REVERSING BRAIN DRAIN: A PERSONAL TESTIMONY

By Dr. Bisrat Hailemeskel

I am an intellectual product of the Addis Ababa University (AAU). I received my Bachelor's Degree in Pharmacy and a Masters Degree in Chemistry from AAU in the 1980's. Although I came to the U.S. to pursue a higher education, like many other Ethiopian colleagues in Diaspora, I remained in the U.S. after completing my studies in the 1990's. Since then, I have been looking for opportunities to give back or "To reverse the brain drain." My first opportunity, thank God, came during the first meeting of the Ethiopian Northern American Health Professionals Association (ENAHPA) held in Washington, DC. Anna Hovde, one of the speakers at the meeting, was pleading conference participants to deliver a few lectures while traveling to Ethiopia to visit friends and relatives. I am working as a professor at Howard University, teaching at the School of Pharmacy, and the idea of giving lectures was a perfect match for me. I stayed behind and approached her to talk to her in more detail. She gave me a contact name of a person which turned out to be the beginning of a productive and a long lasting journey.

After a few e-mails and phone calls, I made my first trip in April 2002 to teach a 2-credit hour course. I loved it. It was one of the most rewarding experiences I had ever had. I went back twice in that same year. Since then, I have been traveling to Ethiopia on a regular basis. The first formal trip came during October 2003 when I traveled along with a group 40 other members of ENAHPA. The trip was the first major surgical and medical intervention trip and was led under the leadership of Dr. Ingida Asfaw. More recently, I went back this December and stayed there from 12/4/04 to 12/22/04. It was my most recent trip and the focus of this report.

It seems that my level of involvement and degree of contribution has kept growing more and more since my first trip. The primary purpose of this report is to share with you my testimony on how a simple e-mail can turn out to be the means of a major contribution. Here is the summary of my accomplishments and contributions during this recent trip. Of course, the following list includes only the ones that I believed to have had an important contribution to "Reversing the brain drain". However, it does not include involvements related to my other personal matters or activities related my family or friends.

1. TEACHING A GRADUATE COURSE

   Addis Ababa University (AAU) is one of the largest higher learning institutions in Africa that was established at the end of the 1940s. Then, in 1978-79, School of Graduate Studies was established in Addis Ababa. Currently, the university is undergoing a major restructuring to expand its programs and its quality primarily in the area of post graduate studies. Under this expansion program, the graduate program in the Addis Ababa University is expected to increase by 400% in the next coming calendar year. Although it is very ambitious, the University has no adequate staff or infrastructure to handle the incoming graduate students to fully equip them with what is needed or required. The university is going to be dependant on foreign professors and is undergoing several restructuring to accommodate the new changes with the current available resources.

   I have been teaching a 2-credit hour course entitled "Advanced Pharmacology of Cardiovascular Drugs" at the Department of Pharmacology, Faculty of Medicine for the last 3 times. The Department headed by Professor Eyasu Mekonen. Professor Eyasu is handling a workload equivalent to what 15 faculty members in an U.S institution are handling. He made special arrangements to have a block system in the graduate program to accommodate me and two other visiting professors from the U.S. I was meeting with the students for 4 hours a day for 5 to 6 days a week for two weeks consecutively to cover all the course materials in time. I scheduled the final exam on the last day of my trip and was able to submit the grades to the department just before returning to the U.S.

   A total of seven students (1 physician with MD degree; 1 veterinarian with DVM degree; and 5 pharmacists with B.Pharm degrees) took the course this year. The course was structured to have an active learning component where students took active part in the class discussion. The entire course is based on series of clinical cases. Part of the cases was e-mailed ahead of time for students to start preparing for the actual class. Working with cases and involving students in active participation format helped me to evaluate the students' knowledge thoroughly and to know their deficiencies. Most of my lectures then were focused on discussion to address the knowledge gaps and deficiencies as I see it during the discussion.

   During coffee breaks and in between classes, most of our discussions focused on what life looks like in the U.S. Although the students are well informed, they had lots of questions about Western countries and modern life in the U.S. We usually have discussion regarding the culture, the lifestyle, and the overall living conditions in the U.S. No one failed my course partly because majority of the work is done by the students before coming to class and each student is required to make an informal presentation of his or her findings for each case. This made them put a lot of effort in solving the problems in the case prior to class. Questions that arise in class are usually limited to those that are advanced; new, or complicated concepts. By the time we complete the class; students are comfortable about the topic and are ready for the next concept. The experience was overwhelming to me and to the students. Majority of students scored the course very high in the end of class evaluation survey. I am looking forward to continue to participate in similar activity in the future. It has been only a few weeks since I returned from the trip, but I have already started preparing for next year batch.

2. PARTICIPATING IN A WORKSHOP

   Drug Administration and Control Authority (DACA) coordinated a workshop entitled, "Training on the operations of drug and therapeutic committees in health establishments" and it was held at the Pan Afrique Hotel, Nazreth from December 15 - 18, 2004. The workshop was organized under the leadership of Mr. Abrahm G. Giorgis, the Head of Planning and Drug Information Services, DACA. The goal of the conference was to bring together stake holders and decision makers from selected health institutions to educate them on how to establish and successfully run a Drug and Therapeutic Committee (DTC). The participants comprise of Medical Directors, Hospital Administrators, and Chief Pharmacists from 10 selected major referral hospitals in various regions of the country. I was told this is the first time such an effort and campaign is conducted on a national level to establish such committees throughout the country. Mr. Abrahm recently retuned from England after spending a year in intensive training and successfully completing a Masters Degree in Honors in Health policy management related topic.

   I was invited to share my experiences and speak on how to establish and run a successful DTC. I have been serving as the Director of Drug Information Services at Howard University Hospital since 1997 and participated heavily in DTC activates. Most U.S hospitals established DTC in the late 1960's and several advances have been achieved the last couple of decades. It was my deepest pleasure to have such a chance to contribute my knowledge and the things I do on daily basis to my colleagues in Ethiopia. I gave a 2 hour presentation and there were number of interesting questions from participants. I had also a chance to present the role of pharmacists and other health practitioners as a health care team using the Howard University Hospital as a model example.

   Pharmaceutical services that are provided by pharmacists that were discussed in detail include nutrition services, pharmacokinetic services, anticoagulant clinic, adherence clinics, patient counseling, research and other similar services. The conference ended on December 18. At the end of the conference, the participants developed and voted on the action plan of implementation which I was told to be the first in the history of pharmaceutical services of the country. I would like to thank Mr. Abrham and the conference participants to give me such an opportunity to discuss on a topic that is crucial to the country and is way overdue.

3. PARTICIPATING IN A RADIO INTERVIEW

   After my presentation at the workshop in Nazreth, the Ethiopian Radio program news agent was very much interested in interviewing me on my opinion on the current health policy and issues of the country. The Radio station is the oldest station serving the country for the last several decades. The topic of the discussion was on the health care delivery in Ethiopia comparing to that of the Western countries. Most of the questions were around the role of the Government in providing health or access to health and how the civilized countries were able to resolve some of the difficult issues that are still major obstacles of health care delivery in Ethiopia. The interview lasted about 30-45 minutes and aired at one their sessions locally.

4. PROVIDING A CONTINUING EDUCATION FOR PRACTICING PHARMACISTS

   I made arrangements with the President of the Ethiopian Pharmacists Association (EPA) and DACA before leaving the U.S to hold a continuing education program to practicing pharmacists. The topic of the presentation was entitled, "Current advances in the management of peptic ulcer diseases" and it revolved on the role of helicobacter pylori and the various choices of its management. Statistics conducted in two areas of the country have shown that 79-93% of peptic ulcer disease in Ethiopia is due to helicobacter pylori. Moreover, there is at least one published report that there is a high level of resistance of helicobacter pylori to ampicillin, metronidazole, or doxycycline.

   The 2 hour program was held at the Global Hotel, Addis Ababa and it was sponsored by DACA. About 100 participating pharmacists attended the program. At the end of the presentation, a gift and a Certificate of Appreciation was given in behalf of the EPA to me and to ENAHPA by Dr. Ephrem, EPA President and Director of the Graduate Program, AAU. A reception was held right after the program for all attendees. It was then followed by a group picture taken outside the hotel.

5. DONATING A $1,000 TO Ethiopian Pharmacists Association (EPA)

   A $1,000 USD was donated to EPA on behalf of the ENAHPA at the EPA office. The money was donated to EPA to support the salary of the newly hired program officer and to also assist in sponsoring future continuing education programs. In my last year's trip, we were able to collect and donated 5,000 birr to the association. About 6 months ago a similar contribution was done by a few members of ENAHPA to assist the association to buy and install a fax machine in their office. This is the third contribution made from ENAHPA.

   The following member of ENAHPA contributed for the donation: Dr. Getachew A.; Dr. Meseret Nega; Dr. Diana and Edom, senior Pharm.D student; Dr. Bisrat H.; Dr. Yeshewaneh; Dr. Tayech and Ms. Aster. The money was donated in cash at the ceremony held at the EPA's office to the Administrative Assistant and the Program Officer. The cash donation was announced to the EPA members at the continuing education program held at the Global Hotel and a special gift and a Certification of Appreciation was presented in behalf of the ENAHPA members.

6. A SEMINAR PRESENTED TO THE FACULTY AND STUDENTS OF SCHOOL OF PHARMACY, AAU.

   Professor Tsige, the Dean of the School of Pharmacy, AAU invited me to speak on a topic entitled, "Advances in the management of heart failure" at the School of Pharmacy during their noon conference. Several faculty members of the School, graduate and senior pharmacy students attended the 1-hour conference.

   Cardiac problem is the most common non-infectious cause of death in the country. Although rheumatic heart disease is the most common heart problem, diseases like heart failure and hypertension are increasing in an alarming manner. It was crucial to make the health care practitioners and students to alarm them about the diseases and discuss the long term benefits of life saving drugs such as angiotensin converting enzyme inhibitors, aldosterone blockers, beta adrenergic blockers, and the role of diet and life style changes.

   Most of the School's training was based on preparing students to be knowledgeable in the pharmacokinetics and physicochemical characteristics of drugs. Some efforts have been made to incorporate pharmaceutical care concept into the curriculum but, as I was told, it is still in its infancy. Continuing education programs that are clinical in nature is in a high demand and can be taken as an initial step to bring the level of the students and faculty members to get ready for the implementation of pharmaceutical care concept through the newly proposed Pharm.D curriculum. The conference was well received and it was followed by a luncheon from Professor Tsige.

7. SERVING AS AN EXTERNAL EXAMINER FOR TWO GRADUATE STUDENTS DURING THEIR THESIS DEFENSE

   I was also invited to serve as an external examiner for two graduate students who are finishing up their Master's degree program in pharmacology. Mr. Solomon's thesis was entitled "The safety and gastro-protective efficacy of water extract of Fingerwood and Linseed in comparison to omeprazole". The thesis was well defended and the experiment was well done. According to his study, the plants studied were as equally as effective as omeprazole in healing peptic ulcer disease. The study was done in animals with hydrochloric acid and histamine-induced peptic ulcer. The animals were pretreated with either omeprazole, the plants under investigation, or placebo. The studied plant is used widely locally for the management of stomach ailment besides their other uses. Dr. Ephrem, Director of Graduate Studies, AAU was the internal examiner. The study was very encouraging, and it reinforced what is a common knowledge among the local people. The second student Dr. Workneh, a veterinarian by profession, worked on the research entiled, "Phytochemcial, antifertility efficacy and safety evaluations of Achyrantes Aspera leaf extract". It is about the anti-fertility use of a locally abundant plant, and he also reported very encouraging results. The plant is used as birth control drug at lower doses and an abortificient when the doses increased. The study was also well designed and well presented.

8. ATTENDED A REUNION OF CLASS OF 1981.

   A class of 1981 from my college held a mini class reunion in honor of my trip and contribution. About 8 of my colleague classmates attended the reunion and it became one of the happiest moments of my trip. It was wonderful to see so many of my old classmates. I met some of them for the first time in about 20 years. All of them are doing very well financially and professionally. Almost all of them are in private sector and over half of them own their own business. Some of them, as I was told, became multimillionaires. Sure, a newly built restaurant, provided us with special Shuro Wat with meat and a variety of delicious Ethiopian dishes followed by a spiced hot tea to serve as a digestant.

9. CONDUCTING A PROGRAM EVALUATION OF A VIDEO CONFERENCING TRAINING

   A live video training program conducted to educate practicing pharmacists in Ethiopia on the latest advances in the management of HIV/AIDS and in antiretroviral agents. The program was conducted in collaboration with Howard University, ENAHPA, Mayo Clinic, University of Maryland, and Bethany Foundation. The program was a six-week program and was very successful. The participants who completed the program received a certification at the end of the completion. Three months later, we did a survey to determine the usefulness of the training in an effort to plan similar future training. Accordingly, during my trip, we called a meeting of all the participants and asked them to complete a two page survey questionnaire. The following comments were given as summarized below.

   There were 16 surveys (53%) completed and returned. There were 2 females (12.5%) and 14 males (87.5%) who completed the survey. Majority of survey participants said they have a bachelor's pharmacy degree (75%) and the remaining (25%) said they have a Master's Degree. The average age of the participants was 33.3 years and it ranges from 25 to 45 years of old. Most of them hold managerial or director position in their workplace and come from various practice sites as shown in the table below.

   Participants were asked to give their opinion on the overall merit of the program using a scale of 1 to 5 (1 = Strongly agree and 5 = Strongly disagree). The best score was given when the participants were asked to rate the competency and knowledge of the presenters and the program facilitators (1.2 and 1.4 respectively). The least score was given when they were asked about the length or the format of the program and if they incorporated the knowledge they gained to make changes in their professional practice (2.3 and 2.1 respectively).

   Overall, the program was highly rated and well accepted by all participants as described during the discussion period. There are plan to train about 50 other professionals locally by the trainers of the program based on the knowledge gained during the program and the materials supplied by program coordinators. When the participants were asked about future programs, all of the participants said they are highly interested in participating in similar future programs. Most of the participants appreciated the effort done and thanked the coordinators of the program. They also suggested that to expand the training to other disease areas that are also have prevalence rate in the country.

10. PARTICIPATING IN A REVIEW OF DRUG INFORMATION CENTER PROPOSAL

    The School of Pharmacy, AAU is proposing to establish the first formal drug information center in the country and requesting funding from external sources. Ethiopia has thousands of health care practitioners but have no place where clinicians can call to find information on drug related issues. Looking at the need, the AAU School of Pharmacy is pioneering to take the lead in establishing such a center. DACA has a drug information unit but the focus of the service is disseminating information primarily related decision made by DACA or by Ministry of Health or educating professionals on proper use of drugs. As I was told, there is no formal drug information center is available with active personnel fully dedicated to handle drug information questions that come from practitioners on daily basis. Having such training-based drug information center as planned by the School of Pharmacy prepares students for this challenge profession and supplements the effort that is undergoing by DACA.

    As a drug information specialist with lots of experience, I was asked to review their proposal and provide them with my input. We raised several issues and address number of areas of the proposal at the School's meeting. The project is promising and planned to go forward.

11. PARTICIPATING IN A REVIEW DOCTOR OF PHARMACY (PHARM.D.) CURRICULUM DEVELOPMENT

    The School of Pharmacy at the AAU has a very ambitious proposal to establish a doctor of pharmacy (Pharm.D) degree which is to be the first in the nation (may be second in the content of Africa). The AAU School of Pharmacy was established in 1961 as one of the departments of the Faculty of Science. In 1978, it was raised to a full faculty status under the name of "School of Pharmacy". Despite the major shortage of infrastructure, educators, and budget, the School of Pharmacy stands firm to start the Pharm.D. Program in 2006-2007 calendar year. The program is an add-on program tracking in students during their last two years of training. Those who have a high GPA and interest will be tracked in to the Pharm.D program and will receive an extra year of intensive clinical training before receiving their degrees.

    Currently, as I was told that there is only 1 pharmacist with a Pharm.D degree in the entire country and that person is not even an employee of the University. Several practice sites have recommended for student clinical rotation but none of these sites have pharmacists with a Pharm.D degree working there. The Dean of the School of Pharmacy is optimistic and said, "We are not ready to start a Pharm.D degree program now and we will never be. So, what are waiting for?" I agree with the Dean and I also believe there is no better time to start a Pharm.D program in the country. Having a Pharm.D program in the country is a crucial step in taking the level of pharmacy services and the profession of pharmacy to a much higher level. It is also the first step in implanting a pharmaceutical care services.

12. PARTICIPATING IN PLANNING FOR MEDICAL EQUIPMENT DONATION

    I with 2 of my other colleagues had a meeting with the Deputy Ministry of Health, to discuss the country's plan in expanding the health services to the rural areas and the ways how the Diaspora can of assistance. With an average growth rate of 2.7% the population of Ethiopia is expected to reach 82.1 million by year 2009. A very large proportion, 85% of the total, lives in rural areas. One of the major policy initiatives that have been placed in motion recently is institutionalization for the village health services through the implementation of health service extension program as an institution framework. As of 2003, excluding Addis Ababa, there are 423 Health Centers (HC's), 2302 Health Stations (HS's), and 1,386 Health Posts (HP's). These represent only 18% of HCs and 12% HPs of the requirement as measured by the nation standard of health facility to population ratio. Under this expansion program, by 2009, there will be 12,249 new HPs to bring the total to 13,635 and 563 new HCs and upgrade of 2,167 HSs to health centers to bring the total to 3,153 HCs.

    One of the goals of our discussion was how the Diaspora can contribute to this aggressive and very ambitious strategic plan. The group discussed in depth and decided to focus our entire effort in assisting in raising equipment donation. The required list of medical equipment will be provided to ENAHPA members soon and each member especially those who have connection to institutions either private or governmental with such resources are required to donate their time and effort and in getting medical equipments. EKTTS promised to handle the shipment to the required destination in Addis Ababa, Ethiopia. There will be a central location in the U.S to store the donated equipment as it was done for the book shipment during collection period.

SUMMARY

This report highlights the summary of some of the activities I was engaged in my most recent (December 2004) trip to Ethiopia. I think, what is really matters is one's willingness and dedication to commitment. I am a witness that if we have the will and the blessing from God, miracles will follow. ENAHPA paved most of the road blocks to make interested health care professionals and individuals contribute their share with a minimum effort. The purpose of this report is to share with you my story and how it can be achieved if one has the will and the commitment. My wish is also to stimulate interest in the Diaspora community and hopefully generate motivation in those who are looking for opportunities. Most of us take our experiences for granted. We also tend to undermine the knowledge we acquired through years of experience. But it is a miracle to see that how such small things in our eyes could be cumulative to make major impacts on the lives of individuals back in Ethiopia.

ACKNOWLEDGMENTS

I would like to give thanks to many people who contributed to make life easy for me. As you all know, I could not do all these things in such a short period of time without for the help of these hard working citizens. I would specially like to acknowledge Professor Eyasu Mekonen, who is the head of the Department of Pharmacology, Faculty of Medicine. If it was not for him, I would have not even taken the first trip. When I contacted him for the first time which was right after I got his contact information from Ann, he took my offer seriously and responded immediately. He made the necessary arrangements that was needed before I traveled and during my stay in Addis. Although he has no working internet connection at his office, he always responds to my e-mails and my messages promptly and provided me with all pertinent the information in a timely manner.

Mr. Abrahm, the Head of Planning and Drug Information at DACA, is an action-oriented person who makes things happen. I applauded him for his courage to decided to come back home after completing his graduate program in England with distinction. His dedication to his job and to his fellow citizens amazes me. I appreciate his motivation and hard work.

The other person I would like to take the time to thank is Professor Tsige, the Dean of the School of Pharmacy. In addition to his regular responsibilities, he took the courage to lead his department in taking the challenge of establishing a Doctor of Pharmacy Program and a Drug Information Center. He is a very hard worker who loves his profession and loves serving his fellow people. He is the first and the only Ethiopian full professor in the School of Pharmacy. I get to work with him very closely during the launching of the videoconferencing program last year and recently in review of the Pharm.D curriculum and Drug information proposal.

Dr. Ephrem, the president of EPA and Director of Graduate Program has also been instrumental in organizing any association related activities. He played a major role in organizing the continuing program for practicing pharmacists. I have been communicating with him for several months regarding all aspects the Ethiopian Pharmacists Association. Despite his three major appointments as the Director of the Graduate Program, AAU, his responsibilities as the Department Chair at the School of Pharmacy, and as the President of the Ethiopian pharmacists Association, he is always respond to all my questions on time.

Such are the type people who stood beside me and gave me the courage and the motivation to do more and kept me going in my efforts. God bless them all. As it is said in ENAHPA's motto, together we can make a difference.

"TOGETHER WE CAN MAKE A DIFFERENCE"

Dr. Bisrat Hailemeskel is Associate Professor in the School of Pharmacy at Howard University
bhailemeskel@howard.edu