The what, why and how of health and development

Bringing morphine to millions

The following article was originally published on Think Africa Press in December 2012. The site has since closed down but since this topic is still a very important one and still close to my heart,  I wanted to republish the original (pre-edit) version here:

Bringing morphine to millions

Credit: Treat the Pain

Credit: Treat the Pain

For millions of people living with difficult health conditions, only the strongest form of relief allows them to live without the trauma of unrelenting pain. Morphine, a Class A opioid, is cheap, plentiful and frequently prescribed in the UK to aid suffering or, for many, ensure peaceful final days. But for many millions more this essential relief is another denied right.

Living with an open tumour on his neck, isolated because his family had been unable to cope with the stench of the final stages of his cancer, Frank, a 49 year old Ugandan man, had not slept or eaten in weeks because of the pain.

Found by a community volunteer worker from Hospice Africa Uganda (HAU), Frank was fortunate. He was referred to the hospice team and having cleaned the wound and showed him how to use oral morphine, the hospice worker talked with the family who returned to continue his care.

“He was able to eat a little, sleep a little more, and settle his affairs before he died at peace, with his family and pain-free three weeks later,” says CEO of the hospice Zena Bernacca. “Having pain relief makes a real difference, otherwise one’s whole existence is narrowed down to suffering unimaginable pain, obliterating everything else.”

Relief from pain means other social and emotional needs can be addressed such as future childcare or religious wishes. For Frank, the palliative care and morphine provided by HAU meant he could be with his family.

“I have slept for the first time in many weeks,” he told hospice care workers. “This wound is clean and no longer smells, I have my family back and I have food to share. I am blessed.”

Considered essential by the WHO, morphine costs pennies to provide. But 80% of the world’s population doesn’t have access to this treatment and where demand is highest, access to pain relief is at its lowest. Accounting for 70% of cancer deaths and 99% of HIV related deaths, low and middle income countries consume just 7% of world’s medicinal opioids.

“Pain relief is a central component to palliative care,” says Dr Emmanuel Luyirika, Executive Director of the African Palliative Care Association. “Without immediate release oral morphine it’s impossible to manage moderate to severe pain.”

A survey conducted by the International Narcotics Control Board in 2010 found the main reason given by governments for low availability of opioids was concerns about addiction, followed by reluctance to prescribe and insufficient training for professionals.

“There’s an issue of strict regulations in countries based on unfounded fear of abuse but also limited understanding of palliative care at most levels of policy, service provision and community within those countries,” says Dr Luyirika.

However several models of pain treatment in Africa have caused palliative care on the continent to grow at an increasing pace, providing opportunities for governments and organisations to collaborate and learn.

Hospice Africa Uganda offered the earliest model designed for the African setting. Founded by Dr. Anne Merriman in 1993, HAU has long produced oral morphine for growing numbers of patients each year. But two years ago they broadened the reach of this drug significantly when Uganda experienced a national stockout. Encouraged by NGO Global Action for Pain Relief (GAPRI), the hospice tendered for the contract and has since been selling stocks to the government for distribution nationally.

Uganda also overcame another obstacle by becoming the first country to train nurses to prescribe morphine. Previously only doctors could prescribe this drug but rural Uganda has just one doctor for 50,000 people and meeting demand was impossible. Routine meetings and training allow the hospice to alleviate any staff worries about misuse, who in turn are able to placate any fears from patients and families.

“Out of ignorance, so many are concerned about potential addiction” explains Bernacca. “However, once there is an understanding of how morphine works as a pain-killer and when used appropriately, it does not cause addiction, the patient is relieved and the majority of carers are also relieved of the distress of witnessing such pain.”

Along with programmes in Tanzania, Kenya and Zimbabwe, this public/private partnership is now a model of morphine production other countries are learning from. Research into palliative care and pain relief best practice on the continent is lacking but these programmes are building understanding of how this care can fit alongside other African health policies.

“These palliative care programmes are helpful because they show us what is possible,” says Director of GAPRI, Dr Meg O’Brien. “They provide models that can be adapted to other programmes and they give us evidence about the cost and impact of services that we can use to help leaders in other African countries make more informed decisions about what kind of care is achievable.”

The complexity of supplying morphine means that in many African countries political will is not enough. GAPRI have consistently found governments keen to provide pain relief services but facing technical and bureaucratic barriers.

Pain treatment doesn’t sit easily in one area, which can cause questions about department responsibility. Alongside this, an effective programme requires cooperation among disparate groups including policymakers, training institutions, hospital administrators, drug procurement bodies, financing offices, clinical guidelines committees, and drug regulators.

“Sorting out the necessary collaborations is time-consuming and many governments simply lack the capacity to push changes through quickly,” says Dr O’Brien. GAPRI address this by helping Ministries of Health with research, chasing paperwork, consultations and consolidating data. At just two and a half years old, they’re a young and small organisation but their work is developing at a rapid pace, reflecting the growing interest in pain treatment.

As calls grow for non-communicable diseases to be included in any future post-2015 sustainability goals, palliative care and pain relief programmes could offer an initial achievable step in this direction. Uganda has one radiotherapy machine, as does Kenya, which treats two people per day and 80% of its use is to palliate. Scaling up resources to combat increasing cases of NCD’s requires a long-term strategy and significant funding. Pain relief programmes offer opportunities to initially expand into this area and start bridging the false divide between communicable and non-communicable diseases.

“Rather than distract Ministries, I think an initial focus on palliative care actually focuses efforts,” suggests Dr O’Brien.

“Provision of modern pain relief and palliative care is a “low-hanging fruit”. It can be done using existing funds and resources and will have an immediate benefit for cancer patients and others who suffer pain. I see it as an ideal starting point for Ministries to expand care for NCDs while the international NCD community works on expanding funding and staff.”

Reblogged from The Wire: India Must Resist US Pressure on Generic Drugs, African Leaders to Tell Modi

This explainer from journalist MK Venu writing for the Indian magazine The Wire talks us through the pressures on the Indian government from US pharma and African governments, representing both sides of the generic medicine debate:

In his ‘Mann ki baat‘ radio show on Sunday, Prime Minister Narendra Modi proudly spoke about how India will host 54 heads of state from Africa for the first time to reinforce “our nation’s historical and cultural links’ with African countries.

However, invoking this very spirit, the visiting African leaders will place before the Prime Minister an issue of life and death for their peoples in which India can play a critical role – the export of cheap and affordable generic medicines for the cure of AIDS and other deadly diseases. The African heads of state will urge Modi to resist growing pressure from the United States government and Western drug multinationals on India to stop exporting cheap generics to Africa.

Continue reading at The Wire.

UK ranked top for palliative care by Quality of Death Index

The UK continues to deliver the best palliative care in the world according to the latest revision of the Quality of Death Index.

The report commissioned by a Singapore philanthropic organisation the Lien Foundation and released by the Economist Intelligence Unit compares palliative care services in eighty countries using interviews with more than 120 experts.

As in previous reports, the UK was followed by Australia, New Zealand, Ireland and Belgium as the best countries in terms of structures supporting palliative care, although the report did not look at the effect these services had on patients and families.

Funding is a key factor in determining the quality of these structures, although examples of resource-poor countries that have made gains in this area include Panama – which has integrated palliative care into primary care and Mongolia – where education and the enthusiasm of individuals has also helped to develop services.

Click here to read the full report

Malaria control “great public health success story” but drug resistance concerns persist

The number of people dying from malaria has dropped 60 percent since 2000, according to a UN report declaring the goal of halting the spread of the disease has been “convincingly” met.

The report released today from the World Health Organisation and UNICEF says that 6.2 million lives have been saved in that time and new malaria cases have also dropped by 37 percent.



According the report, the latest data shows that the malaria Millennium Development Goal, which aimed to halt and begin the reverse the incidence of malaria by 2015, has been met.

The vast majority of people saved were young children, the UN organisations said.

Director General of WHO Dr. Margaret Chan described global malaria control as “one of the great public health success stories of the past 15 years”.

She added: “It is a sign that our strategies are on target, and that we can beat this ancient killer, which still claims hundreds of thousands of lives, mostly children, each year.”

The report claimed it was a surge in funding since 2000 that helped to tackle the onslaught of the disease, with approximately one billion insecticide-treated bednets (ITNs) being distributed in Africa, thought to account for an estimated 68 percent of malaria cases prevented since 2000.

The increasing use of rapid diagnostic tests, and effective treatment using Artemisinin-based combination therapies (ACTs) are also factors contributing to the drop in the number of people dying from malaria.

The number of deaths due to malaria are still extremely high, however, with an estimated 438,000 dying in 2015 alone from the preventable and treatable disease, the majority in Sub-Saharan African countries.

The report also emphasised that 1 in 4 children in sub-Saharan Africa still lives in a household with no ITN and no protection provided by indoor residual spraying.

Recent research has also pointed to the growing resistance of some malaria parasites to treatment.

Researchers at the London School of Hygiene & Tropical Medicine, writing in the journal Antimicrobial Agents and Chemotherapy, confirmed in April this year early indicators of the malaria parasite in Africa developing resistance to the most effective drug available.

Mutating the malaria parasite in a laboratory to mimic mutations seen in Kenya, they found the parasite required 32 percent more of the anti-malaria drug artemisinin to be killed.

Separate research published in the New England Journal of Medicine in July 2014 also found that resistance to artemisinin is now present in Eastern Myanmar, Thailand and Southern Vietnam, as well as Western Cambodia.

No Sex Please We Are As Embarrassed As You Are


Funny insight from 17-year-old girl into the realities of school sex education. Worth a read!

Originally posted on Yomikomi:

Sex Ed

If I could sum up my sexual education provided by my school in Devon in 5 thoughts they would probably be-

Why is Mr Hake looking like he would rather be in hell right now?

Why do the model penises look more like a murder weapon than genitalia?

Is this really what sex is?

Do teachers have sex?

Is it odd that half the girls in my class seem to know exactly how to put a condom on without instructions from the teachers?

I think at this point in my life the closest I got to the world of sex was seeing my rabbit try to hump my pillow. So, as you can imagine, my perception definitely expanded on that wet Thursday of awkward lessons.

At the time, I thought it was great because it meant we could play with condoms and not really listen but actually, now that I…

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Improving food security can affect HIV outcomes

Providing financial and agricultural support to people living with HIV improves their bodies’ defences against the disease, according to a study that researchers say is the first to link agriculture with HIV outcomes.

Scientists say that patients with HIV who were given farm management training, microloans, and support using new technologies, saw an increase in the infection fighting white blood cells (CD4 T-cell). Their rate of viral suppression also increased by about one half.

The results of the study, carried out with 72 participants over the course of a year at two Family AIDS Care & Education Services (FACES) health facilities in Kenya’s Nyanza region, were released ahead of its publication in the journal AIDS.

In a separate control group of 68 people, who did not receive the farming support, both the CD4 cell counts and the rate of suppression fell.

The trial’s co-primary investigator Sheri D. Weiser, from the UCSF Division of HIV, Infectious Diseases and Global Medicine at San Francisco General Hospital, said: “While this was a pilot study, these results prove the concept that improving food insecurity and alleviating poverty can affect HIV clinical outcomes.”

“HIV/AIDS and food insecurity are intertwined in a vicious cycle, with each increasing vulnerability to and exacerbating the severity of the other. We have the biomedical tools to treat and prevent HIV, but we need interventions like this that combine healthcare with development, and address food insecurity, poverty and disempowerment if we are to achieve the UNAIDS goal of ending the HIV/AIDS epidemic by 2030.”

Palliative stories – turning the negative into a positive


A touching story from an accountant who was inspired to study nursing and palliative care after the death of her husband (part of the EAPC Palliative Stories blog series):

Originally posted on EAPC Blog:

Palliative Stories – the EAPC’s blog series from the perspective of patients and family carers

Today, Jennifer Fox shares her story.  Jennifer recently completed a PhD exploring the transition to palliative care at Institute of Health and Biomedical Innovation and School of Nursing, Queensland University of Technology, Brisbane, Australia.

“We must turn this negative into a positive.” My husband of 26 years said these simple, optimistic words on the day he was diagnosed with melanoma and was informed he might only have months to live. These words were an unexpected source of strength and guidance for me during his illness and continue to inspire me now, almost 10 years on from his death.

Jenny Fox with her husband, Murray, three months before he died Jenny Fox with her husband, Murray, three months before he died

In 2004 my husband was diagnosed with melanoma. Five months after diagnosis the surgeon delivered the news, “go home and get your affairs in order…

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