Prof. Léonie Claudine Lougue Sorgho, Minister of Health of Burkina Faso. Photo: © Jonathan Leighton
Nothing has greater urgency than preventing or relieving intense suffering. Unfortunately, medicine has traditionally focused more on treating disease than on alleviating pain and suffering. This problem is especially acute in low-income countries like Burkina Faso, where patients are often not adequately treated for diseases like cancer, and then die in agony because there is no palliative care provided by the state healthcare system and rarely any morphine available. A recent initiative has taken things forward in this country.
A local initiative to relieve suffering
Dr. Martin Lankoandé founded Hospice Burkina, the Palliative Care Association of Burkina Faso, with the objective of making palliative care an essential part of his country’s healthcare system. He had already specialized in anesthesiology in order to focus on pain relief, and he subsequently trained in palliative care with Prof. Anne Merriman at Hospice Africa Uganda. This institution has made Uganda a frontrunner in Africa in providing palliative care to those in need, with its philosophy of proximity to the patient and its pragmatic approach to safely providing low-cost liquid oral morphine. Much of their experience is directly applicable, with adjustments, to other lower-income countries. Martin envisaged a national conference where all major stakeholders could be brought together to discuss the needed reforms and commit to implementing them.
Organising a national conference
The Organisation for the Prevention of Intense Suffering (OPIS), a Swiss think-and-do tank, had already been advocating for access to morphine as a human right, with an expert panel event at the Human Rights Council in 2018 and the production of an advocacy guide to the issue. Martin contacted OPIS in view of a possible collaboration. In the absence of immediate funding sources, we conducted a successful crowdfunding campaign to cover the costs of a conference. We then drafted an advocacy document making the case to the Ministry of Health, which agreed to support the initiative. Martin had worked previously with the new Minister of Health, and this fortunate circumstance facilitated the contact.
Around 100 participants attended the conference in Ouagadougou on 2-3 December 2019, including doctors from around the country, representatives of the government, a WHO representative, and also specialists from other countries, including Prof. Anne Merriman and Prof. Benoit Burucoa, head of the International Francophone Palliative Care Federation (FISP). Documents detailing strategies for providing access to morphine, introducing training and education, and making legislative changes were prepared in advance and discussed, refined and validated at the conference. The Minister of Health, Prof. Léonie Claudine Lougue/Sorgho, gave a talk, met with the organisers and promised to implement our recommendations.
Minister of Health, Léonie Claudine Lougue Sorgho with the authors and other conference participants. Photo: © Perside Tindano
Maintaining momentum
Since the conference, the government has confirmed its intention to carry through on the recommendations and also make legislative reforms. Palliative care curricula are already being planned at some of the country’s medical schools. The coronavirus crisis has meanwhile been commanding attention and resources and delayed implementation of our initiative. But of course, patients continue to die in pain without morphine and palliative care, and the coronavirus has only increased the number of patients with such needs – a plight that tends to be forgotten with the focus on deaths rather than suffering. We are hopeful that the momentum created will be recovered and that the implementation of palliative care in Burkina Faso will soon be given the priority it so urgently requires.
Key principles for promoting palliative care
There are a few key principles we think are worth sharing. First of all, it is essential to have one or more local, visionary champions who are passionate about relieving suffering and perseverant in the face of challenges, in order to take the initiative and create the momentum needed for change. Providing support to any new trailblazers is one of the best investments one can make in promoting palliative care in a country.
But little can be achieved without the buy-in and support of a country’s Ministry of Health. It is crucial to establish contacts with the government and make the case for palliative care, which according to a 2014 World Health Assembly resolution is an obligation of member states.
In order to provide an overriding legal framework for action, a priority should be to establish legislation guaranteeing the right to access effective palliative care, including essential pain treatment.
Palliative care must be incorporated into the educational curriculum for all healthcare practitioners. Education should include sensitization and strategic action to dispel myths, fears and misconceptions associated with the use of morphine, emphasizing that addiction does not occur when oral morphine is used for severe pain. Health professionals and regulators should also be given special courses on morphine metabolism and the benefits of oral morphine for ensuring smooth pain control versus injectable morphine.
Because there are not enough doctors to provide palliative care or prescribe morphine in most lower-income countries, it is important to empower nurses and also authorize them to prescribe morphine once they have undergone a specific training program. Mobile palliative care units associated with medical centers can provide palliative care to far more patients at home than if terminally ill patients need to travel. Each health center should aim to have at least one trained nurse prescriber who can lead a team and prescribe morphine for severe pain.
As there is no palliative care possible without morphine, all potential obstacles to procuring and importing it, manufacturing liquid oral solutions, distributing it and prescribing it must be identified and addressed. Oral morphine can initially be made in local pharmacies while demand is low, using the “kitchen sink” method. A central manufacturing facility can later be established by the Ministry of Health or through a public-private partnership, providing distribution throughout the country.
Excessive legal restrictions and burdensome regulatory frameworks based on unfounded fears of misuse or diversion must be relaxed, including limits on the number of days’ supply that can be provided in a prescription, limits on doses, limitations on which doctors can prescribe, special procedures and forms that are difficult to obtain, excessive penalties for prescription errors, limited availability in pharmacies, unreasonable storage requirements, and a refusal of doctors to prescribe it.
The use of morphine should be destigmatised through an information campaign, informing patients and doctors that everyone has the right not to die in pain, and countering the false belief that morphine use by patients leads to addiction. More generally, for ethical and practical reasons, national drug policies need to shift from a criminal justice approach to one anchored in public health and human rights.
Mamadou, a terminal cancer patient we visited in Ouagadougou. Photo: © Benoit Burucoa
Seeing the suffering up close
Suffering can seem abstract until one is reminded of the reality of it. Accounts of cancer patients unable to treat their severe pain are heart-wrenching. The day before the conference, a few of us visited two cancer patients for medical consultations in their homes in Ouagadougou. Although they were materially better off than most of the population, both were in constant pain, and one of them, Mamadou, lay in bed in agony. He died a week later. Thousands in his country and millions worldwide share the same fate every year. It is essential that we keep aiming for a world where no one is ever left to live their final days in a state of pain, and where the relief of pain and suffering is given the highest priority by governments everywhere.
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