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We published in BMJ Supportive & Palliative Care on the role of religious practices in enhancing the quality of life (QoL) for patients receiving palliative care at Ocean Road Cancer Institute (ORCI) Tanzania. That study revealed that prayer and other spiritual practices were in high demand among inpatients and correlated with improved perception of well-being.1 However, despite this strong spiritual engagement, most patients still reported poor overall QoL (84.7%). Now, this paradox raises an important question: what other factors, beyond spirituality, may shape QoL in Tanzanian palliative care?