Lee_Sharkey comments on Increasing Access to Pain Relief in Developing Countries - An EA Perspective - Effective Altruism Forum

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Comment author: Austen_Forrester 02 February 2017 11:17:13PM 2 points [-]

One good thing about this space is that, unlike so much other policy work, access to pain relief doesn't have corporations interfering by paying off government, etc. If anything, corporations would stand to gain by increasing access to pharmaceuticals. So much other policy advocacy is stifled by corporate interference, so palliative care has a huge advantage in that regard. Would it be possible for advocates to work with pharma corporations to lobby for increased access? I know that sometimes governments have good regulations in place but can't find corporations willing to supply/distribute the country with the meds, which I find baffling.

Do you think that an effective strategy for pain relief would be to first convince a Ministry of Health of the importance of palliative care? Rather than putting drugs as the forefront of advocacy, perhaps getting government to agree to the principle of palliative care and pain control first would be more productive because once they agree to that, it is a given that narcotics are necessary.

Increasing pain relief is a notable cause in so many ways. It is a major issue in moderate income countries such as in former Soviet nations. Africa may be the worst, but pain relief restriction is by no means limited to the poorest regions of the world. Just shows that the best altruistic opportunities aren't always in the poorest countries. I would think that the more developed countries would be a priority target for advocacy because they would actually have functional health care systems that would permit implementation of increased palliative care.

From what I've studied so far, I don't see how you can say that increased analgesic access is low-medium in neglectedness and tractability. Dr. Kathleen Foley says that University of Wisconsin's fellows only spend 15% of their time on this and usually make progress in their respective countries. If true, that demonstrates that this issue is severely neglected and tractable with long-term pay-offs, at least in some countries.

Is it possible for existing major global health initiatives to lead this cause? PEPFAR is well-funded and pain relief is part of AIDS treatment. I know you mentioned them, but perhaps they haven't put an appropriate portion of their funding towards this area for political reasons.

Comment author: Lee_Sharkey 03 February 2017 01:20:09AM *  2 points [-]

Hi Austen,

Thanks for all your interest!

I would have to disagree on your point about corporate influence. Pharma has been implicated heavily in the current opioid epidemic in the States and elsewhere. See the John Oliver expose for a light introduction (link above). In this area, if anything, there is even more reason to be wary of pharma influence because the product is so addictive when misused. Pharma does do some positive work - I'm aware of a BMS-funded training hospice in Romania (Casa Sperantei). I've only heard good things about it.

You've hit on an accepted strategy for promoting pain relief access/palliative care. One only knows one has succeeded in making a MoH care about the area when it does something about it, such as developing a policy. The 'public health approach' to increasing access to pain relief/palliative care, supported by WHO, recognizes policy as the foundation on which other progress can be built. Without it, success in other areas of the approach (namely medicine availability, education, and implementation) is much less likely. Kathy Foley and colleagues introduce the public health approach here http://www.jpsmjournal.com/article/S0885-3924(07)00122-4/pdf

Regarding tractability:

The issue is likely to be more tractable in some countries than in others, and so it's hard for me to give anything but a range.

I'm adding retrospective justification for my choice of low-moderate tractability here, but compare this cause to similar ones assessed by 80k. The scores given to them according to their scoring matrix are: Smoking in the Developing World - 3/6; Health in poor countries - 5/6; Land Use Reform - 3/6;

(Where 3 is "Some possible ways to make progress, with significant controversy; Significant uncertainty about how to approach, solution at least a decade off; many relevant people don’t care, or some supportive but significant opposition from status quo.")

Judging by the rest of the scoring matrix I think a range of 2 - 3.5 in most countries is appropriate, which roughly correlates to low-moderate in my book.

So I think I would stand by my choice of low-moderate. I probably a proclivity for pessimism so perhaps I'm not being generous enough about its solvability here. The problem may be highly tractable in some countries but I feel that to recognise it in the range would misrepresent the issue. As for Wisconsin, I would hesitate to proclaim its effectiveness before more specific analysis. So even if they only spend 15% of their time on it, that may not mean much in terms of tractability or neglectedness. It does seem promising though.

Other funding: There are reasons other than politics that PEPFAR may not have chose to fund palliative care measures. Preventive measures may just be way more cost effective in the long run. I haven't looked closely into it.

An area where palliative care is of growing interest is in multidrug resistant TB.

Comment author: Austen_Forrester 03 February 2017 06:01:15PM 1 point [-]

I'm a little confused as to why you are trying to promote a cause that you think is low priority and financially inefficient. Anyhow, I don't find your anti-corporate stance convincing. Lack of corporate involvement (ie. to distribute analgesics) is the missing link preventing some countries from having functional palliative care in some countries according to Dr. Foley. It's important to work with all stakeholders for progress in any space. The affordable anti-retroviral movement made progress by working with pharma. The risks of working with industry in the public's interest can be minimized with appropriate controls.

Access to properly regulated mobile phone, internet, and financial services have greatly helped the poor and require corporate involvement. Unfortunately, they are underutilized because SJW's like to maintain their purity and reject corporate involvement. I hope your palliative care movement doesn't suffer from the same self-defeating ideology.

Comment author: Lee_Sharkey 04 February 2017 04:19:53PM *  2 points [-]

Hi Austen,

Just to clarify, I'm not trying to promote or demote the cause. I'm aware that the cause is of interest to some EAs, and as someone in a good position to inform them, I thought something like this would help them make their own judgement :) I'm just sharing info and trying to be impartial.

Sorry if I my comments gave the impression that I thought it was low priority and financially inefficient. To reiterate I've withheld strong judgement on its priority, and I said I haven't looked into its financial efficiency compared with other interventions. Because its importance/effectiveness depends heavily on ethical value preferences, both of these question are hard for me to take strong stances on.

My apologies for seeming contrary here, but I'm not taking an anti-corporate stance either. I made those points because the way you had originally put it made it seem like you believed that access to pain relief was unique in that corporate influence didn't carry much risk compared with other causes. Unfortunately, it isn't so. Of course pharma involvement is essential, yet the history of this very cause illustrates the risks. I'd agree with you that lack of corporate involvement is the missing link in some aspects of increasing access, but we should both be specific about the sectors we're talking about to avoid appearing broadly pro-corporate or anti-corporate, which we both agree is unhelpful.

I haven't got a wide enough grasp of the palliative care movement to say if it suffers from an anti-corporate agenda. 'Global health' in general tends to be pretty anti-pharma, and it's hard to argue that the short-term externalities of the existing capitalistic model of drug development and production favours the 'Global health' agenda over the agenda of 'health in the developed world'. So Global health's culture of being anti-pharma is at least understandable, even if it relies on discounting the potentially-positive long-term externalities of the capitalistic model. It's hard to say if access to pain relief/palliative care is more antagonistic to pharma than the rest of Global health. If it is suspicious of opioid manufacturers being involved in other aspects of the movement such as policy, then, without being too SJW, I actually think they actually have good reason to be so, given the history.