New IAHPC Board member Dr. Esbtasam Ahmed, a Clinical Professor for the Department of Clinical Health Professions at St. John’s University College of Pharmacy and Health Sciences in New York, hails from Egypt. Here, she reflects on the issues of palliative care in her home country.
Speaking from my own experience as an individual who grew up in Egypt, lost a family member to cancer with no access to palliative care, and is a frequent visiting scholar to advance palliative care education and training in Egypt, I can say that despite the global growth of palliative care worldwide and its integration in different state-funded health care programs, developing countries are generally falling further and further behind developed countries.
In Egypt, there is an evident lack of national health policies that support palliative care development, poor understanding and awareness of the role of palliative care in the community, lack of facilities and resources for palliative care, extreme fear of pain medications such as opioids, lack of communication with concerned departments, and no statistical data about how and where patients die, or how many receive palliative care. The same government spends limited effort in the prevention and early detection of many chronic diseases.
In the cancer context, for instance, many patients only visit a health care provider when their disease progresses to advanced — and often incurable — stages of the disease, where the main treatment consists of pain medication and symptom control at the end of life. Unfortunately, and putting many other challenges aside, the already very limited palliative care units suffer from constant opioid inadequacy, despite their presence on the World Health Organization (WHO) Essential Medicines List. Lack of effective and inexpensive opioids, such as immediate-release oral morphine, presents a problem that is particularly tragic for cancer and terminally ill patients.
What complicates the matter further is the extreme, irrationally strict opioid prescription and dispensing policies that result in low opioid consumption as reflected in statistics showing that Egypt is among the lowest consumers worldwide, supporting anecdotal evidence that cancer pain control there is largely inadequate. Islam is the religion of the majority in Egypt, and observant Muslims believe that having an illness represents an opportunity to enhance the Muslim's degree of piety, or recompense for personal sins. Yet, Islamic teaching encourages Muslims to seek treatment and take medication when they fall sick, as it is believed that God did not send down a sickness but rather a medication for it. Additionally, Islamic teaching considers the relief of suffering to be highly virtuous. This is extremely important as we discuss the need to improves access to pain medications for palliative care patients within Egypt.
For many Egyptians, approaching the end of life is associated with an extended experience of chronic progressive disease accompanied by pain, suffering, excessive cost, and uncertainty. Unfortunately, most Egyptians are not familiar with the concept of a palliative care and its role in preserving the dignity and individuality of the dying but, instead, elect for invasive medical procedures that may contribute to increased pain and unnecessary suffering.
Most doctors in Egypt have not been trained to clearly convey information that includes unpleasant news, and often perceive treatment failure as a personal failure. This is predominantly true in countries where market dynamics govern the functioning of the health care system, as in Egypt. This means that a doctor who gives false hope has better chances at surviving in a competitive environment, making more money, and gaining a more favorable reputation. This commonly found behavior is disastrous as, in this context, physicians are dealing with very vulnerable patients and caregivers.
Palliative care in Egypt is in an early stage of development and has a long way to go. There is a crucial need to develop culturally sensitive palliative care models appropriate to the country’s resources, to raise awareness and knowledge among health care professionals and providers by introducing palliative care curricula and training at all levels, and to educate the public and communities. There is a need for a national palliative care policy and surveillance of the implementation of such policy. The restrictive regulations regarding opioids should be amended; accessibility and availability of opioids should improve throughout Egypt, especially in rural areas.
At its heart, we, as health care providers, are responsible for palliative care often being viewed as a foreign word in Egypt. We need to be aware of our right to palliative care during treatment and when approaching death. We must understand that ‘investing’ in our loved ones’ well being is not about introducing them to advanced, invasive, or expensive medical care, but to selflessly listen to the patients’ needs and preferences, and doing whatever we can to help them.
Dr. Ebtesam (Sammi) Ahmed is a member of the IAHPC Board of Directors. To read her bio click here.