Poor countries
get 1% of global supply … to treat half the world’s people. In Ethiopia, a new
initiative has begun, but too late for those suffering without oral morphine
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Palliative care nurse Filagot Tadele gives basic painkillers to
cancer patient Kedija Deltera in Addis Ababa – all she can offer in the absence
of morphine. Photograph: Fred Harter
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Filagot Tadele, a palliative care nurse, spends her days crisscrossing Ethiopia’s capital, Addis Ababa, caring for cancer and HIV patients. Many of them are slowly dying and in extraordinary pain.
She
carries with her a box of assorted medicines, but lacks the one drug she needs
to relieve suffering: oral morphine. The powerful opioid is not made in
Ethiopia and shortages of imported medicines mean it has disappeared from
pharmacy shelves.
Filagot
makes do with painkillers usually recommended for mild aches and pains. These barely
dent the agony endured by patients like Marset Ermelo, who is undergoing
chemotherapy and has advanced bowel cancer.
“It’s
really frustrating,” says Filagot. “Our patients are like our family – the
relationship is really strong. So if you feel you are not doing anything to
help them, it hurts a lot.”
Marset
is in so much pain she struggles to stand up or find the energy to speak.
Morphine is traded on the hidden market, but neither Marset nor Hospice
Ethiopia, the organisation that employs Filagot, can afford the sky-high prices
it fetches.
The
only thing Filagot can do when she visits Marset in her apartment on the top
floor of a run-down housing complex is listen and provide emotional support
while her patient discusses the symptoms. Marset says, "The pain is
impossible to describe and it gets worse every day.
Such
pain offers a window into a large, unnoticed drug crisis that is the opposite
of what is occurring in more affluent nations. While uncontrolled opioid
addiction, including that to fentanyl, claims tens of thousands of lives
annually in developed nations, millions more people in the developing world are
suffering in pain due to a lack of access to medicine.
The
poorest countries receive just 1% of the global morphine supply, despite having
50% of the world’s people, according to a report published in 2017 by the
Lancet’s commission on palliative care and pain relief. In Nigeria, for
example, there is only enough morphine available to meet 0.2% of needs. In
Canada, by contrast, there is enough to meet more than 3,000% of national
needs.
"Absolutely
unnecessary suffering" is the outcome, according to Ephrem Abathun,
executive director of Hospice Ethiopia. His nonprofit is the only one in
Ethiopia, the second-most populous nation in Africa with more than 120 million
inhabitants, that is committed to provide palliative care services. In Addis
Abeba, Hospice Ethiopia assisted 280 people who were chronically and terminally
ill last year. There is absolutely no relief for the tens of thousands of sick
Ethiopians.
The
worst anguish imaginable is being felt by them, adds Ephrem. Some of my
patients have requested euthanasia purely out of desperation. When people who
have previously used morphine for relief don't have access to it again, it is
especially upsetting to them.
The
World Health Organization calls morphine “a gold standard for pain relief” and
has included the opioid in its essential medicines list since 1977. It is
strong, fast-acting and easy to administer. It is also cheap. Making morphine
available as part of a wider palliative care package would cost just $3 a head
in poor countries, according to the Lancet. When prescribed as a drinkable
syrup, it is too weak for addicts.
Yet
in many African countries, doctors are often reluctant to prescribe the drug,
seeing it as addictive or dangerous. This stems from a lack of training, with
palliative care rarely featuring on medical school curricula, says Dr Yoseph
Mamo, one of the handful of Ethiopian health professionals with palliative care
expertise.
The
supply of morphine is further constrained by inadequate investments in
palliative care, outmoded rules intended to minimize use, and poor
doctor-to-patient ratios. In nations like Ethiopia, a lack of foreign currency
makes it prohibitively expensive to import pharmaceuticals, and inadequate
supply-chain management frequently results in shortages.
Morphine
effects have the potential to be transformative. "If I get morphine, my
pain is more manageable, and I can talk to my family and sleep," claims
Marset. "I can't speak if I don't take morphine."
According
to Elubabor Buno, director of medical services at Ethiopia's Ministry of
Health, the national health policy places no importance on end-of-life care.
Instead, it focuses on reducing infant mortality and combating illnesses like
malaria.
“The
main constraint at the ministry is the limited budget,” says Elubabor. Ethiopia
allocates 5% of its budget to health, despite being a signatory to the African
Union’s 2001 Abuja declaration, which commits it to spending 15%.
Things
are slowly changing. Taking the lead from Uganda’s innovative approach, which
focuses on free access to morphine, several African countries including Rwanda,
Malawi and South Africa have integrated palliative care into their health
systems. Ethiopia has more work to do, but has developed national guidelines
for palliative care, and a plan to produce morphine locally “is in the
pipeline”, says Elubabor.
However,
homegrown production is not a panacea. Ethiopia once had a company that made
oral morphine, but it stopped production due to lack of demand from doctors
fearful of prescribing the drug. Guidelines cannot be followed by doctors
unless they have proper training, says Yoseph.
Some
terminally ill and chronically ill people turn to conventional treatments when
their healthcare system fails to provide them with an adequate course of
treatment. Breast cancer sufferer Kedija Deltera uses honey and crushed black
cumin applied two to three times daily to ease her agony. She learned this
treatment from the Qur'an. According to Ephrem at Hospice Ethiopia, many
Christian patients use holy water in a similar manner.
Without morphine, cancer patient Kedija Deltera uses a traditional
remedy of crushed black cumin and honey to treat her pain. Photograph: Fred
Harter
Kedija
frequently experiences pain in her legs and chest, as well as itchiness in her
hands and arms where her lymph nodes have enlarged. She was compelled to
abandon her position as a security guard because she becomes lightheaded when
she stands.
“But
when I am taking morphine, I feel very little pain. I can live almost as
normal,” she says. But, like Marset, she cannot pay hidden market prices, so
has to do without: “It’s too expensive.”
Yoseph
spends part of his time as a volunteer, teaching other health professionals how
to integrate pain relief into their daily work. He says the importance of
palliative care has gone unrecognised for too long.
“You
can still do something for people who can’t be cured,” he says. “You can give
them their quality of life back and return their dignity. It is saying to the
patient, ‘I will not abandon you, I will be there for you.’ And that is a very
important thing.”
Source: The Guardian
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