International Pharmacy Experiences
Leah Edenfield, PharmD BCOP BCPS
Hematology/Oncology Clinical Pharmacy Specialist
Wake Forest Baptist Health
I had my first opportunity to practice pharmacy abroad during an advanced pharmacy practice experience (APPE) rotation in Cape Town, South Africa, offered through Child Family Health International. As a student pharmacist, I wanted to develop skills in working with culturally diverse patients and providers, learn to serve in a setting with limited resources, and gain insight into healthcare challenges both internationally and at home. Although I did not yet know that I would become an oncology pharmacist, I knew that during my career I would look for ways to serve as a pharmacist internationally. A few years later, I was able to participate in two medical mission trips to Kenya. In each place, I worked in an unfamiliar setting with a new patient population and gained a fresh perspective on healthcare disparities and my role as a pharmacist. My preceptors and colleagues modeled ways to provide excellent patient care when one had little to work with, and I remember many of the patients I encountered in these communities.
During my APPE month at Victoria Hospital in Cape Town, I participated in ward rounds and assisted with dispensing and projects in the pharmacy. Each pharmacist checked orders on a designated ward, including the medical, surgical, emergency, and pediatric wards. While the pharmacist reviewed charts to verify appropriate prescribing and to provide medications from the pharmacy, I would also look over the medication list and patient notes for drug interactions and proper use. On some mornings, I went on medical rounds with the physician assistant students who were also studying through Child Family Health International and the local medical students, residents, and an attending physician. While being attentive to the medication aspects of a patient’s case, I was able to observe the importance of the physical exam in a hospital where costly diagnostic tests were not readily available.
Back in the pharmacy, while I was assisting with order verification, I became familiar with international drug names and the formulary restrictions of a public hospital. I also performed pill counts to check adherence for patients visiting the HIV clinic. As my project for the site, I conducted a survey of patients in the waiting room to assess wait times, adherence, medication storage and disposal, and preferences for counseling and labeling. These patients spoke nine primary languages, so noting their preferred language could help ensure that they were provided translation and counseling when needed. Though most patients also spoke English, 17% expressed a preference for receiving counseling in another language, and I did work with a translator for one interview. When I found that 54% of patients did not understand what happens in a pharmacy, a local intern was tasked with creating educational posters for patients to read during their lengthy waits.Throughout my rotation, I observed a number of challenges in the South African healthcare system: access issues; health inequities; healthcare staff shortages; and the burden of HIV, tuberculosis, and noncommunicable diseases. The healthcare providers I met were committed to serving patients well, despite these barriers. For example, I watched my preceptor passionately advocate for a patient with diabetes who was admitted after struggling to travel safely to her local pharmacy for insulin and obtain it when she arrived. I appreciated the opportunity to communicate with patients on rounds and through my survey. I gained perspective both on their difficulties and on their gratitude for the health care they received.
More recently, I traveled to Kenya for medical mission trips in March 2016 and March 2017. Our team of pharmacists, physicians, nurses, and other volunteers filled suitcases with medications and set up a weeklong clinic for patients with limited access to health care. On the first trip, we set up our pharmacy in a tent near a growing community outside of Malindi. On the second trip, we traveled to a rural area a few hours from Mombasa that had a public health center but not the staff to hold daily clinics for sizable crowds.
Patients would first see the physicians or nurses and then proceed to the pharmacy with a card listing their complaints and prescriptions. In the pharmacy, we would often recommend a medication depending on our inventory and then provide an appropriate dose. Although nearly all patients received multivitamins and anthelmintics, to some patients we dispensed antibiotics, antihypertensives, acid suppressants, and other medications as indicated. We worked closely with our translators, many of whom were healthcare professionals, to provide medication counseling.
Our interventions often felt small and temporary in light of the striking resource disparities that our patients faced, but for some patients even a small supply of acetaminophen could be meaningful. Because the healthcare providers and churches we worked with not only showed wonderful hospitality to our team but also made connections with the hundreds of patients who came to our clinics, they provided continuity in addressing the physical and spiritual needs of our patients.It was a joy to serve on these trips, both when the pharmacy tent was flooded with fun-loving children and when our other pharmacy was literally flooded during an unexpected rain.
Working as a pharmacist in another country and culture will challenge you to be flexible and embrace the unfamiliar, but I would recommend the experience. These trips have made me more keenly aware of both the privileges of practicing health care in the United States and the inequities that are present here as well. In hematology and oncology pharmacy, our patients also have their own unique struggles. The importance of valuing and advocating for our patients is universal, and the responsibility of providing optimal medication management with finite resources always applies. Though I may travel back to Kenya or elsewhere in the future, for now I can serve my patients here compassionately and seek to support my colleagues around the world.
If you are interested in learning more about international rotations through Child Family Health International, information about these programs is available at https://www.cfhi.org/all-programs. I would also recommend looking for volunteer and mission opportunities through organizations in your own community.