Introduction

This memorandum provides an overview of Human Rights Watch's concerns and recommendations regarding the poor availability of adequate treatment for people who suffer from severe pain due to cancer, HIV/AIDS or other health conditions in Cameroon.

Human Rights Watch is submitting this memorandum to the United Nations Committee against Torture ("the Committee") in advance of its pre-sessional review of Cameroon with the hope that it will inform the Committee's consideration of the Cameroon government's

("the government") compliance with the Convention against Torture and Other Cruel Inhuman or Degrading Treatment or Punishment.

In Cameroon, there is a wide gap between the need for treatment for severe pain and its actual availability.  Based on cancer and HIV/AIDS mortality figures and the consumption in the country of morphine - the mainstay medication for treatment of severe pain - an estimate can be made that tens of thousands of terminal cancer and AIDS patients suffer from severe pain without access to adequate treatment.  Tens of thousands more are likely to suffer from severe pain due to injuries and other health conditions.  The government of Cameroon has failed to take even basic steps to ensure that pain treatment is available for those who need it.

Denial of access to pain treatment as cruel, inhuman or degrading treatment

As the Committee may be aware, in February 2009 Professor Manfred Nowak, the UN Special Rapporteur on Torture and Other Cruel, Inhuman and Degrading Treatment or Punishment, stated in his report to the Human Rights Council that "de facto denial of access to pain relief, when it causes severe pain and suffering, constitutes cruel, inhuman or degrading treatment or punishment."[i]  There is no doubt that many patients who are unable to access pain medications experience severe pain and suffering.  Severe chronic pain is a common symptom of cancer, HIV/AIDS and many other health conditions.  Without pain relief, injuries and surgery may also cause severe acute pain.  

Like torture, chronic pain has a profound physical and psychological impact.  Chronic pain can cause depression, anxiety and reduced mobility resulting in loss of strength.  It can compromise the immune system and interfere with a person's ability to eat, concentrate, sleep, or interact with others.[ii]  Human Rights Watch has found that many people who experience severe pain express sentiments similar to those of victims of police torture or ill-treatment: all they want is for the pain to stop. In interviews, these people told us that they had wanted to commit suicide to end the pain, or told doctors or relatives that they wanted to die.[iii] 

The Committee has stated that cruel, inhuman or degrading treatment or punishment "may differ [from torture] in the severity of pain and suffering and does not require proof of impermissible purposes."[iv]  The Committee has further stated that the Convention requires States parties to take "effective preventative measures" and "eliminate any legal or other obstacles that impede the eradication of torture and ill-treatment."[v] 

As all strong pain medications are narcotics regulated by international drug conventions, their production, distribution and dispensing is under exclusive government control.[vi]  Without government action, including appropriate legislative measures, to ensure their availability, severe pain and suffering is inevitable.  Human Rights Watch firmly believes that where governments fail to take steps to make pain medications available, widespread denial of access to appropriate pain treatment should be considered a violation of the prohibition of cruel, inhuman and degrading treatment.  We therefore encourage the Committee to examine Cameroon's record on providing access to treatment for severe pain as part of its review of Cameroon's compliance with its obligations under Article 16 of the Convention.

Background: pain and pain management

Prevalence of pain

The World Health Organization ("WHO") estimates that tens of millions of people worldwide suffer from moderate to severe pain without access to treatment, including 5.5 million terminal cancer patients and 1 million end-stage HIV/AIDS patients, even though pain medications are safe, effective and inexpensive.[vii]  A March 2009 Human Rights Watch report, "Please, do not make us suffer anymore...": Access to Pain Treatment as a Human Right, concluded that a "shocking willingness by many governments around the world to stand by passively as people suffer" was a chief reason for this situation.[viii]

Chronic, moderate and severe pain is a common symptom of cancer and HIV/AIDS, as well as of various other health conditions. A recent review of studies of pain among cancer patients found that more than 50 percent of cancer patients experience pain symptoms,[ix] and research consistently finds that 60 to 90 percent of patients with advanced cancer experience moderate to severe pain.[x]  Although no population-based studies of HIV/AIDS related pain have been published, multiple studies report that 60 to 80 percent of patients in the last phases of the illness experience significant pain.[xi]  One authoritative study estimates that 80 percent of terminal cancer patients and 50 percent of terminal HIV/AIDS patients will develop moderate to severe pain symptoms, on average for a period of about 90 days.[xii]

Pain management: elements, effectiveness, cost

The basis for modern pain management is the WHO's Pain Relief Ladder, which recommends the administration of different types of pain medications according to the severity of the pain. With the use of the Pain Relief Ladder, WHO estimates that most, if not all, pain due to cancer could be relieved.[xiii]  While originally developed for treating cancer pain, the Pain Relief Ladder has been applied successfully to other types of pain.

The mainstay medication for treating moderate to severe pain is morphine, an opioid that is made of an extract of the poppy plant.  Oral morphine is the drug of choice for chronic pain, and can be taken in institutional settings and at home.  Due to the potential for its abuse, morphine is a controlled medication, meaning that its manufacture, distribution and dispensing is strictly controlled both at the international and national levels.

Basic oral morphine in powder or tablet form is not protected by any patent and can be produced for as little as US$0.01 per milligram.[xiv] A typical daily dose in low and middle income countries ranges, according to one estimate, from 60 to 75 milligrams per day.[xv] Because oral morphine can be produced cheaply, providing pain management should be possible at the community level even in developing countries.

Chronic pain management is often a part of broader palliative care services, which aim to improve the quality of life of patients and their families facing problems associated with life-limiting illnesses.[xvi]

Widespread consensus: pain relief medications must be available

There is a decades-old and widespread consensus that states must make opioid pain medications, including morphine, available for people facing severe pain. The 1961 Single

Convention on Narcotic Drugs ("Narcotic Drugs Convention") recognized that narcotic drugs continue to be "indispensible for the relief of pain and suffering" and that states must make "adequate provision...to ensure" their availability.[xvii] The International Narcotics Control Board, the body charged with overseeing the implementation of the UN drug conventions, clarified in 1995 that the Narcotic Drugs Convention establishes an obligation "to ensure adequate availability of narcotic drugs, including opiates, for medical and scientific purposes..."[xviii] 

WHO has included opioid pain relievers, including morphine, in its Model List of Essential Medicines, a list of the minimum essential medications that should be available to all persons who need them. WHO has also repeatedly emphasized that palliative care and pain treatment are an essential-not optional-component of care for cancer and HIV/AIDS.[xix]  Professor Manfred Nowak, the UN Special Rapporteur on Torture and Other Cruel, Inhuman and Degrading Treatment or Punishment, recommended in his report to the Human Rights Council in February 2009 that "all measures should be taken to...overcome current regulatory, educational and attitudinal obstacles to ensure full access to palliative care."[xx] 

The situation in Cameroon

In Cameroon, more than 50,000 people die from HIV/AIDS, and more than 27,000 people from cancer, each year.[xxi] Research suggests that about 80 percent of terminal cancer patients and 50 percent of terminal HIV/AIDS patients will suffer from moderate to severe pain for an average of about three months before their death.[xxii]  In addition, thousands of other Cameroonians will face moderate to severe pain due to other health conditions, including non-terminal cancer and injuries.[xxiii]

Adequate pain treatment for all of Cameroon's terminal cancer and HIV/AIDS patients would require consumption of an estimated 288 kg of morphine per year.[xxiv]  As a signatory to the Narcotic Drugs Convention, Cameroon is obliged to report its annual consumption of morphine and other opioids to the International Narcotics Control Board.[xxv]  Cameroon has not reported consumption figures since 2004, when it reported that it consumed less than half a kilogram of morphine.[xxvi]  This is sufficient to treat an estimated 82 terminal cancer or HIV/AIDS patients, approximately 0.2 percent of those requiring pain treatment in Cameroon.[xxvii]  

Information gathered by Human Rights Watch suggests that this situation is due, in large part, to the failure by the government of Cameroon to take reasonable steps to ensure that people who face severe pain have access to appropriate treatment.  In particular, Cameroon has failed: to put in place a functioning supply system for morphine; to enact policies that would ensure pain treatment access; and to ensure that healthcare workers receive adequate training on pain management and palliative care.

Supply and distribution system

Lack of access to pain medication must be seen in the context of Cameroon's poor health infrastructure and the government's failure to meet its commitments to allocate more of its budget to healthcare to achieve progressive realization of the right to health.[xxviii]  Yet, even where more expensive medications are available, opioids often are not.  As the production, distribution and dispensing of controlled medications, like morphine, is under exclusive government control, without government action, these medications will simply not be available.

Cameroon has failed to put in place an adequate supply and distribution system.  States are required to submit estimates of their need for opioids for medical and scientific purposes annually to the International Narcotics Control Board and may not import opioids in excess of the estimates approved by the Board.[xxix]  Cameroon has not submitted a consumption estimate for morphine, or any other opioid, for 2009.[xxx]  For 2008, Cameroon estimated its morphine consumption would be just 280 grams, enough to treat just 46 terminal cancer or HIV/AIDS patients, or 0.1 percent of those in need of pain relief.[xxxi]     

To its credit, the government has included injectable morphine, oral morphine solution and morphine tablets on Cameroon's national list of essential medicines, in line with the WHO Model List of Essential Medicines.[xxxii]  The government has failed, however, to ensure a supply of oral morphine.  As far as Human Rights Watch has been able to establish, it appears that  morphine tablets are not, in practice, available in Cameroon.[xxxiii]  At least one health service run by a non-government organization imports oral morphine because it is not able to purchase it in Cameroon, indicating that the government has not taken the necessary steps to put in place functioning supply and distribution of oral morphine.  The Cameroon Baptist Convention Health Board ("CBC Health Board") received authorization from the Ministry of Health to import morphine powder in order to make morphine solution to use its two palliative care facilities.[xxxiv]  As oral morphine solution is an extremely cost effective medication that can be used to provide pain relief to patients being cared for at home, the government should be urged make it more broadly available in Cameroon.

The need to enact appropriate policies

The right to the highest attainable standard of health requires that countries adopt and implement a national public health strategy and plan of action on the basis of epidemiological evidence, addressing the health concerns of the whole population.[xxxv]  In 1996, WHO identified the absence of national policies on cancer pain relief and palliative care as one of the reasons that, in many countries around the world, cancer pain is so often inadequately treated.[xxxvi]  Despite efforts of palliative care advocates, Cameroon does not have a written palliative care policy or plan of action and palliative care is not included in the national cancer policy.[xxxvii]  A team of local experts formed under the auspices of the African Palliative Care Association to improve access to palliative care in Cameroon cited lack of government attention to palliative care as hindering broader access.[xxxviii]   

Training for healthcare workers

Without adequate instruction on palliative care and pain management, the healthcare system will be unable to provide patients with the treatment they require.  The above mentioned team of experts cited limited expertise in palliative care and healthcare workers' attitudes towards opioid medications as major barriers to access.  Lack of awareness in the broader community of palliative care as a treatment option was also identified as a problem.[xxxix]  Instruction in palliative care is not provided as part of the undergraduate or post-graduate medical or nursing curriculum in Cameroon.[xl]  The few doctors and nurses that have received training in palliative care have done so in Uganda or through the efforts of NGOs.  The CBC Health Board employs one doctor and a handful of nurses who have received formal training in palliative care at Ugandan medical schools or at Hospice Africa Uganda.  One nurse serves as a palliative care trainer for other staff.[xli] 

Recommendations for steps the government of Cameroon should be urged to take:

Human Rights Watch submits that many terminal cancer and HIV/AIDS and other patients in Cameroon are suffering from severe pain because the government of Cameroon has failed to undertake basic steps to ensure their access to opioid pain medications.  Indeed, the failure of the government to put in place an adequate supply and distribution system, enact relevant national policies and introduce instruction for healthcare workers condemns to great suffering tens of thousands of people who will develop severe pain symptoms in years to come, as the appropriate infrastructure for providing pain relief is not in place.  The government of Cameroon should be urged to develop and implement a strategy and plan of action for removing barriers to availability of medical opioids and ensuring adequate supply and distribution.  It should urgently implement low-cost reforms that would improve access to opioids for pain relief, such as adopting appropriate policy documents, introducing relevant education for healthcare workers and making oral morphine solution more widely available.  

 


[i] Human Rights Council, Report of the Special Rapporteur on Torture and Other Cruel, Inhuman or

Degrading Treatment or Punishment, Manfred Nowak, "Promotion and Protection of All Human Rights, Civil Political, Economic, Social and Cultural Rights, including the Right to Development," A/HRC/10/44, January 14, 2009, para. 72.

[ii] One WHO study found that people who live with chronic pain are four times more likely to suffer from anxiety and depression: O. Gureje, et al., "Persistent pain and well‐being: a World Health Organization study in primary care," Journal of the American Medical Association, vol. 80, 1998, pp. 147‐51; see also F. Brennan, D.B. Carr, M.J. Cousins, "Pain Management: A Fundamental Human Right," Anesthesia & Analgesia, vol. 105, no. 1, July 2007, pp. 205‐221; B. Rosenfeld, et al., "Pain in Ambulatory AIDS Patients II: Impact of Pain on Psychological Functioning and Quality of Life," Pain, vol. 68, 1996, pp. 2‐3, 323 - 28.

[iii] Human Rights Watch interviews in the Indian states of Kerala, Andhra Pradesh, West Bengal, and Rajasthan; March and April 2008

[iv] UN Committee Against Torture, General Comment No. 2, Implementation of article 2 by States parties, U.N. Doc. CAT/C/GC/2 (2008), para. 10. 

[v] Ibid, paras. 4 and 25.

[vi] The six strong opioids commonly used for pain relief, morphine, fentanyl, oxcodone, hydromorphone, pethidine and methadone, are all regulated by the Single Convention on Narcotic Drugs, 1961, adopted March 30, 1961, 520 U.N.T.S. 151, entered into force December 13, 1964.  Of these, morphine is the gold standard for the treatment of moderate to severe pain.

[vii] WHO, "WHO Briefing Note: Access to Controlled Medications Programme," February, 2009, http://www.who.int/medicines/areas/quality_safety/access_to_cmp/en/ (accessed August 24, 2009), p.1.    

[viii] Human Rights Watch, "Please, do not make us suffer any more...": Access to Pain Treatment as a Human Right, March, 2009, https://www.hrw.org/en/reports/2009/03/02/please-do-not-make-us-suffer-an....

[ix] M. van den Beuken‐van Everdingen, et al., "Prevalence of pain in patients with cancer: a systematic review of the past 40 years," Annals of Oncology, vol. 18, no.9, March 12, 2007, pp. 1437‐1449.

[x] C. S. Cleeland, et al., "Multidimensional Measurement of Cancer Pain: Comparisons of U.S. and Vietnamese Patients," Journal of Pain and Symptom Management, vol. 3, 1988, pp. 1, 23 ‐ 27; C. S. Cleeland, et al., "Dimensions of the Impact of Cancer Pain in a Four Country Sample: New Information

from Multidimensional Scaling," Pain, vol. 67, 1996, pp. 2‐3, 267 ‐ 73; R.L. Daut and C.S. Cleeland, "The prevalence and severity of pain in cancer," Cancer, vol. 50, 1982, pp. 1913‐8;  K. M. Foley, "Pain

Syndromes in Patients with Cancer," in K. M. Foley, J. J. Bonica and V. Ventafridda, eds., Advances in Pain Research and Therapy, (New York: Raven Press, 1979), pp.59‐75; K. M. Foley, "Pain Assessment and Cancer Pain Syndromes," in D. Doyle, G. Hank and N. MacDonald, eds., Oxford Textbook of Palliative Medicine, 2nd ed., (New York: Oxford University Press, 1999), pp. 310‐31; J. Stjernsward and D. Clark, "Palliative Medicine: A Global Perspective," in D. Doyle et al. eds., Oxford Textbook of Palliative Medicine, 3rd ed., (New York: Oxford University Press, 2003), pp. 1199‐222.

[xi] K. Green, "Evaluating the delivery of HIV palliative care services in out-patient clinics in Viet Nam,

upgrading document," London School of Hygiene and Tropical Medicine, 2008; K. M. Foley, et

al., "Pain Control for People with Cancer and AIDS," in Disease Control Priorities in Developing

Countries, 2nd ed., (New York: Oxford University Press, 2003), pp. 981-994; F. Larue, et al.,

"Underestimation and under‐treatment of pain in HIV disease: a multicentre study," British Medical

Journal, vol.314, 1997, p.23; J. Schofferman and R. Brody, "Pain in Far Advanced AIDS," in K. M. Foley, J. J. Bonica and V. Ventafridda, eds., Advances in Pain Research and Therapy, pp. 379-86; E. J. Singer, et al., "Painful Symptoms Reported by Ambulatory HIV-Infected Men in a Longitudinal Study," Pain, vol. 54, 1993, pp. 1 15 - 19.

[xii] K. M. Foley et al., "Pain Control for People with Cancer and AIDS" in Disease Control Priorities in Developing Countries, 981‐994.

[xiii] WHO, "Achieving Balance in National Opioids Control Policy: Guidelines for Assessment," WHO/EDM/QSM/2000.4, 2000, http://apps.who.int/medicinedocs/collect/medicinedocs/pdf/whozip39e/whoz..., (accessed August 7, 2009), p. 1.

[xiv] K.M. Foley, et al., "Pain Control for People with Cancer and AIDS" in Disease Control Priorities in Developing Countries, 981‐994.

[xv] Ibid. This is an estimate for low and middle income countries. The average daily dose in industrialized countries tends to be higher. This is due, among others, to longer survival of patients and the development among patients of tolerance to opioid analgesics: email communication with K. M. Foley, January 23, 2009.

[xvi] WHO, National Cancer Control Programmes: Policies and Managerial Guidelines, 2nd ed., (Geneva: WHO, 2002), pp. xv, xvi.

[xvii] Preamble to the Single Convention on Narcotic Drugs, 1961, adopted March 30, 1961, 520 U.N.T.S. 151, entered into force December 13, 1964.

[xviii] International Narcotics Control Board, "Availability of Opiates for Medical Needs: Report of the International Narcotics Control Board for 1995," 1996, http://www.incb.org/pdf/e/ar/1995/suppl1en.pdf (accessed January 15, 2009), p.1.

[xix] WHO, National Cancer Control Programmes: Policies and Managerial Guidelines, 2nd ed., pp. 83-91; WHO, "A Community Health Approach to Palliative Care for HIV/AIDS and Cancer Patients in Sub-Saharan Africa," August 15, 2004, http://www.who.int/hiv/pub/prev_care/en/palliative.pdf (accessed August 7, 2009), p 6-7. 

[xx] Human Rights Council, Report of the Special Rapporteur on Torture and Other Cruel, Inhuman or

Degrading Treatment or Punishment, Manfred Nowak, "Promotion and Protection of All Human Rights, Civil Political, Economic, Social and Cultural Rights, including the Right to Development," A/HRC/10/44, January 14, 2009, para. 74(e).

[xxi] Calculated using statistics from the World Health Organization Statistical Information System (WHOSIS) http://www.who.int/whosis/en/index.html (accessed July 15, 2009).  Cameroon's population is approximately 18,175,000 (2006), its HIV/AIDS mortality rate is 282.0 per 100,000 (2005) and its cancer mortality rate is 150.0 per 100,000 (2002).

[xxii] K. M. Foley et al., "Pain Control for People with Cancer and AIDS" in Disease Control Priorities in Developing Countries, 981‐994.

[xxiii] Non‐lethal cancer, lethal and non‐lethal HIV/AIDS, lethal and non‐lethal injuries, and various other health conditions can cause moderate to severe pain requiring opioid pain medications.  An estimated 540,000 people are living with HIV/AIDS in Cameroon (WHO, UNAIDS, "Epidemiological Fact Sheet on HIV and AIDS: Cameroon, 2008 Update," September 2008, http://apps.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_C... [accessed August 7, 2009], p.4) tens of thousands of people die of injuries each year (WHOSIS, accessed July 15, 2009), and thousands more suffer from non‐terminal cancer.

[xxiv] The calculation is based on an estimate by K. M. Foley and others that 80% of terminal cancer patients and 50% of terminal AIDS patients will require an average of 90 days of pain treatment with 60 to 75 mg of morphine per day: K. M. Foley, et al., "Pain Control for People with Cancer and AIDS" in Disease Control Priorities in Developing Countries, 981‐994.

[xxv] Single Convention on Narcotic Drugs, art. 20(1)(c).

[xxvi] International Narcotics Control Board, Narcotic Drugs: Estimated World Requirements for 2009 - Statistics for 2007, E/F/S.09.XI.02 (New York: United Nations, 2009), p. 222.  

[xxvii] The calculation is based on an estimate by K. M. Foley and others that 80% of terminal cancer patients and 50% of terminal AIDS patients will require an average of 90 days of pain treatment with 60 to 75 mg of morphine per day. K. M. Foley, et al., "Pain Control for People with Cancer and AIDS" in Disease Control Priorities in Developing Countries, 981‐994.

[xxviii]Cameroon has committed to a target of allocating 15% of government spending on the improving the health sector (Abuja Declaration on HIV/AIDS, Tuberculosis and Other Related Infectious Diseases, April 27, 2001, Abuja, Nigeria, OAU/SPS/ABUJA/3). Government spending on health care reached 10% of total spending between 2003 and 2005, before declining to 8.6% of total government spending in 2006, the last year for which statistics are available (statistics from the World Health Organization Statistical Information System (WHOSIS) http://www.who.int/whosis/en/index.html [accessed August 19, 2009]).  Cameroon has considerable oil revenues but is ranked 141st of 180 countries on Transparency International's Corruption Perception Index (http://www.transparency.org/news_room/in_focus/2008/cpi2008/cpi_2008_table). Corruption at all levels of government impedes greater investment in healthcare and leads to the diversion of invested funds.  Equally, healthcare provider's demands for ‘informal payments' are a barrier to healthcare access.  

[xxix] Single Convention on Narcotic Drugs, arts. 21 and 31; International Narcotics Control Board, "Training Material: 1961 Single Convention on Narcotic Drugs, Part 1 - The International Control System for Narcotic Drugs", UN Doc. E/INCB/2005/NAR_1, 2005, http://www.incb.org/pdf/e/estim/trainmat/NAR_1%20English%202005.pdf (accessed July 16, 2009), pp. 11-14.

[xxx] International Narcotics Control Board, Narcotic Drugs: Estimated World Requirements for 2009 - Statistics for 2007, p. 28.  When a state fails to submit an estimate, the International Narcotics Control Board ("the Board") makes its own estimate of the state's needs, effectively authorizing the state to import opiates, and other states to export to that state, up to the Board's estimate.  For 2008, the Board's estimate of Cameroon's morphine needs was 5kg.  This is sufficient to treat only 2% of Cameroon's terminal Cancer and HIV/AIDS patients, but may reflect the Board's judgment that any larger amount may be vulnerable to diversion for illicit use, as Cameroon lacks a procurement, supply and distribution system sufficient to deliver it to patients.   

[xxxi] International Narcotics Control Board, Narcotic Drugs: Estimated World Requirements for 2008 - Statistics for 2006, E/F/S.08.XI.2 (New York: United Nations, 2009), p. 45. 

[xxxii] WHO, Model List of Essential Medicines, 15th List, March 2007, http://www.who.int/medicines/publications/essentialmedicines/en/index.html (accessed August 5, 2009), p. 2; Liste National Des Medicaments Essentiels - Cameroun. http://collections.infocollections.org/whocountry/en/cl/CL1.4/ (accessed August 5, 2009);

[xxxiii] African Palliative Care Association, "Advocacy Workshop for Palliative Care in Africa", report of workshop held in Accra, Ghana, May 9 to 11, 2007, p. 23; Human Rights Watch interview with Ndikintum George Mbeng, Palliative Care Supervisor and Trainer, Baptist Convention Health Board, Cameroon, 31 July, 2009; Human Rights Watch interview with Dr Jonah Wefuan, Board Member, African Palliative Care Association, Cameroon, August 15, 2009.          

[xxxiv] Human Rights Watch interview with Ndikintum George Mbeng, 31 July, 2009; Human Rights Watch interview with Dr Jonah Wefuan, August 15, 2009.          

[xxxv] UN Committee on Economic, Social and Cultural Rights, "Substantive Issues Arising in the Implementation of the International Covenant on Economic, Social and Cultural Rights," General Comment No. 14, The Right to the Highest Attainable Standard of Health, E/C.12/2000/4 (2000), para. 43(f).

[xxxvi] WHO, Cancer pain relief: with a guide to opioid availability, 2nd ed., (Geneva: WHO, 1996), p. 2.

[xxxvii] African Palliative Care Association, "Advocacy Workshop for Palliative Care in Africa", p. 23; Human Rights Watch interview with Ndikintum George Mbeng, 31 July, 2009; Human Rights Watch interview with Dr Jonah Wefuan, August 15, 2009.       

[xxxviii] African Palliative Care Association, "Advocacy Workshop for Palliative Care in Arica", p. 53.

[xxxix] Ibid, p. 23. 

[xl] Ibid, p. 54; Human Rights Watch interview with Ndikintum George Mbeng, 31 July, 2009; Human Rights Watch interview with Dr Jonah Wefuan, August 15, 2009.           

[xli] Human Rights Watch interview with Ndikintum George Mbeng, 31 July, 2009; Human Rights Watch interview with Dr Jonah Wefuan, August 15, 2009.