South Africa's Palliative Care Failure: WHO Report Highlights Systemic Issues

Damning report from World Health Organisation confirms what professionals already know A child lies dying of cancer in a hospital in Ingwavuma, a remote part of KwaZulu-Natal. Social worker Taryn Bell tries to organise morphine. Without success. The baby dies screaming in pain. A World Health Organisation (WHO) audit of cancer services in South Africa's public health system in May found that South Africa is failing to provide adequate palliative care. The audit, known as an imPACT Review, is yet-to-be-published. Keep up with the latest headlines on WhatsApp | LinkedIn Children are the most neglected population when it comes to palliative care. More than 800,000 children each year in South Africa have life limiting illnesses, according to research carried out by UNICEF and the International Children's Palliative Care Network. Yet there are only five children's hospices in the country. Bell and her husband, a doctor, run two of them: Butterfly Palliative Home at Ingwavuma in KwaZulu-Natal, on the border with Eswatini, and Empangeni. Bell remembers the one-month-old baby with congenital heart disease. Low dose morphine had been prescribed by a paediatrician, with the agreement of the child's mother. The medicine was out of stock in the local hospital, and Bell had to make a plan to get oral morphine from Empangeni, 300 kilometres away. But the hospital ward sister did not want to administer the drug; and the medical manager agreed with her. "They called the doctor, but only to say they are not going to give morphine. The mother then left because she couldn't bear to see her baby suffering. The doctor left because he had fought and lost. A baby died screaming because people didn't feel comfortable giving morphine," says Bell. "There's this entrenched belief in the health system that small children can't handle morphine." The Department of Health employs only one specialist in paediatric palliative care - and only for ten hours a week. She is Dr Julia Ambler, the deputy director and co-founder of Umduduzi Children's Hospice in Durban. Ambler believes that doctors are afraid to administer morphine. "I teach at a medical school, and I'm seeing a change in attitude and a deeper understanding of the drug. But doctors will still phone me and ask, 'What is the maximum dose of morphine', and I have to say, 'There isn't one'. We titrate it upwards according to how much pain the patient is in. If you do that slowly and carefully, it's a very safe drug, but a lot of doctors and nurses are still terrified they're going to stop the child from breathing, which is really not the case," says Ambler. Access to the drug is also a problem. "We have liquid morphine in the country, but it has to filter to the rural peripheries and often it doesn't," says Bell. As for medicine for nerve pain, drugs like Pregabalin [marketed as Lyrica] and Gabapentin are on the essential medicines list, but the KwaZulu-Natal health department does not provide them because of cost. "So, when a tumour or any other disease causes nerve pain, there's very limited options to manage those kids' pain. We have to buy them privately, and don't receive a cent from the state," says Bell. Meanwhile, other things which could help a dying child are not being done, says Ambler. "There's lots you can do for pain that doesn't involve drugs. End-of-life care is one thing, but until a child reaches that stage there's a lot of life to be lived, and there are things you can do that help, including massage, hot and cold therapy, distraction strategies, and so on," says Ambler. But except in a handful of city hospitals, these are not available. In higher income companies, she says, physiotherapists, occupational therapists and social workers work together to help the children. "But for us it's really just the doctor, and the doctor is only good at one thing, quite frankly, if they are even good at that, and that's prescribing," says Ambler. "Children's pain is a blind spot generally." "It's m