Perils of operating Palliative Care in Nigeria
By Odimegwu Onwumere
A country of about 160 million people, 36 States and 774 Local Government Areas (LGA), palliative care in Nigeria is disheartening, given-that in 1996, a-small-amount-of Nigerians initiated a crusade for palliative care.
This promotion included opioids, which was aimed to manage pain. After that palliative care sponsorship there are only two centres across the country, where services to victims of chronic ailments like cancer and HIV/AIDS, renal failures, are being rendered. These centres are the Palliative Care Initiative (Ibadan), and Hospice Nigeria (Lagos). The management of victims in these centres is not unconnected without manmade discomfitures, unalloyed to what victims are suffering from. Harangues are that Nigeria is too far to redeeming the burdens of this sector, incomparable to what obtain in other African countries and the United Kingdom (UK).
Six years after the few Nigerians made that move to introduce palliative care in Nigeria, it was finally made public in 2003, through the Palliative Care Initiative of Nigeria (PCIN), now known as Centre for Palliative Care, Nigeria (CPCN). The year 2003 was when palliative care was properly established to the Nigerian government, policymakers and general public. On-the-other-hand, palliative care is still novel to the country owing to the fact that it is not included as an area of acquisition for health professionals across the country. This could be as a result that in the time past, such non-communicable diseases like cancer, heart and kidney problems, stroke and so on, were far-heard than they are readily experienced among the people today.
There are just two universities in Nigeria that offer the palliative course. One offers it in a revised undergraduate curriculum; while the other has prepared measures to offer it in a post-graduate diploma. Many just operate workshops. These schools are the College of Medicine, University of Ibadan, which swaggers as the first unit in West Africa and has received students for clinical posting from Sierra-Leone, Gambia and Canada. The other is in Ilorin, Kwara State. Against that backdrop, accounts are that there were only 5 RT centers, 60 qualified pathologists, and 20 radiation oncologists serving the entire country, as in 2008. There was a team for RT, which did not include radiation oncologists, medical physicists, radiation technologists, and radiation nurses, which were supposed to be in partnership through the process of planning and the time to deliver RT to cancer patients.
Authorities have bemoaned the need to progress on palliative care for patients with lethal infirmity in the country. It is believed that the first approach is to establish a communication link with the victim, investigate to know the beloved one that he or she would be comfortable to stay with, and how aware he or she was with the ailment. It is based on these findings that palliative care professionals can hint the enduring the content of information that he or she wants to be intimated. And, such threats from the patient like anger, remorse, meditation, a feeling of culpability and mood genuflections are properly handled.
Many victims of terminal diseases have died as a result of lack of knowledge about the palliative care. A professor of medicine in Nigeria on August 15, 2012, said that patients are referred late for care and by the time they get to the palliative care centre, most of them were already down. Lack of money is given as the major physical factor that endangers the patients from acquiring even their pain medications. The professor gave other problems associated with terminal illness as fatigue, shortness of breath, bowel and bladder problems, loss of appetite, nausea, vomiting, anxiety and preparatory grief.
Spiritual impact on patients:
Nigeria is one dodgy religious country. Apart from persons caught-up with old age and did not have extended family members to take care of them, many persons who are unfortunate to be befell by terminal diseases, attribute their predicaments to being spiritual. Such statement like, “God forbid, it is not my portion to suffer this disease”, “Holy Ghost fire”, are often heard among patients. Coupled with aboriginal philosophies, victims relent from going to visit experts. Many would rather prefer going to their religious organisations in what they call, “For divine healing”, instead of going for palliative rather than elusive curative approach. Many Nigerians, though, support this thinking, because it was said by the authorities that the toughest pain medication, which had been advocated for dealing with harsh pain in terminal illness is at-present, not accessible in the country, unlike Uganda said to have been only the third African country to have made morphine obtainable and reasonably-priced to her patient residents.
“One major hindrance in rendering palliative care in our environment is the taboo of speaking of an impending death. There seems to be a culture of “death denial” among patients, their relatives, and healthcare professionals. The Igbo of Eastern Nigeria have a culture of celebrating life (“Ndu bu isi”), while despising and fearing death, especially if the dead was younger than 60 years. Where death is accepted, Nigerians prefer natural prolongation of the dying process and want to be at home so that they can make their peace, say farewell, and give final instructions to immediate relatives. Hence one finds that many terminally ill keep away from medical treatment for fear of hospitalization,” say connoisseurs.
Social and Psychological impacts:
Many Nigerians would not want to be associated with terminal diseases. They believe that if the public comes to know about their state of health, it would bring dishonour to them and family. Because of stigmatisation, family and friends are not informed by many victims, to avoid family self-motivation, which would be troubled; and hopelessness, unalleviated superficial suffering that are associated.
In a testimony of May 2004, a Professor of Anaesthesia & Dean, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, argues that such behaviour is very detrimental. He hinges his point, saying: The members of the palliative care team include physicians (family, surgeons, oncologists, radiotherapists, Palliative care/ pain experts), nurses (hospital, community-based, private duty), pharmacists, social workers, therapists (physiotherapy, occupational, music and recreational), chaplain, families, friends, volunteers. The hospice provides palliative care to meet the entire patient’s needs (emotional, social and spiritual) as well as the needs of the family.
Further, experts argue that as a result that health practitioner/patients have poor knowledge of palliative care, individualistic approach becomes fad to the management of terminal cancer patients, unlike in few countries – South Africa, Zimbabwe, Uganda, Kenya, Tanzania, and Egypt – where established care, support/pain control exist. An account also adds that upon that diseases are global perils, the stigmatisation that is being shown to victims of deadly diseases in Nigeria, affects the socio-eco progress of the country, as the sufferers probably miss work, and are unemployed or stop-working early.
The Head, Centre for Palliative Care, Nigeria, once remarked that palliative care increases excellence of care in all non-communicable diseases, stressing that people can die in peace with good palliative care, while their self dignity is not debased. It’s evident that government took the palliative care with a pinch of the salt and lack of approach, which have enabled the bothersome, unavailability and inaccessibility to patients that are in entreaty of palliative care.
“The problem with opioid analgesics is that we don’t have a system in place to monitor its constant availability and accessibility to patients that need them. The opioid analgesics stock expired since May, 2010 and many representations were made to the Federal Ministry of Health after which the Health Minister directed that some be imported for trauma and surgery but no morphine,” the Head, Centre for Palliative Care, Nigeria, had said.
It’s obvious that government has not grown-up in this palliative care direction, because accounts finger that individuals of poor status, are supposed to be treated without measure, if only government had addressed the issue of inadequate facility to train medical experts and acquire adequate health facilities, to enable everyone, irrespective of financial status, have excellent health care. They say that government is oblivious or swimming in deceit to not noting that the continuous restraints of people with the chronic diseases from having optimum health care, is betrayal to their human rights’ faithfulness.
There is a depressing detail that Opioid importation rates about 15 times the cost in the developed world. As a result, there are strict laws in Nigeria to avert the misuse of opioid, with the Federal Ministry of Health as the sole importer of opioids, while the National Agency for Food and Drug Administration and Control (NAFDAC) is the dictatorial body. But these approaches have much succeeded in making the purchase of opioids for medical utilisation very boring.
“At present, there are no parental preparations of morphine and pethidine available for use in the country. A ban placed on the compounding of oral preparations of drugs in our hospital several years ago was only lifted recently to allow for the preparation of liquid oral morphine used in the treatment of cancer pain in our patients,” says a report.
Palliative care involves the physical, emotional, practical, and spiritual aspects of the patient's suffering in the course of the illness, say powers-that-be. Nigeria has to improve on the hospice movement and modern-day palliative care, which credit was said, goes to Dame Cicely Saunders, who started it in 1967. It was said also that she was first a nurse, then a social worker, and finally trained and qualified to be a doctor; while a Canadian physician Balfour Mount, was credited as the first that coined the term “palliative care,” being a foremost in the Canadian hospice movement.
Policymakers are of the opinion that socio-behavioural attitudes in our country must be drastically reduced, which invariably fosters the increase of terminal illness. Urbanisation, industrialisation, and westernisation of dietary, are other factors that have been mentioned that must be reduced. These were believed would reduce the ratio in HIV/AIDS commonness and death rate, which accrue from them annually. A large number of patients with terminal diseases and needing palliative care, should be encouraged to take solace in palliative rather than in religious homes.
Palliative care has come to stay in Nigeria, as the story goes. A testimony says that a few private-owned and missionary hospices, which existed in murkiness in the country, before the official introduction of palliative care in the country, should not be obliterated. The CPCN, which launched its day-care hospice in 2007, within the UCH, must be upgraded to embrace the modern technologies, as are wont in the physically-developed countries. ‘Our Pain and Palliative Care Unit’, its policies and operations, have to be reviewed after it was established in September 2008, as fraction of the Multidisciplinary Oncology Centre of the University of Nigeria Teaching Hospital (UNTH), Ituku-Ozalla, Enugu.
An investigation reveals that physicians-anaesthetist and nurses from the multidisciplinary oncology unit, apart from being in services, they have to also be on a missionary journey to the localities to redeem patients, who are not informed that there exists a counteractive in palliative care, and encourage them of receiving conventional western medical treatment, than most of them are dispirited from looking for western medicine. The inculcation of traditional healers into palliative care education was said to be obligatory, since many patients prefer their advise. And, this will help to penetrate communities to accept palliative care.
Authorities say that seeking for donours is indubitably and the donations should be judiciously utilised and, untrained professionals in this area must be eschewed. With the escalating patient fill, it has become imperative that palliative care should be integrated into the healthcare configuration. “A leaf should be borrowed from the Ugandan government that has prioritized palliative care, making it accessible to the population of her people,” says information. The Hospice and Palliative Care Association of Nigeria (HPCAN), must endeavour to making-sure that palliative care sooner-or-later has a place in medical education throughout the country. Drug unavailability, lack of referrals, fears of mistreatment of compelling narcotics/under-prescribing, lack of public awareness and inter alia, have to be re-addressed.
Professionals are nonetheless saying that the attitude of Nigerian healthcare professionals in-the-direction-of the use of morphine and other opioids, and the fear to recommend strong opioids, the false beliefs about morphine side effects, addiction issues, and legal constraints, should be discarded to improve on the practice of palliative care; hence health professionals’ beliefs and narrow-mindedness must be re-modelled. “Terminally ill people have a right to be pain free, share quality time with family and friends and put their affairs in order. Hospice and Palliative Care Team can offer the required comfort and peace of mind as people get near to end of life’s journey. These must be incorporated into our national health plan,” says a professor.
Another description says: Government support is needed to educate health professionals and to incorporate palliative care into health care curriculum and health care services in Nigeria. Also, government should make palliative care drugs available, especially oral morphine for severe pain. Awareness can be increased through incorporation of palliative care awareness into cancer and HIV awareness programme. This will help fundraising efforts and provide financial support for indigent patients. More non-governmental organisations, faith-based organisations and individuals, should develop interest in establishing hospice and palliative care centres especially, in their communities.