HISTORICAL DEVELOPMENT
Before 1960, severe undertreatment of cancer pain was the rule; it was described as unavoidable. Cancer prevention, diagnosis and treatment were subjects of interest, but symptom control was excluded.
The majority of cancer patients were not treated for pain at all, or were treated inadequately. Those more fortunate could receive intermittent injections of meperidine or morphine; some dying patients with uncontrolled pain could receive the ‘lytic cocktail’.
Approximately in the 1960s, cancer pain management (CPM) progressively became a duty of some anesthesiologists who performed analgesic blocks, intraspinal therapies, neurosurgical procedures, intravenous infusions, etc, as a part-time activity, with erratic results.
The anesthesiologists had a catalytic influence on CPM. After them, a growing number of health professionals became aware of the magnitude of the cancer pain issue and many of them began to provide pain relief. These professionals realized that pain is seldom the only symptom experienced by cancer patients and that they were best served with an integrated therapeutic approach. In 1990, palliative care (PC) was introduced to the medical scene and, since then, health professionals, patients and the public have slowly and progressively recognized the importance of this issue.
There was a reduction in the anesthesiologists’ roles in CPM using interventional techniques, and CPM was incorporated within PC.
CURRENT STATUS
Despite the progress made in the past decades, only a small fraction of patients with cancer pain receive adequate treatment. Access to PC is inconsistent and poorly coordinated.
Health system
PC is not a priority in public health and has a low importance compared with preventive and curative services. Three factors can be identified:
Insufficient support:
The government is still unable and/or reluctant to fulfill the demand for PC.
PC is not recognized as a discipline nationwide, although it has been recognized as a discipline in one province.
There is no national health policy to implement PC.
Bills, regulations and laws that promote and should guarantee nationwide PC access are still on paper.
Financing challenges:
PC activity is difficult to finance because of inadequate compensation from the health system. Sustainability is solved with mixed approaches: charity, volunteer work, and care paid by the patient (when possible) or by health coverage (some pay for PC).
Barriers to opioid availability and accessibility:
In 2006, the mean morphine and methadone consumptions were 0.66 mg and 0.24 mg per capita, respectively; global means were 8.74 mg and 5.98 mg per capita, respectively.
There is good availability of commercial and compounds of weak and strong opioids but their high prices limit access and use.
Although morphine and codeine should be supplied free to all patients, provision is variable to inpatients and limited to outpatients in public hospitals; this also varies by region.
Outdated and nonscientific prescribing regulations restrict the use of opioids.
HEALTH PROFESSIONALS
Teams
The total number of identified PC teams is approximately 70.
Most are in large cities – those within the public health system deliver inpatient care and those in the social security system deliver home care.
Many are interdisciplinary – a trained professional works with professionals of other disciplines according to the patients’ needs.
Only a few teams have specific inpatient facilities – there are approximately 40 PC beds in the country.
Home care has had limited development and day care facilities are scarce.
Access
There is limited national information about the number of patients who receive PC, as well as clinical, organizational and economic issues of the caring process, but it can be estimated that less than 5% of patients who need PC receive it.
Models of care
The traditional medical model is prevalent – quality of life is replaced by excessive medical interventions that too often are futile and expensive, and sometimes in conflict with the patient’s wishes.
National association
The Argentinean Association for Medicine and Palliative Care (AAMyCP) was created in 1991 and currently has approximately 250 members.
Education
Undergraduate education for physicians and nurses is scarce.
Graduate education is available in multiple formats – classroom, bedside, workshops, seminars and e-teaching. Most are interdisciplinary.
Opportunities for intensive training are only available in two cities.
Research
There is limited research activity with heterogeneous quality. The reasons are limited resources, minimal expertise, and lack of trained researchers and training opportunities. The number of publications per year is very low.
Lack of rewards and incentives
Payment mechanisms encourage the overuse of procedural services. It is easier and more profitable to hospitalize a patient, or start an aggressive and often futile treatment, than to provide PC.
Patients and families
The care of the patient with advanced cancer and his family depends on: where they live – most PC is available in large cities because it is hardly obtainable in small cities and rural areas; available resources, effective health coverage and/or money – more than 50% of patients cannot pay for the services or the medication; and age – pediatric PC is limited.
LOOKING FORWARD
In Argentina, there is growing evidence that PC is useful and needed; every year, in many cities, a new team develops. However, availability is still far from an acceptable level. Legislation favours development but bureaucracy and inactivity at the public service level hinder success. Progress will be slow until the country develops a public health strategy that includes PC. A possible catalytic factor for this would be that communities ‘own PC’. This must be understood as a call for social participation. Educating the community about their right to demand high-quality assistance at the end of life will require much effort, commitment and resistance to failures and deceptions.
SOURCE MATERIAL
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