Since we started we realised that we wouldn’t move through Africa unless we trained others to take on what we were doing in Uganda. So we started clinical service alongside with teaching but the more and more we do it we realise that you cannot teach in other countries unless they have a very good service. WHO asks you to have an impeccable service and that is really what we really need. So most of the courses are taking place in Uganda but we do go to other countries and teach there but it’s very hard to find good clinical services to teach with in other countries.

Less than 5% of cancer patients reach oncology or radiotherapy or any kind of… even surgery. In Uganda 57% never see a health worker but the worst scenario I’ve seen is in Ethiopia where 85% never see a health worker. These people have cancer and AIDS, the same as the rest of us and they lie in the villages dying with nothing. We now have community volunteers who keep an eye open in the village and as well as giving basic care they will bring them to us if they’re having severe pain or we will go down to them, which is the usual scenario. They’re too sick to come to us so we go down to them. Persuading medical teams to go down to people in their homes, in Francophone Africa in particular, is very difficult. Now, up to now we’ve only got affordable oral morphine in 15 of the 56 African countries. The Francophone countries, not one has oral affordable morphine.

So what are the really key points that in palliative care you need to communicate to medical communities in order to have effective care for these people?

Number one is that pain control is possible and is affordable and can happen in Africa because nobody saw it happening until we brought in affordable morphine. You need to open the door for people in pain with affordable morphine and then you can give them the holistic care which palliative care brings which is looking at the psychological, the spiritual, the cultural problems and the social problems, and bringing all these. And the spiritual problems in particular; people in Africa are very, very spiritual. So we can’t even talk about those because they’re screaming in pain and their families are so distressed before you’ve controlled that pain. We need to get that message across to the medical profession as well. We’ve done that mainly by teaching medical students since ’93, now everybody who qualified since ’93, all the doctors, know what we’re talking about. But in other countries they haven’t got MTG in the undergraduate curriculums at all as yet so this is taking long. Twenty years is a long time to get something in there.

How do you cope with the prejudices against distributing morphine?

I just stay strong. Particularly because it’s oral morphine it’s not addictive, you have to have mainline to get anything from morphine. But morphine is the least addictive of all, it’s pethidine that most medical people get addicted to because that really does give you a high but morphine…

But governments in particular are reluctant to encourage the use of morphine, aren’t they?

They are because they’re afraid of being labelled as drug traffickers. Now we were very lucky with Uganda when we chose Uganda for the model for the rest of Africa, the Minister of Health at the time allowed us immediately to bring it in. Now he was very distressed at the pain in AIDS as well as cancer and although we were founded for cancer we found ourselves involved with the AIDS community from the second year we were there.

Now, you’re running a course for initiators for Francophone Africa at the moment, tell me what’s happening there, initiators of palliative care.

The initiators would be people who are thinking about it or actually have started a small service. This time we managed to get 27 from 9 different Francophone countries and they came to Uganda and the five week course has actually just finished in May. That five week course gives them two weeks in class in which not only do they learn about palliative care but they share with each other their problems they have and the difficulties they have. They learn not just about medicine but how to approach donors and budgeting and all that kind of thing because no Ministry of Health ever pays for palliative care, not even in Britain and these other countries. But they also then, the second two weeks, they do bedside teaching in the home, what we call mobile rounds and many of them have never been into a home before to see a patient because they sit there and wait for the patients to come to them. Then the last week is what we call training of trainers so that they go back ready to teach others and ready to start a service and be advocates in their country.

Now on the course recently we had quite a few came from Ministries of Health, doctors who work in Ministries of Health, they can advocate and they can really push things so we were very pleased with this course. And they formed an alumni afterwards and they write to each other in French and copy me in, which I can’t always understand but I have a Francophone nurse.

No, I’m not but I have a Francophone nurse who helps me out.

And how is your degree in palliative medicine going as well? That’s another important course.

Yes, well the first graduates were graduated from Makerere in January this year. There were only twelve of them but the numbers have increased. We’re expecting about eighty on the three year courses, if we add up the three years this year. The biggest problem is funding, they have to find funding. None of them can pay themselves, it’s $5,300 a year. The main cost is the face to face, so they come from other countries and their accommodation is the most expensive.

But that’s $5,000 very well spent because the amount of benefit that’s coming from it is immense.

It is, it is immense, because many places don’t have doctors, the nurses and the clinical officers if they’ve got a degree they’ve got more kudos in their advocacy as well as being better teaches etc. So it really is a big thing.

And a degree of professionalism about the whole business as well.

Yes, it’s a Batchelor’s degree. We have a Master’s in the wings, we’ve already planned it and got the curriculum together and we hope to have it running by 2014.

Anne, could you summarise for me the kind of messages that you want to get out, very briefly, to doctors and cancer carers all over the world?

First of all I want them to know that pain can be controlled and that we must ask about pain. Patients won’t come forward to tell you about it unless you particularly ask because they know that they’ve never had any treatment before. Governments need to know that affordable morphine, which costs the cost of a loaf of bread for ten days treatment, which is very, very cheap, is available but they have to give the permissions and to get everything done with the International Narcotics Control Board so that their quota for morphine powder is increased and it can come into the country. Then it can be made very simply, initially we made it in our kitchen at the kitchen sink and put double locked cupboards on the kitchen cupboards and that’s how we started. And you can start as simply as that. Now we make it for the whole country and it’s much more difficult but you can actually make it very simply and very cheaply and using recycled water bottles the whole thing is very cheap. So I want the medical profession to know that, please look at pain, learn how to identify it, how to assess it and how to treat it with oral morphine. Because we’re taught in school how to use injectables but oral is different and you really need to know how to use it or you will say it doesn’t work. So we need some training of our health professionals, particularly oncologists who see a lot of people in pain. We need to get the message out to governments, to members of parliament. We need it to trickle down so that we can say, ‘If you don’t have pain control in my district you will not be voted in as a member of parliament,’ I think that would be a big push.

The other big thing is to question them, have they seen somebody die of cancer and were they in pain and that they shouldn’t have done. We shouldn’t have let them die in pain if we had got this in, let us get it in now. So that when our time comes, because we’re all going to die, and if we live long enough we all die of cancer.