At the end of last year, we published a series about palliative care in the context of humanitarian crises. Contributors looked at the implications of providing palliative care for migrants, refugees and people who have fled war-torn countries and places of conflict.
Today, we are joined by Dr Mhoira Leng, Dr Elizabeth Swain and Dr Alice Gray who have recently returned from a teaching assignment in Gaza where the ongoing siege is part of everyday life.
We face each day examples of inhumanity and injustice in our news, social media or personal experience. We see leaders and factions use difference as a way to build power and attack minorities in many settings and throughout history. In humanitarian settings this can feel out of control.
How can the world allow this to happen? There seems no solution… it can feel hopeless. More people displaced and affected by man-made and natural or climate disasters than in any time in history. Can we even begin to imagine the suffering of people displaced by conflict within, or outwith, their own countries, or those affected by disaster or epidemics? What can we say or do in response?
I want you to travel with us to Gaza – a place of almost unimaginable trials where most aspects of life are subject to limitations, with severe restrictions of freedom to travel, or even live with dignity. Let us examine some of these experiences through the lens of values-based, compassionate individuals and communities.
Come and meet the mother of our articulate, helpful and extremely able teaching assistant Dr Abdelrahman. She is hosting our international faculty group in her home and serving us the most wonderful maqlouba – a traditional dish fragrant with spices, culture and love. As a former English teacher she communicates easily with us many of the significant daily struggles and losses but also the joys of family life in Gaza City. She is proud of all her children but gives her doctor son some specific advice every day when he leaves for study or work. “Remember, Abdel, you are human too and so treat all your patients as you would treat me.” Values instilled from home and rooted in faith that underpin practice.
Palliative care is at heart recognising and seeking a values-based, transformational approach to the relief of suffering, promotion of quality of life and restoring dignity. Exploring this together as an international faculty, in partnership with local leadership from Dr Khamis Elessi, Dr Fadel Naim, Dr Anwar Alsheikhalil and Dr Bettina Boucher from the Islamic University of Gaza (IUG), has been an opportunity for mutual understanding and development especially in teaching undergraduate medical students. Palliative care is now becoming represented in clinical services and very encouragingly being part of the IUG 8th Healthcare conference. This is the first time the topic of ‘Pain and Palliative Care’ has been included in such a conference.
Let’s go to that classroom full of 132 bright, enthusiastic, energetic 4th-year medical students who are bubbling over with ideas and chatter and quickly reveal their intelligence, but also their compassion and sensitivity. We facilitated competency-based teaching through experiential learning in small groups using locally developed patient scenarios – including complex trauma following gunshot wounds – not a problem we see in palliative care in most settings. Background resources include use of the PalliKare app 1 (developed in Bangalore and free for android or apple devices), relevant texts and flipped classrooms. The latter is a way of having the student read or listen to a prepared lecture in order to have knowledge and reflective content online
We also spent time at the bedside exploring how to put knowledge into practice and learning from patients and families. This included a young child with leukaemia, necessitating long periods away from her family while being treated outside Gaza, and an elderly gentleman with chronic obstructive pulmonary disease (COPD) who bounced straight back into the respiratory ward after each discharge due to his panic and fear.
At the end of our week we discussed what we had learned together. As we saw the whiteboard fill up we felt a deep sense of humility and privilege to have the opportunity to interact with inspiring young people living in such difficult circumstances.
‘We need to care for patients with our hearts as well as our heads.’
‘Sometimes our patients just need someone to listen to them, express their fears and worries: good communication is a must.’
and, perhaps most strikingly,
‘Humanity until infinity’.
At first sight this feels like a superhero rallying call. But when we asked the students what values they had identified the list is striking: ‘love, joy, humility, justice, hope, empathy, compassion, team work, humanity, respect’.
Following last year’s Lancet Palestine Health Alliance conference we wrote a letter published in the Lancet. (Read the full letter here)
“To claim that palliative care alone could be the solution to the conflict in the Gaza Strip and other conflicts like it, which often seem like intractable political calamities, would be naïve and careless. Yet we do believe that the compassion and humanity intrinsic to palliative care affords it a powerful role in working towards conflict resolution.”
In the light of the current global shifts caused by the COVID-19 pandemic, please imagine how your life has changed after a few weeks of social isolation and lockdown. Now try to imagine life in Gaza after 11 years of a siege and now facing the same pandemic. Was there ever a more important time to sense our common humanity, see barriers come down across our world – physical and otherwise – and advocate for all to have the healthcare access and dignity they need and deserve.
So we come back to the opening questions. How do we live, think and act in the present reality of amazing opportunity yet such overwhelming suffering. Let’s take our rallying call from our Gaza students ‘Humanity until infinity…’
- PalliKare app – a palliative care app designed and made free by Karunashraya, Bangalore Hospice Trust (BHT) for doctors and nurses with limited knowledge of the subject. (Download from https://play.google.com/store/apps/details?id=org.karunashraya.pallikare&hl=en_GB)
Links and resources
- Contact Dr Mhoira Leng by email.
- Cairdeas International Palliative Care Trust.
- Waldman E and Glass M (eds.) A Field Guide for Palliative Care in Humanitarian Crises. Oxford University Press; November 2019. OUP has generously provided free open access to every chapter.
- PalCHASE – Palliative Care in Humanitarian Aid Situations and Emergencies network with a web page of resources for ‘Palliative Care in the Time of Coronavirus’.
- Palliative Care Guidelines for COVID-19. eBook, edited by Task Force in Palliative Care (PallicovidKerala), Kerala, India.
- COVID-19 resources for palliative care across Africa.
- Webinar: Palliative Care of COVID-19 Patients in Low-Resource Settings with Dr Mhoira Leng.
Read more posts on the EAPC blog about: Palliative Care in Humanitarian Crises and Coronavirus and the Palliative Care Response.
More about the authors
Dr Mhoira Leng is the Medical Director of Cairdeas International Palliative Care Trust and advisor for palliative care in Makerere University, Kampala, Uganda, and University of Edinburgh, Global Health Academy, UK. She has been visiting Gaza as part of a link with the Islamic University of Gaza for six years.
Dr Elizabeth Swain is a Trustee of Cairdeas International Palliative Care Trust with extensive experience of working in Albania and as a tutor for PRIME (Partnerships in International Medical Education).
Dr Alice Gray previously worked with Cairdeas International Palliative Care Trust in Uganda and is now a hospice doctor in Birmingham.