Tessa Haynes visited Uganda and was surprised to find palliative care so well established. She explains why this high priority is justified, given the stretched resources of many developing countries

Peter carefully measures out a bright green liquid, and then pours it into a line of plastic bottles, one by one. He is the pharmacy dispenser at Hospice Africa and his role is to mix this strangely coloured concoction each day. The liquid is morphine; Hospice Africa uses 90 litres each month to control the pain of patients in the terminal stages of cancer and AIDS. For identification, the weak dilution of morphine is coloured green and the stronger morphine is red.

Hospice Africa is based in Kampala, Uganda, and provides relief of pain and symptoms through a team of specialist palliative care nurses and doctors. The aim is to reduce patients' symptoms so that they can spend this important time at the end of their lives living in the fullest way possible, free from overwhelming pain and the loss of dignity that accompanies the pain.

Providing care at home--the belief that "hospice" should be a philosophy of care rather than a place to die--is a fundamental principle of Hospice Africa. Hospice Africa believes that patients are best cared for by those closest to the patient, in a place with which patients are familiar: there are no inpatients. The hospice team supports the patients and their carers in many different ways; providing drugs is only one aspect of the work. The team counsels the patient and their relatives, provides day care to give carers respite, and acts as the patient's advocate in different situations that arise.

When I began my two month placement with Hospice Africa, I was forced to adapt my way of thinking. Symptom control, rather than cure, became the priority. We are all taught to think of pain in a certain way and to use the acronym SOCRATES to remember site, onset, character, radiation, alleviating factors, time course, exacerbating factors, and severity. But this went out of the window, as I tried to get to grips with taking a history, hospice style. Each pain that the patient feels is dealt with separately and plotted on a body chart in the patient's notes. Further questioning determines the details of the pain; whether it is neuropathic or somatic gives clues as to the cause. The patient scores each pain on a scale from 1 to 5. Pain at level 5 is overwhelming--the patient is usually crying. Pain at level 4 is still severe and stops the patient from sleeping. Each score is recorded on a visual pain analogue--a graph of pain severity that helps the hospice to assess how effective the treatment is at relieving the pain.

Taking a social history is usually a quick, "Where do you live? With whom? Do you smoke or drink?" But I suddenly found myself considering all sorts of things I never usually ask about. Did the patient understand their diagnosis, and how did they feel about it? Did they realise there was no cure? What were their expectations about the role of the hospice, and did they have wishes and beliefs about the last stages of their life, that needed to be taken into account? It is customary in Uganda that the dying are taken back, often miles, to the village they grew up in. This poses a special challenge to the team as they try to ensure that the patient's supply of morphine is not interrupted.

A week's supply of morphine costs the same as a loaf of bread, but the relief it gives far exceeds the cost. I saw this in action when I joined the hospice team on visits to patients' homes.

Each morning, four teams of nurses and doctors go out to a different area of Kampala. One Friday morning, I met Rose, a lady diagnosed with liposarcoma of her lower back. Five of us piled into the hospice's vehicle, with envelopes of carefully counted tablets and a rack containing the bottles of morphine. After a bumpy journey, we arrived and found Rose lying in bed, barely able to move due to the pain in her back. She slowly and painfully showed us a huge open wound on her lower back with a serous discharge and parts of the vertebrae visible--the result of failed surgery to remove the tumour. The cancer had spread to her upper right arm, and she had a pathological fracture. Nerve infiltration of the lumbar spinal nerves and the associated numbness and muscle weakness in her left leg were restricting her mobility even more.

We prescribed her low dose morphine every four hours--patients must take the morphine at regular intervals to prevent the pain from returning--and a double dose at night to ensure an uninterrupted night's sleep. We gave her bisacodyl tablets in anticipation of constipation, a common side effect of morphine, ketoconazole for oral candidiasis, and metronidazole tablets to crush and apply to the wound.

When I returned to see Rose a week later, the difference was striking. As we arrived, she was sitting up in a chair having her wound dressed. Her wound was no longer discharging and the inflammation had reduced. Rose seemed relaxed and in good spirits, and the tiredness in her face had gone. She laughed at me and "my mathematics"--her description of the pain scoring system--but reported that each of the her four pain types had improved with the morphine. The negative gradients of patients' pain charts, as pain that scored 4 and 5 decreased to scores of 1 and 2, was one of the things that most clearly illustrated the hospice's effect on people's lives.

Resources are severely stretched in Uganda's health infrastructure. Need is everywhere, but palliative care is a priority in a country so affected by premature cancer deaths and AIDS. People shook their heads when I talked about going to Uganda. "That will be very hard," they said. I saw misery on a scale that I've never seen before; it was shocking and desperately sad in equal measure. The impression with which I leave Hospice Africa is, however, uplifting rather than sad. I'll remember precious time claimed back from pain, dignity and state of mind restored, and people living their lives right to the very end.

Hospice Africa accepts students on electives. Contact Hospice Africa, PO Box 7757, Kampala, Uganda
(email hospug@africaonline.co.ug).