1. Schim, Stephanie Myers PhD, RN, APRN, CNAA, BC

Article Content

Pain and Palliative Care in the Developing World and Marginalized Populations: A Global Challenge


by M. R. Rajagopal, MBBS, MD; David Mazza, BA, MBChB, DCCH, DRCOG, MRCGP, MSc; Arthur G. Lipman, PharmD, FASHP


Haworth Medical Press, 10 Alice Street, Binghamton NY 13904-1580


Tele: 800-429-6784


ISBN 0-7890-1556-0


Prices: $39.95 (softbound edition) $59.95 (hardbound edition)


Drs. Rajagopal, Mazza, and Lipman have made an important contribution to the literature in the domains of palliative care and global health with their 2003 book titled Pain and Palliative Care in the Developing World and Marginalized Populations: A Global Challenge from Haworth Press. As editors of the volume, Rajagopal, Mazza, and Lipman have pulled together a series of articles which were co-published simultaneously as the Journal of Pain & Palliative Care Pharmacotherapy, Volume 17, Numbers 3/4, 2003. As the title suggests, the theme that echoes through all of the papers is the serious challenges faced by those who would work to end human suffering related to disease and the dying process. As a nurse researcher in the areas of cultural competence and end-of-life care, and as a faculty member in community health nursing, I found the book a useful addition to my library resources.


As one mother of a child with severe cerebral palsy once said, "If your problems can be solved by money, you don't have problems!" As I read the chapters in this book which describe the state of palliative care in places around the globe such as India, Argentina, Thailand, New Guinea, and other developing countries, I am struck once again by how true that statement seems. According to the various authors knowledgeable about each specific setting, political will and public policy are more often larger barriers to adequate palliative care than lack of financial resources. In many places, including the United States, governmental and social philosophies are at odds with healthcare provider philosophies of what is in the best interest of particular populations. In many countries, both in the so-called "developed" world and in developing countries, governments operate in fear that people who do not really need such resources as opioids for pain relief will get drugs and divert them for nonmedical uses. The fear of addiction is expressed in public policies that limit access to almost all forms of opium-based medications for pain relief. It seems ironic that in places where the majority of the world's poppies are grown, people should have severely restricted access to medicinal opium. As is clearly pointed out in this volume, the western (ie, US/UK) system of medical education and the social values that accompany western approaches to medicine have been exported all over the world. The US "war on drugs" and traditional puritanical approaches to addiction as moral failing seem to have also crossed national and cultural boundaries. Meanwhile, the healthcare provider communities around the globe tend to have the opposite fear-that people who are truly in need of pharmacological pain relief will not have access. Evidence suggests that morphine is the very best option for relief of moderate to severe pain due to life-limiting illnesses such as cancer and HIV/AIDS; however, access to appropriate forms and quantities of such medications remains very limited.


The chapter by Nixon on palliative care in Saudi Arabia highlights the many barriers to a national program of effective palliative care when financing and pharmaceutical availability are not main issues. By including papers on selected marginalized populations, such as Native Americans and Alaska Natives, prisoners, and those living with HIV/AIDS, the book's focus is expanded to cover groups that have significant palliative care issues in both developing and developed countries globally. Although this volume will undoubtedly be very useful to those who study, practice, and teach in the areas of end-of-life and palliative care, I found three areas I would have liked to see improved.


The smallest, but perhaps most annoying, problem with the text were the numerous typographical errors throughout the chapters. It is unclear if the problem is one of translation, English as a second language, or sloppy typesetting, but a careful proofreading would have greatly enhanced the readability of the text. I also found that the Commentary sections were somewhat redundant. Rather than add a fresh perspective or clarification of the primary papers, most of the commentaries simply repeated the authors' points and thanked them. Thirdly, I would have liked to have more information on specific cultural influences from "emic" or insider perspectives for the countries and cultures explored. Many of the papers were written by healthcare providers who had traveled from more developed countries to consult and/or practice in various parts of the developing world. A few mentions are made of influences of local values, customs, and religious beliefs on the policies and practices in palliative care, but little is said about specifics that would help with transcultural understanding. I would have liked to have read more from local palliative care team members about how they see such cultural influences facilitating and/or inhibiting the relief of pain and other symptoms from their unique perspectives.


Even with these few small areas for improvement, I find that the collection of papers on pain and palliation in the developing world edited by Rajagopal, Mazza, and Lipman was well worth reading. I think that it will be useful as a resource for students and faculty in nursing and other healthcare professions as we look for ways to improve care and relieve suffering at home and around the world.