"Not even highly developed countries can make progress on complex issues such as palliative care without sharing experiences with others," according to Marie-Charlotte Bouesseau, Adviser for the Department of Service Delivery and Safety at the World Health Organization (WHO), who spoke at the University of Navarra's Madrid campus. The expert spoke at a press conference presenting two atlases that analyze the state of palliative care in Africa and the Arab countries in the eastern Mediterranean. The ATLANTES Program at the Institute for Culture and Society (ICS) organized the project.

"These publications represent great hope. In 2014, the World Health Assembly adopted a resolution to strengthen palliative care around the world, a global commitment involving 194 states," she noted.

"In addition to hope," she added, "the question remains as to how the resolution will be implemented such that it reaches citizens. This involves implementing a monitoring system of practices. These atlases take our commitment seriously and help us get a better understanding of what is happening in countries that face many health challenges."

She also referred to the importance of the media’s role in the development of palliative care, saying, "Social debate is key; informing the public is necessary to empower communities, to help people express their opinion and to dialogue with the politicians, health professionals and other actors who are involved."

Other contributors at the press conference included Carlos Centeno, principal investigator of the ICS ATLANTES Program, Emmanuel Luyirika, executive director of the African Association of Palliative Care, and Hibah Osman, executive and medical director of the Lebanese Center for Palliative Care-Balsam.

Services, medicine, professionals and health policies

Dr. Centeno recalled that these volumes are pioneers in their field. A comprehensive study on care for people at the end of life has never been done in the Arab countries of the eastern Mediterranean, while in Africa one was carried out in 2007, but never followed up on.

"These atlases represent a tool that will drive future development in palliative care. They will fall into the hands of healthcare professionals and basically act as a business card for the countries involved. They provide data on every country’s specific situation and where they are compared to their peers,” he emphasized.

He also noted that the volumes provide additional and updated indicators than what the WHO offers, including availability of services, access to medicine, training of professionals and promotion of health policies.

Centeno received a question about limited access to pain-relief medicine, which in Africa is 1 mg per capita per year and in the eastern Mediterranean is 4.5 mg per capita per year compared to 120 mg in Europe.

"The WHO estimates 200 mg per capita per year. One wonders why medicine that is so cheap does not reach the population," he said. He mentioned several possible factors, saying, "On the one hand, there is a fear of morphine and opioids, which many people associate with death— and reflect a fear of dying. One the other, the health systems involved are clearly not working properly because they should ensure that the medicine reaches the population."

In this regard, he mentioned Hospice Africa Uganda as an example of best practices. The hospice is a model care center within the country and it “manufactures and packages morphine for all of Uganda."

Training physicians on the use of morphine

On the other hand, he emphasized that a lack of education is also a fundamental factor. "Morphine does not in itself kill; it relieves the sick and doctors have to be taught to use it. My students at the University of Navarra’s School of Medicine learn about proper dosage for pain management, but in many schools this is not taught," he said.

In addition to the two factors that Dr. Centeno identified, i.e., cultural barriers and training, Marie-Charlotte Bouesseau added another: legislation. "There are very different regulations on access to controlled medicines like morphine. At the WHO, it is important for us to work with countries. There should be regulation, but it should not prevent access."

"In some countries, a weekly prescription is required. People who live in the countryside cannot go back to the city every seven days and so when they need the medication they have no access to it," she added.

Finally, she noted that some countries, such as the United States, have problems with overdose and thus require "strict control," but others "need more flexibility… No one solution fits all contexts and countries." 

Supporting patients with advanced diseases

Hibah Osman, executive and medical director of the Lebanese Center for Palliative Care-Balsam, reported that she has been practicing this specialty for a decade. It all started when working as a family doctor and finding that "there was nothing to offer" patients with advanced disease.

"One of them was a very clever 96-year-old woman. She asked me not to send her to the hospital because she wanted to stay home. It was very difficult to control her pain and I could not treat her when she had complications," she said.

"In Lebanon, many people live with advanced diseases. Cancer is detected in advanced stages and only palliative treatment can be offered. The system was not supporting these patients and we wanted to cover that need," she assured.

Among the difficulties that she encounters in her daily life, she mentioned that in Lebanon family networks are very important and they try to protect the sick by hiding their diagnosis. "Many people do not know they have severe illnesses because their closest relatives do not tell them."

Finally, she referred to the value of the palliative care atlas for the Eastern Mediterranean region: "It not only gives us valuable information, but it also helps researchers in the region and encourages them to promote palliative care in their countries. It empowers us to develop palliative care projects in the future."

Africa: A growing problem of cancer and infectious diseases

Emmanuel Luyirika, executive director of the African Association of Palliative Care, said that the African continent poses major challenges in the field of health: its inhabitants make up 10% of the global population— plus one million refugees from neighboring countries— and they are facing growing rates of cancer and infectious diseases. "Countries aim to invest 15% of their GDP in health, but some nations aren’t even at 7%," he lamented.

In this sense, he stressed that the Atlas of Palliative Care in Africa "allows countries to know where they are in the field of palliative care" in terms of policies, education and human resources, specific programs and access to medicine. "With these publications, we can work with governments to implement international resolutions, such as those from the WHO."

To explain the fact that Kenya, Uganda and South Africa account for 71% of the continent's palliative care services, Luyirika pointed to a historical question: "On the one hand, they are Anglophone and many of their programs were originally linked to others that the United Kingdom implemented. There has also been strong local interest. In addition, the role of NGOs and volunteers should be highlighted."

He also noted that the African Palliative Care Association wants to extend access to services in other French, Portuguese and Arabic speaking countries.

He also recalled that funding for AIDS has played a key role in the development of palliative care on the continent, since there have been 23 million people affected by the disease and treatment options are very limited. "We have access to a model for treating patients in advanced stages of disease. The risk is that, when funding wanes, many palliative programs may be affected," he warned.