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June 06, 2006

HIV/AIDS & Cancer Palliative Care

by Bamuturaki Musinguzi, Kampala, Uganda (June, 2006)

nurse showing patient how to take morphine orally
Nurse Jerith, a CPCC Nurse, shows a patient and family how to measure out liquid morphine.
For a price of two or three loafs of bread cancer and HIV/Aids patients in Africa can now afford cheap pain killers for a week after the continent obtained affordable oral morphine in 1990, which can be used in a home and controlled by the sick.

This also followed the international community declaring “to be free of pain” a human right. This

brought up a challenge for medical and health workers to manage and control pain and give palliative care (a holistic approach looking at the spiritual, physical, social, cultural and economic) of HIV/Aids and cancer patients. It costs Hospice Uganda Ushs. 20,350 ($11) per week to care for a patient. Hospice asks the patients for a contribution of Ushs. 5,000 ($2.7) per week towards the cost of medicines, and less than 1/3 of its patients can afford this. It assists 60 per cent of those who cannot afford.

“It was a big break through because it’s now cheaper to bring in the morphine powder and make it here in a pharmacy,” said Dr. Anne Merriman, director of policy and international programmes, Hospice Africa Uganda.

“ If to be free of pain,’ is a human right then people should ask their MPs to have this service in their constituencies,” Dr. Merriman suggested.

“Its difficult to abuse oral morphine, there is no addiction or diversion compared to the tablets,” Dr. Merriman said.

“When taken by month it dose not give ‘a high’ if you have pain.” According to Dr. Merriman the pain of cancer never goes until one dies:

“We can control the pain of cancer of 98 per cent of the patients we treat and have the pain controlled. For HIV/Aids patients they usually get severe pain from infections such as Kaposi’s sarcoma (commonly called Kisipi in Uganda). If they have access to the antibiotics/fungi then as the infection is cured then we can withdraw the pain killers.” Dr. Merriman, who was the first director of the Nairobi Hospice in 1990 and later left to start a model Hospice in Uganda in 1993 where other countries would learn by taking care of the African cultural and economic aspects, believes making palliative care affordable has been Hospice Africa’s greatest objective on the continent.

Hospice Uganda is the model Hospice for Hospice Africa. Hospice Africa was founded in 1993, to promote the initiation of Hospice in those countries in Africa who have not yet got assistance of palliative medicine.

Uganda was the third country to commence palliative care in sub-Saharan Africa (excluding South Africa). Zimbabwe was the first (1977) and Nairobi Hospice the second (1990). The objectives of Hospice Africa are to provide and promote a palliative care service to patients and families, within a 20 kilometer radius of Hospice. To carry out education programmes in palliative medicine, to health professionals at undergraduate and postgraduate levels throughout Uganda so that this form of care can be available to all in need. It also encourages the initiation or consolidation of palliative care in other African countries, by providing a facility at hospice Uganda fro training, and experience of palliative care working in the African context.

Each year Hospice Africa Uganda has a Palliative Care Week to promote palliative care and to let people know that they have a human right to be free of pain before they die. This years week from May 8 -13th, 2006 under the theme, “We want to see that this Medical Specialty Come to Your Home,” climaxed with a hospice sponsored charity walk on May 13th from the Constitution Square in the capital city and finishing at the hospice headquarters in Makindye a suburb of Kampala to raise money for the terminally ill patients in Uganda. Hospice Uganda is entirely dependent on the goodwill of donors. In UK support comes from two charity shops in Liverpool and Ainsdale, run by volunteers. Donations come from other organizations and individuals all over the world on an ad hoc basis. WHO in 1996 recommended that nurses would be allowed to prescribe morphine in countries where there are insufficient doctors.

Uganda is the only country in the world where nurses and clinical officers have undergone training at Hospice Africa Uganda in palliative care. They can prescribe morphine without a doctor after the Ugandan government amended the law. Hospice Africa Uganda has trained over 2,730 health and non-health professionals in 21 districts of the country of which 325 are community volunteers. Hospice Africa Uganda that started with three staff in 1993 has now grown to 107 workers in three Hospice centers in Kampala, Hoima and Mbarara districts. In the last 13 years it has looked after 9,000 patients 6,000 of whom have been on oral morphine. It’s estimated that up to 60 per cent of its cancer patients also have Aids. With the conquering of infections diseases by improved sanitation and the recent arrival of Aids with its associated cancers, the causes of death are now changing. In those countries without disasters of war or famine, cancer is the first or second cause of death. Unfortunately less than 10 per cent of resources committed to cancer control are available to patients in the developing world where the biggest increase in cancer is taking place.

Hospice Africa says: Patients seek medical care with already advanced cancers and with severe consequences of pain, symptoms and gross disfigurement. Most are sent home from conventional medical establishments and clinics with few simple analgesics at eh most, as there is nothing left to be done fro them. “This leads to untold suffering for the patients and family.”

Currently in Uganda 1.5 per cent of its total population develops cancer each year. The raise from 1 per cent is due to Aids associated cancers in Uganda. Hospice Uganda looks after cancer and or HIV/Aids patients by bringing the modern methods of pain and symptom control.

“Aids has brought an epidemic of death and increased the urgency fro palliative care services not only in hospitals but in the community and reaching to village level where up to 57 per cent of the population may never see a health professional,” Hospice Africa says. “Palliative care must reach these people through training of health and non health professionals who live in the villages. 20-50 per cent of patients with HIV/Aids have severe pain. Aids has brought a great increase in cancers and Kaposi’s sarcoma is now the highest occurring cancer in Uganda.”

There is much attention given to the procurement of ARVs for Africa at present, Hospice Africa observes. “However this will not mean there is no need for palliative care for all, even those who are rich or powerful enough to access them will need palliative care when their time comes.”