Humanitarian pharmacists: the road less travelled

While doctors and nurses are often celebrated for their work overseas through programmes such as Médecins Sans Frontières (MSF), the role of pharmacists in the disaster response care team is rarely acknowledged. However, judging by the room full of pharmacists and pharmacy students who turned up on a Saturday to listen to the likes of Trudi Hilton, a humanitarian aid pharmacist, it is clearly a cause that many pharmacists are keen to be involved with.

The purpose of the Brighton and Sussex Medical School’s humanitarian aid conference, held on 19 March 2016, was to highlight how the skills of pharmacists can be taken outside of their local communities to help populations abroad, for example those that are recovering from conflict and disaster. “[It’s about] taking care outside boundaries into much more difficult environments where there is a much greater need in many ways,” Ash Soni, president of the Royal Pharmaceutical Society (RPS), told conference delegates. “Pharmacists working in this kind of environment are critical. Humanitarian pharmacy is important. It matters,” he added.

The best route

As it currently stands, as Hilton went onto explain, there is “no career path, no postgraduate qualification and no manual” for pharmacists wanting to take part in humanitarian response work. While some organisations such as UK-Med, which helps facilitate the provision of healthcare workers from across the UK to support countries in crisis, have pharmacists on their UK International Emergency Trauma Register, they are yet to deploy any.

“The World Health Organization [WHO] didn’t have a job profile for pharmacy – it wasn’t one of their professional categories,” Hilton said. “They had essential medicines teams but these were mostly run by public health practitioners, not pharmacists who have an understanding of how to manage medicines.”

In 2012 Ina Donat, a lecturer in pharmacy practice at Robert Gordon University in Aberdeen, was involved in the crisis response in Haiti as part of a 17-strong team called Lemon Aid. Donat described how in humanitarian response there is often a doctor’s jacket, a nurse’s jacket, but no pharmacist’s jacket. “We know what pharmacists are, but the wider public don’t,” she said.

Because of the lack of understanding around what pharmacists can bring to crisis situations, Hilton decided to set up the Humanitarian Aid Response Network (HARN), which is accessible to RPS members and has been helping organisations understand the role pharmacists can play. “There are no jobs,” admitted Hilton. “But come through HARN and we’ll try and open up the opportunities to get involved and find out more.”

Challenges of humanitarian response work

Jon Barden, humanitarian and civil military adviser for the Department for International Development, highlighted the four principles of humanitarian aid at the conference: humanity, impartiality, neutrality and independence. “Everyone gets the same wherever the aid may be being provided,” he added.

A key aspect of humanitarian aid is that military assistance is only ever used as a last resort, “not until you’ve thought about everything that you could possibly use to fix the problem,” Barden explained. However, there are challenges with deploying civilians to countries hit by crisis. “People are quite happy to go to fragile states; their employers are not so keen,” he explained. “We have to talk to a lot of people to be able to send a civilian into a conflict zone.”

The difficulties around deploying healthcare staff for humanitarian purposes were also highlighted by Alistair Bolt, a medicines information pharmacist who had worked in Sierra Leone running an Ebola investigational treatment trial. His team had designed and set up an aseptic unit in just two weeks. One of the main problems with getting UK healthcare workers to help in humanitarian crises was with NHS staff being allowed to put their jobs on hold. The benefits that come back to the NHS from those who carry out this kind of work need to be highlighted to those who make the decisions, he said.

Barden also reflected on his experiences with the UK response to Ebola, an effort that required an investment of £325m by the UK government’s Department for International Development (DfID) and required a “special kind of bravery”. He described it as one of the most complicated projects he’s ever been involved in. “Everyone kept saying, it’s Ebola, it’ll go away, it always does! Well it didn’t.”

The DfID has now established an Emergency Medical Team (EMT) model in conjunction with the UK International Emergency Trauma Register to help deal with similar situations. As part of the initiative Public Health England has received £20,000 to help set up a ‘disease detectives programme’ to bring together public health experts who have the skills to help in disasters similar to that caused by Ebola.

Medicines issues in low income countries

There are chronic problems with medicines in resource poor settings that require the help of medicines experts.

Michael Deats, group lead on substandard, spurious, falsely labelled, falsified and counterfeit medicines (SSFFC) for the WHO gave examples of the way medicines are falsified globally. There is approximately one falsified product reported every day, with around 48% of reports coming from African regions. First and foremost, falsified medicines fail to treat the disease they are given to treat and, because they do not contain the ingredients claimed, they can also cause serious adverse reactions.

Deats gave an example in the Democratic Republic of Congo where drug shortages resulted in haloperidol, an antipsychotic medication, being dressed up as diazepam, a muscle-relaxant used to relieve anxiety. Debilitating adverse reactions happened in around 11,000 patients due to inappropriate and unintentional use of haloperidol where diazepam was intended.

Other issues with medicines in low income countries are related to medicines that are donated by well-intentioned but often uninformed donors. “Do not donate medicines anywhere for anything,” Hilton stresses. “There are so many situations where there is a pile of out-of-date medicines. [It costs] US$5 a kilo to destroy medicines.” She explained that there are charities working with medicines dedicated to disaster response. “The recipient needs to call the shots. Tell them what you have to offer and they will tell you whether to bring it into the country.”

“Disasters gives us an opportunity to build back better” Hilton stresses. “Pharmacists add another dimension to the team. Packaging, handling and storage [of medicines] is something pharmacists know something about. People need to understand what they don’t know and then ask for a pharmacist.”

Leaving a lasting impression

Donat highlighted that the key to success for any humanitarian response team was in the local population – if pharmacists from outside the area are able to share their skills with the local healthcare professionals they can leave the community with a lasting asset. This view was echoed by Emma Foreman who had worked as a pharmacist with Voluntary Services Overseas (VSO) in Ghana. During her time in Ghana, Foreman forged a lasting link with the healthcare professionals she worked with.

The Lusaka Brighton Link, which was set up officially in 2006 between University Teaching Hospital Lusaka and Brighton and Sussex University Hospitals and Medical School, enables healthcare professionals in the UK to provide support to staff in Lusaka. Melanie Newport, professor of infection and global health at Brighton and Sussex Medical School who came up with the initiative, says the benefits run two ways. “It makes you realise what you do have here and how to manage resources better.”

“Medicines optimisation is a global priority,” concluded Hilton. “To get the right medicines to the right patients at the right time, you need pharmacists.”