Palliative care services are poorly developed in most resource-poor countries. With the increase in the number of cancer cases being diagnosed in these countries, most of whom present in advanced stages, an urgent need for palliative care is emerging. Pakistan is an example of a resource-poor country where palliative care services are in the initial phase of development.
*Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Washington, DC
†Children Cancer Hospital, Karachi
‡Shaukat Khanum Memorial Cancer Hospital & Research Center, Lahore, Pakistan
Reprints: Aziza Shad, MD, Division of Pediatric Hematology Oncology, Blood Marrow Transplantation, Lombardi Comprehensive Cancer Center Georgetown University Hospital, 3800 Reservoir Rd, NW, Washington, DC 20007-2197 (e-mail: firstname.lastname@example.org).
Pakistan is a low- to medium-income developing country with a population of more than 175 million1 and an annual growth rate of 2.03% [World Health Organization (WHO), 2005].2 The population is young with 39% less than 14 years of age and a literacy rate of less than 50%. A total of 32% of the population lives below the poverty line. Cancer is emerging as a major health-care problem in the country. The precise incidence, mortality rates, number of new cancer cases, and number of deaths annually for Pakistan are not known; however, according to WHO estimates, as many as 61,624 incident cases and 42,624 cancer deaths annually in male population and 75,095 incident cases and 43,188 deaths annually in female population are reported.3 In children, although malnutrition and communicable diseases are still the major killers, cancer is rapidly becoming an important cause of morbidity and mortality. On the basis of data from the Karachi Cancer Registry, it is estimated that approximately 5 to 6 thousand children get cancer every year in Pakistan with survival rates varying between 20% and 60%.
Pakistan has a National Cancer Control Plan in place using evidence-based strategies for prevention, early detection, treatment, and palliation as recommended by WHO.4 Implementation of the plan has been poor, particularly with regard to development of services for early detection, palliative care, and morphine availability. As a result, most patients present with advanced disease in need of palliation from the start, face abandonment when terminally ill and usually die of poorly controlled pain.
Barriers to the development of palliative care in Pakistan are no different from other developing countries (Fig. 1). However, despite these odds and still far from adequate, palliative-care services, including pediatric palliative care, have slowly evolved in Pakistan over the last 10 years.
This remains one of the biggest problems in the implementation of good pain control, especially for terminally ill patients. Morphine is not freely available, even at the major centers that treat cancer, supply is sporadic and there is no support from the government to improve its availability. As a result, Pakistan lags far behind other countries in the consumption of morphine.
Fairly well-developed palliative-care services exist at the Shaukat Khanum Memorial Cancer Center (SKMCC) in Lahore and the Aga Khan University Hospital in Karachi. There are pain-management teams primarily consisting of anesthesiologists at some private hospitals, few hospices scattered all over the country, minimal home care, and poorly developed pediatric palliative-care services.
1. SKMCC, Lahore: SKMCC has introduced the Liverpool End-of-Life pathway and has a well-developed pain-management and palliative-care service consisting of a trained palliative-care physician and nursing team. Services include inpatient care, outpatient clinics, and round-the-clock availability through a 24-hour telephone support helpline. Home care and hospice is not well developed. Morphine is available, however supply is limited. Educational activities include a monthly video conference with St Francis Hospice, UK, where challenging cases are discussed, a monthly palliative-care journal club, training courses for physicians and nurses, and international palliative-care symposia.
2. Aga Khan University Hospital, Karachi: Aga Khan University Hospital has a palliative-care team consisting of a trained palliative-care physician, nurses, and a social worker. Inpatient and outpatient coverage is available and home care is well developed. Morphine is available for patients along with other pain medications. Educational activities include training seminars locally.
3. Pediatric palliative care: This is in its early stages of development. The Childrens Cancer Hospital, Karachi and the Childrens Hospital, Lahore, both started small inpatient palliative-care units in 2008. The unit at Childrens Hospital, Lahore, was established with a grant awarded by “My Child Matters” in 2008 with mentorship provided by Dr Aziza Shad. However, lack of trained personnel and lack of knowledge in palliative care, insufficient supply of morphine, and absence of outreach remain major problems.
Development of Palliative-Care Services in Pakistan
International Network for Cancer Treatment and Research (INCTR) is actively involved in the improvement of palliative-care services in Pakistan.
1. In 2008, the first Palliative Care Symposium sponsored by INCTR and supported by Office of International Affairs, National Cancer Institute was held in Karachi, Pakistan. Attended by more than 100 physicians, nurses, and social workers from all over the country, it resulted in a resolution to establish the Palliative Care Society of Pakistan (Picture 1).
2. INCTR members have been actively involved in subsequent palliative-care workshops in Pakistan, and Dr Shamvil Ashraf has participated in the MECC/INCTR palliative-care workshops in Cyprus.
3. Mentorship for both pediatric palliative-care programs is provided by Dr Aziza Shad. On the initial success of the palliative-care initiative at the Childrens Hospital, Lahore, “My Child Matters” has extended their award for another year.
4. In 2008, INCTR officially partnered with Association of Physicians of Pakistani Descent in North America to initiate a program introducing palliative care all over Pakistan. This program is moving ahead and includes future training workshops, and introduction of palliative care to the medical and nursing school curricula.
Future Initiatives in Palliative Care in Pakistan
1. There is an active interest to formally establish a National Palliative Care Association to introduce the discipline of palliative care into mainstream medicine in Pakistan. The goal is to increase awareness for palliative care in the community, which will make it easier to lobby the government for provision of support and release of morphine.
2. Capacity building in palliative care with the help of organizations such as INCTR and Association of Physicians of Pakistani Descent in North America.
3. Initiation of local training programs in management of pain and end-of-life care.
4. Establishment of a palliative care unit with trained personnel in all centers that treat cancer. Support from non-governmental organizations will be needed for this initiative.
5. Introduction of palliative care in medical, nursing, pharmacy, and social work school curricula in Pakistan.
6. Focus on research in palliative care.