Millions of bucket lists …
I recently had the dubious pleasure of watching the Hollywood actors, Jack Nicolson and Morgan Freeman, traverse the Kenyan savannah in a four-by-four car whilst singing a discordant refrain from The Lion Sleeps Tonight in their poignant film The Bucket List. As the song faded, I found myself reflecting on the concept of ‘the list’ and its applicability to the average African with a life-limiting illness.
The ‘bucket list’ itself is basically a list of desirable things a person wishes to fulfil before s/he ‘kicks the bucket’, a colloquial expression for the act of dying. Nicolson and Freeman, unlikely and comical bedroom partners in a private hospital’s cancer ward owned by the corporate billionaire played by the former, drawn together by desperately poor medical prognoses, vow to realise an end-of-life list that includes travelling the world to view the splendour of the Egyptian pyramids and the Indian Taj Mahal, riding a motorbike along the Great Wall of China, and attempting (albeit unsuccessfully when confronted with adverse weather) to climb the mountains of the Himalaya.
But what, I thought, would be a typical bucket list for an average African? An elderly man diagnosed with HIV/AIDS who is unable to access antiretroviral (ARV) therapy at his local hospital? A divorced mother with a delayed confirmation of cervical cancer in a country with no effective chemotherapy service? Well, clearly nothing comparable with much of the list pursued by Nicolson and Freeman.
Rather it may be for those essential components that comprise the end stage of many people’s lives: for example, effective clinical care, relief from pain, spiritual guidance and support, alleviation of worries regarding the bereavement process, and the comfort of knowing that the needs of those who are left behind (especially the children) have been planned for. And this is exactly what each and every palliative care service should be delivering – or at least aiming to deliver – on the continent, no matter how significant and daunting the challenge.
Confirmation of this is gleaned from every home visit performed by a palliative care worker. 
For example, on a recent visit to an isolated rural home, served by Catholic AIDS Action (CAA), on the outskirts of the town of Outapi, in northern Namibia, in the safety of her traditional kraal homestead, I met Mama†, an emaciated HIV+ woman whose skeletal appearance and weary demeanour belied her 49 years of age. She smiled humbly, grateful for the services provided by CAA, as she quietly explained to her volunteer worker in Oshiwambo, the language indigenous to the region, that she was experiencing appetite loss and bedtime diarrhoea. I left Mama slightly comforted by the fact that she was at least receiving oral rehydration solution and paracetamol, the latter to address the ear pains she was experiencing.
Her plight, however, was not as desperate as that of others; her husband and five children (none of whom were employed) were supportive of her diagnosis, even if the former refused to have a HIV test, and she was scheduled to start ARV treatment the following month. Moreover, her plight is compounded by the nature of rural Namibian society, with family kraals separated geographically from their neighbours, and Namibia’s low population density (i.e. 2.2 people per km2 in a country estimated to have a surface area of nearly 825,000 km2), both of which render the effective delivery of the services she needs problematic. However, no matter how apparently intractable these problems are, solutions must be found so that the care people like Mama need is delivered.
The Bucket List is a moving, delightful treatise on the acceptance of death and the affirmation of life. For example, in the face of his own mortality, as he lays dying on his hospital bed, his cancer now at an inoperative phase, Freeman unfolds a piece of paper that explains the distinct odour that emanates from the exquisite and highly expensive Kopi Luwak coffee beans that Nicolson enjoys ostentatiously consuming. Freeman’s eyes slowly begin to crease with humour as he describes the way in which the omnivorous Asian Palm Civet first eats the coffee berries off the bushes in the Indonesian Archipelago, before excreting the partially digested bean. Local people, he continues, then harvest the beans (with their coating of gastrinal juices) from the civet’s excreta, light roast them, and then export them to their wealthy, adoring (and ignorant) customers. Freeman, with a mental image of Nicolson’s revered beans passing through the rectum of an exotic wild animal, bursts into hysterical laughter.
Ultimately, both men die, at peace with themselves and the world they leave behind. We in Africa, as do those who practise palliative care in other parts of the world, have a human and moral obligation (notwithstanding our occupational responsibility) to ensure that what remains of a person’s life is imbued with as much quality, goodness and celebration as is possible.
The existing disease burden in sub-Saharan Africa has resulted in millions of bucket lists, each one as important as the next for each individual who composed their own. We cannot help fulfil bucket lists that remain in the domain of the rich and famous; but we must aim to tick those items off the list that we can and should be providing. It is our raison d’etre after all.
† For this article, ‘Mama’ is used as a pseudonym.
To learn more about The Bucket List, click here.
Author
Richard A. Powell, M&E and Research Manager
Contact: Richard A. Powell
Postal address: African Palliative Care Association, P.O. Box 72518, Kampala, Uganda
Email: tony.powell@apca.co.ug