In 2017, The Lancet published a report on the international lack of palliative care. It is a tale of woe documenting the sorry state of unrelieved global suffering. Everywhere “people live and die with little or no palliative care or pain relief.” It describes the “access abyss” in which the poor live and die in extreme suffering without receiving pain-relieving medications. They describe the world in which most of humanity lives in as a world of hurt.
The report cites poor public health planning and poor physician understanding of pain relief as the major causes the multinational shortfall of palliative care:
1. International health policy investments have focused on infectious diseases. The lack of pain relief at the end of life is due to the neglect of non-communicable diseases where the need for palliative care is highest.
2. Opiophobia is the “prejudice and misinformation about the appropriate medical use of opioids.” Opiophobia worries more about the addiction of the living than the palliation of the dying.
There is an astounding maldistribution of pain relievers expressed as morphine equivalent opioids (MEOs). Of the 68,000 pounds of MEOs distributed worldwide, only 225 pounds is dispensed in low-income countries. In Haiti, only 5mg of MEOs per patient are available, leaving 99 percent of the palliative care needs unmet. In America, MEOs are a staggering 55,000 mg/patient! This meets >3000% of USA needs vs. <6% of MAO needs in Haiti which leaves almost everyone there suffering from serious health-related suffering (SHS) in pain. SHS is suffering that “cannot be relieved without medical intervention that compromises physical, social, or emotional functioning.”
It is not only the poor countries’ poor who needlessly experience SHS but also the rich countries’ poor and, frequently, the rich countries’ rich. In poorer nations, poor access to “inexpensive, essential and effective intervention” to relieve their physical torment. In America, there are frequent reports that despite the 55,000 mg/patient of MEOs many live with unrelieved SHS. For the authors, this is “a medical, public health, and moral failing.” America’s patients enduring unpalliated SHS are also in this world of hurt.
Relief of unnecessary physical pain is a right of all patients in all places. It is not a lack of drugs but a lack of appreciation that pain is an agony for the sick and their loved ones, that pain destroys the person as well as the body, and that mitigating unnecessary suffering is an ethical obligation. The global lack of pain relief is a hurtful healthcare failing on a distressingly worldwide scale.
At the center of this hurting world is the painfully skewed maldistribution of pain-relieving medications. The WHO has estimated that 80 percent of the world’s population has no meaningful access to MEOs. The International Narcotics Control Board reported that in 2014 a mere 17 percent of the world’s population consumed 92 percent of all MEOs. This disparate distribution of opioids is grimly illustrated by the fact that while over 12 million people died in pain for lack of opioids between 2016 and 2017, over 64,000 Americans died from an excess of them. In a poignant counterpoint to The Lancet report, just seven days after it was published, the U.S. declared the “opioid crisis in the USA to be a public health emergency.”
This globalization of pain is old news. In 2012, the New England Journal of Medicine published an editorial entitled “Painful Inequities – Palliative Care in Developing Countries” detailed the global burden of pain and the global initiatives to relieve. Back then, 150 countries were identified where “morphine is simply not available.” The conclusion about this human catastrophe was, “People dying in pain are generally invisible.”
The Global Access to Pain Relief (GAPRI). GAPRI has estimated that as many as 5 billion people live with “little or no access to pain medications.” This included >5 million terminal cancer patients. Their website is harrowing to peruse.
The American Cancer Association’s Treat the Pain Program has the ambitious goal “to make effective pain medicines universally available by 2020.” The ACA works with governments and international health partners to raise international awareness that the poor feel the same pain as the wealthy. Pain is everywhere on our planet, but pain medications are not.
Unrelieved global pain is not only a “medical, public health, and moral failing,” it is more disgracefully an economic failure. The cost of meeting the global need for pain-relieving opiates is approximately $145 million which is “equivalent to a very small fraction (0.002 percent) of total public health expenditure.” The money is not spent because the problem is not seen. The world-wide unrelieved suffering is appallingly invisible. The farther the problem is from our homes, the farther it is from our consciousness and consciences.
This is not merely an income or geographic problem. Many in the wealthy nations despite being awash in opiates suffer just like those in poorer countries, but the poor of the world suffer more intensely, much longer and in much greater despair. The poor often have no physicians to champion their plight. They are often so ill, in so much pain and so politically disenfranchised that they are powerless to advocate for themselves.
If we are to preserve the dignity of the dying of our world, we must palliate their suffering. Palliative care is a right of all people in pain at home and abroad. The unrelieved pain locally and globally is unfathomable to contemplate and unspeakable to endure. This problem is “generally invisible” only because we choose not to see what The Lancet has revealed. We need to examine their revelations with our eyes wide-opened and see that many people who share our planet live in a world of hurt. Those living in this world of hurt need better pain relief. Attempting to meet these needs will not only preserve the dignity of the dying but our dignity as their fellow human beings as well.
Michael A. Salvatore is a palliative care physician.
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