Vol. 36 No. 5 November 2008 515Commentary

2. Pain and Policy Studies Group. Global, regional,and national consumptionstatistics for2006. Madison,WI: PPSG, 2008. Available at: http://www.painpolicy.wisc.edu/news/international.htm#041508.

3. WHO/UNAIDS. Progress on global access toHIV antiretroviral therapy: a report on ‘‘3 by 5’’and beyond, March 2006. Geneva: WHO, 2006.

4. Selwyn PA, Forstein M. Overcoming the false di-chotomy of curative vs. palliative care for late-stageHIV/AIDS. JAMA 2003;290:806e814.

5. Walensky RP, Paltiel AD, Losina F, et al. The sur-vival benefits of AIDS treatment in the UnitedStates. J Infect Dis 2006;145:797e806.

6. Teixeira PR, Vitoria MA, Barcarolo. Antiretroviraltreatment in resource-poor settings: the Brazilianexperience. AIDS 2004;18(Suppl 3):S5eS7.

7. Boulle A, Ford N. Scaling up antiretroviral ther-apy in developing countries: what are the benefitsand challenges? Postgrad Med J 2008;84:225e227.

8. Tucker M. Revisiting the ‘‘Lazarus syndrome.’’ In:Willinger BI, Rice A, eds. A history of AIDS socialwork in hospitals: a daring response to an epidemic.Philadelphia: Haworth Press, 2003: 255e262.

Palliative Carein Resource-PoorSettings: Fallaciesand Misapprehensions

Richard Harding, BSc, MSc,DipSW, PhD

The modern palliative care movement pio-neered end-of-life care for malignant diseasepatients in developed countries. Since then,the public health approach has advocatedglobal expansion and integration from the

Richard Harding, BSc, MSc, DipSW, PhD, is a SeniorLecturer, Department of Palliative Care, Policy andRehabilitation, King’s College London School ofMedicine, London, United Kingdom.

Address correspondence to: Richard Harding, BSc,MSc, DipSW, PhD, Department of Palliative Care,Policy and Rehabilitation, King’s College LondonSchool of Medicine, Western Education Centre, Cut-combe Road, London SE5 9RV, United Kingdom.E-mail: richard.harding@kcl.ac.uk

DOI of original article: 10.1016/j.jpainsymman.2007.11.015.

point of diagnosis for all life-limiting progres-sive conditions. Despite advances in coverage,inequalities persist irrespective of setting.Even in resource-rich countries, the poor andsocially excluded are less likely to access pallia-tive care, achieve optimum relief of pain andsymptoms, or die in their preferred place.1e4

In resource-poor settings, the implicationsof poverty for palliative care access are greater,where the burden of progressive disease(primarily HIV and cancer) is enormous andpublic health systems generally weaker. The re-sulting tension in allocation of finite resourcesto potentially curative or palliative care is ex-plored by Krakauer in this issue. Krakauershould be congratulated for tackling this com-plex and important debate.

The unhelpful distinction between curativeand palliative resources is even less useful inpoorer countries. The burden of disease andbackground poverty fueling incidence meanthat rather than thinking about whether cura-tive or palliative care need greater resources,the basic epidemiological truth is that bothneed increased attention compared withresource-rich countries.

Krakauer considers the need for integratedcare, embracing the curative and offeringpalliative care as appropriatedwhether that isantiretroviral therapy or opioids at the end oflife, as palliative care establishes itself as a re-quired element of the care pathway. This argu-ment is generally accepted however, it alsoraises a problem in advocating for, and imple-menting, integrated curative and palliativecare alongside new treatments in resource-poor settings. This problem is the lack of re-search evidence to guide appropriate modelsof care in poor settings.

Despite a growth in the number of palliativecare services in poorer countries, we still lackthe evidence to support calls for integrationof curative and palliative care.5 In order to ef-fectively advocate to clinicians, policy makers,funders, and educators, we need to demon-strate the effectiveness of palliative care along-side treatments, and to offer models of carethat are locally appropriate and have proveneffectiveness in terms of both costs and out-comes. Unfortunately, this is where a fallacyarisesdthat the allocation of resources to pal-liative care research is inappropriate where re-sources are generally scarce.

516 Vol. 36 No. 5 November 2008Commentary

We have robust evidence demonstrating theeffectiveness of cancer palliative care6,7 andthat patient and family outcomes are im-proved under HIV palliative care.8 Unfortu-nately, the studies are almost exclusivelyundertaken in resource-rich countries andpre-antiretroviral therapy. It is hard to imaginehow we can influence change in clinical prac-tice, allocation of funds, or medical and nurs-ing school curricula if we lack evidence as towhy palliative care matters alongside curativeapproaches. The very nature of a resource-poor setting indicates that we compete forthose scarce resources among all other gener-alist and specialist groupings in health and so-cial care.

There are further moral imperatives to ad-dress the research needs of palliative care inpoor settings. In resource-rich countries, we at-tempt to provide ‘‘evidence-based’’ care and topromote and replicate models of care that areacceptable, appropriate, and effective in theirsetting. Surely, people in poor countries de-serve the right to have care that is also evalu-ated and effective? We cannot be satisfiedthat we provide care in poor settingsdwemust provide technical support and resourcesto enable that care to be evaluated and offerframeworks for quality improvement. Thetime and resources allocated to research nowimprove access and outcomes for all the pa-tients and families that follow.

The second moral argument is for the wise al-location of scarce resources based on methodsof audit and research that enable us to ensurethat we make the best use of available funds.Clinical research, health services research, andneeds assessments9 are essential alongside thesituational analysis that Krakauer suggests.This would ensure that evidence is robust andrelevant. When we discuss ‘‘poor countries,’’ ho-mogeneity and replicability should never be as-sumed. Local health systems, prevailingdiseases, somatization of illness, beliefs, clinicalpractice,10 and drug metabolism may be ex-pected to vary according to setting. Dr. AnneMerriman, founder of Hospice Africa Uganda,has called for ‘‘each hospice in Africa to be a cen-tre for teaching and research in response to thecurrent dearth of evidence, cultural, spiritual,social and even metabolic differences need tobe researched in order to give the best comfortto patients and families.’’11

Some of the fundamental questions to beanswered are the nature and intensity ofpalliative care needs early in the HIV diseasetrajectory, and the impact of palliation onrisk and adherence (thereby demonstratingour worth to HIV medicine). Although Kraka-uer suggests that palliative care, as defined bythe World Health Organization, is ‘‘not a sci-ence, profession, or academic discipline,’’ itis precisely the science of palliative care re-search, undertaken by local academics guidingthe professional delivery of clinical care, whichis urgently needed in poor countries to achieveKrakauer’s goal, i.e., palliative care that isadapted to setting, addressing sometimes com-plex and often refractory problems. Resourcesare needed to build local research and teach-ing capacity to achieve this.

Lastly, the palliative care movement has failedto work effectively with the influential global non-governmental organizations that promote the in-terests of people living with HIV/AIDS. We mustconvince the people that matter most, i.e., peo-ple living with HIVand otherprogressive illnesses(whose populations will remain progressive evenwith availability of therapeutic regimens). Dem-onstrating the improvements in quality of lifeand a good death alongside antiretroviral ther-apy must surely be our responsibility. Maybethen, patients, families and other advocates,alongside practitioners, may formulate strate-gies to break the fallacy of cure vs. palliation.

doi:10.1016/j.jpainsymman.2008.04.019

References1. Crawley L, Payne R, Bolden J, et al. Palliative

and end-of-life care in the African American com-munity. JAMA 2000;284(19):2518e2521.

2. Decker SL, Higginson IJ. A tale of two cities: fac-tors affecting place of cancer death in London andNew York. Eur J Public Health 2007;17(3):285e290.

3. Higginson IJ, Jarman B, Astin P, Dolan S. Dosocial factors affect where patients die: an analysisof 10 years of cancer deaths in England. J PublicHealth Med 1999;21(1):22e28.

4. Koffman J, Higginson IJ. Accounts of carers’ sat-isfaction with health care at the end of life: a com-parison of first generation black Caribbeans andwhite patients with advanced disease. Palliat Med2001;15(4):337e345.

5. Harding R, Higginson IJ. Palliative care in sub--Saharan Africa. Lancet 2005;365(9475):1971e1977.

Vol. 36 No. 5 November 2008 517Commentary

6. Finlay IG, Higginson IJ, Goodwin DM, et al. Pal-liative care in hospital, hospice, at home: resultsfrom a systematic review. Ann Oncol 2002;13(Suppl4):257e264.

7. Higginson IJ, Finlay IG, Goodwin DM, et al. Isthere evidence that palliative care teams alter en-d-of-life experiences of patients and their care-givers? J Pain Symptom Manage 2003;25(2):150e168.

8. Harding R, Karus D, Easterbrook P, et al. Doespalliative care improve outcomes for patients withHIV/AIDS? A systematic review of the evidence.Sex Transm Infect 2005;81(1):5e14.

9. Higginson IJ, Hart S, Koffman J, Selman L,Harding R. Needs assessments in palliative care:an appraisal of definitions and approaches used.J Pain Symptom Manage 2007;33(5):500e505.

10. Roll IJ, Simms V, Harding R. Multidimensionalproblems among advanced cancer patients in Cuba:awareness of diagnosis is associated with better patientstatus. J Pain Symptom Manage, Epub ahead of print.

11. Merriman A. Pain in developing countries.Hosp Uganda J Palliat Care 2001;4(4):9e17.

Just Palliative Care?Integrated Modelsof Care

Liz Gwyther, MB ChB, FCFP (SA),MSc Pall Med (Cardiff)

In his article describing unequal access tomedical care for the poor, Krakauer makesan important statement that palliative inter-ventions should be integrated with

Liz Gwyther, MB ChB, FCFP (SA), MSc Pall Med(Cardiff), is a Senior Lecturer at the University ofCape Town, and Chief Executive Officer of the Hos-pice Palliative Care Association South Africa, WestCape Town, South Africa.

Address correspondence to: Liz Gwyther, MBChB,School of Public Health and Family Medicine, Fal-mouth Building, Faculty of Health Sciences, Univer-sity of Cape Town Observatory, 7925, West CapeTown, South Africa E-mail: liz@hpca.co.za

DOI of original article: 10.1016/j.jpainsymman.2007.11.015.

preventative and disease-modifying interven-tions. He goes to the heart of a major misun-derstandingdproviding palliative care impliesthe withdrawal of active treatment. This misun-derstanding persists despite a number of state-ments emphasizing the active nature ofpalliative care. The World Health Organization(WHO) definition of palliative care includesthe assertion that palliative care ‘‘is applicableearly in the course of illness, in conjunctionwith other therapies that are implemented toprolong life.’’1 In writing about HIV and palli-ative care, O’Neill and Barini-Garcia describepalliative care as ‘‘complementary care, andnot alternate care, and therefore should notbe provided only when disease-directed ther-apy fails or is unavailable’’2 (Fig. 1).

Integration of disease-oriented care andpalliative care is important to provide optimalcare for the patient. Separation of the twoapproaches results in patients experiencinga sense of abandonment by their doctors,and doctors experiencing a sense of failure ifthe disease continues to progress to a stagewhere it is not curable. This is true for poor pa-tients, who, as Krakauer notes, may not be of-fered expensive disease-specific treatment,and for rich patients, when high-tech, disease-specific treatment fails. Initiating a palliativecare approach alongside curative treatmentdemands that the doctor engage with the pa-tient as a partner in management, keepingthe patient fully informed of the stage of thedisease, and the risks and benefits of treat-ment. This helps in preserving realistic hopeand developing a relationship of trust.

Integrated Care in PracticePaul Farmer, in an article written for the

Council on Foreign Relations, describes ‘‘agrowing awareness that not only doctors andnurses are needed to deliver medical care:many are learning that proper ‘accompani-ment’ d closely supervised home-based ther-apy, social and psychological support, andhelp with everyday tasks including feeding fam-ilies d is what poor patients with HIV/AIDSneed most of all.’’3 The South African HospicePalliative Care Association assists member hos-pices and home-based care organization to im-plement this ‘‘accompaniment’’ through the