Luke Coppen talks to Anne Merriman, the doctor who pioneered palliative care in Africa after a near-death experience of her own
Dr Anne Merriman hurtled down the M6, as she did every weekend. It was 1992 and she was returning home to Liverpool after a heavy week as the locum medical director of a hospice in the West Midlands. When she got to the Gravelly Hill Interchange, better known as Spaghetti Junction, she was shocked to see a police car ordering her to slow down. She pulled over and wound down the window as a burly policeman walked over. He said that he had stopped her because she was zigzagging all over the lane. Noticing that she was tired, he said he wouldn’t give her a ticket if she promised to down a cup of coffee at the next service station. As she drove off Dr Merriman realised that the officer had probably saved her life.
If she had crashed that day it’s likely that thousands more Africans would have died without adequate pain relief over the past 20 years than have actually done so. This is because the very next year, 1993, Dr Merriman founded Hospice Africa, a charity that has provided palliative care to thousands of cancer and HIV/AIDS patients in Sub-Saharan Africa.
When Dr Merriman first arrived in Africa, in 1964, she was wearing the simple white habit of the Medical Missionaries of Mary (MMM). When she returned in 1994 she wore colourful, flowing print dresses. With support from Cafod and Sciaf, she provided palliative home care in the residential section of Nsambya Hospital in Kampala, the Ugandan capital. The first person referred to her was a young woman called Margaret who was suffering from rectal cancer. She was also struggling to run a small shop and coping with heartbreak after her lover abandoned her. Dr Merriman was able to lessen Margaret’s physical pain with oral morphine. In Audacity to ove, a book telling the story of Hospice Africa, Dr Merriman writes that, despite her lover’s cruelty, Margaret kept his picture in her Bible and prayed for him daily until she died. “She passed away three months after we started seeing her. But due to the relief we gave her she was able to work in her shop up until the day of her passing.” Margaret was one of the fortunate ones. In Britain, when you have a headache you pop a paracetamol. In parts of Africa you would be lucky to have a paracetamol during late-stage cancer. Paracetamol is often the only analgesic, or pain reliever, available because African governments strictly regulate stronger opioid analgesics such as morphine because they fear mass addiction. In some countries this “opioid phobia” is so strong that virtually no morphine is imported. “Even if the president gets cancer pain he will get no analgesia,” a World Health Organisation official told the New York Times ournalist Donald McNeil in 2007. According to McNeil, ust six rich countries, including Britain, consume 79 per cent of the world’s morphine. The poor and middle-income countries that account for 80 per cent of the world’s population use around six per cent.
When Dr Merriman began working in Nigeria in the mid-1960s the hospice movement was in its infancy. In 1967 Dame Cicely Saunders founded the world’s first purpose-built hospice in London. When Dr Balfour Mount introduced the movement to Canada in the early 1970s he coined the term “palliative care” because the word “hospice” had the negative connotation of “death house”. Dr Merriman insists that “hospice” means “a philosophy of care”, rather than “a building where you put people that are dying”. Her life’s goal is to establish a palliative care network across Africa, inspired by Dame Cicely’s vision but adapted to the continent’s culture and economic conditions.
Dr Merriman doesn’t explain in detail in her book why she left the Medical Missionaries of Mary after 20 years. She seems to have sensed God calling her to a different kind of mission. When we corresponded recently by email I asked if she still saw herself as a missionary.
“In a way,” she replied. “As an MMM we passed on our ethos through our integrity and services. We did not proselytise. It is the same today for me.” After she left the order Dr Merriman worked in geriatric medicine in Liverpool and Manchester. In 1984 she moved to Singapore to teach at the National University. There, she discovered that hospitals routinely sent patients home when curative therapy failed, often to die in intense suffering without powerful forms of pain relief like morphine. Together with local pharmacists, she was able to achieve a breakthrough, developing a formula for pure liquid morphine. Dr Merriman and a small team of nurses began to distribute this cheap and powerful analgesic to those dying at home. She realised that she now had a model for affordable and accessible pain relief that she could export to Africa.
But it would not be easy. In 1990 she took charge of Nairobi Hospice in the Kenyan capital. She soon found her work hampered by bureaucracy. The red tape was so knotty that she had to leave. She returned to Liverpool, and at that low point nearly lost her life on the M6.
But Dr Merriman made one last effort to fulfil her dream. Following a feasibility study in five African countries asking for a service like the one at Nairobi Hospice, she settled in Uganda and her work began to flourish. In 1998, just four years after she returned to the continent, Hospice Africa opened a small centre in a poor, rural area northwest of Kampala and an innovative mobile hospice clinic in an area south-west of the capital. Crucially, the Ugandan government allowed nurses and clinical officers trained by Hospice Africa to prescribe morphine. Dr Merriman and her team took liquid morphine to patients in 500ml recycled plastic bottles. Each bottle contained 500mg of morphine powder and a dash green or red dye to indicate whether it was weak or strong. One bottle cost less than a loaf of bread and lasted the average patient 10 days.
In 2000 Dr Merriman sat in a Chinese restaurant in London with two leading figures at the Diana, Princess of Wales Memorial Fund. At the end of lunch the waiter brought fortune cookies. Dr Merriman opened hers and read the message aloud: “You are about to come into a fortune.” Sure enough, the Diana Fund gave Dr Merriman an annual grant of £100,000 to take palliative care to other African countries.
Dr Merriman is clearly resilient. But the relentless fight against bureaucratic inertia has tested her. Towards the end of Audacity to Love she asks herself a startling question: “So why haven’t I had a nervous breakdown?” The reason, she tells me, is her trust that she is “continuing the work of Christ”. She also finds daily happiness in “seeing a patient go from despair to joy in living out the final days of life at peace with the family, and with their God”.
“We never have to say: ‘There is nothing more we can do’,” she explains. “There is always something we can do to help if we are trained and have the love to give.” Hospice Africa Uganda is now the model for palliative care elsewhere in Africa. It supports 1,500 patients in Uganda and initiatives in eight other African countries. It has trained 7,800 people so far and health professionals are flocking to its Institute of Palliative Care for Africa in Kampala.
Dr Merriman will be 77 in May, but she is still driven to realise her vision. I ask her to imagine what she might accomplish if she had limitless resources and no bureaucratic obstacles.
“Pain control for all, without any stockouts of morphine and other medications,” she says. “I would like to see all in Africa able to die in peace, not only those with cancer and/or AIDS but all who die. This can be accomplished by the training in palliative care for all health professionals and communities.
“We need to respect death, and come away from this killing and undignified dying prevalent in Africa today.” For further information, to buy the book Audacity to Love: The Story of Hospice Africa by Dr Anne Merriman, or to support Hospice Africa, please write to Professor Ken Holden, Hon Treasurer, Hospice Africa UK, 67 Menlove Ave, Liverpool L18 2EH. Visit Hospiceafrica.org