travel in uganda

Come with me on a short trip to Uganda. The main base for Hospice Africa is in Kampala - the capital city; built across 7 seven hills. Uganda is frenetically preparing for the Commonwealth Heads of Government Meeting (CHOGM) with seemingly every road dug up and a forest of shrubs and plants ready for planting - if only it would stop raining. Several Ugandans asked me whether the Queen would be happy with the preparations and I had to confess I am not often chatting with HRH. Getting around is by minibus taxi known as 'mutato' with most journeys culminating in the taxi park. For the more adventurous there are the motorcycle taxis or 'boda bodas'. No helmets and a dusty ride but at least you can weave through the traffic jams. Several hours down the busy highway towards Rwanda and the DRC, in Mbarara, there is a very different model for Hospice Africa. Here a vehicle laden with medicines, antiseptic wash, morphine and children's toys leaves early in the morning. Stops are made along the 74km main road towards the district clinic where patients waited for their monthly review. Clinics under the banyan tree - often with a curious audience. We drove past the daily events of life in Ibanda district; boys dragging their heavy loads of matoke (staple diet of steamed bananas) to market and car mechanics setting up shop in the street. Martha and her team were not only offering a great clinical service but also were concerned with the financial challenges, family support and spiritual care. Holistic care in action. Our last patient was seen up a dirt track in the dark - and a sobering site as a desperately poor mother tries to keep her family together despite her illness. No sign of food or fire for the night - thankfully the team were able to offer practical help, clinical care and compassionate concern.

Did you sense some of the realities of palliative care in Africa? I is amazing to see how much has been achieved across Uganda with the support of the government and many many people who are committed to bringing comfort and care. We are discussing an exciting and challenging project to support the training and teaching in Kampala. Next week I will be at the African Palliative Care conference in Nairobi where the theme is 'keeping it real'; so watch out for the next post.

Meanwhile my favourite portrait of the inspiration and founder of Hospice Africa, Dr Anne Merriman. Surrounded by kittens and puppies as ever!

uganda

Greetings from the 'Pearl of Africa' It is good to be back and to have such a warm welcome from Dr Anne Merriman and the staff at hospice Africa Uganda. This was one of the early palliative care services in Africa (1993) and sought to provide a model for cost effective care in this continent, as well as offer care to Ugandans. (see BLOG 11/10/06) One of their objectives is also to support palliative care in other African countries; and this is done by education and training support as well as exchange visits. Here you see Dr Anne with 2 nurse colleagues (Funmi and Kuye) from Ibaden in Nigeria. They have a very new palliative care programme and are receiving support and training from Hospice Africa. It was so encouraging to attend a Palliative Care Association of Uganda update and see how much has been achieved since 1993. I have been doing some teaching at the Hospice as well as exploring future ways Cairdeas can offer support.

Let me take you to meet a lady we visited with the Jinja Hospice team. Perpetua lives in a rural setting with her family. You can see her young grandson outside the 'kitchen'. She has been ill for some time and had a miserable experience of uncontrolled pain and expensive visits to hospital with little benefit. With the support of the Hospice team; who can assess and prescribe free drugs including oral morphine; her pain is under control and she is happy to be at home. She wanted to pray for us as she felt God had sent us to help her and give her family support. Here she is reading some verses from her bible and giving thanks for all the help she has received. It is good to be reminded of our core values and purpose in palliative care and to consider the many many people who are not able to access the help that they need.

I hope to visit one of the other sites for Hospice Africa this week so will tell you more of life in Uganda in my next BLOG.


Highlights so far have been many but include a very African church service led by a famous children's choir, Watoto, who are all orphans (many as a result of HIV/AIDS). Dr's Peter and Trish Kiehlmann were also with me on a visit from Aberdeen - small world?

travels

I am finally back in the UK after travelling east with various stops for both work and catching up with friends and family. Thanks to all who have given me a home and welcome on the way. I have met friends from as long as 20 years ago as well as made new friendships and colleagues.

It was great to meet up with Dr Rosalie Shaw and Dr Cynthia Goh again in Singapore. Over a wonderful Chinese meal we had some very interesting discussions re possible areas of future work. Please look at the Asia Pacific Hospice Network's very good website for more information. http://www.aphn.org/
The temperature change from Delhi at 46 degrees C to Sydney and Auckland at 13 was a real shock; necessitating the purchase of thermals!! Katherine is a Cairdeas Trustee and treasurer and we had time for work - but she is also Mum to wee Ruari who is also my godson. Here is Mum and Dad (Rich) with Ruari in the Blue Mountains. I also had great fun with my niece Naama. Kitty (my sister) and Pat are presently in Auckland studying and falling in love with New Zealand all over again. It is such a beautiful country.
Farther east I was introduced to the 'biggest of everything' in Texas and was delighted to accept an invitation from Dr Suresh Redddy to visit the MD Anderson palliative care service in Houston and led by Dr Eduardo Bruera. Not only are they a leading model for palliative care in the USA but also committed to supporting sustainable palliative care across the world. The IAHPC is also based in Houston and it was a pleasure to meet Liliana De Lima, who is the Executive Director. This is an excellent organisation which does much to support palliative care in many parts of the developing world. Please check out the website. http://www.hospicecare.com/
My niece's name, Naama, means Grace in Arabic; and this is such an amazing concept. How do we know the reality of grace in our own lives? I watched the current film about the UK struggle to abolish the slave trade, Amazing Grace, on my transatlantic flight. If you have not seen it please do and tell me what you think. The words of the title song are so powerful, here is a link to remind you. http://www.amazinggracethemovie.co.uk/song.php I found the film a powerful reminder of our responsibility to seek justice in our world. What can we do to make this world a better place - to see justice in the midst of such injustice?
There is a verse in the book of Micah that says 'He has showed you, O man, what is good. And what does the Lord require of you? To act justly, and to love mercy and to walk humbly with your God. For Cairdeas we seek to challenge the injustice that so many are without the most basic access to palliative care. We work with many inspirational people - and there is great need. Thankyou for your support in this vision. What will your challenge be?

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.