A 25 mile-long strip of land bordering Egypt on the southwest and Israel on the east – Gaza is a challenging context to offer quality pain and palliative care services under pressure and resource limitations.
In this context, Dr Khamis A. Elessi MSc, MD is pioneering pain and palliative care as an essential service. He has chaired the medical rehab team at Elwafa Med Rehab Hospital in Gaza for 14 years where he has worked in the field of Neuro-Rehabilitation and Pain Management.
Now he is full time Associate Professor at the College of Medicine in the Islamic University-Gaza where he founded the first Palestinian Evidence-based Medicine (EBM) unit to promote EBM throughout Gaza Strip.
The international edition of ehospice caught up with Dr Khamis Elessi to hear how pain and palliative care is experienced in this context.
What is the context to pain management and palliative care development in Gaza?
In Gaza, the unemployment rate is at 52%, and the poverty rate is estimated at 40%. There is also a high prevalence of anemia and obesity – most people relying on food donated by UNRWA made of high glycemic index foods.
We see a lot of psychological stress and anxiety – noticeably among the young. Out of hopelessness, many youngsters move towards becoming addicts with tramadol. There are very high rates of young people suffering from PTSD.
In this context we are still trying to provide pain relief where it is most needed. Morphine is kept in hospitals and is administered in the in-patient unit. Oral morphine form is largely not available, only from time to time. We can only administer morphine in vial form. Fentaline patches are also needed for various cancers especially colon and lung cancer.
Where are your efforts focused when it comes to pain management and palliative care integration into the Gaza health system?
Comprehensive pain assessment and management was first introduced in Gaza in 2009, when I received a grant from the International Association for the Study of Pain (IASP) to promote proper pain assessment and management among doctors and other health professionals at Elwafa Hospital, which lasted for 2 years and resulted in the adoption of pain as the 5th vital sign in all records.
In 2010, together with Dr. Perez Bird, I conducted the first workshop in palliative care, which was followed by two additional workshops in 2011 and 2012. Since then, I have worked hard to incorporate pain and palliative care into the medical curriculum, however it is challenging to change the mentality of old doctors.
My counter argument was that every patient has the right to live and die pain free. We must target pain in the acute phase, if it is to become chronic, it is also much harder to treat.
We faced resistance in the beginning, but now we have succeeded to create a special module on pain and palliative care and we are able to formally integrate it into the curriculum for the 4th and 5th year medical students. I’ve also been involved in facilitating different workshops at different hospitals and especially at the Alahly hospital and the Rantisy pediatric hospital targeting doctors and health professionals working with cancer patients, as well as patients with sickle cell and on renal dialysis, which has a high prevalence rate.
I have seen agonizing pain in the eyes and bodies of patients in the Gaza strip. Many bed ridden patients with incurable illnesses suffer great deal of pain and suffering as part of these diseases and we can do something to relieve this pain.
What is your main message to medical students in Gaza studying palliative care?
Our mission when providing pain and palliative care – is not only to extend their life. We want to put meaning. Pain is not a destiny. My main strategy is to teach medical students about pain relief and proper communication with patients.
What does pain management and palliative care under Universal Health Coverage look like in the Gaza context – where the health system is near collapse?
The health care system is struggling and on the verge of collapse because of a lack of essential medicines and the need for analgesics. If these are not absent, then they are very deficient. A health system strengthening approach is important to build capacity and mobilize existing resources alongside building of local, regional and international partnerships.
Each patient should know it is part of their right that when they receive treatment – they should receive some counseling or a palliative care assessment, and know what to expect.
Pain and palliative care is part and parcel of every care, not just cancer – or other incurable diseases. My aim is to promote the fundamentals of pain and palliative care with practical implications. But it is costly. Much of this is conducted without funding but working out my own expenses.
Further advocacy is needed to develop pain and palliative care training, research and clinical leadership capacity to ensure that the people of Gaza have the palliative care they need and deserve, with appropriate funding.
You have training in alternative medicine, how do you integrate that with your pain management and palliative care practice?
I completed three courses in Chinese acupuncture to manage pain and neurological disorders and have worked in neurohabilitation at Tel Aviv University. Thereafter, I chaired medical rehabilitation teams – made up of clinicians, physical and occupational therapists as well as psychologists. I specifically studied medical acupuncture for one year to help people when dealing with diabetic neuropathy – focusing on elderly and obese populations (27% of people suffering from diabetes – exhibit peripheral neuropathy, a very painful disorder).
I frequently teach patients to relax and try to cope with their pain in the midst of their symptoms and alternate mild opioids with techniques such as the use of a tens machine, aromatherapy or immersion in hot water, which is helpful for patients. We try to let cancer patients listen to relaxation music and engage in psychosocial and reacreational sessions, especially for children for whom we bring in visiting clowns, for example.
We also established a play therapy room which is allocated for play therapy for patients and families – drawing, music – as well as two psychosocial workers and psychotherapists who offer regular counseling and family support.
More information on Dr Elessi’s work in Gaza is available at the following link:
https://www.cebm.net/2017/06/oxfords-recognition-individuals-can-promote-recognition-home/
About Dr Khamis A. Elessi
Dr Khamis A. Elessi MSc, MD, received his medical education and clinical training in various countries (Philippines, Israel and the UK) with two years in British hospitals. He has chaired the medical rehab team at Elwafa Med Rehab Hospital in Gaza for the last 14 years and mainly worked in the field of Neuro-Rehabilitation and Pain Management. Now he is full time Assistant Professor at the College of Medicine in the Islamic University-Gaza where he founded the first Palestinian EBM unit to promote EBM throughout Gaza Strip.
In 2018, he was selected as by Kellogg College at the University of Oxford as the Top Winner for “The 2018 Award for Community Engagement and Academic Excellence” for his role in teaching, training and promoting comprehensive pain management and palliative care in the Gaza Strip.
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