Our Medical Director, Dr Mhoira Leng, shares her end of year reflections for 2024.

As the year draws to a close let me take a moment to reflect.

At this time, many of us will be singing Christmas carols, and a much loved favourite is O Little Town of Bethlehem. The carol focuses on the events in the town of Bethlehem over 2000 years ago that would have historical and global significance. This part of the world was experiencing conflict, occupation, forced displacement, the killing of children and fear…then and now. Perhaps you will remember the powerful image from the Christian Church in Bethlehem of the nativity with the baby amidst the rubble wrapped in a kufiyeh and Rev Munther Isaac’s sermon; 'Christ under the rubble'. 

As the carol says; ‘the hopes and fears of all the years are met in Thee tonight’

With devastating and ongoing conflicts affecting our partners in Gaza and the rest of Palestine as well as in Sudan our hearts are heavy. We have heard from Dr Khamis Elessi and other dear friends who continue to offer care to patients and families even as their own families are struggling to simply survive. We mourn the killing of dear friends and colleagues and the almost total devastation and destruction of the health system, the education system, systematic starvation alongside everything needed for life and for dignity. We are aghast as international and humanitarian laws are seemingly ignored and the whole foundation of our world order is under threat. When the voice of peace and hope seems unheard and ignored it can seem as though humanity itself is under threat.

Words from Munda Nasser, written in Advent reflections from Bethlehem, have been a support for me. She speaks of hope and reflects on these bible verses; ‘For in hope we were saved. Now hope that is seen is not hope, for who hopes for what one already sees? But if we hope for what we do not see, we wait for it with patience.’ ROMANS 8:24-25. She says; ‘The Christmas story is a reminder for humanity all over the world to reorient its compass and ask: What can we do to build hope, to reconstruct it collectively? Sumud forms our collective Palestinian response to the everyday systematic oppressions that we go through. It forms our stand and our journey toward what we cannot see. It forms our inability to sit with hopelessness —it is a way of saying that hope will always have the final word.’

So what gives me hope as I look back on 2024. I see the amazing way Cairdeas partners are working in challenging situations where resources are constrained and needs can be overwhelming. I see the innovation, resilience and compassion to deliver training, research and clinical care in Uganda, Sudan, Gaza, Mauritania and India. We read the essays from medical students reflecting on holistic care learning in the midst of conflict in Gaza. We hear of the impact our Scholarships have had for inspirational colleagues such as Toko, Vicky, Liz, Philip and Ronald in Uganda. Our Compassionate Leadership Fellows in India are being transformed and already putting their learning into practice. (Please go back and listen to the videos from our Cairdeas Gathering to be inspired)  I am humbled by the many who give their time and expertise in the Cairdeas Faculty and those who give, volunteer, pray and support in so many other ways.

At the heart of Cairdeas is the dignity of the people who face each day living with serious illness and who walk in the twilight days of their lives. Palliative care seeks to accompany people on that journey and focus on listening to concerns, alleviating suffering, supporting quality of life, promoting dignity and being in solidarity for justice. This is the heart of compassionate palliative care. This is the heart of humanity.

Let me mention one project we are focussing on this year for funding support. ‘Sunshine During War’ was formed by Dr Nahla Gafer and colleagues from Sudan in partnership with Sanad Home Hospice Care in Lebanon and CairdeasIPCT. It has brought psychological support for staff, patients and families, offered clinical mentorship and expert support and helped to sustain services within war torn Sudan through practical help for internet access, travel and even at times food and basic living needs. We are now extending this to include Gaza - led by Mervat Hammad, one of our Diploma students, now in Egypt. We will be sharing more of this project soon. Let us hear from Nahla…

‘Yes, we helped them, they needed us, but also, we needed to preserve the work that we had started; we needed to help our patients. It is part of who we are. This way we are really healing, caring and humane health professionals.’

Please consider gifting towards this programme now or in the future. You can do so here.

So wherever you are and however you are feeling at this time of year may we all be inspired, renewed, energised and encouraged to live with hope in hearts full of gratitude.

Author: Dr Mhoira Leng

At this time we are remembering the terrible suffering of the people of the land and the ongoing suffering of the Palestinian and Israeli hostages as well as the hundreds of thousands of displaced, the bereaved, the injured, those who struggle to find hope in the midst of such hopelessness.

This poem from Khawla Badwan speaks so searingly of the many, many years of pain and suffering. Read it with your heart.

Words can be difficult to find. I have found solidarity in sharing the words of our colleagues and friends in Gaza; people we have worked with for over a decade and even now show such courage and compassion even as they cry out to a deaf world to end the suffering.

‘Where we were displaced was in Mawasi Khan Yunis. From morning to afternoon, we died a thousand times from the very high temperature and the hot weather. We have reached the point of pouring water on our heads as we sit to endure the heat. Even the water is hot from the high temperature, and we also drink it warm. What misery we are living in, what fate still awaits us. We are crushed, sadness consumes us. To God only we raise our palms. From the misery of the Gaza Strip, we are still calling out: We have the right to live.’  Randa Said, nurse.

We are part of a humanitarian movement that seeks to advocate for the needs of our brothers and sisters and for the world to ensure humanitarian law is respected even or especially in times of war. This means the protection of all civilians, access to healthcare, protection for healthcare workers and access to food and water at the very least. I have been privileged to speak and share the words and experiences of our Gaza colleagues in many forums; from international cancer conferences, to palliative care events and solidarity events. We continue to explore how to better support those with non-communicable disease and palliative care needs in conflict zones through these forums and with PallCHASE.

A few weeks ago we came together as International and Gaza faculty to repurpose the pain and palliative care course materials for the Islamic University of Gaza. By making these low-bandwidth, asynchronous sessions with embedded case scenarios we were able to support students, who were studying in the most challenging of circumstances, continue their education. We are grateful to the Gaza Educate Medics platform and PalMed, who are supporting a board international network to continue the medical school curriculums online. The Deans of both medical schools are leading the Gaza faculty and guiding the international community. Our students had never had their clinical training induction so worked hard to complete the sessions, the exams and the case reports. They sent me a few photos of their studying conditions. What courage to continue to prepare to be the doctors so needed by their own people!

When I left Rafah in April 2023 it was with a deep sense of foreboding that the world would not stand with the red lines; that Rafah and all the hospitals, clinics, displaced population and wonderful people would be overrun. And so it happened…courageous compassionate people left to struggle in tents which now flood as the weather turns again. Who search for freedom for dignity, for the basics of life and who still find the courage to rebuild hospitals and clinics, to care for those in need, to study and complete exams…to hope.

Palestinians speak of a core value, samud or steadfastness and this is humbling to see yet they also tell us of their exhaustion.

‘We are not well. We can no longer continue, to continue as if nothing has happened. Our hearts hurt because of the weight of what they carried inside them, and our bodies are exhausted because we did not find a safe space in which to retreat. We are tired of concealment, because we are not accustomed to revealing what makes us sad. Our tears used to fall, exposing what we hid. A lot. We feel very tired, but we pretend to resist. If these days pass quickly, we will sleep for a long time. We have no energy to endure anymore. We are tired and every part of us is tired.’ Suha Suleiman Shaath, pharmacist.

When I speak to my dear Palestinian brother, Dr Khamis Elessi, the first thing he says is ‘we are still alive’…he sends his greetings and longs for the war to be over and for people to know the true nature of what they are experiencing. He concluded his message with the words. ’May the sun of hope, freedom, justice and peace shine again.’

May God protect and sustain him, his family and all our brothers and sisters in Gaza and also in Palestine, Lebanon and Israel to bring a just peace to all the land. Let us come together as one humanity to find and demonstrate a different way.

Let me end with a prayer from the Archbishop of Jerusalem, Hosam Naoum, writing last week on the anniversary of the bombing of the Ahli Christian Hospital in Gaza City.

A Prayer for Peace and Healing

Great Healer, we lament the horrific wounds and loss deep beyond comprehension. Repair and restore hearts wounded by unimaginable fear and trauma. Provide a way for healing for the multitude who are injured in body and spirit. May your people and the earth know your mercy and an end to the suffering. May your healing compassion be manifest among creation and the people of the earth. Amen.

Authors: Nahla Gafer and Heba Elsawahli

Nahla Gafer and Heba Elsawahli report from the World Cancer Congress, where they and Dr Mhoira Leng presented on the challenges of cancer care in communities broken by conflict. Firsthand accounts from Gaza present a desperate situation for healthcare workers, fighting to treat people amidst extreme violence and destruction. Examination of Sudan highlights the fragility of health when conflict breaks out, and how quickly circumstances can change. 

They discuss the innovative solutions healthcare workers are finding to continue treating their patients and present their recommendations and a call to action for improving cancer care in humanitarian crises. 

During the World Cancer Congress held in Geneva from the 17^th to 19^th of September 2024, I had the privilege of presenting alongside my esteemed colleague, Dr. Mhoira E. F. Leng the critical state of cancer care amidst conflict and humanitarian crises in Gaza and Sudan. The congress is an initiative of the Union for International Cancer Control (UICC) to unite and support the cancer community in its efforts to reduce the global cancer burden, promote greater equity, and ensure that cancer control remains a priority on the international health and development agenda. It was a gathering of experts, and influential leaders in cancer control besides rising professionals and researchers from all the regions. Palliative care was at the heart of many discussions either as part of cancer treatment or as part of the experiences of people living with cancer. The sessions brought diverse inputs about the challenges and opportunities to emphasize the right to palliative care within different contexts. Our discussions underscored the profound challenges faced by patients and healthcare providers in war-torn regions and highlighted the urgent need for innovative solutions and international solidarity to address the suffering of vulnerable populations.

Gaza: A City in Ruins

“Come with me to Rafah, where the heart-wrenching reality unfolds before us: long queues of trucks, a cemetery surrounded by tents, and the desperate need for water carried by donkeys. The destruction extends even to ambulances, the very lifelines meant to save lives. Here, children are left without schools, robbed of their innocence and future, with nearly 14,000 young lives lost—each one a tragedy to mourn. The staggering statistic of 70% of the casualties being children haunts us. We grapple with the shocking numbers: 100,000 injured and 34,000 dead, which would equate to 85,600 lives lost in Scotland and over 262,000 in the UK. This is not just a distant conflict; it is a human catastrophe. We stand witness to a plausible genocide, where starvation is wielded as a weapon of war, violating the very laws meant to protect humanity. Yet, in the face of this madness, who will rise to stop the tide of suffering? This is a crisis that makes us all less safe, revealing a humanity that is fractured and in desperate need of healing.”

Dr. Leng's presentation focused on the dire circumstances in Gaza, where the ongoing conflict has transformed a vibrant city into a landscape of devastation. Testimonies from local healthcare workers and patients conveyed a heartbreaking narrative of loss, destruction, and an overwhelming sense of despair. A poignant message from pharmacist Suha Suleiman captured the spirit of determination amidst chaos: “Despite the pain, hope persists. We are determined to give and provide service to cancer patients despite all circumstances.” Healthcare professionals in Gaza, including oncologists, face insurmountable challenges as they strive to provide care under life-threatening situations. Many have been injured or killed while performing their duties, and the destruction of healthcare facilities exacerbates the crisis. Dr. Leng highlighted a case involving a 34-year-old civil engineer diagnosed with follicular lymphoma who waited four months for a referral to no avail. He received excellent palliative care from trained colleagues, yet unfortunately, no active treatment was possible for his “curable disease.” This example underscores the critical need for timely intervention in cancer care, which is often compromised during prolonged conflicts.

We are actively fundraising for our partners in Sudan, please see the donations section on our website to donate to this project.

Sudan: The Struggle for Survival

In a similar manner, I addressed the challenges faced by cancer patients and healthcare professionals in Sudan during wartime. A sudden outbreak of war leaves people unprepared. Those who were on the streets on the 15^th of April lost their lives, others were cut off from their homes for days or weeks. Some had to leave their homes without their IDs, certificates or savings. Houses were ransacked, buildings destroyed, and many lost their homes, savings, and jobs.

The conflict has severely disrupted healthcare services: during the first two weeks of war 26 hospitals were bombed in the capital. People moved to safer areas, where the infrastructure was poor, and prices skyrocketed for essentials like food, housing, and medical care. Rent for a one-room house with no windows cost four months' salary, while radiotherapy, available at only one centre in the entire country, cost 50 times the average salary. Healthcare workers experience a cessation of salaries and increased living expenses, leaving them feeling helpless in the face of patients' needs as well as themselves being a target. Cancer management is significantly impacted by these circumstances, as timely treatments and specific interventions become inaccessible. Cancer patients who were free from clinical evidence of disease and were on their way to cure, developed recurrences and metastasis. Doctors reported more side effects and deaths from in patients receiving chemotherapy, mainly because of the poor physique of the bodies, torn by lack of food and psychological stress.

Innovative Solutions Amidst Adversity - Networking and Telehealth

Despite the overwhelming challenges, innovative practices have emerged in both Gaza and Sudan. Networking among healthcare providers has fostered collaboration and support. Through online platforms, healthcare workers share psychological, material, and consultancy resources to cope with the trauma of war. Telehealth has also become an essential tool, enabling healthcare professionals to guide patients and provide care remotely. This adaptation has allowed oncologists to offer necessary support and reassurance to patients navigating their treatment options amidst chaos.

Similarly, healthcare providers in Sudan have utilized telehealth to maintain connections with patients. Oncologists are encouraged to think creatively when faced with deficiencies in available services. For instance, they may rely on ultrasounds and chest X-rays instead of CT scans or make clinical diagnoses when imaging is unavailable. Such adaptations are vital in ensuring that cancer patients receive the necessary care, even when resources are scarce.

Cancer in Conflict: The Lived Experience

The voices of people living with cancer, their families, and caregivers should be amplified in these critical times when human lives are reduced to figures and numbers. Our efforts to describe and call for action to address the catastrophes of the situations in Gaza and Sudan are incomplete without listening to those enduring the pain. In the preparations for the World Cancer Congress, a cancer survivor from Gaza who evacuated to Egypt was invited to different panels to showcase and bring evidence about what she went through in Gaza. However, she was not granted the visa to participate in person, which prompts further questions about the situation of the needed international solidarity. The shared message from the Gaza cancer survivor reaffirmed the need for peace as the best medicine for cancer patients. Ensuring the safety of humanitarian, healthcare, and aid workers during wartime and holding parties accountable for targeting healthcare centers are essential to providing cancer care including palliative care. She also mentioned the importance of coordinating efforts to value the lives of cancer patients through evacuation to centers abroad that continue providing desperately needed care. She emphasized that cancer patients usually suffer from other comorbidities and require at least one person from their family to support them. She called on resuming efforts similar to helping childhood cancer patients that happened earlier in the year but stopped in line with the increasing aggression.

Recommendations:

1. Medical Treatment and Protocols

• Prioritize the use of medications that require less frequent dosing to ensure better management in crisis settings.
• Adapt treatment approaches to available resources during emergencies, allowing for flexibility in care delivery.
• Strengthen systems to procure and distribute essential medications, particularly controlled substances like opioids.
• Guarantee that medications and funds are distributed to those in genuine need, preventing exploitation by privileged individuals or those in power.

2. Healthcare Infrastructure and Continuity

• Focus on building healthcare structures and securing medications for the larger population, rather than relying on evacuating a select few.
• Spread healthcare infrastructure and capacity across multiple cities to prevent over-reliance on a single location in times of crisis.
• Maintain patient care throughout conflict by developing resilient systems that can function even in times of disruption.
• Ensure that palliative care is an integral part of healthcare responses in emergencies, providing holistic support for patients with life-limiting conditions.
• Recognize and prioritize the management of chronic diseases, ensuring they are not neglected during humanitarian crises.

3. Support for Healthcare Workers

• Implement role-making and task-shifting strategies, empowering healthcare staff to take on varied responsibilities, and ensuring continuity of care.

• Provide essential living support for medical staff, including shelter, food, and salaries to sustain their ability to work.

• Offer mental health support to both healthcare workers and patients to address trauma and stress caused by conflict.

• Ensure the protection of medical staff and healthcare facilities, safeguarding them from harm during conflict.

• Facilitate the entry of healthcare workers from abroad who are willing to support patients on the ground.

4. Communication and Collaboration

• Foster strong communication networks among healthcare providers, patients, and staff to ensure care can be coordinated during crises.

• Use telehealth and digital platforms to provide support, education, and consultation, especially in remote or conflict-affected areas.

• Build alliances and coalitions that bring together stakeholders for coordinated efforts in healthcare delivery during emergencies.

• Promote collaborative working relationships that respect and empower local leadership and expertise in healthcare.

5. Advocacy and Policy

• Call for the cessation of wars to protect lives and maintain healthcare systems.

• Call for implementing accountability measures following the targeting of hospitals and healthcare centres.

• Uphold the values of palliative care as a fundamental right, ensuring that these principles are applied universally.

The Call for Action

As healthcare providers grapple with the complexities of delivering cancer care in conflict zones, it is imperative to acknowledge that the challenges faced extend beyond the disease itself, encompassing issues of human dignity and compassion. Our presentations stand as a poignant testament to the resilience of healthcare workers and the significance of solidarity during times of crisis.