In 2001 Dr Nell Muirden Traveled to:
Port Moresby General Hospital and Lae Memorial Hospital Papua New Guinea

Dr Nell Muirden Melbourne, Australia

Highlights

Dr Muirden’s visit greatly increased awareness about cancer pain and the importance of palliative care and pain relief in cancer and other terminally ill patients.

Dr Gertrude Didei, Port Moresby

I circulated a discussion paper relating to the drugs needed for palliative care and the changes that should be made. The Pharmaceutical Advisory Committee subsequently adopted these recommendations, which will lead to a better range of medications to treat pain becoming available throughout PNG.

Dr Nell Muirden

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Full Report

Background

Papua New Guinea (PNG) with a population of over 5 million, is a collection of islands to the east of Indonesia and north of Australia. In the late 19th century, the southern part was claimed by the British, while the Germans laid claim to the northern sector. At Federation (1901) Australia took responsibility for British New Guinea (which had been renamed Papua) and annexed German New Guinea at the onset of the First World War. The Japanese invaded and occupied a large area during the Second World War. After this war, New Guinea became a United Nations Trust Territory, which was administered by Australia, along with Papua, as a single territory. The country was brought forward to independence in 1975. Before WWII, little had been done to promote education or health services, apart from the work of christian missions, but after this time, considerable effort was made by the Australian administration.

During the 1940s and 50s, students went to the Central Medical School in Fiji to train as "assistant medical officers", until the Papuan Medical College opened in 1960. This became incorporated into the University of Papua New Guinea (UPNG) in 1968. It now trains doctors, dentists and pharmacists, some going on to specialist qualifications through a Master in Medicine programme. Many have had experience in Australia and others in U.K. and U.S.A.

My husband and I worked with the Health Department in PNG for 15 years during the 1960s and 70s and I visited briefly in 1989 and 1999. It was a pleasure to return for eight weeks (3rd June to 27th July, 2001) to assess the present situation and promote palliative care.

The need for palliative care at present

While I was in Port Moresby, the Secretary of Health, Dr. Puka Temu, informed the Cancer Relief Society (a charity raising funds for cancer treatments) that 10,000 Papua New Guineans die from cancer every year. Of the 15,000 new cases "most of our patients die and in pain, which is not the way to die at all, given the many currently available treatment modalities for pain control in patients". (PNG Post-Courier, 24/7/01).

The three commonest cancers (cervix, mouth and liver) are increasing in incidence although they are all largely preventable. Mouth cancer has been shown to be related to chewing betel nut with lime, both of which are carcinogenic, with smoking and additional risk factor. However, retailing betel nut is a source of a cash income for many city dwellers. As well as selling it at markets, many squat on footpaths selling betel nut and cigarettes as single items. As in other countries, cervical cancer is associated with promiscuity and poor genital hygiene. Hepatitis B virus (HBV) is the most important aetiological factor in hepatoma, although 26% are associated with cirrhosis. HBV vaccines should help prevent this disease. Unfortunately most malignancies present at a late stage, sometimes after prolonged courses of antibiotics for mouth ulcers or vaginal discharge, or anti-tuberculous drugs for enlarged nodes.

In many cases it is inappropriate to attempt radical surgery in patients with advanced disease, when the chances of cure are slight and the patient risks dying in a hospital a long way from his village.

AIDS has recently become a significant problem particularly in the capital, Port Moresby, the next largest town, Lae, and the Highland centres of Goroka and Mt. Hagen. To 30th June 2001, 3901 cases of HIV infection had been reported with 1366 cases of AIDS and 249 deaths, but as is also the case with cancer, probably the majority are not diagnosed. The peak incidence in those diagnosed is 19-24 in females (many through antenatal clinics) and 25-29 years in males. Most is transmitted through heterosexual sex. The country is unable to afford antiretroviral drugs, so the need for palliative care is paramount. AIDS is now the commonest cause of death in the medical units of the Port Moresby General Hospital (PMGH).

An unusual condition requiring palliative care in children in subacute sclerosing panencephalitis (SSPE). It is due to a persisting viral infection following measles some years previously. Regression in intellect and personality is followed by myoclonic seizures, then decerebrate rigidity and death, progressing slowly over many months or years. PNG is said to have the highest incidence in the world and there is no effective treatment to delay the process.

Itinerary

3-22/6/01 Port Moresby I attended meetings and ward rounds and had discussions with doctors, nurses and pharmacists at the PMGH, PNGs major hospital with over 700 beds. I also suggested treatments for cancer patients in pain and gave lectures and conducted seminars for doctors, nurses and medical students. (See attached lists - appendix A and B). Most of the hospital was rebuilt about 10 years ago as a gift from the Japanese Government.

I visited the Department of Health and also the Medical School, from which 20 - 30 doctors graduate each year. It also offers a Bachelor degree and Diploma in Pharmacy.

The hospital has no medical oncologist, but nurses give chemotherapy prescribed by a range of staff according to protocols. The nurses had concerns that they were not provided with adequate training or protective clothing, nor a laminar flow cabinet to prepare the cytotoxic drugs.

During this 3 week period, the visiting Professor of Anaesthetics, Dr. Gary Phillips of Adelaide, made a 2 week tour of several centres, and a cardiac surgery team from Sydney spent a week operating on patients with cardiac defects.

23/6 - 13/7/01 Lae I attended ward rounds and spoke at meetings and with staff of the ANGAU (Australia New Guinea Administrative Unit) Memorial Hospital and the adjacent School of Nursing.

In 1972 a Radiotherapy Centre, with a second hand cobalt unit, was opened at the hospital, taking advantage of Lae’s geographically central situation, and road access to the populous highland regions. It operated until 2 years ago when the cobalt unit broke down completely and cannot be repaired, and the radiotherapist left. At the moment, Dr. Soctine, the Deputy Director of Medical Services, is in charge and prescribes chemotherapy for a small number of cancer patients. This was given by a nurse, who left recently on maternity leave. The nurses here are also concerned about lack of protection while preparing cytotoxic drugs. Three therapy radiographers are still employed in various capacities. At a random review of patients in the cancer ward, there were 6 with cancer of the mouth, 2 of the cervix and one male with breast cancer. Other cancer patients were seen in the surgical and gynaecology wards.

As well as an oncologist, the hospital was without a head and neck surgeon, ENT surgeon, radiologist, pathologist and anaesthetist, all these latter functions being performed by technicians. During my visit, there was an opening ceremony for the refurbished operating theatres. The theatres were in the Gware wing (with pharmacy, pathology, radiology and outpatient clinics) which was donated by the Japanese government about 10 years ago.

At the request of the librarian I wrote book reviews on two recent acquisitions from WHO: 
Cancer Pain Relief, second edition (1996) and Symptom Relief in Terminal Illness (1998).

14-27/7/01 Port Moresby During this period (18th) I conducted an inservice study day for nurses on pain assessment and management in cancer and AIDS, which had been organised by the Director or Nursing.

(24th) I also circulated a discussion paper (appendix D) relating to the drugs for palliative care in the Medical Stores Catalogue (appendix C). We then held a meeting of senior medical and nursing staff which was chaired by Prof. Kevau, and came to a consensus about changes that should be made (see appendix E).

(26th) Dr. Didei attended a meeting of the Pharmaceutical Advisory Committee which adopted the recommendations of the former meeting.

22-23/7/01 Goroka During this brief visit I attended the first day of the National AIDS Council National Policy and Curriculum Writing Workshop for HIV/AIDS Counselling and Care. I gave a lecture presentation on palliative care and pain management relating particularly to AIDS but also comparing it with cancer.

Barriers to Provision of Good Palliative Care in PNG

I believe there are five factors, particularly relating to pain control :

1. Pain is frequently not recognised or addressed. This may be due to patient related factors or situations concerning staff.

People in PNG traditionally view illness, pain and death as things you can’t control. they rarely question why they have pain, or the cause of death. (Ms Aileen Natera). Many see an illness as having two components - a pathological or "Western medicine" component and a magic/sorcery component. If modern medicine doesn’t work they see a sorcerer to determine what is the problem and whether someone has caused their illness. The sorcerer has to investigate and try to make this person reverse the sorcery. However, more sophisticated patients may travel to Brisbane or Cairns for another opinion (Dr. Ikau Kevau).

With regard to pain, many patients believe that pain relief is not possible, adopt a "stoical" attitude and suffer in silence. This is particularly the case with poorly educated people who are less able to express their feelings and experiences. Dr. Kaptigau observed the same differences at Alice Springs Hospital, between "stoical" aboriginal and more articulate white patients, and believes it is related to education rather than a racial difference. (However, I saw a woman writhing and screaming with the extreme pain of end stage cervical cancer).

On the other hand, busy nursing and medical staff may not recognise that a patient is in pain. When only two registered nurses (together with some nurse aids) have to care for a ward of 50-60 patients, they may have many urgent duties and overlook the pain of an uncomplaining person. (Nurses are only able to care for the very sick, leaving feeding and bathing to guardians). However, pain may not be given a high priority, and surgeons complained that prescribed analgesics are frequently not given, even when the patient is crying in pain. This may be due to myths about morphine. "The blood pressure is too low", "the pulse is too rapid", "the patient is too sick" are reasons given. When speaking to nurses I was told that "morphine is addictive" (still in print in a current nursing manual) and "I saw a patient who had morphine and she died".

In Lae, the cancer ward nurses translated a verbal descriptor scale into pidgin english and it was combined with a Faces Scale. They were encouraged to use it for pain assessment (appendix F).

2. In many cases, the most effective medications for pain and symptom control are not available through the Public Health system. (See appendix C). In the drug catalogue, aspirin, paracetamol and indomethacin are available, although the aspirin is not in a soluble form.

Opioids listed are buprenorphine (sublingual) and papaveratum injection which are rarely used; 30mg codeine tablet and 50mg and 100mg pethidine injections which are all prescribed frequently; morphine 10mg/ml injection (only), and morphine SR tablets, (sustained release) but the 10mg dose only. Thus these tablets are rarely used. Morphine powder has been available in the past, to make up morphine mixture, but in Port Moresby it has been out of stock for all 2001. (In Lae, there were stocks of powder dated October 2000, but it was used and was effective). Morphine mixture is required to titrate the required dose, for breakthrough pain, and for some with mouth cancer who are unable to swallow tablets.

I was asked to treat the pain of a patient with carcinoma of the mouth invading the mandible, replacing her pethidine injections (inadequate relief with 50mg qid) so that she could go home. Her pain was well controlled on 4 x 10mg SR morphine 12 hourly. She was discharged with these and coloxyl, as the two most essential drugs because I did not want to make the regimen any more complicated. As mentioned, the revised list was approved by the Pharmaceutical Advisory Committee and a new catalogue is to be published in November (2001).

3. The management of cancer pain and other symptoms is largely dependent on a reliable supply of pharmaceuticals. Apart from the morphine powder, many other essential supplies were unavailable while I was in Port Moresby - X-ray films, oral contraceptives (combined pill), 4% dextrose saline solution, IV cannulae, and orthopaedic plates and screws for internal fixation. Medical staff write letters of complaint, but problems are longstanding and they become very frustrated. Sometimes patients are told to buy drugs from the private pharmacies, but these may be very expensive. The above patient would have been charged K109 ($A1=K1.4) for a week’s supply of SR morphine, which would have been prohibitive for this mother of five, whose husband was out of work.

It is essential for patients who are in pain to have supplies of medications to take home. They may be able to return for further stocks if they live in the vicinity, or relatives may come with bottles to refill if they live further afield. A doctor may write a discharge letter to another hospital or health centre if the patient is from another area. It is important that all health centres and many aid posts have supplies of oral morphine. The problem of medical supplies has been under review for a long time.

4. Education in pain management and palliative care is necessary for all health workers and doctors, nurses, health extension officers (HEOs) and aid post orderlies (APOs) so that pain and symptom relief is available throughout the country. 

In particular:

pain needs to be recognised, assessed and treated

the WHO guidelines should be followed

it is essential that analgesics be given regularly round the clock as it is very difficult to titrate the required dose, if a number of doses are missed. (In Lae, drugs were rarely prescribed 4 hourly - the drugs charts were ruled up for dosing qid)

oral sustained relief morphine and morphine mixture should be the mainstay for treating pain, and should be readily available for the pain of cancer and AIDS

more severe pain can be treated by regular injections of morphine into an infusion needle inserted subcutaneously and strapped in place

the need for laxatives with opioids to prevent or treat constipation should be stressed

principles of palliative care and pain control need to be incorporated in the syllabus for training all categories of health worker, those for nurses and community health workers being revised at the moment

a manual of pain relief and palliative care for PNG is needed.

5. Families and village members are usually committed to giving physical, psychological, social and spiritual support to ill and dying members. However, fear of infection with HIV has meant that some AIDS patients have been neglected. Palliative care for those with AIDs is essential as curative treatment is not available. There is a great need for education about transmission (by changing sexual partners and from mother to baby in utero) both to prevent infection and to allay the fears of carers. Carers should be taught how to nurse the patients and respond to their needs while minimizing any chance of transmission.

Note on Security

This is a problem in Port Moresby, and to a lesser extent, Lae. Houses have high fences, razor wire and guard dogs due to large numbers of breakins and robberies. Many of the Port Moresby doctors (including Prof. Isi Kevau and Dr. Gertrude Didei) have had their cars taken from them at gun or knife point (she now has no car).

One of the surgeons said that with "tribespeople" who are prone to violence and payback, or demand compensation if the patient dies, he would only operate if the risk was very small and the surgery provided an obvious improvement.

A beautiful big shady tree on the footpath of a Port Moresby street was being cut down with a chain saw. I asked why. I was told that the people in the house adjacent to it were lawyers who were afraid that a disgruntled client might climb the tree to shoot them over their security fence.

Personal notes

1. I survived on $A2883 for 8 weeks by staying in mission guest houses or with friends, having transport by public buses, or walking, sometimes with Lae hospital transport, or being given a lift by friends.

2. The annual Medical Society Symposium is on the topic of "Cancer" this year and will take place in Lae on 2-7 September. I have submitted an abstract titled "’Sori tumas’ - what happens next? Palliative care in PNG" which has been accepted by the organisers. I will go back to PNG to present the paper at my own expense and take various books and resources which have been requested.

3. I have been asked to draft a "Handbook on Pain Relief and Palliative Care" and conduct workshops in 2002 at Rabaul and Madang and in conjunction with the Medical Society Symposium, to teach and rework the draft. This will be sponsored by the MONAHP programme of Australian Aid for International Development (AusAID) and the Government of PNG.

I believe that this has been a very worthwhile project. 

Thank you very much for making is possible.

N. M. Muirden

 

APPENDIX A

Lectures, tutorials and other educational activities

Port Moresby

5th June - to staff of surgical unit on cancer pain and palliative care

6th June - to medical unit staff on cancer pain/palliative care

13th June - to staff of obstetrics/gynaecology unit on cancer pain, palliative care

18th June - to a group of medical students of 5th (final) year - as above

21st June - nurses from cancer unit and surgical wards on pain assessment and management

18th July - inservice study day for nurses on pain assessment, cancer and AIDS and pain management and palliative care

24th July - meeting of senior medical staff to consider my discussion paper and review the list of palliative care drugs in the catalogue.

Lae

26th June - Obstetrics/gynaecology nurses on pain assessment and management

27th June - to medical unit staff on cancer pain and palliative care

27th June - Grand Rounds on cancer pain management

3rd July - to nurses on cancer pain assessment and management

4th July - Grand Rounds on Palliative care

5th July - nurses of cancer ward - tutorial and development of verbal descriptor scale in pidgin english to accompany a Faces Scale for pain assessment

6th July - case presentation for paediatric unit staff

13th July - Grand Rounds on nausea and vomiting

Goroka

23rd July - on palliative care and pain management in AIDS and cancer at the National AIDS Council National Policy and Curriculum writing workshop for HIV/AIDS Counselling and Care

APPENDIX B

People interviewed (shared information on current practices vs. modern management)

Port Moresby

4th June - Dr. Gertrude Didei, Chief Anaesthetist of PNG & pain specialist

5th June - Prof. Isi Kevau, Prof. of Medicine & Director of the Sir Buri Kidu Heart Institute Mary Elemi, Susan Mwadeda, Oli Indolin - nurses of the Cancer Unit Dr. George Gende, Surgeon, particularly of head and neck Ms Etu Azaru, Social Worker, PMGH Ms. Anna Tema, Chief Pharmacist, PMGH

6th June - Ms. Bella Taumomoa, Deputy Chief Pharmacist Mr. Ralph Saulep, lawyer, President of the Cancer Society (I attended a meeting of the Cancer Society) Prof. John Vince, Prof. of Paediatrics

7th June - Mr. Ego Baru, Head of Pharmaceutical Supplies Mrs. Diane Clarke, Anne Kitonika, Maria Nepal - producing a curriculum for Community Health Workers for the Health Services Support Program (HSSP)

8th June - Ms. Tessie Soi, Head Social Worker PMGH

12th June - Dr. Bob Danaya, lecturer in Paediatrics Mr. Rod Menere, interim team leader, National HIV/AIDS Support Project Prof. Glen Mola, Professor of Obstetrics

13th June - Dr. Adolf Saweri, lecturer in Medicine

14th June - Dr. John Christie, team leader HSSP (Australian & PNG governments)

15th June - Dr. Babona, Deputy Director of Medical Services Mrs. Babona, Director of Nursing

19th June - Dr. Ponifacio, Surgeon, particularly cardiothoracic surgery Dr. William Kaptigau, Surgeon, particularly neurosurgery

20th June - Ms. Aileen Natera, lecturer in Sociology, UPNG

21st June - Dr. Ikau Kevau, Orthopaedic Surgeon and acting head of surgery

22nd June - Dr. Alfred Malagesa, Dr. Mahlon Paiva - gynaecology registrars Dr. Reia Taufa, Paediatrician Dr. Ruben Kila, Head and Neck Surgeon, now in private practice Mrs. Rei Kila, University staff counsellor

17th July - Mr. John Izard, Asian Development Bank Ms. Ragajglo, Nurse in Charge, STD clinic Mr. Kapana, Health Extension Officer (HEO) STD clinic Pastor Isumo Tomasilo, Counsellor, STD clinic

19th July - Dr. Chris Marjen - Director of Medical Services, PMGH Ms. Elizabeth Cox, Director of Counselling & Care, National AIDS Council

25th July - Dr. Mobumo Kiromat, Paediatrician

26th July - Dr. John Christie, HSSP team leader Dr. Graham Roberts, Australian team leader, Medical Officer, Nursing and Allied Health Science Training Project (MONAHP) Ms. Effrie Asigau, MONAHP

Lae

25th June - Dr. Mosey Sau, Director of Medical Services, ANGAU Hospital Ms. Sally Pepper, Adviser to the Pharmacy Dr. Songli Soctine, Deputy DMS, in charge of Cancer Unit Ms. Becky Pais, therapy radiographer in charge Ms. Yanami, Nurse in charge, Cancer Unit

26th June - Dr. Meshach Lemang, Chief obstetrician/gynaecologist Ms. Freda Makanda, Director of Nursing Ms. Rita Samo, Librarian

27th June - Dr. Paisin Dakulala, Senior Physician

29th June - Dr. Jerry Tanumei, Paediatrician

2nd July - Dr. Polapoi Chalau, Head of Surgical Unit

3rd July - Dr. Garuai, Gynaecologist

6th July - Dr. Samiak, Paediatrician Ms Lesley Ririka, tutor, Lae School of Nursing

10th July - Mr. David Vorst, Hospital technical advisor

Submitted by: Dr Nell Muirden