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Alleviating the Access Abyss in Palliative Care and Pain Relief— an Imperative of Universal Health Coverage: the Lancet Commission Report

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Alleviating the Access Abyss in Palliative Care and Pain Relief— an Imperative of Universal Health Coverage: the Lancet Commission Report The Lancet Commissions Alleviating the access abyss in palliative care and pain relief— an imperative of universal health coverage: the Lancet Commission report Felicia Marie Knaul, Paul E Farmer*, Eric L Krakauer*, Liliana De Lima, Afsan Bhadelia, Xiaoxiao Jiang Kwete, Héctor Arreola-Ornelas, Octavio Gómez-Dantés, Natalia M Rodriguez, George A O Alleyne, Stephen R Connor, David J Hunter, Diederik Lohman, Lukas Radbruch, María del Rocío Sáenz Madrigal, Rifat Atun†, Kathleen M Foley†, Julio Frenk†, Dean T Jamison†, M R Rajagopal†, on behalf of the Lancet Commission on Palliative Care and Pain Relief Study Group‡ Executive Summary poor or otherwise vulnerable people in high-income Published Online countries—is a medical, public health, and moral failing October 12, 2017 In agonising, crippling pain from lung cancer, Mr S http://dx.doi.org/10.1016/ came to the palliative care service in Calicut, Kerala, and a travesty of justice. Unlike so many other priorities S0140-6736(17)32513-8 from an adjoining district a couple of hours away by bus. in global health, affordability is not the greatest barrier See Online/Comment His body language revealed the depth of the suffering. to access, and equity-enhancing, efficiency-oriented, http://dx.doi.org/10.1016/ S0140-6736(17)32560-6 We put Mr S on morphine, among other things. A couple cost-saving interventions exist. of hours later, he surveyed himself with disbelief. He The global health community has the responsibility *Equal contributors had neither hoped nor conceived of the possibility that and the opportunity to close the access abyss in the relief †Senior authors this kind of relief was possible. of pain and other types of suffering at end-of-life and ‡Study group members are listed at end of this Report Mr S returned the next month. Yet, common tragedy throughout the life course, caused by life-limiting and befell patient and caregivers in the form of a stock-out of life-threatening health conditions. However, unlike many Department of Public Health morphine. other essential health interventions already identified as Sciences, Leonard M. Miller School of Medicine priorities, the need for palliative care and pain relief has Mr S told us with outward calm, “I shall come again next (Prof F M Knaul PhD, Wednesday. I will bring a piece of rope with me. If the been largely ignored, even for the most vulnerable Prof J Frenk MD), Institute for tablets are still not here, I am going to hang myself from populations, including children with terminal illnesses Advanced Study of the that tree”. He pointed to the window. I believed he meant and those living through humanitarian crises, and even Americas (Prof F M Knaul, A Bhadelia PhD, what he said. 2 in the Sustainable Development Goals (SDGs). Yet X Jiang Kwete MD, Stock-outs are no longer a problem for palliative care in palliative care and pain relief are essential elements of H Arreola-Ornelas MSc, Kerala, but throughout most of the rest of India, and universal health coverage (UHC). N M Rodriguez PhD), Sylvester indeed our world, we find near total lack of access to Several barriers explain this neglect: the focus of existing Comprehensive Cancer Center morphine to alleviate pain and suffering. Prof F M Knaul), and School of measures of health outcomes—major drivers of policy Business Administration Dr M R Rajagopal, personal testimony and investment—on extending life and productivity with (Prof J Frenk), University of little weight given to health interventions that alleviate Miami, Coral Gables, FL, USA; Poor people in all parts of the world live and die with pain or increase dignity at the end of life;3 opiophobia, Tómatelo a Pecho, A.C., Mexico City, Mexico (Prof F M Knaul, little or no palliative care or pain relief. Staring into this which refers to prejudice and misinformation about the H Arreola-Ornelas); Fundación access abyss, one sees the depth of extreme suffering in appropriate medical use of opioids;4–6 the focus, in Mexicana para la Salud, A.C., the cruel face of poverty and inequity. medicine, on cure and extending life and a concomitant Mexico City, Mexico 7,8 (Prof F M Knaul, The abyss is broad and deep, mirroring relative and neglect of caregiving and quality of life near death; H Arreola-Ornelas); Harvard absolute health and social deprivation. Of the 298·5 metric limitations on patient advocacy due to the seriousness of Medical School, Boston, MA, tonnes of morphine-equivalent opioids distributed in the illnesses; the focus on preventing non-medical use of USA (Prof P E Farmer MD, world per year (average distribution in 2010–13), only internationally controlled substances without balancing E L Krakauer MD, 1 9–12 Prof R Atun FRCP); 0·1 metric tonne is distributed to low-income countries. the human right to access medicines to relieve pain; Massachusetts General The amount of morphine-equivalent opioids distributed and the global neglect of non-communicable diseases, Hospital, Boston, MA, USA in Haiti is 5 mg per patient in need of palliative care which account for much of the need for palliative care.13 (E L Krakauer); World Health per year, which means that more than 99% of need goes Global health is devoid of the investments, Organization, Geneva, unmet. By contrast, the annual distribution of morphine interventions, and indicators that are essential to ensure Switzerland (E L Krakauer); International Association for is 55 000 mg per patient in need of palliative care in the universal access to safe, secure, and dignified care at the Hospice and Palliative Care, USA and more than 68 000 mg per patient in need of end of life or to the palliation of pain and suffering. Houston, TX, USA palliative care in Canada—much more than is needed to With this Report, we aim to remedy these limitations by: (L De Lima MHA, meet all palliative care and other medical needs for (1) quantifying the heavy burden of serious health-related Prof L Radbruch MD); Department of Global Health opioids on the basis of estimates of the Commission suffering (SHS) associated with a need for palliative care and Population (A Bhadelia, (figure 1). and pain relief (section 1); (2) identifying and costing an X Jiang Kwete, Prof R Atun), The fact that access to such an inexpensive, essential, Essential Package Of Palliative Care And Pain Relief Department of Health Policy and Management (Prof R Atun), and effective intervention is denied to most patients in Health Services (the Essential Package) that would Department of Epidemiology low-income and middle-income countries (LMICs) alleviate this burden (section 2); (3) measuring the unmet (Prof D J Hunter MBBS) and and in particular to poor people—including many need for one of the most essential components of the www.thelancet.com Published online October 12, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32513-8 1 The Lancet Commissions Department of Nutrition (Prof D J Hunter), Harvard T.H. Chan School of Public Health, Boston, MA, USA; National Western Europe Institute of Public Health, 18 316 mg (870%) Morelos, Mexico (Prof O Gómez-Dantés MD); Pan Russia American Health Organization, Afghanistan 124 mg (8%) Regional Office of WHO, 2·4 mg (0·2%) Washington, DC, USA Canada 68 194 mg (3090%) (Prof G O A Alleyne MD); Worldwide Hospice Palliative Care Alliance, London, UK China (S R Connor PhD); Nuffield 314 mg (16%) Department of Population Health, University of Oxford, Vietnam 125 mg (9%) Oxford, UK (Prof D J Hunter); USA Health and Human Rights 55 704 mg (3150%) India Division, Human Rights Watch, Uganda 43 mg Maplewood, NJ, USA (4%) (D Lohman MA); Department of 53 mg (11%) Palliative Medicine, University Hospital Bonn, Germany Haiti (Prof L Radbruch); The Malteser 5·3 mg (0·8%) Hospital, Bonn, Germany Australia Mexico (Prof L Radbruch); Costa Rican 40 636 mg (1890%) 562 mg (36%) Social Security Fund, San José, Nigeria Bolivia Costa Rica 0·8 mg 74 mg (6%) (0·2%) (M del Rocío Sáenz Madrigal MD); Weill Cornell Medical College, New York City, NY, USA (Prof K M Foley MD); University of California, San Francisco, CA, USA (Prof D T Jamison PhD); and Figure 1: Distributed opioid morphine-equivalent (morphine in mg/patient in need of palliative care, average 2010–13), and estimated percentage of need Trivandrum Institute of that is met for the health conditions most associated with serious health-related suffering Palliative Sciences, WHO Source: International Narcotics Control Board and WHO Global Health Estimates, 2015. See additional online material for methods. Collaborating Centre for Training and Policy on Access to Pain Relief, Pallium India, package—inexpensive, immediate-release oral and More than 25·5 million people who died in 2015—45% Kerala, India injectable morphine (section 2); and (4) outlining of the 56·2 million deaths recorded worldwide— (M R Rajagopal MD) national and global health-systems strategies to expand experienced SHS. Of those, more than 80% of the people Correspondence to: access14 to palliative care and pain relief as an integral who died with SHS in 2015 were from developing regions, Prof Felicia Marie Knaul, Institute for Advanced Study of the facet of UHC by applying a balanced approach that and the vast majority lack access to palliative care and pain Americas, University of Miami, ensures adequate attention to both the medical needs of relief. Miami, FL 33146, USA all patients and the risk of non-medical use (section 3).12 Every year almost 2·5 million children die with SHS [email protected] Our findings and recommendations are summarised in and more than 98% of these children are from developing five key messages (panel 1).
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