Two doctors and colleagues from the United Kingdom have this week launched a toolkit for healthcare professionals in poor countries that advises on palliative care. The authors were struck that many countries struggle to provide even the most rudimentary control of symptoms and social support for patients with incurable conditions, chiefly AIDS and cancer.
Vicky Lavy, a doctor at Helen and Douglas House Hospice, Oxford, and an author of the toolkit, said that one of the biggest problems in providing palliative care in many poor countries is the lack of morphine.
In her 10 years’ experience in Malawi, Dr Lavy said that the only painkillers in reliable supply were paracetamol, aspirin, and “perhaps a non-steroidal on a good day. But even ibuprofen is not widely available. Codeine is very expensive.”
Ironically, she said, powdered oral morphine was “dirt cheap” to buy from manufacturers, but many African governments were resistant to free supply because of fears of drug misuse.
The situation in Malawi improved after doctors met with the health minister and convinced him of the need to relax regulations. But countries such as Ethiopia are opposed to relaxing regulations, despite the fact that guidelines from the World Health Organization say that morphine should be available on essential drug lists.
Health professionals are also reluctant to use morphine, says Dr Lavy. “They are resistant to prescribe it because there is a lot of fear over respiratory depression, fears mostly unfounded. Funnily enough, people are happy to use pethidine.”
The other author, Charlie Bond, a consultant in palliative medicine at Severn Hospice, Shrewsbury, said, “It’s a myth that cancer is a Western disease. Cancers of the cervix, head, and neck, for example, are very common in developing countries.
“We have an epidemic coming with HIV related cancers, and tobacco companies have been pushing cigarettes in these regions. Lots of African countries do not have access to chemotherapy or radiotherapy, so the need for palliative care becomes almost immediate.”
The chapter on control of symptoms sets out how to treat, care, and prescribe. Dr Lavy said, “What drove us to do the toolkit are the healthcare workers who get terribly demoralised and swamped by the volume of pathology and suffering. They have droves of HIV patients and feel they do nothing. The toolkit says there is something you can do.”
One of the main thrusts of the toolkit is that palliative care is not difficult or complicated. Even if you accept that in countries such as Ethiopia it will be years before morphine is available, the authors maintain that there is a lot that doctors can do to make a difference to a patient with incurable disease.
“You can do a lot with almost nothing,” said Dr Lavy. “Communication skills can be very poor and are not taught at all.
“So just in terms of breaking bad news and listening, these basic things can make a big difference to people. Even where health carers have non-steroidals or codeine sometimes they are not used properly. The toolkit says don’t just wait until the pain is bad before giving analgesia, give [as required],” she said.
Dr Bond said, “This is about how to do palliative care when existing health structure is very poor. Palliative medicine is a medical specialty in the UK, and it sometimes feels as if it has become more complex and sophisticated to consolidate itself as a specialty.
“In writing the toolkit we wanted to give the message that the core principles of palliative care are simple and can be practiced by non-specialists at low cost. To some extent it is about ‘catching the vision’ that just because people haven’t got long to live doesn’t make them any less important as patients. It is really worth investing time and energy in them.”
Dr Bond added that although cancer and HIV care and care for chronic disease in general were assuming a larger and larger share of the healthcare burden in developing countries, health services and education are still largely geared to the management of acute infectious disease and malnutrition.
The authors say that they don’t expect palliative care services to suddenly start springing up, rather that staff working with, for example, patients with cancer or HIV, will develop palliative care skills, adding better control of symptoms and social support.
They point to the home care services already set up for patients with HIV in parts of Africa, where palliative care skills could be integrated into their existing programme. The toolkit is relevant for doctors who have no experience or training in palliative care and for community nurses.
It includes 18 ready prepared forms and charts and information to enable the service to start.
Staff at the International Observatory of End of Life Care, which is based at Lancaster University and which maps development of global palliative care (www.eolc-observatory.net/global/pdf/world_map.pdf), point to success stories in South Africa, Kenya, and Uganda but have found evidence of only small localised services in many countries, such as Bangladesh, Columbia, and Botswana. No hospice or other palliative care activity has been identified in the lowest rated countries, including Yemen, Afghanistan, and Somalia.
The Palliative Care Toolkit: Improving Care From the Roots up in Resource Limited Settings has been produced by Help the Hospices on behalf of the Worldwide Palliative Care Alliance. It is at www.helpthehospices.org.uk/temp/palliative_care_toolkit.ZIP.