Working as a doctor in Singapore in the 1980s, Anne Merriman saw firsthand the agony that poor, terminally ill patients suffered after being released from the hospital. Treatment for pain, she discovered, was a matter of economic privilege, much like access to health care.
The cost of intravenous morphine was prohibitive for many of her patients. So she came up with an alterative: powdered morphine.
At her behest, a pharmacist at the National University of Singapore, where Dr. Merriman taught, developed a formula with just three ingredients: morphine powder, water and a preservative. The cost was a fraction of that of intravenous morphine. And the simplicity of the formula meant that, unlike medical cocktails containing sedatives and alcohol, it could be quickly adjusted and mixed for each patient to take home.
For Dr. Merriman, a former nun who would go on to expand palliative care in the developing world — introducing a replicable, culturally flexible model of hospice to Africa, treating nearly 40,000 patients and training some 10,000 medical professionals across 37 countries on the continent — that small innovation was, she later wrote, “a game changer.”
Dr. Merriman died on May 18 at her home in Kampala, Uganda. She was 90. The cause was respiratory failure, her cousin Chris Merriman said.
Although hospice centers already existed in Africa when Dr. Merriman began working in Uganda in the early 1990s, she envisioned an affordable model of hospice that could be adapted to various developing countries.
At the time, the AIDS crisis was at its peak. About 30 percent of the population of Uganda was H.I.V. positive, and the cancer rate, as a result, was climbing. Average life expectancy was 38 years. The country had recently emerged from a violent dictatorship and a protracted guerrilla war.
But Dr. Merriman and Mbaraka Fazal, a Kenyan nurse she had met while working in Nairobi, had promising conversations with Uganda’s health minister, James Makumbi, and were confident that it would be safe to make the country their home base — and that they could convince the government of the importance of importing powdered morphine.
So in 1992, Dr. Merriman founded Hospice Africa, with the idea of spreading palliative care across the continent. A year later, she started Hospice Africa Uganda, to introduce her model to the country.
Initially, it was a shoestring operation. Working out of a small two-bedroom house in Kampala, Dr. Merriman and Ms. Fazal mixed morphine powder in buckets with water boiled on the kitchen stove. There was no office equipment, which made writing grants impossible. At one point, their total funding amounted to 19 Ugandan shillings — less than two American pennies at the time.
To make matters worse, local doctors were reluctant to refer their patients, out of fear of enabling opioid addiction or because they equated the analgesic with euthanasia. The first hospice patients — most of them young women with cancer — were referred late and often died within weeks. And the nurses who visited patients in remote locations were not able to administer morphine without a doctor’s prescription, which meant longer waiting times.
But Dr. Merriman pressed on. Driving a donated white Land Rover, she rumbled down bumpy roads that were unpaved or riddled with potholes to visit hospice patients. Cheerful and well turned out, she wore vibrant kitenge dresses, her hair done and her nails painted for meetings with donors. But while she had a gentle bedside manner, she could be steely, especially in meetings with doctors and government officials.
Early on, she wrote in a 2010 memoir, her relationship with the country’s health ministry became “as frosty as it can get in a tropical climate” because of the government’s lack of support for her work.
But eventually things began to improve. Patients in hospice care were no longer in pain, and word began to spread. Medical students that Dr. Merriman had trained became practicing doctors, and they helped shift attitudes. And in 2004, Dr. Merriman finally convinced the health ministry to allow certain nurses to prescribe morphine.
Within five years, Hospice Africa Uganda had three sites in the country. By 2000, Hospice Africa had expanded its training sessions to Tanzania. Today, through its Institute of Hospice and Palliative Care in Africa, Hospice Africa offers degrees in palliative care.
Dr. Merriman, who became known as Uganda’s “mother of palliative care,” reflected on her early days in Uganda and the importance of persistence in an interview with The New York Times in 2017.
“You need someone to shout and scream and keep it going,” she said.
Anne Merriman was born on May 13, 1935, in Liverpool, England, one of four children of Thomas Merriman, the headmaster of a Catholic primary school, and Josephine (Dunne) Merriman, who ran the home and volunteered with Catholic charities.
When she was 12, her younger brother, Bernard, died of a brain tumor that was initially misdiagnosed as tuberculous meningitis, an event that left a deep impression.
A pious Catholic, she was also influenced by stories about missionaries in Africa, including a documentary on Mother Mary Martin, who founded the Medical Missionaries of Mary, an order said to allow its members relative freedom. (The nuns were permitted to ride bicycles and wear dresses that revealed their ankles.)
At 18, she moved to Dublin and joined the order. Two years later, in 1956, she received permission from the order to enroll at University College Dublin, where she studied medicine, specializing in obstetrics.
After she graduated with a medical degree in 1963, the order sent her to work in a hospital outside Uyo, Nigeria, where she did her residency, learning to perform surgery and focusing on general medicine, obstetrics and pediatrics, until the outbreak of civil war in 1967. She returned to the country in 1971 after postings in Dublin, Edinburgh and Liverpool.
But during her second stint in Nigeria, the liberating spirit of the Second Vatican Council put her increasingly at odds with her strict superiors — as did a budding romance with a Catholic volunteer — and in 1973 she left the order and returned to Liverpool.
By 1978, she was overseeing geriatric care for the National Health Service in the city’s Whiston and St. Helens neighborhoods. During that time, watching her mother’s heath fail as a result of an earlier coronary thrombosis, she began to develop an interest in palliative care.
In 1984, Dr. Merriman landed a teaching position at the National University of Singapore, where she helped found the country’s first — and now its largest — hospice-care provider. In 1990, she became the medical director of a hospice center in Nairobi, where she met Ms. Fazal.
Along with various medical papers, Dr. Merriman published a handbook on geriatric medical practices in 1989 and two memoirs, “Audacity to Love” (2010) and “That’s How the Light Got In” (2023), written with Autumn Fielding-Monson.
Dr. Merriman left no immediate survivors.
Despite her accomplishments and awards — she was appointed a Member of the Order of the British Empire in 2003 and received Ireland’s Presidential Distinguished Service Award in 2013 — Dr. Merriman remained loyal to her working-class background. She made a point of avoiding the funerals of famous Ugandans, and was critical of the way the rich were prioritized for medical treatment, not just in Uganda, but around the world.
During her final days, she was as attentive to her appearance as ever, and she specified the outfit she wanted to wear to her own funeral: a purple kitenge dress with a bright yellow pattern. Stitched at the center was a map of Africa.
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