23/07/16

Palliative care in Uganda“How Uganda Came To Earn High Marks For Quality Of Death”

Death in Uganda✤ 0.117 physicians per 1000 people (WHO, 2005) vs 2.452 in USA

(WHO, 2011)

✤ 1 500 000 people living with AIDS (UNAIDS, 2015)

✤ 63 000 HIV/AIDS related deaths per year (AVERT, 2014)

✤ Top causes of death are: 1. HIV/AIDS 2. Pneumonia 3. Stroke 4. Coronary Heart Disease (World Life Expectancy, 2014)

✤ Globally, Uganda experiences the 10th highest death rate due to HIV/AIDS (World Life Expectancy, 2014)

✤ HIV/AIDS contributes 42% of the palliative care burden in Africa (Dr. Lowy, 2016)

In 1960, Dr. Anne Merriman of Liverpool University travelled to Africa to serve as a missionary Doctor, and founded the first palliative care hospice in the Uganda in 1993.

What she saw…

✤ Not enough doctors

✤ Not enough hospitals

✤ Only 2% of Ugandans have health insurance, and medication is often prohibitively expensive

✤ People are sent home dying in agony

Hospice Africa Uganda (HAU)

✤ Introduced widely available morphine: "It's easier than making a cake” (Merriman, 2015)

✤ Water bottles filled with water, morphine powder, a preservative and food colouring

✤ The liquid is colour coded: green is the weakest solution, pink is medium and blue is the strongest

✤ 1 tsp every 4 hours eliminates pain almost completely

✤ Patients keep the bottle at home

A elderly patient with chronic debilitating back pain receives a bottle of liquid morphine during a home visit from a representative of Hospice Africa Uganda.

The ethical issues… opiophobia

✤ Morphine is the gold standard in palliative care for pain management

✤ Addiction and misuse is so common, that there is a deep rooted fear of the drug

✤ Providing a means to suicide?

Other ethical problems✤ Some patients thought they had been cured

✤ ‘It's not always the pain that's their greatest worry. It’s often 'What's going to happen to my children when I die?' It may be spiritual problems, it may be cultural — things they have to carry out before they die. We try to help with all those kinds of things.’ -Dr. Merriman, 2015

✤ …any others?

Success of the program✤ The biggest issue

right now in Uganda is the sheer number of patients in need of care- about 300 000

✤ This program has been hailed as a ‘model of care…to complete the ethical circle of care in resource poor circumstances.’ Dr. Harding, 2010

✤ Now the Anne Merriman Foundation is looking to expand these programs to Malawi, Rwanda and other French speaking African countries