Suffering through pain in Rwanda

From Chris

The first day of the inaugural Rwandan “Zero Pain Conference” kicked off this morning in the beautiful town of Butare, nearly 3 hours drive from Kigali. The two day conference brings together MDs, non-physician anesthetists, physiotherapists, psychologists, researchers and many others interested in pain management. Delegates will have the opportunity to hear from experts in the field of pain medicine, and learn about novel ways to tackle pain both in and out of hospital, with the goal of reaching a “Zero Pain” Rwandan state - a lofty goal, but one that may benefit thousands while striving to reach it. 

Since arriving here last week I’ve heard many times that Rwandans are expected to suffer through pain - whether that be labour and child birth, post-surgical, traumatic, or chronic type pain. The relationship to pain here is unlike any that I have experienced elsewhere. Many feel that pain is something that is meant to be endured, and that in time this may actually lead oneself to become stronger spiritually, physically and psychologically. Many Rwandans are deeply religious and feel that suffering through pain may allow them to become closer to faith. As such, most patients in hospital here do not complain of pain, and would not think to speak with their healthcare team if they felt that the pain regime prescribed to them was inadequate. Chronic pain, in particular, is not a well-known nor discussed topic, and there are currently only fledging programs hoping to change this. 

Access to medications to treat pain are limited by stock-outs, and outpatients who must purchase their only prescriptions often lack the funds to do so. Fentanyl, morphine and ketamine are *usually* available, but these medications are not frequently prescribed on patient discharge, leaving post-surgical patients with limited options to manage their pain upon returning home. It is clear that stigma still exists around the use of these medications for pain management, and given the lack of multimodel analgesia options available, patients are not just accepting of suffering, but are in fact forced to suffer. 

The concept of opioid addiction is complex, and sometimes poorly understood by patients and even their healthcare providers around the world, and that is no different here in Rwanda. Throughout this mornings discussions, the myths around opioid dependence, tolerance and addiction have begun to be broken down. Moving forward, patients and their doctors need to understand that one not need suffer in agony from acute pain purely to avoid the small possibility of dependence or tolerance. Opioids should not be feared, particularly if other options continue to be so limited. Frequent assessment and iterative treatment of pain is essential to ensure that patients do not suffer needlessly, and to prevent the development of chronic post-surgical and post-traumatic pain. 

With the growing community of pain practitioners here in Rwanda, this country is set up to drastically alter the Rwanda experience (and indeed expectation) of pain and suffering. In discussions with the conference delegates today, it’s clear that a wave of change is upon the country - more and more healthcare workers are interested in learning about the pathophysiology, pharmacologic, and importantly non-pharmacologic ways to treat pain. We must continue to support these efforts moving forward, and while we may never see a Rwanda with zero pain, we can certainly strive for amelioration of the suffering that is so pervasive today.