Part 4: Perspectives on Global Health from Pharmacists Around the World

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 needs are met in countless regions across the world. 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 fourth and final segment explores targeted populations in each of the aforementioned countries, the health ailments that burden these groups, and each pharmacist’s proposed pathway to overcome these concerns within these nation states. 

In every corner of this vastly diverse planet, healthcare access and delivery affects countless aspects of humanity’s well-being. These aspects can range from the capability of obtaining the correct medications for treating dermatitis or receiving prophylaxis isoniazid therapy to accessing cancer screening with a pap smear and purchasing levemir at an affordable price. In addition to these direct implications on one’s life, healthcare possesses indirect factors such as social relationships influenced by health, hours lost working due to health commitments, and the emotional burden due to certain ailments. The global health community recognizes that health disparities exist throughout various regions of the world which affect these aforementioned facets. However, the inequalities that exist within explicit populations in these regions are often overlooked or overshadowed by more broad global initiatives.

In this final post for the IH Connect blog series, four practicing pharmacists reveal major concerns in their areas of inhabitation for specific populations: older adults, pediatrics, pregnant mothers, women’s health, and men’s health. These healthcare leaders then offer initiatives and solutions to address these complications to improve the lives of each member of their cherished communities. 

Dr. Moeung Sotheara, Ph.D. 
Clinical Research Assistant & Part Time Lecturer – University of Health Sciences
Phnom Penh, Cambodia 

Cambodia has achieved some remarkable health outcomes in recent decades such as improving newborn and child health, ensuring provision of HIV/AIDS treatment to over 80 percent of the infected population, and expanding vaccination coverage. However, there are a number of population-specific concerns that need to be addressed in order to further improve the overall healthcare and wellbeing of the people.

Older Adults

One of the top concerns regarding older adults in Cambodia is the lack of care centers for older adults and state pension provision. Consequently, the older adults in Cambodia are physically and financially dependent on their children to get access to health services from going to see a doctor to buying medicines. This results in older adults not willing to seek immediate medical care when they have health problems as they feel hesitant to ask for their children to help. Moreover, as they cannot go to the pharmacy on their own, they often miss out on crucial information regarding appropriate drug use. The solution is to provide all Cambodian workers with a social pension scheme and to build care centers for older adults, where they can easily gain access to healthcare.

Pediatrics

The top concern regarding pediatrics is the common and widespread use of fluid infusion. This dangerous practice has become a tradition in Cambodia. When a person is sick, most physicians prescribe intravenous (IV) drips either intentionally or on the patient’s demand even if he/she shows no sign of dehydration or fluid loss and often without careful monitoring. And children are no exception! To solve this problem, there should be campaigns to raise the public’s awareness about the danger of incorrectly used IV drips and to reinforce the doctors’ medical ethics.

Pregnancy

One of the top concerns regarding pregnant women is the use of traditional medicine. Traditional medicine is commonly described at two time points: one month before birth to ease child delivery and postpartum to increase breast milk production and prevent Tos (madness, depression). The most common form of traditional medicine used is herbal medicine which often consists of a mixture of different parts of multiple plants. The toxicity of these plant combinations has poorly been studied. To resolve the problem, a number of well-designed studies should be carried out to investigate the potential toxicity of herbal medicine during pregnancy and post-partum period.

Women’s health

The top concern regarding women’s health in Cambodia is the overuse of skin whitening and skin bleaching products. In a culture where lighter skin is often idealized, whitening is a common practice in Cambodia, especially for women despite the reported danger of those products. Whitening cream or lotion can be dangerous, and many counterfeit products are now on the market, making the practice even more dubious. The problem is of more concern as more and more creams are locally produced without the right standards, by mixing whitening cream with other vitamins and dangerous chemicals. Moreover, they are increasingly available online, or via social media where they are not sufficiently regulated. The immediate solution to this problem is to re-enforce the law regarding online cosmetic products advertisement. Furthermore, all production sites of sub-standard creams or lotions must be closed down. Additionally, any products must be screened for dangerous chemicals before they can be advertised and sold on the market. The public’s education of the danger of sub-standardly-produced skin whitening and skin-bleaching products is also of prime importance. The collective idealization of white skin should be changed and people should be educated to perceive beauty beyond the skin color.

Men’s health

Health impacts related to alcohol overconsumption has become a top concern regarding men’s health in Cambodia. A report by the Asia Foundation in 2015 showed that Cambodian men are drinking 9.7 litres of pure alcohol a year – 3.5 litres above the global average of annual alcohol consumption per capita. Furthermore, the study also found that Cambodian men tend to drink six times as much as their female counterparts. Social, economic and cultural factors together with the influential role of advertising are the predominant drivers of increased alcohol consumption among the Cambodian population, particularly men. Alcohol abuse has resulted in more than 60 major types of diseases including cardiovascular disease, cirrhosis of the liver, cancer and sexually transmitted diseases including HIV/AIDS. Restrictions on alcohol product advertisements, price control strategies and education of the public on the harmful effects of alcohol abuse are among the measures that can be taken to tackle the problem.

Dr. Maneesha Erraboina, PharmD.
International Business Manager – Helics Group Scientific Networks 
Hyderabad, India 

Older Adults

Most older adults use multiple drugs simultaneously for different conditions or for one condition. Polypharmacy causes poor adherence which leads to adverse drug events (ADRs) or medication errors (MEs). To avoid these ADR’s and ME’s, healthcare providers should educate patients about the medication in order to maintain good adherence and try to increase the knowledge of the health condition by performing patient counselling.

Pediatrics

Cost analysis is a ubiquitous problem for all types of diseases in each category of patient populations. In one of my research work entitled “Pharmacoeconomic Analysis and Treatment Pattern in Sepsis Patients: A Cross-sectional Prospective and Retrospective Study”, this publication infers about the cost analysis in sepsis patients particularly in the pediatric population. The major barrier is to overcome situations where health leaders are focused on cost rather than looking at the whole picture in order to provide equitable care. This can be accomplished by having input from these specific populations and reflecting on the role a healthcare provider should have in treatment. 

Pregnancy

For pregnant mothers, perinatal conditions that occur before, during and after the pregnancy can lead to perinatal mortality. In India, the most common conditions resulting in death are haemorrhage, trauma, and severely underweight babies. To avoid perinatal mortality, continuous assessment of pregnant women on medication and diet is needed by encompassing more prenatal and antenatal care health facility visits.

Women’s Health

Breast cancer is one of the top concerns in women’s health throughout the world, and this includes in India. In India, the etiological factors are difficult to identify for this type of cancer; however it mostly occurs in older women. It may occur due to older age and genetics. To decrease the risk of breast cancer, one should focus on non-pharmacological therapy that includes dietary and social changes.

Men’s Health

Commonly, pancreatitis occurs mostly in men with social history of alcohol consumption in India. In a study examining the main causes of pancreatitis, it was found that approximately 1/3rd of all pancreatitis cases was caused by alcohol. Counseling on decreases in alcohol consumption should be undertaken by all healthcare professionals in order to prevent this ailment.

Nazgul Bashir, B. Pharm
Registered Pharmacist – Super Care Pharmacy
Dubai, United Arab Emirates

As a pharmacist, we encounter a number of various types of populations seeking our care, both gender-specific and age-specific. Dubai, being a cosmopolitan city, sees many different ethnic groups and nationalities. With so much of diversity in the community, we see a number of different issues and it is our sole responsibility to identify them, recommend the most appropriate over the counter treatment to fulfill the need of the concerned person, or refer to a prescriber for more serious issues. One of the best aspects about being a pharmacist is that we have the opportunity to encounter new types of people and novel ailments every day. On the other end, some of the ailments encountered are difficult to manage due to a variety of reasons. Different groups of people who visits the pharmacy can be divided into men, women, older adults, pediatrics, and soon to be parents. In each population there are multiple issues which I will describe in detail in the following sections.

Pediatrics 

I would like to start talking about my most favorite population, pediatrics. Multiple concerns are present when it comes to children in the UAE including obesity, vitamin D deficiency, genetic problems, diabetes, and, most commonly, allergies and asthma. Out of these concerns, asthma and vitamin D deficiency are frequent ailments patients seek the care of a pharmacist for. One in every five children is suffering from asthma which initially, parents don’t realize. They self-diagnose it as night time coughing, chest congestion or persistent nagging. The cause is not simple. it could be anything airborne like construction dust (In the UAE, there is constantly large buildings being constructed), sand (UAE being the desert) and pollen from palm trees. Another major cause can be going in and out of air conditioner due to hot & humid weather. Cough suppressants and expectorants are first requests by parents and desperate patients even ask for montelukast or steroid based inhalers which is not an appropriate avenue to address the issue. First and foremost, the triggering allergen should be identified as airborne, smoke, or a viral cold. Educating parents about the importance of flu shots, the use of a peak flow meter to find out a child’s lung function and supplementing them with Echinacea, zinc, Elderberry or even Vitamin C to keep their immune boosted are also viable methods to address this ailment. Vitamin D deficiency is another common concern in children. Because hot and sunny summers last for a long time, children stay indoors rather than going out for any physical activities. Most of the body parts are covered with clothes which is common in UAE. 90% of the population is suffering from vitamin D deficiency including men, women and children. Pharmacists should recommend Vitamin D supplementation during these months in order to prevent this deficiency. 

Men’s Health 

Men’s health is often the most difficult to discuss because males make limited health visits. This could be because men ignore the illness affecting them or they could be uncomfortable discussing their health problems. Mainly, I want to talk about erectile dysfunction (ED) in men. One in every 3 men from age 40-70 suffer from ED, but due to cultural issues, the topic is often avoided. They avoid asking for professional help on this sensitive issue because they feel challenged, embarrassed and/or guilty. High diabetes and obesity rates and smoking/alcohol use are the main factors causing ED. Pharmacist counseling can provide significant help with lifestyle advice, proper supplementation, and education for reasons to follow up with a prescriber.

Older Adults

No matter which part of the world we belong to, a majority of older adults we see are on poly-pharmacy. This creates unique challenges in this population by having multiple health issues and taking a number of medications. In the UAE, proper guidance on use of these medications is often missing which leads to non-adherence to medications. From a patient’s perspective, taking 5 or more medications, either prescription or non-prescription, can be time-consuming and frustrating. For older adults with cognitive issues, issues surrounding medication adherence is exacerbated. As a community pharmacist, I would like to raise awareness about poly-pharmacy, adherence, and its effect on older adults. Many steps can be taken to increase the adherence. Color-coded pill boxes, properly labelled vials and easily read fonts should be used. Technology reminders should also be utilized to improve adherence. Another commonly noticed concern in older adults is drug induced nutritional deficiency which is defined as being on multiple medications that lead to a number of important nutrients being depleted. As pharmacists,  we should inform the patients the importance of this issue and help patients to identify the nutrition depletion by the medications they are taking.

Women’s Health 

Last but not the least, about 60% of the female population has issues regarding women’s health and are visiting pharmacists more often. Women’s health concerns are almost all interlinked including irregular menstruation, infertility, post menopausal symptoms, and urogenital complications. There are many more complications which could contribute to the larger discussion about this population. However, the one problem I would like to discuss is polycystic ovary syndrome (PCOS) which is infrequent or irregular menstruation or increase in androgen levels. It can be difficult to diagnose,  but many symptoms are excessive hair loss, acne/oily skin, weight gain and infertility. UAE has the highest rate of PCOS than any other part of the world. PCOS is a more recent disease which could be linked to modern lifestyles, more indoor activities and a decrease in outdoor activities, stress, and junk food intake. It can be caught initially if any adolescents discover a missed period or heavy periods. Most of the time, they don’t take it seriously and realize it when it is too late which could result in difficulties with conception or infertility. PCOS can not only lead to infertility but also anxiety and depression. Rates of infertility are increasing. When I investigate patients on their cycle most of the time, I find out they were having irregular periods in their early 20s, missed 3-4 months, and no action was taken because of it being such an intimate topic. I believe if we have any female patients coming to the pharmacy with issues like hair loss, excessive oily skin, facial hair, they should be advised for early screening of PCOS. Folic acid supplementation should be advised to people who are trying to conceive with PCOS or anyone with an irregular menstrual cycle. Lifestyle modification and weight loss should be emphasized as well.

Dr. Bryce Adams, Pharm D., RPh.
Oncology Medical Science Liaison
Washington D.C., United States of America 

Older Adults

I believe the biggest health concern for older adults in the USA is Alzheimer’s disease. This has been a growing concern as the human race’s lifespan has been exponentially increasing. While billions of dollars have been spent in research looking for a treatment, there hasn’t been much success. The current treatment options, cholinesterase inhibitors or N-Methyl-D-aspartate (NMDA) antagonists, only slow the progression of the disease, albeit, with limited success. Therefore, these agents are most effective when initiated before the severity of the disease reaches a certain point. To address this concern, I believe we need to work on detecting the disease earlier and continue to research new options. Alzheimer’s screening needs to be incorporated into routine check ups in older adults, and implemented at a younger age with those with a family history of this ailment. Additionally, there needs to be continued research regarding the disease. This includes research to gain a better understanding of the pathophysiology as well as new agents to treat the disease. Most of our current research has been in regards to amyloid beta. While this could lead to better treatments, most of the efforts focusing on this have failed, therefore, I think we should start to focus more efforts elsewhere.

Pediatrics

The biggest health concern for American pediatric patients is the lack of novel treatments. While there have been great strides and new medicines for adult patients, there is typically a delay for access to these medicines for pediatrics. One way to combat this is to ensure there are a proportionate amount of clinical trials that include pediatric patients. This work is currently underway and hopefully will result in greater access to medicines for pediatric patients.

Pregnancy

I believe preeclampsia is the greatest concern during pregnancy as it is fairly common and can result in the death of the mother and/or child. While there are some treatments for this condition, there is still much room for improvement in terms of early diagnosing, prevention, and more effective therapy options. I believe we can improve outcomes by focusing our efforts on the aforementioned methods of improvement: identifying risks for preeclampsia more efficiently and preventative measures. 

Men and Women’s Health

I’ve combined men’s and women’s health into one as I believe the greatest concern is the same: heart disease. While there are several treatments currently for heart disease with decent success, there hasn’t been much advancement in recent years. Our current agents can manage the disease and reduce symptoms, but for the most part, they are unable to cure the disease. In order to combat this issue, American researchers and practitioners need to improve screening to identify the disease earlier on as well as focusing on new treatment options that have the potential to cure the disease.

Happy World Breastfeeding Week!

Happy World Breastfeeding Week (8/1-8/7)! This year’s theme, “Empower parents, enable breastfeeding” is a particularly poignant reminder of how the U.S. government is doing neither for parents and infants entering at the southern border. It is critical to consider the effects of involuntary separation of breastfeeding mothers and their children.

There are short- and long-term physical, emotional, and economic consequences of abrupt discontinuation of lactation. Lactating individuals need to express milk to relieve the pain and fullness in their breasts to avoid plugged ducts and mastitis, a breast infection requiring medical attention. If there is no provision of time, space, and privacy for regularly expressing milk, those individuals will gradually lose their milk supply. Shortened, suboptimal lactation increases risks for breast and ovarian cancers, and metabolic and other diseases and costs $302 billion globally [1].

Infants who no longer receive human milk need a substitute, which will be inherently nutritionally inferior to human milk and cannot provide them the immunologic protection they received from their mothers’ milk [2]. Those infants will need to learn how to feed from a bottle, which may cause distress, can introduce bacteria, and may teach them to ignore satiety cues [3], increasing their risk for overeating as they get older.

Emotionally, the parent–infant bond is severed with involuntary separation. Breastfeeding is not just a feeding method, but also provides an infant with temperature regulation and comfort. We have witnessed maternal distress from this inhumane practice [4]; it is likely that an infant’s distress would be extreme.

On top of the life changing health effects of abrupt discontinuation of breastfeeding, the most egregious offense may be the negation of these individuals’ rights to breastfeed. They were feeding their children optimally until a poor substitute was imposed upon them for political reasons. Now those children have higher risks of infections and chronic disease, from the moment they were taken from their parents and for the rest of their lives.

There have been many discussions about the traumatic effects of parent-child separation but we have not seen or heard a discussion of effects due to abrupt cessation of lactation and breastfeeding. Those effects provide more compelling reasons to end this inhumane practice immediately.

Guest Blog Written By: Jennifer Yourkavitch, MPH, PhD, IBCLC – International Health Section Breastfeeding Forum Liaison, APHA and Research Scientist, University of North Carolina, Greensboro; Whitney P. Witt, PhD, MPH – Chair, Maternal and Child Health Section, APHA and Inaugural Dean and Professor, College of Health, Lehigh University; Briana Jegier, PhD – Chair, Breastfeeding Forum, APHA and Associate Professor, Health Services Administration, D’Youville College

References

1.      Lancet. (2016). Series on Breastfeeding. http://thelancet.com/series/breastfeeding. Accessed July 31, 2018.

2.      Mannel R., Martens P., & Walker M. (eds.). Core Curriculum for Lactation Consultant Practice. Burlington, MA: Jones & Bartlett Learning, LLC, 2013.

3.      Li R., Fein S.B. & Grummer-Strawn LM. (2010). Do infants fed from bottles lack self-regulation of milk intake compared with directly breastfed infants? Pediatrics125(6).

4.      CNN. June 14, 2018, https://www.cnn.com/2018/06/12/us/immigration-separated-children-southern-border/index.html. Accessed July 29, 2018.

Public Health and Migration

Throughout history humans have been on the move, migrating due to famine, war, persecution, and to find a better life. In a new age of “zero tolerance” policies and deeming humans “illegal” it is important to understand that how global policy defines someone matters.

There are many terms for populations that are fleeing disasters and we have to understand globally accepted terms for populations on the move.

    1. Asylum-seekers are people “whose request for sanctuary has yet to be processed”. Every nation has their own asylum system to determine who qualifies for protection and how they request this protection. If the petition for protection does not meet the host country’s criteria the individual may be deported to their home country.
    2. Internally displaced people have not crossed any borders to seek safety but have moved to another location within their home country seeking safety or shelter.
    3. Refugees are people who are forced to flee their home country in order to seek safety from conflict or persecution. This group of people are protected under international law and are not to be sent back to the situation where their safety is at risk.
    4. Migrants are people who choose to move for work, education, family unification, etc. These people can go back to their home country and continue to be protected by their home country government.
    5. Undocumented migrant is a person who has entered a country without proper documentation, or their immigration status expired while in the host country and they have not renewed their status, or they were denied legal entry/immigration into their host country but have remained in the host country.
    6. Statelessness is someone who does not have a nationality. Individuals can be born stateless or become stateless due to nationality laws which discriminate against certain genders, ethnicities, or religions, or the emergence or dissolving of countries.

These international definitions are important, because it determines if, how, and when the international community can respond to crisis situations. A large caveat is that due to national sovereignty under international law a nation must request that international organizations like UNHCR provide international assistance to these particular communities. If nations do not request assistance or reject assistance then these populations are left without any sort of protection leaving them vulnerable and isolated, as seen with Syrian refugees in Lebanon. The international community has also seen the inhumane treatment of people seeking protection to include isolated detention on islands such as is currently used in Australia.

No matter how the international community defines these populations, they face poor health outcomes due to disease, economic stress, and trauma. Examples include:

  • An increase in child brides among Syrian and Rohingya refugee populations. This in turn affects infant and maternal mortality rates as well as the woman’s future economic prospects.
  • Malnutrition of both mother and child leading to increased death rates for children under five and stunting of growth in children that survive. This is currently being seen in Yemen.
  • Decreased breastfeeding rates due to maternal stress, disease, and separation from familial groups/support systems. An increase in breastmilk substitutes in refugee or displaced persons camps is also an issue that goes against international humanitarian policies.
  • During the Mediterranean refugee crisis the international community witnessed large groups of people risking their lives on overfilled boats that often sank, causing large scale loss of life. These refugees then faced xenophobia, closed borders, and detention upon their arrival.
  • Currently in the United States there has been an increase in detaining families and child migrants from Latin American countries for an indeterminate amount of time. Organizations like American Academy of Pediatrics have begun to discuss long term effects this type of detention has on child and adolescent health outcomes such as: high risk of psychological stress that may lead to anxiety and depression due to separation and forced detention, suicidal ideations, victims of assault by other children in these detention centers, or sexual assaults from other detainees or employees at these facilities.
  • In South America sovereign nations have closed their borders or placed restrictive regulations on Venezuelan migrants seeking food, shelter, and basic medical care for their families amid a massive economic crisis. Not only do these migrants face arduous journeys, but they also face poor health outcomes like malnutrition due to starvation, and the potential for contracting diseases due to poor sanitary conditions, and consuming non-potable water.
  • Migrants are a vulnerable population who can succumb to human trafficking and the modern slave trade along their migration routes. Migrants that are caught up in human trafficking often face abuse (mental and physical), serious injury from due to extreme work conditions, and exposure to communicable diseases from overcrowded and unsanitary living environments.   

Humans take immense risks to seek safety and new opportunities that they did not have in their home country. As an international public health community, whether we work in crisis situations or not, we must make it a priority to treat all humans in a humane manner. Health is a human right, and should be guaranteed for all.  

 

Happy Breastfeeding Week! #WBW2018

World breastfeeding week takes place from August 1st to 7th this year. This year’s theme is Breastfeeding: Foundation of Life.

There are tools for all of your advocacy and information needs!

WHO has infographics and webinar information: http://www.who.int/news-room/events/detail/2018/08/01/default-calendar/world-breastfeeding-week-2018

The World Alliance for Breastfeeding Action (WABA) has an action folder in several languages (http://worldbreastfeedingweek.org/actionfolder/) and a social media toolkit (http://worldbreastfeedingweek.org/social-media-kit/).

WABA is also hosting a Thunderclap! Those who join will automatically share the same breastfeeding message at the same time across FaceBook and Twitter on August 1. https://www.thunderclap.it/projects/70825-world-breastfeeding-week-2018

In related news: In the U.S., Idaho and Utah recently passed bills legalizing breastfeeding in public for their residents. It is now legal in all 50 U.S. states to breastfeed in public. Appropriately, this week also kicks off our own National Breastfeeding Month in the U.S. (http://www.usbreastfeeding.org/nbm).

Weekly themes:

  • Week 1: Policy Pulse 
    Finding Solutions: Small policy changes can go a long way toward supporting breastfeeding families
  • Week 2: Special Circumstances & Emergency Preparedness 
    Always Ready: Resources and guidance on how to manage feeding during an emergency
  • Week 3: Call to Action 
    Answering the Call: Everyone can help make breastfeeding easier
  • Week 4: Black Breastfeeding Week 
    Love on Top: On top of joy, on top of grief, on top of everything

Happy messaging! Support breastfeeding everyday!

 

Support the best nutrition for babies everywhere: Urge your U.S. Representatives to protect, promote, and support breastfeeding!

Are you aware that representatives from the U.S. sided with commercial infant formula industry interests at the expense of babies during the recent World Health Assembly (WHA) meeting in Geneva?

Screen Shot 2018-07-17 at 4.48.44 PMU.S. officials at the meeting proposed the adoption of language that would have allowed this industry unrestricted ability to aggressively market breast milk substitutes as part of a WHA resolution on infant and young child feeding that included breastfeeding. Finally, the original wording of the resolution was mostly maintained. However, Ecuador had already been forced to withdraw its sponsorship of the resolution due to U.S. threats to withdraw military and commercial support if they didn’t, instilling fear in all other smaller countries of similar retaliation from the U.S. that may persist into the future. Russia stepped up at the end to sponsor the resolution because they said they support breastfeeding!

Support the best nutrition for babies everywhere.

Urge your U.S. Representatives to protect, promote, and support breastfeeding!

Act now by calling or writing your U.S. Representatives. Need the contact information for your representatives?

The issue and the circumstances are well articulated by two articles found in News Deeply and The New York Times.

For more information about IH Section’s Policy and Advocacy Committee activities, contact:
Kevin Sykes, PhD, MPH and Elizabeth Holguin, MPH, MSN, FNP-BC
APHA, International Health Section Policy and Advocacy Committee Co-Chairs