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Number 163 - April-May 2016
World Health Day is celebrated on 7 April, under the sponsorship of the World Health Organization (WHO). According to the WHO website, the theme for this year is: Beat Diabetes: scale up prevention, strengthen care and enhance surveillance.
The main goals are to increase awareness about the rise in diabetes and its staggering burden and consequences, particularly in low-and middle-income countries; and to generate effective and affordable actions to tackle the disease.
About 350 million people worldwide have diabetes, a number likely to more than double in the next 20 years. In 2012, diabetes was the direct cause of 1.5 million deaths. More than 80% of these occurred in low- and middle-income countries. Type 2 diabetes accounts for about 90% of diabetes worldwide. There are increasing reports of type 2 diabetes in children.
Unfortunately although there is good evidence that many cases of diabetes and its complications can be prevented with simple lifestyle measures, these are not widely implemented. Recommendations to prevent or delay the onset of type 2 diabetes are to: • achieve and maintain a healthy body weight; • be physically active – at least 30 minutes of regular, moderate-intensity activity on most days. • eat a healthy diet of between 3 and 5 servings of fruit and vegetables a day and reduce intake of sugar and saturated fats; • avoid tobacco use – smoking increases the risk of cardiovascular diseases.
Coordinated international and national policies are needed to reduce exposure to risk factors and to improve access to and quality of care.
Also this month, on 4 April, we celebrate the 79th anniversary of the foundation of MMM. Our Constitutions say that for MMMs, 'Their charism as medical missionaries places them in the world of health and medicine, for the missionary service of the universal Church.' We are asked to ‘constantly strive to promote the wholeness of all peoples and of their milieu.’ Raising awareness about health issues is an important part of our work.
In this newsletter you can read about two special women - one a new MMM Associate who has embraced the value of hospitality; the other a palliative care nurse who has experienced first-hand the reality of cancer. You can also read about the legacy of care handed on by successive generations of MMMs.
We wish all of our readers the peace and joy of the Easter season. Thank you again for your interest and support. We pray for you daily.
Sr. Carol Breslin, MMM
‘An eye for an eye will only make the whole world blind’ (Mahatma Gandhi).
Handing on a gift
Since the foundation of MMM in 1937, many people have worked with us as volunteers and lay missionaries, at home and in other cultures, bringing healing to people in great need. While we all gained through this experience, some of our co-workers expressed a wish to share our spirituality at a deeper level.
We formally embraced the MMM Associate Movement at our 1997 Chapter. The introductory handbook, Come, Let Us Listen, states, ‘We are now inviting others who also hear a call to a global healing mission to explore with us a new dimension of their Christian commitment in a way that would respect the uniqueness of their own vocation, their life choices, and commitments.’ The first Associate Medical Missionaries of Mary (AMMMs) made their covenants in the USA in 1999. Since then, over one hundred men and women in fourteen countries on six continents have become AMMMs.
'I have called you friends' (Jn 15:15). In February 2016, there was a gathering of MMM Associates at our Motherhouse when Theresa McDonnell-Friström made her covenant. An Irish woman, Theresa lives with her husband in Brantevik, Sweden. Before she joined MMM, Sister Ursula Sharpe worked with Theresa when they volunteered with Concern in Bangladesh. They later met in Uganda. Ursula told us how their friendship developed.
‘Theresa came to Bangladesh in 1973, a few months after I did. She worked as a secretary in Dhaka and then ran a secretarial school for Bangladeshi women. Because she was based in the Concern “motherhouse” she was always welcoming and available to listen to all our good and bad experiences. She had little treats for us when we came from “up or down country”, where there was little available.
‘Theresa moved on to other places where Concern was based and was a Country Director for some years. We met at reunions and kept in contact.
‘In the early 1990s the Irish Government opened an embassy in Uganda. Theresa arrived with the new ambassador to set up and run the office. By now I had joined MMM and was running a programme in Uganda for people with HIV/AIDS and their families in Masaka and Rakai Districts. Theresa came to visit and it was great to have her around again. She always came with her arms full of goodies and the Irish papers and did not mind our more spartan convent food! Her house in Kampala was our home, too, and we all enjoyed much hospitality there during the years she worked at the embassy.'
Moved with compassion ‘During this time the genocide occurred in Rwanda. The Kagera River, running from Rwanda through part of our work area, began to be filled with mutilated bodies. When the District officials requested our help I asked Theresa to come to see what was happening. It was a horrendous situation. She immediately came and mobilised assistance.
‘She also helped us MMMs with grants for small projects for both Kitovu Hospital and Makondo Health Centre. When she stayed with us she always joined the community for Mass and prayers.
‘Then Theresa met her husband, Gunner. What a great day we all had at her wedding! It was a huge Concern reunion because she was popular and never forgot her friends.
'When Theresa learned that her friends Moira and Eamonn Brehony were MMM Associates she requested to become one as well. Over a few months she learned about our charism and history. She applied for membership and was accepted but because of her husband’s ill health it was a few years before she was free to join. I was privileged to accept her covenant in our Motherhouse in Drogheda on 8 February 2016.
'Our forty-three years of friendship has brought us from Asia to Africa and back to Ireland, where we were once more united in sharing a common vision and charism.'
Living hospitality Our MMM documents say: ‘Hospitality is welcoming others in warmth and acceptance, generously providing them with care and kindness. As Medical Missionaries of Mary “wherever you are, whatever you do, let there be in your heart a space for others to be, so that unafraid, they may experience themselves as loved and so be healed.”’
Theresa shared some of her journey and how the value of hospitality has special significance for her.
‘The first time I can remember hearing about the Medical Missionaries of Mary was when Ursula joined. I worked with her in Bangladesh in the early 70s. My first visit to an MMM house was around 1984. I was working with Concern, based in Dublin, and was to go on a project visit to Sudan. En route, Sudan introduced new visa rules so I couldn’t enter and I was redirected to Nairobi. There I met Moira Brehony, who suggested that instead of hanging around waiting for my return flight to Dublin, I should go and visit Ursula, who was assigned to Kitovu in Uganda.
‘When I arrived in Kitovu, word had spread that I was handy with a scissors and there was a long line of Sisters waiting for haircuts! It was a wonderful introduction and welcome. The next day I travelled with Ursula as she went on her rounds with the HIV/AIDS outreach programme that she had established. We visited the new mission under construction at Makondo. In the following ten to fifteen years I had many opportunities to visit Makondo, and through Irish Aid to support some projects there.’
Sharing the charism ‘Through Moira and Eamon Brehony, and my own discovery of healing and the importance of forgiveness in the healing process, I learned about Associate MMM. As a result I came closer to the charism of healing. This brought me to the two-year Sacred Art of Living and Dying course at Our Lady’s Hospice and Training Centre in Dublin, where I also met Sister Helen Spragg.
‘In that course I learned that our attitude to illness can have a powerful effect on the extent to which illness or pain causes us to suffer. Reflecting on this brought me back to the MMM value of hospitality. In the past few months I’ve tried to offer hospitality to the new guest in our home, dementia. When I remember to do this, I experience its powerful healing.
‘Thank you for accepting me into the AMMM family! I came back to Brantevik with new air under my feet.’
A legacy of compassion: the Ian Jack Prize
A response to evolving needs In the early days of the HIV epidemic in Uganda, Sister Ursula Sharpe, MMM, initiated a mobile AIDS home care programme in Kitovu for people affected by AIDS and AIDS orphans. In the mid-1990s, Sister Carla Simmons, a physician, added a palliative care component to the mobile programme. Basic medical care and social support were provided to countless families.
Gradually the need grew for assistance to people with cancer, especially for pain relief. At the time, Sister Carla commented, ‘We offer this [palliative care] service to our own patients in the AIDS Mobile Outreach Programme and also to patients with cancer referred from the hospital. While the purpose of our programme is to care for patients and families who have been affected by AIDS, you couldn’t have a service in an area as poor as this without it being available to anyone who needs it.’
The World Health Organization (WHO) estimated that in 2005 more than 70% of all cancer deaths occurred in low- and middle-income countries, ‘where resources available for prevention, diagnosis and treatment are limited or nonexistent.’ This means that many people with cancer present in the late stages of disease.
Sister Carla noted, ‘We were very fortunate in Uganda that morphine was available for treatment of severe pain. Because morphine is a classified drug, an opiate, there are very strict laws about its handling, use and prescription.’
Other responses Doctor Anne Merriman established Hospice Africa Uganda in 1993. She said, ‘I recognised that unrelieved suffering was endemic in Africa, where less than five per cent of people with cancer could reach oncology services. The pain they suffered up to death was akin to torture and affected not only the patient but the whole family.’
As recently as 2014, WHO Cancer Country Profiles showed that in Uganda, with regard to cancer treatment services, for a total population of 36,346,000 there was one radiotherapy centre. Chemotherapy was also not generally available in the public health system, nor was community/home care for people with advanced stage cancer and other non-communicable diseases.
Training others to provide care, an important part of our MMM ethos, has multiplied the effects of available services. Handing over projects when staff are trained has also been a common experience. We handed over the mobile palliative care services in Kitovu to deeply dedicated local staff in 2013. One of these staff members was recently the recipient of a very special award.
Doctor Merriman explained, 'The Ian Jack Memorial Prize is given by Professor Barbara Jack in memory of her father. Barbara is Professor of Nursing and Director of the Evidence-based Practice Research Centre, Edge Hill University, in Lancashire, UK. She is a UK Hospice Africa Trustee and a visiting professor at the Institute of Hospice and Palliative Care in Africa (IHPCA). This is the degree-awarding arm of Hospice Africa Uganda.
'Barbara asked for this annual award to be given to the B.Sc. Palliative Care graduate who has overcome the most difficulties during the course, culminating in a successful degree. This year, of the thirty-four graduates in the degree or diploma from the IHPCA, Rose Nabatanzi was selected.'
Rose's story Anne Merriman continued, ‘Rose is a nurse whom we met twelve years ago. She was one of the first to take the Diploma in Clinical Palliative Care in Hospice Africa Uganda, becoming one of the first nurse-prescribers. Rose was working with Sister Carla Simmons in Kitovu Home Care. This is a model for Uganda because it is the only service for HIV/AIDS that has a separate palliative care team. The team can give time to each patient when they are critically ill or coming towards the end of life. Today Kitovu Mobile has more patients with cancer than AIDS. The AIDS death epidemic is reducing and the incidence of cancer is increasing.’
Carla told us how Rose came to join her. ‘I “head-hunted” Rose when I first started working for the Mobile AIDS Programme. I needed a registered nurse who would be eligible to qualify for the Long Distance Learning Diploma in Palliative Care. Rose was interested and well able for the study. Later, Rose married Damian, a secondary school teacher in the parish. They had four children: three girls and a boy. A wonderful wife and mother, her dedication to our patients was outstanding. She was always available - weekends and holidays. Even when she was sick herself, she cared for the patients she met in the hospital.’
It was intended that Rose would take over eventually from Sister Carla, but Rose developed cancer herself. In coping with radiotherapy and chemotherapy she learned at first hand the terrors of the life- threatened cancer patient.
The meaning of empathy Carla continued, ‘In fact, her sickness and all the experience of chemo- and radiotherapy, weeks with a nasogastric tube, gave her an understanding of what was happening to our patients.’
Her illness delayed her applying for the B.Sc. and she was still receiving treatment when she began her studies. Meanwhile, Carla had a series of health issues, including severe back problems. She eventually had to leave Uganda and was unable to return.
Anne Merriman wrote, ‘Sister Carla is greatly missed, both for her contributions to Kitovu and to Uganda as a whole, but she has passed over to a great lady. Rose has taken over the coordination of the palliative care section of Kitovu Home Care. She is also helping the Palliative Care Association of Uganda as a board member. Her service is of a high caring standard. International programmes and the Institute send our students to Kitovu for clinical training.’
On hearing that Rose had received the award, Sister Carla wrote, ‘Having to leave the Palliative Care Programme was heartbreaking, but knowing that Rose was there to manage it made it possible for me to accept. Now that she has her degree, I know that she will keep the programme going and continue her compassionate and skilled care of our patients.’
Congratulations, Rose, 2016 Ian Jack awardee!
P.S. During her studies, Rose delivered a baby girl who attended the final classes with her and was the darling of the students!
A legacy of bringing life
Some of the contributions of the Medical Missionaries of Mary to maternal and child health were highlighted at a recent ‘Historic North-South Spring Conference’ of the Irish Perinatal Society (IPNS). The meeting was held at Our Lady of Lourdes Hospital, Drogheda from 25-26 February 2016. Coinciding with the centenary of the Easter Rising, the theme of the conference was ‘1916-2016: Making the New Island of Ireland’.
In keeping with the mission of the IPNS to ‘increase the availability of up to date information for those working in the field of perinatal medicine’, the agenda focused on a number of topics significant for the healthy growth and development of a child in society.
The opening address was devoted to ‘The Importance of Growing Up in Peace’ by Ms. Jo Berry, daughter of Sir Anthony Berry, MP, who was killed in the IRA bombing in Brighton in 1984. Ms. Berry is the founder of Building Bridges for Peace, a charity launched on the 25th anniversary of the bombing. The organisation works to enable divided communities throughout the world to explore and better understand the roots of war, terrorism and violence - promoting dialogue and mediation as the means to peace.
Consultant obstetrician/gynaecologist Doctor Maire Milner spoke on the legacy of the Medical Missionaries of Mary and announced the Inaugural Ann Ward Medal Winning Presentation. Sister Ann Ward, MMM, now retired, was consultant obstetrician/gynaecologist at Saint Luke’s Hospital, Anua, Nigeria for many years. She was the recipient of an Award of Merit by the International Federation of Obstetricians and Gynaecologists and the Distinguished Graduate Award from University College Dublin for her ‘outstanding contribution in the field of medicine’ in relation to obstetric fistula. A special medal has been inaugurated by the IPNS to acknowledge her lifetime’s work. The Ann Ward Medal was presented to Doctor Victor Mukonka.
Drawing on a wealth of experience Sister Ekaete Ekop, MMM, gave a presentation entitled ‘Perinatal and Maternal Health in Sub-Saharan Africa’. Also a consultant obstetrician/gynaecologist with over twenty years' experience in Nigeria and the Republic of Benin, Ekaete is now MMM Assistant Congregational Leader.
In her background remarks she said that the rural obstetric patient/client in sub-Saharan Africa has characteristics and a socio-cultural context that begs to be understood, not judged or ‘corrected’. She said that the context of providing care is complex and that rural obstetric practice is an adaptive skill. A legacy of training has been left behind by missionaries.
The lifetime risk of maternal death, or the probability that a 15-year-old female will eventually die from a maternal cause, is influenced by the prevailing fertility rate, economic status, average parity, knowledge and us of family planning, available medical facilities and available information. The risk varies greatly from country to country. For example, the risk in Ireland is 1:1610, while in Uganda it is 1:47 and in Nigeria it is 1:22 (WHO, UNICEF, UNFPA, The World Bank, and the United Nations Population Division. Trends in Maternal Mortality: 1990 to 2015, WHO, 2015).
Ekaete pointed out that about seventy years before it became a global issue Mother Mary Martin identified the problem. In 1937, she founded the Medical Missionaries of Mary, setting up a powerful response that spread to many sub-Saharan countries, including Angola, Benin Republic, Ethiopia, Kenya, Liberia, Malawi, Nigeria, Rwanda, Sudan, South Sudan, Tanzania and Uganda. This was fifty years before Safe Motherhood was launched by the World Health Organization (WHO). Choices and consequences Ekaete continued, 'From its inception MMM has been in the health scene in Nigeria. We made a deliberate choice to be with the under-served, which led to other choices. Our Sisters and colleagues had to be adaptable and flexible. As practice evolved, some skills were hyper-developed and we learned to rely on instinct and our clinical acumen and dexterity. Decision-making had to be done in the context of complex realities. A great team spirit developed, involving every cadre of staff, including watchmen and drivers. We had a specialty in multi-tasking!
'In wishing to respect local beliefs and often having to deal with resource limitations, we have to balance what is the ideal with what is possible. We have to ask, "What does the woman accept? What are her options and what are the alternatives? What will keep this mother and baby alive and healthy?"
'Many women in rural Nigeria have an aversion to Caesarean section, which is, often erroneously, not perceived as a real birth; to admission in hospital, especially a prolonged stay; to blood transfusion; and to induction of labour. She values a normal delivery; preserving her ability to have children; mixed gender (having a male child); and having many children.
'In respecting a woman’s situation and beliefs, using a compassionate approach and listening often results in a better outcome for the mother and her baby than trying to impose what is recommended in ideal circumstances. Otherwise a woman at risk will not trust the hospital personnel and will try to deliver at home, usually with disastrous consequences. One of these consequences is very high rate of obstetric fistula, with more than 10,000 new cases every year in Nigeria.
'“For each woman you take to theatre [for a Caesarean section] there are ten more in her village who will refuse hospital delivery” (Sr. Deirdre Twomey, MMM, FRCOG).'
Building trust Ekaete stressed the importance of forming a relationship with the mother, not estranging her by insisting on an ideal solution that she cannot accept. The aim is to keep her alive. Often, if we allow the pregnancy to continue for as long as possible, with strict monitoring and intervention only when necessary, we will win her trust and the chance of her giving consent for a procedure is higher.
If a woman in a rural area goes into labour at home, she will be under pressure to deliver there, usually with untrained assistants. Another obstacle to hospital delivery is often lack of transport, especially at night. In view of these realities, in the 1960s we began to provide pre-delivery accommodation for women with high-risk pregnancies. They formed a small community in the hospital. This practice has only recently been named by WHO as ‘birth preparedness’. For the missionaries, it arose from our experience that in dealing with these mothers it was literally ‘do or die’.
Forerunners of good practice 'While in recent times, partnership with government has narrowed the gap a little, the medical team in rural practice is dealing with a paucity of qualified personnel. Rural areas don’t provide incentives for career progress and raising a family.
'Training, a distinctive feature of MMM health services, developed in many cases as a survival strategy to meet needs. It involves all staff cadres, on-the-job instruction; establishing a culture of training; having standard operational procedures, and widening skills, e.g. staff learned to assist at surgery and monitor vital signs. Nurse aids were trained to recognise emergencies. They in turn trained new staff members. How else would a 53-bedded maternity hospital with few qualified staff manage over 3,500 deliveries annually?
'Our tradition of training others has ensured that the work continues far beyond our scope. The first VVF hospital in Nigeria was pioneered by Sister Ann Ward in the 1980s and was the third of its kind worldwide. Doctor Upuji (RIP) was one of her trainees and continued her work after she retired. The first and only federal government-owned VVF hospital in Nigeria (100-bedded) was pioneered by Prof. Sunday Adeoye, who did part of his residency in an MMM hospital and learned VVF surgery from Sister Ann.'
In conclusion Sister Ekaete said, ‘Our experience has shown that traditional medical training does not prepare one for rural obstetrics. It is a "specialty" that is only developed painstakingly in the field with few or no templates. I hope I have been able to convey something about maternal and perinatal health in Nigeria from the standpoint of those involved where it matters: the daily heroic efforts and usually unsung commitment of those who live and work and celebrate among the under-served and marginalised.’
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