More on palliative care in Uganda

When I rotated with the inpatient Palliative Care service at Mulago last week, I was impressed by the multidisciplinary team and somewhat aware that the very existence of palliative care in the hospital reflected a culture shift, recently brought about by forward thinking and hard work.  But what I did not realize was that this service was just one part of a revolutionary effort in Uganda to bring palliation to dying patients throughout the country, including in rural areas, that dates back twenty years.  Nor did I realize that Uganda is far out at the head of the pack in this movement in sub-Saharan Africa, and that there are many places in Africa where terminally patients are completely cut off from medications like opioids that might ease their pain. 

The effort to bring palliative care to Uganda started in 1993, when a British physician named Anne Merriman was moved by the suffering she witnessed among cancer and HIV patients in Kenya and Africa to found Hospice Africa Uganda.   This organization established a national policy for palliative care delivery in Uganda, and worked with the government to ensure cheap and widespread access to morphine.  They also integrated palliative care education into the curricula of two of the major Ugandan medical schools, Makerere (the med school affiliated with Mulago) and Mbarara. 

Liquid morphine, and a poster in the cancer institute.

Today, morphine is free with a prescription in Uganda and can be prescribed by palliative care nurses in addition to doctors.  During rounds in the Cancer Institute this week I saw ubiquitous bottles of liquid morphine tucked into patients' bedclothes and the green elixir being tipped into patients' mouths from little cups.  The solution is mixed in Uganda, Breaking Bad-style, and comes in two strengths, 1mg/ml and 3mg/ml, distinguished by food coloring. It is packaged in somewhat sketchy looking water bottles, but this creativity is what has kept costs down and facilitated access.

Outside of the hospital, palliative care and basic aid is delivered to terminally ill patients by community health workers, trained volunteers who access patients in remote areas by bicycle.  Like expanded morphine prescribing privileges for nurses, the use of trained volunteers to deliver care is an example of "task shifting," the concept of delegating tasks to less specialized workers to ease the strain of worker shortages.  The World Health Organization recommends task shifting as a public health initiative, particularly in the delivery of HIV care in resource-poor settings. 

By contrast, I learned from a Human Rights Watch report this month that access to opioids in Senegal is extremely limited, and patients must travel from all over the country to Dakar for morphine, and even there can only get a one week supply.   Further, this limited access to palliative care is more the rule than the exception in Africa:

"According to the Worldwide Palliative Care Alliance (WPCA), half of sub-Saharan Africa’s countries have no known palliative care services. Only six sub-Saharan African countries—Kenya, Rwanda, South Africa, Swaziland, Tanzania, and Uganda—have integrated palliative care into their national health plans. Only four countries—Kenya, Malawi, South Africa, and Uganda—recognize palliative care as an examinable subject in medical schools and have it integrated in the curriculum of health professionals. Palliative care seems to be particularly poor in Francophone Africa, with 11 of 18 Francophone African countries having no known palliative care services.  Most palliative care on the continent is provided by non-governmental, faith, or community-based organizations with no guaranteed sustainability. In 2008, morphine consumption in Africa was almost 20 times lower than the global mean."

Kind of incredible that even as the FDA is tightening regulations on opioid prescribing in the US because of an epidemic of overuse and abuse, children with terminal cancer are dying in excruciating pain halfway around the world-- two ugly sides of the same coin.  If only there were the drug equivalent of those trendy canvas shoes Toms, so that every time a suburban kid in Connecticut bought oxycontin, a child suffering from cancer pain in a rural village in Senegal could get a free bottle of morphine?  You heard it here first...