Palliative Care

Prioritizing Palliative Care in Low and Middle Income Countries: a recent perspective.

The WHO Collaborating Centre for Public Health Palliative Care Program in Barcelona under the leadership of Xavier Gomez-Batiste, recently hosted an excellent workshop on palliative care for Central Asia with colleagues from Tajikistan and Kyrgzstan attending.  Delegates from Kazakstan were unable to be there due to national elections. At times, I pitied the excellent translators who at times were translating both Spanglish and Australian into Russian.  PPSG, WHO, and UICC representatives participated in this meeting supported by the OSI’s International Palliative Care Initiative.

There is much to write about this meeting and the potential for change in both countries and the commitment of the delegates to do so.  However I choose to focus on what I consider to be “a light bulb moment” where a switch flicked and a clinician saw a new paradigm in the practice of cancer medicine.

The public health model down which Xavier led the group, included identifying the needs of each country.  Yes, most people present with advanced cancer the delegates informed us.  The discussion moved to the approach to cancer care and how we can integrate palliative care and not take away from the resources that are focused on cure in resource-poor countries.  I took the bait and ask what cancers they were curing and in fact what is the definition of cure?  A rather stunned silence, even allowing for the translation, followed.  5 years, disease free, asked one?

I use a public health model, taught to me by Dr. Charles Olweny.  There is nothing magical about the 5 years as a mark of cure (although 5 year survival has been used extensively to compare cancer care between both regions and countries).  A disease, not an individual, is curable when people with that disease do not die from the disease, that is they die of something else.  I have heard Wendy Harpam, MD, who writes for Oncology TImes and who has undergone multiple therapies for a low grade lymphoma, talk about not wanting to find out she is cured. Why? She would have to die of something else to know that, and she is not prepared to die to find that out!!!!

The reality is that we don’t cure most people living with advanced cancer. Much of what we do in clinical oncology is focus on prolonging life, under the guise of  “curative” treatments.   Even many so called “palliative therapies” are given to prolong life rather than palliate symptoms.  So I presented this and wasn’t that surprised with the reaction.  A long practicing oncologist stated that this was a very pessimistic approach to the practice of cancer medicine and not consistent with what he hears coming from the US and other first world countries.  My rebuttal included the information t that while we are making progress against cancer and more people are living with a cancer diagnosis, half of those who are diagnosed with cancer in high income countries still die of their disease.

To my surprise, support came from an unexpected place, Dr Dimitri Kordzala, a surgeon and clinical from the Republic of Georgia who has been fundamental in the development of the Georgian National Association for Palliative Care.  He stated firmly that in most low and middle income countries, including Georgia, it is not possible to cure most cancers, because people present very late with their disease.  He stated that many things are often done in the name of “cure,” that don’t necessarily benefit the patient overall, and in fact may be a detriment to the overall health care of the country.  Striving for “cure” when it is not possible can be a poor use of resources, particularly for low and middle income countries.  This is one of the reasons, he stated, that Georgia is working to improve Palliative Care Services, ensuring its availability to those with advanced disease.

Georgia serves as a model for the progress they are making in palliative care, not only in Central Asia but for much of the world.  We need both local and regional champions who can share their learned wisdom with their colleagues with others in Central Asia, to turn on the light in the clinical leadership in poorer countries.  But the learning does not just stop there.  The definition of global health indicates that it addresses issues pertinent to us all, and not just to low and middle income countries.  We all have much to learn from Dimitri!

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