Attentive nurse and cooperative patient,

 Primary Health Center No. 11, Balikesir, Turkey

The French poet and pilot Antoine de Saint-Exupéry once famously said, “If you want to build a ship, don’t drum up people to collect wood and don’t assign them tasks and work, but rather teach them to long for the endless immensity of the sea.”

Such was my experience on the WHO / PDA Pharmaceutical Cold Chain Management Course on Wheels. Read my review and comentary here.

China's success is vital to 21st century drug manufacturing. But is it too much to ask too soon for a country still trying to find its way in the new world economy? I only had to look as far as Chicago's lakefront to find a role model, as the June installment of Advanced Degrees in Contract Pharma explains...

As promised, here are the winning photographs taken by the participants of the 2010 Pharmaceutical Cold Chain Management on Wheels Course Istanbul to Izmir Turkey, June 7-12, 2010. Congratulations Sandra and Apichai!

Category: "Learning"

Winner: Sandra Oosthoek, Merck Sharp & Dohme, Haarlem, The Netherlands. Taken with a Canon G7.

Category: "Turkey"

Winner Apichai Supasansatorn, Ministry of Public Health, Thailand. Taken with a Canon D450.

Daily reports from the WHO-PDA Pharmaceutical Cold Chain Management on Wheels Learning Experience

DAY SIX:

GUMULDUR –

            I sensed the group was a bit apprehensive this morning – not wanting the week to end yet looking forward to some time to relax before going our separate ways. Today is the final segment of our incredible journey through this spectacular country. Many friendships have been made along the way and what began as 26 individuals from 16 countries six days earlier has coalesced into a team of cold chain global solidarity.

            We met at 8:00 AM in a conference room beside the dining area at the Denizati Holiday Village for the morning session. Jim Vesper delivered a follow-up to his risk management segment from the day before and I reviewed the results of the Pharmaceutical Transport Challenge. The 5 groups selected on day one were each given 5 separate graphs from the data loggers included with their shipment. The groups had to determine which graph belonged to which packaging technology. We then performed a post mortem on each graph discussing what the graphs revealed about each package assembly, where improvements could be made and what application each technology could best serve in the cold chain.

            After morning coffee Umit Kartoglu presented a video on the WHO shake test, a 100% accurate field test method for determining whether a vaccine had been frozen during its life, rendering it ineffective prior to administration to the patient. We all were able to test our skill at the shake test. This has proven to be an extremely effective tool in the field, particularly in remote and developing areas of the world where the cold chain is difficult to maintain.

 Inspecting vaccines during a shake test. L to R: Jose Rovira-Vilaplana, Ajit Tamhane, Gisele Correa Miranda and Danay Mora Pascual

            Umit then announced that following lunch the group would be treated to an afternoon boat cruise and sail to a nearby cove where we could swim, lay about on the rocks or the boat, enjoy the spectacular view of the Greek Islands in the distance, and a few adult beverages if we so chose, and generally reward ourselves for the hard work and long hours we experienced over the last six days. It was just what the doctor ordered! (Thank you Hakan for arranging the perfect end to an incredible week.)

The gang on our Saturday afternoon reward. L to R Standing: Danay Mora Pascual (Cuba), Andrew Garnett (England), Jeff Hawkins (USA), Marco Del Giudice (Italy), Alex de Beaupuy (France), Paulo Froes (Brazil), Hamed Mahmoud (Egypt), Bruce McCormick (USA), Gokhan Gurses (Turkey), Kevin O'Donnell (USA),Umit Kartoglu (Turkey), Mutlu Topal (Turkey).

L to R Seated: Joseph Jayakar (UAE), Gisele Miranda (Brazil), Hakan Gonendik (Turkey), Ajit Tamhane (India), Apichai Supasasatorn (Thailand), Jose-Rovira Vilaplana (Spain), Sandra Oosthoek (Netherlands), Roger Sabat (Jordan), Sarah Skuce (Canada), Jim Vesper (USA), Georg Roessling (Germany), Yves Loth (France), Rafik Bishara (USA).

            We met for about an hour before the gala dinner where everyone was required to verbally express their honest evaluation of the course, a few even became emotional voicing their experience. It soon became clear: no one in the group of participants had ever experienced learning like this. No conference, no seminar, or no lecture could ever come close to the experiential learning experienced on this voyage through the Turkish cold chain. Novices and experts alike unanimously concluded that this was the best training course they had ever attended. We will all return home with new wisdom, insight and knowledge and be able to apply what we have learned in our work-a-day worlds. Participants were equally grateful to Umit Kartoglu for the design of the course, to the mentors for their expertise and guidance and to Hakan for his phenominal logistics. It has indeed been a unique experience and I am much richer for having participated. (Thank you Umit for the invitation to serve with you as a mentor).

            Judging for the photo contest took place just before dinner. The winners were determined by group vote (mentors were not eligible). There were two categories “Turkey” and “Cold Chain.”  I will post the winners and their winning photographs soon!

            The gala dinner ran until well after midnight. There was a traditional Turkish band who played and graciously allowed members of our group to the stage (me included) to perform, sing and dance. It was a night no one will soon forget.

            I have a 5:00 AM wake up call to begin my 18 hour journey home – a place I long to be, although I am sad to be leaving this extraordinary country and my merry band of cold chain brothers and sisters. Technology being a wonderful thing; we will all stay in touch through an on-line community. I am once again reminded of the phrase that became the theme for this course – the end is nothing; the road is all.

For the last time, I bid you good night from Turkey.

Daily reports from the WHO-PDA Pharmaceutical Cold Chain Management on Wheels Learning Experience

DAY FIVE:

IZMIR -

            Weather holding. Up late last night working on the blog and I could hear singing and laughter drifting in through the open door to my balcony. It seemed to be coming from the pavilion down on the beach where we held our evening “evaluation of the day” exercise and discussion and watched the setting sun dip into the Aegean Sea. No doubt the revelry was coming from members from our group. It was around midnight. I decided I could use a break and I wandered down to the pavilion to investigate. A dozen or so were gathered around Paulo Froes, one of the more gregarious and animated of our group, currently working for UNICEF in Panama. Paulo was strumming away on a classical guitar in the brilliant style of his native Brazil while all the others were festively singing and dancing.  Umit and Rafik insisted that I play a few songs and I obliged them and returned to my room around 1:00 AM to finish the previous day’s posting while the hootenanny was still going strong on the beach.

            Today we left the old world arid coast (not far from Troy) to modern Ege University Hospital in the city of Izmir (pop: 3,525,200). Here we would see pharmacy distribution practices in the private sector. Our visits the previous few days were all part of the national public health program.

            The hospital was a sprawling complex of chaotic activity. We drew a great deal of attention as the 26 of us marched like an army of rag-tag invaders down the broad corridors of the hospital to the pharmacy dispensing area. The room was a bit cramped and bustling with 17 pharmacists and 6 technicians taking orders on desktops in the central pharmacy and dispensing the prescriptions while couriers bundled them in plastic bags and delivered them to the appropriate wards across the three hospitals within the University’s complex.    

            To this point on our journey we have witnessed very good distribution and storage practices throughout the pharmaceutical cold chain in Turkey. That was all about to change. Many of us were very surprised to find that in this sector, those GDP’s and GSP’s appeared to have low priority. We found that by observing and asking relevant questions from knowledge we had gained in the previous day’s use of the ESM tool, many, many shortcomings in receiving and storage of medications, especially temperature-sensitive drugs. It’s not that the staff at the hospital didn’t care. They are committed professionals. The underlying reason is because the level of awareness and education regarding GXP’s in the private sector is far below that of the government sector where routine education and audits are performed by various authorities. Here, in this private hospital there is no accountability from regulators and profit is often the motivator. Hence, things get missed, put aside or ignored. Take for example the hospitals storage facility for drugs. Like most hospitals, receiving and storage occurs in the bowels of the building. There was overhead piping and drains, open basement windows with dumpsters in the ally which could attract vermin, direct sunlight beaming down on cases of antibiotic, no continuous temperature monitoring of the refrigerators and coolers (only cheap household mercury thermometers), inadequate shelving, no surveillance cameras, and easy, uncontrolled access to the facility. Upstairs in dispensing the coolers holding temperature-sensitive products looked nice but lacked continuous monitoring. They were neither locked nor alarmed and the dispatch and cross-checking system was a manual process, rife for mistakes by relying on the aptitude of those involved. But on the surface it looked like a well oiled machine. One of the pharmacists guiding our group through the process summed it up accurately when she said, “Upstairs we are small and pretty, downstairs it is huge and uncontrolled.”

Ege University Hospital "controlled room temperature" drug storage facility. Note the boxes of antibiotic in direct sunlight, overhead piping and open window.

            Our final visit on our journey was to a new distribution warehouse opened by EDAK, the country’s largest pharmacist’s cooperative which serves about 20% of the nations pharmacies throughout western and southern Turkey. Among the many hygienic products, cosmetics and personal care items they provide, there is a considerable pharmaceutical operation – spotlessly clean, modern and high tech. This was a model of modern-day Turkey – an intensive cold chain operation with great care and consideration given to time- and temperature-sensitive drugs. Some of the more sublime activities include receipt and opening of cold chain items only within the cold storage room, temperature data loggers included with shipments are checked. If out of range, the shipment is rejected and returned to the drug manufacturer or importer. This facility has a fleet of refrigerated vans for remote shipments but service nearby pharmacies via motorcycles.

EDAK automated drug picking operation

EDAK motorcycle delivery for urgent requests. Non-temperature-sensitive drugs are put in the black carry-all. Cold chain products are put in EPS insulated containers with frozen gel packs and strapped to the back of the bike.

            We left Izmir in the mid-afternoon for the seaside town Gümüldür, known as the land of  tangerine, 80 km away. This would be the last leg on our incredible journey. Dr. Hakan Godednick, our logistics provider from Tip Kumuru (an accredited WHO learning center), deftly moved our merry band of cold-chainers across 550 km of Turkey without incident. He single-handedly arranged the bus, 5 different hotels, our hotel check-ins, all of our meeting locations, our dinners, lunches, stopovers, sightseeing tours and side trips, shuttles to the airport, all the course materials, our laptop bags, electrical outlets and beam projectors when we needed them for presentations, and any special personal or medical needs we encountered – all without missing a beat. Anything anyone needed, Hakan got it. He is truly an amazing organizer.

            Our last place of residence was at Denizati (meaning Seahorse) Holiday Village on the Aegean Sea. After checking-in we were given 2 hours of free time. Most took advantage of the perfect weather and went swimming in the sea. Then, one more 90 minute presentation poolside by the mentors on risk management and a discussion on the EDAK facility. Had an early dinner (9:00 PM) and for the first time in 10 days I will get to bed before 1:00 AM. I am looking forward to wrapping things up tomorrow, with classroom style discussion until mid-day, a surprise afternoon activity, course evaluation, photo contest and gala dinner. Good Night.  

Mentor Jim Vesper delivering a session on risk management poolside at Denizati Holiday Village. Dr. Umit Kartoglu documenting with camera.