Working at Jolly's Pharmacy

After a beautiful and relaxing weekend in Dominica, we got down to business at Jolly's Pharmacy in Roseau. The senior pharmacist there, Carlton Lanquedoc RPh, took us on a tour of both Jolly's locations and the manufacturing center that are all within walking distance of each other. It was interesting to see how similar the pharmacies were to Walgreens and CVS. Both locations used an electronic system to enter prescriptions and together they filled about 500-700 prescriptions a day. Some differences that we noticed with Jolly's was that everyone waited in the pharmacy for their prescription to be filled, there was no wall of prescription bags waiting to be picked up. Also, we saw that most prescriptions were handwritten, sometimes written on notebook paper or in the patient's medical book (which is literally a composition notebook containing the patient's medical history). 

Carlton Lanquedoc giving us a tour of Jolly's Manufacturing Center

Products manufactured at Jolly's

A view of both locations of Jolly's Pharmacy

We all perused the over the counter (OTC) section of Jolly's to check out what locals typically use. A lot of the products were the same as what you would find in the US, just made by a different company. Some medications that are controlled in the US (pseudoephedrine) or only available as a prescription (Voltaren cream) was available as OTC products at Jolly's. The prices of medications were very different from what you would expect it; seemed like some overpriced medications were cheaper at Jolly's because they purchase from non-US manufacturers mostly. They also shop around to find the best prices on each medication. However, it seemed like generic medications that are on the $4 list in America were more expensive in Dominica due to importing the medication or for other reasons.

OTC aisle at Jolly's Pharmacy

As a part of the Jolly's Pharmacy team we held two health screening fairs where we checked BMI, body fat percent, blood glucose, and blood pressure for free. We could also check an A1c or cholesterol for a fee. The people we saw here were very open with us about their health problems and almost everyone seemed very interested in the information we provided them. Sometimes when we have done screenings though U of Iowa, people want to know what their results are, but then are not very receptive to the information we provide and do not always ask questions.

Jolly's health fair at Campbell's Business System and Services 

Another part of the experience with Jolly's was participating in the Health Vibes show on Wednesday morning, which is a weekly radio show that is popular in Dominica and other Caribbean islands. We went on the show with Carlton and Pearl to talk about oral contraceptives. Important things that Carlton wanted us to cover was other uses of oral contraceptives besides preventing pregnancy, the fact that they do not protect against STI's, and that emergency contraceptives are not for regular use. The following day we provided a continuing education lecture to Jolly's pharmacists and pharmacy technicians on the same topic, but we included information on other types of contraception methods. I think the Jolly's employees really benefited from the session because physicians in Dominica are not as familiar with contraceptives and ask the pharmacists lots of questions. Additionally, women in Dominica do not have to have a prescription in order to obtain oral contraceptives, so the pharmacists need to be able to get a relevant history on the patient and make a recommendation.

Health Vibes on oral contraceptives

Continuing education on contraceptive methods

Working at Jolly's taught us a lot about what pharmacy practice is like in a location where access to medications and medical supplies is somewhat limited. We also learned to be more creative with our suggestions to patients because they may not be able to obtain or afford the supplies and medicines they need. Even our suggestions on lifestyle changes were adjusted to fit the culture in Dominica.

-Macey and Shavea

Our Welcome to Dominica 2017

Top view of the island of Dominica

In the morning of Friday, Jan. 13, we arrived to Dominica in a very small plane. There are only two airports in the island. Interestingly, we were not allowed to take photos at the airport.

After a 45-minute drive on curvy, narrow roads and a few episodes of car sickness, we finally made it to Springfield Guesthouse (a.k.a. Archbold Center). Upon arrival we were greeted by the owner, Nancy, and one of the staff members, Mavlyn. At the Springfield Center we felt close to nature as everything was lush and green and the rooms were opened to the air because there were no window screens. Each bed had a mosquito net hanging above it, which was weird at first to get used to but the nets eventually became cozy, like sleeping in a tent.

Our rooms at Springfield Guesthouse

The first weekend was all about getting to know the island. On the first day, we got to visit the river behind Springfield, which was surprisingly cold. The islanders claim that there are 365 rivers in Dominica. 

River behind Springfield

On the second day, we went down to the market place in Roseau, where we tried fresh coconut, bought souvenirs from local shops and outside vendors, and visited the spice shop at Ruins Rock Cafe. We next headed to Bubble Beach in Soufriere, which was a rocky beach. Finally we ended the day with yoga, taught by "Jungle Bay" Nancy, back in Springfield.

Roseau market

Ruins Rock Cafe

Bubble Beach

On the next day, Sunday, we visited Mero Beach, which has black sand instead of rocks. We had local drinks and food at the Romance Cafe. Here we met with Mark, who is in charge of the Keep Walking Association (KWA), and Maureen, who kindly invited us to her home to learn about local herbs and their use as bush medicine. After stopping at Maureen's place, we headed over to Mark's workshop, where we learned about howhe re-purposes prosthetics for amputees in the island and how the KWA was born. Overall, our weekend experience was mesmerizing as we learned how kind and open the locals are to visitors and how quickly we made new friends.

Mero Beach

Bay leaf to repel insects

Aloe vera for sunburn

Mark's workshop

- Post by Macey Reynolds and Shavea Zapata Juan

Boiling Lake and Rural Health

This weekend we hiked the Boiling Lake trail to experience more of the natural beauty of Dominica, and learn about the medicinal benefits of sulfur. Dominica has 9 dormant volcanoes.  Hot gases are released from underground, making the lake boil and a nearby valley and stream which they named the valley of desolation since nothing can grow there due to the heat.  The sulfur mud found in that valley has healing properties for skin, and the sulfur rocks and crystals can actually be lit on fire. It was a strenuous hike that took all day, which tested both our mental and physical strength, as well as our team-building skills as we helped one another make it through safely.

Sunday we helped execute a 5k run in the native Carib Kalinago territory. We were promoting the health benefits of exercise, and hope they will continue running together after we are gone. After the race we shared educational information on topics such as how to prevent and treat running injuries or foot problems, as well as how to stay hydrated and make their own oral rehydration solution from salt and sugar at home.  We also showed them some simple stretching exercises.

Today was the first day visited the rural health clinic and got to see first-hand the vast discrepancies between privately run pharmacies like Jolly's versus the government run rural clinics.  The rural clinics have very limited formularies of what they can prescribe, and very low quantities of what they do receive so they often run out and access to medications becomes a big problem.  We discussed problems associated with lack of access and variety in formulary, such as resistant bacterial infections, and lack of emergency drugs since they are a long distance from the nearest hospital. They also have to keep all handwritten logs of inventory, usage, and care given since they have no computers. Every person keeps their own medical book which acts as their whole medical history and prescriptions.

--- Erin & Jaclyn ---

Herbal Medicine

Part of our rotation is not only to educate the people of Dominica, but also to learn about their native herbal bush medicines.  We got to visit our good friend Dafrica's father, Marcus Thomas, who lives out in Bagatelle.  He has an extensive yard full of medicinal herbs, plants, and fruit trees.  He gave us a tour of his gardens, and described the medicinal uses for various plants.  For example, he grew ginger for stomach problems, tumeric for inflammation, dandelion for blood toxicity, mint for headaches, hibscus flowers for healing internal problems, and mature papaya seeds for birth control. Then we got to make our own herbal teas straight from the garden. We also got to learn the full process for making coconut oil by hand, all the way from the tree to the finished product, which gave us a new appreciation for it when we realized how much work it was!  Dafrica also walked us through how to make natural soaps, using coconut oil and herbs from the garden.

Today we got to visit our good friend Ceurvon, who walked us through the process of harvesting cinnamon bark. First he helped us select and cut down a good tree. Next we have to scrape all the outer bark off, and score the trunk into 6 inch segments. Then we began the process of carefully separating the inner bark from the core.  The inner bark is the portion of the tree with medicinal properties, such as: for blood pressure, blood sugars, GI problems, and premature ejaculation.  The last step is to sett the bark out to dry in the sun for a few days before we can then use it to make teas, or grind it to use as a poultice.  We found out that we are much better at harvesting cinnamon than we were at preparing the coconut oil!

These experiences really help us to understand how much time and effort it takes to even prepare traditional bush medicine, and its importance within their culture here in Dominica.  The knowledge of the plants and how to properly prepare them seems to get passed down from parent to child as a part of growing up here.  Learning more about herbal treatments makes us more confident in discussing possible uses of herbal products with our patients back in Iowa.

--- Erin & Jaclyn ---

Dominica 2017: Motivation

Sometimes I get motivational emails sent to me.  Since landing in Dominica this time, this is one that held particular meaning to me.

The baby steps in the beginning of a journey, Jeanine Abrons, always seem inadequate compared to the brilliance of the dream that inspired them. This is natural. If the dream wasn't so far "out there" and dazzling, it wouldn't be worth dreaming! Just don't be led to think that the physical ground you cover with your baby steps is all that they accomplish. Because for every mortal step you take, another cog in a giant wheel behind the curtains of time and space advances, and with it 10,000 new possibilities.  I continue to be reminded when we are in Dominica how many things that have seemed impossible are possible because of the many friendships and relationships that have been forged. In particular, I think how fortunate we are for our relationships with Sam Raphael and the Jungle Bay Family as well as Orrin Jolly / Carlton Lanquedoc and the Jollys' Pharmacy family. I hope that the blogs we write over the remainder of the rotation serve as a reflective opportunity. I often realize after the fact how wonderful the experiences are and how blessed we are to be a part of them. I hope wherever you are in this world that you'll believe and see the amazing things that you can do as a person. I hope you will ask the questions: what can I do and is this possible. If you don't ask, if you don't dream, you'll never know.  Happy Saturday to all!

January 23, 2015 - Jones Beaupierre Primary School Visit

Today's activities included the visit to Jones Beaupierre Primary School and making castor oil at Raphael's.

What was most significant about our involvement in community service as pharmacists?

The most priceless part of this experience was seeing the smiles on the faces of the children at Jones Beaupierre Primary School. It was an extremely eye opening experience to see how much they appreciate the little we could do for them. Days like these let us realize that becoming a pharmacist not only enables us to help our sick patients, but anyone in our reach. While talking with the children, we started the conversation asking if anyone wanted to be a pharmacist, and through talking about our paths and the career options that a pharmacy degree entails, the number of hands raised vastly increased by the end of our visit with them. It was satisfying to teach young people about pharmacy and help them become aware of the field as a career option.

 

How was this experience significant to you?   

Living in a rural community, we can't imagine that the children there have all the necessary resources to be aware of the endless careers options possible. For us, this was one of the most meaningful parts of the rotation because we had the chance to plant a seed by talking with the children about career possibilities with pharmacy. We hope that this will grow to increase the number of pharmacists in Dominica.

 

What did you learn about caring for others and improving lives?

Sometimes we tend to spend a little more than necessary because we have the money available. However, we need to take a step back sometimes and realize we can live without some of the luxurious things in life; we need to think about someone else for a change. Other times we complain about how bad our life appears, but there is always someone else in a worse situation. Next time we have some money to spare, hopefully we think to use it to help someone in need, and when we have time to spare, we can give our time to greater causes.

January 20, 2015 - First Clinic Day

Today was the first day of clinic, the “real meat and potatoes” as Tressa says. Our group was to go to Petite Savanne, but upon arriving there, we soon found out that it was cancelled due to an emergency. Dr. Abrons knew this was a sign we were all supposed to stick together today, so we went to La Plaine with the others. We started off in the waiting area and chatted with the locals by introducing ourselves, inquiring about the patient’s background, and then asking what brought them in to the clinic. This then led to further inquiry depending on whether they were in for a follow-up appointment or if they have a more recent problem to address.

We also had an opportunity to talk with the health aid at the center, and she showed us the casualty room, which is where acute situations are managed, such as wound care and motor vehicle accidents. She opened the cupboards and drawers for us and showed us the supplies that were available.

Through these interactions, we learned just how difficult it was for the patients in these rural areas to access healthcare as a single doctor and pharmacist are relied upon to serve multiple communities, and the system falls apart when one falls ill or is unable to make it to the center. We also learned that there are limited resources, as the pharmacy inventory was very small and equipment had to be sterilized in Roseau. We were pleasantly surprised to find that everything at the clinic, including the medication, was free for the patient. Unfortunately, adherence remains an issue, probably due to availability, lack of understanding of medication’s importance and worry of side effects.

Although we did not get to meet Kent today because he was ill, Dr. A filled us in on his role in the pharmacy and we were surprised to hear that he carries around much of his medication supply in a suitcase and is not only responsible for ordering medications, but also medical supplies. Dr. A informed us that he used to also perform blood draws to obtain labs, something that none of us would be capable of doing.

After clinic, Orrin from Jolly’s came to talk with us, and we found it surprising that there is no regulating agency in Dominica, allowing medications to be obtained from any country and for pharmacists to compound any medication they desire. Through this day, we have reflected on how we can make a greater impact at our next clinic days. We hope to have more time to talk with the patients and to have a chance to look at their medical record book before they see the doctor, as well as follow up after they are finished with their appointment. We also hope to find patients with the disease states that we have “become experts” on, and educate them on those topics and provide them with further resources like our brochures.

The three of us finished off the day with some advertising for our health fair on Monday at the La Plaine Health Center, riding around the La Plaine villages and Delice with a bullhorn and announcing details. “Bonjour! Sakafet! Come one, come all!” We’re expecting a great turnout!

 

August 21, 2013

Today we had the chance to make our own cinnamon sticks from scratch. We were invited by Ceurvon, a Jungle Bay tour guide, to go to his house since he grew cinnamon trees in his yard. The tree looked like a normal tree until he described that cinnamon trees were a reddish tint, and thus we were able to find our cinnamon tree. 

Our next task was to find a tree that was easy enough to peel the bark and cinnamon off of. After finding the right tree we were given the responsibility of cutting down an entire tree, which mostly all of us have never done before. We cut down the tree with a machete, and for most of us this was the first time we had ever even held a machete, and carried it to the front yard for Ceurvon to show us how to harvest cinnamon. After cutting the tree down, we had to scrape the bark off of the tree using a knife. This task was somewhat difficult because we had to scrape off just a small amount since putting too much force and scrapping too much would reveal the underpart of the cinnamon we wanted to extract. The next step was to cut the cinnamon tree into smaller pieces and to section off how long the cinnamon sticks would be.  Next, we cut back layers of the cinnamon tree and took a dull knife to slowly peel back the cinnamon in order to make sheets. We brought back the sheets to Jungle Bay and laid them out in the sun to dry. The drying process typically takes about 2-3 days to fully dry and at the end of the process will give cinnamon sticks. 

Cinnamon has many medicinal properties, for example it may be used for weight loss, diabetes, insect repellent ingredient, upset stomach, runny noses, blood thinning properties, and much much more! After seeing how grueling the process of making cinnamon really is, all of us are able to appreciate the preparations that are available and already prepared for purchasing in the United States. 

After making cinnamon we continued on our tour to Tony's. Tony is a local resident of Dominica who has been farming for over ten years! All of his products are organic and he produces a variety of fruits and vegetables to sell to other locals, of which includes Jungle Bay. Tony's farm consisted of at least two green houses in addition to a multitude of land for farming. He gave us avocados from his farm and explained his techniques in farming. One of the interesting techniques were to grow cabbage above ground, of which his reasoning was to keep animals from eating his crop. We also noticed that with the above ground planting, he was able to use less soil and did have to worry about where rain water would go. After seeing all of his farm, we were able to learn about the importance of eating healthy and utilizing organic farming towards our advantage. We were able to learn about GM or genetically modified fruits and vegetables and why they were bad for us. 

After touring Tony's farm, we came back and ate lunch and were given the afternoon to finish our herbal scavenger hunts. Overall today was very educational. Being given the opportunity to harvest our own cinnamon taught us how hard it is to harvest cinnamon and to think twice about how much cinnamon costs in the grocery store in comparison to how much work actually goes into making dry cinnamon. The tour of Tony's was also a good learning opportunity since it taught us how to create sustainability in terms of farming in addition to the importance of eating healthy while emphasizing on Sam Raphael's philosophy of putting in hard work but getting rewarded in the end. Tony puts a ton of time, work, and sweat into his farm, and in return he helps to feed many people, including us at Jungle Bay, with fresh, healthy, and organic food.

Theresa & Bianca

Sea turtle sighting: August 20th

Last night we had the opportunity to go visit the beach where the NET program is currently active.  The NET program is working to protect sea turtles from poachers and the environment.  Turns out a turtle needs to lay nearly 1000 eggs for one turtle to survive! Simon, who currently heads the project as a volunteer, had hopes that a nest would be emerging last night.  However as he dug through the sand he realize that there would be no baby turtles that night.  We did get to see a mother emerge from the ocean and had a chance to pet her!!! Follow this link to read more on the project--http://www.avirtualdominica.com/seaturtles/.

                                                                            Enjoy! 
                                                                      Katie & Dani

LaPlaine Clinic- Tuesday, August 20th, 2013

Today we all passed on yoga to make it in time for our big day at LaPlaine Clinic. We got our things together and headed to our usual group breakfast. I am really going to miss all the fresh fruit and juices I've gotten accustomed to having here. On our way to the clinic, we stopped and picked up the pharmacist Kent. Today was my first time meeting him, and I learned a great deal. When we arrived at the clinic he introduced our group to the patients out in the waiting area. He also explained to us that it would be a slow day as there was no doctor today, and there was a funeral in the afternoon for a younger member of the community that most people planned to attend.
I learned that Kent is a government pharmacist and went to school in Jamaica for 4 years to become a pharmacist. He told us that some people continue their pharmacy education in Canada, the US or England; but he elected to return to Dominica to work. He works everyday and stated that pharmacists are always on call if a doctor needs a medication for a patient. He used to own a private pharmacy in his home, but it was too much work.
Kent also taught us about pharmacy in Dominica and about how prescriptions are dispensed to patients at the clinics. He even let us help him dispense and label prescriptions from patients.
Here is the process:
1. Patient comes up to pharmacy window and hands over their medical record (notebook).
2. Pharmacist looks in notebook to see what medications need to be refilled.
3. Medications are counted and put in plastic bags and labeled with patient name, drug name and strength, directions and quantity. Patients are usually given a 30 day supply.
4. A manual log book is filled out with the patients name and what medication and quantity was dispensed.
5. An inventory balance sheet for each drug is added on to.
6. The patient is given the prescription and counseled on it.
After learning how to fill prescriptions with Kent, I went and interviewed some patients in the waiting area. One of my patients was particularly interesting. She was 35 years old and at the clinic as a caretaker to an elderly woman who was there to see the dentist. She told me that she had no diseases, but she was showing signs of Dengue fever. She was given acetaminophen and would see the doctor if her symptoms of headache, rash and weak joints continued. She told me that she just moved back here from Canada, and had been living there for 12 years going to school. She told me that many of her friends left and went to college in the US or Canada and then got married and became citizens. She ended up having a baby in Canada but was never married so she was asked to leave a few months ago. She took her 5 year old daughter, but had to leave her childs father behind. She was hoping to find a way to move back to the US or Canada. She told me that in Dominica it is mainly the older generation who are using herbal medications and the younger people are using western medicine. She really liked how the medical system in Canada worked a lot faster and you could always see a doctor if needed. In Dominica she said it could take a month.
Today I tried to be more effective at the clinic by trying to ask the patients more about the herbal medications they use. Last week, I hadn't learned as much bush medicine so I wasn't as comfortable with it. Today I asked the patients more about these methods and learned a great deal. I gathered as much information as I could to prepare for my case presentations and tried to focus on the complete wellness of the patients, rather than just the medications they were taking. I also made recommendations for them to see the doctors at the next clinic for certain conditions. All in all, I think the clinic today was a great experience. I learned a lot from Kent about practicing pharmacy in Dominica, and I learned a lot from the patients about bush medicine. I am definitely learning many things here about alternative medicine, that I will incorporate into my practice of pharmacy in the US.
Susan

Dear Future Dominican Rotation Students...

      I think one of most important things to think about when you're preparing for Dominica is actually mental preparation.  Yes, it's a completely different terrain from either Iowa or New York so you'll need to be in pretty good shape to keep up with the rigorous exercise associated with the activities, but I think the bigger thing is just to mentally prepare.  Chances are, Dominica is completely different than anything you've done before. It's not a vacation where you deal with the heat and rain for a few days and then leave, you are here long enough to have to adapt.  
      Bring your raincoat and put pretty much everything in ziploc bags - especially electronics.  Make sure the majority of your clothes are dry fit material because you will sweat... a lot. Bring 4-6 nice outfits for clinic days, but otherwise pack workout clothes.  We had a small bottle of laundry detergent to wash our clothes and brought a clothes line that we put up in our cabin to dry things out.  It is essential that you take care of your feet!! Test out your water shoes before hand to make sure they are comfortable to wear pretty much 24/7.  I got water tennis shoes make by Columbia Sportswear and they worked perfectly for me.  Along the trails, especially in the rain, some of the girls were getting rocks and twigs stuck in their Keens and had to keep stopping to dig them out since they aren't enclosed shoes.  
      Mentally prepare for the physical challenge of the rotation.  No matter how much you work out before hand, you are going to be pushed to your limits as far as what you can physically handle.  If you've got a positive attitude saying you're going to take on each challenge as it comes, you're likely to get through each one and learn a lot from it.  Do yoga in the mornings if you can.  Not only does it help stretch out sore muscles, but it gets you moving and gives you a little more energy to kick start your long days! 
      Have an open mind when learning about the herbals and natural remedies.  The people have a lot of knowledge that they're eager to share, so make sure you ask a lot of questions!  If you're like me, you might struggle to understand them at first, so make sure you pay attention, listen hard, and try to rephrase things if it seems like they didn't understand what you said.  I know we are told natural remedies are inferior to Westernized medicine in school, but these people use it all the time and seem to really benefit from it so try to push all the judgments aside and really learn from them and embrace their culture as much as you can!  
      Go outside of your box and try new things, especially regarding the food.  Everything is so fresh and delicious.  If you don't eat fish, try mahi mahi first... they told me it was the "gateway fish" :)
      One more note about living things... get used to things that crawl.  There are geicos everywhere and you'll see crabs, lizards, snails and other little things around your cabin.. Nothing will bother you, but there are nets above your bed if it makes you feel more comfortable.  I never used mine.  Just give them a name and make them your pets.  
      As always, if there's something you aren't comfortable doing, that's okay, but really try to push yourself if you can!! You will learn just as much about yourself in Dominica as you do about plants and natural medicine.  Lean on the other students when you need to.  You're a team, going through the same things together.  You'll become really good friends in a few short weeks, and sharing this experience will be something you'll always take with you!  Congrats on being selected, I hope you have a great experience in Dominica! 

Megan Schwartz 
University of Iowa College of Pharmacy
PharmD Candidate 2014