Prof Anne Merriman MBE, MCommH, FRCPI, FRCP, born in Liverpool, graduated from UCD in 1963. Having completed initial medical training in International Missionary Training Hospital in Drogheda, she worked as an MMM in Nigeria and continued to train and work in the UK, Ireland, Southeast Asia and Africa. She is widely regarded as one of the leaders in palliative medicine internationally. She introduced palliative care to Singapore and founded Hospice Africa. She also introduced hospice care to Uganda and created the ‘Merriman Model’ of palliative care. She was also instrumental in introducing affordable oral morphine for dying to the continent. Her awards and honours include Honorary Fellow at UCD School of Medicine (2007), an MBE for her contribution to health services in Uganda (2002), the Irish Presidential Distinguished Service Award (2013), a Nobel Peace Prize nomination (2014) and a UCD Alumni Award (2016).

Can you tell us a little bit about your career and your time in UCD?

I was born in Liverpool of Irish ancestry on both sides. I told my Mum when I was 4, that when I grew up I was going to go to Africa and I had to help the sick children. She was receiving a magazine called “Echo from Africa” which told stories of the missionaries and pictures of sick children.

I hoped to become a nurse, but then I joined the Medical Missionaries of Mary (MMM) at 18. Here was a means to reach Africa. After spiritual training, I was designated for two years in the medical laboratory (on my own) where I learned a lot about disease, and then was asked to do medicine. This brought me to UCD and eventually fulfilling my dream to help the sick in Africa.

The MMMs added to the deep spirituality from my parents and has stood by me ever since. Love of our loving God, shared across all religions and giving solace to the suffering, is essential and so necessary in Africa still. We, the carers, must be ready to bring each one through, on their own road. To those who believe and those who do not, we are there to bring peace. We are all spiritual beings and when the spirit leaves the body, it no longer needs a doctor, a lesson we often fail to learn as medics.

I enjoyed UCD so much. I lived in MMM House of studies in Booterstown with about 20 MMMs who were training to be doctors, pharmacists and nurses. It was a very happy but hard-working time. We cycled in, initially College of Sciences, then Earlsfort terrace and then to our respective teaching hospitals: mine was the Mater. Of course as Sisters we could not take part in the social activities of our classmates. We were also human beings so that did not stop us falling in love, but all that had to be suppressed! In my final year, I did well in obstetrics and gynaecology and wanted to specialise in this, but it was not to be.

During my time in Rosemount, the MMM house of studies, I had a lot of time with Mother Mary, the founder of the order. She had such a heart for the sick and suffering, knowing them and giving them holistic care. I realised later on that this influenced me to move into internal medicine, then geriatric medicine and finally palliative medicine.

But before my career progressed through these specialties, in 1964, I was placed in a big hospital in Nigeria, where I learned to do surgery, obstetrics and gynaecology, paediatrics, tropical and general medicine, in a difficult area.

After the Biafran war, I had a year in a smaller hospital where I was the only doctor and I only had 5 nurses for 100 beds, having 200 patients. It was a difficult time and many stories could be told of the difficulties with soldiers demanding treatments ahead of the poor which I could not entertain. Being the only doctor I narrowly missed being put in prison.

The years from the start of the war to 1970, I was back in Ireland with ill health. It was there I took the Irish and later Edinburgh Memberships and eventually became Fellows of each College (RCPI and RCPEd). Leaving the MMMs in Nigeria in 1973 was one of the hardest decisions of my life but God talks to us through our life events and my mother was sick and needed care. I returned to Liverpool where I joined the first UK University Geriatric Medicine team and had to learn Liverpool culture as well as scouse, the accent of my youth!

It was working in geriatric units that I came upon “bad” deaths and turned for help to palliative medicine. I managed to get Dame Cicely Saunders to come to my last hospital appointment in Liverpool, and she spent a day with us. It was so popular we were turning carers away at the door. This was 1981. Palliative care only commenced in Liverpool in 1993, the same year we commenced Hospice Africa in Uganda.

Teaching was part of my work from when I set foot in Nigeria and I have continued ever since. After my mother died, I took a Master’s in International Community Health at Liverpool School of Tropical Medicine, with my research in India, (an experience documented in my thesis, never to be forgotten) and then was advised to go to Malaysia or Singapore as these were safe enough for a single (good looking) lady like me, now on her own without the safety of a community.

It was here that I found myself called to see patients in hospitals who had come to the end of the road, having failed curative therapy which was state of the art in Singapore at that time. These patients were going home in severe pain with no relief. When we went to the pharmacists, at National University Hospital Singapore, to see if we could get morphine, we found they had morphine powder in small quantities to make up “Brompton Cocktail”. This was a mixture designed in the Brompton Hospital in London and contained morphine, a sedative, an antiemetic and the local brew... The small amount of morphine could not be titrated against the pain, as when the patient was drowsy it was hard to tell if it was due to morphine or the other ingredients. Often the sedation just kept the patient unable to complain of the still unrelieved pain.

Our new pure morphine contained only 3 or 4 ingredients. The cost was so cheap, the price of a loaf of bread for 10 days treatment. It was said to be easier than making a cup of coffee, as we made it at the kitchen sink for 17 years before obtaining a manufacturing unit at HAU, to make it for all in need in Uganda.

In Singapore, this was the start of Hospice Care Association (HCA), who now are one of the best in the world and just celebrating 30 years since it was legally established in 1989. In 1989, I was invited to attend an interview for the newly formed and impoverished Nairobi Hospice. I was delighted to be returning to Africa, this time with palliative care.

Can you tell us a bit about your work with hospices in Africa, and how this has changed over the years?

Palliative care has a different ethos and approach to patient care which is so misunderstood in traditional curative medicine. I found in Nairobi that the bureaucracy of the National Teaching Hospital was alive and well in the newly formed Nairobi Hospice and after one and a half years, teaching and demonstrating palliative care approach, I was being opposed particularly from some board members. After taking legal advice, I was advised to resign.

In the meanwhile I had written an article for “Contact” for an edition to be edited by Dame Cicely, at her request, on our work at Nairobi Hospice. I just described the difference we made to one patient. I started receiving letters from 7 different African countries, asking me to help them do what we had commenced in Nairobi now that we could control severe pain. The vision for Hospice Africa was born. After a year in UK working as Locum Medical Director at two hospices, forming a board and getting a constitution, we were ready to move onto a feasibility study in four countries, followed by selecting Uganda for the model and the commencement of Hospice Africa Uganda (HAU).

I owe the initial success of HAU to the first Ugandan nurses who joined me. I had come to the UK with a dedicated nurse Fazal from my team in Nairobi. My first nurses taught me so much about the culture and how to deal with difficult situations, with patients and families. Small teams work so well together. We depended on friends to loan us premises in Uganda for the first year until the Irish Government bought us our first home and renovated it for us.

Can you tell us a bit What is a typical day for you?

I am now 83 and not able to get around as I used to. Having had cancer and a heart attack in 2018 has set me back. I spend more than 8 hours a day in communication, either email or other means. I am called to meetings and I attend day care whenever I am well enough.

My role as Director of International Programmes keeps me on emails a lot giving advice. I am also writing 3 books and still have not had time to get the first one off the ground. I also meet with my team which consists of only 3 nurses and 1 driver. Francophone Africa is changing a lot and interested in palliative care at last. My two Francophone nurses are very busy visiting French speaking countries. We also run two training programmes here a year, one in English and one in French. They are for initiators or those just beginning palliative care in their countries. It is a 5 week course and consists of 2 weeks class teaching and discussions, 2 weeks clinical training in the home at the bedside and finally one week training of trainers to teach others, to be advocates and hopefully run a service adapted to their culture and economy. I still teach a lot on these programmes. I communicate a lot with our volunteer doctors, many are UCD and other NUI graduates. They are so generous and dedicated. They come for 3 months to up to 2 years, funding themselves. We are so grateful for the Irish understanding meeting the needs of the poor and the suffering.

What is the Merriman Model?

It is a model for a continent, based on a model for one country. It focuses on clinical services combined with teaching. Our vision was and is “Palliative care for all in need in Africa”. This can only be reached through an excellent service adaptable to culture and economy.

The Merriman model includes the ethos which we designed for Africa but should be incorporated into ALL caring services, not only palliative care. I could write a whole chapter on this and will do in the present book I am writing on African Palliative Care. The three pillars – context, outcomes and hospitality. It holds the patient and family at the centre of all our decisions and all we do.

What are the biggest challenges you face in your daily work?

Financial support is the oil that keep us going. From the start, when we came to Uganda with enough money for 3 months for a team of 3, we have been on the knife edge due to lack of funding. Today is the worst ever. We are cutting back on numbers of patients and the extent of our services. This sometimes grates against our medical Hippocratic oath and our ethos for Africa. Our clinical teams are struggling to do all they can for our patients on limited funding and reduced salaries to keep going.

Furthermore, as we try to work together with those organisations we have founded to help African palliative care move forward, there remains a struggle as we are all seeking funds from the same pot of money. Palliative care is now the lowest priority in health. I find the terrible suffering here from untreated cancer and poverty, to be overwhelming. The richer countries do not seem to care to help anymore.

What advice would you have for medical students and doctors in Ireland?

Please come and see what we face daily. Our Ugandan palliative care teams are so caring and ready to go the extra mile to bring comfort and peace to our patients. But the suffering due to nontreatment, cultural beliefs, late referrals and poor medical treatment, only prolongs their suffering.

Remember as doctors we are called to be carers more than curers. As David Tasma said to Dame Cicely in 1948: “I want what is in your mind and in your heart”. Are we ready for this?

What do you think are the biggest differences between palliative care in Africa and in the different countries where you have worked?

Money. It takes £1M a year for us to cover 2,000 patients from our three sites and to support our Institute with gaps from lack of scholarships, to teach the leaders of the future. In the UK 10 patients in an in-patient hospice costs the same £1M.

What do you think your greatest career achievement has been, and what would you like your legacy to be?

I was 57 when I started Hospice Africa, with the help of many faithful friends. I see that my whole life was leading to this calling to help the suffering of Africa. My suffering, both in my own life and in our development as a Hospice, is now helping me to help others.

Perhaps the greatest achievement was seeing Uganda recognised as the best and only country in Africa with integrated palliative care by WHO and WHPCA in 2014. In 2015, it was noted to be the second best place to die in Africa by the Economist (Lien foundation) survey. Knowing this is due to affordable oral morphine being available making holistic care possible. Also increasing prescribers where there is no doctor, so that nurses specially trained in palliative care can prescribe morphine. Uganda was the first country to make this in law by changing a statute in 1993.

My hopeful legacy is that our ethos penetrates all the carers in the world, both professionals and non-professionals, (hands on, policy makers and the rich!) so we can help each other both by our care and the decisions we make. This will make us true carers with the hearts to move mountains, to help the suffering.