Thursday, July 31, 2008

Palliative Care in Africa

I originally wanted to combine this post with my previous post on palliative care. Not possible - personal and political.

In the UK there exists an extensive "hospice" network, largely funded by charity organisations.

Antonia is my best friend here - when I fell on some very hard times she put me up for more or less two years until she wisely told me to get out and get my act together.

Both Antonia's mother and maternal Aunt Gertrudes lived in her house. Both died whilst I lived there. Gertrudes suffered from what I imagine the medics call "dementia". But whilst she was physically able, she would make efforts to contribute to domestic life, sweeping the yard etc.

The palliative care in a home-setting was excellent but Antonia's family is relatively well-off. Here in Africa the quality of direct and extended family-care is very dependent on relative wealth, just as in the UK the provision of home-based palliative care is a greater hardship on the poor, although the closer proximity here of the extended-family certainly helps. However, there are no community nursing or social services. Fortunately for Antonia's mum and Aunt Gertrudes there was also a doctor in the family.

Inequalities of wealth have increased since I arrived in 1989. Back then we had a one-party state that had, since independence, tried with large amounts of foreign aid to provide the cradle-to-grave care that even we in the UK find an uphill struggle. The shops were empty.

But there were no old people begging on the streets, no street kids, rural-to-urban migration was low as people on the state-managed plantations were not allowed to starve, and as previously mentioned, we had an expensive primary and secondary healthcare system.

The collapse of the Soviet empire led to a massive decrease in foreign aid (although on the medical front Cuba still provides most of the best specialist doctors in the country). My Ukrainian dentist went home. Democracy came in 1992.

The IMF and World Bank hit us. Reform.

Now the shops are full. Old people begging on the streets, street kids, prostitution on the rise (although never a non-promiscuous society).

Home-based palliative care is becoming financially impossible for many families.

Sure, some sheltered-housing for the old has been built, there is a soup-kitchen for street kids in the city, financed by foreign aid and foreign charities ... but when you go town on a Saturday morning and see the lines of old people lining up outside richer shops awaiting a weekly charitable donation, when you see the street kids trying to sell you seed-bead necklaces or wash your car ....

One day Aunt Gertrudes couldn't get out of bed. She was dying. I cannot recall how many days it lasted but not long. One can often read the signs of imminent death in an old person, so as it approached, when she lost consciousness, immediate family was called.

I have no experience of death-scenes in any culture but what followed was weird, at least to me.

The family sat in chairs around her death-bed to watch her die. No movement, no conversation, no physical contact with Gertudes.

I was disgusted. I got a cup of water and a teaspoon. I sat next to her and gave her water drop-by-drop, wetted her lips.

Some 20 minutes before she died, Antonia told me to stop.

PS: I have just rung a friend to ask if this is traditional death-bed behaviour. No - it just depends.

PPS: There are some national palliatve care organisations aand centres in Africa but not many. The need is enormous - given the levels of cancer/HIV/AIDS/other diseases/physical problems on the continent. Visit here for the continental palliative care organisation.

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