by Dr Anne Merriman, Hospice Africa Uganda

A programme was shown on Channel 4 in the UK on Friday 30 May 2014 -- a most distressing documentary showing the suffering of people of all ages in Senegal.

All of them had reached hospitals and many were receiving chemotherapy and the available therapies, but their pain was not being addressed except by one caring paediatrician.

One oncologist refused to speak to the BBC correspondent on camera.

When the correspondent approached the Minister of Health at a conference, as he could not get an appointment, the reaction indicated that she was too important to give him time.

This situation among the decision makers is the reason for the profound hopelessness of those suffering from cancer in Senegal.

Sadly this programme did not bring hope. But hope is there.

In Africa, Uganda was chosen as the model country to place a service that would be affordable and adaptable to other African countries by Hospice Africa.

After 21 years, Hospice Africa Uganda has established a suitable service which is affordable for most economies in the poorest countries.

Palliative care, with medications including oral morphine, is now available in 75% of the Districts of Uganda.

Here also health personnel from many different countries are being trained as initiators and up to degree level.

They are given hope as they see a caring service where patients are our guests and have choices up to the end of life for their care and where they wish to be.

We have already had 5 medical personnel from Senegal trained through these programmes.

Secondly, WHO has taken up the challenge in earnest this year.

The World Health Assembly listened and accepted an earth-moving resolution, which will encourage governments to recognise the torture of their citizens, which is preventable with affordable simple measures, once they are able to overcome the myths that have haunted health professionals and Government officials for many years.

Once pain is controlled the door is opened for holistic care to be given to patients and family who have been too overwhelmed by physical suffering for other matters to be addressed.

The WHA resolution is presented

The 134th session of the 67th World Health Assembly listened attentively on Friday 23rd May as the resolution “Strengthening of Palliative Care as a component of integrated treatment throughout the life course” was addressed.

This had already been approved by all the countries at a previous WHO meeting and now was accepted by the Governments attending this Assembly.

Palliative care leaders of the world rejoiced as this initiative, initially proposed by Panama and taken to WHO by a team of experts, coordinated by Diederik Lohman of Human Rights Watch, was accepted.

We expect this resolution to have profound effects on the success of advocacy to governments so that pain control and holistic care can be offered to the millions suffering today in the developing world.

There were more than 3,000 delegates present from all over the world and the countries presenting the resolution were cheered on and supported by a group of representatives of palliative care NGOs from every continent.

What does this resolution mean to those involved with supporting palliative care in Africa? Well if we look at the public health approach to introducing palliative care to a new country, we find that the resolution addresses the indicators necessary for services of palliative care in each country.

The patient and family are at the centre of all we (from Government to the simplest actor in the caring team) do.

Each of these areas are addressed in the policy paper:

1. Policy: Most important of all is enabling and encouraging governments to initiate, strengthen and put into practice palliative care policies in their plans. They also urge Governments to fund both human resources and medications appropriate to pain relief and holistic care in order to improve the quality of life of their citizens when in need.​
2. The resolution stresses the need for appropriate and affordable medications required for pain and symptom control to be available. They particularly stress the need for Governments to recognise the need to remove the myths associated with morphine and their fear of addiction and restore the “opioid balance” so that sufficient oral morphine is available for patients to be able to take it at home. Implementation: recognising that the only real witness to the success of palliative care, is the recording of the numbers of patients who are receiving quality care. Recognising that the needs of children are different and that specialised childrens’ palliative care should be introduced wherever possible.
3. Education of all involved at every level commencing with the family and all the way to those in the Ministry of Health. This includes community volunteers, undergraduate health workers and medical students, post-graduates and those in service already, even up to degree level, both Masters and Bachelors, and eventually PhD. Advocacy to the public and communities is an important aspect of this.

The document recommendations are divided into two sections:

1. To member states 

• ​​ This covers in more details the needs for each member state to reach out to prevent and manage the suffering of their people by providing affordable pain and symptom control and palliative care to all in need.
• Stressing access to morphine and the need for a balance in the Government regulations, ensuring those in need receive it. Heavy legislations trying to prevent addiction and drug trafficking should be adapted so that they do not exclude the needs of the suffering.
• Partnerships between Government, NGOs and civil society so that expertise can be shared with the financial and political support of the Government.
• That education of all cadres caring for such patients should be implemented from family and community level, through undergraduate and post-graduate education and CME up to advocacy and education of government officials and law enforcement agencies.
• To assess the needs in each country and to monitor the effects of their services in order to improve them and to continue with sustainable, affordable and accessible service to all, even in the home.

2. Requests to the Governor General

• That the global aspects of diseases are taken into account.Theneed for palliative care across NCDs, as well as the traditional care for cancer and HIV, are included. Disease patterns are changing with developments in life expectancy and economic developments in many countries. NCDs are more frequently among the commonest causes of death.
• That through research and assessment of services in different countries, there is a report back to the 2016 (69th) WHA in the progress of each of these recommendations from these countries.

If these recommendations are taken seriously the progress of palliative care in Africa, and the developing world, should now occur more rapidly. Advocacy to governments needs to be written in stone, so that recommendations agreed from  one Minister of Health are carried forward by the next (they usually change every 3 years), in a logical way to give consistency to the coverage and to ensure that human resources and the funding to sustain them is maintained and secure.

References

Stjernsward Jan: “Uganda: Initiating a Government Public Health Approach to Pain Relief and Palliative Care" (2002) J Pain Sympt Manag. 24 2 257- 64

Referendum presented to WHA: Strengthening of palliative care as a component of integrated treatment throughout the life course.

“It All Started in Africa” PUBIC LECTURE BY Dr Jan Stjernswärd (publication with this issue)