Bangladesh ranked among the worst in palliative care. A decade later, have things gone better?

Aklima Khatun started taking chemotherapy after she was diagnosed with uterine cancer six months ago. After three sessions, she stopped receiving the treatment because of severe complications like pain, vomiting, weakness, and anaemia. That unexpected pause created anxiety leading to her mental breakdown.

The unmarried woman in her late 40s finally found some comfort at Mycare palliative and geriatric care centre of Bangladesh Cancer Society.

The care she receives there is helping her feel better physically and mentally, and continue with her cancer treatment.

Her nephew said he found the centre following information from a friend. "Despite her pain, the doctor did not advise us to consider palliative care," he said.

Lying in a bed at Mycare, Aklima said the cancer treatment has reduced the unbearable pain in her body. “I am unsure about my recovery, but I simply wish to pass the rest of my days with reduced pain.”

A report found Bangladesh among the worst in providing palliative care to its citizens, yet changes are not apparent around a decade after its publication, according to an expert.

Many people lack awareness of palliative care, especially in Bangladesh. Some mistakenly believe it is solely for those nearing the end of life.

While end-of-life care is a component of palliative care, it is not its sole focus.

Palliative care encompasses supporting not only the patient but also their family members.

It is about easing the suffering of patients with incurable illnesses, focusing on physical, mental, social, and spiritual support. This care is provided in hospitals, nursing homes, hospices, or even at home, benefiting both patients and their families.

WHO NEEDS PALLIATIVE CARE?

Palliative care is not only for terminally ill patients. It is also essential for those with chronic lung, kidney, and heart diseases, and also for Acquired Immune Deficiency Syndrome or AIDS.

However, in Bangladesh, it is more commonly provided to cancer patients.

A 2020 study “GLOBOCAN 2020: New Global Cancer Data” revealed that 108,990 people die of cancer in Bangladesh annually.

Another study from 2014 found that every year 700,000 patients with incurable diseases such as cancer, including 40,000 children, need palliative care in Bangladesh.

Less than 0.01 percent of them get the care, according to the study published in the palliative care journal by the National Institute of Population Research and Training (NIPORT) and Bangabandhu Sheikh Mujib Medical University (BSMMU).

A 2020 report by the World Health Organization said approximately 56.8 million people worldwide require palliative care each year, yet only 14 percent have access to it.

The need for palliative care is expected to rise globally because of the ageing population and the increase in non-communicable diseases like heart disease, stroke, cancer, and respiratory issues, as well as infectious diseases like AIDS, tuberculosis, malaria, viral hepatitis, and sexually transmitted infections.

Additionally, palliative care helps reduce unnecessary hospital admissions.

WHERE IS PALLIATIVE CARE OFFERED?

Palliative care is offered by skilled doctors and staff in a limited number of hospitals in Dhaka.

Official providers include the Department of Palliative Medicine at BSMMU, Dhaka Medical College Hospital, National Institute of Cancer Research and Hospital (NICRH), and Bangladesh Shishu Hospital and Institute.

Additionally, patients can access palliative care at private facilities such as ASHIC, Foundation for Childhood Cancer, My Care, Hospice Bangladesh, and the Bangladesh Palliative and Supportive Care Foundation in private facilities.

PALLIATIVE CARE CHALLENGES AND SERVICES IN BANGLADESH

AKM Motiur Rahman Bhuiyan, head of the palliative medicine department at BSMMU, told bdnews24.com that palliative care in Bangladesh faces significant challenges because of weak infrastructure and a lack of priority in medical education.

BSMMU aims to be a pioneer in providing this essential service among the few institutions in the country, he said.

"After 17 years, BSMMU has started a palliative medicine department and course. The department has about 23 staff members, which is not enough. The Prime Minister's Office has taken steps to include palliative care in medical services, but there hasn't been any progress yet despite instructions given in meetings."

The Department of Palliative Medicine at BSMMU has 22 free beds, with 10 designated for men, nine for women, and three for children. Patients can also receive services in cabins.

Services in the department usually cost between Tk 300 and Tk 500 per patient.

The department also provides homecare and community-based services. Patients living within 20km of BSMMU can receive palliative care at home.

Community-based services are provided through two projects: Momotamoyi Narayanganj (Compassionate Narayanganj) and Compassionate Korail. The Korail project is currently overseen by the Palliative Care Society of Bangladesh.

The Mycare Palliative and Geriatric Care Center in Mirpur, operated by the Bangladesh Cancer Society, offers 21 beds for palliative patients. The rent is Tk 600 per bed. It also provides daycare for these patients.

LACK OF MORPHINE, SKILLED MANPOWER

Morphine is an effective analgesic that helps alleviate pain and suffering of cancer patients. But data suggests the supply and application of the drug in the country is far less than what is necessary,

According to the Worldwide Hospice Palliative Care Alliance, a non-government orgaisation founded in the UK, it takes 300kg of morphine to reduce the pain of 700,000 cancer patients.

But Bangladesh used 12kg at most in such cases, so most cancer patients are suffering immense pain before death.

A 2018 report by The Lancet medical journal said the world produces 298.5 tonnes of morphine or similar pain relief drugs every year. Low income countries use only 0.1 tonnes of it, it added.

In Bangladesh, almost 90 percent of the physicians or healthcare workers lack sufficient skill to use morphine, says the country’s National Guideline on Palliative Care.

Motiur, head of palliative care at BSMMU, said they have only three specialists with postgraduate degrees in palliative medicine.

The use of morphine is also subject to different misconceptions, like the possibility of developing an addiction for the drug.

Prof Nizamuddin Ahmed, chief editor of Palliative Care Journal, said: “The International Narcotics Control Board sets the quota for the medicine according to each country’s demands. In our country, Ganasasthya [Kendra] and UniMed UniHealth Pharmaceuticals manufacture morphine tablets, syrups and injections.”

EXPERT INSIGHT

Nashid Kamal, the first female palliative expert of Bangladesh, said: “Palliative care is not an expensive service. It can be acquired at a low cost. But health facilities, doctors and, obviously, the public have little knowledge about where and how palliative care can be acquired.”

Prof Nizamuddin said the World Health Alliance proposed the inclusion of palliative care at every section of healthcare in 2014.

All countries of the alliance, including Bangladesh, signed that agreement. “But the situation has not improved in Bangladesh over the past decade,” Nazimuddin said.

He also mentioned the Economist Intelligence Unit in its 2015 Quality of Death Index study found Bangladesh only ahead of war-torn Iraq when it comes to providing palliative care for its citizens.

“I can’t tell if further work was done on the matter, but no changes are apparent yet,” he said.

“Less painful death should be prioritised the same way safe birth is significant in primary healthcare in the country.”