Equitable access to health care
BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39371.586076.80 (Published 25 October 2007) Cite this as: BMJ 2007;335:833All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Access to pain relief - an essential human right
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
Competing interests: No competing interests