DONALD E. FRANCKE MEDAL LECTURE Starting from the bottom
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DONALD E. FRANCKE MEDAL LECTURE
Starting from the bottom Andrew Lofts Gray Am J Health-Syst Pharm. 2015; 72:460-5
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consider it a signal honor to receive the Donald E. Francke Medal today, and I wish to record my gratitude to the board of directors of the American Society of HealthSystem Pharmacists, who approved the award. Unlike the majority of the previous recipients of this prestigious award, I did not have the opportunity to meet, and no doubt learn from, Dr. Francke. However, I was privileged to meet Dr. Gloria Niemeyer Francke at a number of the congresses of the International Pharmaceutical Federation (FIP); I can therefore at least claim to have been touched by part of that formidable team.1 (As a pharmacist married to a pharmacist, I recognize the many ways in which we complement each other’s practice and support and challenge one another.) At the FIP congress in Beijing in 2007, the Hospital Pharmacy Section dinner was held in a wonderful venue at the Summer Palace. As the section president, I had the honor to preside over a glittering “high table,” with Gloria and an array of ASHP luminaries . . . certainly a night to remember! The invitation to contribute a scholarly paper on some aspect of in-
ternational hospital or health-system pharmacy sets one thinking about the trajectory of the profession and one’s own career. I have chosen to entitle my paper “Starting From the Bottom.” The sense I wish to convey is one of starting not only from the beginning, from a low base, but from far away—from a place that was isolated and out of the mainstream yet also striving to improve. I completed my bachelor of pharmacy degree at Rhodes University, in Grahamstown, South Africa, in 1981, and an internship in community pharmacy in Durban the following year. In 1984, I completed a master of science degree in pharmacy. While my research work, in the field of immunology, was conducted at the University of Natal Medical School, I was unable to register there, and my degree was again conferred by Rhodes University. The University of Natal Medical School was, at that point, reserved for Black Africans and those descended from South Asian (Indian) immigrants in terms of South Africa’s apartheid racial laws.2 After a year of travel in Europe (including a stint dispensing “social beverages”), my wife Rosemary and I returned to
Andrew Lofts Gray, B.Pharm., M.Sc. (Pharm), FPS, FFIP, is Senior Lecturer, Division of Pharmacology, Discipline of Pharmaceutical Sciences, School of Health Sciences, University of KwaZulu-Natal, and Consultant Pharmacist (Research Associate), Centre for the AIDS Programme of Research in South Africa, Durban, South Africa ([email protected]).
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Durban in 1985, and we both secured positions at hospital pharmacies. A discriminatory system My position was at King Edward VIII Hospital, then a 2000-bed public sector teaching hospital, located adjacent to the University of Natal Medical School. Prior to the democratic transition in 1994, all health services in the public sector in South Africa were provided separately to different ethnic groups.3 The hospital was therefore designated only for BlackAfrican and Indian patients and resourced accordingly. This meant overcrowded and poorly equipped facilities in general (including in the pharmacy), grossly inadequate staffing for the inpatient and outpatient load that was faced on a daily basis, and a lack of investment in the information and communications technologies that were by then standard fare in the South African private sector. The bulk of the adult medical wards, for instance, were housed in World War II–era wooden barracks that had been erected as a temporary measure in the early 1950s. Each of these medical wards had 35–50 beds in a single room and adjacent covered
Presented at the ASHP Midyear Clinical Meeting, Anaheim, CA, December 8, 2014. The author has declared no potential conflicts of interest. Copyright © 2015, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/15/0302-0460. DOI 10.2146/ajhp140791
DONALD E. FRANCKE MEDAL LECTURE Starting from the bottom
veranda. On a typical “post-intake” morning, after the medical team had completed a 24-hour stint in the Casualty Department, there could be as many as 20 additional patients on so-called floor beds—mattresses placed between and even underneath the fully occupied beds. In addition to the inpatient load, the pharmacy served upward of 1000 outpatients per day. In 1985, the pharmacy was predominantly serving the wards by means of bulk ward stock, with nurses collecting non–ward stock items from a central pharmacy. The pharmacy service also included a smallscale manufacturing service, mainly preparing oral liquids and topical preparations, and a prepacking unit, preparing patient-ready packs of oral solid dosage forms from bulk packs. Pharmacy staffing comprised about 25 pharmacists and around twice as many support personnel. The pharmacy support personnel were trained inhouse to perform basic functions and were not credentialed in any formal way. Viewed from a North American or European perspective, the pharmacy service was primitive, paper based, and almost entirely focused on distribution, without any apparent redeeming features. There was no intravenous admixture service, no therapeutic drug monitoring, no dedicated medicines information service, and certainly nothing resembling unit dose dispensing. While the pharmacy was physically divided between stores, manufacturing, and inpatient and outpatient areas, pharmacists seldom visited the wards or operating theaters except to check on controlled substances registers. However, there was a spark of something—a sense of camaraderie borne of struggle and a desire to do more than the system expected from a “black” hospital. The University of Natal Medical School was a crucial locus in the antiapartheid struggle, and the spirit of resistance also spread to its adjoining
teaching hospital. As a teaching hospital, albeit one designated to provide a subpar service according to the dictates of the racial policy of “separate development,” King Edward VIII Hospital had a dedicated medical team linked to the University. Vanessa Noble2 has described how this segregated medical education setting “developed as a site of great struggle and a setting of deep contradictions, at times reproducing apartheid conditions, but also unlocking the essential failure of an apartheid ideology, fulfilling some of objectives of separate development, but also contributing to the apartheid state’s demise.” The hospital may have looked like it deserved to be named after the monarch who abdicated his throne, but looks could be deceiving. Starting from scratch Donald C. McLeod4 has written about the critical role played by the journal Drug Intelligence, founded and edited by Donald E. Francke, in the early years of the clinical pharmacy movement in the United States. The successor title, Drug Intelligence and Clinical Pharmacy (DICP), now called The Annals of Pharmacotherapy, was one of only two pharmacy journals that was received on a regular basis at King Edward VIII Hospital Pharmacy; the other was AJHP. The budget for the journals was apparently covered by the nursing college that operated from the hospital (also an institution dedicated to providing training only for Black Africans). Although both journals had by then moved beyond merely describing the new services that were so revolutionary in the late 1960s,5 they were still critical resources for pharmacists in an isolated and embattled setting. It is difficult, in this hyperconnected world, to convey to a younger audience what it was like to open a fresh copy of DICP or AJHP at that time. From a place far away, impossibly exotic, came glimpses of
Andrew Lofts Gray Andrew Lofts Gray, B.Pharm., M.Sc. (Pharm), FPS, FFIP, is Senior Lecturer in the Division of Pharmacology, Discipline of Pharmaceutical Sciences, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa. He is also Consultant Pharmacist (Research Associate) in the Centre for the AIDS Programme of Research in South Africa. Mr. Gray’s research interests include policy analysis around the development and implementation of national medicine policies, rational medicine use, and the application of antiretroviral therapy in resource-constrained settings. He has been a member of the Names and Scheduling Expert Committee of the South African Medicines Control Council since 2000 and was appointed to the National Essential Medicines List Committee in 2012. He is a member of the World Health Organization’s Expert Panel on Drug Policies and Management and has served as a member, rapporteur, and co-chairperson of the Expert Committee on the Selection and Use of Essential Medicines. A past national president of the South African Association of Hospital and Institutional Pharmacists, Mr. Gray also has a long and distinguished record of service in the Hospital Pharmacy Section and the Board of Pharmaceutical Practice of the International Pharmaceutical Federation (FIP). He served as vice president (Africa) of the FIP Hospital Pharmacy Section (2001–06) and as president of the Hospital Pharmacy Section (2007–10). Mr. Gray also served as a member of the Executive Committee of FIP’s Board of Pharmaceutical Practice and as chairman of the Board of Pharmaceutical Practice. Widely published, Mr. Gray is associate editor of the South African Pharmaceutical Journal, is section editor of the Journal of Pharmaceutical Policy and Practice, and serves on the international editorial advisory boards of the International Journal of Clinical Pharmacy, and the GaBI Journal. Mr. Gray has been actively involved in the development and assessment of medicines and other health-related law in South Africa.
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Donald E. Francke Medal Recipients 2015 2014 2013 2012 2011 2010 2009 2008 2006 2006 2005 2004 2003 2001 1996 1995 1986 1978 1971
Andrew L. Gray Eduardo Savio Henri R. Manasse Jr. Barry R. Goldspiel Agathe Wehrli William A. Zellmer Jacqueline Surugue Toshitaka Nabeshima Thomas S. Thielke Philip J. Schneider Colin R. Hitchings Dwight R. Tousignaut Toby Clark Joaquin Ronda Beltran Carl D. Lyons Gloria Niemeyer Francke Joseph A. Oddis T. Douglas Whittet Donald E. Francke
The Donald E. Francke Medal was established in 1971 by the ASHP Board of Directors to honor individuals who have made significant international contributions to health-system pharmacy. Donald E. Francke (1910–78), the first recipient of the Medal, was widely acclaimed for his longstanding efforts to advance American and international pharmacy. He served in many leadership roles with ASHP, including as President and as Editor of the American Journal of Hospital Pharmacy. Within the International Pharmaceutical Federation, Francke was elected to the governing board and as an officer of the section for hospital pharmacists and of the section on press and documentation.
what might be, hints of what was possible. Bill Zellmer,6 in his 2009 Francke Medal Lecture, noted that “much of the ‘international talk’ in hospital pharmacy is, in reality, referential to the Western world and its well-articulated pharmacy education systems and its literature on pharmacy practice.” He called for pharmacy groups to acknowledge that “contemporary Western models 462
of pharmacy education and hospital pharmacy practice are too costly for the current needs in resource-poor countries.” That is practical, pragmatic, and appropriate advice, but it undervalues the “spark”—provided that spark falls in the right combustible environment. Henri Manasse’s7 2012 Francke Medal Lecture mentioned that pharmacy is “made up of polyglot definitions, diverse philosophies, and various viewpoints and is faced with almost infinite challenges.” That is true, but the core principles that animate pharmacists all over the world are shared. That much was clearly demonstrated in the consensus that was reached around the Basel Statements on the Future of Hospital Pharmacy, first articulated in 2008 and recently updated at the FIP congress in Bangkok.8 In my concluding remarks at the Basel meeting, I noted, “Hospital pharmacists have stated clearly that, as a profession, they are both ready and willing to accept responsibility for all medicines, everywhere in the hospital, and at all times”.9 That is what we tried to do at King Edward VIII Hospital from the late 1980s onward, and the ideas we embraced were those that we encountered in the two pharmacy journals. Any systems change involves a team effort, and at least a minimally supportive management, but I must pay tribute to the individual contribution made by Reuben Moss in the innovations we implemented at King Edward VIII. Slowly and deliberately, ward by ward, we expanded the reach of pharmacy. Starting from the medical and pediatric inpatient wards, we introduced ward pharmacists and reduced the reliance on ward stock. By the early 1990s, every inpatient’s medicine-related needs were reviewed by a pharmacist at least daily during the week. Multidisciplinary ward rounds in intensive care wards were routine. A daily meeting with members of the infectious diseases and medical microbiology services
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enabled the effective operation of what would now be termed an antimicrobial stewardship program. Pharmacy contributed to a specialist pediatric epilepsy service, including pharmacokinetic consultations. Inservice training of the new cadre of pharmacist assistants had commenced. There was never going to be a unit dose system, and admixture services were still restricted to oncology products and intravenous nutrition. Such computers as were available were largely reserved for stock control purposes. Computerized prescriber order-entry systems are still rare today in South African hospitals, and decision support systems are largely lacking. Staffing levels did not allow for a 24-hour, seven-day-a-week service. The high outpatient load still needed to be managed. However, the pharmacy department had developed a nationally recognized status and was considered a desirable place to train and to work. Critically, each new service was delivered by staff pharmacists who relied on their undergraduate training, supplemented with their own reading and their own efforts. At the time, I was the only pharmacist on the staff with any form of graduate training. We developed close relationships with the medical school and the pharmacy school at the University of Durban–Westville. The spark was at least partly reliant on that tenuous link with the outside world provided by posted journals. South Africa remained isolated, subject to academic and other sanctions and excluded from many international forums. However, the desire to do something more with the little we had burned brightly. There is a natural tendency to romanticize a time of struggle and to ignore the many negatives. King Edward VIII Hospital was heavily affected by the low-level civil war waged in the province at that time. The staff had to contend with increasing numbers of trauma patients, including those who
DONALD E. FRANCKE MEDAL LECTURE Starting from the bottom
were harshly punished by kangaroo courts.10 However, there is something of value in starting from the bottom, in having to find one’s own way, with minimal resources. Having to dig away in the dusty back shelves of the university library to find Cockcroft and Gault’s11 1976 paper in Nephron and then struggling to convert micromoles per liter to milligrams per deciliter in order to apply the equation, is worth it when it enables one to apply the practice innovations outlined in the latest issue of that exotic journal. The impossible is just in reach. Spreading upward and outward The majority of the new pharmacy services developed at King Edward VIII Hospital, whether based on something reported in the clinical pharmacy literature or purely homegrown, were directed at individual patient care. Even within the provincial health services, a common policy was not developed. There was one avenue for sharing and learning from local experiences, and that was provided by the South African Association of Hospital and Institutional Pharmacists (SAAHIP). The association had a proud history of activism on the issue of equal pay for equal work and had won salary parity for pharmacists of color in the public sector. Its annual conference became the forum for sharing practice research and service innovations. A common theme of many Francke Medal Lectures over the years has been the need for pharmacy leaders to engage, to contribute, and to share. In 2003, Toby Clark12 emphasized the need for international engagement, to “keep the flame burning.” That process starts at the local level, with the acceptance of leadership positions and the opportunity to hone one’s skills. By 1994, when South Africa finally made the transition to nonracial, democratic rule, I had already moved to academia, first via a pharmacokinetics research position but then to a pharmacy practice teaching post at
the University of Durban–Westville. That university, too, was a product of separate development, being specifically developed to serve the needs of the Indian population. However, I retained close ties with hospital practice and continued a pharmacy political career, eventually serving as president of SAAHIP. It was in that capacity that I attended my first ASHP Midyear Clinical Meeting in 1998. The transition to democracy required a wholesale revision of the entire corpus of South African law, and that revision applied equally to laws in the health sector and to those governing the practice of pharmacy. In 2001, as SAAHIP vice president, I had the opportunity to present the association’s positions to some of the first public hearings organized in the new democratic Parliament. Among the highly contested issues in pharmacy law was the prohibition on private hospitals owning their own pharmacies. This had resulted in complex efforts to evade what was clearly indefensible. However, those fights paled into insignificance when compared with the international contestation around access to affordable medicines. South Africa’s Medicines and Related Substances Control Amendment Act of 1997 became a global cause célèbre when its promulgation was interdicted by the Pharmaceutical Manufacturers’ Association and 39 of its member companies in 1998. Pharmacy groupings such as SAAHIP needed to quickly master the intricacies of and develop cogent positions on such issues as parallel trade, compulsory licensing, and mandatory offer of generic substitution. A hospital pharmacy leader was expected to be as comfortable discussing the basis for once-daily aminoglycoside dosing as arguing about the implications of the Agreement on Trade-Related Aspects of Intellectual Property Rights. One needed to be as familiar with Hatch–Waxman as with Cockcroft and Gault. Within academic practice, greater emphasis
was being placed on interdisciplinary learning, with a push toward community-based and problembased approaches. Pharmacy practice teaching and research, we argued, needed to be transdisciplinary in nature in order to adequately address the complex systems in which medicine use occurred.13 In accordance with South Africa’s 1996 National Drug Policy, which was inspired by the World Health Organization’s (WHO’s) essential medicines concept, South Africa committed to the development of a set of standard treatment guidelines and an essential medicines list. The first edition, aimed at the primary care level in the public sector, was issued in 1998. Instead of merely developing a list of medicines (a “formulary” in American terms), the decision was made to develop comprehensive standard treatment guidelines, from which the procurement list would be abstracted. This required not only an interdisciplinary team of medical, nursing, and pharmacy practitioners but also an engagement with the precepts of evidence-based medicine and the determination of cost-effectiveness. South Africa also sought to restructure its fragmented public health sector along primary healthcare lines and reorganize it as a District Health System. From mid1998, I took a secondment for two years as Co-ordinator: Drug Management with the Health Systems Trust (HST) Initiative for Sub-district Support (ISDS). This entailed providing support to the pharmaceutical services in 21 subdistricts spread across all of South Africa’s newly minted nine provinces. HST is a nongovernmental organization created specifically to contribute to the reform of the health system. The initial major funder was the Kaiser Family Foundation, but from the beginning cofunding was provided by the state. ISDS operated predominantly in the most rural and underserved parts of South Africa, where even the levels of pharma-
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ceutical staffing I had been used to at King Edward VIII Hospital were out of reach. I had to think about how best to use midlevel workers, to engage in task-shifting while building pharmaceutical systems that were safe and effective and fit for purpose. I have remained intimately involved in two long-lasting efforts hosted by HST. The first of these is the DRUGINFO listserver, initially aimed at exchanging clinical data but now more focused on pharmaceutical policy issues. The list connects nearly 800 pharmacy, medical, and other health professionals and policymakers across southern Africa and beyond on an almost daily basis. The second is the annual South African Health Review, which has been established as the standard reference work on the health system. In 2002, I moved from the pharmacy school at the University of Durban–Westville to the medical school at the University of Natal, specifically to lead the master of clinical pharmacology (MClinPharm) degree program. In 2001, I also attended my first FIP congress, in Singapore, replacing Reuben Moss as Vice President: Africa for FIP’s Hospital Pharmacy Section. The raison d’être of the MClinPharm program, which eventually developed into a “medicines management specialist” track of a master of public health degree, was the development of a public health clinical pharmacologist (whether initially trained in medicine or pharmacy) with the skills to contribute to the rational selection and use of medicines at both the individual and population levels. Increasingly, while I still do some bedside teaching, my own practice has also moved from the individual to the population level, from optimizing personal pharmaceutical care to ensuring quality policy development processes. Global reach Hospital pharmacists are criti464
cal to many structures involved in medicines selection, not only within individual health facilities (where they often sustain and nurture the pharmacy and therapeutics committees) but also at national and international levels. It has been my privilege to have served as a member of the WHO Expert Panel on Drug Policies and Management since 2007. In that capacity, I have served on the WHO Expert Committee on the Selection and Use of Essential Medicines and as chairman of its Subcommittee on Medicines for Children. The WHO Expert Committee is tasked with updating the WHO Model List of Essential Medicines every two years. When necessary—as was the case with the response to pandemic influenza—the Expert Committee can be constituted at any time. While some may perceive the efforts of the Expert Committee to be of value only for developing or low-income settings, the essential medicines concept has far wider application. Every health system in every country, regardless of the level of economic development, faces resource constraints and needs to make choices about which medicines to procure or reimburse. The prices demanded for new direct-acting antiviral agents have ensured that rationing is no longer an issue that can be ignored. Whether it retains its “third rail” status remains to be seen, but inaction is no longer an option. Rational policy that has a global reach can be developed. The key is the extent to which the policy is true to the evidence and honestly and clearly indicates the extent to which the evidence is lacking. From 2009 to 2013, it was my distinct privilege to serve as a member of the WHO Guidelines Review Committee, initially under the inspirational leadership of Dr. Sue Hill. In all of our careers, there are mentors or colleagues who, in retrospect, have shaped who we are and have somehow enabled us to be more than we ever expected
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was possible. In 2007, Hill and Pang14 wrote of a culture change at WHO and how the organization could lead by example in the way it used evidence to produce policy. I have been lucky to have been part of that change and to have been given the chance to grow through that process, from the bottom. However, no health policy is of any use until it is applied, in the field, to the benefit of patients.15 Clinical experience gained from the bottom—on the wards, in a health system under stress—is indispensable when one is called upon to provide input to the development of global policies that will have wide applicability. However, that does not imply that second-rate care is to be accepted in second-string countries. That much has been clearly demonstrated in the way in which a public health–oriented approach to the management of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) has developed. Not only has the world found a way to increase access to affordable antiretroviral medicines at scale but it has developed appropriate policies to guide rational selection of those medicines. Using our skills and training to contribute to assessments of the interchangeability of antiretrovirals is but one example of how pharmacists can contribute to this process.16 Global pharmacy organizations can also contribute to ensuring that critical issues retain their currency and garner the attention they deserve. One of the most pressing problems facing hospital pharmacists in every country is that of medicine shortages, for instance.17 Pharmacists tend to accept the nature of the market in which medicines are traded as a given. However, innovative funding mechanisms such as UNITAID (a WHO-hosted organization that uses market leverage to make lifesaving health products more affordable for developing countries) have been able to show that market-related
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interventions can improve access.18 Having initially served as a member of the Interim Expert Advisory Group of UNITAID, I have served on the Proposal Review Committee since 2010 and as its chair since 2012. Among the innovations supported by UNITAID, two deserve particular notice. The Medicines Patent Pool “opens the door to generic low-cost production of key HIV therapies as well as fixed-dose combinations and paediatric formulations by creating a pool of relevant patents for sub-licensing and product development.”19 The United Nations Medicines Prequalification Programme, managed by WHO, has been integral to assuring the quality of generic medicines used for HIV/AIDS, malaria, tuberculosis, and for reproductive health; the active pharmaceutical ingredients for such products; and quality control laboratories.20 The challenge, however, remains to ensure that the benefits that have accrued in low-income countries are accessible to those in middle-income countries as well and, eventually, that equitable access to needed medicines is assured in high-income countries. The challenge remains making universal health coverage a reality everywhere. Not losing the view from the bottom At my first FIP congress in Singapore in 2001, I was challenged by Tom Thielke and Phil Schneider, joint recipients of the Donald E. Francke Medal in 2006, to think about how residency programs could be applied in an African setting in order to improve the quality of hospital pharmacy practice. At first glance, the obstacles were obvious and overwhelming. After many years of advocacy, South African hospital pharmacists have finally achieved recognition of a clinical pharmacist career path in the public sector. The question now is how to train that new cadre and populate a specialist
clinical pharmacist register. Fatima Suleman and I21 argued that “we should guard against anything that is overly restrictive, that prescribes only a single route to registration (the plat du jour approach), and seek the greatest flexibility, with appropriate recognition of prior learning and varying routes to a clear demonstration of competency (the smörgåsbord approach).” Instead of a rigid system based only on attaining a specific postgraduate degree (such as a masters of pharmacy degree), we have argued for greater use of part-time fellowship programs as one option among many. I believe that we were being true to our shared experiences at King Edward VIII Hospital—that we were not losing the view from the bottom. In first developing and then updating the Basel Statements on the Future of Hospital Pharmacy, the FIP Hospital Pharmacy Section avoided the trap of being overly mechanical. There was no attempt to carefully parse our shared vision of the future into “light,” “regular,” and “deluxe” versions, and thereby lose the essence of a shared vision. Even as so many of the hospital pharmacy innovations that I encountered in each freshly unwrapped journal seemed impossible to attain, so each retained the power to inspire. Starting from the bottom required, first and foremost, the willingness to start: to refuse to accept the status quo as given and immutable. May none of us lose that sense of wonder at what is possible—no matter where we start from and however far the bottom appears to be from the desired “broad, sunlit uplands.”22 Thank you very much. References 1. Tribute to Gloria Niemeyer Francke: remembrances from family, friends, students, and colleagues. Am J Health-Syst Pharm. 2009; 66:258-78. 2. Noble V. A school of struggle. Durban’s medical school and the education of black doctors in South Africa. Durban, South Africa: University of KwaZuluNatal; 2013:2-5,13.
3. Coovadia H, Jewkes R, Barron P et al. The health and health system of South Africa: historical roots of current public health challenges. Lancet. 2009; 374:817-34. 4. McLeod DC. Contribution of The Annals of Pharmacotherapy to the development of clinical pharmacy. Ann Pharmacother. 2006; 40:109-11. 5. Whitney HA Jr, Nahata MC, Thordsen DJ. Francke’s legacy—40 years of clinical pharmacy. Ann Pharmacother. 2008; 42:121-6. 6. Zellmer WA. The education of a provincial pharmacist. Am J Health-Syst Pharm. 2010; 67:1080-4. 7. Manasse HR Jr. Perspectives on the global evolution and development of pharmacy. Am J Health-Syst Pharm. 2013; 70:675-9. 8. The Basel Statements on the future of hospital pharmacy. Am J Health-Syst Pharm. 2009; 66(suppl 3):S61-6. 9. Gray AL. Conference conclusions. Am J Health-Syst Pharm. 2009; 66(suppl 3):S75-6. 10. Muckart DJ, Abdool-Carrim AT. Pigmentinduced nephropathy after sjambok inju-
ries. S Afr J Surg. 1991; 29:21-4. 11. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976; 16:31-41. 12. Clark T. Keep the flame burning. Am J Health-Syst Pharm. 2003; 60:2209-12. 13. Gray A, Seneque M, Smit J. Reconsidering the need for an epistemology for pharmacy practice. Int J Pharm Pract. 1999; 7: 69-70. 14. Hill S, Pang T. Leading by example: a culture change at WHO. Lancet. 2007; 369:1842-4. 15. Gray A, Collins J, Milani B. Persisting pain in children—ensuring implementation of new guidelines. Eur J Hosp Pharm Sci Pract. 2013; 20:293-6. 16. Ford N, Shubber Z, Hill A et al. Comparative efficacy of lamivudine and emtricitabine: a systematic review and meta-analysis of randomized trials. PLoS ONE. 2013; 8:e79981. 17. Gray A, Manasse HR Jr. Medicines shortages—a complex global challenge. Bull World Health Organ. 2012; 90:158-58A. 18. Waning B, Kyle M, Diedrichsen E et al. Intervening in global markets to improve access to HIV/AIDS treatment: an analysis of international policies and the dynamics of global antiretroviral medicines markets. Global Health. 2010; 6:9. 19. Medicines Patent Pool Foundation. Home page. www.medicinespatentpool. org/ (accessed 2014 Oct 1). 20. World Health Organization. Prequalification programme. http://apps.who.int/ prequal/ (accessed 2014 Oct 1). 21. Gray A, Suleman F. Training for clinical pharmacists—plat du jour or smörgåsbord? South Afr Pharm J. 2012; 79:38-40. 22. The Churchill Centre. Their finest hour (June 18, 1940, House of Commons). www.winstonchurchill.org/component/ content/article/3-speeches/122-theirfinest-hour (accessed 2014 Oct 1).
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DONALD E. FRANCKE MEDAL LECTURE
Starting from the bottom Andrew Lofts Gray Am J Health-Syst Pharm. 2015; 72:460-5
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consider it a signal honor to receive the Donald E. Francke Medal today, and I wish to record my gratitude to the board of directors of the American Society of HealthSystem Pharmacists, who approved the award. Unlike the majority of the previous recipients of this prestigious award, I did not have the opportunity to meet, and no doubt learn from, Dr. Francke. However, I was privileged to meet Dr. Gloria Niemeyer Francke at a number of the congresses of the International Pharmaceutical Federation (FIP); I can therefore at least claim to have been touched by part of that formidable team.1 (As a pharmacist married to a pharmacist, I recognize the many ways in which we complement each other’s practice and support and challenge one another.) At the FIP congress in Beijing in 2007, the Hospital Pharmacy Section dinner was held in a wonderful venue at the Summer Palace. As the section president, I had the honor to preside over a glittering “high table,” with Gloria and an array of ASHP luminaries . . . certainly a night to remember! The invitation to contribute a scholarly paper on some aspect of in-
ternational hospital or health-system pharmacy sets one thinking about the trajectory of the profession and one’s own career. I have chosen to entitle my paper “Starting From the Bottom.” The sense I wish to convey is one of starting not only from the beginning, from a low base, but from far away—from a place that was isolated and out of the mainstream yet also striving to improve. I completed my bachelor of pharmacy degree at Rhodes University, in Grahamstown, South Africa, in 1981, and an internship in community pharmacy in Durban the following year. In 1984, I completed a master of science degree in pharmacy. While my research work, in the field of immunology, was conducted at the University of Natal Medical School, I was unable to register there, and my degree was again conferred by Rhodes University. The University of Natal Medical School was, at that point, reserved for Black Africans and those descended from South Asian (Indian) immigrants in terms of South Africa’s apartheid racial laws.2 After a year of travel in Europe (including a stint dispensing “social beverages”), my wife Rosemary and I returned to
Andrew Lofts Gray, B.Pharm., M.Sc. (Pharm), FPS, FFIP, is Senior Lecturer, Division of Pharmacology, Discipline of Pharmaceutical Sciences, School of Health Sciences, University of KwaZulu-Natal, and Consultant Pharmacist (Research Associate), Centre for the AIDS Programme of Research in South Africa, Durban, South Africa ([email protected]).
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Durban in 1985, and we both secured positions at hospital pharmacies. A discriminatory system My position was at King Edward VIII Hospital, then a 2000-bed public sector teaching hospital, located adjacent to the University of Natal Medical School. Prior to the democratic transition in 1994, all health services in the public sector in South Africa were provided separately to different ethnic groups.3 The hospital was therefore designated only for BlackAfrican and Indian patients and resourced accordingly. This meant overcrowded and poorly equipped facilities in general (including in the pharmacy), grossly inadequate staffing for the inpatient and outpatient load that was faced on a daily basis, and a lack of investment in the information and communications technologies that were by then standard fare in the South African private sector. The bulk of the adult medical wards, for instance, were housed in World War II–era wooden barracks that had been erected as a temporary measure in the early 1950s. Each of these medical wards had 35–50 beds in a single room and adjacent covered
Presented at the ASHP Midyear Clinical Meeting, Anaheim, CA, December 8, 2014. The author has declared no potential conflicts of interest. Copyright © 2015, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/15/0302-0460. DOI 10.2146/ajhp140791
DONALD E. FRANCKE MEDAL LECTURE Starting from the bottom
veranda. On a typical “post-intake” morning, after the medical team had completed a 24-hour stint in the Casualty Department, there could be as many as 20 additional patients on so-called floor beds—mattresses placed between and even underneath the fully occupied beds. In addition to the inpatient load, the pharmacy served upward of 1000 outpatients per day. In 1985, the pharmacy was predominantly serving the wards by means of bulk ward stock, with nurses collecting non–ward stock items from a central pharmacy. The pharmacy service also included a smallscale manufacturing service, mainly preparing oral liquids and topical preparations, and a prepacking unit, preparing patient-ready packs of oral solid dosage forms from bulk packs. Pharmacy staffing comprised about 25 pharmacists and around twice as many support personnel. The pharmacy support personnel were trained inhouse to perform basic functions and were not credentialed in any formal way. Viewed from a North American or European perspective, the pharmacy service was primitive, paper based, and almost entirely focused on distribution, without any apparent redeeming features. There was no intravenous admixture service, no therapeutic drug monitoring, no dedicated medicines information service, and certainly nothing resembling unit dose dispensing. While the pharmacy was physically divided between stores, manufacturing, and inpatient and outpatient areas, pharmacists seldom visited the wards or operating theaters except to check on controlled substances registers. However, there was a spark of something—a sense of camaraderie borne of struggle and a desire to do more than the system expected from a “black” hospital. The University of Natal Medical School was a crucial locus in the antiapartheid struggle, and the spirit of resistance also spread to its adjoining
teaching hospital. As a teaching hospital, albeit one designated to provide a subpar service according to the dictates of the racial policy of “separate development,” King Edward VIII Hospital had a dedicated medical team linked to the University. Vanessa Noble2 has described how this segregated medical education setting “developed as a site of great struggle and a setting of deep contradictions, at times reproducing apartheid conditions, but also unlocking the essential failure of an apartheid ideology, fulfilling some of objectives of separate development, but also contributing to the apartheid state’s demise.” The hospital may have looked like it deserved to be named after the monarch who abdicated his throne, but looks could be deceiving. Starting from scratch Donald C. McLeod4 has written about the critical role played by the journal Drug Intelligence, founded and edited by Donald E. Francke, in the early years of the clinical pharmacy movement in the United States. The successor title, Drug Intelligence and Clinical Pharmacy (DICP), now called The Annals of Pharmacotherapy, was one of only two pharmacy journals that was received on a regular basis at King Edward VIII Hospital Pharmacy; the other was AJHP. The budget for the journals was apparently covered by the nursing college that operated from the hospital (also an institution dedicated to providing training only for Black Africans). Although both journals had by then moved beyond merely describing the new services that were so revolutionary in the late 1960s,5 they were still critical resources for pharmacists in an isolated and embattled setting. It is difficult, in this hyperconnected world, to convey to a younger audience what it was like to open a fresh copy of DICP or AJHP at that time. From a place far away, impossibly exotic, came glimpses of
Andrew Lofts Gray Andrew Lofts Gray, B.Pharm., M.Sc. (Pharm), FPS, FFIP, is Senior Lecturer in the Division of Pharmacology, Discipline of Pharmaceutical Sciences, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa. He is also Consultant Pharmacist (Research Associate) in the Centre for the AIDS Programme of Research in South Africa. Mr. Gray’s research interests include policy analysis around the development and implementation of national medicine policies, rational medicine use, and the application of antiretroviral therapy in resource-constrained settings. He has been a member of the Names and Scheduling Expert Committee of the South African Medicines Control Council since 2000 and was appointed to the National Essential Medicines List Committee in 2012. He is a member of the World Health Organization’s Expert Panel on Drug Policies and Management and has served as a member, rapporteur, and co-chairperson of the Expert Committee on the Selection and Use of Essential Medicines. A past national president of the South African Association of Hospital and Institutional Pharmacists, Mr. Gray also has a long and distinguished record of service in the Hospital Pharmacy Section and the Board of Pharmaceutical Practice of the International Pharmaceutical Federation (FIP). He served as vice president (Africa) of the FIP Hospital Pharmacy Section (2001–06) and as president of the Hospital Pharmacy Section (2007–10). Mr. Gray also served as a member of the Executive Committee of FIP’s Board of Pharmaceutical Practice and as chairman of the Board of Pharmaceutical Practice. Widely published, Mr. Gray is associate editor of the South African Pharmaceutical Journal, is section editor of the Journal of Pharmaceutical Policy and Practice, and serves on the international editorial advisory boards of the International Journal of Clinical Pharmacy, and the GaBI Journal. Mr. Gray has been actively involved in the development and assessment of medicines and other health-related law in South Africa.
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Donald E. Francke Medal Recipients 2015 2014 2013 2012 2011 2010 2009 2008 2006 2006 2005 2004 2003 2001 1996 1995 1986 1978 1971
Andrew L. Gray Eduardo Savio Henri R. Manasse Jr. Barry R. Goldspiel Agathe Wehrli William A. Zellmer Jacqueline Surugue Toshitaka Nabeshima Thomas S. Thielke Philip J. Schneider Colin R. Hitchings Dwight R. Tousignaut Toby Clark Joaquin Ronda Beltran Carl D. Lyons Gloria Niemeyer Francke Joseph A. Oddis T. Douglas Whittet Donald E. Francke
The Donald E. Francke Medal was established in 1971 by the ASHP Board of Directors to honor individuals who have made significant international contributions to health-system pharmacy. Donald E. Francke (1910–78), the first recipient of the Medal, was widely acclaimed for his longstanding efforts to advance American and international pharmacy. He served in many leadership roles with ASHP, including as President and as Editor of the American Journal of Hospital Pharmacy. Within the International Pharmaceutical Federation, Francke was elected to the governing board and as an officer of the section for hospital pharmacists and of the section on press and documentation.
what might be, hints of what was possible. Bill Zellmer,6 in his 2009 Francke Medal Lecture, noted that “much of the ‘international talk’ in hospital pharmacy is, in reality, referential to the Western world and its well-articulated pharmacy education systems and its literature on pharmacy practice.” He called for pharmacy groups to acknowledge that “contemporary Western models 462
of pharmacy education and hospital pharmacy practice are too costly for the current needs in resource-poor countries.” That is practical, pragmatic, and appropriate advice, but it undervalues the “spark”—provided that spark falls in the right combustible environment. Henri Manasse’s7 2012 Francke Medal Lecture mentioned that pharmacy is “made up of polyglot definitions, diverse philosophies, and various viewpoints and is faced with almost infinite challenges.” That is true, but the core principles that animate pharmacists all over the world are shared. That much was clearly demonstrated in the consensus that was reached around the Basel Statements on the Future of Hospital Pharmacy, first articulated in 2008 and recently updated at the FIP congress in Bangkok.8 In my concluding remarks at the Basel meeting, I noted, “Hospital pharmacists have stated clearly that, as a profession, they are both ready and willing to accept responsibility for all medicines, everywhere in the hospital, and at all times”.9 That is what we tried to do at King Edward VIII Hospital from the late 1980s onward, and the ideas we embraced were those that we encountered in the two pharmacy journals. Any systems change involves a team effort, and at least a minimally supportive management, but I must pay tribute to the individual contribution made by Reuben Moss in the innovations we implemented at King Edward VIII. Slowly and deliberately, ward by ward, we expanded the reach of pharmacy. Starting from the medical and pediatric inpatient wards, we introduced ward pharmacists and reduced the reliance on ward stock. By the early 1990s, every inpatient’s medicine-related needs were reviewed by a pharmacist at least daily during the week. Multidisciplinary ward rounds in intensive care wards were routine. A daily meeting with members of the infectious diseases and medical microbiology services
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enabled the effective operation of what would now be termed an antimicrobial stewardship program. Pharmacy contributed to a specialist pediatric epilepsy service, including pharmacokinetic consultations. Inservice training of the new cadre of pharmacist assistants had commenced. There was never going to be a unit dose system, and admixture services were still restricted to oncology products and intravenous nutrition. Such computers as were available were largely reserved for stock control purposes. Computerized prescriber order-entry systems are still rare today in South African hospitals, and decision support systems are largely lacking. Staffing levels did not allow for a 24-hour, seven-day-a-week service. The high outpatient load still needed to be managed. However, the pharmacy department had developed a nationally recognized status and was considered a desirable place to train and to work. Critically, each new service was delivered by staff pharmacists who relied on their undergraduate training, supplemented with their own reading and their own efforts. At the time, I was the only pharmacist on the staff with any form of graduate training. We developed close relationships with the medical school and the pharmacy school at the University of Durban–Westville. The spark was at least partly reliant on that tenuous link with the outside world provided by posted journals. South Africa remained isolated, subject to academic and other sanctions and excluded from many international forums. However, the desire to do something more with the little we had burned brightly. There is a natural tendency to romanticize a time of struggle and to ignore the many negatives. King Edward VIII Hospital was heavily affected by the low-level civil war waged in the province at that time. The staff had to contend with increasing numbers of trauma patients, including those who
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were harshly punished by kangaroo courts.10 However, there is something of value in starting from the bottom, in having to find one’s own way, with minimal resources. Having to dig away in the dusty back shelves of the university library to find Cockcroft and Gault’s11 1976 paper in Nephron and then struggling to convert micromoles per liter to milligrams per deciliter in order to apply the equation, is worth it when it enables one to apply the practice innovations outlined in the latest issue of that exotic journal. The impossible is just in reach. Spreading upward and outward The majority of the new pharmacy services developed at King Edward VIII Hospital, whether based on something reported in the clinical pharmacy literature or purely homegrown, were directed at individual patient care. Even within the provincial health services, a common policy was not developed. There was one avenue for sharing and learning from local experiences, and that was provided by the South African Association of Hospital and Institutional Pharmacists (SAAHIP). The association had a proud history of activism on the issue of equal pay for equal work and had won salary parity for pharmacists of color in the public sector. Its annual conference became the forum for sharing practice research and service innovations. A common theme of many Francke Medal Lectures over the years has been the need for pharmacy leaders to engage, to contribute, and to share. In 2003, Toby Clark12 emphasized the need for international engagement, to “keep the flame burning.” That process starts at the local level, with the acceptance of leadership positions and the opportunity to hone one’s skills. By 1994, when South Africa finally made the transition to nonracial, democratic rule, I had already moved to academia, first via a pharmacokinetics research position but then to a pharmacy practice teaching post at
the University of Durban–Westville. That university, too, was a product of separate development, being specifically developed to serve the needs of the Indian population. However, I retained close ties with hospital practice and continued a pharmacy political career, eventually serving as president of SAAHIP. It was in that capacity that I attended my first ASHP Midyear Clinical Meeting in 1998. The transition to democracy required a wholesale revision of the entire corpus of South African law, and that revision applied equally to laws in the health sector and to those governing the practice of pharmacy. In 2001, as SAAHIP vice president, I had the opportunity to present the association’s positions to some of the first public hearings organized in the new democratic Parliament. Among the highly contested issues in pharmacy law was the prohibition on private hospitals owning their own pharmacies. This had resulted in complex efforts to evade what was clearly indefensible. However, those fights paled into insignificance when compared with the international contestation around access to affordable medicines. South Africa’s Medicines and Related Substances Control Amendment Act of 1997 became a global cause célèbre when its promulgation was interdicted by the Pharmaceutical Manufacturers’ Association and 39 of its member companies in 1998. Pharmacy groupings such as SAAHIP needed to quickly master the intricacies of and develop cogent positions on such issues as parallel trade, compulsory licensing, and mandatory offer of generic substitution. A hospital pharmacy leader was expected to be as comfortable discussing the basis for once-daily aminoglycoside dosing as arguing about the implications of the Agreement on Trade-Related Aspects of Intellectual Property Rights. One needed to be as familiar with Hatch–Waxman as with Cockcroft and Gault. Within academic practice, greater emphasis
was being placed on interdisciplinary learning, with a push toward community-based and problembased approaches. Pharmacy practice teaching and research, we argued, needed to be transdisciplinary in nature in order to adequately address the complex systems in which medicine use occurred.13 In accordance with South Africa’s 1996 National Drug Policy, which was inspired by the World Health Organization’s (WHO’s) essential medicines concept, South Africa committed to the development of a set of standard treatment guidelines and an essential medicines list. The first edition, aimed at the primary care level in the public sector, was issued in 1998. Instead of merely developing a list of medicines (a “formulary” in American terms), the decision was made to develop comprehensive standard treatment guidelines, from which the procurement list would be abstracted. This required not only an interdisciplinary team of medical, nursing, and pharmacy practitioners but also an engagement with the precepts of evidence-based medicine and the determination of cost-effectiveness. South Africa also sought to restructure its fragmented public health sector along primary healthcare lines and reorganize it as a District Health System. From mid1998, I took a secondment for two years as Co-ordinator: Drug Management with the Health Systems Trust (HST) Initiative for Sub-district Support (ISDS). This entailed providing support to the pharmaceutical services in 21 subdistricts spread across all of South Africa’s newly minted nine provinces. HST is a nongovernmental organization created specifically to contribute to the reform of the health system. The initial major funder was the Kaiser Family Foundation, but from the beginning cofunding was provided by the state. ISDS operated predominantly in the most rural and underserved parts of South Africa, where even the levels of pharma-
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ceutical staffing I had been used to at King Edward VIII Hospital were out of reach. I had to think about how best to use midlevel workers, to engage in task-shifting while building pharmaceutical systems that were safe and effective and fit for purpose. I have remained intimately involved in two long-lasting efforts hosted by HST. The first of these is the DRUGINFO listserver, initially aimed at exchanging clinical data but now more focused on pharmaceutical policy issues. The list connects nearly 800 pharmacy, medical, and other health professionals and policymakers across southern Africa and beyond on an almost daily basis. The second is the annual South African Health Review, which has been established as the standard reference work on the health system. In 2002, I moved from the pharmacy school at the University of Durban–Westville to the medical school at the University of Natal, specifically to lead the master of clinical pharmacology (MClinPharm) degree program. In 2001, I also attended my first FIP congress, in Singapore, replacing Reuben Moss as Vice President: Africa for FIP’s Hospital Pharmacy Section. The raison d’être of the MClinPharm program, which eventually developed into a “medicines management specialist” track of a master of public health degree, was the development of a public health clinical pharmacologist (whether initially trained in medicine or pharmacy) with the skills to contribute to the rational selection and use of medicines at both the individual and population levels. Increasingly, while I still do some bedside teaching, my own practice has also moved from the individual to the population level, from optimizing personal pharmaceutical care to ensuring quality policy development processes. Global reach Hospital pharmacists are criti464
cal to many structures involved in medicines selection, not only within individual health facilities (where they often sustain and nurture the pharmacy and therapeutics committees) but also at national and international levels. It has been my privilege to have served as a member of the WHO Expert Panel on Drug Policies and Management since 2007. In that capacity, I have served on the WHO Expert Committee on the Selection and Use of Essential Medicines and as chairman of its Subcommittee on Medicines for Children. The WHO Expert Committee is tasked with updating the WHO Model List of Essential Medicines every two years. When necessary—as was the case with the response to pandemic influenza—the Expert Committee can be constituted at any time. While some may perceive the efforts of the Expert Committee to be of value only for developing or low-income settings, the essential medicines concept has far wider application. Every health system in every country, regardless of the level of economic development, faces resource constraints and needs to make choices about which medicines to procure or reimburse. The prices demanded for new direct-acting antiviral agents have ensured that rationing is no longer an issue that can be ignored. Whether it retains its “third rail” status remains to be seen, but inaction is no longer an option. Rational policy that has a global reach can be developed. The key is the extent to which the policy is true to the evidence and honestly and clearly indicates the extent to which the evidence is lacking. From 2009 to 2013, it was my distinct privilege to serve as a member of the WHO Guidelines Review Committee, initially under the inspirational leadership of Dr. Sue Hill. In all of our careers, there are mentors or colleagues who, in retrospect, have shaped who we are and have somehow enabled us to be more than we ever expected
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was possible. In 2007, Hill and Pang14 wrote of a culture change at WHO and how the organization could lead by example in the way it used evidence to produce policy. I have been lucky to have been part of that change and to have been given the chance to grow through that process, from the bottom. However, no health policy is of any use until it is applied, in the field, to the benefit of patients.15 Clinical experience gained from the bottom—on the wards, in a health system under stress—is indispensable when one is called upon to provide input to the development of global policies that will have wide applicability. However, that does not imply that second-rate care is to be accepted in second-string countries. That much has been clearly demonstrated in the way in which a public health–oriented approach to the management of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) has developed. Not only has the world found a way to increase access to affordable antiretroviral medicines at scale but it has developed appropriate policies to guide rational selection of those medicines. Using our skills and training to contribute to assessments of the interchangeability of antiretrovirals is but one example of how pharmacists can contribute to this process.16 Global pharmacy organizations can also contribute to ensuring that critical issues retain their currency and garner the attention they deserve. One of the most pressing problems facing hospital pharmacists in every country is that of medicine shortages, for instance.17 Pharmacists tend to accept the nature of the market in which medicines are traded as a given. However, innovative funding mechanisms such as UNITAID (a WHO-hosted organization that uses market leverage to make lifesaving health products more affordable for developing countries) have been able to show that market-related
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interventions can improve access.18 Having initially served as a member of the Interim Expert Advisory Group of UNITAID, I have served on the Proposal Review Committee since 2010 and as its chair since 2012. Among the innovations supported by UNITAID, two deserve particular notice. The Medicines Patent Pool “opens the door to generic low-cost production of key HIV therapies as well as fixed-dose combinations and paediatric formulations by creating a pool of relevant patents for sub-licensing and product development.”19 The United Nations Medicines Prequalification Programme, managed by WHO, has been integral to assuring the quality of generic medicines used for HIV/AIDS, malaria, tuberculosis, and for reproductive health; the active pharmaceutical ingredients for such products; and quality control laboratories.20 The challenge, however, remains to ensure that the benefits that have accrued in low-income countries are accessible to those in middle-income countries as well and, eventually, that equitable access to needed medicines is assured in high-income countries. The challenge remains making universal health coverage a reality everywhere. Not losing the view from the bottom At my first FIP congress in Singapore in 2001, I was challenged by Tom Thielke and Phil Schneider, joint recipients of the Donald E. Francke Medal in 2006, to think about how residency programs could be applied in an African setting in order to improve the quality of hospital pharmacy practice. At first glance, the obstacles were obvious and overwhelming. After many years of advocacy, South African hospital pharmacists have finally achieved recognition of a clinical pharmacist career path in the public sector. The question now is how to train that new cadre and populate a specialist
clinical pharmacist register. Fatima Suleman and I21 argued that “we should guard against anything that is overly restrictive, that prescribes only a single route to registration (the plat du jour approach), and seek the greatest flexibility, with appropriate recognition of prior learning and varying routes to a clear demonstration of competency (the smörgåsbord approach).” Instead of a rigid system based only on attaining a specific postgraduate degree (such as a masters of pharmacy degree), we have argued for greater use of part-time fellowship programs as one option among many. I believe that we were being true to our shared experiences at King Edward VIII Hospital—that we were not losing the view from the bottom. In first developing and then updating the Basel Statements on the Future of Hospital Pharmacy, the FIP Hospital Pharmacy Section avoided the trap of being overly mechanical. There was no attempt to carefully parse our shared vision of the future into “light,” “regular,” and “deluxe” versions, and thereby lose the essence of a shared vision. Even as so many of the hospital pharmacy innovations that I encountered in each freshly unwrapped journal seemed impossible to attain, so each retained the power to inspire. Starting from the bottom required, first and foremost, the willingness to start: to refuse to accept the status quo as given and immutable. May none of us lose that sense of wonder at what is possible—no matter where we start from and however far the bottom appears to be from the desired “broad, sunlit uplands.”22 Thank you very much. References 1. Tribute to Gloria Niemeyer Francke: remembrances from family, friends, students, and colleagues. Am J Health-Syst Pharm. 2009; 66:258-78. 2. Noble V. A school of struggle. Durban’s medical school and the education of black doctors in South Africa. Durban, South Africa: University of KwaZuluNatal; 2013:2-5,13.
3. Coovadia H, Jewkes R, Barron P et al. The health and health system of South Africa: historical roots of current public health challenges. Lancet. 2009; 374:817-34. 4. McLeod DC. Contribution of The Annals of Pharmacotherapy to the development of clinical pharmacy. Ann Pharmacother. 2006; 40:109-11. 5. Whitney HA Jr, Nahata MC, Thordsen DJ. Francke’s legacy—40 years of clinical pharmacy. Ann Pharmacother. 2008; 42:121-6. 6. Zellmer WA. The education of a provincial pharmacist. Am J Health-Syst Pharm. 2010; 67:1080-4. 7. Manasse HR Jr. Perspectives on the global evolution and development of pharmacy. Am J Health-Syst Pharm. 2013; 70:675-9. 8. The Basel Statements on the future of hospital pharmacy. Am J Health-Syst Pharm. 2009; 66(suppl 3):S61-6. 9. Gray AL. Conference conclusions. Am J Health-Syst Pharm. 2009; 66(suppl 3):S75-6. 10. Muckart DJ, Abdool-Carrim AT. Pigmentinduced nephropathy after sjambok inju-
ries. S Afr J Surg. 1991; 29:21-4. 11. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976; 16:31-41. 12. Clark T. Keep the flame burning. Am J Health-Syst Pharm. 2003; 60:2209-12. 13. Gray A, Seneque M, Smit J. Reconsidering the need for an epistemology for pharmacy practice. Int J Pharm Pract. 1999; 7: 69-70. 14. Hill S, Pang T. Leading by example: a culture change at WHO. Lancet. 2007; 369:1842-4. 15. Gray A, Collins J, Milani B. Persisting pain in children—ensuring implementation of new guidelines. Eur J Hosp Pharm Sci Pract. 2013; 20:293-6. 16. Ford N, Shubber Z, Hill A et al. Comparative efficacy of lamivudine and emtricitabine: a systematic review and meta-analysis of randomized trials. PLoS ONE. 2013; 8:e79981. 17. Gray A, Manasse HR Jr. Medicines shortages—a complex global challenge. Bull World Health Organ. 2012; 90:158-58A. 18. Waning B, Kyle M, Diedrichsen E et al. Intervening in global markets to improve access to HIV/AIDS treatment: an analysis of international policies and the dynamics of global antiretroviral medicines markets. Global Health. 2010; 6:9. 19. Medicines Patent Pool Foundation. Home page. www.medicinespatentpool. org/ (accessed 2014 Oct 1). 20. World Health Organization. Prequalification programme. http://apps.who.int/ prequal/ (accessed 2014 Oct 1). 21. Gray A, Suleman F. Training for clinical pharmacists—plat du jour or smörgåsbord? South Afr Pharm J. 2012; 79:38-40. 22. The Churchill Centre. Their finest hour (June 18, 1940, House of Commons). www.winstonchurchill.org/component/ content/article/3-speeches/122-theirfinest-hour (accessed 2014 Oct 1).
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