September 10, 2007
Drugs Banned, Many of Worlds Poor Suffer in Pain By DONALD G. McNEIL Jr.
WATERLOO, Sierra Leone Although the rainy season was coming on fast,
Zainabu Sesay was in no shape to help her husband. Ditches had to be dug to
protect their cassava and peanuts, and their mud huts palm roof was sliding
off.
Ruth Fremson/The New York Times
Zainabu Sesay, at her home in Sierra Leone, receives hospice care, but no
morphine is available to ease the pain of breast cancer
But Mrs. Sesay was sick. She had breast cancer in a form that Western doctors
rarely see anymore the tumor had burst through her skin, looking like a
putrid head of cauliflower weeping small amounts of blood at its edges.
September 10, 2007
The New York Times
It bone! It booonnnne lie de fi-yuh! she said of the pain it burns like
fire in Krio, the blended language spoken in this country where British
colonizers resettled freed slaves.
No one had directly told her yet, but there was no hope the cancer was also
in her lymph glands and ribs.
Like millions of others in the worlds poorest countries, she is destined to
die in pain. She cannot get the drug she needs one that is cheap, effective,
perfectly legal for medical uses under treaties signed by virtually every
country, made in large quantities, and has been around since Hippocrates
praised its source, the opium poppy. She cannot get morphine.
Ruth Fremson/The New York Times
A SEARING BURN Momoh Sesay, 2, with his mother, Marie, at the Ola During
Childrens Hospital in Freetown, Sierra Leone. He was badly burned by boiling
water.
That is not merely because of her poverty, or that of Sierra Leone. Narcotics
incite fear: doctors fear addicting patients, and law enforcement officials
fear drug crime. Often, the government elite who can afford medicine for
themselves are indifferent to the sufferings of the poor.
The World Health Organization estimates that 4.8 million people a year with
moderate to severe cancer pain receive no appropriate treatment. Nor do another
1.4 million with late-stage AIDS. For other causes of lingering pain burns,
car accidents, gunshots, diabetic nerve damage, sickle-cell disease and so on
it issues no estimates but believes that millions go untreated.
Figures gathered by the International Narcotics Control Board, a United
Nations agency, make it clear: citizens of rich nations suffer less. Six
countries the United States, Canada, France, Germany, Britain and Australia
consume 79 percent of the worlds morphine, according to a 2005 estimate. The
poor and middle-income countries where 80 percent of the worlds people live
consumed only about 6 percent.
Some countries imported virtually none. Even if the president gets cancer
pain, he will get no analgesia, said Willem Scholten, a World Health
Organization official who studies the issue.
In 2004, consumption of morphine per person in the United States was about
17,000 times that in Sierra Leone.
At pain conferences, doctors from Africa describe patients whose pain is so
bad that they have chosen other remedies: hanging themselves or throwing
themselves in front of trucks.
Westerners tend to assume that most people in tropical countries die of
malaria, AIDS, worm diseases and unpronounceable ills. But as vaccines,
antibiotics and AIDS drugs become more common, more and more are surviving past
measles, infections, birth complications and other sources of a quick death.
They grow old enough to die slowly of cancer.
About half the six million cancer deaths in the world last year were in poor
countries, and most diagnoses were made late, when death was inevitable. But
first, there was agony. About 80 percent of all cancer victims suffer severe
pain, the W.H.O. estimates, as do half of those dying of AIDS.
Morphines raw ingredient opium is not in short supply. Poppies are grown
for heroin, of course, in Afghanistan and elsewhere. But vast fields for
morphine and codeine are also grown in India, Turkey, France, Australia and
other countries.
Nor is it expensive, even by the standards of developing nations. One hospice
in Uganda, for example, mixes its own liquid morphine so cheaply that a
three-week supply costs less than a loaf of bread.
Nonetheless, it is still routinely denied in many poor countries.
Its the intense fear of addiction, which is often misunderstood, said
David E. Joranson, director of the Pain Policy Study Group at the University of
Wisconsins medical school, who has worked to change drugs laws around the
world. Pain relief hasnt been given as much attention as the war on drugs
has.
Doctors in developing countries, he explained, often have beliefs about
narcotics that prevailed in Western medical schools decades ago that they are
inevitably addictive, carry high risks of killing patients and must be used
sparingly, even if patients suffer.
Pain experts argue that it is cruel to deny them to the dying and that
patients who recover from pain can usually be weaned off. Withdrawal symptoms
are inevitable, they say as they are if a diabetic stops insulin. But the
benefits outweigh the risks.
Too Poor for Medicine
In Mrs. Sesays case, Alfred Lewis, a nurse from Shepherds Hospice, is doing
what he can to ease her last days.
When he first saw her, her tumor was wrapped with clay and leaves prescribed
by a local healer. The smell of her rotting skin made her feel ashamed.
She had seen a doctor at one of many low-cost Indian clinics who pulled at
the breast with forceps so hard that she screamed, misdiagnosed her tumor as an
infected boil, and gave her an injection in her buttocks that abscessed, adding
to her misery.
Nothing can be done about the tumor, Mr. Lewis explained quietly. All the
bleeders are open, he said. Her risk now is hemorrhage. Only a knife-crazy
surgeon would attend to her.
Earlier diagnosis would probably not have changed her fate. Sierra Leone has
no CAT scanners, and only one private hospital offers chemotherapy drug
treatment. The Sesays are sharecroppers; they have no money.
So Mr. Lewis was making a daily 10-mile trip from Freetown, the capital, to
change her dressing, sprinkle on antibiotics, and talk to her. He asked a
neighbor to plait her hair for her, so she would look pretty. Mrs. Sesay said
she could not be bothered.
Its necessary for to cope, he said. For to strive for be happy.
I fraid for my life, she said.
Are you fraid for die?
No, I not fraid. I ready.
So what is your relationship to God? You good with God?
I pray me one.
He asked her, half-jokingly, if she still had sex with her husband.
No, she said, since the illness, he stayed in his room and she stayed in
hers. She, too, was joking. In their hut, there is only the one room.
Life has become hard, she added, and her husband is getting too old for farm
labor. She, too, is getting old, she said she is somewhere in her 40s.
We are really being punish.
For her pain, Mr. Lewis gave her generic Tylenol and tramadol, a relative of
codeine that is only 10 percent as potent as morphine. It was all he could
offer. I would consider putting her on morphine now, if we had morphine, Mr.
Lewis said.
In New York, she would have already started on it, or an equivalent like
oxycodone or fentanyl.
Even if his hospice could get it, Mr. Lewis could not give it to her.
Under Sierra Leone law, morphine may be handled only by a pharmacist or
doctor, explained Gabriel Madiye, the hospices founder. But in all Sierra
Leone there are only about 100 doctors one for every 54,000 people, compared
with one for every 350 in the United States.
In only a few places in Uganda, for example does the law allow trained
nurses to prescribe morphine.
And pharmacists will not stock it.
Its opioid phobia, Mr. Madiye said. We are coming out of a war where a
lot of human rights violations were caused by drug abuse.
During the war, the rebel assault on the capital was called Operation No
Living Thing. Child soldiers were hardened with mysterious drugs with names
like gunpowder and brown-brown, along with glue and alcohol.
Esther Walker, a British nurse who sometimes works with Mr. Lewis, said she
once gave a lecture on palliative care at the national medical school.
There were 28 students, and she asked them, Who has seen someone die
peacefully in Sierra Leone?
Not one had, she said.
The Burden on the Young
In the poorest countries like this one, even babies suffer.
Momoh Sesay, 2, (no relation to Zainabu) is a pretty lucky little guy for
someone who tumbled into a cooking pot of boiling water.
He lost much of the skin on his thighs, and his belly is speckled with burns
as if he had been sloshed with pink paint.
But he was fortunate enough to live close to Ola During Childrens Hospital,
the leading pediatric institution.
No doctor was in. There was not even any electricity. At night, nurses thread
IV lines into babies tiny limbs by candlelight. And our eyes are not
magnets, one of them, Josephine Maajenneh Sillah, complained.
But they knew Momoh would die of shock and pumped in intravenous fluids and
antibiotics.
If he had been born in New York, Momoh would have had skin grafts. Here, that
is unthinkable.
Momoh was given saline washes, and his dead skin was scrubbed off with
debridement, a painful procedure. In New York, he would have had morphine.
So probably would Abdulaziz Sankoh, 7, in another bed, who has sickle cell
disease. He moans at night when twisted blood cells clump together and jam the
arteries in his spindly legs, slowly killing his bone marrow.
As would Musa Shariff, an 8-month-old boy whose scalp is so swollen by
meningitis that his eyelids cannot close. Dr. Muctar Jalloh, the hospital
director, said he would not prescribe morphine to babies or toddlers if he had
it. Only in the case of third-degree burns, like Momohs, did he say: I would
consider it maybe.
That flies in the face of Western medicine, which allows careful use even in
premature infants.
The strongest painkiller that Momoh, Abdulaziz and Musa can take, if their
parents can afford $1.65 per vial, is tramadol. It is impossible to know what
morphine would cost if it were here, but it is sold in India at 1.7 cents a
pill by the same company that makes tramadol.
The nurses know the prices because they sell the drugs that are available.
They have not been paid for three years, they say, so they support themselves
in part by filling the prescriptions that the doctors write. Kind as they are
they do extend credit, and are sometimes moved to charity by the children it
is a business.
That is the other reason Dr. Jalloh said he would not order morphine. I
wouldnt want to leave my staff in charge of morphine, he said. The potential
for abuse is so high.
Worries About Abuse
If morphine were to be imported to Sierra Leone, it would be overseen by two
agencies: the National Pharmacy Board and the National Drugs Control Agency.
Kande Bangura, the rangy, sharp-eyed former police commander who runs the
drug control agency, said the country had a serious drug-abuse problem,
especially among former child soldiers.
It also is a smuggling route. He spread out pictures of an autopsy on a
British citizen with Nigerian roots who had dropped dead in line at Freetowns
airport. His intestines were found to be packed with condoms full of cocaine,
one of which had burst.
Mr. Bangura said he had no objections to morphine, however, as long as its
for medical use and is strictly controlled by the countrys chief pharmacist.
Wiltshire C. N. Johnson, the chief of the enforcement arm of the National
Pharmacy Board, explained why painkillers were not imported.
Scarce funds must go to the top five causes of death, he said: diarrhea,
pneumonia, tuberculosis, malaria and sexually transmitted diseases. Im not
saying that palliative care doesnt top the list, too, he said. But its
officially a very small percentage of the requirement.
He also had fears like those of Dr. Jalloh. Theres no way were going to
put morphine in the hands of a pharmacy technician, he said. In the wrong
hands, drugs, like guns, are a greater evil than a cure.
Mr. Madiye, who predicted exactly those answers before the interviews
started, vented his frustration later.
He founded Shepherds Hospice in 1995, saw it destroyed in the civil war and
rebuilt it. But he cannot get the one drug that would let him give people like
Zainabu Sesay the dignified deaths that in the West would be their birthright.
How can they say there is no demand when they dont allow it? he asked.
How can they be so sure that it will get out of control when they havent even
tried it?
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