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>> I'm going to be talking to you about palliative care.
For those of you who don't recognize this opening slide,
this is Georgia O'Keeffe's painting of a poppy,
from which the pain medication morphine is derived,
so it does have a little connection to the -- to the talk.
I'm to you the other day that cancer control.
You're focusing on prevention in this class, but cancer control
and an actual cancer control program includes not only primary prevention, but early detection
and curative treatment and palliative care.
And I think if you're going to have a full orbed cancer control program in your home country,
you really need to focus on these three components
of the -- of the cancer control program.
I count early detection and curative treatment as one leg of the stool,
because early detection, you often hear people say early detection saves lives.
That's not true.
Only early treatment can possibly save a life.
Just detecting something doesn't save a life, so.
And likewise, curative treatment, if it's not started early
in the course of the disease, is ineffective.
So those two really remain linked,
but palliative care is what we're going to focus on today.
Now I mentioned to you the other day that the three most significant features of cancer
in Africa, and low and middle income countries more broadly, are late diagnosis,
late diagnosis, and late diagnosis.
And the fact that cancer is diagnosed late has several implications.
First of all, the curative therapies generally are less effective.
Secondly, there are no role models of cancer survivors, or very few anyway,
by comparison to the situation where earlier detection is prevalent.
There's more suffering and death associated with cancer.
I've heard people say one of the things we have
to do is dispel the myth that cancer equals death.
But if you're detecting cancer at stage 3 or stage 4, it's not a myth.
It's the reality.
Cancer does equal death.
I mentioned the other day that if we took a woman with stage 4 breast cancer in Amman,
Jordan and flew her to in M.D. Anderson in Houston,
she would just die in Houston instead of Amman.
We do not really do very well with late stage cancers,
even in this country, at our best cancer centers.
And then finally, palliative care needs are an even bigger part of the overall picture
of cancer control, and that's where we're really going to focus today.
Now, just to give you a feel for this notion of late diagnosis, I have two examples.
This is looking at cervical cancer stage at diagnosis in the United States and South Africa.
And you can see in the blue bars that the predominant form of cervical cancer
in the U.S. is stage 1, and very little stage 4, whereas in South Africa in the green bars,
you see the stage has shifted toward later stage.
This is looking at breast cancer in India, much the same compared to the U.S. and India
in the -- in the darker green bars.
The U.S. data shows stage zero, 1, 2 as the main stages, whereas in India it's 2, 3, 4.
And if -- unfortunately we don't have good stage data from a lot of different places,
but if we did, almost every low and middle income country in the world would look
like South Africa or, in this case, India, and it would be true for any cancer
that we might choose to look at, not just breast and ***.
So this is a generalization to be sure, but I think it's one that -- that holds pretty much.
The -- I mentioned that even in the U.S., we don't do very well.
The survival data are much poorer at stage 3 and 4 than at stage zero, one, or two,
and the same is true, that survival difference is seen as you move
into low and middle income countries.
So on this slide, you're looking at five-year relative survival
for various cancer sites comparing the U.S. and Uganda,
and again in the green bars are the U.S. data and the lighter green bars are the Uganda data.
And you can see, for breast, ***, ovary, colorectal, stomach, lung, in every case,
the survival, relative survival in Uganda is much poorer than it is in the U.S. And again,
this would be true, not picking on Uganda, this would be true for virtually any country
that you would want to look at if you had the data.
Even cancers that we do very poorly with, like lung cancer
or stomach cancer, it's even worse in -- in Uganda.
Now, for today, I'm going to -- I'm going to start by talking about who, what, when,
and where for palliative care, meaning who needs palliative care, what is palliative care,
when is palliative care appropriate, and where is palliative care delivered.
The who of palliative care.
Palliative care can help people with a variety of illnesses.
Basically, it's a sad fact but true, that 100% of you in this room are going to die,
and you're going to die of something.
And some things are better than others to die of, but nonetheless,
palliative care is applicable to a -- a very high percentage of -- of deaths.
And we focus on cancer, but in Africa, the palliative care focus tends to be on *** AIDS,
because there are five times as many deaths from *** AIDS
in sub-Saharan Africa as there are from cancer.
But also progressive neurological disease, end-stage heart or kidney failure,
and other life limiting illnesses are potential recipients of palliative care.
Now what is palliative care?
Well, palliative care is the active and holistic care of patients
with advanced progressive illness.
It involves management of pain and other symptoms, and I'll come back to that,
but also the provision of psychological, social, spiritual support for these patients.
And the goal of palliative care is to achieve the best quality of life for patients,
and their families, and we'll come -- I'll talk about that a bit.
I also want to emphasize that we're not only talking about a good quality of life,
but also a good quality of the death.
Many aspects of palliative care are also applicable early in the course of illness,
and I'll talk about that when I get to the when part, but it's -- it's not the case that you --
you do curative treatment until you can't do it anymore, and then you switch to palliative care.
That's sort of an old model, but it's not the current model, and I'll discuss that.
The when of palliative care is as follows: palliative care is actually best started
at the time of diagnosis since symptoms are what you're trying to control,
and some symptoms occur very early.
I was reading a -- a paper today that suggested that some very high fraction of young women
with breast cancer, even early breast cancer,
have what is clinically posttraumatic stress disorder, and it --
and it often occurs early in the course of their illness.
Palliative care does not exclude treating with other therapies that --
including those that have a curative intent,
and palliative care can be provided alongside antiretroviral therapy in the case of ***,
but also in the case of cancer, surgery, chemotherapy,
radiotherapy, and other treatments.
And in fact, surgery, chemotherapy, and radiotherapy can
in fact be of a palliative intent.
In other words, they can be delivered.
If you have colon cancer that's metastasized to your bones of your spine,
giving radiotherapy can relieve the pain.
It's not going to cure the colon cancer, so you're giving radiotherapy,
but it's not therapeutic from the point of being curative, but in --
in terms of treating pain in that case.
Now this is one of the more significant papers that was published in palliative care
in the last few years by Tamil et al in the New England Journal in --
in 2010, and what you see here on -- on --
on the right side of the screen is some things having to do with depression,
anxiety, mental health, etcetera.
And this is looking at terminal lung cancer patients who have had standard care
or the introduction of early palliative care.
And you can see from this -- these curves that, you know, low is good here, like golf,
and so the early palliative care bars, the pink bars, show improved depression,
improved anxiety, generally improved mental health.
Everyone sort of already knew that that might be the result.
The surprising thing of the Tamil paper was this figure where the actual survival
of these advanced lung cancer patients were improved by about three months by virtue
of having the palliative care introduced.
So they got standard care and palliative care, or just standard care,
and the ones that got both lived longer by a significant amount.
And I can tell you from having going to ASCO meetings over the years, the American Society
of Clinical Oncology, is if I produced data like this on a new drug for cancer,
I would be written up in the New York Times for breakthrough cancer therapy.
Whereas here, all that's being done is palliative care is being introduced early
in the process.
So palliative care adds life to days, but it also adds days to life,
and I think that's something that we need to keep in mind.
Now, the where of palliative care is a long answer, and I won't go into any of these
in much detail, but the point is that it can occur at a hospital, it can occur in your home,
in an outpatient clinic, in a place that's called a hospice, in a local health center,
in a mobile clinic, in a day care center.
I mean we're -- we're talking about treating symptoms
of the patients, and so those can occur anywhere.
Now, this IOM report that is pictured here made the point that palliative care,
not limited to pain control, should be provided in the community to the extent possible.
So if you live in northern Ghana, you shouldn't have to go to Accra
in order to have your symptoms managed.
There should be something that you can do at home or closer to home than that.
And that relates to this thing that I described as the old model of palliative care
where you engaged in active -- so-called active treatment, that is with curative intent,
and then at some point you said well, there's no point in doing this anymore.
Let's switch to palliative care,
and then eventually the patient sometime after that, dies.
And the problem with this is that it tends to involve an abrupt handoff of patients
from the -- from the team that's been taking care of them to the palliative care team.
And oftentimes the patient feels abandoned by that move,
whereas if the palliative care is introduced earlier, it's a more smooth transition.
That's in fact what's shown here, where in the new model, you have the therapies
to modify disease that are perhaps more intense in the beginning than toward the end,
but you also have therapies that are intended to relieve suffering and improve quality of life.
You also have the end-of-life care, which has to do with life closure, and life closure refers
to that point in time where the person who's dying is still able
to communicate fully with those around them.
They know they're going to die.
They can say I love you, I forgive you, I hope you forgive me for anything I may have done.
Your bringing life to -- to closure.
If you don't have a will, you're getting your -- your papers in order, etcetera.
Hopefully you will have handled your will issues much, much earlier, but nonetheless,
some people put it off to the end.
And in the last hours of life, where the patient is perhaps not as able to communicate, but is --
is -- is in the throes of dying, and all of that is referred to as end-of-life care.
And then you have, even after the death of the patient, there is bereavement care
for the patient's family and friends.
And in fact, this whole continue of symptom management, life closure, last hours of life,
the dying process, and bereavement care all falls under the category of palliative care.
So this is more the model that -- that practitioners are utilizing today,
rather than this abrupt handoff between one or the other.
Now, having said that, I will tell you that in the health care system in America,
this is not being done nearly as well as it should be.
You still have the abrupt handoff model being utilized
in effect, and so there's work to be done.
And the -- the reason why I added this little dotted line here is because as you saw
in the Tamil study, the -- the -- the difference between therapies to modify the disease
and palliative care, that line is blurred a bit
if the palliative care actually improves survival, for example.
So the key messages in palliative care, in particular for --
for cancer, is that it's urgently needed for advanced cancers.
It should start at diagnosis, and also support the families.
It should be integrated within the healthcare system.
It should be linked to prevention and detection and treatment as part
of a national comprehensive cancer control program, and it can be implemented in phases
that are linked to resource availability, and I'll come back to that toward the end.
Now, just to give you a feel for the --
the range of symptoms that a cancer patient experiences, these are data from the U.S.,
and we're looking at breast cancer patients, and we're looking at lymphoma patients.
And these are people who report moderate to severe symptoms that you see here,
so moderate to severe fatigue occurs in 50% of breast cancer,
and two thirds of lymphoma patients.
But the point I want to make here is that the -- the --
the symptoms are quite varied and they go from physical things, like pain and fatigue,
to psychological issues, like sadness, distress, etcetera.
And if you add up these columns, you'll see that they add up to much more than 100%, and by that,
what we mean there is that each patient is experiencing multiple symptoms,
moderate to severe, within their experience with the disease.
So the -- the -- the -- there's talk about symptom clusters, so fatigue, pain and anxiety,
you know, tend to move as a -- as a pack of wolves together in -- in the patient population,
and need to be dealt with as such.
The other thing is that while there are some significant differences between lymphoma
and breast cancer patients, they're more alike than they are similar --
dissimilar, rather, so that you see that there's more fatigue, but in pain, you know,
about 30% are -- are reporting moderate to severe pain in both cases, etcetera.
So I think that one of the things that I would emphasize is that palliative care sort of cuts
across the cancer site continuum.
It also, as I pointed out earlier, is relevant to diseases other than cancer,
so this is a situation where a rising tide lifts all ships.
And so if you improve your palliative care services in your country,
not only going to benefit the cancer patients,
but you're also going to benefit the AIDS patients.
You're not only going to benefit breast cancer patients, but you're also going
to benefit the lymphoma patients, etcetera.
There's not very much symptom surveys done in low and middle income countries.
This is a small study in Africa, and it was done in multiple sites in Africa, and again,
these are the top -- they look at more symptoms than these.
I only plotted the top five symptoms, but you can see that 90% nearly are experiencing pain,
lack of energy, feelings sad, feeling drowsy, worrying, over two thirds, etcetera.
So and -- and the mean number of symptoms here, too, in this African study, is 18.
Each patient on average is experiencing 18 different symptoms that are identified
in both physical and psychological symptoms.
So there is a concept that's referred to as total pain, or distress, it's sometimes called,
which includes not just the physical, but emotional,
psychological, spiritual, and social pain.
In the spiritual pain, questions of even existential questions.
Is this all there is?
Is there anything after this?
You know, that can be painful to deal with as the end of life approaches.
Saint Augustine said, "The greatest evil is physical pain."
So even at this time 1600 years ago, or whatever it was, physical pain was considered something
that -- that people recognized as being a great evil.
And more and more now, there are groups that talk
about the relief of pain as being a human right.
They're approaching the suffering of cancer patients and others as a human rights issue,
and Human Rights Watch, for example, has taken up this -- this idea.
Now, again, I think we need -- we're going to be focusing, as my poppy suggested,
somewhat on physical pain, but we do need to keep in mind the aspects of pain.
So this is a Time Magazine cover of -- of theologian and author C.S. Lewis, wrote the --
the Narnia books, and his comment was, "Mental pain is less dramatic than physical pain,
but it's more common, and also harder to bear.
The frequent attempt to conceal mental pain increases its burden because it's easier
to say my tooth is aching, than to say my heart is broken."
And so you have this whole issue.
This may be one of the few places where C.S. Lewis and Saint Augustine differed
in their perspective on things, but -- but nonetheless, he's making the emphasis here
on the mental aspects of pain of being hard to bear.
And this figure, which I sort of lifted and modified from my friend Frank Ferriss,
on psychiatric interventions, is --
shows the transition from wellness to illness to bereavement.
And the reason why I picked these three shapes is because at each of these transitions,
when a patient is first diagnosed, and then
when patient has died, the whole family changes shape.
You go from a family that has a member, and is experiencing wellness,
to a family that now has a patient, and experiencing illness, and then to a family
where there's a hole in the family where the patient used to be because the patient has died.
They're involved in bereavement.
And in cancer, this transition from diagnosis to death can be years in time.
And so, during that whole period, the patient and their family are going through a lot
of psychological pain in addition
to the physical symptoms that they might be experiencing.
Now, years ago, the WHO created what's called the Three-Step Pain Ladder,
and this is my drawing of it, where step one involves use of non-opioid pain relievers,
like aspirin or Tylenol or something like that.
And then in the second step, if the pain increases,
you can switch to adding a mild opioid for moderate pain, like codeine, for example.
And if the pain continues to increase, then you move to a strong opioid in addition
to the non -- you don't necessarily drop things out, but add them.
And this also makes the point that there are other adjuvant drugs that are involved
in treating symptoms, and even the opioids themselves have symptoms that need
to be managed that they bring on.
For example, constipation is a very common side effect of -- of pain relief using opioids in --
in step two or step three, and so the physician has to be aware that the opioid
and a laxative need to go hand in hand in order to deal with the patient holistically.
And -- and morphine is key, and we'll that as we move forward.
So the question is how can a country assess its palliative care activities?
And I've listed four here.
One is simply to count the services that are delivering palliative care in a country,
and this has been done by a group called the International Observatory on End-Of-Life Care,
and also by the World Palliative Care Alliance, using the Observatory method.
And for example, when the survey was done in -- in Asia, Malaysia was found to have 37 services
at the time this survey was done.
Pakistan had one.
Now, so you can just count services.
It's not getting at how well they're doing or anything like that, but it's --
it does give you how many, if you divide the population by the number of services,
it gives you some feel for how many patients, or how many people in -- in the --
in the country have to be treated or dealt with with each service.
The WHO has said, "A palliative care program cannot exist unless it's based
on rational drug policy, including ready access to suffering patients to opioids."
So if -- if you think you have a palliative care service,
but it turns out you're not consuming much by way of opioid analgesics, morphine and the like,
you're kidding yourself if you think you have a palliative care service,
because you can't have a palliative care service without the rational use of these drugs.
And it's interesting, because morphine turns out to be the first natural product ever extracted
and identified from a plant, and it was done in 1804
when Thomas Jefferson was the President of the United States.
We have his monument downtown, so you know that's a long time ago.
And it turns out that between 1804 and now, nothing has come along or been discovered
or been synthesized that actually is better than morphine for the treatment of --
of pain, so it's -- it's kind of an interesting aside.
There are some other forms of morphine, OxyContin, and other --
other, Hydro morphine, and things like that,
but morphine is still the gold standard after more than 200 years.
This is the mapping of the palliative care services that I mentioned,
and the International Observatory on End-Of-Life Care
and the International Palliative Care Association use this data
and they characterize levels of service as no known activity, capacity building,
isolated provision, generalized provision,
preliminary integration, and advanced integration.
So the goal is to have advanced integration, where palliative care is integrated
into the healthcare system wherever it's delivered.
But you can see from looking at this map that there are many countries of the world
who have no known activity or capacity building,
which still means the patients don't have any place to go for building capacity.
So the red and the first color of orange are basically no services.
The isolated provision occurs more broadly, and then you start getting that,
but very few countries in the low and middle income category have any form of integration.
And in 42% of the world's countries,
there hasn't been even one palliative care service identified
in the surveys, which is abysmal.
This is now switching to opioid use, and I'd mentioned to you that -- that morphine is not --
and pain control, are not synonymous with palliative care.
Palliative care is a lot more than --
than pain control, but it turns out that there are data available for nearly every country
on the planet in terms of how much morphine they consume.
And this data is kept by the International Narcotics Control Board in Vienna,
which is part of the U.N. -- part of the U.N. organization, and countries are obligated
by treaty to report how much morphine they produce and consume, etcetera.
And all of this data is compiled in --
in Vienna, and then it's also used by the Pain Policy Study Group at Wisconsin,
and others, to monitor opioid use.
And they come up with what is referred to as morphine equivalents, meaning --
I mentioned that there are various forms of morphine, but there are conversion factors.
If you're using a fentanyl patch, for example, the amount of fentanyl can be converted
to the amount of morphine that it's equivalent to.
And so you can generate one number for all countries, no matter what forms
of morphine they happen to be using, and that's what's shown here.
And again, one of the things you should always look at when you look
at color-coded maps is what the range of the colors stand for,
so in the green that characterize the U.S. and Canada and most of Europe and Australia,
you have over 100 milligrams per capita in morphine equivalents.
And in the red regions of Africa and India and -- and some in the stands of West Asia and even
in Iraq and Yemen, you have under one, okay?
So there's -- there's more than 100 fold difference between the U.S. and these countries.
And -- and sometimes it's even -- I think the difference between the U.S.
and Ethiopia is 12,000 fold in terms of morphine use, and so there's no -- even the income of --
of Ethiopia is not 12,000 fold lower than the U.S., but the morphine consumption is.
And you can see in Africa that there's very few countries that are using much morphine.
And so the example that -- that I cite here is 180,000 Kenyans die from either AIDS
or cancer each year, and the annual morphine supply is estimated
to be enough to deal with 1500 patients.
So that means under 1% of the patients are being adequately treated, if at all,
and of 250 hospitals in Kenya, only seven of them have ready access to morphine.
So, I mean I don't want to -- I --
I will continue to beat the drum that this is an extremely grim picture,
and one that's literally screaming for our attention.
The WHO has said, and I don't want to knock prevention in any way because we're
in a prevention course, but the WHO has said if you have one dime to spend on cancer control,
that first dime should go to palliative care.
Then you can worry about prevention down the road, because you have patients
that are dying now and are in pain now, and so it's almost unethical to take your dime
and spend it on tobacco control, as important as that is, when patients are suffering
and dying now, and the dime could be used to help them.
Going back, the WHO does estimate that 5.5 million people with terminal cancer,
and a million late-stage AIDS patients are not receiving the pain relief that they do.
And in 150 countries -- does anybody know how many countries there are in the world now?
About 194, 195, depending on how you count them.
So 150 are -- are said to be severely restricted in terms of access to morphine.
Now this is a very interesting graph that -- that I sort of half lifted and half modified,
and it's looking at the GDP of a country on the --
on the X-axis, with the amount of morphine equivalents that they use.
And you can see that the poorer countries are not using much at all.
If you're below $10,000 U.S. in GDP, you're virtually using no morphine in your country.
And then as your GDP rises, you have some --
some additional use, and the top figures there are the U.S. and Canada.
The size of the dot here is the size of the population of the country,
so the big orange circle is China and the big yellow circle is India,
the two biggest countries in the world.
The United States is the third largest country in the world by population.
Interesting little tidbit, but it's up there next to Canada.
And you see variable opioid use in this higher income group, and this --
this intrigued me very much because there were countries
that are using almost no opioids compared to the United States,
but are as rich as we are or richer.
And so that -- that intrigued me and I started looking into this, and among the countries
that are very rich, but who are not using much morphine, are Saudi Arabia, Oman, Bahrain,
The United Arab Emirates Kuwait, and Qatar.
Rich countries of the Arab Gulf who are still falling way off the --
the line in terms of morphine use.
And as a result of this, I started to drill into morphine consumption
in Muslim majority countries to see whether or not there was --
there were cultural issues that might be --
there clearly aren't financial issues in Saudi Arabia
for why they're not using morphine, so what should we look at?
And for this, we started by -- by examining the literature for symptoms in Arab countries,
and again, there's almost no data.
But this is one small Kuwaiti study which shows that 80% of the patients
in this cancer treatment center in Kuwait were experiencing pain.
So not surprisingly, it's not the fact that they're not in pain that accounts
for the fact that they're not using morphine.
I would note also in this study, these authors chose to only look at physical symptoms.
They did not include any assessment of psychological symptoms whatsoever.
And as a result of this examination, and I -- in -- in the interest of full disclosure,
I'm not Arab, and I'm not Muslim, and but my colleague Adina Al Jawi [assumed spelling],
who's a nurse that works in palliative care in King Faisal Hospital
in Saudi Arabia, is both Arab and Muslim.
And so she was quite critical to this particular set of studies, and we published two papers:
one a chapter in a book, and a second editorial, on the need for more and better palliative care
in Muslim majority countries, which are shown in green here.
A lot of people don't realize that the largest Muslim majority country is Indonesia.
It's not in the Arab Gulf at all.
But the interesting thing about the Muslim majority countries is that their range
of income is from $600 a person in Somalia to more than $100,000 a person in Kuwait,
so Kuwait has twice as much GDP as we do in the U.S. on average,
and yet they're not using much morphine.
So -- so this is looking at the opioid use map in the area that encompasses the --
the Muslim majority countries, and what I've done here is I've just overlaid
with this symbol all of the Muslim majority countries that we're talking about.
And so you can toggle back and forth and see that -- that not much is being used.
Again, in this particular map, Iran comes off as a little atypical.
I don't think -- oh no, this is minus method, I'm sorry, so it's not as bad.
But the -- the top country, in terms of --
of morphine use among all of the Muslim majority countries, turns out to be Turkey,
and the country with the most services on a per person basis is Malaysia.
So we also looked into some of the cultural and religious aspects of Islam in order to try
and get a handle on what might be contributing to this low use of morphine.
And it -- the papers that I just cited, if you're -- if you're interested in that,
I'm not going to have time to go into it today, but you can drill into that question
in those two papers that are on the previous slide.
Now, in 2011, some investigators at the WHO came up with yet another way of looking
at morphine use because what they said is because cancer rates are very different
and *** rates are very different, what we need to do is we need
to calculate what a countries needs for morphine are, and then compare that to the use.
And so they came up with this measure that they refer to as Adequacy of Consumption measure,
where they looked at -- at use compared to need, and they defined four categories.
One, well, the four below adequate, moderate consumption, low consumption,
very low consumption, and virtually nonexistent consumption.
And it turns out that only the Americas and Europe get
out of the very low consumption category if you look at the WHO regions of the world.
So the Western Pacific, the Eastern Mediterranean, Southeast Asia, and Africa,
are all in the very low, bordering on virtually nonexistent, consumption.
So even though this is a -- a new metric for measuring morphine, it doesn't change the --
the overall story that morphine consumption is way below the needs.
And in fact, if you look at here using the Human Development Index,
which is a little bit different from just GDP of a country, but you see here, too, that the --
the Adequacy of Consumption measure is different by five orders of magnitude
between the highest developed country and the lowest developed country.
This is what I was telling you before.
There isn't anything that distinguishes these countries at the level of five orders
of magnitude other than palliative care.
Now, what then are the barriers to palliative care?
And this is a survey that was done some time ago now,
but I don't think anything has changed really.
Looking -- asking drug control authorities in 65 countries.
And the things they came up with were fear of addiction; a lack of training
of health care professionals; a lack of -- or a presence of laws or regulations that restrict;
reluctance to prescribe because of fear of legal consequences;
overly and burdensome administration requirements, I have to have six pads
for my prescription if I -- in prescribing morphine, stuff like that;
an insufficient amount imported; the fear of diversion to illegal use; the cost of opioids,
it turns out opioids can be very cheap.
The -- the -- the cost of treating a patient in pain in India for a week is equivalent
to the Indian cost of a half a loaf of bread.
So it's not -- it's not like an expensive monoclonal antibody for -- for treating cancer.
And then inadequate healthcare resources and a lack of national policy to guide these.
All of these were identified.
And -- and I think if your country is amongst those that are the wrong color on the map
and not using much morphine, you will find that some mix of these barriers exist
within your country, and it's fairly similar with nuances
as you move from one country to another.
The workers is particularly a problem.
This is looking at the world's population.
I mentioned to you the other day that 85% of the world's population live
in low and middle income countries.
But if you look at the palliative care workers, the high income countries have them all nearly,
and the low income countries have very few.
So this is probably one of the clearest examples of what has been called the 90/10 principle,
where 10% of the people of the planet get 90% of the -- the healthcare, in this case,
in terms of -- of palliative care.
Now this is not restricted to palliative care.
If you look at the -- the distribution of doctors generally,
you find that there's a huge range there, too,
and sub-Saharan Africa has a shortage of doctors.
It's estimated that 60% of the doctors that were trained in Ghana during the decade
of the '80s have now left the country, and so out-migration of doctors,
and 11 African countries have -- have no medical school in their country at all, okay?
So they need in-migration of doctors.
They're not training any.
And the idea of a doctor training somewhere else and then moving to a country in Africa
that has no medical school and is in need of a doctor, you --
you get that some with the missionaries who are driven by a higher calling,
but it's not the kind of thing that you can build a health care system on.
Just to illustrate this, I've picked out some data here from comparing Tata Memorial Hospital
in Mumbai, India with M.D. Anderson Cancer Center in Houston, Texas.
Now, I -- for those of you who don't know Tata Memorial Hospital,
it is the best cancer center in India.
I think that goes -- I'd be willing to try and defend that, but it --
it turns out that they see the almost identical number of new patients,
30,000 new patients at Tata and at M.D. Anderson.
They almost have the same number of beds between the two hospitals.
But look at the faculty: 117 versus 1400.
Clinical Fellows: 144 versus 900.
All employees: 2500 versus 16,000.
So this -- the -- the -- the -- the way in which cancer is going to be dealt with here
at the premier cancer center in India is quite different, and it may not be surprising
that the doctors there say I -- I really don't have time to deal
with this whole palliative care stuff.
I'm -- I'm -- I'm rushing between one patient and another already.
I would contend that training needs to be thought of as basic, advanced, and specialist,
so that all healthcare workers, starting from the bottom,
should have some basic knowledge of palliative care.
Not talking about now doctors and nurses who are working in palliative care, but doctors
and nurses who are working in everything.
Just like if you have -- if you go to your family doctor with a fever,
he or she should know that infection is one of the causes, possible causes of fever,
that antibiotics exist, that there are things you have to do to figure
out the right antibiotic, so he's not an infectious disease doc, but he knows the basics.
And if you -- if your infection flares and gets worse, he can refer you up the referral chain
to someone who knows more about it than -- than he or she does.
And the same needs to be true in palliative care.
All healthcare workers should have the basics.
Those working in AIDS and cancer should have more advanced training,
and those working in dedicated palliative care units or hospice need the specialist training.
Unfortunately, most of the curricula that are available aim at the high end
of this, and much less at the low end.
And one of the things that I have on my to do list is try
to get more palliative care instruction into the medical school curricula,
into the nursing school curricula, so that everyone is exposed to it.
Because the skills for palliative care are different from the skills for medicine,
they overlap, obviously, but communication, breaking bad news,
is something that doctors admit they're not very good at.
So it's much easier for a doctor to say, "Let's try one more experimental drug
to treat your cancer," rather than say.
"Look, you know, chances are you're probably going to die of this."
Decision-making.
Management of the complications of treatment.
I mentioned constipation with -- with pain treatment and there are others.
Management of pain and other symptoms.
The psychosocial care.
The spiritual understanding and approaches.
Care for the dying.
Bereavement for the family.
So you can see from this that this would best be done by a multidisciplinary team
that included doctors and nurses and pharmacists and social workers and psychologists, etcetera.
And that doesn't exist even in the U.S. many places, but certainly doesn't exist many places
in low and middle income countries.
The WHO has come up with a -- a public health model
for palliative care, which is rather simple.
It starts with a situation analysis.
It gives outcomes and drug availability, implementation and education,
covered by whatever policies are in place for that, sort of gives you the checklist
of things you need to think about.
Now this is, in my view and in the view of others, quite overly simplified,
and the more expanded version of it is shown here, where drug availability is broken
down into all sorts of different issues about import and cost and distribution and dispensing,
and implementation is broken down into training,
the manpower of creating business plans, etcetera.
The policies are also broken down, the education.
I think if you took this slide and used it as a checklist,
you could at least have a fairly good list of the things you should be thinking
about as you start to try and improve palliative care where you are.
There also are a number of resources.
This is the Palliative Care Toolkit that's put
out by a group called Help the Hospice and I recommend it.
It -- it covers virtually all of the -- the things we've talked about in 100 pages.
It -- it deals with head to toe guide to symptom control, end-of-life care,
bereavement messages, advocacy, etcetera.
So if you're going to start somewhere, this Worldwide Palliative Care Alliance booklet on --
Called the Palliative Care Toolkit would be a place to start.
We also were involved in creating a website that at least is intended to be a one-stop shop
for the resources having to do with international palliative care.
So you can see on this -- on the left side here, there are clinical resources, the WHO strategy,
drug availability, education, treating, funding sources, publications, other things.
So ipcrc.net, the International Palliative Care Resource Center,
is a place where you can also start to -- to -- to drill into what you need in your country.
And I -- I close with our -- my favorite quote from Teddy Roosevelt once again,
"Do what you can with what you have where you are."
That doesn't mean you don't try to change what you -- what you can do.
It doesn't mean you don't try to change what you have, but it --
nonetheless, you can get started even if your resources are fairly limited.
And using a model almost like what we've used for the Breast Health Global Initiative,
you can tease from the WHO guide a palliative care module for cancer control,
they break it down into core, expanded, and desirable, in terms of implementation phase.
They don't speak of resources, but you can think of those in a way as being resource levels.
And then short-term, medium-term, and long-term, objectives, and they have various metrics
for what percentage of your population is covered and without going into this,
the idea is that as you move from short-term to long-term, that as you move from poor
to desirable, you have more patients covered and more support
in different settings for your patient population.
I'll stop there and take any questions you might have.
[ Applause ]