Aug 25

Aug 25 My Experience on the Phelophepa Train, South Africa.

Introduction

The Transnet Phelophepa Healthcare Train (Phelophepa is a Sotho and Venda word meaning ‘good, clean health’)[1] is the only primary healthcare train in the world and is an innovative initiative that attempts to make a positive difference to primary healthcare in rural South Africa. In 2016 during the final year of my pharmacy studies, I had the chance to spend a week on the train and experience the Phelophepa program.

Below is where the train stopped for a week.

The Phelophepa Healthcare Train provide crucial primary healthcare made possible by nurses, optometrist, dentist, psychologist and pharmacist. The nurses conduct screenings for cancer, diabetes, and hypertension, with pap smears for women and prostate checks for men [1]. The screening itself is backed by a comprehensive program of education and outreach. The dentist had a whole wagon for themselves and conducts teeth extractions, plaque cleaning and filling of teeth as well as educational talks on how to keep your teeth healthy. The optometrist, with a limited number of patients of 150 a day, conducts check-ups for the eyes and if needed provide reading glasses. They do many tests and they look for certain pathology and testing the eye capacity to see. The psychology students offer emotional support and how to deal with them as well as mental pathology. These sessions may go on for an hour, providing a very limited amount of patients per day. Finally, the pharmacist provides all the medications that have been prescribed by the nurses, dentist and optometrist. The pharmacist role is crucial for checking the correct usage of medications for the patients and for the pharmaceutical care it provides. Each department will provide outreach to the villages and schools to teach health education. The train brings hope and health where it is most needed to the rural areas of South Africa and I was glad to be part of it.

Harrismith, Andreas Astier. — About the Phelophepa program

Quick Facts:

In rural South Africa, there is a ratio of 1 doctor for every 5 000 patients.
Phelophepa is owned and operated by Transnet Foundation.
Since the first train journey in 1994, Roche is the Phelophepa’s main external sponsor.
Started as a three-car train in 1994 it expanded to two 18-coach trains by 2012; this gave rise to Phelophepa I and Phelophepa II.
Annually, the Phelophepa trains run for 36 weeks and travel to up to 70 remote communities.
The program started more than 20 years ago, and it touched the lives of approximately 12 million people. It has dispensed more than half a million pairs of spectacles and provided medication to over 650,000 people.
More than 15,000 volunteers have participated and over three million people have participated in HIV/AIDS and first aid training [1].

*Table 1. Statistics on the Phelophepa train for a week, February 2016. The currency is in South Africa is the Rand.*

*Table 2. A brief overview of the type of popular medication dispensed.*

The most common conditions that were treated were: pain and swelling from trauma or arthritis, lack of vitamins from malnutrition, cramps, stomach pain from too much acid, urinary tract infections and sexually transmitted infections, allergies in the sinus, allergies in the eyes, and dry and wet coughs.

*Table 3. A brief overview of the less popular medication dispensed. Note that aspirin is not that widely used compare to paracetamol (acetaminophen).*

Optimisation for Pharmaceutical care

Why optimising pharmaceutical care important? Its definition is "Pharmaceutical care is the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life [2]". In other words, it is improving the relationship between the medication and the patient through education and awareness on how to take these medications. I will have a blog on pharmaceutical care and pharmaceutics for further explanation on the subject.

How do we optimise pharmaceutical care? The Phelophepa program had a few tricks up their sleeves. Each pre-prepared medication bags had circles representing the number of pills to take and when to take them during the day. For example, there were three circles per bag representing three times a day. If the patient had to take 2 pills in the morning and at night then the first circle and the last circle would have either the number 2 or 2 filled in dots. This was effective to show the patients when they must take the medication and how many. In addition, on each pre-prepared bags, labels were explaining when and how many medications to take and on top of that there were labels/diagrams/pictograms. These were useful as pictograms cleared a lot of confusions for example: finishing the course, drowsiness, vomiting may occur, diarrhoea and others. Labels always had the patients name so that there was less confusion on who was taking them and had directions written out. We had translators, which was useful for patients who did not understand specific languages as South Africa contains 11 official languages.

We also made sure the PH number (a unique number per patient) corresponded with the script of medication so that the patient received the correct medication and hence abolished the mistake of given the medication to the wrong person altogether. The pharmacist could only let us dispense only if he had signed the script making sure the right medicines were dispensed and the rational use of antibiotics. When we could see the patient was still confused, especially for children, we made sure to ask questions such that they knew what to do, how to take and when, for example; how many pills are you taking and when? We did not ask questions that ended with a Yes or No. On certain medications, we further told them interactions that the medication would create, such as antibiotics with alcohol or how to use vaginal creams such as the clotrimazole cream (canalba) and its warnings.

*Our daily view from the Phelophepa train.*

Daily activity report

Monday 15th February

We woke up at 6:01 am at the sound of Anna’s voice saying “Good morning healthcare workers and students. Today is Monday the 15th of February; I hope you had a goodnight sleep and remember we are the Phelophepa train. We are here to serve the community so act appropriately and enjoy your day.” What soon followed was getting ready and then we were heading towards breakfast through the narrow hallways of the train. After breakfast, we brushed our teeth, and we were off towards the wagon number 16, where the Pharmacy was.

Upon our arrival, we had a short tour of the pharmacy and where the main medications were, especially the big four, which these were: Lenapain, napacod, methyl salicylate ointment (rub-rub) and calcium gluconate. We then had to put our details into the computer and printed all the legal papers and signed them. What followed was about 2 hours of pill counting for the pre-packed bags only to restart as the labels and the circles (representing when and how many pills to take) were wrong. At this time, the prescriptions still haven’t arrived yet, which gave us enough time every morning to organize ourselves. The morning went well and smooth; we learned mostly what to look for in a prescription, for example, lenapain interaction with high blood pressure due to caffeine being present, and where the medications were.

Lunch arrived, so we left for the wagon number 5, which felt like a kilometre away. Upon on our arrival, we were greeted by delicious food, which was like that for the whole week, and relaxed for about 30 minutes until we had to go back to the pharmacy.

That afternoon was a lot busier than the morning. More prescription arrived and went. More name-calling was made and the patient responded after a long wait. We still managed to keep a high spirit and great ambience in the pharmacy. When we were not dispensing, we would talk about African cultures and random topics, which was very enjoyable to relax between all the work. By the end of the week, we did grow on each other and it felt like a robust and competent workforce. Although because we dispensed on the side of where the pharmacy was, it was generally cramped with people (from translators being present) and chairs. At times it was difficult to go from one side to the other.

At 6:30 pm we finished and off we went for supper. This is where I met all the Optom’s (optometrist) and soon we became good friends with them. These were Marylize, Michael, Danika, Karine and Michelle. During the week we actually spent a lot of time at their rooms in wagon 6 and had a tremendous amount of fun. These were accompanied generally with coffee and games.

After that, I went to the cramped bathroom where we were only allocated 3 minutes to shower as water very limited. We had to get wet, switch off the shower, shampoo and then rinse, so 3 minutes in total. This was around 10:30 and 11 pm. At this time, I would be getting into bed and catching up with my emails and other messages that I could not attend during work.

Tuesday 16th February

I do not want to repeat myself for every day, as the routines were similar but this morning was Danika’s birthday. Danika is a blonde, blues eyes South African Afrikaner origin and is in her final year of optometry. Throughout the intercoms that morning came the sound of the other 4 optom’s students singing happy birthday. This was a funny and different way to wake up.

Phelophepa waiting area, Andreas Astier.

My second day at the pharmacy and I was already speaking in Xhosa and Sotho in terms of good morning, how are you, I am good, thank you ‘mama’ and ‘baba, tata’. When a foreigner or a white person speaks an African language, there is immediate respect and wanting to listen to that person. This was a crucial skill to use, for when the patients arrived, it made the interactions and pharmaceutical care a lot more effective. When it did get too difficult for me, my translator would then intervene and speak on my behalf. I did make sure she understood what I wanted to say so that no crucial information was lost in the process. I soon learned that joint pain, cramps, stomach pain, allergies and sexually transmitted disease/urinary tract infections were widespread. I grasped all the important information very quickly and used my theory to apply in the working area. Interestingly enough, there were a lot more older female patients than overall male patients. When I asked upon this observation, I was told men do not want to come because they either working or might be something that they don’t want to go to. When kids did arrive the most common medication was allergies for their eyes (stopallerg, spersallergy and tears natural). If they were young (especially around 6 months to 3 years) then the most common medication was multivitamin syrup, acuflu P and amoxicillin to be reconstituted with 53 mL of water and shaken.

That night more hangouts with the optom’s students with coffee and more banter occurred. It is weird how friendship can occur almost at most unsuspecting times and places. What was interesting was that we could exchange our experience in our allocated department. I learned that the optometrist highs were the expressions some patients had when they thought they could see, and when they put on the glasses and exclaim ‘eishu now I can see better!” They said it was a wonderful feeling to see patients being delighted by seeing clearly again. Their lows were seeing patients sleeping just outside the eye clinic so they could be first in line the next morning. At night it mostly rained and it was generally cold, but luckily there were tents.

On top of that, they could only get 150 patients, so how would you feel when a patient walked for 2 hours so that they could be turned away because they had reached the limit? Another example was that some patients had eye problems beyond what the optometrist could prescribe (scope of practice) and the fact that they cannot operate on the patient’s eyes. These were bacterial infections or other pathology, which means you cannot give glasses as you have to treat the infection first and then tell the patient to come back. The problem is that now you have to go see the ophthalmologist or the doctor, which was far and expensive. On top of that, the train was only at its location for a week, so if it took longer for the patient’s eyes to heal they would not be there anymore for any follow ups.

When I received scripts from the optometry department, I would look at the patient’s eye while dispensing. Sometimes it looked fine, but sometimes I could see what I was giving would not help them at all. This is because we don't have the medication for a bacterial eye infection and we don't have the highly specialised personnel such as an ophthalmologist. Hence a sense of hope was produced as they thought their conditions would heal, but we knew it wouldn't. This wasn’t a nice feeling at all. We went to bed at around 11 pm once again.

Wednesday 17th February

The next morning I woke up tired and sore and wondered why I went to bed so late (happens all the time). Apart from that, it was another successful and casual day. We did get a mama (an older lady patient) who got angry with us as she did not get her Rub-rub (methyl salicylate ointment). The reason is we do not have enough methyl salicylate ointment and hence you have to be 60 years old and above to get the 500 grams methyl salicylate ointment. We did explain to her but she was having none of it and walked away swearing in Afrikaans. In cases like that, there is nothing we can do and the swearing didn’t bother me (it was actually a little bit amusing). Some patients took it well and others did not. The Rub-rub was a problem, it seemed everybody wanted that rub-rub. Sometimes really young patients 25 years old would want rub-rub because they have pain in the joints. In my mind, the nurses prescribed unnecessary the methyl salicylate ointment just so they could satisfy the patients. Remember that methyl salicylate ointment is to soothe the inflammation and not cure arthritis or rheumatoid arthritis.

That night for supper we had braai meat (a South African favourite, also known as a barbecue in other countries but the difference it is made with wood fire and love), which was delicious. I must admit the food is exceptional as all I did was eat.

Thursday 18th February

Today went as usual as the other days, enjoyable as always. That night it was a bit different as we played a game called Mafia. This game was very enjoyable and got better the more people we reach. Basically, we hand in cards, which will represent the mafia (2 of them or 3), the doctor, the cop (might go up to 2) and the citizens. Throughout the whole game, no one knows who is who, so it is a trust game. The mafia can take out whomever they went, the doctor can save and the cop(s) can find the mafia and get them out of the game. Through and through it was very funny as we played all the way to midnight in the dinning wagon.

Friday 19th February

I woke up semi tired that morning. Anna’s voice once more spoke through the intercom announcing our beloved pharmacy students were leaving today. It was a bit sad to know we were leaving that afternoon leaving our new friends behind. The morning went well and the lack of sleep did not affect my work since I knew I would sleep on the Greyhound for the return home. As we finished our shift, the pharmacy crew went for a photoshoot in front of the pharmacy wagon number 16. We laughed through the photoshoot knowing that this week was a good week full of hard work and friendship for the ‘legal drug dealers’.

Lunch came and goodbyes were made to everyone that positively affected us. Saying goodbye to the optom’s was bittersweet but I guess it happens all the time on the Phelophepa train. This afternoon we left at 1:30 pm for Johannesburg and arrived there at 4:35 pm, and soon we would be on the Greyhound to arrive in Grahamstown (14 hours later) at Kimberley Hall the next morning. Grahamstown is situated in the Easterncape of South Africa; this is where Rhodes University is located.

Personal experience

I did not know what to expect, but I had a general idea of what might happen on the Phelophepa train. What I experienced was phenomenal. I met wonderful people, I helped people, my confidence grew, and my knowledge in medication and pharmaceutical care sharpened. I may not have learned a lot of new skills, but it just felt right being there and helping these people who do not have primary health care. Personally, I did not have problems or frustration on the Phelophepa train, but I would like the pharmacy on the Phelophepa train to have more medication ready and in the correct amount of stock. It was just sad knowing we could not give medications because we ran out. That did frustrate me. This experience was fulfilling, as the people were so grateful to receive primary medical care.