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Cancer-related pain has become a major problem worldwide. Pain can be caused by cancer, cancer treatment or by the side effects of treatment. At every stage of the cancer trajectory there is also emotional pain for both patients and the family. The dimension of these problems is worse in developing countries, especially countries in Africa, where there is a lot of ignorance about cancer, negative cultural beliefs about illness causes, poverty and lack of government policy on cancer control. Late presentation in hospitals with pain, no option of cure and poor supportive care is therefore very common (over 70%). Denial, anxiety about the future, fear of loss of income and fear of dying contribute to late hospital visits.
The following case scenario illustrates the problem. A 56-year-old government employee presented at a general hospital where a preliminary diagnosis of rectal carcinoma was made. He was referred to a tertiary hospital, 300 km away. He reported at the referral hospital three years later with severe pain having been seeking a ‘cure’ at some financial expense from faith-based and traditional healers. Advanced colorectal carcinoma was confirmed with liver metastasis and ascites. He could only be offered psychosocial support, and pain and symptom control, and he died within six weeks.
The health priorities in developing countries, including African countries, as addressed in the United Nations Millennium Development Goals (MDGs), emphasize “areas that cause widespread illness and death amongst the population”. Listed priorities include eradication of poverty and hunger, universal primary education, gender equality, reduction of child mortality, improvement of maternal health, combatting HIV/AIDS, malaria and other major diseases, environmental sustainability and global partnership for development (1). I believe the way forward for Africa will be to advocate actively for inclusion of cancer among the priority diseases within the MDGs and explore the area of global partnership for effective cancer control and treatment, including the multidimensional problem of cancer pain.
Currently, enough knowledge and skills on cancer pain are available in the developed world for translation into evidence-based, cost-effective and culturally appropriate interventions for Africa. The World Health Organization (WHO) (2) has also pioneered a public health strategy of palliative care to reach everyone in the population through:
Cancer pain was a target symptom and cancer the disease when the strategy was developed. With appropriate education and availability of essential drugs, adequate pain relief can be achieved in more than 75% of cancer patients using simple techniques such as opioids, nonopioid analgesics and adjuvant medications (3).
However, for many countries in Africa, availability of opioid analgesics is a major challenge for effective cancer pain treatment. The mean consumption of morphine for the African region was the lowest of all the WHO regions of the world, at 0.7 mg/capita. South Africa ranked the highest at 3.4 mg/capita (4). Where the drugs are available, cost is a major constraint (5), as is lack of knowledge.
Efforts to improve the situation include the International Association for the Study of Pain current training activities to improve pain management in Africa and other developing countries (6). Culturally appropriate and affordable palliative care is also being promoted within Africa by the African Palliative Care Association in collaboration with several international donors (7). Palliative care emphasizes pain and symptom control, and psychosocial and spiritual support, thus ensuring the best quality of life for patients and support for families. In line with the WHO Community Health Approach to Palliative Care, Uganda has evolved a suitable model for Africa that emphasizes home care, which is mostly delivered by relatives who are supported by specially trained palliative nurse prescribers, an outpatient clinic and a day care hospice (8). Such models can be adopted to provide cost-effective cancer pain relief in other African countries.
With support from the government of each country and international agencies, palliative care models could be developed through public-private partnerships, and standards improved and services upgraded to include advanced pain treatment options. The development of multidisciplinary pain clinics should also be encouraged so that local institutions would be able to include cancer pain management and research in the curriculum of their trainees.