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Controlling pain in cancer
concepts, and discussions for a long time without having their interpretations or sources questioned. If a scientific paper is meritorious who cares what the prior publicity was. If it is not then it should not be published irrespective of previous hype. Careful editing would reduce the glut of, mainly, rubbish and might focus the medical community on those few useful pieces of information that come along every so often. Away with the IngelfingerRelman rule! Actually, a journal that clearly enunciated this philosophy might find itself overwhelmed by the positive response of authors eager to present and discuss their creations and data with colleagues before it is in print. Robert Matz Mount Sinai Medical Center, Mount Sinai Hospital, Mount Sinai School of Medicine, New York, NY 10029, USA
Cuban doctors in Africa SIR—It is with sadness that I have read the debate about Cuban doctors in South Africa.1,2 Your commentators have addressed the problems of the population of African origin, and have defended their right to healthcare offered by doctors who have travelled from far away. I would like to add a few words on behalf of the Cuban doctors. I was among a group of doctors sent to Africa (Namibia) by the Cuban government. I had to leave my family as hostages in my country. My passport was withdrawn by the Cuban embassy when I arrived. I had to live in a closed community and was constantly surveyed by Cuban political police in Namibia. From the money that the Namibian Ministry of Health paid for my services—5000 rands—I received only 300 rands— the Cuban government took the rest. Fortunately, I was able to escape and, after more than 2 years, I was able to join my family, with the help of different governments and organisations who put pressure on the Cuban government to free my family. I wonder if my colleagues and compatriots are still living in the same conditions that I lived in. I would like to believe that these humiliating conditions have been abandoned, that this 20th century slavery has ceased, but in view of the Cuban reality I have to be pessimistic. José Luis Blanco Rivero Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland
1 2
Lee N. Cuban doctors take South Africa by storm. Lancet 1996; 347: 681. Shisana O. Cuban doctors in South Africa. Lancet 1996; 347: 1488.
Controlling pain in cancer SIR—Reidenberg’s commentary on barriers to controlling pain in patients with cancer (May 11, p 1278)1 was timely. In its 30-year existence the British hospice movement has established methods of pain control that are now in worldwide use. Sadly, however, even in the UK, doctors in junior and middle grade posts have often been inadequately taught about the principles and practice of pain control and frequently are inadequately supervised when the only treatment option has seemed to be “tender loving care”. The abbreviation TLC might be more properly interpreted as “too little, cautiously”. Many senior doctors have not advanced their knowledge in line with modern practice. Many think or even say, “He has got cancer and so, of course, he is going to get pain”.
134
Of course, there are physicians who believe that morphine, and more morphine, is the answer to all pains, and who would prescribe the same amount for a 90-year-old woman with chronic renal failure as for a 30-year-old rugby player. In a recent survey of patients admitted to my own hospice, 15% had symptoms that were wholly or to a large extent due to the medication that they were receiving, rather than from the disease from which they suffered. The fear of morphine as a dangerously addictive drug—to be withheld until the last few hours, and even then administered stingily—is counterbalanced by a naive belief that morphine alone is the answer to every problem in the palliation of pain. Truly the epigram of Dr Jan Stjernsward, chief of the World Health Organization’s cancer and palliative care unit, should hang in every consulting room where palliation of cancer is attempted: “The single most useful thing that we can do to help most patients would be to implement the knowledge which already exists”. T Lovel St Benedict’s Hospice, Monkwearmouth, Sunderland SR5 1NB, UK
1
Reidenberg MM. Barriers to controlling pain in patients with cancer. Lancet 1996; 347: 1278.
Economic barriers for tuberculosis patients in Zambia SIR—Pocock and colleagues’ research in Malawi (May 4, p 1258)1 emphasises that the patient’s perspective, although important, is almost entirely overlooked in the study of tuberculosis (TB). Saunderson2 has noted that there have been no reports of the patient-related costs of TB treatment in African countries. His study (in Uganda) found that patients bore 70% of the total costs incurred up to the time of cure, and that half of the monetary costs and the most of the time lost from work were incurred before diagnosis. Clearly, there are economic barriers for TB patients who seek care. We are studying such patient-related economic barriers to TB diagnosis within Lusaka, Zambia. Over a 2-week period, both adult inpatients and outpatients registering with a diagnosis of pulmonary TB at University Teaching Hospital (UTH), Lusaka, were randomly selected. Interviews (30–60 min) focused on each TB-related health-care encounter and associated costs. 23 patients were interviewed (15 male, 15 outpatients, mean age 34 [SD 10] years). The average household number was 6·2 with 4·7 dependents (73% age <15 years). Five patients were unemployed, nine unable to work because of poor health, and nine currently working; half the patients were self employed. The average duration of illness was 77 days, with an average of seven TB-related trips to health-care providers or institutions (52% to UTH). Of the 85% of trips for which a diagnosis could be inferred, 67% were related to investigation or treatment of non-trivial pulmonary disease. Medical-related spending totalled £146 ($US 225). With inexpensive health insurance available, only 15 patients incurred medical costs. The most substantial costs were related to hospital or clinic charges (44%), treatment (21%), and diagnostics (19%). Non-medical costs averaged £9.10 ($14) per patient, split equally between transportation and food. The total direct patient costs of £15.50 ($24) were significant when compared with the patients’ average monthly income of £39 ($60). The median (range) number of days absent from work or self employment was 12·5 (4–140) and 20 (1–240), respectively. Four of the six
Vol 348 • July 13, 1996
Cuban doctors in Africa SIR—It is with sadness that I have read the debate about Cuban doctors in South Africa.1,2 Your commentators have addressed the problems of the population of African origin, and have defended their right to healthcare offered by doctors who have travelled from far away. I would like to add a few words on behalf of the Cuban doctors. I was among a group of doctors sent to Africa (Namibia) by the Cuban government. I had to leave my family as hostages in my country. My passport was withdrawn by the Cuban embassy when I arrived. I had to live in a closed community and was constantly surveyed by Cuban political police in Namibia. From the money that the Namibian Ministry of Health paid for my services—5000 rands—I received only 300 rands— the Cuban government took the rest. Fortunately, I was able to escape and, after more than 2 years, I was able to join my family, with the help of different governments and organisations who put pressure on the Cuban government to free my family. I wonder if my colleagues and compatriots are still living in the same conditions that I lived in. I would like to believe that these humiliating conditions have been abandoned, that this 20th century slavery has ceased, but in view of the Cuban reality I have to be pessimistic. José Luis Blanco Rivero Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland
1 2
Lee N. Cuban doctors take South Africa by storm. Lancet 1996; 347: 681. Shisana O. Cuban doctors in South Africa. Lancet 1996; 347: 1488.
Controlling pain in cancer SIR—Reidenberg’s commentary on barriers to controlling pain in patients with cancer (May 11, p 1278)1 was timely. In its 30-year existence the British hospice movement has established methods of pain control that are now in worldwide use. Sadly, however, even in the UK, doctors in junior and middle grade posts have often been inadequately taught about the principles and practice of pain control and frequently are inadequately supervised when the only treatment option has seemed to be “tender loving care”. The abbreviation TLC might be more properly interpreted as “too little, cautiously”. Many senior doctors have not advanced their knowledge in line with modern practice. Many think or even say, “He has got cancer and so, of course, he is going to get pain”.
134
Of course, there are physicians who believe that morphine, and more morphine, is the answer to all pains, and who would prescribe the same amount for a 90-year-old woman with chronic renal failure as for a 30-year-old rugby player. In a recent survey of patients admitted to my own hospice, 15% had symptoms that were wholly or to a large extent due to the medication that they were receiving, rather than from the disease from which they suffered. The fear of morphine as a dangerously addictive drug—to be withheld until the last few hours, and even then administered stingily—is counterbalanced by a naive belief that morphine alone is the answer to every problem in the palliation of pain. Truly the epigram of Dr Jan Stjernsward, chief of the World Health Organization’s cancer and palliative care unit, should hang in every consulting room where palliation of cancer is attempted: “The single most useful thing that we can do to help most patients would be to implement the knowledge which already exists”. T Lovel St Benedict’s Hospice, Monkwearmouth, Sunderland SR5 1NB, UK
1
Reidenberg MM. Barriers to controlling pain in patients with cancer. Lancet 1996; 347: 1278.
Economic barriers for tuberculosis patients in Zambia SIR—Pocock and colleagues’ research in Malawi (May 4, p 1258)1 emphasises that the patient’s perspective, although important, is almost entirely overlooked in the study of tuberculosis (TB). Saunderson2 has noted that there have been no reports of the patient-related costs of TB treatment in African countries. His study (in Uganda) found that patients bore 70% of the total costs incurred up to the time of cure, and that half of the monetary costs and the most of the time lost from work were incurred before diagnosis. Clearly, there are economic barriers for TB patients who seek care. We are studying such patient-related economic barriers to TB diagnosis within Lusaka, Zambia. Over a 2-week period, both adult inpatients and outpatients registering with a diagnosis of pulmonary TB at University Teaching Hospital (UTH), Lusaka, were randomly selected. Interviews (30–60 min) focused on each TB-related health-care encounter and associated costs. 23 patients were interviewed (15 male, 15 outpatients, mean age 34 [SD 10] years). The average household number was 6·2 with 4·7 dependents (73% age <15 years). Five patients were unemployed, nine unable to work because of poor health, and nine currently working; half the patients were self employed. The average duration of illness was 77 days, with an average of seven TB-related trips to health-care providers or institutions (52% to UTH). Of the 85% of trips for which a diagnosis could be inferred, 67% were related to investigation or treatment of non-trivial pulmonary disease. Medical-related spending totalled £146 ($US 225). With inexpensive health insurance available, only 15 patients incurred medical costs. The most substantial costs were related to hospital or clinic charges (44%), treatment (21%), and diagnostics (19%). Non-medical costs averaged £9.10 ($14) per patient, split equally between transportation and food. The total direct patient costs of £15.50 ($24) were significant when compared with the patients’ average monthly income of £39 ($60). The median (range) number of days absent from work or self employment was 12·5 (4–140) and 20 (1–240), respectively. Four of the six
Vol 348 • July 13, 1996