at Nottingham university's school of pharmaceutical sciences, recently visited Southern Africa as a visiting professor

Dear . . .

I am in South Africa for six weeks at Rhodes university, Grahamstown, as a visiting professor. I am lucky because the national arts festival is on here - it is second only to Edinburgh - there is music and dancing on every street corner and an impossible choice of plays, jazz, concerts, etc. Rhodes university dominates Grahamstown and when the festival is over it will be a very quiet place. The faculty of pharmacy attracts students from all over Southern Africa. The majority of the students are of southern Asian ethnic origin. Their course is a four-year BPharm. The first year is largely taught outside the faculty and is like our A-levels. Like us they are wondering about MPharm and DPharm programmes. I went out with a group of students yesterday to do pharmaceutical care practicals in people's homes in the local township - a very interesting experience. I felt privileged. Sue Burton, one of the lecturers, sets up the practicals. She arranges the visits with the patients when they are at the day hospital clinic. The students go out in groups of four with a retired nurse who acts as a translator. Many people only speak Xhosa, the local language - Mandela's language and one of 11 official South African languages. The students interview the patients and develop pharmaceutical care plans for them - they look at drug related problems, desired outcomes, interventions and monitoring plans. If patients have hypertension they take their blood pressure and they check blood sugar levels of diabetics. Patients have started keeping their own medical records, so they are at hand for the students to check. The students learn a lot about the social and economic factors that affect health, as well as issues around medicines. Following the visits, the students meet a doctor and discuss the interventions they would like to make. Billy Futter, who has a management background, teaches the students pharmaceutical care in an innovative way - they are taught to have a pharmaceutical care approach to running successful businesses. We left the university in a minibus and headed up the hill out of town to the township, hundreds of small houses, many with little gardens growing vegetables. There are goats, dogs, donkeys, chickens and children everywhere. I was struck by the colour and liveliness of the place. The students were very excited and keen to impress me with their knowledge. We saw three asthma patients. They do not have inhaled corticosteroids; people with asthma are on theophylline and some on salbutamol as well. The students checked their peak flows and one man's inhaler technique; he was using the inhaler correctly, but holding it upside down. While he was demonstrating his techniques his two cows stuck their heads through the door of his mud and stick house and mooed loudly. He told us that he had consulted his sangoma (traditional healer) about his asthma but that he preferred our medicine; the sangoma's medicine did not work. The students asked him if he understood what asthma was. They explained it to him with diagrams of pipes and lots of whooshing noises. I really felt all three asthmatics we saw would have benefited from inhaled steroids though; it is tough. Spent Saturday at an elephant park. Amazing! Saw lots!
	Students make the pharmaceutical care report to the patients' doctor
	Students measure an asthma patient's blood pressure
	they also measure his peak flow rate and check his inhaler technique

Dear . . .

Went out with the students again today - I love going into the houses and talking to the people and their families. They seem so grateful for the students' visits and interventions. The worse thing is the treatment for hypertension: most patients are still on reserpine and methyldopa. However, there is light at the end of the tunnel. The new essential drugs list is out and recommends low dose hydrochlorothiazide and an ACE inhibitor. Methyldopa is now reserved for use in pregnancy.
Met a woman today who told the students that she was getting up in the middle of the night to take her methyldopa. Evidently in Xhosa it depends on the way the word for night is emphasised as to whether it means the middle of the night or just at night. She thought it had been emphasised to mean the middle of the night. She had been setting her alarm clock to wake up, but did not always manage it and was missing a lot of doses. She was so happy to know that she could take it before she went to sleep.
Saw some amazing jazz last night; I am hooked. Hope all is well.

Dear . . .

I have been struck by the HIV and AIDS epidemic in South Africa; one in four of all recorded births is to an HIV positive mother. It is a heterosexual disease and many people in their 30s and 40s are dying. They cannot afford AZT and the drug companies will not lower the price. There is a big lobby at the moment; something has to be done. There are many cultural problems about sexual behaviour to be overcome, too.

The students spend an afternoon at a clinic where a lot of the AIDS patients are seen. They visit the family planning clinic and hear the people being told about the importance of using condoms. I wonder what I can do to help from the UK - it seems absurd when the multinationals spend so much on marketing drugs and we spend so much time worrying about the cost of lifestyle drugs. Went to a clinic today run by Irish nuns who are nurses. It is funded entirely by one of their families. Like most clinics in South Africa the nurses do most of the diagnosis and prescribing. Ros Dowse and Tina Ehlers from the department at Rhodes university have been doing a lot of valuable research using pictograms to explain medicines to illiterate patients (International Journal of Pharmacy Practice 1998: 6(2): 109-18). The students use a pictogram to explain how to use paracetamol elixir to a lady with a sick child. The pictograms have been tested on many different groups in Southern Africa and are about to be used commercially.

Using pictograms to explain the correct use of medicine

I saw the saddest woman today when I went out with a group of students. A 31-year-old diabetic, who had recovered from TB last year, she had been compliant with her directly-observed therapy (DOT) and got better. However, she looked awful and I was quite worried about her and felt she should have been in hospital. Her blood sugar level was 23.3mmol per litre, her blood pressure 150/90 and she complained of low back pain (kidneys?) chest pain, ankle oedema and blurred vision. She was thin. She said she wanted to be cured but knew that diabetes was not curable like TB was. She was taking glibenclamide and metformin together. We all felt she needed a complete review, particularly as she might have renal failure, and that she should be started on insulin as soon as possible.

I was horrified that it took a visit from students to identify this woman's problem. There is such a two tier system here: those who can afford it have private heath care, those who cannot have public care, which is good, but overstretched and with the limitations of the essential drugs list. I am realising what inequalities in health really mean. When we visited the doctor and discussed this patient he agreed that she needed an urgent review and that she was probably an insulin dependent diabetic and should be started on insulin. He did not know if they could afford an ACE inhibitor for her hypertension, though. They have been making a video for the past couple of days about the student's work in the township. It has been great fun helping the film maker to capture the atmosphere in the township - you just can not find a goat when you want one and then 10 come along all at once. I have even got a couple of lines to say about my impressions of the place. It is to raise awareness about what they are doing at Rhodes university for recruitment and research grant purposes and also to raise money for a minibus to take the students out. I hope that the students in Nottingham will be able to get involved with supporting this project and go out to Grahamstown: they would learn an awful lot.

Dr Anderson: I am realising what inequalities in health really mean

I cannot believe my visit is nearly over. I have learned a lot and hope that I have helped them too.
Off on safari now so I may not be able to access my e-mail.