June 2007

Dear Readers Here's the Article for this Month:

Roberto Wenk, MD
(Argentina)

Palliative Care Development in South America: A Focus on Argentina.

Author(s): Wenk, R and Bertolino, M.

Journal: Journal of Pain and Symptom Management 2007; 33 (5): 645-650

Latin America and the Caribbean (LA) is a developing region with 35 countries and a population of 551 million. Many national health systems focus mainly on disease prevention, prenatal assistance, and under-nourishment, etc.; most must deal with poverty, inadequate infrastructures and poor administrative systems.

Palliative Care (PC) started circa 1982-85 but it is still only available to a small percentage of patients that need it. The quality of care of most dying patients and their families is poor, with uncontrolled suffering and fragmented assistance.

There is an increasing need of PC due to the increase of the prevalence of chronic diseases and an aged population, but also to the fact it may be the main component of care in resource-poor areas where the disease diagnosis is late and curative facilities are lacking.

This article describes PC in LA with specific data from Argentina; it evaluates measures of resources, processes, results and outcomes.

STRUCTURE

Support of health authorities
Most countries do no satisfy the demand for PC: 80 % do not recognize it as a discipline and it is not included in the public or private health systems. Only Chile, Costa Rica and Cuba have national programs that provide PC nationwide.

Economy
Health systems, most under-funded, pay for futile interventions, but they do not pay, or underpay, for PC. This situation jeopardizes team and program sustainability - most run with volunteer work and resources from charity, NGOs and payments from patients (when possible).

Opioid availability and accessibility
There is good availability of different opioids, but poor accessibility due to their high cost, lack of training of health personnel on how to prescribe and use them, and restrictive regulations.

Teams and programs
There is limited information on the number of teams and programs, and the care they deliver. They differ according to their development - community or hospital based, with one or more disciplines, with mixed or exclusive home, outpatient or inpatient care, etc. They care for mostly cancer patients.

National PC associations
By March 2006 only Argentina, Bolivia, Brazil, Colombia, Mexico, Paraguay, Peru, Uruguay and Venezuela had national associations.

PROCESS

Education
There is an increasing interest of health professionals in PC, paralleled with increasing learning opportunities, but less than 15% of those that deliver end of life care received specific undergraduate education; most acquired knowledge and skills after graduation through teaching programs with differing formats.

Research
There is reduced activity with heterogeneous quality; the reasons are limited resources and minimal expertise in research.

Assistance activity
There is limited information about how and where patients die, how many receive PC, and the characteristics of the caring process.

PC availability, accessibility and affordability are inadequate. Estimated figures: (a) 5-10 % of patients that need PC receive it, (b) > 90 % of PC is available only in large cities, and (c) > 50 % of patients can not pay for the services or the medication.

OUTCOME

There is no available information on how effective PC is or which factors modulate its effectiveness.

Why I chose this article.

I would not feel comfortable to I say that I chose this article because of its quality since I am one of the authors. I chose it because of its relevance to Latin America and because I believe the international community should learn and acknowledge the difficult but sustained development of palliative care in the region.

Latin America is also a developing region with specific needs, with a large population living under the poverty level. However, there is a persistent lack of reference to Latin America in most, if not all, reports about global palliative care issues and development. Also, most of the technical and economic assistance is directed to other developing areas of the world and little is allocated to the region. Palliative care workers from Latin America have engaged in different actions and strategies to meet the needs of patients with advanced, progressive conditions. However, the assistance and support that the region receives from international funders and institutions is very limited and insignificant. I believe Latin America should be considered and supported in ways similar to other regions.

Possible reasons for this lack of attention to Latin America could be due to differences in the burden of disease and the resulting magnitude of the needs; a language barrier which limits our ability to report in English the current situation and needs in the countries of the region; and biases in our perception of our success when reporting our needs, with overestimation of our activity and results that creates an illusion that assistance may be unnecessary.

However, the fact is that there has been an increase in both the demand for palliative care services resulting in many cases in the creation of palliative care services that do not meet the minimum criteria for safety, training and quality. Financial and technical assistance from the international community is urgently needed to help cope with these needs and to guarantee that sustainable programs are fit to provide appropriate care to patients and families in Latin America.

Roberto Wenk, MD
Member of the Board of Directors, IAHPC

Please visit the following link to read past Articles Of The Month:
http://www.hospicecare.com/AOM/