Every time I talk with physicians in Ethiopia, they tell me there are hospitals where pain medication, especially morphine, is available, but physicians don’t know how to use it or are afraid to use it.

— Salahadin Abdi, MD, PhD

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According to the World Health Organization (WHO), approximately 70% of deaths from cancer occur in low- and middle-income countries, where late-stage presentation and inaccessibility to diagnosis and treatment are common.¹ In the sub-Saharan African country of Ethiopia, cancer is becoming an increasing public health burden, with hospital records showing more than 150,000 cases of cancer each year, accounting for 4% of all deaths,² and only one functioning cancer care facility, Black Lion Hospital in Addis Ababa, the country’s capital, to treat patients.

Although pain management is an essential part of oncology care, WHO estimates that 80% of the world’s population has insufficient access to appropriate opioid analgesics such as morphine, despite their designation as a WHO essential medicine.³ In Ethiopia, insufficient access to opioids is not the only barrier for inadequate cancer-related pain management. Lack of structured medical education about pain management, as well as health-care providers’ and patients’ cultural attitudes regarding pain and the use of opioid medications, also contributes to poor-quality pain control.

In response to the urgent need to improve cancer-related pain management and cancer outcomes in Ethiopia, in 2017, Salahadin Abdi, MD, PhD, Professor of Anesthesiology/Pain Medicine and Chair, Department of Pain Medicine at The University of Texas MD Anderson Cancer Center, launched the MD Anderson Pain Management Fellowship Program in Ethiopia. The mission of the 2-year program is to help health-care providers:

• Develop advanced knowledge in malignant and nonmalignant pain management techniques
• Understand the implications, benefits, and risks of anesthetic and neurosurgical procedures to control pain
• Encourage active participation in conversations about pain management with patients, their families, and other health-care professionals
• Analyze practice experiences and improve practice-based activities using a systematic methodology
• Participate in presentations and lectures to facilitate knowledge of palliative care and pain management practices
• Learn to become effective advocates for the rights of their patients and families in serious ethical situations.

The program includes curricula developed by Dr. Abdi and on-site training at Ayder Comprehensive Specialized Hospital at Mekelle University in Northern Ethiopia, which serves a population of 9 million. Plans are also underway to expand the fellowship program in 2020 to possibly three additional sites, including the University of Gondar Hospital in Northwest Ethiopia; Bahir Dar University Hospital, also in Northwest Ethiopia; and Black Lion Hospital at the Addis Ababa University School of Medicine.

Prior to the development of Dr. Abdi’s fellowship program, there were no pain medicine training programs in Ethiopia and no fellowship-trained pain medicine physicians to care for patients with cancer.

Eligibility requirements to participate in the Pain Medicine Fellowship Program in Ethiopia are similar to those in the United States. Physicians must be board certified or eligible in a medical field. Due to a limited number of medical specialists in Ethiopia, general practitioners in Ethiopia with at least 3 years’ experience are also eligible to apply for a fellowship. Participants must agree to remain at the Ethiopian hospital where they receive their training for at least 2 years after graduation. (To learn more about the fellowship program, contact Dr. Abdi at sabdi@mdanderson.org.)

The ASCO Post talked with Dr. Abdi about the pain medicine fellowship program, the barriers to achieving good quality pain control in Ethiopia, and how to increase patient access to pain/palliative care.

Bringing a Multidisciplinary Approach to Pain Management

The primary goal of your pain medicine fellowship program is to increase the number of health-care providers with expertise in the appropriate applications of innovative pharmacologic therapies and interventional procedures for patients with advanced cancer. How many fellows have you trained so far in cancer-related pain management?

Currently, seven fellows have just completed our program: two surgeons, two psychiatrists, one pediatrician, one internist, and one neurologist, so it is a unique group of fellows trained in different backgrounds. And, to be honest, that is the way pain medicine should be practiced. It should be a multidisciplinary approach with providers from different fields working together to help patients with cancer-related pain.

Our fellowship program also includes applications in palliative and hospice care. A lot of what physicians do in Africa, particularly in Ethiopia, to receive training in palliative care is to travel to Uganda for 6 to 12 weeks. Thus, instead of just introducing training in pain medicine, our program would also include additional training in palliative care for other types of symptom management, such as shortness of breath, nausea, and fatigue, so physicians don’t have to travel to other parts of Africa for a few weeks of palliative care training. Now, all the training, including pain medicine and palliative and hospice care, can be done in Ethiopia.

There are a number of volunteer palliative care faculty in the program, and although the majority of our training is done through video conferencing, I and a couple of colleagues travel to various hospitals in Ethiopia to lecture and/or do bedside teaching. Now that we have trained seven physicians in pain management and palliative care, my hope is they may be able to train other providers, including physicians, nurses, and medical students, so the program does not depend solely on us going to Ethiopia for bedside training.

My hope is training of our next group of fellows will take place in three different hospital locations. When my colleague, Ethan Dmitrovsky, MD, former Provost and Executive Vice President of The University of Texas MD Anderson Cancer Center, Director of the Frederick National Laboratory for Cancer Research, and President of Leidos Biomedical Research, and I first discussed launching the pain medicine fellowship program in Ethiopia, we wanted to make sure that patients didn’t have to travel long distances to Addis Ababa for treatment at Black Lion Hospital, the country’s one functioning cancer center.

The Ethiopian government has a good plan to eventually establish five more cancer centers throughout the country. That will reduce the long wait list for care and, hopefully, deaths.

Educating Providers on the Benefits of Pain Medications

In addition to a shortage of trained professionals in cancer-related pain management, a scarcity of pain medicines, including opioids, is another barrier to achieving adequate pain control in patients with cancer in Ethiopia. What is needed in this country to achieve appropriate pain control for these patients?

Education, education, education in having all the stakeholders on your side. Every time I talk with physicians in Ethiopia, they tell me there are hospitals where pain medication, especially morphine, is available, but physicians don’t know how to use it or are afraid to use it, and it sits on the shelf expiring. So, education in the utilization of opioids, and also some other pain medications, is missing from their medical training. In other instances, hospitals, especially small, rural hospitals, don’t have opioid medications. It could be a financial issue, or it could be because they don’t know the benefit of using the medication for pain management. And the majority of patients live in rural areas.

Our fellowship training program in Ethiopia on how to use these medications is similar to our program in the United States, but we don’t want it to be exactly the same because the situation is so different in developing countries, including the availability of medications and money as well as the population itself. There may be a difference in the genetic makeup of this patient population in how they metabolize pain medication, which we will investigate.

Our program gives us the opportunity to collaborate with different academic health-care institutions in Ethiopia, not just regarding patient care, but, hopefully down the road, in research as well.

Overcoming Cultural Attitudes and Beliefs About Pain

Societal and health-care provider negative attitudes about the use of opioids in cancer-related pain management are also obstacles to good quality palliative care. Please talk about the cultural attitudes preventing cancer pain management in Ethiopia and how they can be overcome.

The cultural attitudes and beliefs about pain in Ethiopia are completely different from Western cultural attitudes. When patients in Ethiopia have a terminal cancer, they think pain is just part of the package, so they don’t take that into consideration when seeking care. Another aspect we don’t talk about but we have to be open about is that in those societies, a lot of people worry about how to survive today by getting enough food, so they are not that worried about treating their pain; we have to be aware of that, as well as their cultural and religious beliefs about medical care. There are many barriers we have to gradually overcome by educating lay people, patients, physicians, and nurses.

A study of Ethiopian nurses’ attitudes about pain management found that more than half (53.7%) have a negative attitude regarding cancer pain management, and a large majority (65.9%) have poor cancer pain management practices. Lack of training related to pain, patient and work overload, role confusion, and lack of motivation were identified as barriers for providing adequate pain management to patients.⁴

Nurses are an important component of the cancer care team, but since we couldn’t include all health-care providers in our initial training program, our plan is to start with physicians. The next step will be to educate nurses working in treatment facilities as well as pharmacists.

What I emphasize to our fellows is that I don’t want them to finish the program and open a lucrative private practice in Addis Ababa. I want them to stay in the hospital where they received their training for at least 2 years—if not in the same hospital where they were trained, at least in another nonprofit/government community hospital. In this way, poor patients can receive treatment locally rather than have to travel to the capital city.

There aren’t that many specialists in Ethiopia. When I started the fellowship program at Ayder Comprehensive Specialized Hospital at Mekelle University, there wasn’t a single anesthesiologist in the hospital. Just about a week ago, an anesthesiologist who was trained at Black Lion Hospital started to practice in Mekelle.

Improving Access to Cancer Care

Is cancer care in general improving in Ethiopia?

Currently, there is only one functioning cancer care facility in Ethiopia, Black Lion Hospital, but the Ethiopian government has been establishing five additional cancer centers throughout the country. Thus, more patients will be able to receive treatment near where they live instead of having to travel long distances.

We always have to keep in mind that the building could be completed and the equipment in place, but the key to success is having enough trained personnel, such as physicians, nurses, and technicians, to provide services in the new cancer centers once they are completed. Furthermore, my hope and goal is to have trained pain/palliative care providers in every cancer center that is being established, so patients do not have to suffer in pain. 

DISCLOSURE: Dr. Abdi reported no conflicts of interest.

REFERENCES

1. World Health Organization: Cancer key facts. Available at www.who.int/news-room/fact-sheets/detail/cancer. Accessed January 20, 2020.

2. Woldu MA, Legese DA, Abamecha FE, et al: The prevalence of cancer and its associated risk factors among patients visiting oncology unit, Tikur Anbessa Specialized Hospital, Addis Ababa-Ethiopia. J Cancer Sci Ther 9:414-421, 2017.

3. Saini S, Bhatnagar S: Cancer pain management in developing countries. Indian J Palliat Care 22:373-377, 2016.

4. Kassa RN, Kassa GM: Nurses’ attitude, practice and barriers toward cancer pain management, Addis Ababa, Ethiopia. J Cancer Sci Ther 6:483-487, 2014.