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Alleviating the access abyss in palliative care and pain

reliefan imperative of universal health coverage:

Symposium and Launch of the The Lancet and
University of Miami Commission report
Dr. Felicia Marie Knaul
DPHS Faculty Meeting - December 13, 2017
Overview of Lancet Commission and Report

Health Systems and

Global Health
Palliative Care Specialists

Chair, co-chair
33 commissioners
61 total co-authors,
including ~10 junior
researchers, from over
25 countries

Online release date:

October 12, 2017

Print release date:

April 5, 2018
Global burden of serious health-related
suffering (SHS) in 2015
25.5 million deaths
45% of the 56.2
million deaths
at least 35.5 million
people (non-decedents)
experienced SHS

61.1 million people worldwide suffered

> 6 billion days of suffering
80% in LMICs
Interventions: Essential Package
Medicine Medical Equipment
Amitriptyline Pressure Reducing Mattress
Bisacodyl (Senna) Nasogastric drainage or feeding tube
Dexamethasone Urinary catheters
Diazepam Opioid lock box
Diphenhydramine (chlorpheniramine, cyclizine, or
Flashlight with rechargeable battery
dimenhydrinate, oral and injectable)
Adult diapers/ Cotton and Plastic
Fluoxetine or other SSRI (sertraline and citalopram)
Hyoscine Butylbromide
Ibuprofen (naproxen, diclofenac, or meloxicam)
Human Resources
Lactulose (sorbitol or polyethylene glycol) Doctors (Specialty and General)
Loperamide Nurses (Specialty and General)
Metaclopramide Social Workers and Counsellors
Psychiatrist, psychologist or counsellor
Physical Therapist
Naloxone Parenteral
Omeprazole oral
Community Health Workers
Clinical Support Staff
Paracetamol oral
Non Clinical Support Staff
Petroleum jelly

Aligned with Sustainable Development Goals (SDGs):

Should be made universally accessible by 2030
Global inequity in morphine distribution

The poorest 50%

of the worlds
population receive
< 1% of all

The richest 10%

of the worlds
receives almost
90% of all
Unmet need: pain relief
Distributed opioid morphine-equivalent (and estimated met need
for palliative care for 20 conditions), Morphine in mg/patient,
2010-2013 (INCB)
124 mg (8%)
W. Europe: Afghanistan
2.4 mg (0.2%)
18,316 mg
68,194 mg (3090%)
314 mg (16%)
55,704 mg (3150%)
Haiti: 125 mg (9%)
5.3 mg (0.8%)
Nigeria: 43 mg (4%)
0.8 mg (0.2%)
40,636 mg (1890%)
Mexico: Bolivia:
562 mg (36%) 74 mg (6%)
53 mg (11%)
Source: Author calculations using INCB and GHE 2015 (,
Annual estimated cost of closing the access abyss and
meeting the global palliative care need for morphine

At current
prices: $US600
At best
prices: $US145
For all children with SHS in low income countries:
$US 1,034,000
Global Lessons Learned:
US Opioid Epidemic
Most patients worldwide with a medical
need for opioid analgesics find it almost
impossible to access them
US is an outlier not only in level of
consumption but especially in overdose
deaths compared to all other high-income
countries and especially W. Europe.
Commission recommendations:
Implement strong conflict-of-interest
policies and marketing restrictions
Off-patent, oral immediate-release
morphine focus for UHC
Training of health professionals on
safe, appropriate use of opioid
Monitor the supply and marketing of
opioids using a balanced, public
health agenda approach: regulation,
modern technology, equal concern
for medical need
5 Key Messages
1. Alleviation of the burden of serious health-related suffering
from life-threatening or life-limiting conditions and with the
end of life is a global health and equity imperative.
2. Universal access to an affordable Essential Package of
palliative care can alleviate much of the inequitable and
preventable burden of SHS.
3. LMICs can improve the welfare of poor people at modest cost
by publicly financing the Essential Package of palliative care
through full integration into universal health coverage.
4. International and balanced collective action is essential to
achieving universal coverage of palliative care and pain relief
by facilitating effective access to essential medicines, while
implementing measures to prevent non-medical use.
5. Better evidence and priority setting tools must be generated
to adequately measure the global need for palliative care,
implement policies and programs, and monitor progress
towards alleviating the burden of pain and other SHS

Knaul, Farmer, Krakauer et al, 2017.

The Lancet Call-to-Action:
Dr. Richard Horton, Editor-in-Chief of The Lancet,
in his editorial
A milestone for palliative care and pain relief

... Measures of suffering have been absent, and so

the need for palliative care and pain relief services
has been easy to miss. That excuse no longer holds.
The scale of human suffering is massive The
Commission has uncovered an appalling oversight in
global health.
It is time for that oversight to be remedied.
Four streams of work following report release:
1. Research
Developing metrics for priority setting in PC
Implementation research and evaluation of PC activities/models
Augmented package of PC services
Medicine price variation
Womens disproportionate caregiving burden
Stigma and marginalized groups/diseases
Vulnerable populations (children, elderly, refugees, migrants, individuals affected
by natural disasters and humanitarian crises)
2. In-country implementation
Funding secured for pilots in El Salvador, Haiti, Mexico
3. Global collective action
World Bank, WHO, PAHO, NCDAlliance
4. Global advocacy
With the operational leadership of IAHPC, in partnership with UM,
Implementation Working Group convening global, regional, and national
PC advocacy groups for effective UHC integration
Media coverage of report soft launch
referring to University of Miami
Report contributed to expanding the growing reputation of
UM and MSOM as a research hub, especially for the Americas,
and received wide press coverage (over 650 media hits),
Opiophobia has left Africa in agony - The New York Times
The shocking global pain divide BBC The Inquiry
More than 25 million people dying in agony without morphine every
year The Guardian
America has an opioid crisis, but people in poor countries cant access
painkillers Washington Post
Millions die suffering amid global opioid gap - Associated Press
Global Launch Symposium
at the University of Miami
led by MSOM
Co-hosted with The Lancet
Release of the print version of report
April 5-6, 2018
1.5-day symposium + half-day implementation
working group meeting + research workshop
30-50 invited speakers and guests from
around the world, 100-150 antendees
including students
Global Launch Symposium
at the University of Miami
Key Speakers:
Dr. Rifat Atun, Professor, Harvard School of Public Health
Dr. Julio Frenk, President, University of Miami
Dr. Richard Horton, Editor-in-chief, The Lancet
Dr. Dean Jamison, Professor, University of Washington
Dr. Felicia Knaul, Professor MSOM, Director UMIA
Dr. Liliana De Lima, Executive Director, International Association for
Hospice and Palliative Care
Sir George Alleyne, Director Emeritus, PAHO
Dr. Paul Farmer, Professor, Harvard Medical School
Dr. Kathleen Foley, Professor and Clinician, MSKCC
Dr. Eric Krakauer, Professor, Harvard Medical School

among many other leading voices in global health and palliative care
Global Launch Symposium
at the University of Miami
UM Collaborators:
UM-MSOM: Dean Edward Abraham, Dr. Pascal J
Goldschmidt-Clermont, Dr. Erin Kobetz, Dr. Gilberto
Lopes, Dr. Brian Slomovitz, Dr. Hansel Tookes, Fellows
from The William J. Harrington Medical Training
Program for Latin America and the Caribbean
Gables Campus: Dean Leonidas Bachas (Arts and
Sciences), Dr. Donette Francis, Dean Cindy Munro
(Nursing), Dean John Quelch (Business), Dr. Steven
Global Launch Symposium
at the University of Miami
Will contribute to all 4 areas of folloup work
Share and discuss the major findings and
recommendations of the report
Catalyze a bold, innovative, and evolving research
Solidify major global collaborative research
opportunities (The Lancet, PAHO, World Bank,
NCI, NCD alliance)
Convene global, regional, national advocacy
groups for implementation work and next steps
Expected Outcomes of Symposium
Convene the Commissioners and in-country experts to enable
work on next steps and present globally this important report
Key input for publications and research agenda:
invited 1-year follow-on Lancet paper
additional publications for Lancet Global Health, Health Affairs, among
other journals
Impetus for global collective action
Strategy for national implementation agendas
Promote the UM, MSOM and DPHS objective of stronger
research presence on health systems in LAC

Requested funding will enable us to invite our hemispheric

research and implementation collaborators from LAC
Alleviating the access abyss in palliative care and pain
reliefan imperative of universal health coverage:
Symposium and Launch of the The Lancet and
University of Miami Commission report
Dr. Felicia Marie Knaul
DPHS Faculty Meeting - December 13, 2017

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