“It’s not easy, but we’re trying. You have to do something,” says Dr. Gaston Nyirigira, anesthesiologist and founder of the first multidisciplinary pain clinic in Rwanda, a small east-African country with a population of 12 million. The clinic is one of the first in this region of Africa. Pain management is neglected in many low and middle income countries (LMICs), as expertise, tools, and medications are hard to find.
“It’s a long journey,” says Nyiringira. “We had a pain team. We started with training, but that was for acute pain. We then trained people in the concept of chronic pain and how it differs from that of acute pain.” Since the different specialists that make up the typical multidisciplinary pain team are not always available, a different approach has been taken: team members are cross-trained instead. The clinic is small, just a few rooms, as no space is available. One doctor may see up to 45 patients per day.
Patients often come from small villages far away and have been treated by traditional healers for a long time. They may come with limited understanding or unrealistic expectations.
“When you treat a patient’s pain immediately with medication, the pain becomes more frequent and severe, and then the required doses become higher.” Patients come back sooner than their medication is expected to run out, just so they can get more. “They become very dependent on medication. Then there is no other approach because they know medications are there,” Nyirigira explains. “After looking at that I said, ‘You know what? No. We are failing because we are not helping people.’”
Less than 15% of the world’s opioid production is available to 80% of its population, mostly in LMICs. LMICs have major problems importing sufficient opioid analgesics for patients who need them. About ten years ago, Rwanda imported sufficient opioids to treat about 30 people with cancer pain and other major pain problems: 200 g of morphine per year. Now the annual supply is 9 kg, still far from sufficient. (North America uses 18,000 kg per year – and that is only morphine).
The need to preserve these supplies for people who truly need them makes it even more critical to treat patients with chronic, non-malignant pain with other approaches. Instead of medication, the pain team offers other therapy for their patients, such as physical treatments (stretching, heat, cold), exercise prescriptions, and instructions for healthy eating. But even simple things like heat and cold may be difficult to apply in a rural village without electricity.
The team has to be creative in inventing its own approaches. For instance, nights in Rwanda can get fairly cold, and placing banana leaves outside overnight makes a good substitution for an ice pack. This approach, however, is not always welcomed by the patients who come into the clinic expecting to leave with a prescription.
“They come expecting medicine. They don’t trust you at first. They say ‘What kind of doctor is this? What kind of team is this?’ So we take a lot of time to explain so that they understand their disease.’”
Many of Nyirigira’s patients come with diseases similar to what is seen in higher income countries: chronic back and neck pain, and headaches. But diagnostic and therapeutic approaches to these ailments must be different in the Rwanda setting. Yet the goal of those who started this pain clinic is consistent with pain management specialists around the world: alleviate the suffering of their patients.
As global health worker, Albert Schweitzer, wrote, “Pain is a more terrible lord of mankind than even death itself. Whoever is spared personal pain must feel himself called to help in diminishing the pain of others.”
Dr. Nyirigira’s work remains, and though it is often hard and relentless, with appropriate pain education, management, and teamwork, the Rwandan pain clinic will continue to support pain relief in that small village and, ideally, worldwide.