Palliative Care Neglected Worldwide
(New York) - Tens of millions of people worldwide are denied access to inexpensive medications for severe pain, Human Rights Watch said in a report released today.
The 128-page report, "Global State of Pain Treatment: Access to Palliative Care as a Human Right," details the failure of many governments to take even basic steps to ensure that people with severe pain due to cancer, HIV, and other serious illnesses have access to palliative care, a health service that seeks to improve quality of life. As a result, millions of patients live and die in great agony that could easily be prevented, Human Rights Watch said.
"Worldwide, palliative care needs are enormous, but many governments simply ignore them," said Laura Thomas, health researcher at Human Rights Watch. "There's no excuse for letting people suffer from severe pain when inexpensive medications are available to help them."
Experts estimate that 60 percent of those who die each year in low- and middle-income countries - a staggering 33 million people - need palliative care. In these countries, most cancer patients are diagnosed when they already have advanced disease and can no longer be cured. The only treatment option is palliative care. In high-income countries, palliative care needs are increasing with aging populations and the resulting higher cancer incidence.
The report is based on a survey of policy barriers to palliative care in 40 countries and an assessment of the availability of pain-relieving drugs worldwide.
Human Rights Watch found that in 35 of 192 countries reviewed, fewer than 1 percent of patients with moderate to severe pain from terminal cancer or HIV could get the strong pain medications they needed. These countries are concentrated in Sub-Saharan Africa, but some are in Asia, the Middle East, North Africa, and Central America.
Availability of strong pain medications is very limited in many of the world's most populous countries, Human Rights Watch found. At least 100,000 people die from cancer or HIV/AIDS each year without access to adequate pain treatment in countries such as China, India, Indonesia, Nigeria, Russia, and South Africa.
"My leg would burn like a chili on your tongue," Dilawar Joshi, a Nepali man with a bone tumor living in India told Human Rights Watch. "The pain was so severe I felt like dying. I was very scared. I felt that it would be better to die than to have to bear this pain. [I thought], just remove the leg, then it will be alright. Just get rid of the leg so I'll be free of pain."
The survey found multiple barriers to palliative care in most of the 40 countries surveyed. Three quarters do not have national palliative care policies, despite a World Health Organization recommendation to develop such policies. In most of these countries, healthcare workers are not adequately trained in pain management or palliative care, and in some, no training is offered at all. In 33 of the countries, the government imposes restrictions on prescribing morphine beyond the requirements of UN drug conventions.
Human Rights Watch found a number of bright spots. Colombia, Jordan, Romania, Uganda, and Vietnam have successfully undertaken comprehensive reform programs to improve access to palliative care. In these countries, government officials have worked with the medical community and civil society to identify and address barriers to palliative care.
The World Health Organization considers palliative care an integral component of cancer care and has urged countries to improve its availability. The 1961 Single Convention on Narcotic Drugs, to which 184 states are parties, requires countries to ensure the adequate availability of narcotic drugs for the relief of pain and suffering.
"Colombia and Uganda and the other countries that have worked to provide palliative care powerfully show that all countries can make progress," Thomas said. "The key ingredient is the political will to make these health services available and to relieve people's suffering."
Quotes From Patients and Healthcare Workers Interviewed by Human Rights Watch:
"Before I came [to Kenyatta National Hospital], I couldn't eat or breathe well [because of the pain]. Now that I have been given medicine [morphine], I can eat and breathe. I couldn't sit down, but now I can. I had pain for more than a month. I told the doctor and nurses [at another hospital] that I had pain. It took too long to get pain treatment... Here I got it immediately and started feeling well again."
- - Christine L., an 18 year-old woman with Breast Cancer, Nairobi, Kenya.
"I would sleep maybe an hour and a half per night. I could take any number of sleeping pills [without effect]. With morphine, I can relax. This place [the palliative care unit] is heaven-sent..."
- - Shruti Sharma, Hyderabad, a breast cancer patient, India
"Cancer is killing us. Pain is killing me because for several days I have been unable to find injectable morphine in any place. Please, Mr. Secretary of Health, do not make us suffer any more."
- - A classified ad placed inEl Paísnewspaper in Cali, Colombia, on September 12, 2008, by the mother of a woman with cervical cancer
"I wanted to fall head down and be dead right away so it wouldn't hurt anymore."
- - Vlad Zhukovsky, a cancer patient from Ukraine, describing a failed suicide attempt
"We have no pethidine, no DF-118 (dihydrocodeine) and no morphine.... We have children here with advanced HIV; some are in severe pain. The pain management for children with advanced HIV is not enough."
- - Nurse, Bondo District Hospital, Kenya
"Doctors are fearful of everything to do with opioids."
- - Oncologist, Jorda.