Expanding Access to Pain Medicine and Palliative Care.

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In honor of SPH Narrative Month, I thought I would begin this Viewpoint with the poem “To Waken an Old Lady” by William Carlos Williams:

Old age is
a flight of small
cheeping birds
skimming
bare trees
above a snow glaze.
Gaining and failing
they are buffeted
by a dark wind—
But what?
On harsh weedstalks
the flock has rested—
the snow
is covered with broken
seed husks
and the wind tempered
with a shrill
piping of plenty.

The poem strikes me particularly apt this time of year, as the weariness of winter ebbs and spring emerges with hopes of tempered winds and plenty. But it also evokes the uncertainty of old age, and one big uncertainty for many people is suffering, needlessly, excruciating and isolating pain.

In the US, we hear a great deal about the overprescription of pain medicines, but the reality in most of the world is much different. A 2016 report of the World Health Organization estimates that of the 20 million people requiring palliative care annually, only 3 million (15 percent) receive it. According to the report, 5.5 billion people (83 percent of the world’s population) live in countries with “low or non-existent access to controlled medicines for the treatment of moderate to severe pain.”

One controlled medicine for pain is morphine, which is both extremely inexpensive and effective. Oral morphine in powder or tablet form is not protected by patent and can be produced very cheaply. In India, for example, morphine tablets are sold for as little as 1.7 cents (US) each. At this price, a typical daily dose of oral morphine would cost as little as 12 cents. Yet approximately 90 percent of the total world consumption of morphine occurs in North America and Europe. Low- and middle-income countries consume only 6 percent of the morphine used worldwide, even though they are home to about half of all cancer patients.

In some cases, the situation is unmistakably bleak. For example, in this 2010 article on access to pain treatment as a human right, my co-authors and I calculated that the 49 g of morphine that Burkina Faso sought to import in 2009 would be sufficient to treat about eight patients. More expensive pain medicines are either unavailable or unaffordable for most people in the country, so tens of thousands of people will get no relief from their agony.

Moderate to severe pain has a profound impact on quality of life. It can lead to reduced mobility, compromise the immune system, and interfere with a person’s ability to eat, sleep, concentrate, or interact with others. A WHO study found that people who live with chronic pain are four times more likely to suffer from depression or anxiety. In addition, the physical and psychological effects of chronic pain can directly influence the course of disease and reduce a patient’s adherence to treatment.

Pain also has social consequences for patients and their caregivers. These include the inability to work, reduced capacity to care for children or other family members, and decreased participation in social activities. Pain can also interfere with a patient’s ability to bid farewell to loved ones, potentially leaving a lasting sense of anguish.

In many countries, the lack of access to palliative care stands in stark contrast to the investment by health systems in more expensive curative care and more recent commitments to “universal health coverage” (sustainable development goal #3). Training programs for medical students and physicians routinely do not teach even basic knowledge of palliative care.

There is some good news, however. While access to pain medicine and palliative care is still under-addressed in discussions of global health, human rights advocacy (such as that described here) has helped raise awareness of the issue; identify structural barriers to care; define government obligations; and spark reform of laws, policies, and practices impeding the availability of palliative care services. In 2014, the World Health Assembly issued its first-ever resolution on palliative care, which called upon the WHO, and countries, to improve access to palliative care as a core component of health systems, with an emphasis on primary health care and community- and home-based care.

But the need for palliative care is only going to increase. A recently published study in The Lancet found that there was a 90 percent probability that life expectancy at birth among South Korean women in 2030 will be higher than 86.7 years, and a 57 percent probability that it will be higher than 90 years. We should celebrate such changes, which demonstrate the power of public health (compared with women from 34 other countries studied, South Korean women generally smoke less, weigh less, have lower blood pressure, and see doctors more often because most have health insurance). Lower- and middle-income countries are also seeing increasing life expectancy—and increasing rates of non-communicable diseases, such as cancer, which can cause severe pain. We should pay attention now to better understanding how to deliver palliative care and work to scale up programs worldwide.

William Carlos Williams would surely agree. In addition to being a celebrated poet, he was also a family physician, practicing medicine by day and writing poetry at night. In our efforts to improve the public’s health, there is much to be gained from reflecting on the grace, and struggle, and ultimate rest Williams describes.

Joseph Amon is a human rights activist, scholar, lecturer, and public health practitioner. He currently serves as vice president for neglected tropical diseases at Helen Keller International.