patient visits

I want to invite you to come with me on a couple of visits to the homes of patients. Perhaps you can try and imagine some of the sights and smells and sounds as we travel together. It is hot - more than 42 degrees today but our vehicle has AC. It was donated by the Friends of Vellore, UK. A family have called to say they are worried about their mother who is known to the team. She is very ill and in pain and they asked for help. It can be hard to know how to care for relatives at home without support. There are few comforts at the best of times and still so much fear about diseases such as cancer. Our patient was a lady in her 60's. She was clearly feeling miserable when we arrived - lying on a hard concrete floor, flies buzzing relentlessly and obviously in pain and distress. Our hearts went out to her and her family. Within a short time we were able to help her family wash her and bind her weeping sores. Advice and medication were given. Her son then helped fill a waterbed we had brought - an inexpensive but effective way to relieve pressure sores and give comfort. It was quite a challenge to find the right size of pipe and water funnel!! Meanwhile, the grandaughter had overcome her shyness of the foreign doctor and we were making friends. Soon many of the neighbours in the village had also joined. We left some time later tired and very thirsty but knowing we had been able to help. A drink of tender coconut juice on the way home was wonderful.

Let me take you down to Trivandrum now. I met this gentleman during a visit to the Pain and Palliative Care clinic jointly run by SUT Hospital and Pallium India. I was joining Prof Rajagopal and his team to help with some training programmes. this man lives in a small town 2 hours from Trivandrum. For the past week he has made a daily journey to the palliative care clinic. He has cancer of his mouth with a nasty open wound. Despite good care from his family he began to have worsening pain and swelling. The team have been treating him with analgesics, steroids and antibiotics but also spending time every day removing maggots - totalling more than 100 maggots. This is a distressing yet common complication of these wounds in a tropical climate. He is thankfully much more comfortable now and will be visited by the team at home. He spoke of his pain and his struggle with feeling 'unclean'. Like many patients, his pain is far more than just the physical.

It was great to meet Donald McNeil and Ruth Fremson from the New York Times who are researching the issue of morphine availability. It will be a fascinating story so look out for it.

hot, hot, hot

I realise that the UK had just had the warmest spell 'since records began' but I would love to open a quick window to Vellore and let you feel the heat. With the thermometer hovering around 38-40 degrees C, it is dry and dusty with any breeze circulating the air like a blast furnace. Rain is a welcome relief and washes the trees and shrubs till they sparkle and glow. A few days back we were treated to a spectacular thunder and lightening show and ran through the rain to get a better view. My partners in the madness were Dinesh (from New York) and Graham (chaplain from Adelaide) Here they are making puris one night for our supper!! It has been so lovely to share my time here with many some very special people - thanks to them all. Many have left recently - partly to avoid the worst of the summer heat; and we say our fond farewells. Here is Nita leaving - also a chaplain from Adelaide. The car is an Indian classic and is driven by our friend and driver, Suren. Many Indian friends are planning an escape to the hills too as the children are on their summer break.

One of the excellent projects we are involved with is a Distance Learning Module for Family Practitioners that has it's inspiration and leadership from Dr Vinod Shah. Some of you will recognise him from the days when he was the Director of the Emmanuel Hospital Association. This programme runs over 2 years and has 200 family doctors registered . A great achievement - and much of it due to the innovative and professional way the course is run by Dr Shah and his team. We are writing palliative care modules for year 2 of the course and I joined a writing workshop in Pondicherry. It is a great way to get a group of 'experts' together and some hard graft done - while also enjoying a few days away from the business of CMC. It was fun to explore the streets of this old French area - of course very much Indian now. We did manage some 'Gallic inspired' food and I have some cheese - a real find in India. This course has an important role - as so many Indian in rural areas rely very much on their local doctors. Referrals to hospital may be simply too expensive for many. The standard of practice and training of family doctors can be very variable. The course is also linked with many rural mission hospitals and will have the 'contact sessions' delivered in several locations. Having palliative care as part of the training will help take the philosophy and some knowledge and skill to new areas. Let us hope that in turn, many people and their families who are in need will find benefit and support. Remember, only 3% of the people in this vast and amazing country have access to pain relief at present.

I am off to visit Kerala for some training programmes now so will tell you more in my next post.

ps Dr Danjuma - lovely to hear from you. Let me have your email and I will write.

easter greetings

Sorry for being a week late with my Easter greetings! I was up at 4-30am on Easter Sunday to join a CMC tradition of climbing a nearby hill to watch the sunrise. It was very beautiful and moving to share communion together. I am nicely baking here in Vellore with temperatures around 38 degrees average. I am freezing my water bottles overnight so we can enjoy a cool drink most of the day and switching the fans up high. Think of the patients in the villages with no access to fans, fridges or even water at times!!

The Fellowship programme has now started and Dr's Vishnu and Ravi are the first students. They are both enthusiastic and settling well into the department. The other programmes for the education unit are all in progress and look innovative and exciting. We will also be contributing to an excellent distance learning programme for Family Medicine run by Dr Vinod Shah at CMC. I will only be able to offer support for 2 months this time though the team will be busy with clinical work and education developments over the summer. We are still waiting for some administrative issues to be sorted before the first patients can be admitted to the Hospice- that will be a red letter day!!

I also have a new bicycle as a gift from Reena and Pradeep. It is bright blue and named Miss India (as were all the others in the shop). I am having fun riding around campus starting with an early morning ritual to collect idly or dosa for breakfast. As a contrast, Rishi, Reena's wee son, now says haggis is his very favourite food. Even better than biriyani! How is that for cross-cultural exchange?
One tip - hold on to your biscuits though or a cheeky monkey might whisk them away - as happened to one small boy at church!!

cairdeas ball

Hello from a frosty and crisp Scottish morning. I am sitting with the sun filtered though the light, icy air of Perthshire enjoying Scotland. This is a beautiful country - my 'ain hame' and good to be back for a short while. Come and visit sometime when the heather is blooming, the sun lighting the mountains in amber, the lochs shimmering and the glens calling. That is when it is not raining !!!!We have just enjoyed the first ball for Cairdeas and what a great evening. We had a brilliant ceilidh from the band Shindig as well as good food, a fun auction with Doug Duthie officiating and a chance to share what we have been doing with Cairdeas over these past months. Thanks to all who made this evening a success. So many people put in a great effort and there were some amazing auction and raffle prizes. We even auctioned a sari and a sari tying lesson for a great price - thanks to Shoba who will do the honours. Most importantly folk were enthusiastic in their support for Cairdeas. While back home I have been wandering the UK seeing friends and family and taking the opportunity to be meet and plan for Cairdeas. Here is my wee god-daughter Phoebe and her sister Isobel down in Guildford. It was good to be part of Help the Hospice's training day for those interested in international palliative care, and to be at the APM meeting lecturing to the Doyle Club. All my UK colleagues are looking well if a few more gray hairs to share around. Our Trustees have had a day to look at the vision and planning for Cairdeas. There is much to be thankful for - not least that we have ended the financial year with a small surplus. Thanks so much to all who have supported and helped with this last year. Meanwhile, back in Vellore, the first Fellowship students are preparing to start on Monday the 26th! It is exciting to think that these students will be leading services of their own in years to come. I am looking forward to the sunshine though it is VERY HOT I hear. I have also missed my dosas for breakfast!!!!! Speak to you soon.

delhi

After a great IAPC conference in Mumbai I joined Indian and UK colleagues in Delhi. We were supporting the annual foundation course in palliative care run jointly by Cansupport and IRCH (International Rotary Cancer Hospital). Cansupport, which started with one base led by Harmala Gupta and Ruth Wooldridge, was also marking it's 10th anniversary. There are now 4 bases across Delhi providing much needed support for patients and their families at home. They also have a number of information initiatives - including a telephone helpline. There is a great team which includes trained nurses, doctors, psychologists and an army of volunteers. IRCH and AIMS led by Dr Sushma Bhatnagar have also seen progress this year with the opening of a small palliative care ward. It was such a privilege to teach the enthusiastic participants including a day for volunteers. There were twice the expected numbers which was encouraging and challenging! We managed a Sunday afternoon stroll among the ancient tombs of the Lodhi gardens in Delhi - here are some of the Faculty (Sue Varvel, Harmala Gupta, me, Ruth Wooldridge and Liz Minton with Michael behind the camera) Sue is now in Sierra Leone and we wish her well.

I also took the opportunity to visit my friends at ASHA. You might remember my last BLOG post from there. It is an inspirational project that seeks to 'provide support, education and healthcare for these people, giving them the motivation and abilities to make lasting changes to their lives.' ASHA supports healthcare, community empowerment and environment change and covers 250,000 people in the slum colonies of Delhi. Remember there are 4 million in these slums who are facing the daily grind of poverty and illness!!!! As recently as 2006 a slum was summarily demolished to make room for the planned athletes village for the Commonwealth games. Libby (a friend and young doctor from the UK who is doing a year's palliative care research in Calicut) came with me on a visit to Chandepuri slum. We saw first hand the incredible success of the community empowerment programme and met some of the inspirational women and children who lead the developments. Here is a healthy child - a real tribute to the programme. We are planning to help ASHA look at the palliative care needs later in the year.

mumbai

February 1oth to 12th saw the XIV International conference of the Indian Association of Palliative Care. It was hosted by Dr Mary Muckaden and her team at Tata Memorial Hospital in Mumbaiwhich is one of India's most famous cancer hospitals. Well done to the whole team for all their hard work! It was a great event with good conference sessions focusing on paediatric issues and some of the best posters and free papers of any conference so far. Here are 2 friends and former students Dr's Biju and Sunil (now in Alpha Pain Clinic, Trichur) enjoying a working lunch. It was also a lovely occasion to meet old friends and colleagues and forge new connections and friendships. There were innovative pieces of research being started including an very good early paper on sexuality issues from Manjeri. It is an important time for colleagues who work in isolated areas to have an opportunity to share. One such person is Dr Ujwal who works on her own in Chatisgargh, a state where there is great need - many tribal groups, no palliative care services and no oral morphine available. Dr Ujwal has asked if we can visit and help and this is very much the vision for Cairdeas - to offer support when asked and needed. There was also a colleague from Bangladesh at the conference for the first time forging new links across the borders..

International colleagues and speakers included Michael and Liz Minton, David Oliviere, Richard Hain, Gilly Burn, Jeremy and Penny Johnstone, Nathan Cherney, Suresh Reddy, Nick Pahl, Paul McCann and others!!! We had a whistle stop tour of Mumbai in the crazy traffic and saw the famous dhobi ghat. This is the world's biggest outdoor laundry where, every day, thousands of items of clothing are washed by hand (and feet), pressed with wood fire heated irons and returned to the correct owners!! Around 200 workers and their families literally live on the job!! I also enjoyed a bel puri and mango kulfi on Chowpatty beach with Nathan with no ill effects. Thanks to all for a great time in Mumbai.

Judith and Ismay's visit

It was such a pleasure to welcome our first Cairdeas faculty of 2007 last month. Judith Smith is a very experienced Macmillan nurse who is at present working on a project to implement an end-of-life care pathway (Liverpool Care Pathway). She also spent 5 months teaching in the IPM, Calicut 2 years ago. Ismay Palmer is also an experienced Macmillan nurse who has spent a year in Tunisia and is now preparing to go back there to support palliative care training and development. Here they are after a long international flight - and immediate bonding!! Angela Pick, Judith's longtime friend from Australia, was also able to join us for a week on her travels. Here are some excerpts from Judith's thoughts and impression of her recent visit.

'The last three and a half weeks have been an exciting and memorable time...We arrived first in Cochin before travelling to Calicut. There we were joined in Calicut by Shakila Murali who is the lead palliative care nurse in Vellore and with whom we would be training in the second phase of the trip. We had three well attended and successful teaching sessions with nurses, many of whom were old friends...An overnight train trip to Vellore was such fun! We had a great time and most of us managed to sleep for some of the time, despite the frequent stops, coffee sellers and and changing passengers... Arriving at Sneha Deepam was quite an emotional experience. We were to be the first inhabitants of the building, which in the future will house up to 50 patients and their families in the hospice accommodation. There is also rooms for trainees and external faculty from around the world; as well as training and teaching facilities...We were at Vellore and CMC for 10 days and managed to conduct successful training sessions with nurses in various sites. Shakila, Ismay and I shared the teaching. Once again it felt as though real groundbreaking work was taking place as the first 1 day workshop was held at Sneha Deepam with 12 ward sisters from CMC Vellore...The Burns night was great fun not least from watching some of the slightly bemused faces observing the strange rituals we get up to in the UK! It was such fun to dance the gay gordons and strip the willow in the tropical heat!.....Words cannot explain the inspirational work of the palliative care team who operate under challenging and cost driven infrastructure. The financial constraints of both the society they serve and the organisation in which they are based, are juggled for each case. All of the treatments that are offered have to be looked at as an individual needs based package. The result is that an amazingly high level of care is delivered by the committed and highly skilled members of the team...It proved to be a successful and inspirational experience. The whole trip culminated in being the first international flight to land in the snow at previously closed Birmingham Airport last week'

My thanks to Judith and Ismay, the place is much quieter without you. Your hard work and generous friendship was a great encouragement and blessing.

celebrations and friends

January has been a busy month, not least with the visit of Judith, Angela and Ismay. They will be adding their own impressions in the next post. The rooms were ready in time and it has been such fun to stay here in Sneha Deepam as well as having the honour of being the first faculty to do so. Huge thanks to Rena, Hamilton and the team for working some miracles and making all this happen. This is a now a beautiful building and will be a great resource for the future. We wish God's blessings on all that is done here - both in training but also in the care of patients when the hospice opens.

I was also able to visit Calicut briefly, to see old friends and do a little teaching. Judith was able to se old friends and help with training. Ismay, Shakila and Angela had an opportunity to see the amazing community networks. Then it was off to Chennai to attend a wedding. Kalpena used to be involved in running the service in Calicut and it was so lovely to be invited to her son's wedding. Great too to be with old friends Chitra, Gayathri and Mallika; and to dress up for the occasion.

Burn's night was celebrated on the 27th of January - perhaps for the first time in Vellore. What an occasion! Haggis from Scotland plunged with a carved Rajestani dagger , tartan capped nurses singing 'Donald where's yoor troosers', home made oatcakes, a wee dram, ceilidh dancing and great fun!!! Thanks to all who were brave enough to come and join in the celebrations to make a Scottish lass feel at home.

New Year 2007

What were you doing this New Year? It is a time to reflect, smile at the good memories, perhaps shed a tear for the sad times, plan for the future and be grateful to God we can see in another year. I was in Kerala with friends David and Joyce Wintour, who made a stop in India after spending several months working in a hospital in rural Uganda. It was lovely to see them and to enjoy a Kerala New Year; young dancers performing an ancient Tamil dance form - bharathanattyam; watching the fisherman pulling in their catch at dawn much as they have done for centuries; sleeping under the stars on the backwaters. What an amazing world and a New Year full of promise! An old poem says; 'I said to the man who stood at the Gate of the Year, 'Give me a light that I may tread safely into the unknown' and he replied, 'Go out into the darkness and put your hand into the hand of God. That shall be better than light, and safer than known way'

Dr Reena and the team are now very busy developing the education programme at CMC. I mentioned before that the hospice and education unit was nearly finished and operational. Well, it will soon be true as our first faculty arrive in 3 hours to stay in the new unit. Hamilton and Ramu are hastily putting the finishing touches! Perhaps the train will be delayed!! It is exciting to see everything come together and my next post will tell you more about Judith and Ismay's visit. A major achievement has been the development of a one year, residential, postgraduate Fellowship in palliative care for doctors. The course is now fully approved and applications are being recieved. Here is the web link to the CMC website. The first students will arrive at the end of March.
http://www.home.cmcvellore.ac.in/admissions/admin.htm

What difference will all this make? Let me give you some thoughts. If you are a patient visiting CMC from the north and east of India there are only 3 places you can consistently get oral morphine. You may be travelling up to 800km to get a presciption for your sick relative! Often there is no one you can turn to.You are left without support and without hope. All over India and beyond this despair continues. Only 4 medical schools in India teach undergraduates about pain control and palliative care. So very few have access to palliative care in their communities. However, there are many throughout India who are working to change this situation. At CMC, the palliative care team hopes to train future leaders who can continue to make a difference. It is a privilege for Cairdeas to be a part of this vision. Thank you for supporting us .

comments

Just a quick comment about comments!! It is brilliant to hear your thoughts but please be aware that I don't get your email ID when you post a comment. So if you would like a reply - please include your email ID. I would love to respond. Thanks for reading the BLOG and being interested in Cairdeas.

Christmas greetings

Wishing you a very happy Christmas and God's richest blessings for 2007. Christmas celebrations come early in Vellore with parties galore. There is also the habit of middle of the night carol singing! I was privileged to sing in the college carol service which was very moving - and a bit panicky as we were short of practice. Hamilton, our team chaplain was the conductor, and did a great job. The picture shows him with me and Grace and Fellina. Hope you like the sari! I have been eating lots of chicken biryani - the traditional Christmas fare - as well as the many sweets on offer. These are gulab jamen - and dripping with condensed milk and sygar syrup!! We are looking forward to a busy start to the new year. The hospice will admit the first patients around the second week in January. there is still much to be done but it is exciting. Also we have plans to do some nurse training in the education unit and will be joined by Judith Smith and Ismay Palmer from the UK. The first 1 year Fellowship in palliative care for postgraduate doctors in India has been confirmed and will start in March. Adverts have gone out and we are busy with the curriculum. The time seems to be flying with so many challenges and opportunities. I feel very much part of the team here and so glad that Cairdeas can be involved in this way. Our vision is to see the growth of palliative care in the developing world. Supporting raining programmes in Vellore can have a major impact and my thanks to all of you who are supporting and interested. I was struck again by the need in this country when I met a girl of only 25 who had travelled from Nepal to Hyderabad to get help for her cancer. On the way (several days by train) she was abandoned by her husband who took all their money scraped together for treatment, leaving her with a 4 month old child and 2 other children at home. The need is so great but at least this girl was cared for by people with expertise and compassion. At this time of year when we enjoy the celebrations and the gifts and the fun - spare a thought for those far and near who are vulnerable and hurting this Christmas. It is a time of hope when we remember the promise of that first Christmas - a Saviour who would bring peace on earth and goodwill towards men. Thank you again for all you support - I will keep you in touch with what the New Year brings!!

vellore

Good morning from a warm, clear day in Christian Medical College, Vellore. This hospital, and it's medical college, is now famous across the world with a reputation for excellence in clinical care, research and education as well as a commitment to serve the needy and vulnerable. Over one hundred years ago, a dynamic and resourceful young woman was challenged by the needs of the people of India - especially women. Ida Scudder started on a long journey to make a difference that took her through medical training, many obstacles and led to the establishment of Christian Medical College Vellore - one of the first centres for the training of women doctors in India. Over the ensuing years much has been achieved here - including seminal leprosy research and surgical developments. It is now a 2000 bed multispeciality hospital with undergraduate and postgraduate training. It services the community around Vellore in Tamil Nadu with primary, secondary care and community programmes. It also has patients coming from all over India including some nearby countries such as Bangladesh and Nepal. 70% of patients travel long distances - maybe several days on the train. The palliative care team had been in place for 31/2 years and is based within the main hospital. However, very soon the first patients will come to the new in-patient hospice. We are also busy planning for the new education unit which is part of the hospice building. the main role of Cairdeas is to support the clinical team and help with the development of the education strategy. It is an exciting challenge and I will tell you more in subsequent posts. The photos show the chapel at CMC medical college which is an oasis of calm and spiritual refreshment. The other picture was taken on the way to a rural hospital clinic - a typical and beautiful view of paddy fields. My address here is; Palliative Care Unit, Christian Medical College, Vellore 632004, Tamil Nadu, India.

tamil nadu

Hi from the hot and wet south of India. I arrived 10 days ago in Chennai (used to be called Madras). After meeting friends and collecting my Indian clothes I had left behind, it was on to Vellore to join the team in the palliative care unit at Christian Medical College. This famous hospital is usually known as CMC - as I will refer to it from now on. First I thought I would put in a map of India to help with orientation. Tamil Nadu is the bottom right state - with a long coastline on the Bay of Bengal. You may remember the photographs from the Tsunami as this coast was badly hit. The southernmost point of India is in Tamil Nadu; where the Arabian Sea, Indian Ocean and Bay of Bengal mingle. It has a tropical climate and a combination of beaches and coastal areas, hill stations and mountains, Carnatic music, ancient culture and language. Indeed, Tamil is one of the most ancient of the Indian languages and a source of fierce pride. With a population of 62 million, it is a predominantly agricultural state but it's capital, Chennai is the fourth biggest city in India. I arrived in Vellore on a rainy day, with the mist obscuring the hills, that was almost reminiscent of Scotland. More in my next post.

glimpses of africa

How can I sum up my short trip to Africa? I can only add to my previous posts with some glimpses of Africa that touched my heart, inspired me and will make me hope to return. I visited 3 countries over 6 weeks - South Africa, Uganda and Rwanda. I met so many people committed to palliative care and doing much to improve the access for those in need. As ever there are many difficult memories too. There are many who are hungry and trapped by poverty. There is a shocking lack of justice in how the world's share of resources are shared. There is the huge burden of illness and in particuler HIV/AIDS. Visting the genocide museum in Kigali is so essential in understanding something of the horror yet is an emotionally draining experience. What do you think of when you think of Africa? Let me give you a glimpse through my eyes.

Africa is a land rich in its natural beauty. A beauty which is at once accessible and yet wild. Seeing these giraffe up close was amazing - how did God dream up that neck? A rhino waking from it's slumber is an awesome beast; spotting the zebra so carefuly cammoflaged a delight. Beautiful sunsets, thundering rivers, peaceful lakes. I am glad to have survived my Nile kayaking adventure - and thanks to my guide through the grade 5 rapids. Amazing to think of those great explorers spending their lives finding the source of the Nile and here I am paddling down in a small piece of plastic.

Africa's richest beauty is in it's people. Warmth and smiles and help for a 'poor Mzungu' like me. Amazing colours and hair fashions. Bright, curious children; enthusiatic church services (they even asked me to preach!!); great food - especially when you can add some firey piri-piri; talented craftsmen producing work both ancient and innovative; history going back to the cradle of hunmanity yet modern and devloping. So many impressions! Let us hope that Cairderas is able to work with friends and colleagues to support palliative care developments in this amazing continent.