Angels

What has been the best story for you this year or in your family and country? People who bring news are important and in the Christmas story angels play a significant part. They announce the message of the coming baby to Mary and to Joseph, they told that this baby would be the saviour of the world, they then announced to the whole world in a heavenly choir the great news , peace on earth and goodwill towards men.

I have been thinking about the message of the angels and also how angels can become a symbol of hope and protection. I am sitting on Christmas eve on a balmy evening looking forward to a warm, tropical Christmas without the crispy snow and frost that is so familiar in Scotland. I hear this year there are even storms and severe weather. But then that first Christmas there was no snow, despite our many Christmas cards carols that say otherwise.

I have a banana fibre Christmas tree hung with African angels and several other beautiful angels made from local materials including bark fibre, safety pins and local fabric. We also have shared beaded angels on our Cairdeas stalls for some years made in South Africa and Uganda. 

There have been some precious stories of ways these simple symbols have represented love and care. One of my friends showed me the wee angel I had given when her husband was dying. She has carried in her purse as a reminder of God's care for several years. Another friend shared how her very sick friend asked to her to give an angel to each of her family so they can hang it on the tree and remember her.

We had a party with our patients at Mulago last week and so enjoyed singing in several languages, eating cake and piled high plates of Uganda food. I was sharing one of the names given to Jesus and often given as a name to boys here in Uganda. Emmanuel which means God with us. This was the profound message of the first Christmas. it is also the amazing message still here today. My Rwandan colleagues then spoke of us being little Emmanuel. Being the presence of God in each other's lives and in the lives of those who have little good news and even less peace. We think of our brothers and sisters in South Sudan and Syria and many other places of conflict this Christmas. We think of the many people ill in hospital or at home, those who are missing loved ones, those who do not have food or clothes, who do have choices over their lives.  Many of us will have an symbolic angel in our homes or on our Christmas trees this year. Perhaps we can take the good news the angels sang to heart and let it change our lives but also let it change how we relate to the world around us.  As one of the greatest global leaders said; 'Our human compassion binds us the one to the other - not in pity or patronizingly,but as human beings who have learnt how to turn our common suffering into hope for the future'.  Nelson Mandela

Wishing you 2014 full of hope.

WWLD and WWJD

Last evening I was privileged to attend a celebration of the life of David Livingstone in the soaring and chilly beauty of Glasgow Cathedral. I was then asked to be part of a debate on what would Livingstone (WWLD) do if he were alive today. All the suggestions were persuasive and compelling (eradicating HIV/AIDS; Ms Mphatso Nguluwe , ending modern human trafficking;Sir Kenneth Calman, mobilising churches; Rev CB Samuel and addressing the global pandemic of untreated pain and lack of access to palliative care; yours truly) I have included the whole of my 4 minute speech for you to review. Sorry you can't vote for the others as well. At Cairdeas we are particularly delighted to partner with EMMS International http://www.emms.org/ who are the main support behind the palliative care developments in EHA, India, that we also support, as well as in Malawi. Now to finish packing in time to catch my plane back to the tropical heat of Uganda.....

'My thanks to my fellow debaters for their moving and persuasive presentation, to EMMS and the organisers of this event and to Dr David Livingstone for his inspirational life and example which we have come here to honour and celebrate.

5 billion people in our world do not have access to pain relief and palliative care, many of these with chronic, debilitating, life limiting illness. HIV AIDS as we have already heard but also rising numbers of those with cancer, growing problems with heart disease, rapidly increasing numbers with poorly controlled diabetes, kidney failure with little access to dialysis and multiple respiratory problems due in part to cooking fires in huts with poor ventilation.

This burden of disease has an incalculable effect on individuals, families, communities and even national economies as it disproportionately affects those in low and middle income countries exacerbating poverty and creating a trap for many more to fall into, where meager resources are used in a futile search for help and future generations denied opportunities and hope. This global pandemic of untreated pain affects hundreds of millions of people in our world and is described by the World Health Assembly as an urgent, humanitarian responsibility.

Livingstone's Rousers

Oral morphine, one of the mainstays of pain relief is simply unavailable in most of the world. Of all the morphine legally produced and used every year 94% is used by countries that represent only 15% of the world’s population. One of Livingstone’s achievements was to ensure that a simple medication made from Peruvian tree bark would be available in a safe and effective formulation. These ‘Livingstone’s Rousers’, which combined quinine and  rhubarb, were a significant advance and I think he would use same energy and determination to champion the provision of another God given medication; the extract of opium we call morphine.

Imagine the anguish of medical colleagues seeing patients in such severe pain yet unable to help, imagine the distress on a mothers face when her tiny daughter injured by severe burns when she pulled over paraffin lamp screams in pain without relief, imagine the quiet endurance and silent agony of a young mother whose breast cancer has spread to her bones and dares not move lest it hurt, imagine the nurse who avoids dressing the wounds of her patient as she cannot bear to hear the shouts of pain, imagine the elderly man who prays that God will take him soon to spare him further anguish and stop draining the family finances.

Palliative care is about quality of life and holistic support addressing the physical problems such as pain but also the isolation and financial drain of chronic illness, the loss of hope and meaning, the powerlessness and despair. It is about empowering communities, restoring dignity, relieving suffering, walking alongside those who face darkness and despair with all our medical skills and also a message of hope and promise of presence.

Livingstone engaged with some of the greatest causes of suffering and injustice in his day but above all he was concerned with what would Jesus do. WWJD leads to WWLD.

Livingstone was an ambassador for Christ. Taking the good news of reconciliation with God, with one another, with ourselves and with a world that is beautiful, exciting with untold riches to be explored. Livingstone was also a beacon to challenge and inspire others to be involved in this God ordained work of bringing reconciliation and healing and an end to needless suffering. Livingstone was not afraid to challenge and convict others, to stand against the prejudices of his day and to live his life in the extreme for the cause he believed in.

Many years ago I sat under a baobab tree in Malawi and made a decision to engage in this cause in Africa and India. It has been a wonderful adventure and tremendous privilege for me filled with challenges and blessings. This tree was over 200 years old and local legend has it that Livingstone would sit there; perhaps also contemplating the calling God has put on his life.

  

Ladies and gentleman; lack of access to pain control and palliative care is one of the most significant global injustices facing our world today.  I put it to you that freedom from pain, restoring dignity and relieving suffering would have been a concern, a motive, an imperative and a journey of untold adventure for Livingstone; as it is for each one of us.'

Inspiring leaders

Amazing LDI family

One of the greatest privileges of my life is to be a mentor; to see and support others to explore themselves and to develop and grow. I meet and work alongside inspiring and committed people who are open to learn, eager to develop new skills, thirsty for knowledge and willing to share something of their life's journey with me. To see a young and perhaps faltering student manage to develop clinical judgement; to watch a young physician in training realise the impact of holistic care; to help colleagues do their first research project; to see clinical skills honed; to facilitate the journeys of self awareness and self acceptance; to support national leaders take up their roles with confidence and to listen as colleagues struggle to balance the commitments and dedication to palliative care with family and personal needs and demands is demanding yet such a blessing.

Anjum and Dinesh with their sleepy mentor

I have just returned from the Leadership Development Initiative course now hosted by Ohio Health. 21 leaders along with the innovative and hard working faculty, the visionary funders and gifted mentors spent an amazing week together sharing their stories, learning how to communicate our messages and encouraging one another in our journeys internal and external to be leaders in palliative care.http://www.ipcrc.net/news/category/international-leaders/ This initiative seeks to grow leaders in order to advance palliative care and to make a difference for the many many people who are in need across our globe. It was incredible to hear tales from 5 continents and to listen to how often it is a personal tragedy or experience of loss or pain that acts as the spur to be involved with this demanding yet rewarding path that so deeply connects with the pain in our world yet also brings hope and joy to the places of despair and sadness.  We also heard of incredible achievements; Nepal now has access to affordable oral morphine
thanks to the work of Dr Bishnu. Dr Eva wrote the first ever morphine prescription in Guatemala. Dr Chitra is pioneering the need for holistic care within chronic mental health. Dr Odontaya is now a TV celebrity in

Team building last course

Mongolia integrating palliative care in that resource limited situation. Dr Israel is preparing to start the first postgraduate training for palliative care in Nigeria. Dr Dinesh plans to have a message that 'pain can be helped by choosing palliative care' screened in the cinemas of Assam and even available as a ring tone. Dr's Snezana (Serbia) and Dilsen (Turkey) are making their vision for integrating palliative care in oncology centres a reality.

Dr and Mrs Israel Kolawole

Dr's Shoba and Anjum are establishing their hospital as centres of excellence for training in Jaipur and Bangalore. Dr Nicholas, Marta and Leonardo are changing the face of palliative care in Latin America. Dr's Ali, Narine and Silviu face huge challenges in Albania, Armenia and Romania and can feel overwhelmed yet are helping build their societies and make a significant difference. Dr Rumana is one of very few palliative care clinicians working in her nation of Bangladesh. Dr's Sam and Charmaine, you are reaching out to some of the most vulnerable in Uganda and South Africa and Dr Esther is working in our sister hospital in Kenya and now has a mandate to represent the needs to her Ministry of Health. To all of you and to the amazing faculty and fellow mentors; thank you for the sacrifices and commitment; thank you
for sharing your journey with me and each other, thank you for blessing my heart and for being a blessing to so many.

These next few weeks I will have the opportunity to share more of the work of Cairdeas and our partners at meetings and conferences in the UK. Please come and join if you can.  https://www.facebook.com/events/687542981262603/. There will also be a UK based conference to look in more depth at mentoring and sharing with colleagues involved in the THET palliative care project as well as Palliative Care Works and an opportunity to share at the Scottish CMF conference. I'm looking forward to meeting many folk after a long gap and sharing some of the blessings I receive as a world citizen and representative for Cairdeas and reflecting the Gaelic meaning; friendship and fellowship. I quoted from Tennyson's famous poem Ulysses when he says 'I am a part of all that I have met'. In this global age we are still brothers and sisters; sharing in the joys and the pains. The boundaries of nation, faith and ethnicity serve to enrich but should not divide. Each meeting, each experience, each challenge serves to enrich our lives and help us grow in love and service. As the man of wisdom says in the book of Ecclesiastes; 'there is a time for everything under the sun; a time to weep, a time to laugh, a time to mourn and a time to dance'
Let me finish this post with a quote from one of my colleagues and former students who summarised the role of a mentor in a way that humbles and inspires me. A mentor is 'the one created by God to wear another's shoes'.

Tastes of heaven; part 2; west african spice

A few weeks ago I made my second visit to West Africa and my first to the power house of Nigeria. I had been promised a warm welcome with plenty spice so after a lengthy visa process taking several months I arrived in Lagos surrounded by the energy and colour of a fast growing city of over 8 million. Relaxing before travelling on to my destination of Ilorin in Kwara state, I thought I would test the food; 'pepper fish and jollof rice please' and almost found my chilli match. For those of you who know me that is no mean feat and confirmed I would love this place.

Dr Israel Kolewole and his team at the University of Ilorin Teaching Hospital (UITH) were welcoming hosts

and  ably demonstrated the leadership and commitment needed to make their palliative care programme into one of the centres of excellence in Nigeria. Nigeria has had steady but slow development of palliative care and scarce availability of essential medications and trained staff. This is now changing and with the leadership from the Hospice and Palliative Care Association of Nigeria and the help of partners such as Hospice Africa Uganda and Treat the Pain significant progress is being made.

In Ilorin Dr Israel is one of the leaders being supported through the Leadership Development Initiative and I was visiting to see what he has been achieving and to offer mentorship. He is a senior colleague with a Masters in Palliative Care who is a anaesthetist and specialist in pain management. He is committed to ensuring palliative care is integrated and made available to those in need. He has established an enthusiastic team with several trained nurses and plans to support them to access Diploma and Degree courses in Uganda.

We spent time on clinical rounds in the very impressive University Hospital and in meeting key leaders and

colleagues. Dr Israel had developed and submitted and innovative curriculum for Postgraduate Diploma in Palliative Medicine at the University of Ilorin and I was delighted to be hosted by the Vice Chancellor and Dean who not only made a public commitment to ensuring this programme becomes a reality but also that palliative care is integrated into the undergraduate medical curriculum. This will be the first postgraduate training available in West Africa and establishes Ilorin as a key centre for Nigeria and the region. Congratulation for this breakthrough although I realise much work lies ahead! Check out the link to the article on the University website.

https://www.unilorin.edu.ng/index.php/en/component/content/article/237-unilorinnews/1714-unilorin-to-introduce-postgraduate-study-in-palliative-care?highlight=WyJwYWxsaWF0aXZlIiwiY2FyZSIsInBhbGxpYXRpdmUgY2FyZSJd

The Chief Medical Director of UITH, Prof. A. W. O. Olatinwo, is committed to seeing holistic and quality care offered in his hospital and community and sees palliative care as providing key leadership  This is such an exciting combination of senior palliative care leadership with a major hospital leader understanding and wanting to integrate palliative care. He arranged a senior meeting of his staff in the hospital and allowed us to present integrated palliative care and then listened to his colleagues before making

a public commitment to moving PC forward. There is already a new Hospice building on the hospital site which Israel hopes to be the focus of a day care and community outreach programme. Topping off my visit was a meeting with the Ministry of Health district office who committed to PC in all hospitals in the region and the charity arm of the presidents wife in Kwara state who were asked to support women and children's needs. All in 5 days!

Many thanks to Dr Israel and his family as well as Abiola, Aligeh and the rest of the wonderful team. They were amazing and generous hosts including praying for me in my hotel room and when I left, taking very good care of any security issues and helping me explore my new found pleasure in Nigerian food and dress. This amazing gown not only was a wonderful present but make travel back to Lagos a dream; dress like this in Nigeria and even the airline check-in staff ask for a photo. 

Back to the food; if you get the chance make sure you try efo riro, pepper soup, egusi, fried plantain, jollof rice, amala, fufu and of course pounded yam. I might give the pomo (cow skin) a miss next time.

For me personally there was also the opportunity to connect with a special person in my past; my maternal grandfather Robert Forrest. He worked in public health in Nigeria, including Kwara state, for more than 20 years in the 1920's to 40's. My Nigerian friends gave me honourary Yoruba status and were delighted to phone and greet my mum in the UK who has many memories of visits to her father. Those journeys were by boat and fraught with the dangers of malaria but after a 4 day journey home (care of many delays) I can empathise a wee touch.

Tastes of heaven; part 1

One of the fascinating aspects of travel is being able to experience local traditions and cultures. It is humbling to be welcomed into villages and homes and to share our basic humanity as well as all the quirks and nuances that make each one of us unique. I have been introduced by a friend and colleague in India as a 'chameleon' which  think as meant to be compliment to my ability to blend in rather than a comment about wrinkles. I was talking with one of my Ugandan friends, Florence, and we spoke of the amazing differences and cultures and how this can create challenges as well as joys and her reply was 'we had better get used to it as it is a taste of heaven'. Let me share some places and people that have given me a 'taste of heaven'  these past few weeks and months.

Mhoira and Julia

Celebration with Mwazi

Early January saw the culmination of many many years of hard work for faculty and students with the first graduates from the BSc programme in Makerere University and run by Hospice Africa Uganda. Some



unfortunately could not afford the travel but we gathered from Uganda, Tanzania, Cameroon, Malawi and Kenya. MPCU (Makerere Palliative Care Unit) had 3 graduates; Mwazi Batuli, Liz Nabirye and Frida Kolya so extra special celebrations. There was also a Ian Jack Memorial special award to the student who had achieved this despite many personal challenges and this was given to our inspirational friend from Zimbabwe Franciscah Tsikai. This award was given by Prof Barbara Jack in memory of her father. Francis  I still remember your first year when you stood with me in church and wept tears as you gave thanks that God had blessed you with the fees for one year and for all his goodness.

Proud graduates and faculty

Franciscah with her award in Zimbabwe

Participants Lucknow leadership course

4 weeks in India allowed me to sample 4 climates from the foggy mornings and chilly days in Lucknow to the balmy warmth and crazy traffic of Bangalore and the cool of Guwahati. In SGPGI Lucknow we were running workshops in leadership, management, teaching, self awareness and symptom control; Cairdeas was working with Pallium India, Emmanuel Hospitals Association and SGPGI. We had an amazing time with great faculty ( thanks Chitra, Sanjay, Anne, Charu, Angela and Carl) and enthusiastic participation (spot the innovative giraffe) from colleagues across UP state but also including Assam, Mahrashtra, Bihar, Gujarat and Kerala. In all EHA sent participants from 7 hospitals (Prem Sewa in Uttarala, HBM in Lalitpur, Duncan in Raxaul, BCH in Fatehpur, GM Priya in Dapegaon and Baptist CH in Tejpur) and have already started 3 palliative care programmes with one more to follow very soon. meanwhile SGPGI is developing as a centre for palliative care excellence and we were able to work with them to plan ahead. In Bangalore we

Angela 'at home'

Chitra helping Carl and Angela to shop

Charu, Angela and I travel in style

MPCU winning poster

took part in the Indian Association for Palliative Care 20th conference and joined the celebrations of 25 years of palliative care at Kidwai Cancer Institute. MPCU had 5 presentations and sessions and managed to be awarded one of the first prizes for the posters and the oral presentations  Angela Kaiza from Tanzania joined us for the whole trip as part of our collaboration with PCPi (Palliative Care Partnership initiative and Tanga region and was able to lessons from her setting. She took to India like a duck to water - though was very happy to taste an authentic Lucknowi biriyani with plenty meat! Dr Jo Dunn was also able to join us from London and helped deliver an excellent ethics symposium.  Lastly on my tour was the city of Guwahati set on the banks of the Brahmaputra river and capital of the state of Assam. Dr Dinesh Goswami is one of the leaders being supported by the Leadership Development Initiative and it is my privilege to offer mentorship. He organised

Lakshmi puja, Guwahati

only the 2nd (last one 10 years ago) state wide meeting to discuss integration for palliative care and opioid availability as well as a workshop at the local medical college.Anyone who knows Dinesh can vouch for his gracious and dedicated spirit and he amazing work he has done.
Home via the snows of bonnie Scotland but I am realising there are too many 'tastes of heaven' for one blog post. So I will keep the tales of Scotland, Cairdeas developments and recent events in Uganda for a post next month.
Let me finish with a quote from some of our students that encouraged us and encourages all who teach;   'Thank you so much for the support you accorded me throughout the course. It was strengthening at my point of weakness and source of support when I needed it most. Your contribution was so great and words cannot explain it fully. You were great and thank you so much for that!.
This is Holy Week in the Christian calender and a time to remember the incredible hope we have in God. I pray this Easter time you find that sense of hope and meaning and spend time with people and in places to gladden the heart and encourage the soul.