KwaZulu-Natal pharmacy expert Andy Gray has spent much of his career writing treatment guidelines and essential medicines lists for the country’s public health system, and choosing the right medicines for South Africans.
The pharmacologist also authors a daily e-mail digest of news on medicines and health-care policy called Druginfo, which combines information from a comprehensive range of regulatory bodies, medical journals and news outlets.
The newsletter is curated for a local health-care audience with intuition and dedication, and, he tells Sean Christie, writing for Bhekisisa, “it has become a bit obsessive. If that listserv falls over, I’m like, the world is not normal”.
“It costs me about an hour before work starts. Over the years I have got to know the information sites really well… it takes seconds to know if there’s something new in a major regulator’s website, or in a newspaper.”
Gray spends much of his time working as a senior lecturer in the division of pharmacology, but to call him an academic would be misleading, as a typical day includes participation in the meetings of a wide array of institutional committees and boards.
He is a member, for example, of the national essential medicines list committee, several South African Health Products Regulatory Authority committees, and a span of World Health Organisation panels and groups, including the Expert Panel on Drug Policies and Management and the Guideline Steering Group for Family Planning.
“I like to have my fingers in the pie. I dislike sitting on the outside, commenting only,” he says.
The pathways by which Gray has arrived at such influence are not linear, but his approach has always been straightforward. His unabridged CV is 36 pages long, and bears out the adage often attributed to Franklin Roosevelt: if you want something done, ask a busy person.
Where would he fix himself on the spectrum of workaholism?
“Ag,” he exhales, “I think there’s something about academia that means you never shut the till. I do struggle to take a whole weekend off.”
Why choose pharmacy?
Born in Worcester in the Western Cape, he moved with his family to the Eastern Cape in 1965, originally to a farm his grandparents managed in the Cathcart district. When his mother took up a teaching post at Queen’s College in Queenstown, this enabled Gray to attend the school, which he praises for giving him “an incredibly strong base”, until he matriculated.
Gray was torn between social sciences and the sciences – he studied English, history, Latin, maths, chemistry and physics – and considered studying law but ultimately committed to pharmacy. His decision was informed in no small way by the many childhood hours he had spent hanging out in Mager & March (now Magers), the Queenstown pharmacy founded in the 1880s by William Mager.
“There has been a Mr Mager running it ever since. Mike Mager was in charge when I was growing up, and an absolute inspiration – this man in white, who allowed me to fiddle around in the storeroom and restock my chemistry set,” says Gray.
When Andy met Rosemary
Four years of undergraduate study at the pharmacy school at Rhodes University would give Gray more than a degree – in Grahamstown he studied alongside and fell in love with Rosemary Burrows. “After graduating, we interned at pharmacies right here in Umbilo,” he says.
"As an intern I came to know some of the lecturers at the medical school, which was then part of the University of Natal. One was a larger-than-life American immunologist called Steve Gaffen, who asked me if I would like to join his lab and do my master’s.”
Gaffen was doing early work in immunology, using immunoglobulins (a protein that helps the body fight infection) to treat gram-negative infections (infections caused by bacteria that are resistant to many drugs).
“He was using animal models,” says Gray, “and so for my master’s I looked at eye infections in rabbits.”
After Gray finished his master’s in 1984 he “did a duck to England, where he worked as a barman, among other things”. When Gray and Burrows (now Mr and Mrs Gray) returned to South Africa in 1985, they both found jobs in hospital pharmacies – he in the pharmacy at King Edward VIII Hospital, then a 2 000-bed public sector teaching hospital next to the University of Natal Medical School.
Gray was ultimately conscripted by the SANDF, and served in the military’s medical services for two years, before returning to work in the King Edward VIII pharmacy.
Journal subscriptions
Until 1994, all health services in South Africa’s public sector were provided separately to different ethnic groups and King Edward VIII Hospital was designated only for black and Indian patients.
In a lecture Gray gave in 2015 after receiving the Donald E Francke Medal (awarded to individuals who’ve made significant international contributions to public health pharmacy), he explained how his time in the hospital’s pharmacy forced a confrontation with a discriminatory system, characterised by “overcrowded and poorly equipped facilities, grossly inadequate staffing for the inpatient and outpatient load faced on a daily basis”.
“The pharmacy service was primitive. It was paper-based, there was no intravenous admixture service and no therapeutic drug monitoring, but there was camaraderie and opportunity,” he says.
“We would get visiting clinicians coming in from other countries, and we would say to them, think of a disease, something that you’ve never seen – neurofibromatosis – and we are sure to have it. That’s an incredibly rich place to be. But you’re stuck at the bottom of Africa, under sanctions in the middle of the 1980s. So what can you do?”
Quite a lot, it turns out. With minimal resources, Gray and his colleagues, “expanded clinical pharmacy until King Edward became a very desirable place to join the pharmacy department”.
For Gray, the unlikely ties that connected King Edward to the front edges of pharmaceutical progress were two journal subscriptions that used to land in the hospital pharmacy every month, as if by magic: Drug Intelligence and Clinical Pharmacy, and the American Journal of Health Systems Pharmacy.
“To this day I have no idea who ordered them but when they arrived in the post you devoured the latest research and thought: ‘I can do this.’ There’s something very special about working in an embattled context but being able to find a formula for assessing renal function in a paper in an old journal.”
Gray entered academia in 1993 but his time in hospital pharmacy had sparked a parallel journey in pharmacy politics – he went on to lead the South African Association of Hospital & Institutional Pharmacists at a time of “wholesale revision of the entire corpus of South African law”.
“A hospital pharmacy leader was expected to be as comfortable discussing the basis for once-daily aminoglycoside (a drug that works against many types of bacteria) dosing as arguing about the implication of the agreement on trade-related aspects of intellectual property rights.
“Everything had to change, everything was up for grabs and you could step up and tackle issues and change things,” says Gray, who gave workshops on medicines regulation for the Treatment Action Campaign, and as a member of the Unitaid Proposal Review Committee was involved in the decision to establish the Medicines Patent Pool, led by the access activist Ellen t’Hoen.
“Much of my work has been about choosing the right medicines and writing the right guidelines so that people use them better. That immediately brings up the question of cost, and how we intervene to make these things more affordable.”
Political weaknesses of SA pharmacy
Driving to his Westville home, I had passed gardens stuffed with flamboyants and tibouchinas, but with the scars of the 2022 mudslides still faintly discernible under new grass.
“The flooding wasn’t such a problem for pharmacy but the 2021 unrest exposed a major political vulnerability,” Gray says.
“When the N3 Mooi River toll plaza turns into a burning wreck, pharmaceutical supply freezes, because almost everything in this country moves by road and practically the entire pharmaceutical industry is in Jo’burg.”
He adds that the over-concentration of pharmacy on the Highveld echoes a far bigger pharmaceutical supply chain problem, “and that is over-concentration of production, especially the production of the active ingredients, in China and India, specifically for off-patent, older molecules, such as penicillins”.
One of the items Gray posted on Druginfo was a link to a Health Policy Watch article citing a British Medical Journal study revealing that, to reverse the trend of pharmaceutical offshoring, the US Government invested nearly $31.9bn in mRNA technology alone.
“If you convert that into rands, it’s our entire economy, so we can’t make that sort of investment,” says Gray, who believes there is a contradiction in South Africa’s national drug policy.
“We say we would like to boost our local production and reduce prices. Now, somewhere along the line those objectives are going to clash.”
Serendipity
His wife, Rosemary, has had a stellar career of her own, and Andy recognises the ways in which they have complemented each other’s practice.
“We’ve almost never been in the same field at the same time. When I was doing postgraduate training, Rosemary went to Addington Hospital and worked in the public sector. While I was moving into research, she ran a specialist, intravenous nutrition outsourcing service. Her experience makes me a more complete pharmacist,” he says, and Rosemary adds that the same applies to their elder daughter, who has followed her parents into pharmacy.
“Would you believe it, but Mike Mager’s granddaughter, Nicole, did her internship with my daughter Sarah. How’s that for completing the circle,” says Gray, beaming at the serendipity of it all.
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