Pharmacists under pressure

Anso Thom spent a day with Ruth Ngbokota, a pharmacist at Michael Mapongwana Community Health Centre, Khayelitsha.

7.45am ‘€“ A British Airways Boeing droning overhead on its way to nearby Cape Town International Airport momentarily muffles the hustle and bustle outside the clinic gates. Taxis race to a screeching halt outside the gates, doors grind open and patients spill onto the pavement.

One man leans heavily on a crutch, dragging his left leg behind his frail body as he makes his way to the entrance, concealed in the corner of the drab single-storey building. A security guard in a neat, blue uniform swiftly pushes a wheelchair to a bench next to the boomgate where a thin, pale woman, wrapped in a thick purple blanket is lifted by her mother into the mobile chair. A toddler, with wide eyes, follows them as they join the steady stream towards the door.

7.55am ‘€“ Nurses in private cars that look out of place among the shacks and empty parking lot, start arriving. Dressed in crisp white shirts and navy uniforms they put up the sunscreens in their gleaming cars, sling their lunchtime cooler bags over their shoulders and press past those gathering outside the entrance catching the early morning sun.

8am ‘€“ A ‘€œgogo’€ wrapped in a pink Winnie the Pooh blanket alights from a taxi, the baby on her back gazing at the organised chaos with keen interest.

8.05am ‘€“ Pharmacy workers shuffle through the waiting area, unable to ignore the hundreds waiting on long steel and wooden benches outside the two dispensary windows.

‘€œWe are going to work our backsides off today,’€ sighs Bokkie Marcus, one of the few agency pharmacists prepared to work shifts in Khayelitsha.

8.10am ‘€“ Nomzi, Judy and Zuki ‘€“ all pharmacy assistants trickle into the cramped dispensary and catch up on the last 12 hours while sweeping the floor and trying to create some order amid the chaos of boxes upon boxes of medicine.

8.15am ‘€“ An urgent knock on the wooden shutter enclosing the dispensary window interrupts the chatter. Judy opens and listens patiently to the woman on the other side.

‘€œGet ifolder from the clerk mama,’€ she says several times before the woman wanders off, muttering something about ‘€œservice’€. Judy closes the shutter and continues to unpack medicine.

Ruth Ngbokota, a slight woman with a shock of curly, black hair wanders in, her handbag tucked under her arm and her white coat hanging loosely around her frame. Ngbokota is the chief pharmacist. She has been at ‘€œMichael M’€, as it is referred to in the community, since 1996, when it opened its doors. ‘€œAt the time I was the only pharmacist prepared to work here,’€ she says in an earlier interview.

8.20am ‘€“ ‘€œI need to have some porridge, I never had breakfast,’€ Judy says, to nobody in particular.

‘€œJa, I had to eat my toast in the car this morning,’€ answers Ngbokota, her ear glued to the phone in the tiny administrative office at the back of the dispensary.

8.30am ‘€“ Ngbokota leans over the counter and peers through the dispensary window: ‘€œNo folders have been issued by the clerks, so we can’€™t start dispensing yet,’€ she remarks.

8.40am ‘€“ The first patient arrives and slides her grey file underneath the window.

Ngbokota points to a sheet of paper stuck to the shutter. ‘€œThat’€™s a list from head office with the (61) items that are out of stock. I always put it there so I can show the public I’€™m not lying. Sometimes (getting the drugs) is like drawing teeth,’€ she says.

8.50am ‘€“ The fourth pharmacy assistant, ‘€œMister Tom’€ comes strolling in. ‘€œGood morning. Eish my stomach is not so well,’€ he mumbles, before settling down on a chair, seemingly flustered by the barrage of questions around his whereabouts the previous day.

Four files have been handed in and are lined up at the next window, the boxes and bottles of drugs piled on top. Marcus bends over the files, re-checking whether all is legitimate.

9.08am ‘€“ ‘€œGuys, I’€™m worried we’€™re going to run out of Adalat (chronic hypertension drug),’€ Ngbokota says.

‘€œPhone for you,’€ someone shouts and Ngbokota leaves her post to take the call.

‘€œI need to phone Stefan or page Mr Titus (at the Woodstock depot) to find out whether my order will be arriving today,’€ Ngbokota reminds herself.

9.10am ‘€“ After prompting by Ngbokota, Nomzi starts dispensing medication to the first patients.

9.11am ‘€“ Ngbokota takes receipt of file 11.

9.12am ‘€“ ‘€œGuys, we’€™re back to dispensing 14 Adalat, they don’€™t have stock,’€ Ngbokota shouts after replacing the receiver. ‘€œIt’€™s crazy, we’€™re not allowed to give the patients IOU notes because head office is afraid they will go to the media, so they have to come back in two weeks with their empty boxes and we give them the balance, putting more pressure on us,’€ Ngbokota complains.

9.15am ‘€“ ‘€œI can’€™t believe the number of hypertensive patients,’€ Marcus remarks.

9.40am ‘€“ File 33 arrives. Medicine for file 29 is dispensed.

9.45am ‘€“ Patient 40 hands in his file.

9.50am ‘€“ ‘€œMister Tom, it’€™s nearly time for the fisheries. My stomach is telling me,’€ shouts Ngbokota, hardly missing a beat as she places another blue and while box of state-issue Paracetamol on a file.

10am ‘€“ ‘€œNow what was doctor thinking,’€ asks Ngbokota under her breath. ‘€œSometimes the scripts are very interesting. They will prescribe treatment for ulcers and it will be with something that causes ulcers. Or my favourite was deworming medication for ring worm (a skin infection)!’€ exclaims Ngbokota.

10.05am ‘€“ Ngbokota hands Mister Thom her order for two ‘€œvetkoek’€.

10.07am ‘€“ A nurse arrives at the window, shouting at Ngbokota for sending a patient back to the hypertension club. ‘€œI’€™m phoning the sister-in-charge, I’€™m sick of this woman,’€ says Ngbokota, who had refused to dispense the specific patient’€™s medication until the nurse had rectified the dates as her next consultation was due two days after the chronic medicine was finished.

‘€œThey don’€™t want to listen, they think I’€™m being difficult,’€ she says.

10.12am ‘€“ Ngbokota’€™s patience start wearing thin. ‘€œWait, I’€™m still busy with the other patient, she tells the next person who is waving their file underneath the window.’€

10.20am ‘€“ ‘€œIs the kettle boiling yet?’€ asks Ngbokota. ‘€œI’€™ll finish when I’€™ve done 40,’€ she adds, before receiving the 66th file for the day.

10.25am ‘€“ ‘€œSophie is nice and quiet today,’€ quips Ngbokota as she receives a file from a ‘€œregular’€. ‘€œJa, last week she was vomiting and complained she had worms,’€ adds Judy.

‘€œMost of the patients, if you tell me their first names, I will be able to tell you their surnames,’€ says Ngbokota.

‘€œWhere have you been,’€ she asks the next patient, studying her chart. ‘€œYou have not been taking your pills for two months. Do you realise you could get a stroke,’€ she berates her, before smiling and handing her the 80th token in return for the file.

10.30am ‘€“ An emergency order Ngbokota placed last Thursday has still not arrived and this poses a problem as an HIV patient with a script for severe skin infection, one of the medicines on order, arrives. ‘€œHonestly, now they tell me Mr Titus is on leave for two weeks. I gave him the emergency order which probably explains why nothing has been done about it.’€

10.40am ‘€“ Mister Tom returns with the two greasy vetkoek in a plastic bag.

10.45am ‘€“ ‘€œAh, that’€™s number 40 for me, I’€™m now having a cup of coffee,’€ says Ngbokota, motioning for the next patient to sit down before closing the shutter.

10.50am ‘€“ A pharmacy assistant takes over from Ngbokota. A knock on the back door signals a delivery, but still no sign of the emergency medicine. ‘€œI give up,’€ Ngbokota sighs, and picks up the phone. Her coffee stands on a table getting cold.

11.05am ‘€“ A call from the warehouse sheds no light on the missing medicine.

11.10am ‘€“ Ngbokota resumes her dispensing duties, explaining each and every drug to the patients, some nodding, other simply staring at the boxes and bottles with frowns etched on their foreheads.

11.25am ‘€“ Ngbokota heads for the restroom after dispensing script number 100.

File number 120 is handed in. ‘€œIf we’€™re going to dispense 400 scripts they need to speed up,’€ comments Ngbokota, glancing at the clock above the shelves.

11.30am ‘€“ Ngbokota takes a phone call. ‘€œIt’€™s my husband, he’€™s covered in green paint and needs a detergent to remove it,’€ she smiles.

11.35am ‘€“ A male patient returns a file, not prepared to wait for his consultation while the nurses are on lunch.

11.40am ‘€“ Script number 110 is dispensed.

‘€œIt’€™s for high-high,’€ Ngbokota explains in isiXhosa, ‘€œhigh-high’€ referring to hypertension.

11.45am ‘€“ Script 120 is dispensed. The umpteenth script is dispensed to a ‘€œchild’€ collecting chronic medicine for a parent. Ngbokota says she has heard there is a regular taxi service taking medicine from the Western Cape to patients in the Eastern Cape.

12 Noon ‘€“ Both pharmacists and the four pharmacy assistants are working flat out. Folders are slided along the long counter as if on a conveyor belt.

12.05pm ‘€“ ‘€œThat’€™s three people who said thank you today and only one swear word,’€ Ngbokota remarks wryly. ‘€œYou’€™re doing well,’€ Marcus responds.

12.10pm ‘€“ The clinic nutrition advisor arrives to help, something she does on a regular basis when she has not patients. ‘€œWe tried to get her trained, but the department refused,’€ says Ngbokota.

12.20pm ‘€“ ‘€œPlay safe, condomise,’€ Ngbokota urges a patient as she dispenses treatment for a sexually transmitted infection.

‘€œIs it lunchtime,’€ Ngbokota asks nobody in particular, answering herself with a ‘€œyebo’€.

12.25pm ‘€“ A pharmacy assistant takes over from Ngbokota.

12.35pm ‘€“ ‘€œIf this doesn’€™t get the paint off, nothing will,’€ says Ngbokota, before leaving to have lunch with her two young sons and husband at their Mandalay home nearby.

12.40pm ‘€“ Script 140 dispensed.

12.45pm ‘€“ A dentist enters asking staff where they are hiding the codeine. Ngbokota had explained earlier that these scarce painkillers were kept for ‘€œspecial cases’€.

Judy scratches in a drawer and hands him a plastic packets with pills in.

12.47pm ‘€“ The nutrition advisor leaves and a nurse with a file and script arrives.

12.50pm ‘€“ Script 155 is dispensed.

12.55pm ‘€“ Another nurse with a file and script enters. Both find the medicine and ask Marcus to sign.

1pm ‘€“ Script 177 dispensed.

1.20pm ‘€“ 190 scripts dispensed, with Marcus and three pharmacy assistants working. Mister Tom had still not returned from a prolonged lunch.

1.30pm ‘€“ Script 204 dispensed. Marcus asks whether ‘€œwe are making a dent’€.

‘€œNo, we still have a long way to go,’€ replies Nomzi, glancing through the serving window.

1.40pm ‘€“ Ngbokota returns from lunch. ‘€œBokkie, are you going to take a break,’€ she asks Marcus.

1.45pm ‘€“ Ngbokota checks the scripts before running to take a phone call.

1.48pm ‘€“ Script 220 dispensed.

1.55pm ‘€“ Ngbokota calls script 224 over the public intercom system to collect their medication. ‘€œThank you,’€ says Script 227 as she stuffs her pills into a red handbag.

‘€œSure, no problem,’€ says Ngbokota, adding under her breath, ‘€œthat’€™s (thank you) number four’€.

2pm ‘€“ A mix up in the number discs handed to patients when they hand in their files and scripts causes a short hiccup, but it is quickly sorted out and the ‘€œconveyor belt’€ continues.

2.15pm ‘€“ Script 253 dispensed.

2.20pm ‘€“ Ngbokota hands the ‘€œstatistics’€ for April to a clerk. The numbers show that 6 500 scripts were dispensed during April, totaling 32 998 items, an average of five per patient.

2.30pm ‘€“ For the first time a patient tests Ngbokota’€™s patience as she demands an explanation as to why there is a shortage of the hypertension medication. ‘€œWhere’€™s my inhaler. I want my rubbing stuff,’€ she demands, before leaving with a ‘€œHey suka (go away),’€ directed at Ngbokota. ‘€œHey suka yourself,’€ Ngbokota fires back, while turning her attention to the next script.

2.35pm ‘€“ The pharmacy take delivery of the 320th script. ‘€œWe’€™re winning guys,’€ Ngbokota cheers.

2.40pm ‘€“ Ngbokota tasks Zuki with phoning the Woodstock warehouse to enquire about the emergency and hypertension medicine.

2.45pm ‘€“ Script 275 dispensed. Mister Tom makes an animated announcement over the public address, explaining to patients which cards they need to produce when collecting their medicine.

2.55pm ‘€“ ‘€œRuth, the emergency medicine will arrive in the morning,’€ Zuki whoops.

‘€œHalleluja, Amen!’€ Ngbokota shouts. ‘€œBut they still have a problem with the Adalat (hypertension medicine),’€ Zuki adds.

3pm ‘€“ An assistant takes over from Ngobokota as she makes her way to the matron’€™s office to send a fax to head office.

3.10pm ‘€“ The queue outside has shrunk to a few patients.

3.15pm ‘€“ ‘€œHave we reached the end of the queue?’€ Ngbokota enquires, as no patient arrives to hand in a script.

3.17pm ‘€“ The final patient, script number 386 hands in her file.

3.20pm ‘€“ ‘€œAfter action, satisfaction,’€ Mister Tom sighs from behind a shelf.

3.30pm ‘€“ Script 386 is dispensed to a patient.

3.35pm ‘€“ Ngbokota does a quick tour through the clinic to check whether there are anymore patients waiting to be served. ‘€œWhat a beautiful sight, an empty waiting room,’€ remarks Ngbokota as she makes her way to the trauma room.

3.40pm ‘€“ Shelves are stocked and staff collects their belongings.

3.50pm ‘€“ Judy, Zuki and Nomzi leave.

4pm ‘€“ Ngbokota helps medical students with data they need for a research project.

4.30pm ‘€“ Ngbokota leaves for home, May 31 being her last working day before she jets back to the United Kingdom, her birth country. ‘€œI need to take a break from the stress, but I will return one day,’€ she says.

E-mail Anso Thom


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