Wednesday, October 21, 2015

Quality of Death Report

Did you know that the Quality of Death Report was recently released?  The best place to die is the UK.  Canada can in at number 11.  Bangladesh was ranked 79th out of the 80 countries surveyed.

Here are the details: (From a recent editorial which I wrote on the subject)

The recent 2015 Quality of Death Index, published by the Economist Intelligence Unit, released on October 6th, describes the status of palliative care in 80 countries from around the world.

The Lien Foundation, a Singapore-based philanothropic organisation, commissioned the Quality of Death Index, based on in-depth research and interviews with local and international palliative care experts.

Palliative care is an approach that focuses on improving the quality of life for patients with life-threatening illness and their families. The goal of palliative care is to relieve physical, psychological and spiritual suffering.

The United Kingdom, where palliative care is well incorporated into the National Health Service, tops the ranking. Additionally, the UK demonstrates key measures which are instrumental in providing high quality and accessible palliative care, including comprehensive national policies, a strong hospice movement and extensive community involvement on the issue.

The report ranked Bangladesh in 79th out of the 80 countries surveyed, noting that palliative care remains an “unresolved hurdle” for the country’s public health system. Indeed many significant hurdles are present at this time in the development of palliative care services in Bangladesh.

The report demonstrates that, in general, income is closely correlated with high quality palliative care. High-income countries dominate the top 20 positions in the ranking. Australia and New Zealand rank second and third, the US is 9th, and Canada is 11th.

There are notable exceptions to this correlation, with several less developed nations demonstrating that integrating palliative care into the public health care system is possible and indeed a vital component of basic health care. Specifically, the report highlights the efforts in the Indian state of Kerala and Panama (31st) where innovative efforts have lead to the incorporated of palliative care into primary health care.

Palliative care can be a very cost effective form of health care. Palliative care can be delivered in homes and health centres, in addition to hospitals and hospices. Palliative care is most successful when it is initiated early in the course of illness, and early palliative care reduces unnecessary hospitalizations. Additionally, early palliative care has been shown to improve the quality of life for patients.

Recently, in collaboration with the National Institution of Population Research and Training (NIPORT), the Centre for Palliative Care at Bangabandhu Shiekh Mujib Medical University (BSMMU) completed an Assessment of Palliative Care in Bangladesh.  An estimated 600 000 patients in Bangladesh require palliative care any point in time. If family members, who often require psychological, social and spiritual support, are included, then the number of individuals who need palliative care may be as high as 2 million (20 lakh).

Globally, children suffer disproportionately from a lack of access to palliative care. The majority of low and middle-income countries, where 98% of the world’s children required palliative care reside, have very limited palliative care services for children. Unfortunately, the situation in Bangladesh similar, with very few children having access to the palliative care they require.

A lack of training and awareness of palliative care are major barriers to the provision of palliative care in Bangladesh. Education of physicians and nurses will be vital to improving local palliative care services.  Palliative care must be incorporated into the training curricula for all new health care professionals from primary health care workers in rural areas, to specialist physicians in Dhaka.

Palliative care is not only for patients with cancer. It is also required for a wide range of chronic and life-threatening diseases, including heart disease, chronic lung diseases, renal disease, diabetes, dementia, and other incurable and serious conditions. In Bangladesh, the majority of deaths are now due to non-communicable diseases (NCD). When developing National Policies for the management of these conditions, palliative care must be incorporated. Palliative care will not only relieve suffering and improve the quality of life of individuals with these conditions, it will also be instrumental providing cost-effective care and reducing unnecessary health expenditures. Frequently, patients with advanced cancer spend large sums of money on unnecessary treatments, which do nothing prolong the duration or improve the quality of life, and instead lead to significant financial suffering for families.

Pain management is an important component of palliative care. Pain is one of the most frequent and troubling symptoms experienced by patients with life-threatening conditions. The World Health Organization (WHO) estimates that 80% of patients with cancer will experience moderate or severe pain at the end of their life.  Opioids pain medications, such as morphine, are essential for the treatment of pain in many palliative care patients. Morphine is safe and effective for the treatment of pain and patients who require morphine for pain do not become addicted.

The WHO has included morphine and several other opioids on its list of Essential Medications. In the past several years, progress has been made in Bangladesh to ensuring that all patients who need these medications will have access to them.  Local production of morphine started in 2007, and there are presently 3 local pharmaceutical companies who are manufacturing morphine.

There are still substantial barriers to ensuring appropriate pain management in Bangladesh. Many physicians are unaware of that morphine is available locally, or are hesitant to prescribe opioids as they incorrectly fear that patients will become addicted.

Public and patient misconceptions about the safety of morphine compound the issues facing physicians. Patients are often unaware that opioids are a safe and effective option to treat their pain. 

Although there are many challenges for palliative care in Bangladesh, even the longest and most difficult journeys beginning with a single step. So we have taken our first steps, and the future holds much promise for the further development of palliative care in this country. 

Saturday, October 10, 2015

Cancer as a neglected Disease

Several months ago, I was interviewed by Jocalyn Clark, who works at ICDDR,B (International Diarrheal Disease Research Institute, Bangladesh) about childhood cancer in Bangladesh.  Here's a link to the article which she published on the BMJ (British Medical Journal).

There are an estimated 7000-9000 cases of childhood cancer occurring annually in Bangladesh, but less than 10% of these children are seen by a specialist. Without access to a childhood cancer specialist, a child with cancer does not have any chance of cure.  The treatments for acute lymphoblatic leukemia, the most common type of childhood cancer in Bangladesh and globally, are relatively simple and inexpensive.  The majority of children diagnosed with cancer in Bangladesh could be given treatment aimed at cure, if these children were seen and diagnosed by a childhood cancer specialist.

Sadly, the majority of children with cancer are dying without access to potentially curative treatment.  Lack of awareness among the general public, that cancer is curable, as well as among health care providers means that most children are discouraged from considering treatment. Primary health care providers or those outside Dhaka, at district hospitals, are unaware that childhood cancer is curable, and often tell parents that there is no hope of curing the child.

The World Child Cancer Twinning Project in Bangladesh, is focussed on providing these health care workers with improved training to ensure that they understand how to recognize and then refer children with suspected malignancies.