Comment
Access to palliative care—the prevention and relief of physical, emotional, social, or spiritual suffering associated with any chronic or life-threatening illness, beginning from the time of diagnosis—is at the core of the right to health and is fundamental to health care. Alleviation of all forms of pain and suffering, both acute and chronic, is an ethical duty of societies and health professionals.1,2 Yet most of the world’s population has little or no access to pain control and palliative care, forcing patients and families to endure a tremendous burden of avoidable suffering.3 The absence of palliative care also undermines efforts to improve human wellbeing, and impoverishes a host of interventions intended to reduce human suffering and strengthen health systems. The need for palliative care is ubiquitous and will grow with population ageing and as chronic disease becomes increasingly common.4,5 In 2010, non-communicable diseases (NCDs) accounted for 54% of the global disease burden, compared with 43% in 1990.6 More than twothirds of deaths are attributable to NCDs, and 80% of these deaths are in low-income and middle-income countries (LMICs).7 Furthermore, palliative care is essential not only near the end of life, but also in combination with curative or disease-modifying treatment from the time of diagnosis.8 Infectious diseases such as HIV/AIDS, multidrug-resistant tuberculosis, and ebola, and complex humanitarian emergencies and severe injuries, also cause suffering that requires pain control and palliative care for patients and their families. Access to pain control and palliative care is currently grossly inequitable.9,10 Most untreated pain and suffering happens in LMICs, and data for opioid access poignantly show this reality. High-income countries account for less than 15% of the world’s population and 94% of global morphine consumption. In the poorest 10% of the world’s countries, a patient with pain who dies from AIDS or cancer has access to on average 200 mg of oral morphine (or equivalents); in the richest 10% of countries, the average morphine consumption per death in pain from AIDS or cancer is 99 000 mg. To remedy the neglect and marginalisation of palliative care, health systems and medicine need to be
redefined. Global health is marked by a dearth of interest, indicators, investment, and interventions to provide for safe, secure, and dignified death, and palliation of pain and suffering throughout the life course. People highly value the avoidance of pain and suffering, yet priority-setting methods that guide health-investment decisions focus almost exclusively on extending life and increasing productivity. In clinical medicine, the obsession with extension of life and treatment of disease, at any pecuniary or emotional cost, displaces adequate attention to human dignity and quality of life.11,12 Terminal illness is stigmatised, and dying patients are too often expelled or excluded from health-care systems. Universal health coverage—the widely accepted quest of health systems13—must include access to pain control and palliative care with financial protection as a fundamental goal.14 However, health entitlements and essential packages typically do not include drugs and other interventions to alleviate pain and suffering.15 As a result, many opportunities to provide access to palliative care through health-system reform and national insurance have been missed. In LMICs, regulations hampering opioid accessibility, combined with the scarcity of trained doctors and other health professionals, has stymied delivery of pain treatment and palliative care. But these barriers are not insurmountable. Integration of pain control and palliative care into health provision is a quintessential example of a diagonal strategy that can strengthen health systems through positive externalities for disciplines as diverse as surgery and social work.16,17 Novel initiatives from developing regions provide valuable lessons to share and scale-up.18,19 Comprehensive pain control and palliative care are embedded into the Costa Rican health system.20 Several countries including Albania,21 Colombia,22 Mexico,23 India,24 and Rwanda25 have implemented palliative-care laws or national plans. Uganda26 and Nepal,27 despite high levels of poverty, are establishing national oral morphine-production programmes. Innovative models for training of clinicians at all levels of the health-care system in palliative care have been piloted in several LMICs. Furthermore, recent advances in the global
www.thelancet.com Published online March 9, 2015 http://dx.doi.org/10.1016/S0140-6736(15)60289-6
Amelie-Benoist/BSIP/Science Photo Library
Closing the divide: the Harvard Global Equity Initiative–Lancet Commission on global access to pain control and palliative care
Published Online March 9, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)60289-6
1
Comment
2
health agenda will enable action.28 In 2014, the World Health Assembly adopted a landmark resolution that exhorts both Member States and the WHO Secretariat to integrate palliative care into universal health coverage.2 The Harvard Global Equity Initiative–Lancet Commission on Global Access to Pain Control and Palliative Care (GAPCPC)29 will build on previous work to harness these opportunities. GAPCPC will work with inclusive definitions, and develop and apply comprehensive frameworks of palliative care embedded in universal health coverage, design measures and apply frameworks of economic evaluation that value the alleviation of pain and suffering throughout the life course, delineate essential and augmented service packages, develop strategies for integration of pain control and palliative care into health systems, identify capacity-building innovations, and describe promising and scalable innovations and models of delivery and financing. The Commission brings together experts from diverse specialties and regions. It unites spheres of action where dialogue, debate, and engagement have been scarce: pain medicine and palliative care, human rights, global and public health, epidemiology, health systems, and health economics. The Commission draws on scientific advisors, works closely with global civil society through the International Association of Hospice and Palliative Care,30 and welcomes information sharing and broad interaction. The enormous global divide in access to pain control and palliative care constitutes an ongoing crisis that plays out almost entirely to the detriment of poor people. The chronic deficit in outrage and outcry is a moral failure that requires remedy. The divide between rich and poor generates a health, equity, and ethical imperative that demands an immediate response based on global and systemic approaches to address rapidly increasing need. The present architecture of global health is ripe to host a response. What has been absent is recognition of pain control and palliative care as an essential part of health systems and a priority for investment in health: this is the motivation and rationale for the GAPCPC.
HGEI-Lancet GAPCPC Commissioners: George Alleyne, Rifat Atun, Agnes Binagwaho, Snezana Bosnjak, David Clark, James Cleary, José Ramón Cossío Díaz, Liliana de Lima, Paul E Farmer (Cochair), Kathleen Foley, Julio Frenk, Cynthia Goh, Mary Gospodarowicz, Liz Gwyther, Irene J Higginson, Thomas Hughes-Hallett, Huda Abu-Saad Huijer, Dean Jamison, Felicia M Knaul (Chair), Eric Krakauer, Emmanuel Luyirika, Diederik Lohman, Rafael Lozano Ascencio, María Elena Medina-Mora, Faith Mwangi-Powell, Sania Nishtar, Meg O’Brien, Lukas Radbruch, MR Rajagopal, Srinath K Reddy, María del Rocío Sáenz Madrigal, Judy Salerno, Yi-Xin Zeng.
*Felicia M Knaul, Paul E Farmer, Afsan Bhadelia, Philippa Berman, Richard Horton
18
Harvard Global Equity Initiative, Boston, MA 02115, USA (FMK, AB); Harvard Medical School, Boston, MA, USA (PEF); and The Lancet, London, UK (PB, RH) [email protected]
19
FMK is Director of the Secretariat of the Global Task Force on Expanded Access to Cancer Care and Control, and founding President of Tómatelo a Pecho. FMK, PEF, and AB declare no competing interests. 1
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Worldwide Palliative Care Alliance, WHO. Global atlas of palliative care at the end of life. January, 2014. http://www.who.int/nmh/Global_Atlas_of_ Palliative_Care.pdf (accessed Jan 25, 2015). WHO. Resolution WHA 67/19. Strengthening of palliative care as a component of comprehensive care throughout the life course. May, 2014. http://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_R19-en.pdf (accessed Oct 5, 2014). Human Rights Watch. ‘Please do not make us suffer anymore…’: access to pain treatment as a human right. 2009. http://www.hrw.org/sites/default/ files/reports/health0309web_1.pdf (accessed Jan 1, 2015). Bonita R, Beaglehole R, Horton R, et al. Priority actions for the noncommunicable disease crisis. Lancet 2011; 377: 1438–47. Cohen J, Deliens L. Applying a public health perspective to end-of-life care. In: Cohen J, Deliens L, eds. A public health perspective on end of life care. Oxford: Oxford University Press, 2012: 3–18. Murray CJL, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2197–223. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2095–128. Krakauer EL. Just palliative care: responding responsibly to the suffering of the poor. J Pain Symptom Manage 2008; 36: 505–12. Knaul FM, Adami HO, Adebamowo C, Arreola-Ornelas H, Berger AJ, Bhadelia A. The global cancer divide: an equity imperative. In: Knaul FM, Gralow R, Atun R, Bhadelia A, eds. Closing the cancer divide: an equity imperative. Cambridge, MA: Harvard Global Equity Initiative, 2012; 29–60. American Cancer Society. Access to essential pain medicines brief (2012 data). Treat the Pain, a program of the American Cancer Society. May, 2014. http://www.treatthepain.org/Assets/Fact%20sheet%20May%202014.pdf (accessed Sept 17, 2014). Gawande A. Being mortal. Medicine and what matters in the end. New York, NY: Metropolitan Books, Henry Holt and Company, 2014. Krakauer EL. To be freed from the infirmity of (the) age: subjectivity, life-sustaining treatment, and palliative medicine. In: Biehl J, Good B, Kleinman A, eds. Subjectivity: ethnographic investigations. Berkeley, CA: University of California Press, 2007; 381–96. Knaul FM, González-Pier E, Gómez-Dantés O, et al. The quest for universal health coverage: achieving social protection for all in Mexico. Lancet 2012; 380: 1259–79. Callahan D. Ends and means: the goals of health care. In: Danis M, Clancy CM, Churchill LR, eds. Ethical dimensions of health policy. New York, NY: Oxford University Press, 2002: 3–18. Jamison D, Summer L, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013; 382: 1898–955. Sepúlveda J, Bustreo F, Tapia R, et al. Improvements of child survival in Mexico: the diagonal approach. Lancet 2006; 368: 2017–27. Knaul FM, Alleyne G, Piot P, et al. Health system strengthening and cancer: a diagonal response to the challenge of chronicity. In: Knaul FM, Gralow R, Atun R, Bhadelia A, eds. Closing the cancer divide: an equity imperative. Cambridge, MA: Harvard Global Equity Initiative, 2012; 96–113. Steedman MR, Hughes-Hallett T, Knaul FM, Knuth A, Shamieh O, Darzi A. Innovation can improve and expand aspects of end-of-life care in low- and middle-income countries. Health Aff (Millwood) 2014; 33: 1612–19. Liberman J, O’Brien M, Hall W, Hill D. Ending inequities in access to effective pain relief? Lancet 2010; 376: 856–57. Pastrana T, Torres-Vigil I, De Lima L. Palliative care development in Latin America: an analysis using macro indicators. Palliat Med 2014; 28: 1–8.
www.thelancet.com Published online March 9, 2015 http://dx.doi.org/10.1016/S0140-6736(15)60289-6
Comment
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European Association of Palliative Care. Albania passes first palliative care laws. Nov 12, 2014. https://eapcnet.wordpress.com/2014/11/12/ albania-passes-first-palliative-care-laws/ (accessed Dec 11, 2014). de Lima L. Ley nacional de cuidados paliativos en colombia. eHospice edición América Latina. http://www.ehospice.com/americalatina/ articlepreview/tabid/6950/ArticleId/9960/language/es-ES/Default.aspx (accessed Dec 11, 2014). Secretaria de Gobernación. Diario oficial de la federación. Capítulo VIII bis, disposiciones para la prestación de servicios de cuidados paliativos cle 166 Bis. 3. http://dof.gob.mx/nota_detalle.php?codigo=5320513&fec ha=01/11/2013 (accessed Dec 11, 2014). Kmietowicz Z. Indian parliament votes to increase access to morphine. BMJ 2014; 348: g1744. Ntizimira C. Integration of palliative care in Rwanda. eHospice Africa edition. http://www.ehospice.com/africa/ArticleView/tabid/10701/ ArticleId/5401/language/en-GB/View.aspx (accessed Dec 27, 2014).
26 Merriman A, Harding R. Pain control in the African context: the Ugandan introduction of affordable morphine to relieve suffering at the end of life. Philos Ethics Humanit Med 2010; 5: 10. 27 Paudel BD, Ryan KM, Brown MS, et al. Opioid availability and palliative care in Nepal: influence of an international pain policy fellowship. J Pain Symptom Manage 2014; 49: 110–16. 28 Powell RA, Mwangi-Powell F, Radbruch L, et al. Putting palliative care on the global health agenda. Lancet Oncol 2015; 16: 131–33. 29 Harvard Global Equity Initiative. HGEI–Lancet Commission on global access to pain control & palliative care. http://hgei.harvard.edu/icb/icb.do?keywor d=k62597&tabgroupid=icb.tabgroup191254 (accessed Oct 5, 2014). 30 International Association for Hospice and Palliative Care. Vision and mission. http://hospicecare.com/about-iahpc/who-we-are/vision-andmission/ (accessed Oct 5, 2014).
www.thelancet.com Published online March 9, 2015 http://dx.doi.org/10.1016/S0140-6736(15)60289-6
3
Access to palliative care—the prevention and relief of physical, emotional, social, or spiritual suffering associated with any chronic or life-threatening illness, beginning from the time of diagnosis—is at the core of the right to health and is fundamental to health care. Alleviation of all forms of pain and suffering, both acute and chronic, is an ethical duty of societies and health professionals.1,2 Yet most of the world’s population has little or no access to pain control and palliative care, forcing patients and families to endure a tremendous burden of avoidable suffering.3 The absence of palliative care also undermines efforts to improve human wellbeing, and impoverishes a host of interventions intended to reduce human suffering and strengthen health systems. The need for palliative care is ubiquitous and will grow with population ageing and as chronic disease becomes increasingly common.4,5 In 2010, non-communicable diseases (NCDs) accounted for 54% of the global disease burden, compared with 43% in 1990.6 More than twothirds of deaths are attributable to NCDs, and 80% of these deaths are in low-income and middle-income countries (LMICs).7 Furthermore, palliative care is essential not only near the end of life, but also in combination with curative or disease-modifying treatment from the time of diagnosis.8 Infectious diseases such as HIV/AIDS, multidrug-resistant tuberculosis, and ebola, and complex humanitarian emergencies and severe injuries, also cause suffering that requires pain control and palliative care for patients and their families. Access to pain control and palliative care is currently grossly inequitable.9,10 Most untreated pain and suffering happens in LMICs, and data for opioid access poignantly show this reality. High-income countries account for less than 15% of the world’s population and 94% of global morphine consumption. In the poorest 10% of the world’s countries, a patient with pain who dies from AIDS or cancer has access to on average 200 mg of oral morphine (or equivalents); in the richest 10% of countries, the average morphine consumption per death in pain from AIDS or cancer is 99 000 mg. To remedy the neglect and marginalisation of palliative care, health systems and medicine need to be
redefined. Global health is marked by a dearth of interest, indicators, investment, and interventions to provide for safe, secure, and dignified death, and palliation of pain and suffering throughout the life course. People highly value the avoidance of pain and suffering, yet priority-setting methods that guide health-investment decisions focus almost exclusively on extending life and increasing productivity. In clinical medicine, the obsession with extension of life and treatment of disease, at any pecuniary or emotional cost, displaces adequate attention to human dignity and quality of life.11,12 Terminal illness is stigmatised, and dying patients are too often expelled or excluded from health-care systems. Universal health coverage—the widely accepted quest of health systems13—must include access to pain control and palliative care with financial protection as a fundamental goal.14 However, health entitlements and essential packages typically do not include drugs and other interventions to alleviate pain and suffering.15 As a result, many opportunities to provide access to palliative care through health-system reform and national insurance have been missed. In LMICs, regulations hampering opioid accessibility, combined with the scarcity of trained doctors and other health professionals, has stymied delivery of pain treatment and palliative care. But these barriers are not insurmountable. Integration of pain control and palliative care into health provision is a quintessential example of a diagonal strategy that can strengthen health systems through positive externalities for disciplines as diverse as surgery and social work.16,17 Novel initiatives from developing regions provide valuable lessons to share and scale-up.18,19 Comprehensive pain control and palliative care are embedded into the Costa Rican health system.20 Several countries including Albania,21 Colombia,22 Mexico,23 India,24 and Rwanda25 have implemented palliative-care laws or national plans. Uganda26 and Nepal,27 despite high levels of poverty, are establishing national oral morphine-production programmes. Innovative models for training of clinicians at all levels of the health-care system in palliative care have been piloted in several LMICs. Furthermore, recent advances in the global
www.thelancet.com Published online March 9, 2015 http://dx.doi.org/10.1016/S0140-6736(15)60289-6
Amelie-Benoist/BSIP/Science Photo Library
Closing the divide: the Harvard Global Equity Initiative–Lancet Commission on global access to pain control and palliative care
Published Online March 9, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)60289-6
1
Comment
2
health agenda will enable action.28 In 2014, the World Health Assembly adopted a landmark resolution that exhorts both Member States and the WHO Secretariat to integrate palliative care into universal health coverage.2 The Harvard Global Equity Initiative–Lancet Commission on Global Access to Pain Control and Palliative Care (GAPCPC)29 will build on previous work to harness these opportunities. GAPCPC will work with inclusive definitions, and develop and apply comprehensive frameworks of palliative care embedded in universal health coverage, design measures and apply frameworks of economic evaluation that value the alleviation of pain and suffering throughout the life course, delineate essential and augmented service packages, develop strategies for integration of pain control and palliative care into health systems, identify capacity-building innovations, and describe promising and scalable innovations and models of delivery and financing. The Commission brings together experts from diverse specialties and regions. It unites spheres of action where dialogue, debate, and engagement have been scarce: pain medicine and palliative care, human rights, global and public health, epidemiology, health systems, and health economics. The Commission draws on scientific advisors, works closely with global civil society through the International Association of Hospice and Palliative Care,30 and welcomes information sharing and broad interaction. The enormous global divide in access to pain control and palliative care constitutes an ongoing crisis that plays out almost entirely to the detriment of poor people. The chronic deficit in outrage and outcry is a moral failure that requires remedy. The divide between rich and poor generates a health, equity, and ethical imperative that demands an immediate response based on global and systemic approaches to address rapidly increasing need. The present architecture of global health is ripe to host a response. What has been absent is recognition of pain control and palliative care as an essential part of health systems and a priority for investment in health: this is the motivation and rationale for the GAPCPC.
HGEI-Lancet GAPCPC Commissioners: George Alleyne, Rifat Atun, Agnes Binagwaho, Snezana Bosnjak, David Clark, James Cleary, José Ramón Cossío Díaz, Liliana de Lima, Paul E Farmer (Cochair), Kathleen Foley, Julio Frenk, Cynthia Goh, Mary Gospodarowicz, Liz Gwyther, Irene J Higginson, Thomas Hughes-Hallett, Huda Abu-Saad Huijer, Dean Jamison, Felicia M Knaul (Chair), Eric Krakauer, Emmanuel Luyirika, Diederik Lohman, Rafael Lozano Ascencio, María Elena Medina-Mora, Faith Mwangi-Powell, Sania Nishtar, Meg O’Brien, Lukas Radbruch, MR Rajagopal, Srinath K Reddy, María del Rocío Sáenz Madrigal, Judy Salerno, Yi-Xin Zeng.
*Felicia M Knaul, Paul E Farmer, Afsan Bhadelia, Philippa Berman, Richard Horton
18
Harvard Global Equity Initiative, Boston, MA 02115, USA (FMK, AB); Harvard Medical School, Boston, MA, USA (PEF); and The Lancet, London, UK (PB, RH) [email protected]
19
FMK is Director of the Secretariat of the Global Task Force on Expanded Access to Cancer Care and Control, and founding President of Tómatelo a Pecho. FMK, PEF, and AB declare no competing interests. 1
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Worldwide Palliative Care Alliance, WHO. Global atlas of palliative care at the end of life. January, 2014. http://www.who.int/nmh/Global_Atlas_of_ Palliative_Care.pdf (accessed Jan 25, 2015). WHO. Resolution WHA 67/19. Strengthening of palliative care as a component of comprehensive care throughout the life course. May, 2014. http://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_R19-en.pdf (accessed Oct 5, 2014). Human Rights Watch. ‘Please do not make us suffer anymore…’: access to pain treatment as a human right. 2009. http://www.hrw.org/sites/default/ files/reports/health0309web_1.pdf (accessed Jan 1, 2015). Bonita R, Beaglehole R, Horton R, et al. Priority actions for the noncommunicable disease crisis. Lancet 2011; 377: 1438–47. Cohen J, Deliens L. Applying a public health perspective to end-of-life care. In: Cohen J, Deliens L, eds. A public health perspective on end of life care. Oxford: Oxford University Press, 2012: 3–18. Murray CJL, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2197–223. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2095–128. Krakauer EL. Just palliative care: responding responsibly to the suffering of the poor. J Pain Symptom Manage 2008; 36: 505–12. Knaul FM, Adami HO, Adebamowo C, Arreola-Ornelas H, Berger AJ, Bhadelia A. The global cancer divide: an equity imperative. In: Knaul FM, Gralow R, Atun R, Bhadelia A, eds. Closing the cancer divide: an equity imperative. Cambridge, MA: Harvard Global Equity Initiative, 2012; 29–60. American Cancer Society. Access to essential pain medicines brief (2012 data). Treat the Pain, a program of the American Cancer Society. May, 2014. http://www.treatthepain.org/Assets/Fact%20sheet%20May%202014.pdf (accessed Sept 17, 2014). Gawande A. Being mortal. Medicine and what matters in the end. New York, NY: Metropolitan Books, Henry Holt and Company, 2014. Krakauer EL. To be freed from the infirmity of (the) age: subjectivity, life-sustaining treatment, and palliative medicine. In: Biehl J, Good B, Kleinman A, eds. Subjectivity: ethnographic investigations. Berkeley, CA: University of California Press, 2007; 381–96. Knaul FM, González-Pier E, Gómez-Dantés O, et al. The quest for universal health coverage: achieving social protection for all in Mexico. Lancet 2012; 380: 1259–79. Callahan D. Ends and means: the goals of health care. In: Danis M, Clancy CM, Churchill LR, eds. Ethical dimensions of health policy. New York, NY: Oxford University Press, 2002: 3–18. Jamison D, Summer L, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013; 382: 1898–955. Sepúlveda J, Bustreo F, Tapia R, et al. Improvements of child survival in Mexico: the diagonal approach. Lancet 2006; 368: 2017–27. Knaul FM, Alleyne G, Piot P, et al. Health system strengthening and cancer: a diagonal response to the challenge of chronicity. In: Knaul FM, Gralow R, Atun R, Bhadelia A, eds. Closing the cancer divide: an equity imperative. Cambridge, MA: Harvard Global Equity Initiative, 2012; 96–113. Steedman MR, Hughes-Hallett T, Knaul FM, Knuth A, Shamieh O, Darzi A. Innovation can improve and expand aspects of end-of-life care in low- and middle-income countries. Health Aff (Millwood) 2014; 33: 1612–19. Liberman J, O’Brien M, Hall W, Hill D. Ending inequities in access to effective pain relief? Lancet 2010; 376: 856–57. Pastrana T, Torres-Vigil I, De Lima L. Palliative care development in Latin America: an analysis using macro indicators. Palliat Med 2014; 28: 1–8.
www.thelancet.com Published online March 9, 2015 http://dx.doi.org/10.1016/S0140-6736(15)60289-6
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European Association of Palliative Care. Albania passes first palliative care laws. Nov 12, 2014. https://eapcnet.wordpress.com/2014/11/12/ albania-passes-first-palliative-care-laws/ (accessed Dec 11, 2014). de Lima L. Ley nacional de cuidados paliativos en colombia. eHospice edición América Latina. http://www.ehospice.com/americalatina/ articlepreview/tabid/6950/ArticleId/9960/language/es-ES/Default.aspx (accessed Dec 11, 2014). Secretaria de Gobernación. Diario oficial de la federación. Capítulo VIII bis, disposiciones para la prestación de servicios de cuidados paliativos cle 166 Bis. 3. http://dof.gob.mx/nota_detalle.php?codigo=5320513&fec ha=01/11/2013 (accessed Dec 11, 2014). Kmietowicz Z. Indian parliament votes to increase access to morphine. BMJ 2014; 348: g1744. Ntizimira C. Integration of palliative care in Rwanda. eHospice Africa edition. http://www.ehospice.com/africa/ArticleView/tabid/10701/ ArticleId/5401/language/en-GB/View.aspx (accessed Dec 27, 2014).
26 Merriman A, Harding R. Pain control in the African context: the Ugandan introduction of affordable morphine to relieve suffering at the end of life. Philos Ethics Humanit Med 2010; 5: 10. 27 Paudel BD, Ryan KM, Brown MS, et al. Opioid availability and palliative care in Nepal: influence of an international pain policy fellowship. J Pain Symptom Manage 2014; 49: 110–16. 28 Powell RA, Mwangi-Powell F, Radbruch L, et al. Putting palliative care on the global health agenda. Lancet Oncol 2015; 16: 131–33. 29 Harvard Global Equity Initiative. HGEI–Lancet Commission on global access to pain control & palliative care. http://hgei.harvard.edu/icb/icb.do?keywor d=k62597&tabgroupid=icb.tabgroup191254 (accessed Oct 5, 2014). 30 International Association for Hospice and Palliative Care. Vision and mission. http://hospicecare.com/about-iahpc/who-we-are/vision-andmission/ (accessed Oct 5, 2014).
www.thelancet.com Published online March 9, 2015 http://dx.doi.org/10.1016/S0140-6736(15)60289-6
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