Sultan Dajani, a member of the Royal Pharmaceutical Society's Council, visited Jordan recently. He reports here on pharmacy and pharmacists in that country
I was recently invited to give a presentation to pharmacists in Jordan. In preparation for my visit, I extensively researched the archives and the internet for any information about pharmacy that I could find. Alas, I found just one reference relating to an article from 1986. That article stated that pharmacy had originated in the Middle East as far back as beyond 5000BC and that still, in 1986, employee pharmacists were unhappy about their promotional prospects. There was no information about the systems in place or the pharmacist's role. I thought, "This is nothing new, pharmacy is being ignored again". So, I arrived in Jordan armed only with blank sheets of A4, mosquito repellent and plenty of apprehension.
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The author takes time out to visit some ruins at Mount Nebo, Jordan |
The Hashemite Kingdom of Jordan is situated in the Middle East, neighbouring Iraq, Israel, Saudi Arabia and Syria. Needless to say, it has had a turbulent past. King Hussein ruled it for 45 years and when he died earlier this year he left his son, the present King Abdullah II with a country which is undergoing a steady and continual social and economic growth. This fast rate of development is the largest in the world at 4.8 per cent growth per annum which is largely due to an ever increasing tourist trade; tens of thousands annually flock to see the wonderful views of Petra, the city carved into a mountain, to swim in the Dead Sea, or to visit Moses Springs, an oasis where Moses is reputed to have washed and rested during his trek across the desert. Others come to visit relatives in the West Bank and the Gaza Strip. Jordan definitely offers something for everyone.
If a country richly steeped in history, culture, customs, traditions, scenery and religion is not to your liking, there are extensive bars and restaurants like the Hard Rock Café and McDonalds! There exists a very active social scene and you will not find all of the religious customs that are strictly imposed in most of the other Muslim countries.
Jordan seems to have undergone a pharmaceutical revolution so secret that no one outside the country knows about it. Could the present prime minister of Jordan, His Excellency Abdul Raef Al-Rawabdi, who just happens to be a pharmacist, have anything to do with it?
The 5,600 pharmacists all have to be registered with their governing body, the Jordanian Pharmacists Association (JPA), and all practising pharmacists must have a recognised pharmacy degree. The JPA has an eight-member council elected every two years and has a regularity affairs department like our very own Professional Standards Directorate. It also has various committees, with the science committee being the most prominent. Despite being a relatively new organisation, the JPA organises several educational seminars and one pan-Arab pharmacy conference every two years. It has ambitious plans to build its first library and drug information centre soon. It does not have an organised communications network, any official form of continuing professional development or even a journal of any sort, but these are on the agenda too.
There are about 700 new graduates a year from the eight schools of pharmacy, two of which are government controlled and the rest being private institutions. The pharmacy courses last five years but there is an unfortunate loophole that disadvantages those pharmacists educated in Jordan. This is because some Jordanians who have qualified outside Jordan, after only three years, return to obtain jobs two years before their counterparts would even be qualified. The irony in this is that those who benefit from this discrepancy are either the rich or those who have had to travel abroad to obtain their qualification because they failed to get the grades in Jordan.
Jordanian pharmacists rely heavily on foreign publications, especially the British National Formulary, the British Pharmacopoeia, the Pharmaceutical Codex and, of course, Martindale. The Pharmaceutical Journal is like gold dust; it is well read when it is obtained through various sources and there is always a waiting list, with every issue practically falling apart after the 20th reader, all anxious to quench their thirst for knowledge. Jordanian pharmacists do, however, have a book called ‘Drugs in Jordan', published by the JPA in conjunction with the faculty of pharmacy at the Jordan university of science and technology. The aim of this book is to provide a comprehensive guide to the drugs available in Jordan and their uses. The proceeds from the sales of this book are invested in the establishment of a scientific pharmaceutical library.
There are 1,600 pharmacies serving a population of four million people; thus, each premises serves an average of 2,500 people. Jordan has a distinct advantage over Britain in that each pharmacy must be owned by a pharmacist and no one may own more than one. There are no multiples. While this may be good for contractors it is bad for employees as promotional prospects are usually bleak in community pharmacy. Provision of advice, health promotion, pleasant professional surroundings and long hours are the recipes for success. Extended roles have not yet reached Jordan but pharmacists are aware of them.
Anyone in doubt as to the consequences of losing resale price maintenance and control of entry regulations in Britain should look at Jordan. After they lost their controls of entry, many pharmacies appeared around the busy town centres, resulting in a shift away from poorer rural areas where pharmaceutical services are perhaps more urgently required. People have to travel further and the competition among pharmacies is so severe that medicines are heavily discounted by as much as 15 per cent. Prices are regularly bartered by the patients and in some cases professionalism has been ignored in the fight for survival.
The Ministry of Health runs Jordan's "NHS" and is a major health provider employing many hospital pharmacists. Clinical pharmacy and other hospital pharmacy specialties have not arrived in full force yet and the pharmacist's role is one of procurement, stock control, dispensing and advice. However this is changing, especially within the private hospital sectors and the military hospitals. One of the Jordanian hospital pharmacists I met does a form of medicines management with her patients, even though it is not in her remit and she does not get paid for it. I told her this was a universal problem and doing the job for the love of it as opposed to doing it for financial gain was renowned. She said: "We have a sophisticated capability to provide better health for our patients, through disease prevention and, of course, through the medicines we supply. We are just beginning to knock on the doors of the other health professionals and showing them the benefits of the multidisciplinary approach."
Amman, the capital city, has many wholesalers. One of the largest and most renowned is the Jerash Drug Store, whose director is Husam Khatib. Mr Khatib qualified as a hospital pharmacist in New York before embarking on a career filled with diversity, ranging from serving in the armed forces as the chief pharmacist to being a director of materials in Saudi Arabia. Wholesalers are not allowed to buy pharmacies or have any financial interests in more than one pharmaceutical business, so he is a sole agent who specialises in the importing and distribution of pharmaceuticals, sundries and all items related to the promotion of good health. The Jerash Drug Store, like all the other wholesalers in Jordan, has ambitions to expand its businesses and provide the best possible service for its customers, patients and the other health professionals. Mr Khatib said: "I devote my time and all the available resources for the development and growth of my society. I try to establish strategic alliances with our suppliers geared towards achieving mutual goals and satisfying our pharmacists' customer needs. My ultimate goal is to provide quality products at reasonable prices in a timely manner and set up an effective two-way communication system with the pharmacists."
The Ministry of Health runs a well-equipped central laboratory reminiscent of the chemistry laboratory at the "Square" but spread out over four floors. Here, the chief pharmacist and his 30 staff test each batch of pharmaceutical preparations before they are sold to the public. Now I knew where all my pharmaceutical chemistry knowledge would have been useful. It is a sight to behold because despite using outdated British publications and equipment that we all used as students, they still have an impressive track record.
Ten years ago, over 70 per cent of tested batches failed; now the quantities of failed batches are negligible. I saw extremely appreciative letters from pharmaceutical companies and the World Health Organisation regarding errors with potentially fatal consequences discovered by Dr Sameer Al-Qammaz and his quality control team. "This is what it is all about," he said, "safeguarding the public at large and ensuring they remain confident with the work we do on their behalf." It showed me that money and technology were not as essential as as enthusiasm, dedication and great commitment.
There are over 16 factories producing a substantial percentage of the country's medicinal requirements. Almost all the international companies are represented. I met
Mr Usama Adeeb, a Parke-Davis representative, who provided me with facts and statistics about the pathology of an illness. I then realised that the representatives in Jordan have a sort of unofficial continuing education tutor type role. At last, I found the first strains of continuing professional development here!
Another representative I met was Mr Adnan Abdul-Hamid, who qualified from Sunderland university in 1973 and who is still a member of the Royal Pharmaceutical Society of Great Britain. He told me that it was vitally important that people in Jordan, like all over the world, have a democratic right of choice, whether it was in an electoral system, the type of health care or even the availability of medicines. Part of his remit running the Al-Nahdah Drug Store was to provide as much choice as possible from proven medications, and he was always on the look out to bring new medicines into Jordan.
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Mr Adnan Abdul-Hamid in the Al-Nahdah Drug Store |
I also met Dr Mayadah Shehadeh who is now the assistant professor in pharmacognosy working at the faculty of pharmacy and medical sciences at Amman university. She said she remembered me from when she was a PhD student at the "Square" in 1993 and how I used to ask for her help on many occasions. Any good reputation I had suddenly evaporated in the heat!
When I arrived in Jordan I was expecting not much in the way of pharmaceutical services but I was wrong. I found a strong pharmaceutical infrastructure. With the country developing so fast there is a great potential to incorporate pharmacy into the new health network. The Jordanian pharmaceutical profession is also developing at a rapid pace. Pharmacists have many dreams and aspirations. They want to be more clinically involved and move more into medicines management. They are enthusiastic and enjoy what they do and they do it well. They would dearly like to liaise and communicate more with the outside pharmaceutical bodies, to be involved in exchange schemes and to exchange views and ideas.