JOURNAL OF PALLIATIVE MEDICINE Volume 14, Number 3, 2011 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2010.0428
Palliative Care for Patients with Hematologic Malignancies in Morocco: A Real Challenge Illias Tazi, M.D.
Dear Editor: Palliative care is active total care aiming to improve the quality of life of patients and families who face life-threatening illness by providing symptom relief, and spiritual and psychosocial support from diagnosis to the end of life and bereavement. In patients with advanced hematologic malignancy the assessment of relevant psychological domains, but also of physical symptoms such as asthenia/fatigue, nutritional problems, or pain is often underestimated. Once the decision has been made not to attempt further curative treatment the overall aim of management changes to palliation; the patient must be helped to have as good a quality of life as possible for the time that remains. Morocco is a country of 30 million inhabitants. The per capita income is $1200 and the minimum wage $180. The annual per capita medical expenditure is $50. Morocco faces problems typical of developing countries. In all, 19% of the population is below the poverty line and up to 50% is illiterate. Only 15% of the population is covered by health care insurance. Hematologic malignancy is emerging as a major public health problem in Morocco, with approximately 2000 new hematologic malignancy cases reported each year. The first hematology department in Morocco was created in Casablanca in 1980. In 1982, a unit of pediatric hematology and oncology opened in the Children’s Hospital in Rabat. In 1996, another unit of pediatric hematology and oncology was set up in the Children’s Hospital of Casablanca. Some patients are treated in private clinics located primarily in Casablanca and Rabat. Currently, a new hematology department is being started in Marrakech. The public hospitals have very limited resources and rely heavily on nongovernmental organizations for the care of these patients. The need to provide palliative care to patients with hematologic malignancies is emerging as a priority area in Morocco. Palliative care should be integrated in a national cancer control program, which shows political willingness; there are still several hurdles to overcome. Palliative care is multidisciplinary, where every team member has an equal input. Hematologists, referring physicians, nurses, pharmacists, and other members of the health care team must be educated regularly about the treatment regimen, the expected toxicities, supportive care guidelines, and contingency plans. Some suggest scaling up the infrastructure for palliative care, that is, opening more hospices and training oncologists, but others
believe a cost-effective approach of ensuring affordability, availability, and coverage of oral morphine is more suitable for a resource-poor country like Morocco. Regardless of whether a resource-poor country has the provisions to provide palliative treatments, patients with incurable hematologic malignancy should at least have access to palliative care to ensure symptom control and quality of life by optimizing their comfort, function, and social support. A further problem is inadequate pain control, with most patients not having access to drugs such as morphine. In resource-poor countries this problem is mainly because of laws that restrict availability of narcotics including opioids. In most of these countries, like in developed countries, opioids are only accessible when they are distributed through specific channels (e.g., hospital pharmacies) and health care professionals can only prescribe limited amounts. Another problem is that many hematologists could have difficulty caring for patients who are terminally ill because they might feel that they do not have the specific knowledge or skills necessary for palliative care. For many, palliative care has not been part of their medical training, and has only recently been integrated into oncology training curricula in developed countries. Therefore, the integration of the teaching of palliative care into undergraduate and postgraduate educational programs is essential. Organizing palliative-care programs costs money, and funding needs to be available for educating health care professionals on the provision of this care, for ascertaining the availability of drugs, and for infrastructural needs. The hospital, on the other hand, has very limited resources and cannot provide the very expensive treatment for this kind of disease. The doctors understand that they cannot improve the quality of care without extra help. This proved that even in a difficult situation, it is possible to get fairly good support and bring back hope to patients and their families.
Address correspondence to: Illias Tazi, M.D. Hematology Department CHU Mohamed VI, Cadi Ayyad University Marrakech, Morocco
Hematology Department, Chu Mohamed VI, Cadi Ayyad University, Marrakech, Morocco.
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E-mail:
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