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Appalachian Diary-Despair, Concern, Hope
By William F. McGhan and Ronald L. Williams
Before I came into the project, I had no idea what I wanted to do or could do. I hated pharmacy and saw no future in it for me as a profession. This feeling of frustration was mostly my inability to see that the profession goes beyond the activities of one or two people who have only a profit motive and encompasses many more people who are deeply concerned with patient care and drug education of the public. So I had made a hasty and rash judgment. Well, nine weeks later I have a renewed interest in my profession and an awareness of the innumerable possibilities and opporrtunities to deliver health care and to become actively involved with other health professionals.
T
hus read the personal evaluation written by one of the 21 members of the Student American Pharmaceutical Association who spent last summer taking part in the 1970 Appalachian Student Health Project. The project-launched in the summer of 1969 by the Student American Medical Association and the Appalachian Regional Commission-in its first year placed 94 medical students and 20 nursing students in the Appalachian states. Although the interdisciplinary nature of the project was to be expanded in 1970, program officials failed to recognize the potential contributions of pharmacy students and as a result would not provide the necessary funding. However, through the determination of Student APhA leaders and the generous financial contributions of nine pharmaceutical manufacturing firms and foundations, 21 pharmacy students joined 94 medical students, 20 nursing students and six dental students in the 1970 summer project. The Appalachian Student Health Project has been a student endeavor through the Appalachian Regional Commission with the main goal of attracting future health professionals to practice in the region. The program's overall objective is to influence career choices by exposing students to the health manpower needs, the opportunities 380
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for providing health services and the satisfactions and rewards of living and practicing in rural Appalachia. The project provides nine-week preceptorships in rural health care directly involving students with the health care systems, both in the provision of care and as a learning experience. There is a critical deficiency of health manpower in the nation, but the maldistribution of health professionals away from isolated and rural areas has had a devastating effect. Nowhere is this more evident than in Appalachia, where 17 million inhabitants suffer from a higher death rate in general and where the infant mortality rate is much higher than the national average. The student participants quickly realized what many people have stated in the past-that an effective health care system is composed of many facets, and no such system can perform satisfactorily in an impoverished society characterized by malfunctioning social, educational and economic structures. Students saw firsthand the social, economic and political problems that must be improved before the area's health level can be raised. For example, 60 percent of the housing units in many areas has been judged unsound, and the per capita income is 23 percent lower than the national average. The pharmacy participants were provided with unique e~perience and insight into the dynamics of health care in Appalachia, for they were placed throughout the region -from the farm lands of Ohio, through the coal fields of West Virginia, to the red earth and green pines of Georgia. But as stereotyped misconceptions dissolved, students came to realize that the region's problems are unique only in their magnitude and that these problems exist throughout the nation. And with this realization came a better understanding of the opportunities available to expand the role of pharmacy in health care. All students were assigned to volunteer preceptors with whom they were expected to work for two days each week.
The remammg three days were to be spent with participants from other disciplines in what would hopefully develop into team-oriented, community health projects. This aspect of the program was purposely unstructured, and students were allowed to develop their own projects and to define each participant's individual role. Ideally these projects were devised so that they would not be temporary services but would establish concepts that could be continued by permanent area health agencies or interested citizen organizations after the summer project ended. Because of the freedom allowed students in developing their summer projects, many performed functions not traditionally associated with their professional role models, but rather those that could be performed due to educational background and previous professional experience. As the summer progressed, student team members gained a greatly expanded appreciation of the training that students from other professions had received and, consequently, the contributions they could make to the total team effort. Students therefore developed responsibilities and functions based on capability and training rather than on stereotyped role expectations. The students' contact with their preceptors seemed to be mutually advantageous. Because of their relationship with their preceptors, the participants were able to enter more easily into the medical, social and political structure of their communities, as well as to observe and participate in pharmacy practice in the rural and poverty areas of the region. The preceptors benefitted by becoming familiar with aspects of health care which thay had never previously considered. Many pharmacists were brought out from behind the prescription counter for the first time and exposed to the health care process through the students' experiences with other health professionals. Although it will be a few years before statistics will prove or disprove the success of the program in increasing the number of health care personnel in Appalachia, preliminary figures are encouraging. In 1969, 20 percent of the participants indicated at the end of the project that they would consider returning to Appalachia to practice, while in 1970 the figure rose to 65 percent-medical, 64 percent; nursing, 82 percent; dental, 40 percent, and pharmacy, 56 percent. No person or report, of course, can relate what happened in Appalachia during the summer of 1970 as well as the students who were there. As part of the evaluation process, participants were required to keep a daily log of their experiences. The result was a collection of chrono-
June 21, 1970
I have just finished talking to the preceptor of the medical student and he has suggested that I make rounds with him and the medical student, and that I take drug histories. He has also given me a list of drugs which he uses, plus a list of particular problems he has run into and I am to find out as •much as I can about them. Naturally I am excited about the prospects of using some of the pharmacology I have had. But more than that, I'm scared to death! June 22, 1970
Just listening to my preceptor, there are no Negroes here and they probably wouldn't be welcome. But
William F. McGhan was the Student APhA pharmacy coordinator for the 1970 Appalachian Student Health Project, served as the pharmacy member of the Student American Medical Association's Standing Committee on Community Health and chaired the corresponding Student APhA committee. He received his PharmD degree from the University of California at San Francisco in 1970 and has just completed a residency in hospital pharmacy at the UC Medical Center Hospital. Interested in a career in organizational pharmacy, McGahn is a member of APhA, Student APhA, the American Society of Hospital Pharmacists, the California Pharmaceutical Association, the Peninsula Pharmaceutical Society and Rho Chi. He holds editorial positions with UC's Bulletin of the Hospital Pharmacy and the Drug Information Analysis Service and the Pharmacy Bulletin of the Veterans Administration Hospital in San Francisco. Ronald L. Williams was named as first executive secretary of the Stl!dent American Pharmaceutical Association when it was recognized as an official APhA subdivision in May 1969. He is a graduate of Ohio Northern University where he received a BS in pharmacy in 1957. Licensed in Ohio, he practiced in Akron and Cuyahoga Falls and served as the 1962-63 president of the Summit County Pharmaceutical Association and was active in committee work of the Ohio State Pharmaceutical Association. Due to his liaison work with the Summit County Medical Society, he was presented an associate membership in the American Medical Association, and he holds membership in APhA , Kappa Psi and the American School Health Association. He entered graduate school at Ohio State University in 1966, prior to joining the APhA staff in 1968.
logical records of not only "what-I-did-today," but also a personal and permanent record of the students' feelings about the project, the people of Appalachia, the beauty and problems of the area, and most importantly, their own perception of their relationship to it all. The following log is not that of a single participant; it is a compilation of extracts from the daily logs of 21 pharmacy student participants. It appears exactly as written by students at the end of each day's activity. Only names and places have been deleted--the thoughts, opinions and emotions remain untouched.
if they minded their own business, they would be · alright. Also longhaired fellows with beards and such are not welcome. If they want to live here they have to look like boys and be clean. When he was first asked if he'd like a pharmacy student for the summer, Mr. S's reply was ••no long hair and I expect him to be clean.'' I guess I meet the criteriahaven't heard any complaints yet.
up the hollow a ways and saw some nice painted homes, not modern but well kept up, and others that were really in rough shape. The hou,ses all had front porches and most had people out front. They seemed real friendly and would wave to us. There were horses by the road, gobblers in the ditches and all of this in one of the most beautiful states I have ever seen.
June 23, 1970
June 24, 1970
After work, a medical student and I went to eat, then took a drive around. We went down some backward road to a town about eight miles away. The road was terrible and the town wasn't much better. We drove
We were having a terrible time finding poverty for a project. By chance we walked out the back of our house and found a true slum right under our noses. There are two terrible shanties with at least 15 chilVol. NSll, No. 7, July 1971
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dren in them. Right now discussing our approach-tomorrow we will go back and talk. This could be a basis for our project. June 25, 1970 After less than a week I'm finding out the internal problems of the system. This area is sadly lacking in young professionals-or any health professionals for that ~ matter. It seems that this town has the typical problem of old doctors second-rating other professionals and seeing pharmacists as retailers. With the exception of two doctors, there is no relationship between pharmacists and doctors here. The local pharmacy association is crumbling due to lack of interest. Many pharmacists appear complacent about the problem.
really a skeleton crew (one RN and one orderly). There was one car accident (a doctor on call also), a man with a possible ruptured eye from a fight, three sick kids, a young girl who fell off a foot bridge, a woman with a migraine headache, a man with "nerves," and a drunk kid who complained of pain in his fingers (where the doctors had fixed a cut
them that we visited, still in good spirits and with determination not to give up. July 2, 1970
I was feeling sort of helpless about where to start or how I could help when one of the medical students brought a small boy from a nearby
June 26, 1970
I was surprised that so many people call my preceptor .. doc" and I asked him about it. He says it hangs over from when they called his dad that. He gets bogged down with the paper work of welfare Rx's and many times has to take it home because in addition to being a pharmacist, he is also chief fountain filler, floor sweeper, orderer, bookkeeper, window washer, consultant to patients -their complaints, comments and gossip. He does the job of ten people, but he still loves to spend his time talking to people who come into the store. June 27, 1970
Have been keeping a mental note on the types of drugs prescribed at the clinic. It seems strange that a rural area has such a high incidence of anxiety, hypertension and gastric problems. One would expect this to occur in high frequencies in more urban areas. The pharmacy also dispenses a lot of glyceryl guaiacolate, Orthoxicol and antihistamine preparations for the miners with Black Lung Disease. June 29, 1970 I am picking up a lot of medical knowledge by just listening and occasionally asking questions. It is very interesting discussing medicine in all its aspects and not limiting the discussion to only the physical side. The other students have accepted me, I think, as part of the "team" and often call on my limited knowledge to explain a drug reaction. It is unbelievable how helpful they all are in explaining terminology and medical findings. June 30, 1970
I was at the hospital this evening and assisted the night staff, which is 382
Many student projects were not health-oriented, at least not in the traditional sense, as demonstrated here by Richard Kozark (left), a medical student from the University of Wisconsin, Carlos Garza, a pharmacy student from the University of Texas, and children from a youth opportunity camp where the students served as part-time counselors.
artery the week before). All of this was compounded by the telephones which were in poor working condition. The doctor could only be summoned by someone going after him. I had to drive downtown to get a cab, plus work the switchboard while the nurse was in the emergency room. If the medical student and I hadn't been there, the staff would have been severely overworked. Only three doctors work the ER in rotation, and they have to be responsible for the whole hospital. July 1, 1970
The lighter side of these two days was when we visited the elderly patients. In one home was a 79-year old black lady helping a 77-year old white woman who had arthritis. While we sat there in the living room, the black lady was smoking her pipe full of Prince Albert tobacco and the other lady was making jokes. A nursing student from the project was there also, and she cut the patients' fingernails and toenails. The lady couldn't get over the fact that a manicurist had come over to take care of her. · She said the next thing she'd have to do is get some paint to paint her toenails. It was nice to see these particular old ladies and others like
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
coal camp to eat supper with us. He couldn't write his name and added 1 + 1 == 3. He was terribly uneducated for eight years old. I couldn't help but think of the hundreds of others that were in the same shape. They don't get a proper education because of poor environment (community and home) and also because of health problems that are undertreated or untreated. I am sure that many of the children are not getting full benefit from the education they are getting because of poor eyesight and hearing. Because this kid and others are just a part of a large group they are not getting the proper treatment they should be getting. They never get the chance to better themselves because of the lack of a good building block like education. These kids have no stimulus or interest. All they see is despair and a future of coal mining. It makes me sick. I feel so frustrated that I want to rush out and help everyone. Then I realize that I am not going to help anyone that way and just might hurt any possible help through hasty, thoughtless action. I have learned to practice patience, but how long I can do this without an emotional outburst that could blow any hope of help is not known.
July 3, 1970
Today I was able to witness a delivery. Dr. B said it was alright if a medical student and myself watched him. I had never seen this before, and the first time is exciting. I also feel that I am learning from this type of experience because I am seeing the drugs I have studied in the books being used. A motorcycle case died today and we saw the autopsy. We walked in and he was peeling back the skull-1 got used to it after a while. The guy died from a severe skull fracture which we saw quite plainly. There was a lot of necrotic brain tissue on his left side. If he would have lived, he would have been a vegetable. July 5, 1970
I went in the ambulance to pick up a patient. She was paralyzed from the waist down after an attempted suicide a few years ago. We picked her up in a run-down house where five kids were running around and the older folks were sitting around talking. A younger man asked if he could ride to the hospital with us and I found out later that they were to be married sometime this week, and what she had actually wanted to come to the hospital for was to get a blood test so she could be married. It's situations like this that really set me back. I listen to it and then try to shake it off as being a story, and then I realize that it is all true. It's really too much to believe. July 6, 1970
The RN at the hospital got me aside this evening to look at the chart of a diabetic patient. She was concerned abo.ut the medication because the patient seemed to be having problems. I wasn't really sure what I could say, but I did copy down the drugs she was taking and told the nurse I would check them out. But I was pretty sure that the patient was just a little ~~woozy" from the combination of Librium followed two hours later by Doriden. I was glad that the RN was concerned enough to seek some outside he Ip even if it probably wasn't warranted. I also don't think the doctors would like it too much to have the nurse doubt their capabilities in prescribing. July 7, 1970
S and I are formulating a program to make fluoride toothpaste, toothbrushes and vitamins with fluoride available to some of the families. To start things off we are going to give each Head Start student his own toothbrush and instruct him in the proper technique. We have en·
couraged the teachers to allow brushing with fluoride after their luncheon meal. We hope to be able to offer the parents of these children some sort of alternative to the severe damage that is being done by poor conditions and poor dental care. If the companies respond to our requests for samples, we should at least be able to make this problem a challenge. We are also thinking about aspirin in ~~child proof" bottles, iron supplements and ipecac. The project is developing into something that can become ongoing and beneficial. July 8, 1970
Tonight I stopped by the hospital on my way to the hotel after my trip. Even though I was not dressed very well, having spent the last two days in the same clothes, they asked me to stick around and help. The docs just got out of an appendectomy when a gunshot victim came in. He was shot more than seven times by his 15-year old son. I learned that the man had been beating his wife and kids when he was drunk and his son got hold of a .32 caliber revolver and fired two rounds of ammunition at his dad. I just wonder who was really to blame for the shooting? The guy was cussing out everyone in sight and kept two orderlies busy. Finally a nurse came down and asked me to come up and help a man back into bed. I hated to run around the hospital in muddy clothes, but I went. I lifted this man back into bed, and I learned that one hour later he died. I wonder if the hospital wasn't so tied up with the gunshot wound that perhaps the other man might have lived. He was old and had advanced TB and other things, but Hell, he has to have every chance to live. July 9, 1970 N and S are working on a project with pregnant women, and they seem to think that if I did a follow-up, explaining birth control pills to the women that come into the clinic, it would be of benefit to them. Birth control does seem to be a major problem here among the poor, and many just can't understand the use of the pill. One woman was supposed to be taking them and the public health nurse asked her why she wasn't. She shrugged and said, ~~I don't know." The nurse asked her why four were missing and she said, ''The children got hold of them." July 10, 1970 Today it suddenly hit me that my preceptor was depending more and more on me. It is a wonderful thing to be trusted to do such work as fill Rx's. I have to watch this, however,
for it might boomerang on me. I have to hang loose so the preceptor doesn't expect me everyday, when I should be out in the community. I think that this is one thing that kills any help the pharmacist can offer the community-he generally is so busy that he cannot spare much time outside the pharmacy. Tonight at the hospital, two deaths within minutes of each other. One elderly woman and one-half of a set of twins. One just ending a full life and one who never had the chance. But Hell, in this area even if a child lives, does it have much of a chance at life? July 13, 1970
People are infatuated with medicine around here. They think that they should take everything. However, this presents problems. An old man had a new prescription for digitoxin and I had a hard time trying to get him to understand that he couldn't get his old prescription for digitalis refilled. The people are always asking what their medication is
Pharmacy students gained the respect of other health professionals as the summer progressed. Above, a nurse consults with a pharmacy student, Steven Swanson, about medication entries on a patient's chart.
for, and I hate to tell them more than I have to because they will use the medication for what could be the wrong reason. If you tell them it is for nerves they will use it for any condition if they think it is nerves. They like to save everything. Trying to convince them to throw away old Rx's is like taking away their welfare check. July 14, 1970
The meeting with Dr. F was excellent. What may be the pith of his discussion is-man's behavior to man has grown absurd in his quest for money and power. If he lives Vol. NSll, No. 7, July 1971
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what he said, his life must not be easy; otherwise it is a life of mammoth hypocrisy.
Direct patient contact was the most educational part of the program for many students. In a rural hospital, pharmacy student William F. McGhan counsels a patient on the medication he is taking.
watches a prostate surgery. Since I am not a medical student, Dr. S said I'm not permitted in the operating room. Sometimes it can be frustrating to be in the health field but not be accepted as such. Maybe we can change that.
July 20, 1970 Went over to the hospital late and arrived just in time to get some static about the doc not being there. Christ, the guy has to sleep sometime! These people come in at night to avoid the wait during the day. Another brought in a kid who was running a fever (supposedly), but he wasn't complaining of a thing. If these people could be taught the basics of home care-the use of . aspirin, vaporub and hot water bottles. These kids get sicker by travelling at night. Dr. A sat down and told me they won't get any more doctors here. The patients are "spoiled," according to him. The doctors are overworked as it is and that just adds to it. It's no wonder that most leave after their residency requirements for citizenship are fulfilled. July 21, 1970
July 15, 1970 Our third stop of the day only brought the loud warning barks of a German Shepherd. Mrs. B told us she had often been threatened in her work but never injured. My opinion of social workers as just "busybody do-gooders" has changed considerably. They are brave women who travel into little-known regions bringing hope and encouragement to families that need it so badly. I see a great need for public health nurses who could go along with social workers and help with nutritional and dental problems and health care in general. If nurses need a challenge, here it is.
July 16, 1970 I did a little work in the pharmacy today, but I also went to see the health department and to check out Soon their family planning clinic. the county is going to have a model health system utilizing medical teams and outreach teams, so all that public health will deal with is preventative medicine. The student team is working on a project of transportation for the people to get into town to the health department. I think the five of us here are really getting together.
July 17, 1970 It's about 10:30 a.m. and I'm sitting in the hospital lobby while D 384
One thing that keeps coming back to me about this place is that the colored and the whites have no open discrimination. I struck up a conversation with a Negro man in town. He pointed out that everyone was friendly and that the color of the skin made no difference, even to dating. I cannot say what kind of hidden feelings there are. There is some kind of latent discrimination, but people for the most part treat people as people. Now this is in the poorer towns where this is taking place. As a person from a large metro area, I find this hard to believe. People in a big city are paranoid and discrimination is rampant. Even though these people don't consider themselves poor, there is something about being poor that provides a common denominator that crosses racial barriers. Everyone is in the same boat arnd is willing to help in his own poor way a neighbor who needs it.
July 22, 1970 Went with the rest of the group to a crippled children's camp. The camp had rock bands at night so the kids could dance. I really have to give these kids credit for guts. I wouldn't have been caught dead on a dance floor at their age and they have handicaps to boot. I had a wonderful time dancing with the kids, some of them no taller than my hips. The ones that couldn't dance by them-
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
selves, we picked up and held them while we danced. My heart went out to these kids-they were looking their handicaps right in the eye and working to overcome them. I don't think I could do what they are doing!
July 23, 1970 After having a discussion on drugs with the doctor on call at the hospital, he started talking about his sex life. I think he has accepted me as a member of the medical profession. He is not a god, just a human like me. I wish that this could be done in other places where the medical disciplines are able to work together. I think that all pharmacy students should do a certain amount of work in a hospital to get the feel of how the doctors work and think. July 24, 1970 Scary for a while-1 returned to the public health department to take the drug inventory, and I discovered an error in dosage strength that had been made and corrected it. I was terribly embarrassed but happy that it was corrected before the patient was affected. The inventory checked out and is now all set up in a cabinet in a small x-ray room instead of in cardboard boxes in an unlocked hall closet. They seem to have a problem in ordering drugs from th e state hospital-we will look into it and see what can be done. I would also like to talk to Dr. H about their prescription filing system. The nurses and Dr. H are very appreciative. July 27, 1970 Kids with the head lice are looking better-still may have to cut off half of Roberta's hair to get the lice out. Dr. M is strangely reluctant (or indifferent) about taking a water sample and prescribing worm medicine. Depressing situation. Will the people ever change? Are they satisfied living this way? What would they do with a garbage can if it was available? . . . Even if there were a garbage service. July 28, 1970 Of the families we have interviewed thus far, most of them really show love and concern for the health of their children, and more than one family mentioned how blessed they were to have children. It was so good to hear, s-ince we live in a day condemning families for having more than two children. Most of the homes had pictures of Christ and I feel it is their faith in and love for God that sustains them.
July 29, 1970
August 3, 1970
I talked with the workers in a school house today, and they made me realize how I had taken my education so much for granted. I find it hard to imagine how grades one through eight could be taught in one room at the same time. The girls were telling me how the kids dropped out of school after the eighth grade because the high school was too far away to walk, and they had to walk miles to the paved road to catch a school bus which presents problems during the winter.
Mr. 0, my preceptor, and I spent some time discussing the image of pharmacists as businessmen vs. professionals. He said that several years ago pharmacists got together with county physicians to discuss similar problems and questions only to have the 'meeting ruined by a pharmacist dwelling on "goddam welfare blanks." The county pharmaceutical association does meet, but Mr. 0 has been so disgusted that he rarely goes. He feels that there is still too much competition among pharmacists for them to sit down and talk professionally as physicians do.
July 30, 1970 Learned much about people, mining, politics and injustice.
July 31, 1970 With Dr. D and Dr. M, we discussed legality of operations for miners, birth control measures and problems of one-pharmacist towns. It was interesting for me to learn about the problems doctors face. I only wish that other pharmacists and pharmacy students could get together with physicians informally to discuss common problems and mainly to learn to understand each other. Why
August 4, 1970 In the afternoon we drove to the town. It is divided into a black and white section, and the line of demarcation between the two is quite sharp. Driving through the white section, one feels a certain stillness-that there is life somewhere behind the doors and windows. With the blacks, one notices feelings of life. You can hear music coming from the homes and see kids tossing a ball. The people truly color their lives and inject some joy into the frustration which is very much there. As one woman said to me. "Do you like the
run to when things go bad-just a cold and empty trainloader to stare at across the street. If nothing else, we who cross their paths, if only once, owe them love.
August 6, 1970 Went over to see how the Poison Control Center project is doing. I got the definite opinion that the pharmacist isn't going to do anything unti I he gets a comparison with other centers. I'm surprised that even though I'm offering my time free of charge, they won't act on the problem. I guess I haven't impressed upon them the fact that they have a bad poison control center. In this program it is awfully hard to really convince people to change things at all. Even ones who are progressive have a stigma about being the first to try a change. But the more I'm down here, the more I believe there is a certain period of confidence-gaining before anything constructive can be done. These people are superficially extremely friendly-and deep down, suspicious.
August 7, 1970 Our team spent the week as counselors at a youth camp for underprivileged kids. We supervised games, went on hikes, helped quiet down the cabin at night and taught first aid and other classes. Got some good advice from one of the older cour1selors. At the beginning of the week I was trying to mold the children's behavior to my middle class standards. This is not only impossible but unfair. Coming from the environment that these kids do, it is "normal" for a fight to break out every five minutes, for stealing to go on and personal hygiene to be as suc.h. Should I try to change them? They're at home right now picking up bad habits all over again. Should I try to discipline them after the most crucial stages of their development have already shaped them?
August 10, 1970 "If nothing else, we who cross their paths, if only once, owe them love."
can't they have joint meetings to iron things out? Since being able to meet physicians face to face I've come to appreciate them as human beings trying to do their jobs just as any other health professional. More and more I've recognized how much we all need to work together and we can only do this when we learn to communicate with each other. I'm not afraid any more to talk with physicians as I would have been earlier in the summer.
hills? Glad you do. I sure don't. Guess though that I'm stuck here for the rest of my life."
August 5, 1970 On our visits with the public health nurse, we saw several cases of mentally retarded children. Children are very delicate things and deserve the Thinking back, best to grow by. there was no place for the children to study. There was nothing to stir the human heart-no flowers, no arms to
Today was an exceptionally interesting day, making rounds with Dr. W. We saw a great variety of patients, from a very young girl who had an appendectomy to a 93-year old woman who wouldn't eat the hospital's breakfast because her relatives were going to bring some biscuits later. As is the case with most hospitals, it was very overcrowdedthere were even patients out in the hallway. The large number of visitors also caused problems. It was hard enough to get through the halls with the beds, etc., but we also had to work our way through the people. Vol. NSll, No. 7, July 1971
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August 11, 1970 1n one of the homes a patient told me the doctor had given him pills to take for his kidneys. He also compl,ained of being "tongue-tied" at times. When he showed me the pills, I realized why. They were tranquil-
August 12, 1970 There is only one thing that keeps plaguing me. If I came back I would not have the same thing where I could get together with the rest of the group in the area. We managed to put together a very close-knit group that worked well together. You had someone to talk to about the problems. What you couldn't do, someone else in the group could. It was so great to have such a close relationship among the disciplines-especially the pharmacy students who have traditionally been away from the medical scene. Thi.s summer has given me better guidelines on how I could use my knowledge of pharmacy to serve the people and help the rest of the medical team. How can I say goodbye to these people? They are beyond description. If I don't show up when I am expected, they worry about me. What about the old man who stands around the hospital an extra hour after he brings his wife to work so he can talk to me about the community? Damn -and I don't even know his name. I cannot even begin to mention the people who know me now. It makes me almost afraid to go back to the large metropolitan area because there will be no "howdy" as I drive by or
Note: The above was compiled from daily logs submitted during the project by the following pharmacy student participants-Elaine Balawejder (Philadelphia College of Pharmacy and Science), Wayne Coleman (University of California), Gene Ann Cox (University of Kentucky), Philip A. Cusumano (Ohio Northern University), Joseph L. Fink III (Philadelphia College of Pharmacy and Science), Mary Jean Forman (Idaho State University), Carlos Garza (University of Texas), Lawrence E. Gluertin (Albany College of Pharmacy), Mary Janice Gullett (University of Mississippi), Linda T. Helms (University of Southern California), Robert G. Helms (University of Southern California), Karen E. Renzi (University of California), J. Craig Hostetler (University of Kansas), Wayne T. Hutchison (University of Colorado), James Marttila (University of Minnesota), William F. McGhan (University of California), E. Michelle Monezis (West Virginia University), Erika M. Papai (Ohio State University), John N. Pierce (University of Michigan), Steven Swanson (University of Minnesota), Robert K. Sylvester (South Dakota State University).
be the new attitudes that will accompany their use. Just as Izaac Walton once created the concept of The Compleat Angler, the times now call for The Compleat Apothecary. He will come into existence, not by governmental edict, or the majority vote of any professional organization, or the urging of the socalled ivory-tower types in the pharmacy schools, but because economic, clinical and social pressures will demand it. Today, the public is in serious need of such a personal representative. It needs an advocate in this confused but tremendously significant area of drugs, a defender against irrational prescribing, a friend in clinical court, someone who can see to it that the patient will get the maximum benefits and the minimum risks from his drug dollar. Perhaps better than anyone else, the Compleat Apothecary can take on this function. Many of you are beginning to move in this direction. You have
already come to the recognition that you must work with but not for the drug industry. You must work with but not for physicians. And you have recognized that you must work both with and for your patients. With such services, you can make a truly heroic contribution to the improvement of health care, to the prevention of needless drug expenditures, to the prevention and control of needless, destructive, costly illness. For such professional services, you will no longer be overtrained or overpaid. And for such services, you will deserve compensation befitting the value of your contribution. Will this mean higher professional dispensing fees, higher incomes for pharmacists and thus higher drug prices for the public? In some instances, it may well be-but it will also mean better, safer and more effective drug therapy. I can conceive of no better investment for the public to make. •
August 13, 1970
" ... I feel it is their faith in and love for God that sustains them."
izers (Mellaril 50 mg) and he was taking two every four hours, although the directions said one every four hours. He said the doctor told him to do so.
'Now It's Their Turn' (continued from page 375)
detect or preferably to prevent adverse drug reactions. You are aware of the challenges which will be posed by the inevitable widespread use of prepackaging, of automated dispensing and of computer-based data processing. You are aware of the nature and potential impact of such .approaches as professional dispensing fees, which now seem destined to replace the percentage markup completely; and capitation fee schedules, now being tested in Europe and almost certain to be tried in the United States. You are aware of the contribution which clinical pharmacists are now beginning to make in hospitals and the contribution they could make in group practice clinics and other nonhospital operations in the community. But all of these, as important as they may be, are only techniques and hardware. Far more important will 386
••how're ya today, Buddy?" as I walk to the post office. Give me a smalltown atmosphere any day. It is great. Damn it, this county is in such a pitiful state that it stinks, but the people are so beautiful. It makes it like looking at a garbage dump and imagining a rose garden. •
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
Before I came into the project, I had no idea what I wanted to do or could do. I hated pharmacy and saw no future in it for me as a profession. This feeling of frustration was mostly my inability to see that the profession goes beyond the activities of one or two people who have only a profit motive and encompasses many more people who are deeply concerned with patient care and drug education of the public. So I had made a hasty and rash judgment. Well, nine weeks later I have a renewed interest in my profession and an awareness of the innumerable possibilities and opporrtunities to deliver health care and to become actively involved with other health professionals.
T
hus read the personal evaluation written by one of the 21 members of the Student American Pharmaceutical Association who spent last summer taking part in the 1970 Appalachian Student Health Project. The project-launched in the summer of 1969 by the Student American Medical Association and the Appalachian Regional Commission-in its first year placed 94 medical students and 20 nursing students in the Appalachian states. Although the interdisciplinary nature of the project was to be expanded in 1970, program officials failed to recognize the potential contributions of pharmacy students and as a result would not provide the necessary funding. However, through the determination of Student APhA leaders and the generous financial contributions of nine pharmaceutical manufacturing firms and foundations, 21 pharmacy students joined 94 medical students, 20 nursing students and six dental students in the 1970 summer project. The Appalachian Student Health Project has been a student endeavor through the Appalachian Regional Commission with the main goal of attracting future health professionals to practice in the region. The program's overall objective is to influence career choices by exposing students to the health manpower needs, the opportunities 380
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for providing health services and the satisfactions and rewards of living and practicing in rural Appalachia. The project provides nine-week preceptorships in rural health care directly involving students with the health care systems, both in the provision of care and as a learning experience. There is a critical deficiency of health manpower in the nation, but the maldistribution of health professionals away from isolated and rural areas has had a devastating effect. Nowhere is this more evident than in Appalachia, where 17 million inhabitants suffer from a higher death rate in general and where the infant mortality rate is much higher than the national average. The student participants quickly realized what many people have stated in the past-that an effective health care system is composed of many facets, and no such system can perform satisfactorily in an impoverished society characterized by malfunctioning social, educational and economic structures. Students saw firsthand the social, economic and political problems that must be improved before the area's health level can be raised. For example, 60 percent of the housing units in many areas has been judged unsound, and the per capita income is 23 percent lower than the national average. The pharmacy participants were provided with unique e~perience and insight into the dynamics of health care in Appalachia, for they were placed throughout the region -from the farm lands of Ohio, through the coal fields of West Virginia, to the red earth and green pines of Georgia. But as stereotyped misconceptions dissolved, students came to realize that the region's problems are unique only in their magnitude and that these problems exist throughout the nation. And with this realization came a better understanding of the opportunities available to expand the role of pharmacy in health care. All students were assigned to volunteer preceptors with whom they were expected to work for two days each week.
The remammg three days were to be spent with participants from other disciplines in what would hopefully develop into team-oriented, community health projects. This aspect of the program was purposely unstructured, and students were allowed to develop their own projects and to define each participant's individual role. Ideally these projects were devised so that they would not be temporary services but would establish concepts that could be continued by permanent area health agencies or interested citizen organizations after the summer project ended. Because of the freedom allowed students in developing their summer projects, many performed functions not traditionally associated with their professional role models, but rather those that could be performed due to educational background and previous professional experience. As the summer progressed, student team members gained a greatly expanded appreciation of the training that students from other professions had received and, consequently, the contributions they could make to the total team effort. Students therefore developed responsibilities and functions based on capability and training rather than on stereotyped role expectations. The students' contact with their preceptors seemed to be mutually advantageous. Because of their relationship with their preceptors, the participants were able to enter more easily into the medical, social and political structure of their communities, as well as to observe and participate in pharmacy practice in the rural and poverty areas of the region. The preceptors benefitted by becoming familiar with aspects of health care which thay had never previously considered. Many pharmacists were brought out from behind the prescription counter for the first time and exposed to the health care process through the students' experiences with other health professionals. Although it will be a few years before statistics will prove or disprove the success of the program in increasing the number of health care personnel in Appalachia, preliminary figures are encouraging. In 1969, 20 percent of the participants indicated at the end of the project that they would consider returning to Appalachia to practice, while in 1970 the figure rose to 65 percent-medical, 64 percent; nursing, 82 percent; dental, 40 percent, and pharmacy, 56 percent. No person or report, of course, can relate what happened in Appalachia during the summer of 1970 as well as the students who were there. As part of the evaluation process, participants were required to keep a daily log of their experiences. The result was a collection of chrono-
June 21, 1970
I have just finished talking to the preceptor of the medical student and he has suggested that I make rounds with him and the medical student, and that I take drug histories. He has also given me a list of drugs which he uses, plus a list of particular problems he has run into and I am to find out as •much as I can about them. Naturally I am excited about the prospects of using some of the pharmacology I have had. But more than that, I'm scared to death! June 22, 1970
Just listening to my preceptor, there are no Negroes here and they probably wouldn't be welcome. But
William F. McGhan was the Student APhA pharmacy coordinator for the 1970 Appalachian Student Health Project, served as the pharmacy member of the Student American Medical Association's Standing Committee on Community Health and chaired the corresponding Student APhA committee. He received his PharmD degree from the University of California at San Francisco in 1970 and has just completed a residency in hospital pharmacy at the UC Medical Center Hospital. Interested in a career in organizational pharmacy, McGahn is a member of APhA, Student APhA, the American Society of Hospital Pharmacists, the California Pharmaceutical Association, the Peninsula Pharmaceutical Society and Rho Chi. He holds editorial positions with UC's Bulletin of the Hospital Pharmacy and the Drug Information Analysis Service and the Pharmacy Bulletin of the Veterans Administration Hospital in San Francisco. Ronald L. Williams was named as first executive secretary of the Stl!dent American Pharmaceutical Association when it was recognized as an official APhA subdivision in May 1969. He is a graduate of Ohio Northern University where he received a BS in pharmacy in 1957. Licensed in Ohio, he practiced in Akron and Cuyahoga Falls and served as the 1962-63 president of the Summit County Pharmaceutical Association and was active in committee work of the Ohio State Pharmaceutical Association. Due to his liaison work with the Summit County Medical Society, he was presented an associate membership in the American Medical Association, and he holds membership in APhA , Kappa Psi and the American School Health Association. He entered graduate school at Ohio State University in 1966, prior to joining the APhA staff in 1968.
logical records of not only "what-I-did-today," but also a personal and permanent record of the students' feelings about the project, the people of Appalachia, the beauty and problems of the area, and most importantly, their own perception of their relationship to it all. The following log is not that of a single participant; it is a compilation of extracts from the daily logs of 21 pharmacy student participants. It appears exactly as written by students at the end of each day's activity. Only names and places have been deleted--the thoughts, opinions and emotions remain untouched.
if they minded their own business, they would be · alright. Also longhaired fellows with beards and such are not welcome. If they want to live here they have to look like boys and be clean. When he was first asked if he'd like a pharmacy student for the summer, Mr. S's reply was ••no long hair and I expect him to be clean.'' I guess I meet the criteriahaven't heard any complaints yet.
up the hollow a ways and saw some nice painted homes, not modern but well kept up, and others that were really in rough shape. The hou,ses all had front porches and most had people out front. They seemed real friendly and would wave to us. There were horses by the road, gobblers in the ditches and all of this in one of the most beautiful states I have ever seen.
June 23, 1970
June 24, 1970
After work, a medical student and I went to eat, then took a drive around. We went down some backward road to a town about eight miles away. The road was terrible and the town wasn't much better. We drove
We were having a terrible time finding poverty for a project. By chance we walked out the back of our house and found a true slum right under our noses. There are two terrible shanties with at least 15 chilVol. NSll, No. 7, July 1971
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dren in them. Right now discussing our approach-tomorrow we will go back and talk. This could be a basis for our project. June 25, 1970 After less than a week I'm finding out the internal problems of the system. This area is sadly lacking in young professionals-or any health professionals for that ~ matter. It seems that this town has the typical problem of old doctors second-rating other professionals and seeing pharmacists as retailers. With the exception of two doctors, there is no relationship between pharmacists and doctors here. The local pharmacy association is crumbling due to lack of interest. Many pharmacists appear complacent about the problem.
really a skeleton crew (one RN and one orderly). There was one car accident (a doctor on call also), a man with a possible ruptured eye from a fight, three sick kids, a young girl who fell off a foot bridge, a woman with a migraine headache, a man with "nerves," and a drunk kid who complained of pain in his fingers (where the doctors had fixed a cut
them that we visited, still in good spirits and with determination not to give up. July 2, 1970
I was feeling sort of helpless about where to start or how I could help when one of the medical students brought a small boy from a nearby
June 26, 1970
I was surprised that so many people call my preceptor .. doc" and I asked him about it. He says it hangs over from when they called his dad that. He gets bogged down with the paper work of welfare Rx's and many times has to take it home because in addition to being a pharmacist, he is also chief fountain filler, floor sweeper, orderer, bookkeeper, window washer, consultant to patients -their complaints, comments and gossip. He does the job of ten people, but he still loves to spend his time talking to people who come into the store. June 27, 1970
Have been keeping a mental note on the types of drugs prescribed at the clinic. It seems strange that a rural area has such a high incidence of anxiety, hypertension and gastric problems. One would expect this to occur in high frequencies in more urban areas. The pharmacy also dispenses a lot of glyceryl guaiacolate, Orthoxicol and antihistamine preparations for the miners with Black Lung Disease. June 29, 1970 I am picking up a lot of medical knowledge by just listening and occasionally asking questions. It is very interesting discussing medicine in all its aspects and not limiting the discussion to only the physical side. The other students have accepted me, I think, as part of the "team" and often call on my limited knowledge to explain a drug reaction. It is unbelievable how helpful they all are in explaining terminology and medical findings. June 30, 1970
I was at the hospital this evening and assisted the night staff, which is 382
Many student projects were not health-oriented, at least not in the traditional sense, as demonstrated here by Richard Kozark (left), a medical student from the University of Wisconsin, Carlos Garza, a pharmacy student from the University of Texas, and children from a youth opportunity camp where the students served as part-time counselors.
artery the week before). All of this was compounded by the telephones which were in poor working condition. The doctor could only be summoned by someone going after him. I had to drive downtown to get a cab, plus work the switchboard while the nurse was in the emergency room. If the medical student and I hadn't been there, the staff would have been severely overworked. Only three doctors work the ER in rotation, and they have to be responsible for the whole hospital. July 1, 1970
The lighter side of these two days was when we visited the elderly patients. In one home was a 79-year old black lady helping a 77-year old white woman who had arthritis. While we sat there in the living room, the black lady was smoking her pipe full of Prince Albert tobacco and the other lady was making jokes. A nursing student from the project was there also, and she cut the patients' fingernails and toenails. The lady couldn't get over the fact that a manicurist had come over to take care of her. · She said the next thing she'd have to do is get some paint to paint her toenails. It was nice to see these particular old ladies and others like
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
coal camp to eat supper with us. He couldn't write his name and added 1 + 1 == 3. He was terribly uneducated for eight years old. I couldn't help but think of the hundreds of others that were in the same shape. They don't get a proper education because of poor environment (community and home) and also because of health problems that are undertreated or untreated. I am sure that many of the children are not getting full benefit from the education they are getting because of poor eyesight and hearing. Because this kid and others are just a part of a large group they are not getting the proper treatment they should be getting. They never get the chance to better themselves because of the lack of a good building block like education. These kids have no stimulus or interest. All they see is despair and a future of coal mining. It makes me sick. I feel so frustrated that I want to rush out and help everyone. Then I realize that I am not going to help anyone that way and just might hurt any possible help through hasty, thoughtless action. I have learned to practice patience, but how long I can do this without an emotional outburst that could blow any hope of help is not known.
July 3, 1970
Today I was able to witness a delivery. Dr. B said it was alright if a medical student and myself watched him. I had never seen this before, and the first time is exciting. I also feel that I am learning from this type of experience because I am seeing the drugs I have studied in the books being used. A motorcycle case died today and we saw the autopsy. We walked in and he was peeling back the skull-1 got used to it after a while. The guy died from a severe skull fracture which we saw quite plainly. There was a lot of necrotic brain tissue on his left side. If he would have lived, he would have been a vegetable. July 5, 1970
I went in the ambulance to pick up a patient. She was paralyzed from the waist down after an attempted suicide a few years ago. We picked her up in a run-down house where five kids were running around and the older folks were sitting around talking. A younger man asked if he could ride to the hospital with us and I found out later that they were to be married sometime this week, and what she had actually wanted to come to the hospital for was to get a blood test so she could be married. It's situations like this that really set me back. I listen to it and then try to shake it off as being a story, and then I realize that it is all true. It's really too much to believe. July 6, 1970
The RN at the hospital got me aside this evening to look at the chart of a diabetic patient. She was concerned abo.ut the medication because the patient seemed to be having problems. I wasn't really sure what I could say, but I did copy down the drugs she was taking and told the nurse I would check them out. But I was pretty sure that the patient was just a little ~~woozy" from the combination of Librium followed two hours later by Doriden. I was glad that the RN was concerned enough to seek some outside he Ip even if it probably wasn't warranted. I also don't think the doctors would like it too much to have the nurse doubt their capabilities in prescribing. July 7, 1970
S and I are formulating a program to make fluoride toothpaste, toothbrushes and vitamins with fluoride available to some of the families. To start things off we are going to give each Head Start student his own toothbrush and instruct him in the proper technique. We have en·
couraged the teachers to allow brushing with fluoride after their luncheon meal. We hope to be able to offer the parents of these children some sort of alternative to the severe damage that is being done by poor conditions and poor dental care. If the companies respond to our requests for samples, we should at least be able to make this problem a challenge. We are also thinking about aspirin in ~~child proof" bottles, iron supplements and ipecac. The project is developing into something that can become ongoing and beneficial. July 8, 1970
Tonight I stopped by the hospital on my way to the hotel after my trip. Even though I was not dressed very well, having spent the last two days in the same clothes, they asked me to stick around and help. The docs just got out of an appendectomy when a gunshot victim came in. He was shot more than seven times by his 15-year old son. I learned that the man had been beating his wife and kids when he was drunk and his son got hold of a .32 caliber revolver and fired two rounds of ammunition at his dad. I just wonder who was really to blame for the shooting? The guy was cussing out everyone in sight and kept two orderlies busy. Finally a nurse came down and asked me to come up and help a man back into bed. I hated to run around the hospital in muddy clothes, but I went. I lifted this man back into bed, and I learned that one hour later he died. I wonder if the hospital wasn't so tied up with the gunshot wound that perhaps the other man might have lived. He was old and had advanced TB and other things, but Hell, he has to have every chance to live. July 9, 1970 N and S are working on a project with pregnant women, and they seem to think that if I did a follow-up, explaining birth control pills to the women that come into the clinic, it would be of benefit to them. Birth control does seem to be a major problem here among the poor, and many just can't understand the use of the pill. One woman was supposed to be taking them and the public health nurse asked her why she wasn't. She shrugged and said, ~~I don't know." The nurse asked her why four were missing and she said, ''The children got hold of them." July 10, 1970 Today it suddenly hit me that my preceptor was depending more and more on me. It is a wonderful thing to be trusted to do such work as fill Rx's. I have to watch this, however,
for it might boomerang on me. I have to hang loose so the preceptor doesn't expect me everyday, when I should be out in the community. I think that this is one thing that kills any help the pharmacist can offer the community-he generally is so busy that he cannot spare much time outside the pharmacy. Tonight at the hospital, two deaths within minutes of each other. One elderly woman and one-half of a set of twins. One just ending a full life and one who never had the chance. But Hell, in this area even if a child lives, does it have much of a chance at life? July 13, 1970
People are infatuated with medicine around here. They think that they should take everything. However, this presents problems. An old man had a new prescription for digitoxin and I had a hard time trying to get him to understand that he couldn't get his old prescription for digitalis refilled. The people are always asking what their medication is
Pharmacy students gained the respect of other health professionals as the summer progressed. Above, a nurse consults with a pharmacy student, Steven Swanson, about medication entries on a patient's chart.
for, and I hate to tell them more than I have to because they will use the medication for what could be the wrong reason. If you tell them it is for nerves they will use it for any condition if they think it is nerves. They like to save everything. Trying to convince them to throw away old Rx's is like taking away their welfare check. July 14, 1970
The meeting with Dr. F was excellent. What may be the pith of his discussion is-man's behavior to man has grown absurd in his quest for money and power. If he lives Vol. NSll, No. 7, July 1971
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what he said, his life must not be easy; otherwise it is a life of mammoth hypocrisy.
Direct patient contact was the most educational part of the program for many students. In a rural hospital, pharmacy student William F. McGhan counsels a patient on the medication he is taking.
watches a prostate surgery. Since I am not a medical student, Dr. S said I'm not permitted in the operating room. Sometimes it can be frustrating to be in the health field but not be accepted as such. Maybe we can change that.
July 20, 1970 Went over to the hospital late and arrived just in time to get some static about the doc not being there. Christ, the guy has to sleep sometime! These people come in at night to avoid the wait during the day. Another brought in a kid who was running a fever (supposedly), but he wasn't complaining of a thing. If these people could be taught the basics of home care-the use of . aspirin, vaporub and hot water bottles. These kids get sicker by travelling at night. Dr. A sat down and told me they won't get any more doctors here. The patients are "spoiled," according to him. The doctors are overworked as it is and that just adds to it. It's no wonder that most leave after their residency requirements for citizenship are fulfilled. July 21, 1970
July 15, 1970 Our third stop of the day only brought the loud warning barks of a German Shepherd. Mrs. B told us she had often been threatened in her work but never injured. My opinion of social workers as just "busybody do-gooders" has changed considerably. They are brave women who travel into little-known regions bringing hope and encouragement to families that need it so badly. I see a great need for public health nurses who could go along with social workers and help with nutritional and dental problems and health care in general. If nurses need a challenge, here it is.
July 16, 1970 I did a little work in the pharmacy today, but I also went to see the health department and to check out Soon their family planning clinic. the county is going to have a model health system utilizing medical teams and outreach teams, so all that public health will deal with is preventative medicine. The student team is working on a project of transportation for the people to get into town to the health department. I think the five of us here are really getting together.
July 17, 1970 It's about 10:30 a.m. and I'm sitting in the hospital lobby while D 384
One thing that keeps coming back to me about this place is that the colored and the whites have no open discrimination. I struck up a conversation with a Negro man in town. He pointed out that everyone was friendly and that the color of the skin made no difference, even to dating. I cannot say what kind of hidden feelings there are. There is some kind of latent discrimination, but people for the most part treat people as people. Now this is in the poorer towns where this is taking place. As a person from a large metro area, I find this hard to believe. People in a big city are paranoid and discrimination is rampant. Even though these people don't consider themselves poor, there is something about being poor that provides a common denominator that crosses racial barriers. Everyone is in the same boat arnd is willing to help in his own poor way a neighbor who needs it.
July 22, 1970 Went with the rest of the group to a crippled children's camp. The camp had rock bands at night so the kids could dance. I really have to give these kids credit for guts. I wouldn't have been caught dead on a dance floor at their age and they have handicaps to boot. I had a wonderful time dancing with the kids, some of them no taller than my hips. The ones that couldn't dance by them-
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
selves, we picked up and held them while we danced. My heart went out to these kids-they were looking their handicaps right in the eye and working to overcome them. I don't think I could do what they are doing!
July 23, 1970 After having a discussion on drugs with the doctor on call at the hospital, he started talking about his sex life. I think he has accepted me as a member of the medical profession. He is not a god, just a human like me. I wish that this could be done in other places where the medical disciplines are able to work together. I think that all pharmacy students should do a certain amount of work in a hospital to get the feel of how the doctors work and think. July 24, 1970 Scary for a while-1 returned to the public health department to take the drug inventory, and I discovered an error in dosage strength that had been made and corrected it. I was terribly embarrassed but happy that it was corrected before the patient was affected. The inventory checked out and is now all set up in a cabinet in a small x-ray room instead of in cardboard boxes in an unlocked hall closet. They seem to have a problem in ordering drugs from th e state hospital-we will look into it and see what can be done. I would also like to talk to Dr. H about their prescription filing system. The nurses and Dr. H are very appreciative. July 27, 1970 Kids with the head lice are looking better-still may have to cut off half of Roberta's hair to get the lice out. Dr. M is strangely reluctant (or indifferent) about taking a water sample and prescribing worm medicine. Depressing situation. Will the people ever change? Are they satisfied living this way? What would they do with a garbage can if it was available? . . . Even if there were a garbage service. July 28, 1970 Of the families we have interviewed thus far, most of them really show love and concern for the health of their children, and more than one family mentioned how blessed they were to have children. It was so good to hear, s-ince we live in a day condemning families for having more than two children. Most of the homes had pictures of Christ and I feel it is their faith in and love for God that sustains them.
July 29, 1970
August 3, 1970
I talked with the workers in a school house today, and they made me realize how I had taken my education so much for granted. I find it hard to imagine how grades one through eight could be taught in one room at the same time. The girls were telling me how the kids dropped out of school after the eighth grade because the high school was too far away to walk, and they had to walk miles to the paved road to catch a school bus which presents problems during the winter.
Mr. 0, my preceptor, and I spent some time discussing the image of pharmacists as businessmen vs. professionals. He said that several years ago pharmacists got together with county physicians to discuss similar problems and questions only to have the 'meeting ruined by a pharmacist dwelling on "goddam welfare blanks." The county pharmaceutical association does meet, but Mr. 0 has been so disgusted that he rarely goes. He feels that there is still too much competition among pharmacists for them to sit down and talk professionally as physicians do.
July 30, 1970 Learned much about people, mining, politics and injustice.
July 31, 1970 With Dr. D and Dr. M, we discussed legality of operations for miners, birth control measures and problems of one-pharmacist towns. It was interesting for me to learn about the problems doctors face. I only wish that other pharmacists and pharmacy students could get together with physicians informally to discuss common problems and mainly to learn to understand each other. Why
August 4, 1970 In the afternoon we drove to the town. It is divided into a black and white section, and the line of demarcation between the two is quite sharp. Driving through the white section, one feels a certain stillness-that there is life somewhere behind the doors and windows. With the blacks, one notices feelings of life. You can hear music coming from the homes and see kids tossing a ball. The people truly color their lives and inject some joy into the frustration which is very much there. As one woman said to me. "Do you like the
run to when things go bad-just a cold and empty trainloader to stare at across the street. If nothing else, we who cross their paths, if only once, owe them love.
August 6, 1970 Went over to see how the Poison Control Center project is doing. I got the definite opinion that the pharmacist isn't going to do anything unti I he gets a comparison with other centers. I'm surprised that even though I'm offering my time free of charge, they won't act on the problem. I guess I haven't impressed upon them the fact that they have a bad poison control center. In this program it is awfully hard to really convince people to change things at all. Even ones who are progressive have a stigma about being the first to try a change. But the more I'm down here, the more I believe there is a certain period of confidence-gaining before anything constructive can be done. These people are superficially extremely friendly-and deep down, suspicious.
August 7, 1970 Our team spent the week as counselors at a youth camp for underprivileged kids. We supervised games, went on hikes, helped quiet down the cabin at night and taught first aid and other classes. Got some good advice from one of the older cour1selors. At the beginning of the week I was trying to mold the children's behavior to my middle class standards. This is not only impossible but unfair. Coming from the environment that these kids do, it is "normal" for a fight to break out every five minutes, for stealing to go on and personal hygiene to be as suc.h. Should I try to change them? They're at home right now picking up bad habits all over again. Should I try to discipline them after the most crucial stages of their development have already shaped them?
August 10, 1970 "If nothing else, we who cross their paths, if only once, owe them love."
can't they have joint meetings to iron things out? Since being able to meet physicians face to face I've come to appreciate them as human beings trying to do their jobs just as any other health professional. More and more I've recognized how much we all need to work together and we can only do this when we learn to communicate with each other. I'm not afraid any more to talk with physicians as I would have been earlier in the summer.
hills? Glad you do. I sure don't. Guess though that I'm stuck here for the rest of my life."
August 5, 1970 On our visits with the public health nurse, we saw several cases of mentally retarded children. Children are very delicate things and deserve the Thinking back, best to grow by. there was no place for the children to study. There was nothing to stir the human heart-no flowers, no arms to
Today was an exceptionally interesting day, making rounds with Dr. W. We saw a great variety of patients, from a very young girl who had an appendectomy to a 93-year old woman who wouldn't eat the hospital's breakfast because her relatives were going to bring some biscuits later. As is the case with most hospitals, it was very overcrowdedthere were even patients out in the hallway. The large number of visitors also caused problems. It was hard enough to get through the halls with the beds, etc., but we also had to work our way through the people. Vol. NSll, No. 7, July 1971
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August 11, 1970 1n one of the homes a patient told me the doctor had given him pills to take for his kidneys. He also compl,ained of being "tongue-tied" at times. When he showed me the pills, I realized why. They were tranquil-
August 12, 1970 There is only one thing that keeps plaguing me. If I came back I would not have the same thing where I could get together with the rest of the group in the area. We managed to put together a very close-knit group that worked well together. You had someone to talk to about the problems. What you couldn't do, someone else in the group could. It was so great to have such a close relationship among the disciplines-especially the pharmacy students who have traditionally been away from the medical scene. Thi.s summer has given me better guidelines on how I could use my knowledge of pharmacy to serve the people and help the rest of the medical team. How can I say goodbye to these people? They are beyond description. If I don't show up when I am expected, they worry about me. What about the old man who stands around the hospital an extra hour after he brings his wife to work so he can talk to me about the community? Damn -and I don't even know his name. I cannot even begin to mention the people who know me now. It makes me almost afraid to go back to the large metropolitan area because there will be no "howdy" as I drive by or
Note: The above was compiled from daily logs submitted during the project by the following pharmacy student participants-Elaine Balawejder (Philadelphia College of Pharmacy and Science), Wayne Coleman (University of California), Gene Ann Cox (University of Kentucky), Philip A. Cusumano (Ohio Northern University), Joseph L. Fink III (Philadelphia College of Pharmacy and Science), Mary Jean Forman (Idaho State University), Carlos Garza (University of Texas), Lawrence E. Gluertin (Albany College of Pharmacy), Mary Janice Gullett (University of Mississippi), Linda T. Helms (University of Southern California), Robert G. Helms (University of Southern California), Karen E. Renzi (University of California), J. Craig Hostetler (University of Kansas), Wayne T. Hutchison (University of Colorado), James Marttila (University of Minnesota), William F. McGhan (University of California), E. Michelle Monezis (West Virginia University), Erika M. Papai (Ohio State University), John N. Pierce (University of Michigan), Steven Swanson (University of Minnesota), Robert K. Sylvester (South Dakota State University).
be the new attitudes that will accompany their use. Just as Izaac Walton once created the concept of The Compleat Angler, the times now call for The Compleat Apothecary. He will come into existence, not by governmental edict, or the majority vote of any professional organization, or the urging of the socalled ivory-tower types in the pharmacy schools, but because economic, clinical and social pressures will demand it. Today, the public is in serious need of such a personal representative. It needs an advocate in this confused but tremendously significant area of drugs, a defender against irrational prescribing, a friend in clinical court, someone who can see to it that the patient will get the maximum benefits and the minimum risks from his drug dollar. Perhaps better than anyone else, the Compleat Apothecary can take on this function. Many of you are beginning to move in this direction. You have
already come to the recognition that you must work with but not for the drug industry. You must work with but not for physicians. And you have recognized that you must work both with and for your patients. With such services, you can make a truly heroic contribution to the improvement of health care, to the prevention of needless drug expenditures, to the prevention and control of needless, destructive, costly illness. For such professional services, you will no longer be overtrained or overpaid. And for such services, you will deserve compensation befitting the value of your contribution. Will this mean higher professional dispensing fees, higher incomes for pharmacists and thus higher drug prices for the public? In some instances, it may well be-but it will also mean better, safer and more effective drug therapy. I can conceive of no better investment for the public to make. •
August 13, 1970
" ... I feel it is their faith in and love for God that sustains them."
izers (Mellaril 50 mg) and he was taking two every four hours, although the directions said one every four hours. He said the doctor told him to do so.
'Now It's Their Turn' (continued from page 375)
detect or preferably to prevent adverse drug reactions. You are aware of the challenges which will be posed by the inevitable widespread use of prepackaging, of automated dispensing and of computer-based data processing. You are aware of the nature and potential impact of such .approaches as professional dispensing fees, which now seem destined to replace the percentage markup completely; and capitation fee schedules, now being tested in Europe and almost certain to be tried in the United States. You are aware of the contribution which clinical pharmacists are now beginning to make in hospitals and the contribution they could make in group practice clinics and other nonhospital operations in the community. But all of these, as important as they may be, are only techniques and hardware. Far more important will 386
••how're ya today, Buddy?" as I walk to the post office. Give me a smalltown atmosphere any day. It is great. Damn it, this county is in such a pitiful state that it stinks, but the people are so beautiful. It makes it like looking at a garbage dump and imagining a rose garden. •
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION