Perspectives on Global Health from Pharmacists Around the World, Part 3

As healthcare continues to morph and adapt based on the requirements of kind, compassionate, evidence-based care, pharmacists are playing a vital role in ensuring patient’s needs are met in countless regions across the earth. In this four-part IH Blog series, the pharmacy role accompanied by profession-related challenges and pharmacist-led global health initiatives will be explored within a profession that is often underappreciated. The following perspectives, shared by practicing pharmacy professionals from the United Arab Emirates (UAE), India, Cambodia, and the United States of America (USA) aim at highlighting various aspects of healthcare that should be properly addressed by governmental bodies, NGOs, and all stakeholders by both sustainable political will and empowering solutions. 

This third segment focuses on local and global pharmacist roles in each of these areas and the thoughts that pharmacists from these respective nation states have been willing to share with IH Connect.

Healthcare systems across the globe are unceasingly identifying novel approaches for health professionals to fulfill. The traditional roles that physicians, nurses, and other allied health workers performed in the past have metamorphosed as patient-care management is altered to effectively accompany patients. A few illustrations include: one of the most prominent international non-governmental organizations (INGO), Partners In Health, has a nurse – Sheila Davis – as it’s CEO contrasting a physician fulfilling this position; physician assistants and nurse practitioners being heavily utilized as primary care providers; and the introduction of community health outreach specialists as vital patient resources. The vocation of a pharmacist, in particular, has been altered significantly depending on the area of the world one inhabits. The majority of humanity believe that pharmacists are those who solely dispense medications, but several regions on the earth have realized the benefit of incorporating pharmacists in direct patient management, treatment guideline development, and even directors of ministries of health. Regardless of the development of pharmacy in a country, this healthcare profession is a key to kind, compassionate patient-centered care. The following commentaries from the United States of America, India, United Arab Emirates, and Cambodia explore the profession of pharmacy both locally and internationally while exposing initiatives to improve global health through pharmacists.  

 Dr. Moeung Sotheara, Ph.D. 

Clinical Research Assistant & Part Time Lecturer – University of Health Sciences

Phnom Penh, Cambodia 

In Cambodia, a large proportion of pharmacists work in community pharmacy, pharmaceutical enterprises and hospital pharmacy. However, there is still an insufficient presence of pharmacists in each area. In community pharmacy in particular, the inadequate presence of pharmacists is due to the current system of “name renting”, a legacy of post-war public health policy in response to the shortage of healthcare professionals. In such a system, any person having minimum knowledge in medicine dispensing and having been trained by the Ministry of Health for a specific period of time can “rent” a pharmacist’s name to apply for a pharmacy permit. Nevertheless, despite the growing number of pharmacists owning a pharmacy in recent years, the pharmacists’ role remains the traditional product-oriented functions of dispensing and distributing medicines and health supplies. In other words, pharmacists are still viewed as “simple medicine sellers” by the public. As the country develops and medicine consumption has increased, the pharmacist’s services in community as well as in hospital pharmacy must shift from medication dispensing to a focus on safe and effective medication use to achieve optimal patient outcomes. Pharmacists must assert themselves as medication experts and play a more active role in patient counseling and promoting the rational use of medicine. In addition, pharmacists must also be actively involved in public health. The functions of public health that can benefit from pharmacists’ expertise may include disaster preparedness, immunizations, preventive health measures and educating other healthcare providers about various techniques of prescribing medications and issues related to the drug use process.

Transitioning the discussion to global health, pharmacists have unique skill sets and assets that put them in a prime position to collaborate with members of the health care team to address global health issues and challenges. However, there is limited information on the role of the pharmacist in this field. There are 3 areas pharmacists can play in global health in the future: global health practice and program delivery, global health research, and global health policy. In the area of global health practice and program delivery, pharmacists can serve an important role on the health care team in under-served countries by helping address barriers to the delivery of care due to their knowledge of drug products, storage requirements, dispensing requirements, and logistics of pharmacy operations. They can improve clinical outcomes through patient-centered services such as glucose monitoring and blood pressure management, and also potentially work with local and national health organizations to help develop global health programs based on successful interventions made locally in the community. In the area of global health research, pharmacists who are affiliated with a university that has a focus on this area can assess global health projects and research initiatives to determine if opportunities exist for pharmacy to get involved and to add new dimensions to existing global health research. Finally, the outcomes of global health research often stimulate the need for proposing and evaluating global health policy at both the governmental and national level at which pharmacists can lend their expertise. As medication experts, pharmacists routinely exercise their knowledge of the rational use of medications, their cost-effectiveness, and the safety and efficacy of therapeutic regimens. These concepts can be applied domestically toward the development of policies that have global implications.

Nazgul Bashir, B. Pharm

Registered Pharmacist – Super Care Pharmacy

Dubai, United Arab Emirates

The role of the pharmacist varies from region to region and differs in several aspects. While there are areas of this world in which Pharmacists have vital roles in health sectors, there are other parts where pharmacists are given underutilized roles. Pharmacists are scattered throughout the community allowing them to be the most approachable healthcare professional – needing no appointment, no time restrictions and often being available 24 hours. Due to their aforementioned accessibility, their roles should be thoroughly revised, and the public should be made more adequately aware of their significance in communities.

Regarding the regional role of pharmacists in the United Arab Emirates, there was little utilization of pharmacists 10 to 20 years ago. Even now, some locations lack proper utilization due to their role being more product-based selling and dispensing any medication prescribed by the physicians. This occurs even though pharmacists in UAE are available in hospitals, health clinics, community and in retail stores allowing them significant access to patients.

To elaborate on the under-utilization of pharmacists, the current healthcare system typically does not promote pharmacist’s interventions in patient-management. This could include managing the dose of a hypertension agent, discussing change of therapy to more efficiently achieve patient outcomes, and a larger role in discharges from hospitals where pharmacists can provide counseling and follow-up.

Immunization is another role of pharmacists which could make a huge impact. Currently, most of the immunizations in this region are taking place in hospitals and health centers which are handled by nurses and physicians. However, this role can be handed to pharmacists in the community who can bring awareness to communities so that people won’t miss their vaccinations . In particular, many people are not even aware about the importance of flu shots. Pharmacists should be given an equal responsibility in bringing the awareness in a community and assisting people to receive their shots on time and prevent ailments. Counseling on family planning, use of contraception, palliative care, prevention of disease, identifying high-risk patients for diabetes and cardiovascular diseases are services not offered in pharmacies. Over-the-counter advice and educating patients on dietary supplements are often performed, but pharmacists are still underutilized overall.

However, the future of pharmacists in UAE look promising as several chain pharmacies make new exceptions in implementing more significant roles for their pharmacists. For example, physicians are advised to use the generic name so that pharmacists can choose to dispense the trade name.Additionally, pharmacists are being advised to minimize the use of antibiotics by making them strictly prescription based thus avoiding unnecessary use of them. Many barriers for increased pharmacist services need to be overcome: lack of time to offer services, shortage of pharmacists, lack of patient demand and low patient acceptance, lack of knowledge and skills, and underestimation of enhanced pharmacy services by physicians. With these barriers in mind, government and health authorities are planning their best and making promising change to bring the best of the pharmacy divisions.

Dr. Bryce Adams, Pharm D., RPh.

Oncology Medical Science Liaison

Washington D.C., United States of America 

Before delving into the role of the pharmacist in the United States, I would like to highlight the Oath of a Pharmacist as this serves as the model of how a pharmacist should view their role:

“I promise to devote myself to a lifetime of service to others through the profession of pharmacy. In fulfilling this vow:

  • I will consider the welfare of humanity and relief of suffering my primary concerns.
  • I will apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for my patients.
  • I will respect and protect all personal and health information entrusted to me.
  • I will accept the lifelong obligation to improve my professional knowledge and competence.
  • I will hold myself and my colleagues to the highest principles of our profession’s moral, ethical and legal conduct.
  • I will embrace and advocate changes that improve patient care.
  • I will utilize my knowledge, skills, experiences, and values to prepare the next generation of pharmacists.

I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public.”

Currently, the USA is in the midst of a great shift in the pharmacist profession. According to 2017 statistics, 60% of pharmacists in the United States were practicing in retail pharmacies – this includes drug, merchandise, and grocery stores. However, these roles are expected to decrease over the coming years. There are several contributing factors for this decrease – one being a decrease in the price margins per prescription. As pharmacies make less money for each prescription that is filled, businesses have to fill more prescriptions with less staff. This can cause a host of issues, such as having less time to counsel patients, more reliance on technology to catch errors, an increase in likelihood for medication errors, and a more difficult time fulfilling the oath of a pharmacist. Ultimately, this leads to under-utilization of the pharmacist profession by placing less of a value on their role of positively impacting patient care.

Fortunately, pharmacists have been realizing this shift and have been proactive in adapting. They have achieved this by advocating for additional venues to provide value, such as being able to bill for medication therapy management services and administering vaccines. These services are extremely beneficial for patients and also increase revenue for the businesses. While roles in the retail setting are expected to decrease, roles in the hospital and ambulatory care settings are expected to increase. Currently, 30% of pharmacists are in these settings. With an increasingly elderly population, these roles are becoming even more important.

These aforementioned pharmacist provided-services typically utilize this profession in a more productive way by rounding with physicians and helping to inform clinical decisions for specific patients. The rest of pharmacists are scattered across a variety of specialties. Two of these specialties are academia and the pharmaceutical industry. Both of these have more of a global health impact, as academia is training the next wave of professionals who will have an international presence and will impact care while the pharmaceutical industry is developing the next wave of transformative medications that will improve patient care on a global level.

Before I finish, I want to revisit the oath of a pharmacist. As the United States healthcare system is being scrutinized due to the cost, as technology is becoming more utilized, and processes are becoming more automated, pharmacists will need to “embrace and advocate changes that improve patient care.” Pharmacists are in a unique position as the medication experts to greatly impact patient care, and it’s up to this profession to ensure that the right patient gets the right drug at the right dose via the right route at the right time.

Dr. Maneesha Erraboina, PharmD.

International Business Manager – Helics Group Scientific Networks 

Hyderabad, India 

In theory, the role of Indian pharmacists is to dispense medications by adjusting the dose for patients based on their health condition, and they play a major role in the rational use of drugs especially antibiotics. However, in India, it is very difficult to find a pharmacist in clinical hospital settings and none of the medical organizations have pharmacist professionals in the healthcare team. 

According to mainstream Indian psychology, most of the population only accepts medications from physicians rather than another profession, like pharmacists. This is an ongoing trait of Indian citizens that has existed for several years with very few signs of significant change in the future. 

In my own personal experience, I had an opportunity to attend an interview for a pharmacy position; however, the role was not directly related to dispensing medications. Due to the disconnect between the doctorate level education and the available job opportunities, I ended up in another profession within the health arena that wasn’t directly related to my education. Although I feel all PharmD. graduates are in a very good position today, they may need to explore unique opportunities as the profession catches up with the education level. 

In the future, I feel pharmacists could play an active role in the healthcare system as they are meant for patient care. I believe this feeds into having a primary role in clinical hospital settings. In addition, Pharm.D graduates will have other opportunities in clinical and medical research, pharmacovigilance, teaching, and scientific journal publishing companies in India.

In India pharmacists are underutilized in professional pharmacy roles such as a clinical pharmacist. However, in exploring other areas of the health field, Indian pharmacy graduates have taken advantage of their education to influence the global health society. As a personal example, my current role as an international business manager allows me to organize health conferences around the world to advance healthcare. As the pharmacy profession continues to grow and adapt across the globe, I believe one role for pharmacists will be ubiquitous: avoiding the irrational use of drugs to protect patients and improve health outcomes.

Have you read the latest issue of our newsletter, Section Connection?

The latest issue of Section Connection, the IH Section e-newsletter, is now available!

You can find the latest issue of the newsletter here: 

http://bit.ly/SectionConnection12

In this edition, you will hear more about the different Annual Meeting events our section hosts; learn more about our Student Committee; and get up close and personal with IH section member – Dr. Idong Essiet-Gibson. We will share updates from the Global Health Mentoring Committee, the Climate Change and Health Working Group, the Communications Committee and Social Media Subcommittee, the Systems Science for Health Systems Strengthening Working Group and the Community Based Primary Healthcare Working Group.

We hope you continue to stay connected and involved with our section. See you in November in Philadelphia!

Private Sector and Pandemic Preparedness: Beyond the $$

The global health community knows that the world is unprepared for the next influenza pandemic. While public health practices have come a long way in terms of preparedness since the 1918 Spanish flu, which killed around 50 million people, we are still far from ready for an outbreak of that scale today.

According to PreventEpidemics.org, more than 100 outbreaks occur daily and can be spread worldwide in just 36 hours because of increased global travel. The cry for better pandemic preparedness is loud (Bill Gates, Margaret Chan, former director of the World Health Organization (WHO) and Robert Redfield, Center for Disease Control and Prevention (CDC) director) but is only being heard in certain circles; and the global health community needs the message to get out more broadly, especially in the private sector. 

The bottom line

Disease outbreaks, even if they only occur within a country or region, affect everyone and negatively impact the global economy. A World Economic Forum/Boston Consulting Group report stated that epidemics have negative impact on the private sector by impacting their employees, customer bases and operations. 

The World Bank projects that a large pandemic will cause an average annual economic loss of 0.7 percent of global gross domestic product (GDP) or $570 billion USD. The 2009 H1N1 pandemic resulted in an economic loss of 0.14 percent of GDP, or $1.09 billion USD, and the Ebola epidemic in 2014 resulted in an economic loss of $2.2 billion USD in GDP, threatening macroeconomic stability, food security, human capital development and private sector growth across West Africa. 

The private sector is no stranger to making financial contributions for pandemic preparedness and response. In 2014 the private sector contributed $500 million USD to the Ebola outbreak response, and these days the private sector can financially assist in pandemic preparedness through the World Banks’ Pandemic Emergency Financing Facility (PEF). However, while financial contributions are always needed there are other ways the global health community can engage the private sector to improve pandemic preparedness.

More than money

In 2018, the WHO surveyed member states to assess global pandemic preparedness and found levels of preparedness to be “far from optimal” even among high and middle income countries. Based on these survey results the WHO identified several areas for improvement in regards to preparedness, four of which are particularly advantageous for private sector partnerships.  

  1. Conducting simulation exercises to test pandemic plans

The Institute for Disease Modeling (IDM) is one example of a private sector partnership to assist in pandemic preparedness. IDM’s Epidemiological MODeling software simulates the spread of disease to help determine the combination of health policies and intervention strategies that can lead to disease eradication. There are a number of other modeling and simulation tools available for pandemic preparedness, however, some of these tools require financial and/or technical resources not available to a global health organization. Private sector companies that use, or produce modeling software could be favorable partners for testing preparedness plans, since these companies already have the modeling skills to use the software and interpret results. 

      2. Establishing mechanisms to secure access to vaccines during a pandemic

There are two notable private sector partnerships already working to secure access to vaccines, GAVI, the Vaccine Alliance, and the Coalition for Epidemic Preparedness Innovations (CEPI) are both working on improving vaccine supply chains and healthcare infrastructure in low-and middle income countries in order to increase access to routine vaccinations, as well as secure access to vaccines during a health emergency.

       3. Preparing mechanisms to conduct risk communications and community engagement during a pandemic

There is also potential for collaboration with the private sector in regards to risk communications and community engagement. Social media companies already have platforms to engage large audiences, as well as lucrative business platforms to sell ideas, information and products. Engaging people in preparing for and acting appropriately during a pandemic will require persuading an audience – something social media companies have already mastered.

      4. Establishing SOPs to conduct systematic influenza risk assessments using surveillance data

Several consulting companies offer pro bono services, such as Deloitte and PwC. Consulting  firms have the business acumen to offer services that could help design effective pandemic SOPs for multilateral organizations, country governments and agencies, as well as non-governmental organizations working on pandemic preparedness. 

Building these private sector relationships needs to happen now, and not in the midst of the next outbreak. Mutually beneficial partnerships will ultimately help the private sector, the global health community as well as the entire population when, not if, the next pandemic occurs.

Global News Round Up

Politics & Policies

A new study by WHO, published in Lancet Global Health, found that investing $6 billion per year in eliminating hepatitis in 67 low- and middle-income countries would avert 4.5 million premature deaths by 2030, and more than 26 million deaths beyond that target date.

There isn’t a single country in the world with 100 per cent universal health coverage. All global health systems have room to improve. But UHC as it has been held up as a UN goal leaves much to be desired.

A new KFF online resource tracks more than 30 bills introduced in the current Congress that would affect global health policy.

Programs, Grants & Awards

The United States government announced US$45 million in funding to respond to the critical food security situation in the upcoming lean season between October 2019 and March 2020 in Zimbabwe.

There is a great deal of institutional interest among health professions students in joining global health programs, with more than 25% having participated during their training. However, when programs rely on short-term fixes to long-standing infrastructure and resource deficits, some of the world’s most vulnerable, poor patients can be exploited.

European University Alliance for Global Health has been launched with a press conference in Paris. Part of the European Universities alliances receiving funding by the EU Commission to collaborate across borders, the network is composed of five international partners.

Research

Visceral leishmaniasis infects an estimated 300,000 people annually and causes 20,000 deaths every year, according to the World Health Organization.

The World Health Organization (WHO) considers antimicrobial resistance to be one of the 10 threats to global health in 2019. 

Malaria, one of the world’s leading killers, could be eradicated as early as 2050, according to a new report published by The Lancet Commission on malaria eradication.

Diseases & Disasters

Measles is proving fatal at an alarming rate, far faster than Ebola in the Democratic Republic of the Congo (DRC).

The Bangladeshi government has confirmed another five deaths from dengue fever, bringing the total number of fatalities in the country since January to 23, the Directorate General of Health Services (DGHS) reported Tuesday.

Malaria has killed more than 1,800 people in Burundi this year, the UN’s humanitarian agency says, a death toll rivalling a deadly Ebola outbreak in neighbouring Democratic Republic of Congo.

Obesity is a growing problem in many countries around the world. Obesity is reaching further into Mexico and costing their citizens and healthcare system millions of dollars.

Technology 

It is hard to get much of a reputation if nobody knows you’re around, and that has definitely been the case for mycoplasma genitalium, the tiny bacteria estimated to be more prevalent than the bug that causes gonorrhea but is almost completely off the public’s radar.

Technology designed to intercept online extremism is being deployed to tackle vaccine misinformation.

Environmental Health

Common ingredients in the cleaning sprays for your kitchen and bathroom make mice less fertile, suggesting the compounds could do the same to humans, according to a new study.

Ocean heat waves, which can push out fish, plankton and other aquatic life, are happening far more frequently than previously thought, according to a study published today in the Proceedings of the National Academy of Sciences.

The climate crisis represents the biggest threat to the future of global health over the next quarter of a century, according to a survey of top medical professionals.

 

Equity & Disparities

The Bill & Melinda Gates Foundation has published a report, Examining Inequality, on how the world is doing. In short, it’s not great. It’s even worse if you are a girl.

The darkening clouds are ominous for many in this urban neighborhood in Kampala, promising rushing rainwaters stinking of human waste from overflowing septic tanks.

 

Women, Maternal, Neonatal & Children’s Health

UNICEF and the World Food Programme provide food and nutrition aid to North Korean children—but a lack of funds, fueled by political tension and the US-led strategy of pressure and isolation of North Korea, have limited their reach.

New Zealand’s government announced that it plans changes to the country’s abortion laws that would treat the procedure as a health issue rather than a crime.

 

World Suicide Prevention Day 2019

Author’s Note: This article discusses suicide and may be triggering for individuals with lived experience. While resources will be presented later on, this website has a list of country specific resources for those who need them. If you or someone you know is struggling with passive or active suicidal ideation, please reach out for help. 

The National Suicide Prevention Hotline in the USA is 1-800-273-8255.

Every 40 seconds someone, somewhere in the world, takes their own life. That amounts to over 800,000 deaths per year. On September 10th each year, World Suicide Prevention Day, the world comes together to reflect on the lives lost and bring suicide prevention to the forefront of the conversation. 

What Suicide Looks Like Around the World

Like most things in global health, there’s no single causal factor and no “one-size-fits-all” solution. Preventing suicide globally will require an understanding of the way individual, interpersonal, societal, and cultural factors interact to affect suicidality. High income countries, on average, have higher rates of suicide than low- and middle- income countries (LMICs), with the exception of LMICs in South-East Asia where the regional suicide rate is the highest in the world (17.7 deaths per 100,000 people). While rates may be higher elsewhere, suicide isn’t just a problem for high-income countries. The majority of suicides actually occur in LMIC settings, highlighting these countries as important stakeholders in the global conversation around suicide. 

Image Credit: World Health Organization (WHO)

Like the rates themselves, at-risk sociodemographic groups vary from region to region. Suicide is the second leading cause of death, globally, for young adults (18-29 years of age). Middle aged men in high-income countries generally have a higher risk, while adolescents and aging adults in LMICs are more likely to take their lives. 

Globally, males are 2-3 times more likely to complete suicide than women. This has long been blamed on differences in care seeking behaviors and socially acceptable coping mechanisms deemed acceptable for different genders. But it’s important to keep in mind that women are generally more likely to experience suicidal ideation and more likely to attempt suicide. Men, however, have historically used more lethal methods of suicide and more likely to take measures to prevent intervention. 

The means of suicide attempts vary drastically and adapt to environments. Pesticide poisoning accounts for about one-third of global suicides. Almost all of these deaths occur in rural subsistence farming communities. Self-inflicted firearm injuries account for a large proportion of suicides in the Americas. Urban contexts with much stricter firearm regulations, such as Hong Kong and Singapore, experience a higher number of deaths related to jumping from buildings and bridges. 

What We Can Do

Suicide may look differently depending on where we sit on a map, but the truth remains that the pain and suffering that causes and is caused by suicide cuts across every sociodemographic variable and exists in every corner of the world. Despite its inclusion in both the WHO’s Mental Health Action Plan and the United Nation’s Sustainable Development Goals (Target 3.4), suicide remains a low-priority agenda item for policy-makers worldwide. Only about 40 countries currently have national strategies or action plans in place to respond to suicide, and even fewer of these are in LMIC settings where the majority of suicides occur. 

While national strategies with government engagement will be crucial to eliminating suicide, suicide prevention requires multisectoral and multilevel approaches that treat suicide as the complex public health problem that is. It is the community and the individuals close to a victim of suicide that will suffer the most in the aftermath and have the most power in targeted prevention efforts delivered to the individual. 

Primary care professionals, especially those serving communities that are underserved by specialists, can and should be more familiar with using depression screeners like the Patient Health Questionnaire or Beck Depression Inventory to assess suicidality in the exam room. Educators can advocate for school-based intervention and encourage (not punish) help-seeking behaviors. And while we can’t all be psychiatrists, suicide crisis line volunteers, or counselors, we can all be kind people to those around us. Use today to raise awareness for the issue. Educate yourself (and others) about suicide prevention resources available in your community. As friends and family members, we can all do a better job of dismantling the stigma around mental health and identifying when those close to us are experiencing acute stress or grief that may serve to trigger or exacerbate existing suicidality. 

Where we live might affect what suicide looks like, who is at risk, and how often it happens. Our professional roles may dictate at what level we help break the cycle. But today is a reminder that we are all responsible, as stewards of humanity, for reducing the number of suicides in our world. In the time it took you to read this article, five people will have taken their own life. Every suicide death is one too many, so now is the perfect time to consider: what will YOU do to make sure it doesn’t happen again?

Looking for a starting point? I’ve compiled a wealth of resources that may be helpful, in addition to the links embedded in the text throughout the article. 

Helping Individuals At-Risk:

List of International Suicide Crisis Lines
Learn the Signs Factsheet (Take 5 to Save Lives)

Helping Someone in Crisis (Take 5 to Save Lives)

Find a Mental Health First Aid Course (USA)

Suicide Prevention: A Resource for General Physicians (Available in Multiple Languages)

Get Involved in World Suicide Prevention Day:

Download and post a WSPD banner in your native language

“Light a Candle” for victims and survivors of suicide

Post on social media using the hashtags: #wspd, #suicideprevention

Data:
Look up your country’s suicide rates

Suicide Factsheet (WHO)

Suicide Prevention: A Global Imperative (WHO)

World Suicide Prevention Day Fact Sheet (IASP)

National Prevention Strategies:
Does your country have a national action plan for suicide prevention? 

National suicide prevention strategies: progress, examples and indicators (WHO)

Evidence based strategies for safer access to pesticides (WHO)