The Pharmaceutical Journal
Vol 269 No 7229 p934-935
21/28 December 2002

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A pharmacy student in Madagascar

Hopitaly Vaovao Mahafaly (HVM) is an independent mission hospital in the north of Madagascar working in conjunction with the Baptist church and serves a population of approximately 250,000 people over an area about half the size of Wales.

It has been operating for the past seven years and has 20 inpatient beds, a large outpatient service for medical and surgical consultations and a widespread community health programme, which runs in partnership with Tearfund (an evangelical Christian relief and development organisation). Medicines are supplied primarily by the International Dispensary Association, a non-profit making wholesale procurement organisation for essential drugs and medical supplies. It is based in the Netherlands but supply only to non-commercial health care projects in developing countries.

The staff were mostly Malagasy, either from the capital, Antananarivo, or from the local area. In addition there were two European doctors, an Australian laboratory technician, and two Swiss nurses.

The hospital does not have a pharmacist, but does have a technician with some training in the dispensing of medicines. My role, therefore, was to find out what were the current issues related to medicines in the hospital, including storage, stock-control, administration and, a well-known problem in developing countries, the use and disposal of expired medicines.

It was made clear to the hospital that I was there in the capacity of pharmacy student, although before my degree I had worked for some years as a pharmacy technician. In addition, I had benefited from two summer vacation experiences under the East Anglia pharmacy training programme, in a district general and a teaching hospital, and this experience proved invaluable.

Daily routine

The hospital routine at HVM started at 7am with tasks such as cleaning and stocking up for the day. At 7.30 there was an optional bible story on the ward and in the outpatient area, followed by a health education talk at 7.45 and a multidisciplinary ward round starting at 8am. The rest of the day was taken up with outpatient consultations and surgery, which was scheduled for three days per week.

My first week involved getting used to the routine, observing how things were done and finding out from various staff what issues and questions they had relating to pharmacy and medicines.

Administration of medicines

A large proportion of patients in the Mandritsara area are poorly literate and although there are places to buy medicines, they are expensive. In an attempt to address the issue of poor literacy with respect to medicine-taking, tablets are dispensed in small plastic bags with pictograms on the front. The bags are marked with the drug name and quantity and the dose is represented by numbers under pictures of the sun and moon (Figure 1). In addition, every medicine has to be verbally explained, which takes a great deal of time.

Before my visit I had been interested in the use of pictograms and their efficacy and had conducted a small literature search, but I found scant evidence of research in this field and consequently little evidence to prove their value.

I was still surprised, however, by how difficult it was for patients to understand how and when to take their medicines: this raises an interesting area for future research. Is the poor comprehension due to a lack of familiarity with medicines, or something related to illiteracy that is deeper than just the inability to read and write?

The hospital formulary is restricted to approximately 130 different drugs, some in various formulations and strengths. The staff in the pharmacy were not aware of the cautionary and advisory labels (CALS) related to the medicines being given out, so one of my tasks was to list all the CALS related to the medicines used and translate them into French, which was the language used by the staff alongside Malagasy.

This proved an interesting challenge from the cultural aspect. For example, paracetamol carries several CALS, including not taking it with other paracetamol products, but how relevant is that in a community where people rarely, if ever, have medicines stored at home? A contrasting example, however, is metronidazole, widely used for giardia and trichomonal infections in a community where alcohol is freely available. With a short list of counselling points, the staff were made aware of how important it is to tell people to avoid alcohol when taking it, and they were keen to receive any information that would help them in giving best care to their patients.

Another challenge came in the administration of 5ml doses of oral liquids, particularly paracetamol and antibiotics. There was no supply of 5ml spoons as used in the United Kingdom and the prescriptions were usually written in terms of local coffee spoons. In fact, the coffee spoons only hold approximately 2.5mls which meant that, for antibiotics, a reduced dose was likely. This problem was well illustrated when giving a bottle of ampicillin syrup to a mother for a neonate; it came to light that the only spoon the family had was a tablespoon. How do you advise on an accurate dose?

Thinking on my feet was a common occupation at HVM and the closest available measuring implement was the lid of the bottle. On measuring it accurately, I discovered it contained 5mls when filled to the brim so that has become the standard for 5ml doses while I try and source a sustainable cheap supply of 5ml plastic spoons.

Expired medicines

Expired medicines are a significant problem for hospitals in developing countries. HVM makes an annual order for its medicines, which are sea-freighted from the Netherlands. This makes the control of stock a great challenge with the problem of both expired medicines and supply shortage. There are pharmaceutical suppliers in Madagascar, mainly in the capital, which is two days drive away, and for urgent supplies this has been a solution. However, it is much more expensive and is not a long-term option.

Two days were spent sorting through expired and donated drugs and deciding on their appropriate disposal. Donated drugs provide a particular problem for developing countries who often have to pay a customs charge to receive a box of medicines of unknown content, which then proves unusable and, in some cases, difficult to dispose. The Royal Pharmaceutical Society has produced a document in conjunction with the World Health Organization guidelines on appropriate drug donation, which was made available to me before I left and provided some helpful advice. Most of the expired medicines were disposed of in the hospital incinerator but the hospital is left with a large quantity of salbutamol aerosols and two bottles of halothane for which there are no easy means of disposal.

Reconstituted injections

Many of the injections that are used come in dry powder form and staff commonly queried for how long they could be stored after reconstitution. This was a straightforward question for multidose vials, answered by identifying the relevant information from data sheets supplied with the vials, tabulating the storage and expiry times and circulating the information to relevant staff. Less straightforward, however, were the many injections that came in glass ampoules. To take part doses from ampoules and then have to discard the remainder is extremely costly for the patients. It will be interesting to see if multidose vials are available for some of these drugs, which may be more expensive to purchase but give more flexibility and cost-effectiveness in practice.

Disease prevalence

There are large seasonal variations in disease prevalence and many of the diseases are rarely seen in the UK.

In the dry season, which is winter in Madagascar, the main health problems relate to malnutrition while people wait for crops to be harvested. Influenza increases and Madagascar has recently suffered a large scale influenza outbreak which was worse than normal due to the aftermath of recent political difficulties. Medicines have been in short supply, people are more malnourished than usual and many people have lost their jobs and consequently their income, which makes medical help unaffordable. As a result many people have died.

During the wet season, malaria is more common and falciparum malaria is a particular problem. Diarrhoeal diseases are also more prevalent due to contamination of water supplies. Parasitic infestations are seen all year round: bilharzia is contracted from wading in stagnant water and is difficult to avoid in rice growing areas.

I therefore came across a few drugs that are not commonly seen in the UK such as praziquantel, albendazole and niclosamide, which are used for various helminth infections. In addition, there is some chloroquine resistant malaria and artemether is used occasionally in severe cases of cerebral malaria. Giving oral quinine to children was a particularly distressing side of the dispensary work due to its intense bitterness and the idea of formulating a pleasant tasting syrup holds great attraction for a future project.

Herbal remedies

Madagascar has a unique flora and the use of herbal remedies is widespread. In the local community the plant, locally known as Mangidy, which literally translates as "bitter", is commonly used as a tonic. There appears to be a correlation between its use and the occurrence of haemolytic anaemias and gastrointestinal haemorrhage, although attributing these disorders solely to the herb is difficult. Patients presenting with severe malaria also suffer with haemolysis, and with a prevalence of hepatitis-associated liver disease with oesophageal varices, the cause of gastrointestinal haemorrhage is not always clear. A laboratory technician at HVM, Annie McColm, has been documenting case histories over several years and it is hoped that once this particular plant is identified by its botanical name, further study may clarify any association.

Application of learning

My experience at HVM has required me to identify pharmacy-related needs in a new situation, and to prioritise interventions, including deciding what was achievable in the short time available. In addition, it has enabled me to recognise the limitations of my knowledge at this stage in my pharmacy career, while also enabling me to apply theoretical knowledge from areas such as pharmaceutics and pharmacy practice to a real situation.

My short visit to HVM was eye opening and having returned to the UK, I believe there are many ways in which a pharmacist would benefit the hospital in the future. I would like to return, although with the final year of my degree and a preregistration year ahead of me, it will not be in the immediate future. I hope, however, at least to provide some ongoing support to HVM via e-mail.