Many ill South Africans live and die suffering from unnecessary and excruciating pain. It is estimated that almost all HIV patients (96%) and more than two in three (70%) of cancer patients experience severe pain during the course of their disease because they do not have access to cheap and effective pain medication.
Morphine is a safe, effective and cheap treatment for pain, yet, many people don't have access to it, and in fact, many South Africans die in agonising pain because it is not made available to them.
"Pain, pain, pain. The last two weeks of that man's life was just pain from beginning to end," recalls Sister Delores Cano, a nurse at the Nightingale Hospice in De Aar in the Northern Cape. Cona had to stand by helplessly while a 49-year old cancer patient died in unbearable pain because the local health services refused to issue him with more morphine.
"Doctors are scared to prescribe morphine and we have to put up a big fight to get it for our patients," says Cona, a stout woman with a kind face who speaks pure Afrikaans with a charming Cape accent. "And often when we get morphine, the doses isn't enough to cover the pain for long."
When a patient's disease has progressed to a certain point, some medical professionals are of the opinion that they have done all they could and then stop treatment, often because they don't want to spend any more money or resources on a patient who will day in a couple of days anyway, explains Cona.
"But we [hospice] don't work that way. The patient still needs everything. It is not in our hands to say he will die now, or die later."
Proper pain management is an issue not only in the rural communities of South Africa, but all over the country, according to Dr Liz Gwyther, CEO of the Hospice Palliative Care Association of South Africa (HPCA).
Doctors have been taught that pain is a sign of something else, and in their quest to find and treat the cause, they often neglect to treat the pain, says Gwyther, who also teaches palliative care at the University of Cape Town. "They often don't even assess the pain adequately."
But there is hope for patients. A new law that will enable trained and registered nurses to prescribe scheduled medicine, including morphine, is expected to come into effect before the end of the year. This will mean that patients can be prescribed morphine at clinics that operate without doctors - as most clinics in the country do. Although this new legislation will put patients one step closer to accessing pain treatment, there are still more barriers to overcome.
In 2009, at least 200 000 South Africans died while suffering moderate to severe pain, 111 307 of them without receiving any treatment for it. This is according to the Global Access to Pain Relief Initiative, who calculated these figures using South Africa's cancer and HIV/Aids death statistics. These numbers therefore do not include traumatic injury, childbirth or other painful causes of death, and numbers are possibly much higher.
Even more alarming is that the number of cancer cases is estimated to double over the next 20 to 40 years, and the greatest increase is expected in low and middle-income countries, like South Africa. By 2030 it is predicted that there will be 26 million new cancer cases and 17 million cancer deaths per year.
"People with cancer and HIV equate the illness with pain, and many don't realise that treatment for pain should be available," says Gwyther.