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8 Articles in Volume 8, Issue #7
Class IV Therapy Lasers Maximize Primary Biostimulative Effects
Functional Restoration and Complex Regional Pain Syndrome
Hamular Process Bursitis
Longitudinal Study of Long-term Opioid Patients
Omega-3 Fatty Acids and Neuropathic Pain
Osteopathic Manipulative Medicine (OMM) for Lower Back Pain
Pain Care for a Global Community: Part 2
Practical Application of Neuropostural Evaluations

Pain Care for a Global Community: Part 2

Ethics and Economics in Intersection

“Make me a meal and I eat for a day…teach me to forage, harvest, and cook and I shall feed myself always…”

Practicalities of a Core Philosophy of Pain Care

The argument for pain medicine to adopt a strong “…philosophical foundation that allows practical articulation across a diversity of socio-cultural contexts and circumstances” in order to adequately confront and address chronic pain on a worldwide level cannot ignore the implications and obligations entailed by such a core philosophy.1 The tenets of this philosophy do not depict medicine, in general, or pain medicine more specifically, as being articulated in a socio-cultural vacuum. To the contrary, by articulating the need for, and practical ends of a right and good care of pain patients, this philosophy acknowledges particular environmental and cultural contingencies along with the effects and implications of changing economic forces. Without grounding pain care to such a philosophical foundation, we believe that it would be relatively easy to overlook the complexity of variables that influence the provision of medical treatment. In misrepresenting, or not considering these factors, a true appreciation of the hierarchical needs of chronic pain patients nested within (and affected by) various societies and cultures, as well as a validly beneficent response of an internationally-relevant pain medicine, would be unlikely.2

In this essay, we describe the dynamic interplay between patient-specific, political, and economic factors inherent to the socio-cultural environment(s) of various nations, (as applicable to both diagnosis and therapeutics), and opine that these factors must be recognized and engaged in order to plan and implement pain care that is tangible and sustainable in developed, developing, and non-developed nations.3-10 Although a strong scientific and humanistic philosophical foundation is integral to the treatment of chronic pain on a worldwide level, in and by itself this is not sufficient, as real-world execution of medical care is enacted within—and between—the national political infrastructures that can incur economic limitations, burdens, and risks. In this way, any realistic application of a core philosophy and ethic(s) of pain care on a global level must also identify and account for how politico-economic variables influence the calculus of resource-reliance, -provision, -allocation, and -use.

Global Issues in Pain Care

To be sure, this is not only important when considering pain care in developing, or non-developed countries. For example, the inadequacy of chronic pain treatment in the United States has been well-documented, particularly with regard to the inappropriate exercise (i.e. under-use and/or incorrect/excessive use ) of various diagnostic and therapeutic technologies, and a failure to provide integrative treatment approaches that address psycho-social, as well as biological aspects of pain.11-15 Certain racial and ethnic groups, children, and seniors are at particular risk for inadequate chronic pain management given insufficient insurance coverage for, and/or lack of access to those (diagnostic and therapeutic) approaches that could maximize beneficial health outcomes.16-18

Recently, we have argued that the use of technology—while important to diagnosis and treatment of pain—cannot (nor should not) be employed without prudent evaluation of 1) benefit: burden: risk ratios; 2) time- , cost- and outcomes’-effectiveness, and 3) viability in an integrative diagnostic and therapeutic plan that combines objective and subjective dimensions of assessment and care.19,20 Moreover, it is important to consider whether the availability and/or use of such technologies are, in fact sustainable. It has been posed that shortcomings in the treatment of chronic pain in the United States reflect both a shortage of pain practitioners and the relative unavailability of state-of-the-art techniques and technologies provided under the diligent aegis of specialized, multi-disciplinary pain care.21,22

In light of the fact that 1) the economic profile of the United States and other western countries is considerably higher than second- and third-world nations, and 2) deficits in the provision and accessibility of pain therapeutics are notable in, and among, western nations,23,24 we are prompted to question the status of chronic pain care in less-developed countries. It is likely that the extent of chronic pain mirrors the overall quality of healthcare in a particular country. Relatively little is known about chronic pain management in developing nations. While painful musculoskeletal conditions were thought to be more prevalent in developed nations,25 recent studies have indicated that the prevalence of chronic pain is actually higher in non-developed and developing countries than in developed nations.26,27 This is consistent with findings that a high prevalence of chronic pain has been reported in Africa,28 Indonesia,29 Thailand,30 Vietnam,31 Pakistan,32 Oman,33 Lebanon,34 and Nepal.35 It has been suggested that in non-developed and developing countries, the prevalence of chronic pain may reflect hesitance to seek (early and/or continuing) treatment, social stigma associated with pain, and occupational obligations incurred by poverty that mitigate availability, adequacy, and/or continuity of care.36,37 Still, as Brennan and colleagues note, most of the statistics used to illustrate the “problem of pain” and direct pain therapeutics reflect epidemiologic data from “first-world” nations and thereby overlooking, or frankly neglecting, the issues and needs of developing/non-developed countries and this may contribute to a “…global failure to adequately respond to the challenge” of pain.38

“The under-treatment of chronic pain in developing nations is related to factors such as economic instability, conditions of poverty, and lack, and/or incapacity of medical infrastructure.”39

The under-treatment of chronic pain in developing nations is related to factors such as economic instability, conditions of poverty, and lack, and/or incapacity of medical infrastructure.39 Taylor and colleagues note that “… barriers …include poor understanding and lack of education regarding pain…” , given that “…pain management in poor countries must compete for limited resources with other primary health care services, as well as with other social concerns such as food.”40 While pain medicine is recognized as a distinct specialty in most western countries, and chronic pain is ideally treated by a specialist, even in developed nations like the United States, the vast majority of chronic pain is treated by generalists.41 The majority of developing nations have a paucity of physicians and medical resources on the whole and, as a consequence, pain management specialists and the specific diagnostic and therapeutic resources inherent to effective pain practice are, for the most part, direly lacking.42

Consideration of Biopower and Biopolitics

While it is evident that developing nations are in need of greater medical (personnel, technological, educational and administrative) resources, we believe that the solution does not merely involve the simple provision of these elements. Given the premises that 1) pain care—as both profession and practice—is based, in part if not largely, upon a maxim of beneficence; 2) the axiomatic “good” of this practice is “other”-directed, so as to focus upon the needs of the pain patient; and 3) relational asymmetries shape the moral responsibilities and conduct of the profession and practice, then it becomes clear that any effort toward a truly global pain care must be non-egoistic.43 Establishing circumstances in which the well-being (in this case, prevention and relief of pain) of populations of non-developed and developing nations become reliant and longitudinally dependent upon the resources of developed countries, further marginalizes and controls those in need.

Such subjugation is what the French philosopher Michel Foucault referred to as “biopower” and, in many ways, inflicts political influence (ie. “biopolitics”) through implicit or explicit external market controls upon local economies.44 Thus, to simply “provide” developing and/or non-developed nations the technical, personnel, educational, and fiscal resources necessary for a system of pain medicine without accord of microeconomic variables inherent to each socio-cultural situation could actually 1) take advantage of extant asymmetric relationships of information, goods, and manpower and promote greater inequalities and inequity in the future; 2) monopolize such goods and services; and thereby 3) become exploitative through the imposition of negative externalities that incur both immediate and long-term dependencies.45

In reality, such practices are likely to create ever larger gaps between the “haves” and “have nots” that instill imbalance(s) in capacity for implementation, regulation, and flexibility. Simply put, without careful consideration of 1) local needs and capabilities and 2) what forces are necessary and required to both initiate and independently maintain a healthcare system that engages resources that can be locally cultivated and stabilized, any imposed change will lead to progressively worsening oscillations in local healthcare service stability, and ultimately the failure to achieve and maintain pain medicine as a viable social good. We propose that this would occur, as a consequence of initial—ut not independently sustainable—improvements, followed by rapid decline as fiscal demands of continued external dependence exceed the capacity of the local economy, thereby resulting in somewhat broad(er) social impact (e.g.- resource-failure, increased incidence and prevalence of pain, loss of man-work hours, incapacity to engage healthcare services, etc).

Toward Resolution: Step One—Microeconomically Sensitive Models

In light of this, any resolution to the problem of inadequate resources necessary to initiate pain care in developing and non-developed countries must account for and address:

  1. What indigenous factors—e.g.- educational and clinical infrastructures, viable pools of healthcare personnel, local production of pharmaceuticals and/or use of geographically-relevant phytomedicinals, capacity for technological manufacturing and use, proximate and non-proximate economic impact of healthcare on workforce dynamics, etc—are viable for the upkeep of the healthcare system at-large, and pain medicine, specifically.
  2. How time-limited allocation of external inputs could be used to cultivate both indigenous resources, and allow sustainability of these factors.
  3. What models of provision, growth and sustainability best accommodate these variables toward maximizing public good.

Given that needs and contingencies differ considerably in, and among developing and non-developed countries,46 it becomes clear that a single compensation-based model would be inadequate to effectively address and meet each and all of the cost-benefit scenarios that could, and would, be encountered. Obviously, optimizing potential “gains” among groups of pain patients (within each socio-economic milieu) would entail some possible “loss(es)” (e.g.- to either the initial service/resource provider(s), and perhaps to certain recipient factions, as well). Thus, simple “total win-win/non-loss” models, (i.e.- what are known as Pareto or strong Pareto criteria47) can be seen as un-realistic, as “total win-win” models tend to be time-limited within real-world markets, and can ultimately revert to market-failure (characteristically through resource exhaustion, and strong resurgence of supply and demand imbalances). Instead, a more prudential approach would be to consider a range of possible cost-benefit efficiencies—such as those originally proposed by Nicholas Kaldor and John Hicks (viz.- Kaldor-Hicks efficiency/Scitovsky criteria48-50)—that account for some “losses,” but which seek and implement mechanisms to compensate such loss (through market balancing) even if this equilibrium is achieved over a longer period of time.

In this case, the “losses” or “losers” might be the intermediate-timescale profit loss incurred by large scale technologic/economic agents as developing and non-developed nations decrease the influx of external resources while cultivating and expanding their own. However, this decrement in external economic interaction would, in fact, tend to stabilize (if not reverse) as the healthcare infrastructure of developing countries progresses, and these nations then participate in health and biomedical services’ and products’ exchange on the world market.51 In this way, the losses tend to be on supply-side, which are less than demand-side (on a relative, per capita basis), and which can be recouped by both exchanges with other components of the market, and/or eventual resumption of exchange(s) with the now more developed nation(s). Rather than castigating the market, this scenario recognizes relevant dimensions of market-failure, and seeks to instill resource cultivation so as to create socio-economic sustainability in developing countries, diminish inequity that is linked to resource inequalities, and allow more durable stability within the market.52

Step Two: From Philosophical Premises to Policy

Granted, while such models attempt to realistically illustrate the current and future trends in healthcare economics that exist between and within developed, developing, and non-developed nations, it is impossible to accurately predict the nature and extent of political influence that could dictate market behavior, and the conduct of healthcare in a particular socio-cultural milieu. To implement a proposed core philosophy of pain medicine in practice, the aforementioned variables of healthcare needs, resources, relational (i.e.- economic and power) asymmetries, optimal welfare contingencies (e.g.- losses and gains), and compensation efficiency must be considered and addressed. The claim that “…pain care cannot be one size fits all,”53 takes on new meaning when regarded as a potential social good on a multi-national, global scale.

Thus, just as individualized pain therapeutics must be bio-psychosocially patient-centered, pain care as a public good of a healthcare system must account for and accommodate the needs, resource-capabilities, and exigencies of the society and/or nation in question. If this is the purpose described and served by a core philosophy of pain care, and if such pain care is to be relevant and applicable to a global community, then careful regard for the persons, economics, and politics of each constituent community must be a foundational premise that is part of the epistemology, anthropology, and ethics entailed by this philosophy. These premises serve as guideposts for policy formulation that seeks to direct the equitable allocation of resources so as to address both the problem of pain—on a worldwide level—and the socio-economic and political problems and issues that arise within the interaction of developed, developing, and non-developed nations.


This essay was adapted from: Giordano J, Benedikter R, Schatman ME. Pain care for a global community- Implications of a core philosophy, ethics and economics: considerations for social policy. In: Giordano J, Boswell MV (eds.) Meaning and Morality in Pain Medicine: Philosophy, Ethics, and Policy. Linton Atlantic Press, Kentucky. Forthcoming in 2009.

Last updated on: December 20, 2011
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