We do not intend the Global PC Day, which took place on 29thNovember 2018, to have been a talking shop.  We want to learn from it, and we know that those who came along to share and listen and learn, also want to make a difference.  All of us in the field of palliative care seek to ensure that health inequalities between nations are levelled out and, in keeping with the title of the conference, that ‘none are left behind.’

During the day of the conference, between the individual presentations, there were compelling group discussions that continued, informally, throughout lunchtime. Many had flown in specifically for the conference, bringing direct experience of their overseas work to bear.

Where palliative care sits on the pecking order of health needs was a hot potato for some.  In many low-income countries more generalised healthcare and access basic services is prioritised above palliative care.  There was a discussion about advocacy, lobbying and the opportunities arising from both the WHO Declaration and Lancet Commission Report in advancing the case of the palliative care and in raising it to the level of other important primary health care needs.

An ongoing theme was that of holistic care – treating the whole person by understanding their suffering and building a package of care around their stated needs. This is about listening, it’s about piecing together the jigsaw to meet the needs of the person and not simply the illness.  For example, talking about what matters to the person and asking, “what brings your life meaning?”, and then enabling them to do more of what matters to them was felt to be core to good palliative care.

Despite the strides that have been made in recent years in raising the profile of palliative care, one breakout session discussed the need for ongoing awareness-raising and how further understanding needs to be built to support specialisation in palliative care.

Of course, given the global aspect of the conference, the issue of culture was high on the agenda, and many examples were provided as to how different cultures impact on the work of doctors, nurses, social workers and religious leaders. Learning how to tailor palliative care appropriate to the prevailing culture was deemed key.  For example (but by no means exclusively) within the Muslim culture it can be a challenge to discuss and present a prognosis of having a short time left to live.

Models of integration were discussed.  One of those presenting noted that the World Health Assembly set the policy in 2014, but asked, how we might now integrate this into clinical practice?

Delegates left the conference energised and enthused for the future and with increased determination that they would contribute to more equitable palliative care globally. We look forward to seeing both familiar and new faces at the 2019 Global PC Day when it comes around again at the end of the year.

A fairly typical cold and wet November day in Edinburgh was significantly brightened for all those who attended the Global Palliative Care Day in St. Catherine’s Argyle Church on the south side of the city.   Jointly organized and run by Cairdeas, The University of Edinburgh’s Global Health Institute and the International Children’s Palliative Care Network (ICPCN), it wasn’t simply the scope of the presentations that made it ‘global’, but the participants from nine different countries, who represented cutting edge palliative care research, policy, and practice from around the world.  Delegates from the UK included primary healthcare researchers, palliative care (PC) Registrars (from London, Manchester, Newcastle and Glasgow), students completing their Masters Programmes in areas related to PC, and GPs and Consultants with specialisms in PC.

Professor Julia Dowling focused on the five key messages of the Lancet Commission Report stressing that, in keeping with the call for universal access, palliative care is notan optional extra.  Given Julia’s background (ICPCN) she understandably has an emphasis on the palliative care needs for children, telling us that $1 million would cover the morphine needs for children globally, a paltry figure in today’s million pound budgets.

Some of the most memorable moments of the day came from the real life stories that were told by in-country doctors such as Dr. Mhoira Leng, Medical Director of Cairdeas. Mhoira told us about Diane, who had end-stage organ failure and leg lesions and was receiving medical treatment in Kampala.  Restricted to a hospital bed, the most important thing for Diane was that she didn't feel abandoned and that she had someone to talk to.  Mhoira told us, “Palliative Care means dignity, and treating Diane as a whole person gave her the dignity she needed.”  Dr. NahlaGafer, who works in Sudan, had similar stories to tell, relaying the words of one patient who told her, “when I come to the clinic, I feel like I am not a sick person – I feel like I am coming to meet my friends.”

In the context of global news, we constantly hear about refugees being refused entry at borders, turned away, ‘contained’, or shunned.  It was heart-lifting, therefore, to listen toDr. Gurswan Purewal present on the her work with the refugee population in Adjumani District in Uganda.  She spoke of how the local population welcomed the refugees, referring to themselves as the ‘host’ population and calling the refugees’ region as a ‘settlement’ as opposed to a ‘camp’.  But behind the semantics, there lies a very real sharing of heath and social care resources between the host population of 240,000 people and 260,000 refugees  – would that we were all so sharing.

The following is a list of the presenters and the topics on which they spoke:

Prof. Julia Downing– Severe Health Related Suffering - a new paradigm in Lancet Commission Report;

Dr. Sebastian Moine– Astana and Palliative Care;

Dr. Mhoira Leng- 10 year evidenced based review from Makerere University and Mulago Hospital (MMPCU), Uganda;

Dr. Dan Munday – Developing and implementing the SPICT-LIS;

Dr. Nahla Gafer– Pioneering palliative care in Sudan;

Joy Kemp– Palliative care and midwifery – commonalities in health partnerships,

Appraisal in the refugee population in Adjumani District in Uganda;

Dr. David Fearon– pioneering palliative care in Mauritania;

Dr. David Butler -PRIME UK Teaching palliative care in different settings; cultural issues;

Dr Gursaran Purewal- Rapid Systems Appraisal in the refugee population in Adjumani District in Uganda;

Dr. Laura Tupper - Lessons from Chile.

All of the presentations have been made publicly available under the resources section of the Cairdeas website – for quick reference follow this link.

Visiting Bethlehem and the West Bank is such a privilage and yet holds many contradictions. Wandering the ancient streets and enjoying coffee with a local man who tells me stories of the old days and his faith for the future; staying at the beautiful Dar Sitti Azziza with Nabiil and Emily and hearing stories of centuries of this orthodox family; time with the faculty and Dean, Dr Mariam Awad, in the beautiful Franciscan Bethlehem University and see the students and staff thriving despite many many challenges not least those presented by 'the wall'. Exploring the back streets of Hebron to find amazing coffee and remember Abraham's decision but also see the tension and poverty of this ancient city.  Climbing Herodian Hill and thinking of the hills and valleys Mary and Jospehy navigated....when about to deleiver her first baby!!! I have an unusual nativity scene bought next to 'the wall' in Bethlehem which shows the Wise Men challenged as they try 'come and worship'.

In the midst of this let me intoduce 2 shining stars for me who are working to mprove the lives of their patients and families and the wider population. Let me tell you about Dr Amal Awad, Director General of Education in Health and Dr Rania Shahin, Director of Pharmacy at the Palestinian Ministry of Health. They have worked together to ensure availability of oral morphne in sustained released and immediate release tablet formulations as well as oral oxycodone syrup for children. They are then rolling out education and training accross West Bank usuing a guideline adapted from our work in Uganda. It has been my privilege to work with these and other colleagues and amazed at their efficiecny and efffectiveness as they listened to the evidence, changed formularies and started to institute change. I am looking forward to visiting next year and offering further support but also to know there will be many many people receieving pain relief this year because of this work.

Let me share Dr Awad's words 'Two Pain management Protocol workshops were conducted by the General Directorate of Education in Health in coordination with the General Directorate of Hospitals and the General Directorate of Pharmacy. The main purpose of the workshops was to respond to one of the main CPD Needs highlighted by physicians, midwives, nurses, and pharmacists in response to patients’ concerns of under prescription or over prescription. The workshop targeted systematic pain management according to global standards using a unified pain management protocol within hospitals to clarify misconceptions regarding pain management.
In consultation with Dr. Mhoira Leng the standard training workshops agenda for pain assessment and management was developed and conducted twice to facilitate access for health care providers. The first workshop was conducted in Ramallah for the North area of the West Bank on November 22nd , and the second workshop was done on December 9th in Bethlehem for the south area of the West Bank. The following was our agenda for the workshop:
 Welcoming and introduction
 Pain Protocol using a person-centred approach within a multidisciplinary team/ Presented by: Dr Amal Abu Awad
 Physiology, Pathology, and Assessment of Pain/ Presented by: Dr. Nizar Taraweh
 Taking pain management forward; non-pharmacological approaches/ presented by: Mr Bashar Qashu
 Pharmacologic Treatment of Pain /presented by: Dr Safa Blaibleh
 WHO ladder in the management of Pain: use of opioids including oral morphine./ presented by: Dr Layla Al-Khayyat
 Discussion and Steps Forward/ by all presenters

Many thanks goes to our supporting partners UNFPA, MAP-UK, all our presenters, and to Dr. Mhoira.
Let us always remember that together as a team we can make a difference in decreasing the suffering of our patients.'

As we see this huge step forward in West Bank we also hope and to see pain relief available for so many in need in Gaza.

It is humbling to reflect on the amazing peoeple we have worked with this year..and the many many challenges still faced to bring relief of suffering.  We will share more soon about the serious crisis of funding for colleagues in Uganda. Meanwhile, may this bright hope from Bethlehem inspire us all this Christmas season as we pray for peace and remember the Prince of Peace.