bonnie scotland

As promised I am giving you a flavour of my few weeks in Scotland. I love to travel and am continually amazed at the wonder and beauty of so many places. But Scotland has a special place in my heart!! These photos are of Aberdeenshire. Aberdeen has wonderful parks and floral dis[plays - often winning City in Bloom contests. It also has an amazing coastline with fantastic beaches just perfect for a BBQ and paddle - if you are willing ti brave the cold North Sea. Highland games are a feature of the summer months complete with dancing, pipe bands, and athletic feats. My Indian friends Chitra and Shoba enjoyd a dram of whisky with the Chiefton at Dufftown. Cairdeas has its roots in Scotland and the colour of our logo reflects the purple hue of the heather. It has been great to have the chance to share with so many about Cairdeas. Thanks to all who are involved at the 'home end' - I hope to have some photos of our teams soon. We are encouraged by those who are wanting to become regular supporters and hope to see an increase in the Cairdeas 200. (see website for further details www.cairdeas.org.uk) I am delighted to have the opportunity to meet the Aberdeen Indian society soon at their independance day celebration and share about Cairdeas. I am now working for a few weeks in Shrewsbury and preparing for a trip to Africa. More in due course. Keep October the 22nd free if you can come to Aberdeen for our annual meeting.

round the world

Hi everyone and sorry for the long silence. I have been round the globe since my last posting and then back to sunny Scotland (yes it is true!!) Leaving India after 5 months was hard and those I worked with are often in my mind and thankfully often in contact. I saw my new wee godson Ruari in Sydney (son of Katherine and Rich Burnett; Katherine is a Cairdeas Trustee and treasurer). Then it was off round the globe with a brief and idyllic stop in the Cook Islands. It is a beautiful paradise in the middle of the Pacific. Great to see friends in LA then back to Scotland. We have been busy with Cairdeas work - meetings, networking and planning groups. I have been humbled by the interest of so many. Our Trustees have approved the projects in Rwanda and Vellore. We have agreed next years budget too - just need the money now! Cairdeas 200 is our vision of 200 people to support us a minimum of £10 per month and act as our founder members and advocates. Slowly this group is coming together (15 so far) If you would like to be part of this please get in touch. www.cairdeas.org.uk or info@cairdeas.org.uk Thanks to all who have and are supporting us. A special thanks Steven who did a 10km run earlier this year and to those who tried to do a parachute jump but were thwarted by the clouds. They are all scheduled for September so have fun and take care! My next posting will have pictures of bonnie Scotland!!

cochin

As you may know, my main role over the past few months was to work with the team in cochin based in the Amrita Institute of Medical Sciences. It has been a rewarding and challenging time - and a time of real upheaval and change. My thanks to the warm welcome I was offered. My involvement has included support and training for the 2 year Diploma students, clinical teaching, setting and assessing assignments, arranging examinations (the first OSCE for ?Kerala) and offering management support and mentoring. Can I pay tribute to the work done by Prof Rajagopal and Dr Gayathri Palat in the development of this service and wish them well as they move on to other roles? Best wishes too to this years Diploma graduates as they move on (Biju, Biju and Sunil). The picture shows a social gathering. It was a real pleasure to work with the students and team and learn from them. They have made a real impact in AIMS with innovative practice and sound clinical work. I look forward to seeing some published work such as the experience with 'allow natural death' orders. We shared much over these months and laughed together many a time. Dr Charu Singh with the backing of Dr Sangeev Vasudevan will be leading the department now and I wish them all the best. I have been invited back as an external examiner for the Diploma exam in January 2007 so will get an opportunity to see the students again - even if not at their most relaxed!!

home care

I want to give you a glimpse into palliative home care. You have heard from Jan and Graham about their experiences and it is always a privilge for me to join a home care visit. In Calicut, a team consisting of trained volunteers, nurse, doctor and driver go out every day. Patients are reviwed, urgent visits arranged, proceedures carried out such as IV infusions, dressings, tapping of fluids in the chest or abdomen, medication supplied, social support given and emotional and spiritual support offered. The driver's role is the most intriguing as he at starts by negotiating the rural roads like a pro, reversing up impossible lanes before changing roles and assisting in dispensing medication and is then asked to help with preceedures. The combination of local knowledge (coming from the volunteers, who often live in the area) and the health care skills is inspirational. Here is one of the volunteers being introduced to me - he is a huge support to so many families. Coping with the journey, hot and humid climate, responding to unexpected needs, supporting relatives and patients is a draining yet rewarding task for the teams. What a privilege it is to be invited into someone's home often at a very difficult and vulnerable time. The photo here shows an elderly lady who was sharing some difficult feelings. Can you see how the team is around her offering her unspoken support, listening and concern? A real picture of palliative care in action. Some families are known over many weeks and months allowing real relationship building and trust. Othere are referred very late - though the network of local volunteers is helping prevent this. The teams offer an opportunity for training and mentoring as well as care for patients and their families. Areas of particular need have been identified such as psychiatric and psychological support, rehabilitation for spinal injuries; and these areas targeted for training and service development. A dynamic and responsive service - and an inspiration.

visiting impressions from Jan and Graham

"Gods Own Country"

Just back from India we wanted to say a few words about our time with Mhoira in Kerala....

This trip was only for two weeks but in that short time we were challenged,inspired,suprised and blessed in ways we had not expected by this wonderful place and people. Kerala is a beautiful place,as are its people.Mhoira's descriptions can give you a real flavour,but going out to see for yourself you experience the sights sound and smells will challenge any preconceptions about India and in our case has left us humbled and much richer for our time there.

Mhoira organised much of our trip for which we are grateful and highlights of Kerala included a boat trip on the beautiful waterways which criss cross Kerala(called the Backwaters), travelling in old white "Ambassador" cars and crazy auto-riskshaws(the only way to travel!) a stay in a coffee and vanilla plantation in the hills of Wynaad complete with a bush safari and elephants,and lovely meals out with Mhoira's friends sampling the yummy South Indian food,and the warmth and ready smiles of the locals .We could go on!!...but the real highlight was seeing some of the work Mhoira is involved in and meeting some of the great people she works with.

In Calicut,like Kenny, we had a chance to see first hand how the original vision of pioneer Prof Rajagopal, and his team has continued and grown into an impressive and unique model of community involvement in assessing,treating and supporting people in need of Palliative Care.Graham and I come from a shared professional background of psychiatric nursing,engineering,statutory and voluntary social work and were overwhelmed by the sheer numbers,as well as skills and commitment of local volunteers who are an integral part of the project,and in some areas take a lead role.They come from a variety of backgrounds including, on our trip, a local primary school teacher and retired engineer.This level of community involvement is unique in my experience,and our time out with Mhoira and one of the home care teams,visiting patients in the rural areas around Calicut,was both moving and humbling.
If only we had this kind of commitment in our communities back home! We were also impressed by the commitment to training,and I was delighted to meet one of the psychiatrists involved in teaching volunteers psychological skills,particularly as he has worked in the same psychiatric service as me in Edinburgh!

The opportunities for training,as Mhoira has described already, are there,and having seen the commitment and enthusiam for it, as well as the potential to change whole communities we have come back challenged about our own work,and inspired by what Mhoira and others have and could achieve. Do go see if you can...and meantime get behind the work of Cairdeas. These are real people,like Praveen, who need support for training and equipping so that they can make a difference. Oh and if you do go....watch out....those homecare drivers will take you on a journey you won't forget!

Jan and Graham Beckett (Mhoira's sister and brother-in -law)

calicut

You may have noticed how often I mentioned Calicut in my posts and newsletter. Let me tell you a little of the history of this pioneering service in Northern Kerala. In 1993 Prof Rajagopal, Dr Suresh Kumar and a small team formed the Pain and Palliative Care Society (PPCS) and began to develop a palliative care service based in the government medical college. A busy OP, with the words 'listen' pinned to the walls, was the focus with home care teams and link centre clinics. Negotiations with government made morphine available and a unique model of empowering faimiles and training volunteers developed. This was recognised with WHO demonstration project status as a model of palliative care for developing countries. Over the ensuing time this service has continued to evolve. In 2002 a movement known as NNPC (Neighbourhood Networks in Palliative Care) mobilised whole communities where the service was owned and run by the volunteers with input from health care workers. Perhaps I will tell you of this in a separate BLOG post. In 2003 a centre for education, training and in-patient care was opened - the Institute of Palliative Medicine. Much of the training is for volunteers with staggering numbers completeing basic and advanced training. This includes an innovative project to train trainers in offering psychological interventions as part of their therapeutic care. The nurse with a young patient on the left is Mina - one of the original team . Her smile and skilled care speak volumes. Praveen is a volunteer who has worked for 13 years in the PPCS and is involved in many of the training programmes. Here he is teaching communication skills. I have been involved in Calicut since my first visit to India in 1999, and it is always like coming home. This trip I have contributed to the BCCPM - a 6 week training programme for doctors (see picture)and the Fellowship programme for distance learning. The slogan for the PPCS sums it up - 'People for People in Pain' It is a place of ideas, energy, skill, inspiration and compassion. I am delighted to say that Cairdeas will continue to have a working partnership here and I will continue as visiting faculty to the Institute.

visit to vellore

As I mentioned in a previous post I was able to make a trip to Christian Medical College(CMC), Vellore recently. This is a famous hospital and nmedical school in Tamil Nadhu started by a missionary doctor (Ida Scudder) over 100years ago. It has always had a vision to minister to the poor and suffering and is renowned both in India and internationally for it's excellence in medicine and education but also it's service to the community. Patients still travel from long distances to recieve treatment. As an illustration, I attended an oncology round where 4 out of 16 patients were from Tamil Nadh and another 4 from neighbouring states. The remainder were from distant places like West Bengal, Sikkim, Banglagesh, Assam, Mizoram and Bihar. (you might want an atlas to check these out!)
Palliative care services started 3 years ago and the small department is led by Dr Reena George. The picture shows the rest of the team, and my thanks for their warm welcome. Already there is an active inpatient and outpatient service with home care to the surrounding villages 3 times a week. An exciting new development is the building of a hospice and education unit a few km away. You can see the contruction work in the photo, with an expected opening date of August 2006. We had some great discussions as to the development of CMC as an educational hub for palliative care. It is well placed to offer an excellent and credible training base that can reach many areas where palliative care is in it's infancy. I am delighted to say we have agreed a joint project to support these developments and I will be dicussing these plans with the Cairdeas Trustees soon. As ever issues of practicalities and finance come into the equation but am optomistic that we will be able to proceed.

Easter Greetings

Easter in India is very different. No daffodils or spring lamb or familiar church traditions. Especially as the Hindu New Year coincded with Good Friday. It was for me a chance to stop for a brief monent and consider the true meaning of life and salvation. I missed being able to be at church but was able to read the Easter story sitting on a beach overlooking the Indian ocean and watch the sunrise over the Kerala backwaters. Swimming at dawn, I was remembering that ancient dawn when Mary found the stone rolled away and the truth of Christ's resurrection began to be made known. What an amazing moment. My sister, Jan and her husband Graham arrived on Easter Sunday complete with M@S hotcross buns and chocolate eggs for the teams here. They are spending 2 weeks here and seem to be enjoying every moment.
I hope you all had a special time in whatever way you celebrate and sense the hope of a new spring and new life.

ASHA slum project

I have had the privilege of visiting this project in Delhi on several occaisions and thought you might like to hear more. It is a community empowerment and development project bringing 'hope to those who need it most' Each Slum Colony starts a programme of empowerment and primary health care, education and community development with training and support from the ASHA society. Over the past 15 years the project has grown to include >250,000 people and is a resounding success. Figures for child health, immunisation, family planning, TB control, school attendance and maternal health are well above the national average for India - never mind the usual picture in a city slum. ASHA is based on sharing the love of Christ in action and as such shares much in common with Cairdeas. Dr Kieran Martin, the founder was challenged to support those who have so little future and hope and has been awarded the Padmashree for her services to the poor. Issue of chronic disease such as mental health and diabetes are now being addressed and we hope to work together on a palliative care needs assessment next year. Here are some photos that illustrate the environment and the sense of hope. They were taken on my most recent visit last week. The wee baby is being held with her road to health chart - a WHO method of monitoring child health. The water pump is one of 50 for a population of 50,000 - previuos to ASHA's support there were only 5!

glimpses of india

I thought I would post a few pictures to give you a feel of life in India - just some of my observations about this facinating country. In fact, I will only give you some glimpses of Kerala this post. India is home to one of the oldest civilisations and more than 1 billion people. It is also a very young country, both in its population and it's recent independance. Kerala is a socialst state (the only state previously to democratically elect a communist government) with high literacy and an active civil society. It's language is Malayallam and is home to 35 milion people squeezed into a small land mass. It has a range of mountains (Western Ghats ), a narrow strip of land then the Indian Ocean. Known as 'Gods Own Country' the name Kerala means 'land of coconuts'. The backwaters region is unique and beautiful as seen by the first photos. Elephants might be seen in the game reserves, temple 2 festivals or even the street! Kids attend school smartly dressed - even if the transport is crowded. Food is light, tasty and unlike any 'Indian' takeaway you have tasted. Here is masala dosa - one of my favourite breakfasts. Lfe is always colourful, often frustrating, run on IST (Indian stretchable time) and invarably surrounded by warmth and friendlieness. Close your eyes and imagine hot moist air, spinning fans, scents of jasmine and spices, endless coconut palms, sunset over the Indian Ocean, tooting horns, crazy traffic, a cow causing a traffic jam, no personal space, ready laughter, bustling cities, vibrant colours of saris and the smile of a beautiful woman, and you have a glimpse of where I am. Come and see for yourself sometime!!

kenny's impressions

I mentioned in my last post that my colleague Kenny Ferguson was here for 2 weeks running chronic oedema training. It was a crazy couple of weeks with very sucessful training and adventures gallore. The photo shows the course participants in Calicut. Here are Kenny's thoughts;


'firstly i would like to thank mhoira and Cairdeas for the
opportunity to work in and experience India albeit for a very
short time. nonetheless this proved to be one of the most
enjoyable and important experiences of my carreer in
palliative care to date. also a big thanks to mhoira for all
the background support work she did on my behalf which
ensured the smooth running of the course and for making me
feel so welcome. all of this background work and support made
it so much easier to settle in quickly and get on with the
work. my work focused on training the trainers in the
management of chronic oedema (a significant health problem in
India).these courses were offered from two centres, Calicut
and Cochin each course running over three days.i also spent
some time observing the work of the home care service offered
by volunteers up in the Waynad district of Kerala.this was
indeed a great example of palliative care for the community
by the community.i think india has a lot to teach the west
about the importance of strong family ties and community.

in the face of huge resource difficulties i was amazed at
the morale, committment, energy and thirst for knowledge
shown by both groups of nurses. we had great fun during the
courses with much moothie playing and laughing at ourselves.
hopefully the courses went well and we certainly initially
got some very positive feedback from course participants. a
lot of thought and discussions needs now to continue with
mhoira and our indian nurse and medical colleagues as to how
best continue to support oedema work in kerala into the
future. this was a very important and enjoyable (if
exhausting) experience for me.it reminded me of why i came
into nursing and particularly palliative care.while i went
out to india in a training role i know i learned more from
the nurses and volunteers i worked with than i could ever
give. it was my pleasure and
priveledge to work with such professional and committed
indian colleagues.once again thanks to them and to cairdeas.'

first cairdeas course

A red letter day! I was joined this week by my Scottish colleague Kenny Ferguson from Moray. He has more than 25 years experience as a palliative care nurse, the last 15 in a community Macmillan role. He has also set up a chronic oedema service and we have been planning for him to visit India to assisst in training for some years. Advanced, chronic oedema is a major problem affecting the quality of life for many patients. It is usually related to diseases such as cancer and their treatments but in this part of the world filariasis is also very common. Kenny has worked hard to prepare a training programme focusing on 'training the trainers' If there is a pool of experienced and trained nurses they can continue the sharing of expertise. We spent a few days in Cochin then off to Calicut to repeat the training. Kenny has taken to India like a natural and it has been lovely for me to enjoy his enthusiasm and company. His Scottish banter and moothie have gone down a storm. I think his years in mountain bothies have prepared him well for adapting to India - a qualification I had not considered in our Cairdeas Consultants!! Here is a picture of the Cochin nurses and I will ask Kenny to add his comments for the next blog entry.

jaipur

Hi from Jaipur - the pink city in Rajestan, the most royal Indian state. Dr Gayatri and I were invited to take a seminar at an important oncology conference. It was the first time in Rajestan that there had been a palliative care seminar at an oncology conference so the local team were very encouraged. There is only a small service here with a need to work together and try and develop some co'ordianation in training and networking. As ever we meet people who are committed to making a difference. We visited an inspiring hospice where 5 nuns run a very good unit with such care and compassion but with very little medical support and would so welcome further training. (see photo) We have been offered a very warm welcome if we were able to return and help with training and development. Rajestan is a large, spparsely populated state with many villages that are far from city centres such as Jaipur. As ever there is so much needing to be done to improve the lot of the poorest patients. Our hosts Dr Malti and Anjum were very generous and welcoming, helping us to experience some of the cultural highlights.

overdue update

Hi again. A whole month has gone by. Apologies for the lack of entries but I have been having real internet access problems.

It has been a busy month. I have been teaching and training at cancer centres in Hyderabad and Trivandrum as well as day to day work in Cochin. Feb 9th-11th I participated in the IAPC international conference in Chennai which had the topic of Pain and Beyond - focusing on psychosocial and spiritual issues. It was a great conference and a chance to catch up with colleagues from the UK. There is a small cohort who come each year to support training. You may know people such as Dr Micheal Minton, Dr Ian Maddoks, Dr David Frampton, Judith Smith, Gilly Burn, Jeremy Johnstone and the team from Severn Hospice ... Some of us try dressing up -we looked good in our Chennai silk saris! Above is a photo of me and the Cochin team. They are delighted that they will be hosting the 2008 conference.


At Trivandrum I was joined by colleagues Dr Rosalie Shaw and Dr Cynthia Goh from APHN / Singapore which was a great chance to talk about wider palliative care issues.

I also had the chance to travel to rural Andrha Pradesh to visit a village ministry project (Indian Village Ministries ivm@sancharnet.in) run by old friends from Aberdeen Suresh and Roja, and meet a friend from my church back home, Peter Ross. Perhaps their project will involve palliative care in the future.

Tomorrow I am off to teach in Jaipur, Rajistan - the pink city. More in the next entry!

It is hot and humid and getting hotter - I would love a few hours in the snow. Hope my fellow Scots are not suffering too much this winter.

Cairdeas

Hi

Forgive my lack of expertise on my first BLOG post.

This is my on-line diary helping me to keep in touch and inform about my role with Cairdeas. If you dont know what Cairdeas is then check out www.cairdeas.org.uk. We are a charitable trust that seeks to facilitate the growth of palliative care in the developing world. We will work mostly in supporting education and training.

As Medical Director of our new Trust I have two main roles. Firstly to help to develop the strategic planning and in doing so make connections with those involved in key positions in palliative care in the developing world. Secondly I have the privilege of offering my support in training and educational planning.

What am I doing now?

On Dec 31st I flew out of a cold and snowy UK to the country of India - arriving appropriately on the first day of the new year. I spent a few days in Delhi catching up with friends at the ASHA slum project before flying to the tropical south - Kerala.

A few words about palliative care in India. Since the 1980's there were hospice developments but these were only available to very few. In 1993 a clinic was started in Calicut, northern Kerala by Prof M R Rajagopal which sought to model a different form of palliative care delivery. Through an outpatient and home care service and more than 30 link centres 30-40% of the population were able to access help. Since then this service has been further developed by Dr Suresh Kumar and team to the NNPC (neighbourhood networks in palliative care) with the community (in the form of volunteers) running the service. More than 80% coverage has been obtained with this model.

Good news except that around 3% of India's population have access to pain relief and way less than 1% have access to a doctor working in palliative care. A recent estimate by Suresh and Dr Jan Stjernsward suggested only 100 full time doctors - that's for 1 billion population!!!!

So hence the need to get involved in training.

So what am I doing at the moment.

Cochin has sen the development of the first supervised Diploma - 2 years of structured training. I am here as visiting lecturer at Amrita Institute of Medical Sciences to support this programme and help with other courses such as the 6 week short course.

A few days after I arrived we had the first students pass the Diploma - well done to Dr's Biju, Biju(an orthopeadic surgeon!) and Sunil. It is an excellent course with tough standards so all were justly pleased. Dr's Robert Tycross and Rena George were external examiners. You can see the photo evidence.

I am busy supprting the 6 week training students. A recent review of training showed that more than 80% were leading services and teaching as well as taking referrals after only 6 weeks. Not surprisingly many feel out of their depth but the courage and committment are very impressive. I hope to be more involved with mentoring these young palliative care doctors. Incidently one current trainee is a Professor of Anesthetics so young in palliative care experience only!

Enough for now. My next few weeks involve taking part in the 13th International conference of the Indian Acssociation for Palliative Care and brief visits to help with training in Hyderabad, Calicut and Trivandrum.

When I was chatting with Jan Stjernsward (previous director WHO cancer and palliative care programme and responsible for the WHO cancer pain relief) about the desparate shortage of palliative care doctors he suggested I should 'spend the rest of my life doing something about it' That is just the essence of Cairdeas and it feels a tough challenge but still a privilege.