Working in the Pharmacy

Inzame Zubantu, otherwise known as Brown's Farm clinic, is one of two clinics in the Phillipi area south of Guguletu. Together, these clinics serve 80,000 people in an area roughly 2-3 square miles. The clinic started about 15 years ago by Rev. Spiwo using 12 donated shipping containers. The clinic operated in this way until last September, when a brand-new building was opened on the same site. (The clinic had to operate in a converted community hall for one month as the containers were removed and the new building was completed.) The two pictures above show the clinic's main entrance and its main hallway. The pharmacy would be immediately on your right, with the waiting area just down the hall. There are five consulting rooms, a "lab" room, a treatment room (for bandaging and other wound care), a staff kitchen and two offices further down the hallway.

The clinic sees an average of 200 patients per day, all in about 5-6 hours. People start arriving at about 6:00. By 7:00 the outside waiting area is full. Although clinic staff are trying to tell people to come throughout the day, everyone has been arriving at dawn for years and are unwilling to change (they're partly afraid they won't be seen, as is the case in many rural areas where health care is poorly available). Clinic opens at 8:00 and by 2:00 most days everyone has been seen and sent home with prescriptions.

Inzame Zubantu translates loosely as the People's Initiative. I've had a couple people tell me it's difficult to translate, in that Inzame doesn't have a direct meaning in English. It's meant to portray a positive try or attempt, almost like a challenge but not quite as daunting. I get the sense that Initiative is close but needs to be more action-oriented.

The pharmacy is small, about 16'x16' with an additional 10'x12' room for storage. It's normally staffed by Tami (pronounced Tommy), the pharmacist (sitting on the chair) and Ntombikayise, the helper (what we'd call a technician). (I learned yesterday that Ntombikayise's name means "daughter of Kayise" or "Daddy's girl." Her words, not mine.)

The pharmacy stocks about 300 different drugs. This includes about 200 oral tablets/capsules (probably 175 unique drugs, some with multiple strengths), 30 oral liquids, and 30 topicals, with the rest being injections or other dosage forms. The drugs that are stocked are on the South Africa Drug Formulary, which appears to be derived from the World Health Organization's Essential Drugs List. All treatments are dictated by a government-approved set of guidelines and link to the Formulary. More on that in a second.

Most of the oral medications come pre-packaged in 28-day supplies from the government supply house. Since every patient is scheduled to return every 4 weeks it's very convenient. Those that don't come pre-packaged either have to be counted when dispensing (slow) or prepared in the pharmacy. Part of what I do when I get in each morning is help pre-pack items so that we don't run out during a busy time. We also pre-pack products that came in as donations, things like multivitamins. Donations allow the clinic to spend more money on prescription items and not over-the-counter products. I prepared about 50 bags of chewable vitamins on Monday, tablets that came from some Americans visiting the Zwane centre a while ago. It's a little strange to be using Target vitamins in Phillipi, but whatever works...

As I mentioned, all treatments are dictated by a standard set of guidelines. This means nearly all patients with the same disease or condition get the same medications. (My apologies to the non-clinicians for the next few paragraphs.) For high blood pressure, people start out with hydrochlorothiazide 12.5mg daily. Step 2 adds enalapril, usually starting at 5mg twice daily. Most patients end up on 10mg twice daily (the ratio is about 10:1 , 10mg vs. 5mg). Step 3 would add amlodipine 5mg daily. Step 4 adds atenolol 50mg daily. And that's about it. No one gets anything else (we don't stock any other drugs in these classes, except carvedilol) and doses cannot be increased above the standards without getting a cardiologist consult, which rarely happens. I've only seen one patient on max'd doses of these items, and one on spironolactone.

For diabetes, all of which is Type-2, it starts with metformin 500mg twice daily, working up to 850mg twice daily. Only a couple people have been on 850 mg tid. Step 2 adds either glibenclamide 5mg twice daily or gliclazide 80mg twice daily. About 10% of patients get gliclazide 160mg bid. If those two drugs don't work, then it's on to insulin. That happens in about 10% of cases, with nearly everyone getting 70/30 and two injections a day.

Asthma is a big problem here because of poor ventilation in the shacks and the use of paraffin (kerosene) heaters and wood fires to cook and keep warm. Everyone starts with a salbutamol (albeterol) inhaler as needed. Step 2 adds a budesonide inhaler, 2 puffs twice daily. Step 3, which usually occurs concurrently with the steroid, adds theophylline. We're supposed to dispense a sustained-release product, but we don't have that. So, everyone gets plain theophylline 200mg twice daily. On a rare occasion we may give out an ipratropium inhaler but we haven't had any in stock for a month. (Note: It could be because for the first couple days I was there we ran out of salbutamol inhalers and substituted ipratropium. I had a hard time doing that but it's what we had. When we ran out of those we gave people salbutamol tablets twice daily. No one's come back complaining of problems yet.)

Antibiotics are also limited. We have doxycycline, penicillin VK, amoxycillin, erythromycin, and flucloxacillin. We have ciprofloxain, but it's limited to 500mg stat doses for STDs and PID. We have metronidazole, both 2gm stat doses and 400mg tid. If it's not a stat dose it's either 5 or 7 days, usually 5. There's no cephalosporins, no alternative macrolides, no quinolones (except stat cipro). For antifungals we have amphoteracin B lozanges and nystatin suspension for thrush. Wehave fluconazole but it's locked up and rarely used because of the cost (it is not available under government contract so it's very expensive). We have only clotrimazole one-dose tablets for yeast infections.

For topicals we have hydrocortisone, betamethasone, clotrimazole, and a couple other antibiotics. We have some compounded items, including coal tar ointment and methyl salicylate ointment (which they call Rub Rub - go figure). Eye drops include a couple for allergies and some artificial tears.

The rest of the products we stock are a mix of some antihistamines (mostly promethazine), psychiatric meds (I haven't yet seen anyone being treated for depression), antiepileptics (phenytoin, valproic acid, and carbamazepine), hormones (I've only seen one person get birth control), vitamins, antiworm drugs, and various one-off meds. The only sleep aid we dispense is amitriptyline 25mg.

Everyone who comes to the pharmacy gets paracetamol (acetaminophen), and about half will also get ibuprofen. Most people also get a multivitamin, and about one-third get supplemental thiamine and/or vitamin C.

I haven't spent much time looking at prices, but those I have seen are on par with Medicaid's generic prices. Inventory levels are kept at a bare minimum, and it's not uncommon to run out of something (or many things) before the next order arrives. Since none of the prescriptions or patients are computerized, there's no good way to track usage and predict order patterns. The clinic is supposed to be computerized later this year which will be a big help but also a major time drag. The only reason we can dispense 400-600 prescription in 5 hours with 2-3 workers is because we don't have to enter anything into a computer (all labels are hand written with check boxes for dosages) or submit insurance claims. We'll see what happens.

Medication compliance is very bad. No one's measuring it but based on my discussions it's less than 50%. Some people sell their medications, but most just don't use them because they either don't want to or don't understand the need to. I'm not sure how to change this (yet).

As always, if you have specific questions about some aspect of the clinical care, drop me a line or leave a comment to this posting.

More to come.