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| Narrative History of Palliative Care in Poland |
| Uniquely amongst the countries of central and Eastern Europe, the hospice movement in Poland began during the 1970s, when the country was under communist rule. Against a backdrop of debate about the nature of Christian love9, a group of parishioners from the Lord's Ark Church in Nowa Huta, led by Halina Bortnowska, began to visit the dying in the local hospital; an initiative that came to be regarded as Poland's first informal hospice service. From the outset, it was recognised that 'Krakow's beginnings were not totally imported from abroad and from the west.'10 The visit and lectures of Cicely Saunders in 1978 added momentum to this nascent movement. After she left: |
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'Several groups were initiated with the aim of visiting patients at home to bring them help, medicine, companionship and love.'11 |
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| As the 1980s began, an outburst of energy resulted in significant developments. The first registered hospice, the Society of Friends of the Sick, was established by volunteers at Krakow in 1981. In Gdansk, Hospicjum Pallotinum - a voluntary home care team - was founded in 1984 by Fr Eugeniusz Dutkiewicz, a Catholic priest. This home care model became very popular and was replicated by numerous groups, both religious and secular. In 1987 the first palliative care service to be organised within the national health structure opened in Poznan, led by Jacek Luczak. |
| Alongside the development of hospice, the 1980s saw the growth of Solidarity, a trades union that aimed to support the people of Poland by supplementing provision within the national health service. Consequently when plans were put forward to establish a church-based hospice in Krakow, the project became incorporated into the demands of the union at the Lenin foundry.12 Although the church came to favour a different option, Solidarity's support for hospice is emblematic of the common values within the two organisations. Jacek Luczak comments: |
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To the 'ethos' of solidarity as a social, economic and political movement was added the 'ethos' of the hospice movement, as a symbol of humanity.13 |
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| Robert Twycross, in an interview undertaken within the Hospice History project of the University of Sheffield, comments on the special relationship that developed between Solidarity, early hospice and the Catholic Church: |
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'After a year or two, Solidarity was outlawed. Now quite a number of leading academic doctors had been members of Solidarity, so when it was outlawed they … had to take lowly posts down the road in the municipal hospital. So they were then stuck: they no longer had this outlet called Solidarity to dig at the government and they wanted to have some other outlet. So certainly in Gdansk, the home of Solidarity, they decided to set up a hospice. Now of course you can't set up a hospice programme in protest against the government, it would be illegal, you have to have legal permission, but they would never get legal permission, so they did it within the umbrella of the Catholic Church. But early hospice, certainly in Gdansk, in Poland, was a subtle protest movement by displaced medical academics… So a protest movement with a difference.'14 |
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| As the decade came to a close, hospice in Poland had developed clear features that differentiated it from other countries, particularly in the west. Writing in 1991, Ben Zylicz observes: |
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Those features are the result of communist rule, a rule which restricted the amount of space available for these types of activities. All care is given free by unpaid volunteers, including many doctors, nurses and medical students who visit patients at home in their free time. The final responsibility for the patient (including morphine prescriptions), however, lies with the local health authorities and district doctors who turn a blind eye to the activities of the hospices due to their own workload, and also to their ignorance.15 |
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With the collapse of communism and the introduction of a market economy, a broader vision of palliative care could begin to develop. This vision was debated during a ground-breaking conference held at Radziejowice (near Warsaw) in May 1990. As a result, a call was made for the inception of international conferences, a programme of courses by visiting teachers, the participation of Eastern European countries in the activities of EAPC, the initiation of research in palliative care, and the establishment of palliative care units in large teaching hospitals.
Fired by this new sense of direction, wide-ranging developments took place during the next decade. In 1991, the National Forum of the Hospice Movement was founded in Gdansk. A new unit opened at the Medical Academy, Poznan, followed by a unit in Bydgoszcz. The first free-standing unit was established at Elblag in 1992; others followed at Bialystok, Torun, Myslowice and Lomza.16 In 1994, Tomasz Dangel established the Warsaw Hospice for Children, providing a model for other paediatric services in Lublin, Lodz, Poznan and Myslowice. |
| An academic collaboration was established between the Medical Academy, Poznan, and Sir Michael Sobell House, Oxford. This resulted in a succession of foundation and advanced courses held at Puszczykowo conference centre (near Poznan). These courses had a formative influence, not only upon palliative care in Poland, but in the wider region. |
| Education was also developed at centres in Bydgoszcz, Gdansk, Krakow, Lodz, Wroclaw and Szczecin - which in turn had an influence upon undergraduate and postgraduate palliative care education. The post of national palliative care consultant was established in 1994 with Jacek Luczak as the first incumbent. There are now four Chairs of Palliative Medicine in Poland. - at Poznan (J Luczak) and Bydgoszcz, where the Polish School of Palliative Medicine is led by Zbigniew Zylicz, medical director of Hospice Rozendaal in The Netherlands. |
| Significantly, the Ministry of Health and Social Welfare introduced a programme in 1991 to establish palliative care throughout the country as part of national health policy. Two years later a defining moment occurred when a sum c4.2 million new Polish zlotys or cUS$1.5 million was allocated by the Ministry of Health to the budgets of the voivoids (provincial authorities) for the development of palliative care. During the same year, the National Council for Palliative and Hospice Care was established - an organisation that encouraged the introduction of provincial palliative care councils and addressed the issue of palliative care standards. |
| A formative meeting took place in 1998 when participants at the 9th annual conference at Puszczykowo issued a statement that became known as the Poznan Declaration. Delegates from Belarus, Bulgaria, Czech Republic, Hungary, Latvia, Lithuania, Poland, Romania and Slovakia commented on the status of palliative care in their countries. They called for the development of national policies, a programme of palliative care education, increased drug availability, a growth in palliative care services and increased public awareness. The following year, this declaration prompted the establishment of the Eastern and Central European Palliative Care Task Force (ECEPT), headquartered in Poznan. |
| In 1999 palliative medicine was accepted as a medical specialty in Poland. The Ministry of Health published guidelines for palliative care alongside policies for cancer pain relief. To improve pain control 150,000 copies of a booklet were distributed to doctors, nurses and pharmacists. Polish standards of paediatric palliative care were published in the same year and the first international conference on paediatric hospice care was held in Budapest at Tomasz Dangel's instigation; the second took place in Warsaw in 2001. |
| Palliative care is more developed in Poland than in any other country in the region. Indeed, Poland alone has more palliative care services than all of the other countries in this study combined. Zbigniew Zylicz suggests why this is so: |
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'I think there are a number of factors influencing this, one of them is that I see this as a very historical development … I'm reading now the history of Poland by [Norman] Davies and what is striking me is the formation of the whole intelligentsia, the descendents of richer, noble people, and in the 19th Century they moved to the cities, they left their farms and they moved to the cities, and this was very unique in Europe. I mean we had a separate class of this intelligentsia and this is something that is very important in the development of culture in Poland.
In the time of communist, in many countries, the tiny, small numbers of intelligent people, the intelligentsia, they were killed away, they were smashed away and deported to Siberia, or whatever, or they emigrated to the west. And in Poland there were so many of these people - we're talking about 10 or 20 percent of the whole nation - so this made Poland much more able, together with the Catholic Church, to defend against destruction. So these people survived and all this tradition survived.
So these people were very much involved in societal developments…and in Poland you needed just a spark and the fire started, and … I think Cicely was the spark. Cicely Saunders was the spark that started this fire, and the background was ready for it and was sensitive to it…When she came in 1978, this spark made a fire and it never stopped, and this makes so much difference than in other countries, where single people were busy with developing palliative care, and they had more difficulties than we had in Poland.'17 |
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