IAHPC Traveling Fellow's Report:
Teaching in Sudan
Ahmed Elsayem, MD
Assistant Professor in Palliative Care
UT MD Anderson Cancer Center
Houston , USA
After receiving a grant from IAHPC, as a Traveling Fellow, I traveled to Sudan in the period August 23, 2005 through September 16, 2005 with a purpose of implementing a palliative care service there.
Sudan
Sudan is the largest country in Africa with a size of one million square miles. It has an estimated population of 33 million with only 2% of the population over age 65. Poverty is wide spread particularly in rural areas. Health resources are very limited helping to explain a very short life expectancy of 57 years and an infant mortality rate of 65 deaths per 1,000 live births . Nine countries and the red sea border Sudan . These countries include Egypt , Eritrea , Ethiopia , Kenya , Uganda , Congo , Chad , Libya and the Central Africa Republic ,. The country has suffered from a devastating civil war for the last 22 years that has left millions of its population poor, homeless and refugees. As a result of famine and poverty, the health system has suffered significantly and the spread of infectious diseases such as HIV/AIDS has reached an alarming level.
Cancer in the Sudan
Cancer ranks second as the most common cause of death after infectious diseases (mainly malaria and tuberculosis). There is only one major cancer center in Sudan (The Radiation and Isotope Center ) located in the nation’s capital Khartoum . This cancer center receives referrals from all over the country. Two radiation oncologists and 4 medical oncologists operate the center. The center sees about 15,000 cancer patients per year. In this cancer center, surgery and radiation therapy are the main modes of cancer therapy. There is a deficiency of chemotherapy.
The staff of the cancer center has very limited information about the use of opioids and fears the possibility of opioid addiction/diversion. Dr. Ibrahim Elfadil, one of the medical oncologists, has expressed a strong interest in leading a palliative care initiative. He is a gynecologic oncologist who trained in Europe and recently arrived in the Sudan.
HIV/AIDS
HIV has increased significantly, especially over the last 10 years in war torn areas of Sudan . According to the 2004 UNAIDS/WHO global update, there is an estimated four hundred thousand people living with AIDS in Sudan with a high estimate approaching one million and three hundred thousand, especially in the southern part of the Sudan. Efforts to control the disease and to educate patients are limited by the political and social stigma of this disease, as is in the majority of Muslim countries. The majority of these patients in Sudan do not receive anti-retroviral therapy.
Palliative care:
Unfortunately, awareness about palliative care is non-existent. The majority of cancer patients die at home without medical help or the control pain and other symptoms. Many of the advanced cancer patients are sent home to die without end of life care. Nonsteroidal anti-inflammatory drugs are the main modality of pain management. The following medications were also available in the pharmacy at the cancer center:
- Extended release morphine 15 & 30 mg
- Tramadol tablets 50,100 & 150 mg
- The total number of tablets of morphine dispensed last year was less than 3,000 tablets,
- IV morphine and Demerol are mainly used for postoperative pain
Most cancer patients were given opioids for only 2-3 days. There are strict rules for dispensing opioids, and involve filling out a long form and taking the ID of the prescribing physician. Opioids are not available in the street pharmacies.
My visit:
1. As a native of Sudan , and a palliative care physician, I have been very interested for a long time in helping design and develop a palliative care program in the country. I am familiar with the cultural and socioeconomic conditions in Sudan as well as the cultural beliefs surrounding care of dying patients. I am therefore able to identify with the locals and communicate effectively with them.
2. During my one month stay, I had the chance of meeting and working with many colleagues who are practicing in Sudan . I discussed with them the importance of introducing the palliative care concept s into their hospitals and practice in order to help improve the care of the many suffering and dying patients. Physicians and staff expressed great interest in incorporating palliative care.
3. I presented a lecture about pain and palliative care at the Radiation and Isotope Cancer Center in the presence of all medical and radiation oncologists, nurses, psychologists and other supporting staff. The lecture was followed by a didactic session where barriers to implementing palliative care were discussed. This session resulted in significant enthusiasm to start a Palliative Care service
4. I gave a lecture at the Pediatrics Grand Rounds in the Khartoum Teaching Hospital entitled: Pediatric Palliative Care. More than 150 physicians attended. This was followed by discussion about the need to implement palliative care for children in the Sudan .
5. Because of the limited availability of opioids, I arranged for a meeting with the chief of the Central Pharmaceutical Supplies who was a previous minister of health. I have discussed with him in great detail the importance of introducing different opioids, which may be required including methadone, short acting oral morphine & hydromorphone. He expressed concerns about opioid diversion or misuse. After a long discussion he expressed strong support and willingness to cooperate in bringing in all needed opioids if there’s a trained medical staff that is able to use them.
6. I saw many advance cancer patients during this visit both in Khartoum Teaching Hospital and also in other hospitals.
7. I have discussed the issue of hospice care with Dr. Abbashar Hussain, an associate professor of neurology at the University of Khartoum . He chaired a similar work for epilepsy patients which was supported by volunteers. We discussed the issue of establishing hospice care in Sudan and he showed great enthusiasm and interest in pursuing this.
I would like to express my gratitude to the International Association for Hospice and Palliative Care for their support and encouragement.
  
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