Editor’s note: The 17th IASP World Congress on Pain took place September 12-16, 2018, in Boston, US. At the Congress, 12 early-career pain researchers took part in the PRF Correspondents Program, a science communications training experience that provides participants with knowledge and skills needed to communicate science effectively to a wide range of pain researchers, and to patients and the wider public. As part of this program, the participants conducted interviews with plenary speakers at the meeting.
Here, plenary speaker Cynthia Goh, MBBS, PhD, FAChPM, FRCP, chats with PRF Correspondent Hayley Leake, a PhD candidate at the University of South Australia, Adelaide. Goh is an associate professor, Lien Centrefor Palliative Care, Duke-NUS Medical School Singapore; senior consultant and head, Department of Palliative Medicine, National Cancer Centre Singapore; and a clinical associate professor, National University of Singapore. She has made pioneering contributions to palliative care throughout the Asia-Pacific region, and spoke with Leake about her work in this field, how the Opium Wars and religious beliefs have shaped views of opioids in this area of the world, and much more. Below is an edited transcript of the conversation.
Talk me through some of the harder decisions you’ve made in your career journey.
I come from a family of doctors, so it was assumed I was going to be a doctor. The choice came midway through secondary school: I had to choose between physics and history. I knew I needed physics to get into medical school, but history was my favorite subject, so giving it up was really hard.But I chose medical school and trained in internal medicine.
Starting a PhD was also a hard decision. The postgraduate dean at the National University of Singapore told me that only a woman could do it—that a man must earn a living and support his family, that my husband is supposed to support me, and that I can do what I like, take a pay cut and have no career at the end and still be okay.
The advice from everybody was that I wouldn’t find a job after my PhD because of taking so much time off from practicing medicine. After I got my PhD I tried to get a clinical job, and people were absolutely right—I couldn’t get a job in Singapore! So I volunteered full time for a hospice organization in 1992. This is where my career moved toward palliative medicine.
You were instrumental in setting up palliative medicine in Singapore. What was treatment of cancer pain like in Singapore before palliative care was established?
There was no discussion, and no cancer pain relief. People would come up to us and say, “My father’s dying of cancer and he’s in severe pain. They can’t do anything about it in the hospital—what can you do?”The nuns who ran St. Joseph’s Home, a home for the aged, decided they were going to do hospice, but they didn’t know how. So they asked two volunteer doctors, Dr. Anne Merriman and myself, to help. Neither of us was trained in palliative care; we just did what we could and learned how to do it. It’s a long way from there to becoming established and having accredited training and institutions, which is what you must do to get the specialty recognized and make the work sustainable.
How did you begin the process of palliative medicine being recognized as a specialty in Singapore?
You can only do that in the public sector, in the academic institutions. My first attempts were met with, “I’ll give you a table in the lobby where you can give brochures for volunteers." I said, forget it, that’s not what palliative care is about. Eventually I saw eye to eye with a new director of the National Cancer Centre in Singapore, who had traveled to international hospitals and seen their palliative care departments. He agreed that, to be a comprehensive cancer center in this day and age, you need a department of palliative medicine.They offered me the job in 1999, and 12 years later the department had 31 people in it—consultants, advanced care nurse practitioners, some clinical staff and research staff, and so on.
You then introduced palliative care in other countries. Can you describe the transition to establishing palliative care services across Asia?
I thought the greatest need was in countries that had absolutely no palliative care services and no morphine. But we can’t do it in a vacuum; you can train people, but if they don’t have a service to work in, they will lose their skills. We had to advocate for the services to be set up, and we needed local partners who could help us access people at different levels. So we advocated at a hospital level, to medical superintendents and consultants who might object to resources being spread out. We advocated at the level of the ministries of health, to top civil servants who make policy. And if morphine was not available or was very restricted, then we worked with drug regulators as well to educate them as to why the medication is needed and how to make it safe from diversion.
It cannot be just you—local people really had to guide us. They made sure we met the right people and told us the right thing to say. Finally, you’ve got to do the practical bit. Where will palliative services find their morphine? Are they going to make it themselves? Are they going to import it? Where are they going to import it from?
Misuse and overuse of opioids is a big problem in the West. Do you see similar issues in Asia?
The issues that we fight in the East are very different from the opioid crisis in the West. The greatest barrier to palliative care medicine is fear of using morphine. In the general population in Asia, people don’t want to take morphine because they think it’s addictive and will kill you. This predates what’s happening currently in America. For a long time in Asia, we had the Opium Wars.
How have the Opium Wars influenced the public’s view of opioids in modern-day Asia?
This is a very dark side of history that is never advertised in the West. The Opium Wars took place in the mid-19th century. At that time, Britain was building its empire and wanted to buy tea from China to sell in the European market. Initially, Britain paid for tea using silver, but it was very expensive. The cheaper solution was to buy tea with opium, which the British could grow cheaply in India. This created a population of opium addicts in China. The Opium Wars started after a Chinese patriot burned a British shipment of opium, giving the British an excuse to make war with China. Technologically, China was very backward in those days, and so it lost the Opium Wars.
Opium had become very common in Asia. There were opium parlors—instead of boozing up, people would smoke opium. Many people became addicted. Today, the legacy of the Opium Wars remains, and people are very afraid of opium because they know it is addictive. Our patients don’t want opium. They don’t want morphine. Morphine is a really bad word that they associate with addiction and death; they think you only use morphine when you are about to die.
How do you handle this long-standing fear of morphine addiction?
Educating the public is hugely important. This includes explaining that morphine won’t shorten life or kill a person but rather that it only controls the pain. It also involves explaining that people don’t need to worry that if they take morphine now that they will have pain that cannot be controlled later on, if the cancer grows. Those kinds of myths are common throughout our area of the world, so our public health messaging is very different than in the West.
Are there other religious or cultural beliefs that influence perceptions of opioids in Asia?
Having a clear mind is very important, particularly in some religions. Two of our major religions, Hinduism and Buddhism, believe in reincarnation. In the Buddhist religion, some Buddhists believe that your last thought helps determine exactly at which level your soul is going to be reincarnated, so you have to have a very clear mind. They don’t want to take anything that will dim the mind and change their last thought.
You have to bargain with patients to get their pain controlled. You might say that we’ll never get pain to a zero out of 10; maybe five out of 10 will be good enough because the mind remains clear. Treatment is individualized—you need to know your patients, and to understand their beliefs and preferences, and titrate pain management to that level.
Understanding religious beliefs is important to control pain in this population. Some religions, like Taoism or Chinese folk religion, believe in a series of punishments for the bad things one has done in life—for stealing, adultery, taking of life, and so forth. Graphic illustrations of the punishments, like being boiled in oil and other torture, may be found in temples, theme parks, and comic books. While these may be used to instill virtue in life, they often fuel fear of death. As we know, pain may become very difficult to control when there is great fear. To alleviate this kind of fear, good deeds such as donations to temples may help, and indirectly become part of pain management.
End-of-life care is also different. In the West, people don’t want to suffer; many want a morphine drip and to drift off. In the East, not all people want to die in their sleep. Some do, but they rarely want you to help them with drugs.
Can you describe some of the issues around access to morphine in Asia?
In India, in most cancer treatment centers, there is no morphine available to treat cancer pain. This may be because they don’t have a license to use it, they don’t have the supplies, or they don’t know how to order or prescribe it. India is the biggest producer of morphine, producing 80 percent of the world’s supply, and uses something like 5 percent of it. Imagine having no morphine for not only cancer pain but postoperative pain as well. I have seen people go through operations with no morphine at all in many Asian countries.
We have a project that introduces training in palliative care, together with tools for pain management and oral morphine, to cancer treatment centers. So far, we’ve involved 31 centers in India.
But I do think that in our part of the world, where morphine is not available, when people have an operation they expect to have pain, so they tolerate it a lot better. In the West, people are taught to blame their doctor if their pain management is not good. In the East, if you fall down and have a trauma or have an operation, you expect to have pain.
Is there a consensus view in palliative care medicine on euthanasia?
It’s sometimes not called euthanasia, but rather Medical Aid in Dying, or MAID, to make it more acceptable. There are palliative care physicians who would support it. I belong to the Asia Pacific Hospice Palliative Care Network. When we first set up, hospice leaders in our region had a lengthy discussion to answer the question, Should palliative care include a service to help patients die, as opposed to looking after them until they die? We concluded that euthanasia was not part of our palliative care, and we never wanted it to be.
It would be impossible for us to practice palliative care if we were ambivalent about this. Patients are already asking us if we are trying to kill them by giving them morphine. We reply very clearly that we will not do anything to shorten life because we value every moment of life. And we know that good palliative care does allow patients to survive longer. But if we’re ambivalent about euthanasia, how would patients trust us? It would make our position that morphine is not going to kill you untenable. Also, in many Asia-Pacific countries, religions—Christianity, Buddhism, Hinduism, Islam—are all against euthanasia.
So very early on, before we even registered the Asia Pacific Hospice Palliative Care Network, we made a declaration saying that we will not support anything that has the intention of ending a person’s life; this was written into our constitution when we registered as a network. So our position is very clear. But the world has changed since then. I have found there are a number of palliative care physicians in the Western world—in Australia, America, and Canada—who cannot sign up for that declaration, so they cannot become members of our network.
Do you have any advice on what makes a good doctor?
That’s a question I’ve been answering throughout my career. Medical school taught me not just knowledge, but a set of values. The thing about knowledge—particularly scientific knowledge—is that it changes all the time; there is no absolute. Filling students with knowledge is not the idea. Helping them to search for knowledge and ask questions about it—that’s what it’s all about.
Any words of wisdom for someone beginning a career in research?
A PhD helps you analyze things a lot more clearly, and to form hypotheses and think of ways to disprove them. It also teaches you persistence—if you think your theory is right, you work at it until you get evidence—and it teaches you to think independently and confidently. These are all life skills that you pick up along the way, and they’re never wasted.
If you were to retire, what would you do with your time?
People tell me that I can’t retire—and they might be right. If I can still do some good, I think I should continue to do it. But the day will come when I physically can’t do the work I’m doing right now. If I did retire, I would like to spend more time reflecting—just having time to think and to enjoy beauty, whether it’s the beauty of nature or anything else.