AORTIC 2011, Cairo, Egypt 30 November–2 December 2011
Palliative care in Africa
Dr Anne Merriman – Hospice Africa, Kampala, Uganda
Palliative care was very slow to make a start until affordable morphine was available in Africa and over the last twenty years since we first brought it in, twelve more countries have taken it on whereas before there were two countries only in the previous twenty years, so that was a big move. It actually reflects what we all know, that until you can control pain you really can’t practise palliative care. The morphine that we make here in Africa is very affordable, it costs $1 for ten days’ treatment and it can be taken at home by the patient, the patient is in control. So we’re able to then, once the pain is controlled, we’re able to go forward and look after their spiritual problems, psychosocial problems, their cultural problems, so many things that come up when we have time and we can sit and talk to them and try and help them and advise them on those things and take action on things that they have.
So Uganda is an example, it’s now considered the model for this. We are now making morphine for the whole country from the hospice for the whole of Uganda and that’s new, that’s only started this year. As long as the money is coming from the government we won’t have any stock outs but there have been terrible stock outs and it’s happening all the time across Africa. Countries just starting with morphine, they’re not getting it through first of all to the people on the ground and the very poor people, but then suddenly the supply stops because they haven’t imported it in time and that causes terrible suffering as well. So we’re trying to prevent all these things which are coming forward. At first it was just get it into the country, now it’s get it through the country.
Does this problem come from lack of production and risk management?
It’s probably mismanagement in ordering it in time. Somebody keeping… and there’s a lot of bureaucracy and there’s a lot of people in the bureaucratic chain don’t want to import morphine and if they can they’ll block it. It’s really sad because they’ve been brought up to think it’s addictive and it shouldn’t come into the country and trying to change them is very difficult. But the big thing for actually changing it is to get undergraduate training for palliative care into the undergraduate curriculums, particularly for doctors and nurses. Now we’ve been doing this since 1994 in Uganda and now every doctor and nurse that’s come through since then knows what palliative care is. It’s made a huge difference in the country but it’s very slow getting through. We’ve got five universities in Nigeria and only one of them has an undergraduate curriculum in palliative care. In that huge country, 150 million people, it really needs help.
Could you talk about your involvement with the National Cancer Control Program?
Yes, there’s six booklets from WHO on that and one of them is on palliative care. There’s a lot of concentration, in fact the two blend with each other on chemotherapy and radiotherapy which is terribly expensive but has to come in. It has to come in but the people doing radiotherapy and chemotherapy need to work alongside us, we need to be together from the start, from the diagnosis onwards in cancer. If we don’t work together then the patients won’t get the best care so they brought in palliative care because 95% of people in Africa now never receive chemotherapy or radiotherapy. In Uganda, where we’ve only got one centre when I calculated the numbers they are less than 5% of the people who need it are reaching them. But still we’re reaching less than 10% in palliative care and yet palliative care is cheap, it’s just a matter of increasing the knowledge and allowing the morphine to get through to them so that they can practise palliative care.
Has the attitude towards palliative care been changing?
It’s changed a lot in Uganda. I find in Nigeria it’s still very, very difficult. They had it in and it was blocked, even releasing it once it was in so it went out of date. Then they wouldn’t release it because it was out of date and yet you can still use out of date stuff, it still has the potency but they wouldn’t release it because that was what was written in the book. So the result was that they’ve had a block out now for two years, they’ve no morphine after having it originally.
What has the effect been with HIV related cancers?
The HIV related cancers are actually changing because antiretrovirals are now so much more available. They’re only available to people who can reach the centres and so there are still at least a third of the people with HIV who get into stage 4, which is AIDS, and cannot reach antiretroviral therapy because they can’t even afford the bus fare, they can’t even… anything they have is going to take away from the food in the family, from the school fees for whatever. So they don’t go for it and they will still die of HIV/AIDS. But the others, if they can have continuous supply of ARVs will actually die of something else. But the cancers have changed. Kaposi’s sarcoma was our number one cancer up until 2002/2003, now it’s about number four. Cancer of the cervix is number one now and breast is second so it’s changing, the whole pattern is changing and we have to keep an eye on it and address the needs at the time, what is there. But for us in palliative care, the burden for palliative care is much higher in cancer than it is in HIV/AIDS, that’s because AIDS is going down and cancer is going up.
What can be done for the future of palliative care?
I just feel it’s only through those we train that we’re going to spread palliative care throughout Africa. We have now an institute of palliative medicine for Africa which last time I talked to you we didn’t have, that was our education department that’s now recognised as a university level. And we have a degree and we hope to have a Masters next year or the year after. This is for the whole of Africa and people are coming from all over the place which is wonderful. It’s through those we train that the future of palliative care will be extended in Africa, not through the small numbers that we see but we must have perfect palliative care so that we can train people and show them how to do it right and how it can work in the African situation. Palliative care in the West is not suitable for the economies we have, we have to be able to work within the economical constraints and to show them how to adapt what they see from us to their own situation. We go into their countries after them and follow them up and see how it’s working and try and help them. We also try to make sure that those that we train go into palliative care and actually work in it. There’s a tendency in Africa for everybody wanting to do training and to have another certificate in their portfolio but they don’t actually carry it out afterwards. But if somebody does a training in palliative care and doesn’t practise it, they’re de-skilled, they may as well not have done it. So we’re now looking more to see whether their employers are prepared to put them into palliative care after they come on the degree or after they come on a year’s course. We have a lot of short courses as well but for those longer courses which are expensive, we really need to put the money and the training into those people who are going to be leaders in palliative care in the future.
