PALLIATIVE CARE DELIVERY IN LATIN AMERICA: OBSTACLES AND SOLUTIONS



Cancer continues to grow as a health care problem in Latin America. In developed countries, the number of cancer deaths is expected to increase by 50% in the next decade. Data from Colombia, Mexico and Brazil suggest that in Latin America we can expect an even larger increase. The cost of patient care has the potential to bankrupt the health care system of most Latin American countries.

While only approximately 50% of cancer patients in developed countries, and less than 30% in developing countries can be cured, a significant proportion of the manpower and financial resources in the region are dedicated to the administration of expensive treatments, including surgical oncology, radiation therapy, and chemotherapy to patients who have a minimal chance of benefitting from the intervention.

The World Health Organization considers palliative care to be one of four components of a national cancer control program, together with prevention, early detection and treatment. Palliative care has developed a solid body of evidence-based knowledge that allows for adequate assessment and management of the devastating physical and psychological symptoms that affect cancer patients and their families. These interventions are simple and inexpensive.

In March 1990, physicians, health care workers and government officials from Latin America met for the first time in San Nicolas, Argentina to identify problems and solutions for the delivery of palliative care in the region. After this initial meeting, a number of groups maintained regular contact and significant cross-fertilization of knowledge occurred in the region. A symptom assessment system developed in Colombia was used in three other countries. Methods for parenteral hydration and opioid administration from Brazil were adopted by six other countries. Several countries adopted methods for low cost production of oral and parenteral opioids from Argentina. Drug regulators from Colombia and Spain assisted colleagues from Mexico, the Dominican Republic and Brazil.

In 1996, the number of groups has increased to include physicians, psychologists, nurses, pharmacists, volunteers, pastoral care workers, officials from federal and provincial governments, hospital administrators, senior executives from pharmaceutical companies, and representatives from non-governmental organizations. Probably the most important achievement of these meetings has been the increased understanding by each group of the points of view of each other. Clinicians were able to understand from drug regulators the historical background for existing restrictive legislation and to provide them with their clinical perspective. Government officials were able to understand the reasons for the high cost of commercial opioid preparation and work with volunteers, clinicians and the pharmaceutical industry to find effective solutions.

As a result, measurable outcomes have changed dramatically in the region. The number of patients treated by palliative care groups has increased more than 10 times in six years. Opioid use has increased and the cost of drugs has decreased. Faculties of medicine are conducting education in palliative care both at the undergraduate and postgraduate level. National and provincial governments have developed palliative care policies.

These achievements were only possible because of the invaluable help of experts from the WHO Collaborating Centers who provided technical expertise and moderated the dialogue under the leadership of the WHO Cancer Unit.

This issue of Cancer Pain Release provides an excellent summary of the current achievements and challenges ahead. The information in this issue should help individuals working in Latin America, but also assist individuals working in other developing areas of the world and agencies planning programs of assistance to developing countries.

-- Eduardo Bruera, MD
Coordinator of the WHO Cancer and Palliative Care Program for Latin America.