This troubled year is ending, with its death toll, its burden of inequities, fragile victims, exploited individuals. Awareness is not enough. As Giuseppe Pellegrino, a pharmacist with a long-standing background of humanitarian actions, recalls in this interview, actions are possible, and should be carried out. Giuseppe is a free spirit: “I’ve always worked independently, also because I’ve never met pharmacists who actually set up laboratories. As you said, it takes a spirit of collaboration, commitment, and motivation. I never had any contracts—always worked on my own. I was fully aware of the freedom this gave me and of the reasons why I was doing it. So, I am simply a board-certified pharmacist, specialized in galenics, tropical medicine, and international cooperation. And I use all of these skills in Africa. As for Linda, we are working together: she is a nephrologist and former head of the Nephrology and Dialysis Department at San Bonifacio Hospital. She has experience in the field of dialysis in Africa (Guinea-Bissau, Ivory Coast)”. Linda and Giuseppe are partners in humanitarian missions and in life.

An interview with Giuseppe Pellegrino

In 1997, I carried out my first mission in Africa, spending one year in Burundi. The country was in the midst of a civil war, and due to the embargo it was not possible to land in Bujumbura; the nearest functioning airport was in Kigali, Rwanda. I had been appointed to direct the hospital pharmacy in Ngozi Province, in the northern part of the country.

I found myself facing a reality that was entirely different from anything I had known before. As a typical European, I wondered which system was “right” and which was “wrong,” but of course no such answer existed. The only meaningful response, within the limits of my responsibilities, concerned the management of medications—or at least the few that could be sourced locally. My first task was therefore to reorganize the hospital pharmacy and train the staff to manage medications rationally. I also prepared a simplified pharmacology course in French, because the drug prescriptions I reviewed revealed significant gaps in the nurses’ pharmacological training.

What struck me most, however, was discovering that most of the drugs available locally were ineffective. It was impossible not to compare them with drugs donated from Italy, which theoretically contained the same active principles. Many medications purchased locally even came in packages that had previously been used for other products, such as paint. It was during this period that the idea of producing essential medicines within the hospital, for internal use, came about. Patients had the right to be treated with non-counterfeit medicines. “Counterfeit” was the word that best described the situation in that part of Africa, a situation I later learned was common in other regions as well. Patients themselves admitted they knew about the problem but, lacking alternatives, and often being unable to afford safer medications, they were forced to use counterfeit drugs. The idea of creating a small laboratory, however, was not pursued at that time.

In 2000, I created a project for local drug production and presented it to the Xaverian Missionary Fathers in Burundi, who recognized the seriousness of the problem and endorsed the initiative. The project was approved and funded by Manos Unidas, a Spanish organization. It involved setting up a small pharmaceutical production unit capable of manufacturing essential medicines in the form of capsules, tablets, creams, and disinfectants, using certified raw materials sourced from Italy and ensuring appropriate dosage and quality. This production unit was later selected by the Thai Ministry of Health, through its embassy in Kenya, for the production of antimalarial drugs to be distributed in the region. I remained in Burundi for six years to support the project.

In the years that followed, I visited several countries, including Guinea Bissau, Ivory Coast, Tanzania, and Madagascar, and in some of them I was able to set up galenic laboratories; some were limited to capsule production, others were equipped to produce tablets as well (Figs. 1, 2, 3). In every country, I observed the widespread presence of counterfeit medications: drugs that did not contain the dosages declared on the label, and in some cases substances with no therapeutic value at all. The extremely low cost of many medicines sold in local markets is itself a strong indicator of counterfeiting. This is a serious public health issue, particularly with antibiotics and antimalarials, and in my own small way I continue trying to respond, refusing to accept a situation in which sick people have no access to appropriate treatment.

Madagascar, the technician prepares the excipients needed for the capsules of moringa oleifera, an antiinflammatory phytotherapeutic agent

Madagascar, the technician proudly shows the first capsules of paracetamol 500 mg

The team of lab technicians, with Pino in the teacher's role

In recent years, I have developed what I like to call a “connection” between dialysis and the production of medications. The idea of producing drugs for the prevention of kidney disease came from a mission in Guinea Bissau. In many parts of Africa, dialysis is still a far away dream: often nonexistent, or available only in insufficient capacity to meet demand. There are private clinics offering dialysis for a fee, but very few patients can afford it. Conditions such as hypertension and diabetes can lead to kidney failure when not treated adequately, particularly when available medications are ineffective. For this reason, even small communities can benefit from a small laboratory producing effective medications, ensuring economic savings and, above all, saving lives. All individuals, and I will never tire of repeating it, have a full and undeniable right to health.

This universal right to health, despite the many declarations made over time, has not yet been achieved. In many regions, there is no healthcare system comparable to those in Western countries. As a result, patients must pay out of pocket for medical services. Considering that per capita income in so-called emerging countries is very low, it is evident that healthcare access is limited, with predictable consequences.

However, the worst problems I encountered during my 25 years of missions in Africa do not only concern the cost of medications, which is often prohibitive, or the difficulties involved in obtaining them on the market. Counterfeiting is a serious issue. Dosages are often incorrect, and the quality is uncertain. Although patients are aware of this, when I asked why they continued to use such medicines, their answers fell into two categories: they have no means to purchase safe medications or they have no alternatives, as only one source of medicines is available.

Why a galenic laboratory? one may ask. I have a deep conscience inherent to the noble profession of pharmacist. Creating small galenic laboratories capable of producing safe and effective medications, reducing costs, and ensuring the constant availability of essential drugs—for example, those related to kidney failure—can become a reality. Improving adherence to chronic therapies for hypertension and diabetes is the first step toward reducing the likelihood of developing kidney failure. A galenic laboratory can prepare virtually any type of medication, on a smaller scale than the pharmaceutical industry, while adhering to good preparation practices, and to the strict rules required to obtain safe medicines. In these laboratories it is possible to prepare capsules, tablets, syrups, for example for children, and other pharmaceutical formats. The work begins with raw materials in powdered form; these are compounded with appropriate excipients to fill capsules or produce tablets. For practical reasons, producing medicines in capsule form is generally preferable: the technique is simple and does not require expensive or sophisticated equipment.

The creation of these laboratories is currently one response, and possibly the only concrete one, to the problems described above. It requires commitment and awareness, but trust is the first requirement; believing and acting as if borders do not exist, may seem extreme, but it works.

Small projects make us aware that we can change complex situation and overcome high, long-established barriers. We need cooperation and empowering our local coworkers, providing education, and promoting understanding and awareness.