Early cancer detection
Breast: mammogram, digital mammogram; MRI
Lung: low radiation CT scan
Prostate: PSA, multi-parametric MRI
Large bowel: fecal occult blood, recto-sigmoidoscopy, colonoscopy, virtual colonoscopy
Hepatocellular carcinoma: alfa fetoprotein; liver ultrasound
Surgery
Minimally invasive surgery
Sentinel LN examination
Radiation therapy
Intensity modulated radiation therapy
Image-guided radiation therapy
Proton therapy
Radiosurgery (brain, lung)
Interventional radiology
Image-guided biopsies
Obliteration of metastasis with radiofrequency, heat, or cryosurgery
Infusional therapy
Radio and chemoembolization of liver metastases
Cytotoxic chemotherapy
New and more effective drugs
Improved in supportive care (nausea and vomiting, myelosuppression, and mucositis)
Ever more sensitive instruments to detect cancer in asymptomatic individuals
Minimally invasive procedures that reduce the risk and the discomfort of surgical treatment and the time to postsurgical recovery
New and more effective forms of locoregional treatment that may obviate the need for surgery for early disease (radiosurgery, cryosurgery, etc.) and may lead to better control of cancer metastases (radiofrequency and thermal ablation, regional infusional therapy)
Targeted antineoplastic drugs that are both more effective and less toxic
More effective palliation of symptoms related to cancer and its treatment
By and large, these advances imply a substantial increase in the cost of health care [12, 13] that cannot be afforded by developing countries, especially when the government and the economy of these countries have been made unstable by war. In some situations, modern technology may compensate for the scarcity of specialists in some areas of the world: for example, radiosurgery of lung cancer has been used in lieu of surgery in countries with a scarcity of thoracic surgeons [14]. Again, this type of technology is very expensive however and requires a well-organized medical and social infrastructure.
Perhaps the advances of major interest concern the delivery of palliative cancer care. In a seminal study, Temel et al. [15] demonstrated that early application of palliative care in patients with metastatic lung cancer resulted in improved quality of life, decreased cost, and kind of unexpectedly it led to improved survival. In this randomized controlled study, the scope of palliative care went beyond pure symptom management and included a discussion of treatment goals and treatment plans as well as the caregiver’s support. This approach appears particularly appropriate for unstable countries for several reasons:
Symptom palliation is the most basic medical need and should be assured prior to any other medical intervention [16].
In face of limited resources, a discussion of patient’s priorities and values may allow a more effective utilization of these resources congruent with individual patient’s wishes.
As demonstrated by the study of Temel as well as in previous studies [16], symptom palliation is effective in prolonging survival. Interestingly, Temel’s study suggests that aggressive antineoplastic treatment may compromise the survival of these individuals in addition to increasing the treatment cost.
Even in the absence of a cure, palliative care may be a source of healing [17]. Healing refers to the personal experience of the disease and is the ultimate goal of medical care. As death is unavoidable, the final task of the health professional is to help patients to deal with their deaths, to coopt death as a living experience.
Symptom management includes a wide array of symptoms such as pain, discomfort, nausea and vomiting, fatigue, and d epression, just to mention a few. Though pain and suffering are mostly associated they need to be considered different symptoms [18]. You may have pain without suffering, as reported in the case of a catholic priest with metastatic prostate cancer [19]. The patient asked that only p.r.n. opioids be prescribed as he wanted to feel closer to the crucified Christ, when he experienced his pain. Likewise, a person with unresolved emotional burdens may experience suffering without pain [20]. Clearly, pain and suffering may need different approaches.
The distribution of medical resources should follow strict ethical principles [21]. These include autonomy, beneficence, non-maleficence, and justice. Justice holds that the treatment available should be offered to every patient irrespective of sex, age, ethnic origin, and beliefs. At the same time, the principle of autonomy holds that patients may refuse any medical intervention. That is when the discussion of patient’s priorities and values [22] is important. An elderly patient with limited life expectancy may decide that the ordeal of cancer treatment is not worthy for him/her and choose a peaceful death, making more resources available for the treatment of young and healthier individuals. This decision should be made by the patient him/her and in no circumstances the provider is allowed to discriminate between patient and patient.
Healing is a spiritual experience that involves the discovery of one’s life meaning even in the face of disease and death [20]. Palliative care is essential to healing [23]. Symptom control s allows a person to communicate with his/her loved ones, to proclaim and receive love, to ask for and concede forgiveness. In addition to these necessary healing steps, symptom control may allow a person enough thought concentration and depth that he/she becomes able to distillate from his/her own history those lifetime experiences that have been more meaningful [19]. Ideally, a spirituality professional should be available in the palliative management team. Spirituality professionals include but are not limited to religious ministers. In the USA, hospital chaplains maybe lay individuals trained to minister to patients of different religious belief and no belief at all [24].
Delivery Venues of Health Care in Countries in Transition
Any form of health care delivery requires a proper infrastructure that may be supported by the government, by private enterprise, or by philanthropic organizations. Jewish, Christian, and Moslem congregations have been on the forefront of health care delivery for centuries, until the eighteenth century [25].
A number of situations that jeopardize health care delivery may occur in countries in transitions:
When the country is at war with another country, the national and local government are still empowered, but weakened from the tolls of war; in the case of occupation, the occupying government becomes responsible of health care.
In the case of civilian conflicts, several different temporary governments may rule the same region in rapid succession and occasionally at the same time.
Warlords and tribal leaders may dominate a certain area of the country and consider health care a commodity under their own full control. They may prevent the delivery of health care from philanthropic organizations not to lose their absolute control of the population.
In any country at war, a medical black market may flourish [26]. Scalpers may hoard medications and medical supplies and sell them at increased price. Also they may dilute the doses of medications and sell it at full dose price. Both these phenomena had been observed in Europe after World War II. In addition, at the same time blood was diluted with normosaline and diluted blood was sold on the black market.
In the majority of countries at war, different religious beliefs are professed. These beliefs may represent one of the very roots of the conflict, as currently is the case in Nigeria or in Syria and Iraq . Religious beliefs may influence the delivery of health care in different ways, including refusal of Western medicine in favor of traditional medicine, mistrust of the health care professional, and denial of the care of the enemy as a form of religious duty. When the Italian heretic Giordano Bruno was being burned at the stake in Rome’s “Campo de Fiori” prior to losing his senses, he encouraged an old woman particularly eager to feed the pyre with more wood because he told her ironically “you are being a reliable and faithful servant of your God!” Things may not have changed that much since the inquisition executions of the sixteenth century.
In war-torn countries, health professionals will have to rely most of the time on philanthropic organizations for resources. Whenever possible, they need to assure the cooperation of the local government and law enforcement. In the meantime, they must try to avoid any activity or statement that may be constructed as an endorsement of the current regimen, as this may compromise their activity under a new regimen. Political neutrality appears as a must. Most of all, as the Reggiori experience suggests [8], health professional need to gain the trust of the local population to assure its support and cooperation. In the absence of an effective government and law enforcement, the local population, when adequately motivated, may assume the responsibility of health care management.
It is self-evident that health care professionals should avoid to step into religious conflicts. In the meantime, it may be wise in most circumstances to work with religious leaders to gain the trust of the population and to work with, rather than antagonizing, the practitioners of traditional medicine.
Finally, there may be situations where the delivery of health care may appear all but impossible, and the decision may have to be made to close the health care facilities not to jeopardize the life of the patients and of the health care workers, and to use the limited available resources in a place whether they may be more effective. The health care provider is responsible to take this difficult decision as he/she is responsible of the welfare of the staff and of the patients and of the proper management of the medical resources. Such situations might have occurred in Somalia few years ago, when battling warlords prevented free movements between different areas of the country and where stockpiling the country alimentary and medical supplies for military use and personal profit was common.
Health Care Priorities in Countries at War
As outlined in the previous section, the delivery of health care is influenced by a number of variables, most of which are outside the control of the health care professional. The professional in charge will have to establish the priority of health care delivery based on ethical principles and practical considerations. The ethical principles include [21]:
Autonomy: no intervention may be performed without the patient consent, which includes disclosure of potential benefits and complications of the intervention and assessment of one’s priorities and values. Clearly, in conditions of emergency when the patient cannot offer consent, one can presume that consent is present for life-saving procedures.
Beneficence: the therapeutic index of the intervention (the ratio of benefits and risks) is positive.
Non-maleficence: the intervention should not cause unnecessary damage. This principle needs to be emphasized in countries in transition and with limited resources, where the desire to do something may be the cause of hurt. My spouse and I, several years ago, visited an African country, and we were told by a local surgeon that the only procedure offered to men diagnosed with prostate cancer at that time was an orchiectomy. In patients asymptomatic and with early disease androgen deprivation may be the cause of discomfort and medical complications without any real influence on the course of the cancer and should be avoided [27]. Likewise, one may be tempted to use indiscriminately inexpensive antibiotics [28] in febrile patients with the triple risk of causing medication side-effects, antibiotic resistance, and reduced availability of drugs for the patients who need them.
Justice : as already mentioned, it is not legitimate for a practitioner to discriminate among patients based on demographic variables. As an example, it is not legitimate to deny a life-saving procedure to an old man because with the money saved one can treat the life-threatening diarrhea of a 100 children. It is legitimate however for the patients to refuse the intervention if he/she feels that the potential benefits are not worthy the risks, the discomfort, and the cost. Unlike the practitioner in charge of the individual patient, the institution that manages health care resources (government, philanthropic organization) has the right and the duty to prioritize the use of these resources. It is legitimate, for example, to renounce expensive chemotherapy treatment in favor of better maternal fetal care or prevention of malnutrition. To be consistent with the principle of justice, this decision must involve the whole population under the institution’s jurisdiction.Related posts:
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