Global Health Policy
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September 10, 2007
Ease the Pain: An Opportunity for AIDS Funders to Build Health Systems
Posted by Ruth Levine at 03:24 PM
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.
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the developing world are routinely denied this type of palliative care because of a combination of over-regulation and outdated medical practices.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.
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Comments
It is nice to be able to affect change. It is nicer to affect these changes. Are there any cases of PEPFAR money being successfully used to change "statute, regulations or policy to broaden access to pain medication"?
Posted by: Tor User at September 10, 2007 11:58 PM
This is a very important issue but it goes well beyond the availability of drugs. My own experience (Bukavu, RDCongo) is that there is a whole aspect of "medical culture" involved. Pain, sufferings are NOT the primary concern, not even an important one, even when drugs are available. This is true for doctors as well as nurses. We are trying to set up a sensibilization and training program for hospital personnel.
Posted by: Philippe DeVille at September 19, 2007 05:21 AM
I was pleased to see the NYT stories about pain and lack of access to opioid analgesics; Donald McNeil, the writer, interviewed our colleagues in Sierra Leone, India and Japan. But there was little information provided about how to fix the problem; our small group at the University of Wisconsin has for a decade been developing methods to evaluate national drug control policy and remove barriers to improving availability and access to essential but controlled pain medicines. Our work has resulted in peer reviewed articles about the methods and results in India, Italy, Romania. We have Fellows working on the problem in 8 low and middle income countries including Vietnam and are providing technical assistance in sub Saharan Africa. I would invite anyone interested in making a difference in opioids for pain relief for HIV/AIDS and cancer in any country to visit our website at painpolicy.wisc.edu; there you will find guidelines for addressing--specifically--how to evaluate national drug control policies as well as a page of information for every country. Please contact us if you have further questions.
David Joranson
Distinguished Scientist
University of Wisconsin
Posted by: David Joranson at November 29, 2007 05:49 PM