Sun, Sep 16, 2007 - Page 17 News List

Lacking drugs, world's poor die in agony

Though opium is cheap and could be made readily available, millions of the world's poor are dying in excruciating pain

By DONALD G. McNEIL Jr.  /  NY Times News Service , WATERLOO, SIERRA LEONE

Nor is it expensive, even by the standards of developing nations. One hospice in Uganda, for example, mixes its own liquid morphine so cheaply that a three-week supply costs less than a loaf of bread.

Nonetheless, it is still routinely denied in many poor countries.

"It's the intense fear of addiction, which is often misunderstood," said David Joranson, director of the Pain Policy Study Group at the University of Wisconsin's medical school, who has worked to change drugs laws around the world. "Pain relief hasn't been given as much attention as the war on drugs has."

In Sesay's case, Alfred Lewis, a nurse from Shepherd's Hospice, is doing what he can to ease her last days.

When he first saw her, her tumor was wrapped with clay and leaves prescribed by a local healer. The smell of her rotting skin made her feel ashamed.

She had seen a doctor at one of many low-cost "Indian clinics" who pulled at the breast with forceps so hard that she screamed, misdiagnosed her tumor as an infected boil, and gave her an injection in her buttocks that abscessed, adding to her misery.

Nothing can be done about the tumor, Lewis explained quietly. "All the bleeders are open," he said. "Her risk now is hemorrhage. Only a knife-crazy surgeon would attend to her."

Earlier diagnosis would probably not have changed her fate. Sierra Leone has no CAT scanners, and only one private hospital offers chemotherapy drug treatment. The Sesays are sharecroppers; they have no money.

So Lewis was making a daily 16km trip from Freetown, the capital, to change her dressing, sprinkle on antibiotics, and talk to her. He asked a neighbor to plait her hair for her, so she would look pretty. Sesay said she could not be bothered.

"It's necessary for to cope," he said. "For to strive for be happy."

"I 'fraid for my life," she said.

"Are you 'fraid for die?"

"No, I not 'fraid. I ready."

"So what is your relationship to God? You good with God?"

"I pray me one."

He asked her, half-jokingly, if she still had sex with her husband.

No, she said, since the illness, he stayed in his room and she stayed in hers. She, too, was joking. In their hut, there is only the one room.

Life has become hard, she added, and her husband is getting too old for farm labor. She, too, is getting old, she said - she is somewhere in her 40s.

"We are really being punish."

For her pain, Lewis gave her generic Tylenol and tramadol, a relative of codeine that is only 10 percent as potent as morphine. It was all he could offer. "I would consider putting her on morphine now, if we had morphine," Lewis said.

In New York, she would have already started on it, or an equivalent like oxycodone or fentanyl.

Even if his hospice could get it, Lewis could not give it to her.

Under Sierra Leone law, morphine may be handled only by a pharmacist or doctor, explained Gabriel Madiye, the hospice's founder. But in all Sierra Leone there are only about 100 doctors - one for every 54,000 people, compared with one for every 350 in the US.

In only a few places - in Uganda, for example - does the law allow trained nurses to prescribe morphine.

And pharmacists will not stock it.

"It's opiod phobia," Madiye said. "We are coming out of a war where a lot of human rights violations were caused by drug abuse."

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