Imagine 45 degree heat and 7 hours of teaching per day when all of your participants have not eaten or drunk anything since 3am. Add some of the most hospitable and generous people you have met with a heart to make a difference for the suffering and needy in their country along with amazing culture, colourful markets and fantastic food (after 730pm) and you have sense of my recent experience in Khartoum, Sudan during Ramadan. Dr Nahla Gafer, clinical oncologist and palliative care champion at RICK (Radiation Isotope Centre Khartoum), along with Dr Ahmed Elhaj, Dr Mohja Khair Allah, Mr Alfaki Suliman (from Soba hospital) and the rest of the team arranged the first palliative care training for oncology staff. This was in partnership with the Comboni College led by the inspirational Fr Beppino Puttinato and Fr Jorge Naranjo
 (https://www.combonikhartoum.com/short-courses/palliative-care.html)

They invited facilitators from the Makerere Palliative Care Unit to share their experience and to join the Sudanese team to teach and advocate for palliative care.  More than 20 students from 4 hospitals, representing several disciplines and levels of experience worked hard with a willingness to share and consider how they will implement their learning. We had key discussions and offers of support from the Ministry of Health non-comunicable diseases department and the WHO representatives. We met committed hospital directors  from the Khartoum Breast Cancer Center, RICK and Medani and heard of the progress in access to oral morphine and the hope to integrate palliative care throughout the hospital setting even beyond oncology and to dream of how this can be available in the rural settings of this large and varied country. We heard too of the challenges with high inflation, geographical distances, lack of training options available in
Sudan and the many upheavals politically in the region. For Mwazi Batuli and myself as well as student and Sudan enthusiast Emilie Myers it was an amazing 2 weeks. We miss the baobab and karkadi drinks, the rugag soaked in milk, the guiding skills of young Yousif, Arabic henna, bustling night markets, the sound of the muzzein folllowed by mouth watering  fatur and the deep

faith of Sudan's people but feel privileged to be part of this palliative care journey and look forward to being able to work together in the future. I return with my Sudanese name; Dr Mohira, a beautiful Dafuri basket on my wall, some Arabic henna, a few more Arabic words, a new tribal dagger to cut the haggis at my Burns night celebrations and the joy of renewing friendships, building new relationships and
see people transformed to influence and change their health systems. Shukran. Maybe next time we will get to explore more of this amazing country but to all the palliative care friends we wish you well and know you are going to do great things inshallah.

Often these posts are about travels and adventures rather than the day to day clinical rounds. Some of you asked for another wee peek into a typical day and some of the people who make life so rich, unexpected and challenging.
The traffic in Kampala gets worse and worse but if you get up before dawn, arm yourself with a large mug of spicy Indian tea and leave as the sun is just rising you can almost keep your sanity. The beauty of a soft red sun rising above the busy morning activity and the smart youngsters on the way to school makes getting up early worth it (almost). The small team office fills up as one by one everyone arrives though as it is rainy

season they can be delayed. For the past few years we have been privileged to have UK volunteers working with us and they add to so much to our great MPCU team. Anna has just left but Eilidh and Gurs are with us right now and have joined me on the early start. Each day our priority is the patients and families we support on wards throughout the Mulago site. Last year we saw more than 600 patients and their families and many many more were also supported through the volunteer and link nurse programmes. Today Mulago is as busy as ever but has got some smart new beds, mattresses and even hand sanitiser containers (not always full but a good step forward). The nurses look smart in their uniforms and red belts and seem to keep going even when the number of patients seems overwhelming. Let's visit some wards together. Here is a young girl from the west of the country who has had very traumatic events in her childhood and now has an unusual type of cancer and is receiving chemotherapy. Her parents are with her constantly to do all of her personal care and at least she is sleeping quietly today. We can now go and see a young man of 23 who has been diagnosed with liver cancer that is very uncommon in the UK but sadly common here. It is associated with hepatitis B and

perhaps one day vaccination can stop this cycle of infection, inflammation and cancer. Today we need to speak with him and his family and break the news about how far the disease has progressed. At least his pain is well controlled today with the help of oral morphine that is presently in good supply. Our next patient has several problems that are linked; stage 4 HIV/AIDS which drops the immunity and leaves people vulnerable to other problems such as the advanced TB he is being treated for and now a kind of cancer, Kaposi sarcoma. We have some  colleagues with us today who are going to be pioneers of palliative care in their Francophone countries; Tunisia, Senegal, DRC and Benin. Chedly from Tunisia has never seen a patient with KS which shows the huge difference in this continent of Africa. They are adding a whole new dimension for the round and stretching my rusty French language skills. Come with us too and see a young girl that has advanced heart disease (called endomyocardial fibrosis) that is fairly common here but very rare in the UK. She has responded to treatment overnight but remains very ill. We have suggested to her mother that we ask for Hospice Africa Uganda to help with her care at home and the mother claps her hands. Why? She is also a patient at Hospice and knows how much care and love they will offer. Still sad for this lovely family but glad Octivia from Hospice is on our round today as she is several times a week. Lastly we prepare to lead a clinical meeting, called the grand round, to talk about difficult conversations at the end of life to help our colleagues think about how to handle these situations and to explore the ethical issues   involved.  We are going to tell the story of a courageous little girl we looked after recently who agreed to let us share her words. She was very ill with advanced lung fibrosis and had many questions. Am I going to be OK? Why do other children get better and go home but not me? She also got
very frightened at night and asked 'Is Satan coming to get me?' 'Can you help me go to a church?' She was too unwell to go to church but we listened to her fears, supported her family, prescribed some medication to help her breathing and then suggested we brought church to her thanks to our great volunteers. They came with songs, stories, a radio, some ice cream, a children's bible and prayers. Holistic care in action. It was also encouraging to see how many came to the teaching session and were willing to explore and learn how to respond to these very important questions. It underscores how much our colleagues appreciate palliative care and are willing to develop their own skills with enthusiasm and compassion.
Its been a busy day and now we have plenty paperwork, examinations to set and mark, panicked students to support who are trying to get their research work in for marking, planning for our next THET project support visits to Uganda, Zambia, Kenya and Rwanda, looking to see how we can manage the budgets this year, answering the hundreds of emails and of course the prospect of battling with the Kampala traffic to get back home to my wee house.