A compelling article in today's New York Times highlights the suffering of individuals in poor African countries who have cancer and other diseases that cause devastating pain. Unlike those of us in rich nations, people facing even the most severe pain in much of the developing world do not obtain common, effective and relatively low-cost pain medication. In fact, just six countries - the U.S., Canada, France, Germany, Britain and Australia - consume 79% of the world's morphine, compared to just 6% in the low- and middle-income countries that make up more than 80% of the world's population.Global Per Capita Morphine Consumption by Country (2002)And lack of appropriate use of pain meds is not due to a shortage of the raw ingredients, or the cost of the products. Despite an overabundance of the raw ingredients for opium, morphine and codeine, and the ability to manufacture it for medical use very cheaply, patients with extreme pain the developing world are routinely denied this type of palliative care because of a combination of over-regulation and outdated medical practices. Fear of patients' addiction combine with concerns about leakage of products to the black market; importantly, donors traditionally have steered completely clear of this controversial area.Enter U.S. President's Emergency Plan for AIDS Relief and a few other funders of HIV/AIDS programs, which have palliative care as an explicit part of their mandate - in PEPFAR's case, to a level of 15% of total spending. PEPFAR defines palliative care broadly, but includes the clinical management of pain with morphine and related drugs, and even includes guidelines (.pdf) that encourages policy change when needed:
In countries where national legislation or government regulation or policy prohibits or severely restricts the use of opioids for palliative care, including end-of-life care, USG teams should advocate for changes in statute, regulations or policy to broaden access to pain medication in ways that will increase the ability of providers to alleviate suffering while continuing to maintain appropriate safeguards against abuse of medications.
In a very clear and powerful way, funding for AIDS has the potential to break a path toward a stronger and more responsive health system - if those who are promoting and implementing AIDS programs take the palliative care priority seriously, and use their leverage to promote positive policy change.(For a useful review of the issues, see "
Pain Control for People with Cancer and AIDS" in
Disease Control Priorities in Developing Countries.)
Update: The Times ran a second piece in the series focusing on
palliative care in India.
CGD blog posts reflect the views of the authors, drawing on prior research and experience in their areas of expertise.
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