Report
I remember waking up to birds singing and a soft breeze blowing, in the beautiful Caribbean island of St. Lucia. It was my first morning, and I had just arrived from a very chilly, snow- laden Montreal, in Canada. I was a travelling fellow with the International Association for Hospice and Palliative Care, and had been invited by The St. Lucia Cancer Society. The society compromised of the Board of Directors, Dr. Bristol, Lista the secretary and Marion Greer, who was the director. The Cancer Society was already doing such a good job in providing information about cancer, and focusing on preventive measures, with a very limited budget. I was amazed at Marion’s energy and passion to help both Cancer and AIDS patients and their loved ones. I had already communicated by internet with Monica Felix, a community nurse supervisor, and the only nurse in the Caribbean who had received any formal training in palliative care. She had attended courses in the UK, and was still missing a special brand of tea, only found there! Monica welcomed me into her home; I became part of her family and enjoyed many discussions with her husband about the culture of orchids and even his recipe for ginger chicken. Both she and Marion quickly became my dear friends, and as a team, we embarked on the adventures of improving palliative care in St. Lucia.
I made home-visits to several advanced cancer patients, in different parts of the island and was able to observe some of the realities that they were facing. Many were poor and unable to afford, already difficult to obtain opioid analgesia, other types of medication, transport to hospital and any kind of nutritional supplements. For a population of roughly 155,000 people, the incidence of cancer is high. I was unable to obtain statistics, but the main cancers for females are cervix and breast, many of the women being young adults. For males, the primary cancers are prostate and oesophageal. Many males still smoke, alcohol consumption is high and many people smoke marihuana. As I discovered the island, receiving free accommodation from several hotels, I fell in love with the people. I remember one hotel in particular; it provided me with the most spectacular view from my room. An open concept, no window, just situated in a tropical forest, overlooking the beautiful blue-green Caribbean Ocean, nestled between "Les deux pitons" or two volcanic mountains. It will forever stay embedded in my memory. One of the areas where I stayed and worked is in fact the only "drive in volcano" and I had the pleasure of early one Sunday morning, bathing in the warm, sulphur- spring waters. The people are a mixture of African, Indian, British and French heritage. In fact, the island has changed hands 14 times between the British and French. I was so attracted by the beautiful children, one young, two year-old, whilst enjoying his fresh red-snapper at a local fishing village party, caught my attention, as he rhythmically danced to Reggae music.
As well as making home-visits to cancer patients, I was able to conduct several workshops for doctors, nurses, volunteers and non-governmental organisations. After observing, discussing with health professionals and the public, my plan of action was to identify needs and problems, build alliances, develop strategies and targets, hopefully mobilize resources, by attracting funding and actually start to implement activities. Developing a support system to continue the project was vital and a Strategic Committee was formed. The following was presented to the Committee:
As stated by the WHO, approximately 10 million people will develop cancer yearly, two-thirds in developing countries, who only possess 5% of global cancer resources. Worldwide, approximately 4 million people suffer from cancer pain, often needlessly so. The goal of my project is to improve palliative care in St. Lucia, and hopefully other Caribbean islands. Some obstacles in providing care that I observed are:
Lack of awareness of policymakers
Lack of knowledge and skills for healthcare professionals-- (much suffering could be prevented if existing knowledge was implemented.) Medical and nursing indifference about pain.
Lack of awareness and education in the general public
Cultural issues regarding disease and pain, lack of communication, "conspiracy of silence". Patients are not reporting their pain, symptoms, and poor compliancy in taking medications. Use of uncontrolled herbal medications
Lack of resources, and badly managed resources.
Poor drug availability, especially opioids, often due to regulatory drug restrictions, cost of analgesics. Fears of addiction to opioids among policymakers, regulators, doctors, nurses and the public.
Inadequate communication and liaison between the hospitals and community
Lack of teamwork.
SOME THOUGHTS AND STRATEGIES FOR IMPROVING CARE.
Policymakers need to acknowledge and identify the problems, define policy aims, ensure that resources are available, be aware that cancer pain control need not be expensive.
Plan---meet with policymakers and drug regulators, implement changes in regulations, legislation and availability of drugs. Contact drug company responsible for Fentanyl Patch and discuss situation in St. Lucia. Dr. Winston Parris will discuss ordering of Methadone—(very cost-effective opioid) with drug regulators for the Caribbean.
Plan a Caribbean Symposium, sponsored by the St. Lucia Cancer Society, for Healthcare Professionals. Dr. Neil MacDonald, an expert in Palliative Care and educator from Canada, Dr. Bruno Gagnon and myself, would conduct the workshops.
Expand use of media.
Define and develop role of Cancer Society---Arrange for Marion Greer to do training sessions with the McGill University Health Centre-MUHC, focusing mainly on teaching of volunteers.
Develop a policy manual and standards for Palliative Care (this has been started).
Increase skills and knowledge for Health Professionals
Plan-----Train more nurses and doctors in palliative care---in the hospital and community setting.
Arrange for training sessions in Montreal. Monica Felix would be willing, if sponsored, to spend 2 weeks at the MUHC---for training in palliative care. Arrangements could be made for MD who is interested in palliative care----to spend some time at MUHC.
Conduct workshops for doctors and nurses, focusing on topics such as pain and symptom management, communication skills, working in partnership with patients and families.
Develop a nursing curriculum to increase knowledge and skills, improved use of teamwork.
Expand the liaison between hospitals and community by improving communication documents concerning the patient history and care.
Increase awareness of the general public
Plan----by using the already excellent and well -established Cancer Society, provide workshops and information sessions.
Increase media attention on the subject and provide leaflets.
Give workshops to families, focusing on improving coping strategies, becoming familiar with facts and feelings and how to care for their loved one in the home. Empower patients and families, in both a psychological and community fashion, by working actively in partnership with health professionals.
Educate concerning the many myths of palliative care and pain control
