Dispense like an Egyptian
John Minshull is a preregistration trainee at Pennine Acute Hospitals NHS Trust
In 2003 Sayed El-Awady, professor of pharmacology at Suez Canal University, Ismailia, Egypt, was awarded funding from the EU to improve educational links between Mediterranean and British schools of pharmacy. A relationship with the University of Bath was established with the remit to implement computer-aided learning at Suez Canal University. Included in the EU grant was the provision to allow UK pharmacy students to visit Ismailia and Egyptian pharmacy students to visit a British school of pharmacy. I, along with another student on my course, was selected to make up the English contingency visiting Ismailia.
On our arrival in Cairo we were met by Dr Sayed, who drove us to Ismailia. It was dark for much of the two-hour journey to Ismailia, but within seconds of arriving in the canal-side city, we were treated to our first two experiences of true Egyptian culture. Both of these were associated with weddings. The first was a wedding car convoy weaving through the streets, beeping car horns and flashing lights. The second was a wedding photo session taking place in the photography studio next door to one of Dr Sayed’s pharmacies. A large crowd of people (invited and otherwise) had gathered around in colourful clothing, chatting and taking pictures on their mobile phones. We knew immediately that Egyptians were fond of having a good time.
A few mornings of the trip were spent in one or other of Dr Sayed’s pharmacies. This was an opportunity to learn about pharmacy practice in Egypt and the educational requirements that precede it. The Egyptian pharmacy course leads to a BSc after five years of study. The first three years of the course at Suez Canal University focus on anatomy, biology and chemistry. The final two years introduce the student to the concept of clinical pharmacy and clinical pharmacology. Immediately after graduation, the Egyptian pharmacy student is qualified as a pharmacist and is capable of working in such a capacity.
Pharmacists are in abundance in Ismailia (and Egypt in general), which is useful since there is a plethora of pharmacies. However, it is not compulsory for a pharmacy to be staffed by a qualified pharmacist at all times. On the contrary, as long as the management of the shop is conducted by a pharmacist, any person trained in the sale of medicine is able to take personal control.
Egyptian medicine controls differ greatly from those in Britain. Many items which would require a prescription for purchase in the UK (eg, beta-blockers, morphine, and antibiotics) can be “prescribed” by the person in personal control of the pharmacy. As well as reflecting a high opinion of the capabilities of the pharmacist, this is indicative of the financial situation of many of Ismailia’s residents. For instance, obtaining a prescription to treat a throat infection in the UK requires a visit to a physician followed by payment of a prescription charge for the medicine (if required) to treat the illness (if such a thing is appropriate). Instead, in Egypt, the patient is empowered to diagnose the illness themselves, consult a pharmacist on the choice of drug and pay just for the medicine. Although this may jar with many UK health care professionals, it is a viable alternative for a country unable to maintain as comprehensive a social health system as Britain. Conversely, it does lead to major problems with resistant bacterial strains, since patients are also empowered to demand the medicine they want and may not see the possibility of an infection being viral and the condition being untreatable with antibiotics.
There are some medicines for which a prescription is essential. This is to protect the patient from misuse. Benzodiazepines fall into this category. Another drug that falls into this category was brought to our attention on the first Friday morning of our visit. A man presented in the pharmacy requesting misoprostol (a drug we had mistakenly assumed would not be available from a community pharmacy) to terminate a pregnancy. However, he was unable to furnish a prescription and the pharmacist had to turn him away.
Two evenings were spent at a Suez Canal Authority employees’ social club. The club overlooks the canal and provides a large, open recreation area for residents of Ismailia. It is common for Egyptians to spend leisurely summer evenings in such an environment to avoid the torturous heat of their apartments and houses. These sojourns run on late into the night, especially on Thursday and Friday, when people are able to celebrate the weekend.
Being posted in Ismailia put us in close proximity to Medical Union Pharmaceuticals at Abu Sultan. Each morning for a week, a driver came to collect us from the hotel and deliver us to the factory. This drive allowed us to savour the isolated desert and appreciate just how much space there is in this large country. To put the available space into context: Egypt has a population of about 70.5 million people living in almost 1 million sq km (70.5 people per sq km) compared with Britain’s 59.8 million living in 0.24 million sq km (250 people per sq km.)
The desert was stark in comparison with the city, which, due to its location halfway along the Suez Canal, is commonly referred to as the garden of Egypt. The Suez Canal, as well as being the third largest contributor to the Egyptian economy, provides the city with the water required to turn desert into lush greenery.
The factory for Medical Union Pharmaceuticals is home to a research and development suite, quality assurance and quality control departments, as well as a large production unit. MUP is a big player in the Egyptian pharmaceutical game, producing drugs developed by itself (such as the rapid release ibuprofen tablet) and in partnership with international names (eg, Schering-Plough). We were able to visit the company’s production unit, which was, at the time of visiting, being prepared for an inspection by the Ethiopian health board before producing drugs to be sold in Ethiopia.
At the end of our packed visit to Ismailia, we were accommodated as guests at the Suez Canal University in Cairo. This gave us the opportunity to visit many of Egypt’s more famous sights, such as the Pyramids at Giza and the Mohammed Ali Mosque. In the typically generous style of the Egyptians we met, the head of the quality control department at MUP had volunteered her son (also a pharmacist) to accompany us around the capital. He was able to show us the best restaurants and coolest bars (all serving fresh fruit juice and no alcohol in accordance with strict Muslim law) while describing to us his transition from pharmacy student to medical representative (a career favoured by Egyptian pharmacy graduates who do not want to work in pharmacies).
My thanks go to Steve Moss (University of Bath) and Dr El-Awady who made this trip possible. Thanks also to everyone in Ismailia and Bath who worked to make the visit a success.