Terminal suffering can be stopped, plus trouble brews in the Congo

World | by Gywnne Dyer

Terminal Suffering: Only The Poor Die Screaming

If you had a million dollars to spend (but not on yourself), where would it do the most good? Well, the cost to cover morphine or a morphine-equivalent pain relief treatment for all the sick children younger than 15 years who are in really serious pain in low-income countries would be just $1 million per year. Total.

About half of those children are going to die, but with morphine at least they wouldn’t die screaming.

That’s how a great many people died in the past: no pain relief or aspirin at best, and so cancer victims, gravely injured people and many others spent their last days, weeks or months in agony. Everybody still dies in the end, but now they die with far less pain — in the richer parts of the world. Elsewhere, however, it’s still the Bad Old Days.

This is not because the pain-relief drugs are expensive: they are all off-patent and quite cheap. Yet according to a study published in October by The Lancet, one of Britain’s two leading medical journals, almost half the people who die each year are still dying in ‘serious health-related suffering’ (SHS), as the experts call it. Or agony, as the rest of us call it.

The Lancet went to the trouble of setting up a commission to look into this phenomenon because it just doesn’t make sense. Of the 56 million people who died in the world last year, 25 million experienced short- or long-term SHS before they died. And four out of five of those who died in great pain lived in developing countries. Yet it’s not just happening because they are poor.

All the rich countries except the United States have an average life expectancy above 80 years, but that’s not really a big deal. Middle-income countries like Jamaica, Vietnam and Algeria are all in the mid-70s and even half the countries of Africa have average life-spans above 70 years. It’s not their health services in general that are failing; it’s their palliative care and pain management in particular.

The contrast between rich countries and lower-income countries is far greater in pain control than in any other facet of medical practice. The average annual amount of morphine-equivalent opioids given to patients worldwide in 2010-13 was 298·5 metric tonnes. Of that small mountain of morphine, only 0·1 metric tonne — that is, one hundred kilogrammes — was given to patients in low-income countries.

So 25 million people die in great pain each year, and another 35 million live on in chronic pain and distress — all of which could be prevented for a very modest investment in pain-killing drugs and would require almost no new medical infrastructure. It is an astounding failure that at first seems almost impossible to explain. But there are explanations, of course.

Morphine is three or four times more expensive in most lower-income countries than it is in the rich countries. It doesn’t have to be that way, but the governments of those countries have not intervened to force prices down in the same way they did, for example, with the cost of retrovirals to control AIDS.

Why not? “I don’t think we have cared enough about poor people who have pain,” said Prof. Felicia Knaul, co-chair of the Lancet commission. “It doesn’t make them live any longer. It doesn’t make them more productive. It is simply the human right of not suffering any more pain, and we don’t care about that for people who are poor.”

There are other reasons too, of course, like ‘opiophobia’ — the fear that allowing the drugs to be used in hospitals will lead to addiction and crime in the community. It’s also known that some nurses are uncomfortable giving high doses of narcotics even if ordered to do so, for fear of being held responsible for the patient’s death (even when the patient is terminal). But Knaul is right: the fundamental reason is that we don’t care enough.

Okay, but who’s “we” in this case? It’s not the traditional suspects: selfish people in the rich countries. Nobody is getting rich from this massive and needless neglect. Those to blame are the political and medical leadership in the poor countries themselves, who have failed to give any priority to reducing the horrendous pain suffered by their poor fellow-citizens because that is not one of the metrics by which their success is measured.

Get the death rate down, and you’re a hero. Cure glaucoma and give people back their vision, or eliminate some parasite and get thousands of people back on their feet and working, and you’ll get honours and promotions. End the almost invisible distress of millions of humble people living out their last days in agony, and nobody will even notice. They’re not watching that.

The Lancet commission has proposed an Essential Package of drugs, equipment and training that would cost poor countries only $2 a year per capita and provide pain control for every citizen in lower-income countries, but it’s governments that actually have to do it, in collaboration with their own medical professions. Get your priorities right, and the rest will follow.

The Congo: Drifting into Dangerous Waters

You have to admire Joseph Kabila’s cheek, if nothing else. On Saturday Jan. 27, at his first press conference in seven years, the long-serving president of the Democratic Republic of Congo said: “We have to have elections as scheduled.” But they were scheduled for December of 2016.

Kabila had been in office for 14 years by then, but somehow he had forgotten that you need an up-to-date voters’ list before you can hold an election. So he generously offered to stay in office as president for another year while this was done, even though he was not allowed to run for a third term as president.

The various opposition parties and the Catholic Church, which has immense influence in the DRC, were not greatly pleased by that. However, they reluctantly agreed to go along with it and the election was rescheduled for December 2017 — last month.

As it became clear that the deadline would not be met the demonstrations and protests multiplied, and the ‘security forces’ grew more repressive: a recent UN report found that state agents had carried out 1,176 killings in 2017. And late last year Kabila declared that the elections would have to be postponed again, to December 2018.

“Kabila does not have any intention to leave power,” said Felix Tshisekedi, a prominent opposition leader, after the latest postponement. “His strategy is to spread chaos across the country and then delay elections because he’ll claim there is too much violence.”

The violence is certainly increasing, and there is a serious risk that Congo is sliding back towards civil war, but it’s too simple to blame it all on Kabila.

Joseph Kabila came to power when his father Laurent-Desire Kabila, a warlord who had emerged victorious in the first civil war in 1997, was assassinated in 2001. He was only 29 at the time (although his father had already made him army chief of staff), and he had no political following of his own.

He has subsequently become very rich, but he is still not a powerful figure in his own right. He was put in office by the security forces, now dominated by the men who led his father’s rebel army, and he remains largely a figurehead while they make the real decisions. The problem is that they can’t decide who should replace him.

Kabila didn’t actually forget to change the law that restricted him to two terms of office. Doing that would have been simple enough if the men who really run things had all wanted him to stay in office. (Three other African leaders have changed the rules on term limits so they could stay in office in just the past year.)

Nor is there much doubt that Kabila would have won if there had been an election last year or the year before. It’s the regime’s own people who are slowly compiling the voters’ lists, and the choices they make will doubtless guarantee a victory for the regime.

The situation is drifting towards chaos because the various factions within the security forces cannot agree whether to keep Kabila in power or switch to another figurehead.

It’s all about who has access to resources (for which read money) within the regime, but meanwhile 81 million Congolese are being dragged towards another civil war. The last one, in running from 1998-2003, killed at least five million Congolese, mostly from hunger and disease. They do not need another.

There is already heavy fighting between militia groups and the army in the east and south-east, with the majority of the casualties, as usual, being civilians. It would be comforting to believe that an election could stop all this, but it can’t. What is required is a strong and reasonably honest government that can reassert control over this huge country, the poorest in the world.

It is sheer fantasy to imagine that a country bigger than all of western Europe, but with less in the way of all-weather roads than tiny Luxembourg and a per capita income of about a dollar a day, can be saved by a free election. Communications are so poor that there is no genuine ‘public opinion’, and beyond Kinshasa, the capital, almost all political loyalties are tribal.

Democracy is important, and for most African countries — for most countries anywhere — it is the best solution. But the Congo is too big, too poor and too ethnically fragmented for that to work yet. Elections are symbolically important because they embody the principles of popular sovereignty and the rule of law, but everybody who might actually get elected belongs to a small, privileged elite.

A relatively small part of that group, the ‘security elite’, have actually been running everything since the turn of the century, and the first order of business must be for them to make a deal on who their candidate will be at the next election. Whoever that is will certainly win, and it hardly matters whether it is Kabila or somebody else. Those behind the scenes will still pull the strings.

But until they reach an agreement about the regime’s candidate, the country will continue to drift — and it is drifting into dangerous waters.