By John Davies MBA

Chief Operating Officer, COMPASS-Ghana

Ten weeks in and I am minded of many a Christmas afternoon. When we were young, the film families watched after a wholesome lunch, would be the “Sound of Music”. It’s a long film.  Julie Andrews plays a novice nun “Maria”. She is sent by the Abbess to look after the Von Trapp family. She is falling in love, frightened and confused; she leaves the children to return to the Covent, to seek refuge, solace and her faith. The Abbess kind and thoughtful consoles her and tells Maria she must return; God will not love her less, looking into her eyes she tells her “As one door closes another will open”. Maria returns to the Von Trapp family. She falls in love, the children are safe, they live happily ever after, and the music continues to resonate even today. The music the Abba before “Waterloo”. How right was the Abbess. How beautiful and tuneful the music.

This is how we feel, our deep disappointment and frustration is turning into excitement and dare I say it – an adventure. We have on this journey, often been told by wise individuals, well versed in the complexity of Africa, to take one step at a time. To address disappointment and success in equal measure and to reflect and breathe often.

COMPASS-Ghana set out on a journey to enable palliative and end of life care.  Allowing this essential and timely care to become accessible to all and in particular the hard to reach and resource poor communities. This vision has not diminished, in fact it has been burnished, it glints in the powerful sunlight of the equator.  But the task is far harder than we could have ever imagined.  

The challenge facing us is how best to transfer our knowledge in a way that is transferable, substantive, resilient and enduring. We are not interested in developing parallel models but emboldening and developing what is already there and to help coordinate what is to come.

Our focus is to support the development of a sustainable resilient capability, one that creates a “whole system” approach, not just one-off projects – We might well celebrate an immediate task well completed, but experience tells us that it will not be there tomorrow. This has been the learning of the last ten weeks.

Ghana is a proud and noble land deeply steeped in tradition. The Ashanti region is a Royal kingdom and their King Otumfuo Osei Tutu II, and his wife Queen Julia attended the coronation of King Charles 111.  Laughter, prayer, and music resonate around this kingdom. A kingdom that proudly remembers the “bloodied nose” given to the British.  Traders sell their wares and the cramped “Tro-Tro” stop and drop off passengers only to pick up new ones as the conductor (the “mate”) screams out the next destination. You dither at your peril. We have yet to summon the courage to enter the cramped vehicle. We watch and smile. They take pictures, we regally wave. The soft, tread bear tyres carry their load onwards.

Tradition, custom and beliefs influence everything. Death is a stigma that few talk about but celebrate with a zeal afterwards. This is a beautiful yet harsh land. We are learning and learning fast. How do we reopen the door, that appeared to be closing?

Last time I wrote about time and that theme still resonates. In marketing they talk about “The Product Adoption Curve” – Innovators (enthusiasts), Early adopters (Visionaries), Early Majority (Pragmatists), Late Majority (Conservatives), Laggards (Sceptics).

We were asking ourselves, where are the innovators there are so many conservatives, but breathe deeply …they are appearing.

Palliative care is not new. Dame Cicily Saunders (1918 to 2005) founder of the palliative movement – transformed the way society viewed care for the dying.  “You matter because you are you. You matter to the last moment of your life, and we will do all we can to help you not only to die peacefully, but also to live until you die” It is a simple but powerful mantra, one I would often quote at a Hospice team meeting. We need to “dare to dream” and believe in ourselves.

In the UK there is a document called “Ambitions for Palliative and End of Life Care – A National Framework for local action 2021 to 2026”. It is not new and is refreshed regularly by the National Palliative and End of Life Care Partnership. Strangely for the National Health Service, it is a very readable document. It sets out six ambitions – I love that word, ambitions.

• Each Person is seen as an individual.
• Each person gets fair access to care.
• Maximising comfort and wellbeing.
• Care is coordinated.
• All staff are prepared to care.
• Each community is prepared to help.

Ghana has its own overview – contained in section five of its National Cancer Strategy 2013 to 2016. It is two pages and a table. Yet it is not very different.

How do we help open that door? How do we make our intent simple and compelling?

Exciting new partnerships are emerging, ideas are being discussed, that are bold, innovative, and patient centric. It has been a challenging but enthralling few weeks.

Finding an analogy that works to describes a whole system approach/perspective is interesting. I refer to the concept of having a canvass with a faint picture as a backdrop, which will come to the fore once all the overprinted dots are joined. The reality it does not really matter in what order each dot is chosen, of course it helps, but what really matters is that the dots are interrelated and mean something to the picture – the plan.  It is something to work toward to, to adapt and really treasure on its completion. In terms of our journey, right now we are very much into the understand piece. To our great satisfaction we have made significant strides and the closed door is open once again.

As to the team well life in Ejisu, our new home is interesting and a contrast to Patasi.  Significantly more rural and quieter.  Today the rain has been Monsoon like. The electricity surprisingly reliable and with our excellent broadband and VPN – the TV is a great comforter – we have discovered – late to the party – the adventures and tribulations of Dr Max and his team in “The New Amsterdam”, that is until the electricity goes off.  At which point a deep suffocating darkness enfolds you.  A darkness like forest block B on Sennybridge (A military training centre located in Mid Wales = United Kingdom) – if you have never been there – close your eyes, really tight. You are there.  But in Sennybridge you either cut yourself with a tin opener as you try to open a tin of cold baked beans – no cooking in the block!!  or poke out your eye on a pine twig. Here in Ejisu, there is a sudden unexpected darkness, there is no backup generator…oh and silence!!!  However, there is something magical about warm rain, schoolchild like, in the darkness, we dance in it.

Over the last few weeks, we have also been fortunate to host Mr Alipitio Boo, a specialist nurse studying to become a Specialist Haematologist. He comes from a small village in the Northern region.

Boo has taught us many things about real life in Ghana, it was a very special journey, and we miss him.  He taught us not to be afraid of rice and introduced us to Jollof – with chicken, beef, and goat, and just in case we missed it – with chicken beef and goat.  Cassava, Red Red, Kelewele and fufu. The ultimate for Boo is Tilapia – in our case BBQ Tilapia, bought with a head torch on the high street. Apparently, it is a Friday night delicacy shared by many over a beer. I tried to point out to him that our late dearly loved Queen Mother nearly choked on a fish bone. A comment unusually lost in translation as I pulled – using my right hand, thumb and forefinger the 600^th bone. Tilapia is, served with a spicy fresh salad, which is delicious (think Dona Kebab). But apparently not nearly as delicious as the fish head, consumed as a whole…with bones, that crunch. There were three of us, so two fish heads were saved in the fridge. I make no comment.

Our Golf at the Royal Kumasi Golf Course continues apace, we have decided that at our age we will volunteer /work for four days and enjoy ball hunting every Wednesday. The Caddies queue up. We have heard we are too generous with our tips; we seem to be charming but incompetent, which provides a huge degree of humour…which we also enjoy. Today I was supported by Mr Champion and Katie by Mr Bismark, and we played Texas two ball. it was great fun. We are getting better.

We also met our first ex pats.  A lovely couple from South Africa, who can obviously play golf, they just have that aura – the cap is branded, and the glove is on the correct hand. When Louise appeared at the club house, I was eating, ravenously, a bacon and egg sandwich, Katie having purchased it for me from the club bar. Almost finished, faster than a fish head, Louise asked me how it was. With my mouth full, Katie replied watching me – “I think rather delicious. “Good, as I make them” was her response with a bright grin.  Note to self – always be aware of one’s surroundings you never know who you are talking to, I shook my head in eager acknowledgement.

Politics is also never far away.  No sooner had Louise left then an elder gentleman, a mentor for others joined us. There followed a very sensitive 30 minutes of delicate responses and debate. There are many challenges here, many sides and strong opinions. Caution is advised, but democracy is very much alive and robust.

So where are we ten weeks in? We have learnt resilience and how to manage and address setbacks. That language is important – “yes please” does not always mean “yes”. That the need for palliative and end of life care is as strong now as ever, that a bottom-up approach will yield greater impact and influence. That there are many dedicated professionals who care and families who love. To never give up and to stay focused on the dream. That there are many moving parts, often oblivious of each other, but once sighted, together will make a real difference. That Ghana is an amazing country where Status and Survival are unhappy bedfellows. Where poverty is cruel and indiscriminatory.

The next month will be interesting, we certainly feel that door is opening, and the hills are coming alive. With small steps we will make progress – community care is a reality. This will be a long journey and will continue long after we are gone.