Page 18 Guide to Pain Management in Low-Resource Settings

6 Wilfried Witte and Christoph Stein

medicine from acute (infectious) diseases to cancer and brochure, the WHO fi lled the gap by “forcing” health
other chronic diseases in the fi rst half of the 20th cen- care systems to use opioids according to the now
tury. Th e term “palliative care” (or palliative therapy) widely known three-step “analgesic ladder.” Th e suc-
comes from the Latin word “pallium” (cover, coat) and cess of this initiative was, unfortunately, not the same
is supposed to alleviate the last phase of life if curative in diff erent regions of the world. While opioid avail-
therapy is no longer possible. Palliative care is, a priori, ability and opioid consumption multiplied in the An-
designed to concentrate on quality of life. It has roots in glo-American and Western European countries, other
non-Christian societies, but it is mainly regarded to be regions of the world observed only minor increases or
in the tradition of medieval hospices. However, the his- even falling numbers of opioid prescriptions. It must
torical background of the hospices was not the same in be added, though, that in the Anglo-American and
every European country, and neither was the meaning Western European sphere, facilitated access to opioids
of the word “pallium”; sometimes it was used by healers has promoted an uncritical extension of opioid use to
to disguise their inability to treat patients curatively. noncancer pain patients as well. Th is use might be jus-
Palliative care became even more important tifi ed in cases of neuropathic or chronic infl ammatory
when another totally unexpected pandemic occurred pain, but it should be regarded as a misapplication in
in the mid-1980s—HIV/AIDS. Particularly in Africa, most other noncancer pain syndromes. Opioids should
this new “plague” rapidly developed into an enormous not be used as a panacea (one remedy working for all),
health problem that could no longer be ignored. Cancer and current practice in some countries might threaten
and neuropathic pain play important roles in patients opioid availability in the future if health care authori-
with HIV/AIDS. Th e development of palliative medi- ties decide to intervene and restrict opioid use even
cine in Africa began in Zimbabwe in 1979, followed more than today.
by South Africa in 1982, Kenya in 1989, and Uganda In conclusion, the understanding of pain as a
in 1993. Th e institutions in Uganda became models in major health care problem has come a long way. From
the 1990s, based on the initiative of the physician Anne the old days, when pain often was regarded as an un-
Marriman (1935-), who spent a major part of her life in avoidable part of life, which humans could only par-
Asia and Africa. Uganda provided a favorable environ- tially infl uence because of its presumed supernatural
ment for her project “Hospice Africa Uganda” because etiology, a physiological concept has developed, where
at the time Uganda was the only African country whose pain control is now possible. In the last few decades
government declared “palliative care for AIDS and can- the “natural science” concept has been revised and ex-
cer victims” a priority within its “National Health Plan.” tended by the acceptance of psychosocial and ethno-
Th e rate of curative cancer treatment in Uganda is low, cultural infl uencing factors. Although basic research
as in most economically disadvantaged countries. Th is has helped to uncover the complex mechanisms of
situation makes problems associated with cancer and pain and facilitated the development of new strategies
AIDS all the more urgent. to treat pain, the age-old opioids are still the mainstay
Broad acceptance of chronic pain manage- of pain management for acute pain, cancer pain, and
ment in the 20th century required the leadership of neuropathic pain. While the understanding and treat-
the World Health Organization (WHO), stimulated ment of other chronic noncancer pain syndromes are
by Jan Stjernswärd from Sweden (1936–). In 1982, still demanding, cancer pain, acute pain, and neuro-
Stjernswärd invited a number of pain experts, includ- pathic pain may be relieved in a large number of pa-
ing Bonica, to Milan, Italy, to develop measures for tients with easy treatment algorithms and “simple”
the integration of pain management into common opioid and nonopioid analgesics. Th erefore, the future
knowledge and medical practice. Cancer was cho- of pain management in both high- and low-resource
sen as a starting point. At that time, the experts were environments will depend on access to opioids and on
concerned about the increasing gap between success- the integration of palliative care as a priority in health
ful pain research, on the one hand, and decreasing care systems. Pain Management in Low-Resource Set-
availability of opioids to patients, especially cancer tings intends to contribute to this goal in settings
patients, on the other. A second meeting took place where the poor fi nancing of health care systems high-
in Geneva in 1984. As a result, the brochure “Cancer lights the importance of pain management in pallia-
Pain Relief” was published in 1986. In distributing this tive care.