The International Narcotics Control Board²⁹ has published the following figures for the consumption of narcotic drugs in South Africa: codeine 7,587 kg; morphine 156 kg; dihydrocodeine 85; pholcodine 98; dextropropoxyphene 1,934; pethidine 283 kg; methadone 1kg; diphenoxylate 1kg; and cocaine 4kg.

For the years 2000-2002, the average defined daily dose consumption of morphine for statistical purposes (S-DDD)³⁰ in South Africa was 103. This compares with other African countries as follows: Swaziland 1; Egypt 2; Uganda 4; Zimbabwe 13; Namibia 73. Twenty nine countries reported no morphine consumption during 2000-2002 (Table 8).

I was going to say that our legal system is supportive; but in fact we’re just battling a bit with new dispensing laws that really are putting the dispensing all back to the pharmacists - so the doctors are unable to dispense and of course the nurses are not able to dispense. So, having come from that meeting in Arusha where Uganda has just licensed nurses to prescribe and dispense morphine, we seem to be taking it a step backwards, in that the dispensing can only happen at pharmacy level now. Morphine is available. We don’t have a wide range of opioids. We have morphine - and methadone’s really only available for weaning addicts; it’s not really available as a pain relief medication. There has to be immense motivation to use it anyway as our step three analgesic, and so the prescribing of Schedule 7 medications must be by a doctor. So doctors have to be knowledgeable in prescribing how to use morphine. So that’s our biggest barrier right now, the actual doctor’s knowledge. And coming from Port Elizabeth this morning, it’s again the nurses who are looking after hospice patients who will say to the doctor, ‘You know, doctor, this patient needs to be on morphine,’ and ‘This morphine does need to be increased ..’. so it makes it quite a tedious way to go. Liz Gwyther – education and research co-ordinator, HPCA.³¹

Table 8 Average daily consumption of defined daily doses (for statistical purposes) of morphine per million inhabitants, 2000-2002: countries of Africa

Source: International Narcotics Control Board Narcotic Drugs: Estimated World Requirements for 2004. Statistics for 2002. New York: United Nations, 2004.

We have such a struggle in getting medication to our patients because most of our patients are government patients and some of them live 60 kilometres away from main hospital centres; so they don’t get enough morphine. Sometimes they sit all day in a hospital which cost them 60-odd rand to get there, to be told, ‘Come back tomorrow, we’re too busy’. They just can’t do that. Or they’re given a little bottle of morphine syrup that’s gonna last them a week. So we’ve had to learn to supplement medication, but it’s such an expense. Our volunteer coordinator took it upon herself to create a fund, a medicine fund, and with this fund we buy extra medication so that when there are patients who are really in need - through our doctor prescribing and so on – we support them and supplement their drugs, because they just cannot have access to proper medication. So that’s been a great help, to have a source of income that we know, if there’s really a patient that can’t afford medication, we can go to that source and lobby for it and say, ‘This is the background ..’ and then we buy medication from the fund. So that’s been a great help. Marisa Wolheim – executive director, Shanti Nilaya, Hospice in the West

Traditional healers

As in other African countries, western medicine and traditional healing run side by side. Many patients routinely visit traditional healers before consulting staff trained in western methods. While such healers focus upon herbal remedies, they also represent indigenous traditions that acknowledge the dis-ease caused when the equilibrium of life has been disturbed. Ancestors feature prominently forming an unbroken, transcendent link between past, present and future that provides a sense of continuity and belonging. In the context of care at the end of life, there is a growing appreciation that collaboration with traditional healers bring benefits for the patient:

I’m also working with traditional healers. My aim in the beginning was to give them knowledge because they were treating these people who are HIV positive, not knowing that they have this [disease]. So it was to make it clear to them that these patients were not going there to be trained as traditional healers but they were sick. And then the traditional healers taught me the traditional uses of the plants. So now we have a project of traditional healing, and we have a garden where we grow those plants I’m using for the immune system. Sr Priscilla Dlamini - founder, Holy Cross Hospice, Gingindlovu:³²

My relationship with the traditional healers actually started with a patient. If the patient believes in traditional healing I don’t discourage it. Fortunately in Tembisa, there are a lot of home-based care projects, amongst which we have got one project that is managed by a traditional healer. She actually convinced us that she understands HIV/AIDS is incurable and also, she is a chief of all the traditional healers in Tembisa - and they all understand that HIV/AIDS is incurable. So she has been able to influence other traditional healers, saying that in their practice they must take care of infection control, they must educate their patients, that whatever they do is just to make them comfortable and treat opportunistic diseases - especially sexually transmitted diseases. But they must understand that HIV/AIDS is incurable. So she has been of great help to us because, even with the medicines that she is using the patients know that they are more palliative than curative. So we do have a good rapport with the traditional healer because of this common understanding that HIV/AIDS is not curable. Flora Kobotlo Modiba – founder/ directorArebaokeng Hospice.³³

People think, you know, something has happened to them because they have failed to appease their ancestors in one way or the other, or they have omitted some rituals, or they’ve angered their ancestors by doing something they shouldn’t have done, and, yeah, this is quite common - and it’s very important not to overlook that and to appreciate what they think. Most of the time they would talk about that and they would ask what you think, which is quite interesting, because you would be listening to them, talking about all this. And then they’ll suddenly ask you what you think. Then you would say, ‘From what I have been taught, it is this way and that way,’ and at times it helps, if we have something in writing – or it could be pictures or a pamphlet - just to prove to them that we conceive illness to be from this and that, but actually this is also the case, and it’s scientifically proven so why not try it? Because by the time they come to hospice for help they will have tried all other avenues. Thembi Nyuswa – sister, Highway Hospice, Durban.³⁴

It’s actually a very exciting cultural environment to explore and I think that St Luke’s Cape Town} has looked at this and has a very strong multifaith spiritual counselling team: and I think that the philosophies of hospice, of the patient making the decisions and the patient leading the team so that, if they can be fully informed and then they make the decisions, then who they choose to go to, or when we’re talking about traditional healers who are also the spiritual leaders in the African culture, I think that that is respected by hospice people. The Military Hospice has got quite strong links with traditional healers, and also places like South Coast Hospice have a traditional healer that actually looks after their herb garden, because there are a lot of traditional plants that he grows to treat various ailments, and a lot of our hospices have connection with the traditional healers to, so that we try and make sure that the patient will still be able to get their pain medication, for example, but will be able to take whatever they need on the traditional side - because there’s such a complex treatment from the traditional healer’s point of view. I mean, it’s the throwing of the bones, it’s the actual calling of the ancestral spiritual medium where the spirit speaks through the traditional healer, plus herbal medicines. So it’s been kind of getting that understanding, and in my impression, it is still in its infancy, this real strong team between hospice and traditional healer. But the team that includes the multifaith minister, imam or rabbi or Buddhist or whoever’s there, is a stronger team - and the link with the traditional healers is growing. Liz Gwyther – education and research co-ordinator , HPCA. ³⁵