Feeling Crafty!

In true tourist fashion Kristin and I went to the craft market set up on Sundays at a local shopping mall and the Kabwata Cultural Village. At both of these places Zambian artists were very eager to sell their artwork to us. We honed our price negotiation skills as we tried to get the best deals on the souvenirs we wanted. We even traded a few hairbands with brothers who wanted to give them to their sisters to wear in their hair for school. Many of the people at the craft market travel to Lusaka from Livingstone which is about 6 hours by car and 7.5 hours by bus. In contrast, the people at the Kabwata Cultural Village live there year-round in traditional straw-topped huts without electricity. Kristin and I managed to make some friends along the way and found some treasures that we can't wait to share with our friends and family!

Crashing the Classroom

Yesterday Kristin and I had the pleasure to attend a lecture being given by one of our pharmacists, Martin Kampamba, to the fifth year student pharmacists here at the University of Zambia. The class was learning about how to develop a pharmaceutical care plan by working through various patient cases. This style of learning is very similar to how our classes our structured at the UNC Eshelman School of Pharmacy. Students come prepared to classes ready to apply previously obtained knowledge in case-based lectures. Martin was very engaged with his students, including Kristin and I, calling us out by name to contribute our thoughts. He emphasized the role of the pharmacist to correct actual medication-related problems and prevent potential medication-related problems. I am confident that this group of UNZA student pharmacists will continue to advance the role of the clinical pharmacist in Zambia and will apply the skills we learned in the classroom to their practice sites.

We were thankful that the power came back on right in time for class to start. In the time leading up to the lecture power had gone out at the hospital for about 20 minutes. It would have been difficult to present the lecture content without projecting the slides Martin had prepared. During the hot and dry month of October there is often power outages. The weather has consistently been in the 90s throughout our time here and it has only rained one afternoon. We were told that Victoria Falls was more dry than usual this year because they were pumping the water for power! Kristin and I will just miss the rainy season that should begin in a few weeks which should provide some much needed water for Zambia.

CDH

Yesterday, we spent the day in the Cancer Diseases Hospital, also known as CDH. CDH was first created in 2007 and just a few months ago they expanded the building to include an additional 250-bed hospital. CDH is the only hospital in Zambia that provides comprehensive cancer care. Cancer is a disease state that was never that prevalent in Zambia until recently, which may partially be due to increasing life spans in the country. The most common types of cancer seen are Kaposi sarcoma (usually due to HIV co-infection), breast cancer and cervical cancer. The main downfall to the pharmacy department in CDH right now is man power; there are simply not enough pharmacists to complete the amount of work that needs to be done. For example, there is only one clinical pharmacist at CDH. This pharmacist verifies chemotherapy doses daily but, because he is responsible for all patients that come through, he does not have enough time in his schedule to do a further work-up of the patient such as assessing interacting drugs and other co-morbidities. There is also not a pharmacist that verifies the chemotherapy doses as they are being prepared. One technician makes all the chemotherapy batches in a day.

The good news is, with the new expansion recently opened, CDH is working to grow and improve its site. It may take a little bit of time for pharmacy to catch up but the department is aware of its weaknesses and is working arduously to overcome them. Observing CDH was another reminder of numerous resources we take for granted in the United States.

The Falls

Unrelated to pharmacy, we got to take a quick trip to Livingstone this weekend to visit Victoria Falls. We were warned that the falls are quite dry at this time of the year but that didn't stop us. We still thought they were absolutely stunning!

Hillary in Zambia

In the spirit of election season, look who we found on a plaque in Zambia! The United States funded the building of the Pediatric Centre of Excellence. This building is one of the nicest in the hospital, second only to maybe the cancer disease hospital section. The Pediatric Centre of Excellence focuses on the care and treatment of children living with HIV. Amanda and I had the pleasure of working in the HAART clinic there for an afternoon. Unfortunately, there is a negative stigma associated with the building, as Zambians know this is where one goes to get HIV treatment. Sometimes this can lead to embarrassment and lack of a patient to receive care. Nonetheless, it is quite an exceptional clinic that takes great care of this special population.

Side note: Zambians love to ask us who we are voting for in the upcoming election and they are never shy to voice to us who they think we should vote for.

The Pediatric Nephrologist

On the schedule this week, we have been working in the pediatrics ward. Specifically, we have been rounding with the clinical team in the pediatric intensive care unit. The PICU holds nine beds and overall feels much calmer than the crowded internal medicine wards we were in last week. Common disease states encountered include acute renal failure, complications of malnutrition, and severe septic infections. The consultant this week was a specialist in pediatric nephrology, which worked out in our favour as almost all the patients in the ICU this week have had kidney problems. After completing a renal rotation at Moses Cone Memorial Hospital, I was intrigued to draw comparisons between care in Zambia versus in the United States. One of the patients was a fourteen-year boy on hemodialysis due to end stage renal disease secondary to steroid-resistant nephrotic syndrome. One of the greatest barriers to his long-term care was the fact that there are only four hemodialysis centers in the whole country of Zambia. (There are at least that many dialysis centers in Greensboro alone, if not more!) Each of the centers is located in a major city in Zambia; however, this child lived in a village far from the city. His family did not have the money to pay for the transportation into Lusaka three days a week. The only true solution to solve his kidney problem is a transplant but there is not any hospital in Zambia that does transplants. The consultant stated that if someone can pay, they will send them to India for a transplant. This was terribly saddening to me because I knew that that also would never be an option for this child.

My next thought was, if hemodialysis is not an option, how about the use of peritoneal dialysis in Zambia. We do not seem to use peritoneal dialysis as frequently in the United States as hemodialysis but I have heard that peritoneal dialysis is quite common in the European countries. Peritoneal dialysis is nice because it allows the patient to have more flexibility as they do not have to come in multiple times a week for treatment, which would be especially optimal in Zambia when hemodialysis centers are not conveniently located in the rural villages. The consultant informed me that the limiting factor to PD is hygienic conditions. Many patients’ living environments, specifically those in the villages, do not meet sanitation standards to accommodate the resources needed for peritoneal dialysis. For example, many do not have access to clean water at their homes. It’s an extremely tough situation and one that I was very saddened to hear about. It makes you extremely humbled for all the resources that we have available to us at home. Don’t forget to be thankful.

Jolly Juice

The inpatient internal medicine wards at UTH can get VERY crowded with all of the patients, their caregivers, healthcare professionals and sanitation staff members. During our first few days in the wards I found myself observing my surroundings and trying to take in every little detail. Next to each patient's bed you can find a small cabinet that doubles as a bedside table. On those cabinets you can find many items brought to the ward by caregivers such as pots and bowls for meals, bottles of clean drinking water and often other drinks the patients may prefer like orange Fanta. One special drink that I noticed almost all patients had on their stands in the wards was Jolly Juice. I asked my preceptor about the drink because we don't have this available to us in the U.S.

Bottles of Jolly Juice 

He told me that the Zambian people believe that because the liquid is a dark color similar to blood that the liquid provides health benefits and "is good for the blood". I found this very interesting as anemia is one of the most common conditions we encounter on the wards. The common causes of anemia seen at UTH are chronic illness, malnutrition and pregnancy.  Most patients that we cared for on the internal medicine wards required a blood transfusion and/or iron supplementation and the pharmacy team played a major role in monitoring the hemoglobin level for improvement in their anemia.

While the Jolly Juice may not have any direct benefit on improving the anemia or the blood quality of the critically-ill patients, I bet patients had a little more energy after consuming Jolly Juice due to the sugar content and additional calories in this drink!

Staple Food

It’s called nshima. The ‘n’ is silent and it is the food that Zambia lives off of. Most Zambians eat nshima for at least one meal of the day, if not more. The best way I can think of to describe it based on what we have in America is thickened grits (same texture but it can hold its own shape liked mashed potatoes). Nshima usually accompanies a meal; it is served piping hot so be careful not to burn your fingers. You pinch off a piece of the nshima, roll it around in your hand, and then use it to pick up the meat and vegetables on your plate. The nshima itself does not have much flavor but it is extremely filling.  After eating nshima, you won’t be hungry for hours.

We had consumed nshima multiple times prior to today [there is a special at the hospital cafeteria for chicken and nshima for ten kwacha (equivalent to one dollar) every Friday that we always take advantage of] but this evening we learned how to make it ourselves with the help of our friends Jimmy and Potre! Nshima is made out of maize meal. I was surprised to find out how simple it is to make: wlavor ece of the nshima, roll it around in your hand, andal and you use it to pick ma forarm up water (but don’t boil it), sprinkle in the maize meal slowly while stirring, let it sit to thicken up, then add some more and keep stirring and before you know it, vualah, you have a masterpiece, nshima. Delicious!

Nshima family dinner

Aerobics at Sunset

We discovered our preceptor's (Martin) passion the other day, and it is fitness. A few years ago, him and his wife started attending outdoor aerobics classes and now he travels the country with this fitness group to inspire others to take charge of their own health and exercise! Amanda and I, both being retired student-athletes, were extremely excited to hear him talk about this. The first question out of my mouth was "when is the next class!?" Martin was thrilled that we were interested in attending an aerobics class with him and it took him no time at all to bring us to a class.

Amanda and I with our preceptor, Martin.
Check out that gorgeous Zambian sunset.

This aerobics class was like zumba on steroids. Parts of it felt like kickboxing, parts felt like an Insanity workout. It was so much fun! The class took place on a big empty field; there was a stage set up at the front where the motivators would show everyone what to do and large speakers that blasted beat-dropping music. There was so much energy in the crowd, everyone was so excited to be there. I would say there were at least two-hundred people out on the field doing aerobics. Whenever there was a super high intensity portion, such as sprinting in place with high knees, people would make small circles with their neighbors to encourage each other to keep pushing as hard as they could. You truly felt like you were working together as a team and that motivated you to work even harder. It reminded me of being on the gymnastics team again.

Part way through the class, the power went out, but that didn't stop us. (Zambia utilizes hydro-power, and when the water is low -like it is right now during the dry season, power outages are pretty frequent). It was dark outside but a few people parked their cars on the field and used their headlights to light the way while the speakers got hooked up to a car stereo and started to blast from there. 

The class lasted a total of 2 hours, which is pretty darn long for a strictly cardio workout. Most aerobic like classes I got to in the United States are only 45-60 minutes. Needless to say, I was exhausted by the end of it but I couldn't stop smiling from ear to ear. I loved seeing all these people come together and inspire each other to "be their own life insurance."

Fee-Paying Toilets

UTH is the main public hospital in Lusaka and they will accept anyone who is referred or comes to receive care there. With that being said, the hospital is clearly divided into socioeconomic status. There are low cost wards and high cost wards. (There are even fee paying toilets and non-fee paying toilets!) The low cost wards are free to the patients and, as such, are often quite crowded with cots crammed close together and even mattresses on the floor if there are no cots available. With the amount of patients in the low cost wards, it comes as no surprise that there is very little privacy between patients. Privacy is often something I take for granted in the United States. During ward rounds in the morning, patient charts are kept at the foot of the bed of the patient and it is not unlikely that charts get put on the wrong patient’s bed. Also, in Zambia, it is the role of the family and loved ones to act as caregiver to the hospitalized patient.  This caregiver cleans and feeds the patient, comforts them, and sometimes administers home medications (especially antiretroviral therapy); this role is in addition to the nursing staff that already works on the floor. When you add all the caregivers to the already overcrowded rooms, it becomes quite a mess. Even going into the nursing room where medications are stored, pill bottles are left wide open, they are all stored together in the same cabinet, sometimes medications themselves are even mixed together in the same bottle. It is quite chaotic!

Medicine cabinet in nursing room of low cost ward

The high cost ward is strikingly different. It is more similar to what you might picture a hospital stay being when you are in the United States. These patients either have insurance or will pay out of pocket for their care. Each patient has a decent size room with walls and curtains to separate them from the other patients on the ward. There is a sink, refrigerator, and shelf in each of these rooms. It is much quieter in these wards; the nursing room is organized and clean. I have never seen such a staunch difference between living conditions in one hospital!

Entrance to one of the high cost wards

We are currently working with our preceptor to develop research topics to target some of the major problems we have observed in our first few days in the internal medicine ward. We are hoping to find ways for pharmacists to expand their role in these wards and improve patient care.

RVD-R patients at UTH

This morning we were introduced to the team of pharmacists who work in the HIV clinic dispensing antiretroviral therapy. All antiretroviral medications are FREE to the people of Zambia! Three months after the patient is started on treatment and once the patient is stable they begin coming to the clinic where we were located. A patient first sees the doctor to assess their current condition and completes labs for monitoring their CD4 count, viral load, renal function, liver function and blood counts. After seeing the doctor they come to the pharmacy area to pick their prescriptions and receive counseling. The room has seating to see three patients at a time which while very efficient, limits the privacy for the patients. They have a drug dispensing database that they use to track refills dispensed which was one of the first times we have seen technology used! The first line regimen in Zambia is tenofovir/emtricitabine/efavirenz (Atripla). If the patient is not improving on the first line regimen they often switch out efavirenz for nevirapine or emtricitabine for lamivudine. Also if the patient is experiencing renal dysfunction they will switch tenofovor (TDF) for another agent like abacavir. We will will return to this clinic on Thursday afternoon to see patients who have failed the first and second line therapies and who are now on third line therapy. There are so many opportunities for Kristin and I to learn!

The clinic pharmacist also explained HIV prophlyaxis following a potential exposure. One patient that we encountered was a young woman who was a victim of sexual assault. The pharmacist explained to me that in Zambia a woman is considered to be at fault for sexual assault which often delays women from coming to the hospital to receive appropriate treatment. Women who experience sexual assault are educated and encouraged to come to the hospital as soon as possible, especially within 72 hours. Women will receive HIV prophylaxis with (tenofovir/emtricitabine) Truvada and lopinavir/ritonavir (Aluvia) or atazanvir/ritonavir. In addition women are offered an emergency contraceptive and antibiotics.

In addition, when Kristin and I were on OB/GYN ward rounds last week we were caring for many patients who were HIV positive. In order to try to maintain their privacy during patient presentations on ward rounds, we referred to their positive HIV status as "RVD-R", which stands for retroviral disease reactive. We are practicing becoming accustomed to this term to protect the sensitivity of this diagnosis, which much of the population views negatively.

Third Time's the Charm

This week, we have bounced around to a few different residences. Due to unfortunate circumstances, we had to leave our first guesthouse on the second day. We then moved to a luxurious hotel where our faculty member was staying (shout out to David Steeb for all you did this week for us, I owe you my first born) until we figured out a different place to stay. And, now, we have settled into a guesthouse that is on the grounds of UTH. It's a cozy place. Amanda and I are sharing a small room with two twin beds. There are other people staying in the guesthouse that are also visitors to UTH. There is an open heart surgeon from Ukraine who has been here for about a year and an anesthesiologist from Mansa (northern Zambia) who is here for a few weeks. When we moved in yesterday, we crossed paths with a neurologist from Vanderbilt University who'd been here for a month or so and who was heading back to the United States. Everyone has been friendly and welcoming. There is a lovely housekeeper named Bridget who looks after the place and lives right next door. I feel very safe here. It is definitely more basic than our previous guest house, no air conditioning or hot water, but I am happy with the proximity to the hospital and the safety I feel. We also have the free perk of an alarm clock in the form of a rooster that lives in our backyard. Excited to meet other guests that move through the household while we're here!

Week One in the Books

Our first week in Zambia has come to a conclusion and an interesting one it has been! The University of Zambia and the University Teaching Hospital of Zambia have graciously welcomed us into their country. The hospital itself spans a fairly large area of land and has multiple "blocks" that consist of the main focuses of the hospital -pediatrics, ob/gyn, internal med, and surgery. There are also numerous clinics connected to the hospital as well as a fairly new cancer disease hospital.
This week we worked in the OB/GYN wards with Jimmy, one of the clinical pharmacists at UTH. Jimmy is an extremely smart, funny guy. He caught me off guard because whenever he asks a question and you answer, he gives you absolutely no sense of affirmation. I was never sure if I was right or wrong and then I would start questioning myself and then he'd start laughing at me and say I was right all along. Needless to say, I think he had a fun time worrying me. Jimmy wrote this fantastic book of ob/gyn focused cases that he loaned us; it was a great resource to have as our wifi access was very limited.
 Mornings consisted of ward rounds where we visited patients with a team of health professionals -the consultant (the equivalent of an attending in the United States), medical residents, medical students, pharmacy interns and the pharmacist. The team size averaged around 15 health professionals per day but Jimmy told us that these teams can get as large as 30 when all the students are back in session. With multiple patients in a room plus the entire rounding team, things could get a little squishy at times. We encountered numerous disease states including anemia, pre-eclampsia, placenta previa, pre-term membrane rupture, HIV, malaria, steroid use in pregnancy, and Rhesus disease. The biggest difference between these rounds and those that I have experienced in the United States was simply technology. UTH utilizes handwritten medical charts whereas I, and I'm sure all of my classmates, am used to using an electronic medical record. It really humbled me to be brought back to paper charts, trying to decipher what the doctor had written in the drug chart and having to share the one version of the medical chart between the whole team. And, honestly, it really tested my knowledge because I had no means of looking up drug information or pathophysiology while on rounds. I solely had to depend on what was in my head. It's challenging because I feel that I've become so reliant on all the amazing drug resources I normally use: UpToDate, Micromedex, Pubmed, etc. It's all gone and now I have to step up and show some confidence of what I've been putting into my brain these past three years.
Afternoons were fun because we had many topic and case discussions. Jimmy taught us a lot about the protocols here at UTH. Sometimes, there were pharmacy interns that would join us. In Zambia, once a student finishes their Bachelor's of Pharmacy degree (takes 5 years and includes undergrad), they are required to complete an intern year, where they rotate through the different sites of the hospital and sometimes community. I equate this to our final year in the PharmD  program because it is on site training.
Today, our last day of the week, we had the opportunity to hang out in the delivery ward and watch the miracle of life happen in front of us. It was my first time watching a baby be delivered and I don't think I'll ever forget it. I found it interesting that there were absolutely no men (except the doctors) in the ward, no husbands, no family members. It may be because the ward is already so busy, any extra bodies would just be in the way. As soon as a mother has delivered, they are cleaned up and sent to wait out in the hall until the baby is good to go. I have never seen a live birth in America but that is not how I pictured it going. The nurses and doctors were extremely skillful and able to handle multiple mothers in labor at once.
If this first week is any indication of how much I'm going to learn in the next month, I absolutely cannot wait. The people here have been so kind to us and truly go out of their way to ensure that we are having the best learning experience possible. Up next on the agenda, internal med next week!

Travels and Smiles

We have safely landed in Lusaka, Zambia and made it to our guesthouse. We could not be more excited to begin our new adventures this month. Stay updated on all things pharmacy in Zambia here!