2011; Volume 12, No 01, January

 
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Regional Reports – Sudan and Egypt

PALLIATIVE CARE IN PRACTICE - SUDAN

2010 was an exciting year for developments in palliative care in Sudan because a palliative care clinic was launched at the main oncology hospital, the Radiation and Isotope Centre of Khartoum (RICK), and numerous advocacy, training and development activities occurred.

Palliative care healthcare professionals have been visiting Sudan for a number of years and have created a growing awareness of the need to develop services for the 10,000 new cancer patients referred to oncology care each year (Hamad 2010). It represents just one-third of the estimated 30,000 newly diagnosed patients who are in need of care. Sadly, this is common throughout much of Africa where the majority of needy people never receive the therapy or care they require (Downing et al 2010).

Sudan is a huge country, the largest in Africa, with a population of 43 million (UNAIDS 2010). Access to health care services is hampered by a lack of infrastructure, years of civil war in the South, on going conflicts in Darfur and a lack of trained healthcare professionals. Efforts are being made to educate the population regarding the importance of early screening and the signs and symptoms of cancer, however it remains a topic only heard by a minority of the population. This contributes to late presentation of so many people seeking treatment. At RICK approximately 80% of patients present with advanced cancers that are only suitable for palliative therapies (Hamad 2006).

HIV/AIDS is a growing epidemic with approximately 1.25% prevalence rate across the whole of the country (north and south Sudan). Voluntary counselling and testing centres are growing in number but are inadequate because of the growing need for limited antiretroviral drugs. It is estimated that approximately 12,000 (UNAIDS 2010) Sudanese die each year from AIDS. Only those referred to RICK for oncology care ever receive palliative care.

In 2009, a palliative care nurse Esther Walker moved to Khartoum with her husband to work at the British Embassy. Previously she had worked as a volunteer nurse with the Shepherd’s Hospice in Sierra Leone. She approached RICK to see if she might work with them. Dr Kamal Hamed senior consultant oncologist assigned a consultant oncologist, Dr Nahla Gaffer, to work with her. Together they provided a series of lectures on basic oncology and palliative care to the nursing staff.

It was clear that the patients being cared for at RICK would benefit from a dedicated palliative care team to improve patient care and promote access to opioids. Following networking by the Sudan Health Consultancy Group (SHCG) in the UK, Esther was put in touch with Mr Suliman at Soba University Hospital (SUH) who was keen to see palliative care services developed at Soba. In November, both Dr Nahla and nurse Alfaki Adam from SUH travelled to Hospice Africa Uganda to participate in a five week training course. This was made possible after a traveling scholarship was awarded to Dr Nahla by the International Association for Hospice and Palliative Care.

During the early months of 2010, HAU sent Dr Anne Merriman, and others, to Khartoum for advocacy visits and a four week training course in basic palliative care and volunteer training.


Dr. Anne Merriman at Soba

In February, Sudans’ first dedicated palliative care clinic opened at RICK. To date over 300 new patients have been referred to the service. The palliative care team led by Dr Nahla Gaffer consists of nurses, medical officers, psychologists and volunteers. This service has developed without specific funding but with essential support and encouragment from the HAU, IAHPC, SHCG and APCA as well as with the enthusiasm of volunteer health care professionals.

In December 2010, a three-day workshop ‘Palliative Care in Practice’ was held at SUH. Prof Ahmed Elsayem from MD Anderson in Houston, US was our guest speaker. He is Sudanese by birth and sadly knows from personal experience the enormous need for the development of palliative care in Sudan.

During the workshop, patients with palliative care needs were assessed by participants and each group had a palliative care team member to lead the care. Patients were then presented to the wider group and revisited to implement the care agreed upon. This was a powerful teaching tool that demonstrated many of the palliative care principles that we were teaching. In particular, they observed the effectiveness of oral morphine and the importance of psychological care.

The workshop used multiple teaching methods related to aspects of palliative care including the importance of communication skills and disclosure of the diagnosis and prognosis. The latter highlighted the urgent need for research into Sudanese attitudes towards death, dying and the disclosure of the diagnosis.

As the workshop concluded, key areas for development were identified and an agreement was made to form a taskforce to work on them.

Participants were given a book ‘Palliative Care in the Developing World’ published, and kindly donated, by IAHPC (picture below).

In 2011, we hope to see the opening of dedicated palliative care beds for both adults and children at RICK, the development of a palliative care team at SUH and, if funds and staff permit, the development of a desperately needed homecare service. To do this we need the international palliative care community to continue supporting our efforts.

Esther Walker

References:
Hamad H M A (2006) Cancer Initiatives in Sudan, Annals of Oncology 17, (supplement 8): viii32-viii36
Downing J et. al (2010) Challenges to palliative care service provision for cancer patients in Africa. (unpublished) . African Palliative Care Association

 

A regional palliative care workshop conducted by WHO-EMRO Egypt,
from 17th to 20th of October 2010

A palliative care workshop was conducted in Cairo, Egypt in October, 2010. The workshop was an initiative of the world Health Organization - East Mediterranean Regional office (WHO-EMRO).

The participants were pioneers in palliative care from 13 countries. The speakers discussed important topics regarding palliative care such as principles of pain management, communication skills and end- of life- care. The meeting also was a great chance to discuss the current situation and challenges of implementing palliative care in these countries.

Morphine consumption is very low in this part of the world which suggests poor palliative care and pain management. The reasons vary, but the main factors are lack of awareness and fear of morphine by doctors, “over protective” rules and regulations, and the unavailability of drugs.

By the end of the meeting, participants had agreed on recommendations that will be adopted by WHO-EMRO as guidelines for ministers of health, they are: include palliative care in health care strategy, introduce palliative care in undergraduate and postgraduate training, and make opioids easily accessible to all patients. They also agreed to start an association of palliative care for EMRO countries.

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