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Rapid Responses: Rapid Responses published:
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Finally we recognise an important issue
- Christopher Buttery (26 October 2007)
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Health Care and Demography in Sub-Saharan Africa
- James G Danaher (28 October 2007)
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Sanitation
- Edoardo Cervoni (2 November 2007)
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Access to pain relief - an essential human right
- Vanessa Adams (2 November 2007)
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Christopher Buttery, Clinical Professor, Virginia Commonwealth university 23298
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In 1972, at the annual Communicable Disease Control Conference, I published three years of observational research, funded by the CDC, on the effects on socioeconmic difference on diseases [socioeconmoic stratification as a tool for disease control, CDC conference DHEW Pub# HSM) 73-8172)]. I was able to demonstrate significant differences in disease incidence/rates for STDs, TB, vaccine preventable diseases, and infant mortality. I have used this and similar data over the years to motivate communities where I was a local health director, to improve the health of their citizens, as well as teaching students of public health about this relationship. Reading this month's articles and editorials makes it all finally seem worthwhile. Thank you. Competing interests: None declared |
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James G Danaher, Retired NHS GP 33 Ashby Road, Ravenstone, Leicestershire LE67 2AA
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James Tumwine, Professor of Paediatrics in Makerere University, Uganda, writes, “most people would agree that urgent action is needed to reduce the unacceptably high number of deaths of children living in resource constrained countries.” (BMJ 27 Oct 2007) This is certainly true, but there are some who have had hesitations. Here are two examples: William Vogt in his book The Road to Survival (1948) tried to persuade the United States government not to give poor countries life- saving aid unless contraceptive help was given at the same time. He believed that life saving measures without birth control would cause a huge increase in population, accompanied by hunger, poverty and conflict. He had a point. Dervla Murphy in her book The Ukimwi Road (1993) recounts that, whilst cycling through Malawi at a time when Dr Hastings Band was still in charge, she met a local Chief: "The Chief recalled his youth, when the people of this area only had to go hunting to secure an adequate meat supply for their families. He was not enough of a Banda man to eschew the World Service and had recently heard a WHO spokesman mentioning the victory of medical science over African diseases. He mused, ‘Was it good to check these diseases that kept the population down, when the West couldn’t give good health to the extra millions? Isn’t there more happiness in the world if an area has five million well-fed people, with enough wildlife to give them protein, instead of ten million, always hungry, never rightly developing their minds or bodies?’" According to the United Nations, Malawi’s population was 2.8 million in 1950, and 11.6 million in 2000. In Uganda, the population was 5 million in 1950 and 24 million in 2000. The population of Sub-Saharan Africa as a whole was 180 million in 1950 and 680 million in 2000. All these figures for the year 2000 are expected to double before 2035. (See http://esa.un.org/unpp) Hunger, inevitably, still distresses people in Malawi and in many other countries in Sub-Saharan Africa. And yet, in Malawi, and in Uganda, and in much of Sub-Saharan Africa, family planning is woefully inadequate. (The United Nations gives the following figures for contraceptive use by couples: Malawi 30.6% and Uganda 22.8%. These compare with Brazil 76.6% and China 83.8%). In Africa, sick children undoubtedly need urgent help now, but the sick children of the future – when conditions will be more difficult – need our help even more. We should not shy away from providing effective family planning to the people of Africa. Gerald Danaher (Retired NHS GP) 33 Ashby Road Ravenstone Leicestershire LE67 2AA jgd@gerrydanaher.com 01530 836122 Competing interests: None declared |
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Edoardo Cervoni, MD PR9 0HP
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I feel that once again is given far more importance to the delivery of healthcare as synonym of medical/surgical treatment rather than to Sanitation intended as hygienic means of preventing human contact from the hazards of wastes to promote health. Hygienic means of prevention can be by using engineering solutions (e.g. sewerage and wastewater treatment), simple technologies (e.g.latrines, septic tanks), or even by personal hygiene practices (e.g. simple handwashing with soap).The problem is political in the first place. If we really do care about equitable healthcare access, then we should focus on sanitation rather than on the access to healthcare facilities and treatments. To do so we should create compulsory funds to finance major engineering solutions. Competing interests: None declared |
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Vanessa Adams, palliative care and oncology pharmacist consultant to Help the Hospices WC1X 9JG
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I read with interest, Professor Tumwine’s thought provoking observations addressing equitable access to health care and reducing infant mortality in the developing world. These, were reflected in the report published by Help the Hospices ‘Access to pain relief – an essential human right’, published last month (http://www.worldday.org/documents/access_to_pain_relief.pdf). This report includes a survey of medical staff in 69 hospice and palliative care services across Africa, Asia and Latin America. As highlighted by Professor Tumwine, poorly developed and resourced health systems were one of the key elements that limited their access to analgesics on the WHO Essential Medicines List, EML and the International Association of Hospice and Palliative Care, IHAPC’s list of essential medicines for palliative care(1). One aspect of this was the significant shortage of health care workers. Further to this, within the palliative care field there was a lack of training of health care workers (82% in Latin America and 71% in Asia having had no palliative care or pain control teaching in their initial training). Education therefore needs not only to cover health workers but everyone from policy makers, donors, international organizations through drug regulatory personnel to the public. Uganda has provided good examples of increasing access through: i. Advocacy(2) eg leading to the inclusion of palliative care in government health policy and the provision of oral morphine ii. education of communities(3) leading to the active care and referral by community volunteer workers. However, unlike Professor Tumwine’s observation of demotivated staff, the questionnaire respondents, and personal contacts I have had in the palliative world within resource poor areas, has shown these health care workers as exceptionally caring and professional. Differences may stem not only from the fact palliative workers are often employed by NGO’s (and hence pay may be more reliable) but also from being able to see the direct benefit palliative care can bring. I feel it is a dangerous pathway to give financial incentives for specific interventions; surely, there should be a strong move to help ensure adequate and reliable pay for all health care workers. Drug cost was another limiting factor in the study, despite the fact analgesics can be provided in a relatively cheap and exceedingly effective manner (in Uganda the average cost of oral morphine to keep a cancer patient pain-free for two weeks is equivalent to the local price of a loaf of bread). Promotion of non-generic medicines was found to hinder access. There is an urgent need to strengthen the WHO EML and national treatment protocols with regular and timely updating. Once this is in place, a way to ensure the reliable and on-going provision of these essential drugs at cost price or free to all needs establishing, especially as Professor Tumwine highlights, when time is critical. Amid all the commendable efforts to improve survival rates of patients in resource-poor settings, those who cannot be cured are all too often overlooked. The bitter truth is that in many resource-constrained situations more than half of patients presenting with diseases such as AIDS and cancer are beyond curative treatment by the time they ever see a medical professional. These people are more often than not sent away without even an aspirin to ease their agony, because ‘nothing can be done’ for them. The fact is that this is far from true. Palliative care and access to essential pain relieving medicines should be an integral part of all national policies relating to cancer, HIV/AIDS and other chronic diseases. Where treatment is possible, for example in the case of ARV (anti-retroviral) therapy for AIDS patients, adequate palliative care to relieve pain, distressing symptoms and anxiety – which may be caused or exacerbated by the treatment itself – can improve adherence to treatment, thereby positively impacting survival rates. Pain relief is not a ‘nice to have’ – it is a human right. Mrs Vanessa Adams Palliative care and oncology pharmacist and author of ‘Access to pain relief – an essential human right’ richandness@hotmail.com 1. De Lima L, Krakauer EL, Lorenz K, Praill D, MacDonald N, Doyle D. Ensuring palliative medicine availability: the development of the IAHPC list of essential medicines for palliative care. J Pain & Symptom Management 2007; 33(5): 521-526 2. Jagwe J, Merriman A. Uganda: Delivering analgesia in rural Africa: Opioid availability and nurse prescribing. J Pain & Symptom Management 2007; 33(5): 547-551 3. Kikule E. A good death in Uganda: survey of needs for palliative care for terminally ill people in urban areas. BMJ 2003; 327(7408); 192- 194 Competing interests: None declared |
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