Africa's hugely limited access to pain relief leaves many people to suffer terribly, but are there signs of progress on the horizon?
For people with difficult health conditions which cause them unrelenting pain, only the strongest form of relief can allow them to live an anywhere near comfortable life. For many in the West, the cheap and plentiful opioid morphine provides this respite. But for millions elsewhere, this essential relief is yet another denied right.
Frank, a 49-year-old Ugandan man, had been living alone with an open tumour on his neck, abandoned by his family because of the stench caused by his illness. He had not slept or eaten in weeks because of the pain.
Frank was fortunate enough to be found by a community volunteer worker from Hospice Africa Uganda (HAU). He was referred to the hospice team, who treated his would, and he was shown how to use oral morphine. Soon after, his family returned to continue his care.
"He was able to eat a little, sleep a little more, and settle his affairs before he died in peace, with his family and pain-free three weeks later", Zena Bernacca, CEO of the hospice, tells Think Africa Press. "Having pain relief makes a real difference; otherwise one's whole existence is narrowed down to suffering unimaginable pain, obliterating everything else."
Relief from pain also allows for time to address other social and emotional needs, such as future childcare or religious wishes. For Frank, the palliative care and morphine provided by HAU meant that he could be with his family.
"I have slept for the first time in many weeks", he told hospice care workers shortly before his death. "This wound is clean and no longer smells. I have my family back and I have food to share. I am blessed."
Considered essential by the World Health Organisation (WHO), morphine costs relatively little to provide. But 80% of the world's population lacks access to this treatment. In fact, where demand is highest, access to pain relief is at its lowest. Low- and middle-income countries, which account for 70% of cancer deaths and 99% of HIV-related deaths, consume just 6% of the world's medicinal opioids.
"Pain relief is a central component to palliative care", says Dr Emmanuel Luyirika, Executive Director of the African Palliative Care Association. "Without the immediate release of oral morphine, it's impossible to manage moderate to severe pain."
According to a 2010 survey conducted by the International Narcotics Control Board, the major reasons given by governments for the low availability of opioids include fears of addiction, a reluctance to prescribe, and insufficient training for professionals.
"There's an issue of strict regulations in countries based on unfounded fear of abuse, but also limited understanding of palliative care at most levels of policy, service provision and community within those countries", explains Luyirika.
Setting a trend
However, a number of models of pain treatment in Africa have allowed palliative care on the continent to grow, providing opportunities for governments and organisations to collaborate and learn.
Hospice Africa Uganda offered the earliest model designed for the African setting. Founded by Dr Anne Merriman in 1993, HAU has long provided oral morphine for a growing numbers of patients. Two years ago it broadened the reach of this drug significantly when Uganda ran out of stock. Encouraged by The Global Action for Pain Relief Initiative (GAPRI), an NGO working to spread awareness of palliative care methods, the hospice tendered for the contract and has since been selling stocks to the Ugandan government for national distribution.
Uganda also overcame another obstacle by becoming the first country to train nurses to prescribe morphine. Previously only doctors could prescribe the drug, making it impossible to meet demand. Routine meetings and training allow the hospice to alleviate any staff worries about misuse, and staff can in turn placate any fears from patients and families.
"Out of ignorance, so many are concerned about potential addiction", explains Bernacca. "However, once there is an understanding of how morphine works as a painkiller, and that when used appropriately it does not cause addiction, the patient is relieved. And the majority of carers are also relieved of the distress of witnessing such pain."
Along with programmes in Tanzania, Kenya and Zimbabwe, this public/private partnership is now a model of morphine production, and other countries are following suit. Research into palliative care and pain relief on the continent is still lacking, but these programmes are building understanding of how such care can be incorporated alongside other African health policies.
"These palliative care programmes are helpful because they show us what is possible", says Dr Meg O'Brien, Director of GAPRI. "They provide models that can be adapted to other programmes, and they give us evidence about the cost and impact of services that we can use to help leaders in other African countries make more informed decisions about what kind of care is achievable."
Obstacles on the road
Indeed, the complexities of supplying morphine mean that in many African countries political will is not enough. GAPRI has consistently found governments to be keen to provide pain relief services, but hampered by technical and bureaucratic barriers.
Pain treatment does not sit easily in one area of healthcare, and this can cause questions about department responsibility. Moreover, an effective programme requires cooperation among disparate groups that include policymakers, training institutions, hospital administrators, drug procurement bodies, financing offices, clinical guidelines committees and drug regulators.
"Sorting out the necessary collaborations is time-consuming, and many governments simply lack the capacity to push changes through quickly", says O'Brien. GAPRI addresses this by helping ministries of health with research, chasing paperwork, consultations and consolidating data. Founded only two and a half years ago, the organisation is young and still small, but its rapid development reflects a growing interest in pain treatment.
As calls increase for non-communicable diseases (NCDs) to be included in any post-2015 sustainability goals, palliative care and pain relief programmes could offer an initial achievable step in this direction. Uganda has only one radiotherapy machine, which is held together with sticky tape. Scaling up resources to combat the increasing incidence of NCDs requires a long-term strategy and significant funding. Pain relief programmes offer opportunities to expand into this area and start bridging the false divide between communicable and non-communicable diseases.
"Rather than distract ministries, I think an initial focus on palliative care actually focuses efforts", suggests O'Brien.
"Provision of modern pain relief and palliative care is a 'low-hanging fruit'. It can be done using existing funds and resources and will have an immediate benefit for cancer patients and others who suffer pain. I see it as an ideal starting point for ministries to expand care for NCDs while the international NCD community works on expanding funding and staff."
Maddy French is a freelance journalist who writes about global health and development. She has written for the Guardian and blogs at Investigate: Health. Follow her on twitter @hinvestigator.