Painful Inequities – Palliative Care in Developing Countries


Painful Inequities – Palliative Care in Developing Countries
Autors: Daniela Lamas, M.D, and Lisa Rosenbaum, M.D
Article of “ The New England Journal of Medicine”

I have chosen this article because I consider that the palliative care it is very important for the pain treatment.

As you are going to read on the article, there are some developing countries where the opioids are not legals like Ucrania, India, Mexico… and the procedure to prescribe painkillers could become a nightmare for the doctors.

I cannot understand why there are still some countries where the patient suffer when there is no necessity for that. Nowadays there are different treatments like the opioids which are easy to produce and cheap.
It makes no sense that people in their last days of life have to be in this terribly situation .It is enough suffering for them the fact that they have to face up an illness that probably will take their lives away and also they suffer severe symptoms.

As a medical student I think that Goverments should be informed about the potential benefits, and not only the side effects, of opioids and let the doctors take their own decisions when prescribing prescription pads.

I hope that the world will open the eyes and these countries would use these treatments like a solution for pain.

If you were working in any of the countries above mentioned, what would you do to change this situation?

Some Vocabulary:
– Witness: a person who sees sth happen and is able to describe it to other people.
– Burden: difficulty
– Hasten: to make sth happen sooner or more quickly
– Marshal: to gather together and organize the ideas that you need for a particular purpose


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11 respuestas a Painful Inequities – Palliative Care in Developing Countries


    Extreme pain reduces a person’s quality of life. Quality of life is the general well-being of an individual but also of a society. Developed countries fancy having quality of life, standards of living and achieving human rights and freedom for all and each of their citizens. As persons from an industrialized country, we cannot forget that a developed country means a society in which these standards are not fulfilled. As well as the lack of use of opioids, we can find in those countries many other items that will surprise and upset us. But I believe that we see them from an occidental point of view. We trust that ours believes are the right ones and we tried to influence other cultures. Maybe it is true that our ideas are the right ones. However I don’t find correct to criticise different cultures so hard.
    As an European medical student I see obvious that we must take care of patients at their end of life and that reducing their suffering is a main tool. I cannot but admired those doctors who, in order to relieve their patients from extreme pain, are forced to go through complicated bureaucratic troubles or even risk their own safety. Thanks to them, the little help the richer countries give and the natural development of those societies already in their way, the painkillers will start being used.

  2. IRIS dijo:

    To begin with, some issues complicate the use of opioids such as the fear of trafficking and the notion of opioids which is given to doctors in some countries.
    On one side, it is right to fight against trafficking. It can be done in different ways, however. Keeping an eye on trafficking and protecting the reasonable and required use of opioids at the same time would be the best.
    One important point the text refers to is different uses and concepts of ‘morphine’. Us, as Spanish students, have been taught morphine is commonly used in cases of severe pain. It makes no sense to think of side effects while patient is suffering. The aim is patient’s wellness and we must know how to handle that.
    A doctor’s duty is not just to cure, but to take care of his patients. A doctor has to try to make his patients feel comfortable in their way to death. Because of that I consider there is no reason not to provide them painkillers treatments. Therefore, I would be in favour of the use of opioids if I were working as a doctor in some of those countries mentioned. Nevertheless, it is obvious the importance of the way that we have been taught. When benefits from morphine are not showed at Faculties of Medicine and legal barriers to prescribe it are so impassable it is comprehensible the lack of use of these substances.


  3. BELÉN dijo:

    As a Medicine student, I cannot understand how a doctor, who is supposed to be a scientist and care for people, can fall into prejudices. In a globalized world the information is accessible to most of the countries. All doctors should be aware of the benefits and side effects of opioids. However, we’ve read a study in class that says doctors from the uruguayan Hospital Maciel do not know which is the correct use of opioids. They also ignored the pain ladder for managing analgesia recommended by the WHO.
    Trafficking is also a serious problem, as this article says opioids are easy to obtain and cheap. Developing countries may not have the means to fight agaisnt drug trafficking. Yet in Spain this is also a big problem, and we can assume that Spain is a developed country.
    I think culture is the main issue. Ignorance and fear are the obstacles to accept a drug that could help so many people to deal with painful diseases. And I agree with Ana, these prejudices aren’t exclusive of developing countries. In many occidental countries tobacco is legal, and cannabis is illegal. It is proven that cannabis reduce the side effects of quimiotherapy in the treatment of cancer, and it isn’t as perjudicial as tobacco. To be doctors we have to leave our believes aside and attend to facts.
    I’m sure Spanish people still mistakes paliative cares with euthanasia or dysthanasia (to keep a person artificially alive). This is truly sad, because paliative cares just try to reduce pain in pacients with terminal diseases, and give them physical and psycological support. This should be the objective of any doctor, doesn’t matter where they are from.
    What would I do to change that situation, if I were a doctor in Mexico or Ukraine? I’m not sure, since you must be very brave to go against laws. Maybe the best weapon is education. I’d try to make people aware of how important is to use those drugs properly to avoid the patient’s suffering, and pressure politicians or international organisations to change the laws.


  4. ingleslleida dijo:

    A couple of days ago, I read an article of mostly the same topic, and I was surprised that almost 58 million people die each year, 48 in Countries in development and most of them don’t have a sanitary system of paliative cares.
    In Countries like India, Africa or Mexico, as we have read, paliative cares almost don’t exist, They are visible thanks to the work of volunteers, NGOs and a few doctors. This countries have restrictive politics about the use of morphine and other opioids, which are used as painkillers in terminal patients to keep them calm.
    I think the problem lies in three items:
    1. the fear to the addiction or to the inadecuate use, although the WHO includes them in the list of essential drugs. In most of this countries, the only painkiller terminal patients can use are aspirines. This drugs maybe have effect in headaches, but if we talk about terminal cancers they don’t have any result, pacients continue suffering.

    2. Doctors skills, it’s not normal that nowadays doctors don’t now the benefits of opiacids In this type of patients, so they must be well educated during their career, so that they can be competent.
    3. Doctors not only safe people, sometimes its inevitable that people die, for example in advanced cancers or very old people, in this cases their work is to provide them drugs that keep them calm, whitout pain and beeing with them their last days.
    So, what would I do to change this situation?
    Firstly I would try to talk to the goubernment, I would ask for help to the NGOs and I would explain the patients the situation, I think if we get everyone agree, institutions would listen to us.
    Finally I think paliative cares are as important as surgery or other fields of medicine, so doctors do have the tools to carry it out.

  5. SANDRA dijo:

    After reading this article, I am not able to understand why doctors of other countries don’t use palliative care yet. When a patient has a lot of pain because of its disease, one of the goals of a doctor is to solve this pain. Nowadays we know that it has a solution, which is using palliative care (opioids). So, for that reason it has no sense that a doctor with all the resources to improve the quality of life of a patient doesn’t use them. Moreover, there are many studies which confirm the benefits of the opioids as a palliative care. Although there are some side effects, they are insignificance if we compare them with the benefits.
    As a Medicine student in Lleida, we have a subject (palliative care) where we learn the benefits of opioids and how to treat a patient who needs this treatment. So in our future as professional doctors, we’ll be able to prescribe opioids because we know it’ll be the best for our patients in some situations.
    So in these countries where doctors don’t use opioids, a best way to introduce them is starting for the education in the universities. If Medicine students of these countries knew what the opioids benefits were and everything they should know about this issue, they would open their minds and think about a change. In addition to this, there is a legal problem because doctors aren’t able to prescribe them, although they would want to. There would have to be also a legal change. But I think that this legal change would be possible if doctors changed their point of view about opioids. So to sum up, good education of Medicine students is vital and necessary in order to have competent professional doctors.



    Patients have the right to die without pain or at least, the minimum pain and accompanied by someone who looks for their welfare. Palliative care has advanced greatly in recent years, but there are countries in which authorities don’t ensure the adequate policies for the citizens to have a proper health service.
    Spain is one of the most advanced countries in the world in palliative care. Some years ago, Spain introduced a new law that controls the use of opioids. Patients have access to them when their doctors consider it is necessary.
    In the past, this law was operative in only two countries; Ireland and Australia. There are a lot of researches that support that in these countries the results were great and patients felt more helped.
    Thereby, from my point of view it’s important that all countries use these drugs in order to guarantee a good care of the patients. Governments should consider introducing this law to regulate this part of the medicine.
    It is not necessary that patients suffer when there are treatments that can make them feel better. The doctors are doctors not only to help people to recover of diseases, but to improve the quality of people’s life until they die.
    There is a sentence that I like about palliative care:
    “You matter because of you are, you matter until the last moment of your life, and we will do our best, not only to help you to die peacefully, but to live until you die”

  7. Carolina Pérez Benito dijo:

    From my point of view, developing country actions should cover all aspects that favour the development of the country itself, like the use of palliative care.
    Advances and improvements in health care are one of the most important and fundamental points on which we base this development. As has been mentioned, in Spain we are fortunate to have highly specialized departments on this issue and we should be proud. However, the fact that other countries don’t use ‘opioids’ for example does not mean it’s wrong but it’s just that there are two different points of view. I believe that no country wants its people to die in a painful way. It’s about changing the mindset like we did in Spain many years ago, because we also couldn’t use methods to reduce the pain of dying patients. Don’t criticise the other methods used but try to show that what we think is best, it really works.
    In our case, future doctors, is important to know all kinds of palliative care and to be informed on new developments in order to offer our expertise to patients in need.

    However it’s sad to think that in some countries doctors have to sacrifice and risk his job to give their patients drugs so they don’t have pain. It’s important to take these drugs as addictive controlled but this doesn’t mean to be banned. The quality of life of people has to be good until the time of his death.

  8. Belén Leal Mora dijo:

    The author of this text highlights the basic need of treatments against severe pain in patients just during their last part of the cancer disease. This kind of patients can suffer from such an agonizing pain that in some cases, if they are not receiving any treatment, can make them find the idea of suicide attempt very tempting.

    According to my knowledge, as a Medicine student, it is true that Morphine and other opioid, just as Methadone and Fentanyl, have their important side effects: sedation, difficulty breathing, sickness and vomits, constipation, euphoria, and others like sweat and itching. Nevertheless, these painkillers also have potential benefits, most of them focused on the control of extreme pain. As my classmates have already said, the most important in a patient of palliative cares is his/her wellness, so I feel if our patient needs a morphine tablet due to calm his/her severe pain, doctors must give it to him or her.

    In this text, Dr. M.R Rajagopal puts into words his disagreement with the fact that modern principles of pain treatment and palliative care still are not taught to medical students in a high percentage of the world. Medicine students from Lleida faculty can be so pleased with being taught these important aspect, so we are able to say that for a cancer disease patient, there is no only need to give him or her chemotherapy and/or radiotherapy, but is also necessary to prevent, treat, manage and research his or her pain. The pain is just a symptom, like fever and cough, so at the same time these symptoms must be treated, pain must be treated too. Finally, as one of my friends has already said, it makes no sense to worry about side effects or “collateral damage”, as it is written in the document while patients are suffering from a terrible pain.

    On the other hand, I feel it is very difficult to change lots of years of believes and thoughts of people from different cultures and countries that opioid drugs are completely dangerous due to the danger of becoming addict. Although it is true that opioid addiction exists, and illegal drug trafficking is currently widespread around the whole world, and it is really need to prevent and stop it, people who work in public health system, and also students who are aware of this issue, should spread our own knowledge of the importance to provide a painkiller to these patients wracked with pain because of their disease.

    To sum up, and in relation with the question of Maialen, if I were working in any of the countries above mentioned, or some other that it is not allowed to receive morphine or other opioid to treat cancer disease severe pain, I would try to do everything I could to change this situation. I would try to explain in my best way the benefits of these socially looked down upon treatments, and the necessity for the control of this patient’s extreme pain. If it were need, I would give them some examples, I would try to show them as much as possible the benefits of these treatments, repeating it to them all the times it were needed, trying to open the medical world’ eyes to this fact.

  9. MANUELA dijo:

    I agree with all of you that a palliative care is essential for patients in a terminal illness, I must point out that is a right to die with a minimum of quality of life. In my opinion the support of a painful disease is as important as the support of his family. It is too hard to see a relative suffering, knowing that there exist painkillers to help them which are forbidden in your country.

    Even if I am a defender of the use of painkillers in terminal patients, I understand the apprehension about the use of them. If they are different treatments like the opioids easy to produce and cheap, what I see is that the laws refuse it because the government is scared about their side effects, and they are not acquainted about their benefices. What I would do in that situation is trying to introduce gradually the opioids with the minimum side effects, I would try to educate the physicians and medicine students to prescribe those painkillers so they could avoid the overdose or the dependency. Therefore, I think that new laws take their time to be settled and we should not pressure them because in Spain, a developed country, palliative cares is not yet a specialty.

  10. CRISTINA dijo:

    I think that this article is very interesting because it talks about a situation that nowadays is very important in my opinion.
    I´m not agree with this rule in those countries. Medical practice is more than treat or diagnoses, it is helping people in a difficult situation. This problem makes me wonder, if you can´t treat a disease, you leave the patient in a situation of distress and pain? I think that this isn´t medicine.
    It´s true that opioids have side effects that can be dangerous, but like all the other drugs. If you take control of the doses and the health of the patient, it need not to be harmful. In medicine there are an important rule that is balance between risks and benefit and i think that this case the patient takes more benefits .
    In Spain we don´t have this measure and I think that we are right. Palliative care is a necessary part of the medicine and it seems to me very hard, but the fact that of helping people in the last part of their lifes, trying to do this more bearable and being a support for them and their families, it results very comforting.
    If I will work in this countries, it would be very difficult for me to deal with a situation where terminal patients ask you for medication to reduce his pain , and you can´t help them because it´s avoid. I think that those countries have to take as an example other countries where opioids and palliative care are allowed, and realize that it´s a very important part of medical practice.


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