Interview: Interest in Pain and Palliative Care: An African Perspective

Abstract

Olaitan A Soyannwo speaks to Roshaine Gunawardana, Commissioning Editor: Olaitan Soyannwo is a Professor of Anesthesia, Consultant and former Dean of Clinical Sciences of the College of Medicine, University of Ibadan, Nigeria. She is currently the head of the first hospice and palliative care unit established in Nigeria, at the University College Hospital, Ibadan, in 2007.

Q How did you come to specialize in anesthesia & what led to your early interest in pain?

I graduated from the University of Ibadan, Nigeria medical school in 1971 and after my internship, I decided to pursue residency training in pediatrics. However, after 1 year of a very hectic schedule including marriage and my first pregnancy, I found the rotations too busy and my friend, who had already spent a year in anesthesia, convinced me about a friendlier schedule in her department and the fact that I could study to obtain a postgraduate diploma within a year. I then switched over, found it interesting and developed a new interest in pediatric anesthesia. My personal experience with cesarean section for my first baby in 1973 gave me an insight into how little priority is given to pain of labor, intraoperative and postoperative pain. In those days, general anesthesia was the preferred choice for cesarean section, and in an effort to prevent respiratory depression in the baby, the mother is given very little or no analgesic. Opioid analgesics were also prescribed sparingly by obstetricians in the postoperative period due to an erroneous fear of addiction. This experience resulted in my research interest in pain of labor and postoperative pain and advocacy efforts for opioid availability and effective pain management.

Q Could you briefly describe some of the avenues of your past research into pain & anesthesia?

In 1978, my teacher, JAO Magbagbeola, a member of the International Association for the Study of pain (IASP), introduced me to pain research by arranging for a 1-year specialist registrar rotation for me in the UK to complement my postgraduate residency training in Nigeria. I spent 6 months as a registrar and clinical research assistant under JP Payne, of the Research Department of Anesthetics, Royal College of Surgeons, London, UK, and 6 months under JU Utting of Royal Liverpool Hospital, UK. This exposure gave me the opportunity to observe and assist in both clinical and basic science research. The posting in Liverpool included a 1-month rotation through Walton Hospital, the regional neurosurgical and pain unit. I was appointed as lecturer in the University of Ibadan, Nigeria, in 1981 and had access to my first university senate research grant to study the use of Entonox™ (BOC Gases, Nigeria) analgesia for pain relief in labor [1]. I became a member of IASP in 1981 and exposure to IASP further increased my interest in pain and the activities of the organization. I attended my first IASP World Congress in Vancouver, Canada, in 1996 and presented a poster on ‘pain assessment and analgesic usage in Nigerian physiotherapy patients‘. At this conference, IASP president JM Besson and executive secretary L Jones encouraged me to start an IASP pain chapter in Nigeria. The inauguration of the Society for the Study of Pain, Nigeria, became a reality in June 1998 with support from IASP. As an anesthetist, my clinical work influenced my research interest in areas of postoperative pain, pain in children and cancer pain. We were able to show from our studies that two-thirds of patients had unrelieved moderate-to-unbearable pain postsurgery, while only half of the patients in pain in the emergency department received any analgesia at all, thus raising awareness of pain management issues. My research pathway from pain into palliative care was influenced by further exposure to the suffering of the terminally ill in Nigeria. In order to enhance my skills in that area, I went for a special training program on palliative care at Hospice Africa, Uganda, in 2003, attended the Research Summer School, End of Life Observatory Course, Lancaster University, UK, in 2005 and had a short rotation at the MD Anderson Cancer Center, Houston, TX, USA.

Q You have had some experience of working in the field of pain & anesthesia in both the UK & western Africa. How do you find the approaches in this field – both from a clinical practice perspective & research perspective – differ between the two countries & can you identify any particular reasons for this (e.g., do you think there are extra strains placed on a few specialists to perform a wide range of services, such as teaching, research & administration)?

In 1995, through the University Staff Development Fund, I had the opportunity to have another experience on pain management and research in the UK at Great Ormond Street Hospital and Walton Hospital, Liverpool, and Marie Curie Hospice, Liverpool. This was to further upgrade my knowledge and skills to re-establish a pain clinic in my center. Although the exposure was very educative, the required facilities and support to fully put what was learnt into practice at home was lacking. I found that unlike surgeons or physicians who could function clinically and research fully in their areas of post-specialist qualification or subspecialty, the few specialist physician anesthetists working in Africa have to cover all areas of anesthesia service, resuscitation, intensive care, teaching (undergraduate and postgraduate) and administration, with less time for specialist duties such as acute pain services or chronic pain clinics, research and publication in high-impact journals. Africa, similarly to many developing countries, is a consumer nation where the industrial sector markets their finished products. Hence, there is very little or no support for research, academia and continuing medical education from the major drug and equipment companies, unlike what happens in the developed countries.

Q What role does education – both of clinicians & patients – play in anesthesia & pain management in the developing world & in particular in western Africa where you are based?

Anesthesia is an unattractive area of specialization for young medical graduates in western Africa because the undergraduate medical curriculum has only a short period (2–3 weeks) devoted to anesthesia posting, and pain is not taught or examined as a specialized unit. Students and interns also view anesthesia as a supporting specialty without the high profile of other specialties such as surgery. The nursing curriculum is also deficient on pain issues, hence pain is not regularly assessed as part of vital signs and patients are also not educated enough to complain and ask for effective pain relief. The situation is, however, beginning to improve as many professional societies such as those for anesthesia, national chapters and members of the IASP, neurology, oncology, palliative care, nursing, physiotherapy and pharmacy now have members who are interested in pain management and research. In Nigeria, for example, the number of IASP members has increased from two in the 1990s to over 60 at the 2010 World Pain Congress. Educational grants have been utilized by IASP members for pain education, advocacy for pain service and safe use of opioid analgesic workshops. These have led to more interest in pain and palliative care, increased efforts to teach and examine pain as a subject, inclusion in curricula, government importation of opioid analgesics and establishment of pain and palliative care teams/services in many hospitals and tertiary institutions.

Q Part of your activity is in advocating effective pain management & opioid availability in developing countries. Could you please explain the importance of this work & whether there have been any major positive developments in this cause?

Unrelieved pain is associated with a lot of suffering for both patients and their families, and opioid analgesics are very essential for relief of severe pain. Advocacy for the availability of opioid analgesics is therefore a prerequisite for effective pain relief. Hence, I made this a priority in the early days of my interest in pain issues and have coestablished three organizations in Nigeria to champion the issue of effective pain management. The Society for the Study of Pain, Nigeria, established in 1998, now has zonal branches across Nigeria and holds workshops and annual conferences to address pain management and research. In order to address the pain and suffering being experienced by millions of cancer patients, most of whom present in late stages, and those with other life-limiting illnesses, a palliative care group was established and registered as a not-for-profit organization: the Centre for Palliative Care. With assistance from A Merriman, founder of Hospice Africa, Uganda, and the African Palliative Care Association (APCA), Hospice and Palliative Care Association, Nigeria (HPCAN) was formed in 2007, enabling more Nigerians to advocate for cancer pain management and promote the availability of opioids, especially oral morphine, as an essential aspect of pain management and palliative care.

Q Some of your work has involved pediatric anesthesia & you are a member of the IASP Pain in Childhood Special Interest Group. Could you please briefly describe your experience in this area & the aims of the IASP special interest group?

Pain in children, especially in the younger age groups, is often overlooked by healthcare professionals and thus unassessed, undertreated or not treated. Untreated pain suffered early in life can lead to long-lasting effects on social and physical development, and can cause permanent changes in the nervous system that will affect future pain experience and development. It is therefore important to emphasize adequate pain relief for both acute and chronic pain conditions, including painful interventions. The IASP Pain in Childhood Special Interest Group (SIG) is dedicated to improving pain prevention and treatment for children everywhere. The SIG aims to:

▪	Promote education regarding pain in children;
▪	Share relevant information regarding children‘s pain control;
▪	Advance our ability to alleviate children‘s pain from an international and interdisciplinary perspective;
▪	Encourage research, particularly multicenter studies and studies that focus on unique problems of pediatric patients, including newborns.

Members of the SIG hold scientific meetings and share information related to the objectives through discussion forums, newsletters and through the internet [101].

Q What has been your experience of palliative care in the field of pain management & how would you like to see this improving?

I became interested in pain associated with cancer in the 1990s from providing anesthesia for patients (adults and children) with advanced disease. Approximately 70% of cancer patients in Nigeria present in late stages and many are offered palliative surgery with attendant excruciating postoperative pain and suffering in the absence of opioid analgesics for use. Palliative care is holistic care and encompasses pain relief and relief of other distressing symptoms (physical, psychological, social and spiritual). Thus it helps to address ‘total pain‘ and supports patients and their families. Since the escalation of HIV/AIDS, the palliative care philosophy is now sweeping through Africa as more health professionals are becoming interested. More emphasis is now being given to opioid availability issues, including oral morphine and pain management, which was hitherto missing from the palliative care offered to HIV patients. In the vanguard of these changes are Hospice Africa, Uganda, and the APCA through education, training and working with governments to establish palliative care services. In Nigeria, for example, a chapter of the IASP was inaugurated in 1998 and through advocacy, education and training by members, opioid analgesics became available for use. With support from Hospice Africa, Uganda, training and establishment of palliative care teams in different parts of the country has materialized, while the APCA supported the establishment of a National Hospice and Palliative Care Association in 2007.

Q Could you briefly explain your hopes for the future of research & study into pain & anesthesia in western Africa & other developing countries?

I would like to express my hope for the future of anesthesia and pain study in the common expression used in Nigeria – ‘the young shall grow and prosper‘. If the current government interest in the area of tertiary education and capacity building for health and science continues, more professionals in western Africa will develop interest in anesthesia and pain-related issues. Already, the situation is much better than when I got involved in the 1990s, as evidenced by the increase in the number of universities in Nigeria (e.g., from less than 20 to over 100) and the number of specialist physician anesthetists in Nigeria and western Africa. Also, the world has become a global village, and most international organizations interested in the study and management of pain have members and national and regional chapters in the developing world, including Africa, western Africa and Nigeria. Collaboration with the IASP, other organizations such as the WHO, world societies of anesthesia and neuroscience will also assist with training. Thus, with sustainable government health policies within developing countries, more experts will emerge and train others within their own regions, leading to the emergence of regional and national training centers and growth in services and pain research endeavors.

Financial & competing interests disclosure

OA Soyannwo has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.