First thoughts on re-entering a developed country

I am currently on a little holiday in South Africa!  It’s very exciting and there is a lot to look forward to, especially as my parents are arriving here on Thursday.

We left a hot, dry and dusty Chad on Friday lunchtime.

Take-off from N'Djamena

 

26 hours, 3 planes and 1 hotel room in Addis Ababa later, we arrived in Durban.

 

View from hotel in Durban

 

I’d been told that Addis was fairly developed compared with Chad, and my first thoughts as we descended into Addis in the dark was ‘wow, there are so many street lights!  Obviously no electricity problems here!’ 

On descending into Johannesburg (short stop before the last flight down to Durban) my first thought was ‘wow, it’s so green!’

On arrival into Durban our first port of call was the beach!  Yes the beach!  Coming from Torquay where I would see the sea on a daily basis, living in a land-locked country for the last 7.5 months has meant I’ve missed seeing that blue expanse and the white crested waves.  Although it was about 7pm we still paddled as the water was so lovely and warm.

Today has been my first full day here.  I am spending a few days as a lone traveller before my parents arrive and am loving it!  My hotel room has sea views which are amazing and I’ve enjoyed just being able to walk up and down the promenade, take in the views and experience the South African holiday vibe.  The weather is warm but humid and it rained today too.  I enjoyed sitting out in it as it wasn’t that heavy.  I’ve walked a little into the city and came across a supermarket.  The choice and range of stuff available was immense and slightly overwhelming.  I bought a random assortment of things – mince pies (Rebecca made some in Chad which were great but when I saw them for sale here I had to taste more!), a twix (you can get in Chad sometimes but usually melted and re-solidified, was nice to have one of factory quality!), a can of pepsi max (my favourite soft drink, can’t get it in Chad), two bananas (staple fruit for me in Chad, buying them is a habit now) and a bottle of water (I am so used to drinking litres and litres of water a day that I’m getting really thirsty here).

Having a holiday where your starting point was a developing country means what you do on holiday, and what you consider ‘holiday treats’, is going to be different than normal.  I am looking forward to hopefully getting my hair cut, buying new flip flops, buying new clothes, getting gifts from home via mum and dad and just being able to relax with no heat/sweat/dust getting in the way!  Oh and obviously doing the standard tourist stuff too, don’t get me wrong!

It’s been a strange 48 hours and I’ve definitely felt reverse culture shock having come from a fairly basic existence in Chad.  However though it all I’ve known that God is the same wherever I am in the world and that’s helped me a great deal :)

Medication ordering

Really boring title for this entry, but to be quite honest it’s difficult to dream up a witty title for a process that is slightly – vast understatement – very frustrating!  To be honest this post is probably only going to be vaguely interesting for those working in the pharmacy/medical world back home but I did promise a post on this subject in my last blog, so here it is! 

There’s an agreement that we will endeavour to source medication for the hospital within country, rather than import from abroad.  The latter would be more reliable in terms of knowing when we’d get the order and not much more expensive.  However, we live and work on the outskirts of the capital of Chad and so have easy access to the main wholesaler for the country.  Also in the capital is a slightly smaller wholesaler and numerous ‘depot pharmacies’ (even smaller wholesalers) and then retail pharmacies.  So we have access to a wide range of potential medication wholesalers and as such are in a far better position than those working in other towns around the country.

That’s probably where my positivity ends!!  I am in Chad and I must remember that. 

All of the above wholesalers only mainly stock generic medication which is good as they are more affordable for our patient population.  The retail pharmacies only stock branded medication and as such charge a premium for them.

Within the pharmacy here at Hopital de Guinebor II, all of our stock records are on paper in a big red file – the ‘classeur rouge’ is referred to and multiple times a day.  The regular use and dust in the atmosphere means this file looks rather tired and the pages within slightly brown!  Keeping on top of what medication or sundries have left the pharmacy is a challenge but we now have a good system that only falls down when one of us forgets to write in the notebook what we’ve issued.  There’s always going to be small element of human error when everything is done manually!!

 

Paper stock records

We aim to use the main wholesaler for the bulk of our ordering as it’s by far the cheapest.  However we’re obviously not the only hospital ordering from them as they are basically the main wholesaler for the whole country.  As with all things in Chad, the order is done on paper – no internet connection to the wholesaler with same-day delivery here!!  I wish, it would make life much simpler!  I usually place an order that will last us about a month, based on consumption in the preceding few months.  Most tablets come in boxes of 1000 and injectables in boxes of 50.  So making exact orders can be tricky with these pack-sizes!  Even if you hardly use a certain tablet you have to buy 1000 of them!  We just try and ensure they’ve got a long expiry date!  Once I’ve figured out what to order, this gets printed twice, once for us and once to take to the wholesaler.  Once dropped off we have to go back a week later to pick up the ‘proforma’ – which is our order, plugged into their computer by hand and then printed out.  I then have to check the proforma against my original order and make any corrections (there’s always at least one).  It also gives me chance to see what they’ve not got in stock and make other arrangements to get those products from another wholesaler (more expensive).  We then take the proforma back to the wholesaler and wait....and wait.....and wait....and make numerous phone calls to check on progress....and wait a bit more and then in about a month after we dropped off the original order we can go and pick up the order.  The length of time from start to finish varies – the shortest has been 3 weeks and the longest 2 months!  Meanwhile, I am having to figure out orders on a weekly basis at the second largest wholesaler in town.  The big advantage of this place is that you get products the same day but they sell the exact same products as the main wholesaler but 20% more expensive.  So we’re not keen on making orders with them although they’re really convenient and when the main wholesaler is taken a-g-e-s to get our order ready and/or they’ve run out of something, we have to. 

These two wholesalers are where we get most of our products but we can’t get everything from them all the time as they often have stock-outs.  An example was two weeks ago – we received our large monthly order from the main wholesaler but with only 4000 paracetamol – this is enough to last us 2 days!  I’d ordered 40000 tablets but they’d run out, meaning we had to get the remaining 36000 from the more expensive wholesaler.  Slightly annoying!

There are numerous other smaller ‘depots’, one of which will deliver out to the hospital.  Given that it’s a good 30 minute drive into town, this is a great help.  Although he obviously sells at a slightly higher price.  I have been known to haggle with him over his prices!  As he’s a smaller private business, this is easier to do.  That was a weird experience at first, bartering over buying ampoules of ampicillin but it’s become strangely ‘normal’ now!!

So keeping on top of drug ordering here is a fairly busy task and a crazy juggling act – trying to get the most we can from the most cost-effective place, but having to deal with long lead times and frequent stock-outs of important drugs.  There’s usually a way around it though, we end up being fairly resourceful out here out of necessity!

Part of a monthly order waiting to be unpacked in pharmacy

 

A day in my Chadian life

I thought it would be good to outline a typical day for me here as I work in the pharmacy.  I’ve been finding my feet and a few different things have needed to be sorted out, hence why I’ve not blogged about my work until now.  

No two days are ever identical to be honest, but there is some kind of routine established now.

So my day starts with the dreaded alarm at 6.30am.  Closely followed by a cold shower – no hot water here but to be honest, after a night in the early 30s, a cool shower is just what you crave!  Despite the bright mornings – it’s lovely to wake up to blue sky and sunshine 90% of the time – I am still a zombie at that time in the morning!

At 7.30am I walk up to the hospital, about 100 metres away, for our morning prayer/devotion time.   This includes singing in French, with varying degrees of tunefulness (don’t be tricked into thinking that all African’s can sing well, as I once thought.....believe me, they can’t!!).  The songs tend to be fairly old and traditional.  Some I recognise as direct translations from old English hymns such as ‘To God be the Glory’ and ‘What a friend we have in Jesus’. 

8am is the official work start time for most staff.  It is the changeover time for the nurses and midwives and the start of the day for everyone else, apart from the two guys who work in triage who start at 6.30am and screen every outpatient.  At 8am all staff meet for a morning meeting, where any information pertinent to everyone is shared.  This usually lasts about 10-15 minutes

Outside la pharmacie - obviously not open at this point!!

I usually start in the pharmacy at about 8.15am and greet Elisabeth and Cleopas, my two fellow pharmacy workers.  Generally speaking, Cleopas is the dispenser for all drugs to outpatients and Elisabeth ensures all the stock records (on paper, no access to computer stock records here!) are up to date and goes into town to buy drugs from various sources.  Sourcing and buying of drugs is a blog topic all of its own, so watch out for that  update in the future!  Let’s just say there’s no broadband internet connection to the local wholesaler, who’ll deliver twice a day.......!  Ensuring we don’t run out of essential drugs is a time-consuming and sometimes frustrating task.  It is also one big juggling act.  At the moment we’re in the peak of malaria season, so making sure we’ve enough anti-malarial drugs has been a challenge.  So far we’ve managed to have a continuous supply but the drug supply chain as a whole in Chad is fairly precarious, with things in and out of stock nationally on a regular basis.

My role here is to try and exert some sort of control over what medications and sundries (urinary catheters, cannulas, bandages, scalpels, NG tubes, syringes, needles, plaster of paris, IV infusions etc etc) are released from the pharmacy.  Previously, nurses and midwives would come to pharmacy and write an order for what they required.  It was often quite a random list with random quantities – this is a culture where you don’t forward-plan and you crisis manage.  So the concept of thinking ahead as to what drugs etc you may need over the next day or so is not one that comes readily to your average Chadian.  That’s just the way they are and it isn’t anything against our staff, it’s how Chadians ‘tick’.  A kind of ‘live for the day’ mentality – often borne out of extreme poverty – they often don’t have money to forward plan, they only have enough to live on day-to-day and hope that something comes along after that.  So my role is to devise stock lists and ensure that each area of the hospital – maternity, emergency room, operating theatre, adult wards and paediatric ward – have their allocated stock level each day.  So far maternity, emergency room and the operating theatre are up and running and I’m in the process of sorting out the inpatient wards.  The storage of drugs on the inpatient wards is ok at present but could be vastly improved.  I’ve just designed a drug trolley which we are going to ask a local carpenter to make.  A drug trolley will reduce the potential risks of medication error that are currently a possibility with the existing system of drug storage on the wards.  In the interim Sue (nurse here) and I have found a cabinet on wheels that will suffice as a drug trolley until my prototype is made.  Drugs here come like they used to in the UK – either loose in tubs of 1000 or as strips of ten in boxes of 1000.  So no individual patient packs to neatly sit in a drug trolley!  We have to be pretty inventive with storage solutions here in order to segregate drugs on the wards and stop them being mixed up (which is what can currently happen).

So, each morning I go to each area, count the drugs they’ve got and then top them up to the allocated level.  Pretty straightforward stuff, although you try doing it in rooms of around 40°C!  Another of my roles is to work with Elisabeth on the drug orders she needs to collect from town.  As I said, that’s a blog entry all of its own and is a very time consuming process.  I also give Mark (doctor here) monthly statistics on drug availability and, at the moment, the level of anti-malarial usage.  I also ensure we always have a spare gas cylinder for the pharmacy fridge (gas powered, and I’m getting good at predicting when it’s going to run out!  There’s no way of telling exactly when the bottle will run out, which can be tricky in this heat if we miss it and the fridge is off for a few hours).  I also help Cleopas at the outpatient counter when it’s really busy, getting medication ready for him to dispense.  Unless the patient speaks French, I can’t dispense drugs to them as I can’t explain how to take what they’ve been prescribed.  Most patients at our hospital speak Arabic and I can’t!  So that stops me being able to have any patient contact in terms of dispensing drugs to them.

Talking of languages, the official language of the hospital is French.  So I am immersed in French all day, which doesn’t tire me out as much now as it did at the beginning!  I can make myself understood and can run the pharmacy on a day-to-day basis so my French is bearing up and we’ve had no major miscommunications yet!  I’ve had to learn the French words for loads of what I consider basic medical and pharmaceutical words, such as tablet, cream, syrup, gloves, water for injections, hydrogen peroxide, scalpel, crepe bandage etc etc.  The most confusing thing to me is that IV cannulas are ‘catheter IV’ in French and urinary catheters are ‘sonde urinaire’.  That took a lot of getting used to and remembering because as a British primary care pharmacist, a catheter is usually referring to a urinary catheter.  Simple things can be really confusing!

Another role I have is ensuring the lab have enough reagents, test strips and so on.  As I had in my last blog entry, you have to learn to step outside of the ‘usual’ pharmacist’s remit here and help out where you can.  Fortunately for me, the head lab technician is on the ball and lets me know when they’re getting low.  I just have to check the quantities he’s ordering sound reasonable and sign off his order.  One test we have had to buy lots of at the moment are the malaria finger-prink tests.

Our day officially ends at 3.45pm, and we usually get a break at lunchtime.  However if there are a lot of outpatients, we sometimes end up staying until 4-4.30pm to enable them to get their prescriptions before they leave the hospital.  As well as bringing in revenue for the hospital, our prices for drugs are a lot less than if they took their prescription into town to a pharmacy there.  So it’s a win-win situation!  There’s no NHS-equivalent here, all patients have to pay a fee to consult a nurse or doctor, a fee for lab tests and a fee for their prescribed medication.  If they are hospitalised, then flat-rates per night are paid depending on whether they’re medical or a surgical case.  This covers all their care and their drugs given on discharge.   We are fortunate that kind individuals from the West often send money to the hospital which we put into a benevolent fund, so that if a person really can’t pay, we can subsidise their hospital costs.  We endeavour to keep our prices as low as we can and just ensure we cover our running costs.

So there we have it, an account of what I get up to out here!  Elisabeth and Cleopas both have a good sense of humour which means we often have a lot of laughs in the pharmacy.  One such example was the other week.  It was really hot in the pharmacy (I know, the drugs, there’s not a lot we can do as we’re not on city-power so have no means to run air-con – we have the fridge for items that must remain cool).  I was feeling the heat after a morning of walking around the hospital checking on stock levels and distributing drugs and other sundries.  We had a lull and no patients were at the counter for prescriptions, so I was sat by the fridge, longing to get in it!!  I then had a little brainwave – I explained to Elisabeth and Cleopas that in the UK when it’s cold, we have something called a hot water bottle to warm us up.  So I thought to myself, I need a cold water bottle at the moment!  In the freezer compartment of the fridge we keep ice packs, so that if drugs are taken out of the pharmacy in cool bags, we can add an ice pack to keep them cool.  I took one of the ice packs out of the freezer and hugged it like a hot water bottle!!  It was sooooooo good!  Below is a photo of me in the pharmacy hugging my ice pack J

In la pharmacie with my ice pack!

 

Carry on crutches!

I am currently preparing a blog entry that will outline a typical day for me here working in the pharmacy.  However, when working in a situation such as this, I am fast learning that I can’t just stick to medicines in my day-to-day work.  It’s all hands to the pump with whatever needs to be done.  If it’s possible for you to assist and carry out a task safely, then you do it, even if it’s not what a pharmacist usually does!

One such example happened a couple of Fridays ago.  Fridays here are half-days for most of the staff, as the afternoons tend to be quieter - most people are at the mosque for Friday prayers and so don’t come to the hospital unless really ill.  This particular Friday, a Chadian patient (who happened to be known to us expats) had been to see Doctor Mark because of a painful knee.  After she had finished seeing him, one of the things she required was a pair of crutches.  Crutches are stored in the pharmacy, as are a lot of other things you wouldn’t see in a hospital pharmacy in the UK, for example cannulas, needles, syringes, plaster of paris bandages, scalpels, sutures!  So I was called to open up the pharmacy and provide the lady with her crutches.  We can only source wooden under-the-arm crutches here (physio’s hold those gasps!) and so they are better than nothing at all.  They are hand-made to the specifications of an expat physio who works here a couple days a week.  They are fully height-adjustable and so I asked Doctor Mark for guidance on how high they should be made for the patient, both in terms of the hand-bars and the whole height of the crutches.  Typically, they weren’t the right height for the patient.  The screws required removing, the pieces of wood moving up and then the screws replacing.  Sound straightforward?  It wasn’t!  It was now 4.30pm.  The hospital handy-man who was my first port of call to do the adjustments had already gone home.  Cue a 10 minute search for a screwdriver and pair of pliers.  Then cue a search for people to help me.  Fortunately Malc was still in his office finalising the week’s figures and he agreed to help, as did Alain the local Chadian interpreter (who also happens to teach me French).  The crutches had been carefully made to a good standard, and then varnished.  However, the guy who’d made them had varnished *over* the screw heads.  Removing the screws proved to be a time-consuming task anyway but we had the added task of getting through the varnish before removal could begin.  We took the crutches to the consulting room where the patient was patiently waiting.  It took ages to remove all the screws, washers and nuts, with a few rolling onto the floor – good job the patient was alert and could tell us where they’d gone!  It then took three attempts to replace them all at the right height.  Darkness was fast approaching which didn’t help (no lights in the consulting room as they’re only used by day....normally.... and our solar energy is better conserved for use on the wards at night).  Other patients kept knocking on the door asking to be seen – I draw the line at extending my duties to consulting patients and making diagnoses!  Finally, after an hour-and-a-half, lots of laughter at our ineptitude at adjusting crutches and a comment in jest from the patient (‘je veux rentrer aujourd’hui - I want to go home today!), we had finished!! 

So that’s another string to all of our bows, should the need ever arise again!!

Things I miss and things I like!

I thought I’d document what I miss from home and things that I like here in Chad J

Things I miss:

·         Sleeping under a duvet

·         Fast broadband internet

·        Going to a shop and being able to get change - coins are in short supply here and most times at the shops they ask if you’ve got coins.  Which can be a bit annoying if you’re trying to save them to buy smaller value items such as bread or fruit from road-side vendors

·         Being able to easily buy meat that’s ready to cook

·         A more comfortable climate – although see below too!!

·         Looking like ‘me’ – I don’t normally have my hair tied up and under a headscarf for the majority of the day, nor do I always wear ankle-length skirts

·         Being able to converse freely and accurately in the native language

Things I like about Chad:

·         Blue skies and sunshine 95% of the time

·         Bananas that taste like banana – trust me, the ones in the UK are tasteless in comparison!

·         Colourful and busy markets

·         Fresh baguettes for the equivalent of 15p

·         Vibrant Church services

·         Meeting people from a wide variety of countries and backgrounds

·         Working alongside other expats and Chadians at the hospital

Cool water?

When it’s hot weather in the UK, we think nothing of taking a glass, turning on the cold tap and pouring ourselves a nice drink of cool water. 

Here in Chad there’s a slightly longer process we have to go through before we can pour ourselves a glass of cool water!   In the hottest weather we drink on average about 4-5 litres of water a day.  Mainly just plain water but we can get a sugary powder in a myriad of artificial flavours, which we can add to the water if we want to.  There are other ideas too for flavouring water, such as adding a peppermint or lemon teabag to a jug of water and letting it soak overnight.  When you’re drinking so much cold water you need a bit of variation!

This blog outlines the process us expats go through on a daily basis in order to ensure a constant supply of cool water is available:

1.  Fill bowl with tap water

 

 



2.  Pour tap water into water filter

3.   Once water has filtered through to the bottom chamber (a very slow process), fill bottle or jug with the filtered water

 

 4.   Place bottle of water in fridge and leave for a couple of hours to cool

Once all that is done, there is a supply of cool water in the fridge!

Just for a bit more background, I thought I’d explain where the tap water comes from.  There’s no piped water provided by a national company here.  The tap water in our houses and also for use at the hospital is pumped from an underground source, using a generator, into a water tower on site.  It takes about 30 minutes for the generator to pump enough water to fill the tower.  Below is a picture of yours truly posing by the water tower!

The water in the tower doesn’t last the compound very long and so water is pumped into it about 3 or 4 times a day.  We often turn on a tap and find no water and then go and find a guard to put the generator on.

Sometimes the generator is out of action, although thankfully this hasn’t happened yet since I’ve been here!  Alongside the generator-driven water pump, there is also a hand water pump that can be used.  This sources water from underground, there’s natural water not far below the surface.  So if the generator is out of action, we use the hand pump to pump water into buckets, bowls (anything really!), to be used in the houses or on the hospital wards.  Below is a photo of me at the hand pump!

So there we have it, a brief description of water here!

Wimbledon: Arabic style!

Last Saturday a few of us expats went to our friend’s house.....cos she has cable TV and invited us to watch some Wimbledon!  So three of us from the compound here at Guinebor II Hospital went into town, armed with home-made scones and chocolate brownies.  After everyone had arrived there were three Brits, two Americans, a Dutch girl and a Swiss girl (who was very despondent that Federer had already gone out!!).  We enjoyed some lovely food that people had brought and sat down to watch a match.  Our friend’s cable TV is Arabic and so the commentary was in Arabic.  It was a bit strange not having the usually John McEnroe, Tim Henman and Sue Barker trio giving us the lowdown.  What was even more strange was the fact that the studio presenter on the cable channel was in full Arabic dress.  I suppose it’s not that strange that Arabic TV presenters wear Arabic clothing, but it was strange to see as a Westerner.  A few times they cut over to a correspondent at Wimbledon and had both presenters on the screen at the same time.  See picture below.  This is Wimbledon Arabic style!

We had a fun afternoon chilling out and watching a game.  Us Brits were sooooo excited when a shot of Sue Barker came on screen.....although she was muted!  So this was another slightly different experience here in Chad!