Regional Reports: Tanzania, Georgia and Nepal

Achieving a morphine breakthrough in Tanzania

In Tanzania, it is estimated that 40,000 new cancer cases are diagnosed each year, but only 4,000 reach the Ocean Road Cancer Institute ( ORCI) for care while 21,000 die (1). The country is also home to over 2 million people who are HIV-positive. When thinking about all these people with painful life-threatening diseases, the question arises as to how can palliative care and effective pain management become a reality in our country?

Despite an obvious need, Tanzania remains one of many developing countries where the use of morphine for the treatment of pain is extremely low. According to Mr Sillo Hiiti, Director General of the Tanzania Food and Drug Authority (TFDA), for our population of over 40 million, only 750 grams of morphine powder were imported during 2009 and 1647.7 grams in 2010. The consumption of morphine is negligible in Tanzania when compared to countries with better pain management, like the USA, in which morphine consumption is 76.7 mg/capita (2).

For years, morphine has only been available in four treatment sites in the country, they are: ORCI which is the only cancer treatment centre in Tanzania, PASADA, Muheza Hospice, and Selian Hospice. All these centres are in urban or semi-urban areas, which leaves rural-based populations with very limited or no access to morphine.

Many factors contribute to poor access to morphine in Tanzania and these include the failure of many hospitals to meet the TFDA criteria for approval (e.g. application procedures, possession of qualified pharmacists, timely submission of narcotics consumption reports, etc.). Due to the ongoing efforts of key organisations such as the Tanzanian Palliative Care Association, ORCI, and the Evangelical Lutheran Church in Tanzania, and after a very successful meeting with TFDA authorities in February 2011, we secured TFDA permits for the procurement and use of oral morphine in 15 hospitals located in resource-poor rural settings. ORCI agreed to provide training for the staff of the recipient hospitals -- Kagera Government Regional Hospital, Shirati Mennonite Hospital and 13 others in the Lutheran hospital network.

On Friday 4 th March 2011, the first group of trainees completed their clinical placement on the use of oral morphine. The trainees included three pharmacy staff and three clinicians from Ndolage, Gonja and Machame hospitals. They were able to take home their first supply of five litres of oral morphine which became available for patient use on 7 March 2011. Three more hospitals have since completed another course at ORCI and morphine is now available for their eligible clients.

This breakthrough marks the very first time that widely scattered rural health facilities in Tanzania can use morphine for the management of severe pain. It is my hope that with improved advocacy, the powerful voices of palliative care providers and the Ministry of Health and Social Work will continue to bring attention to the needs of patients for access to morphine and better pain management in rural Tanzania.

Author:

Paul Zebadia Mmbando (MBChB, MPH, DrH)
Manager, Palliative care (CHAT) Project
Evangelical Lutheran Church in Tanzania (ELCT) Health Department
Arusha, Tanzania
Email: [email protected]

References:

1. Kagashe, Beatus. “ Tanzania: Cancer Awareness Still Low” The citizen 12 March 2011. 22 March 2011 http://allafrica.com/stories/201103140376.html

2. International Narcotic control Board; United Nations population data By Pain & policy studies group, University of Wisconsin/WHO collaborating center, 2009. http://www.pain policy.wisc.edu/ internet/countryprofiles.htm

From Grahamstown South Africa

“In Grahamstown, South Africa, HIV and TB co-infection rates are over 70% and the number of drug resistant TB patients is rising steadily. There are two types of drug-resistant TB -- multidrug-resistant TB (MDR-TB), which is resistant to at least two first-line anti-TB medicines, and extensively drug-resistant TB (XDR-TB), which is resistant to all first-line drugs and some second-line antibiotics. MDR treatment is costly and time consuming for clinical staff since patients require injections five days a week, typically over a four to six month period. Some have described the rise of MDR as a ticking time bomb.  In an attempt to reduce this pending problem USAID ( http://www.usaid.gov/ ) has generously funded a one year trial in four hospices in the Eastern Cape to work with the Department of Health to treat MDR patients.” 

David Barker
 Director Grahamstown Hospice

Uniting Lawyers with Hospices in Georgia

by Tamar Ezer

“People facing life-threatening diseases can benefit significantly from
palliative care. As defined by the World Health Organization, palliative care
helps patients and their families relieve pain and suffering by providing
physical, psychosocial, and spiritual support. Helping patients and their
families address legal and human rights issues is a crucial part of the holistic approach of palliative care.

People living with AIDS or cancer often face complicated legal questions
related to the disposition of property, planning for children, accessing social
benefits, and combating discrimination. Caregivers may be particularly
vulnerable to human rights abuse. Over the past four years, the Open Society Foundations have supported efforts to link palliative care providers with legal advocates to address these issues in Georgia, Kenya, South Africa, Tanzania, Uganda, and Ukraine.

In Georgia, this has taken the form of pro bono legal services. Legal
services are expensive in Georgia and beyond the means of many palliative care patients, who have undergone long-term, intensive, and costly treatment, exhausting their budget. In October 2008, the Open Society Georgia Foundation held an introduction session on palliative care for legal groups. Kordzadze Law Office, a prestigious Georgian law firm, dedicated one of its lawyers to visit the hospices and remain on call to meet with patients.

A year later, the Open Society Georgia Foundation organized a public launch of the initiative to interest additional law firms. At the launch, a documentary film highlighted the dramatic case of one of the first patients benefiting from the program. The Kordzadze Law Office helped reunite a cancer patient with her husband, who was serving a prison sentence, four days before her death.

After the launch, two additional law firms volunteered to provide free legal
services to palliative care patients. Today, three law firms have partnered with the hospices in Georgia to provide patients with comprehensive care that addresses legal needs. Twenty-five patients have had legal issues successfully resolved through this project. The lawyers have further expanded beyond helping individual patients to working with the hospices on their legal matters, such as cooperation agreements with
insurance companies.

Georgia has provided us with a successful model of integrated legal and
palliative care services. But this collaboration between lawyers and health
providers is all too rare, and there is much more work to be done to provide
palliative care patients with good, holistic care. Please stay tuned for an
update from our projects piloting these integrated services in Africa.”

Tamar Ezer
Tamar Ezer is a Senior Program Officer in the Law and Health Initiative of
the Open Society Public Health Program.

Reprinted with permission

Good News from Nepal

Dear Colleagues,

I just returned from visiting Dr. Bishnu Paudel in Nepal and would like to announce some good news. As of two weeks ago, both morphine syrup and 10 mg scored morphine tablets are available cheaply in Nepal , and both are manufactured in Nepal . This is a major advance because it proved impossible to import oral morphine from India in a reliable and timely enough manner to avoid stock-outs. It was Dr. Bishnu’s determination and hard work that made this happen.

Dr. Bishnu (Left) with Mr. Bharati, founder and director of the charity hospice located at Pashupathinath, Nepal ’s most sacred Hindu temple. The hospice is open to anyone of any faith and provides all care free of charge. Dr. Bishnu serves as volunteer medical advisor to this and one other hospice in Kathmandu .

In addition, the Nepal Association for Palliative Care (NAPCare), organized by Dr. Bishu and for which he serves as Secretary, is nearing completion of a Pain Relief Protocol that will help both to standardize pain assessment and treatment in Nepal and to promote education for Nepali clinicians in pain assessment and treatment.

Finally, Dr. Bishnu worked with the leadership of the National Academy of Medical Sciences in Kathmandu to inaugurate annual training in pain relief and palliative care for all second year residents in all fields. The first training was held on March 25, 2011.

Dr. Bishnu deserves our heartiest congratulations.

Best regards,

Eric L. Krakauer, MD, PhD
Director, International Programs Harvard Medical School Center for Palliative Care

Printed here with the permission of the author.