IAHPC Welcome and Housekeeping
Moderator: Dr. Katherine Pettus,
Information and Partnerships Director, IAHPC
Opening by HE Ambassador Cheryl Spencer,
Permanent Representative of Jamaica to the United Nations, Vienna
Dr. Dingle Spence
Consultant in Oncology and Palliative Medicine
President of the Caribbean Palliative Care Association (CARIPALCA)
Verna Edwards (DPharm)
Dept. of Standards and Regulations, Ministry of Health and Wellness, Jamaica
Dr. Karen Cox
Family Physician and Consultant (Ag) in Palliative Medicine
Member of CARIPALCA and the Palliative Care Society of Trinidad and Tobago
Bibi Salim (RN)
Head Nurse at Beacon Hospice Foundation, Guyana
Patient, Featured in video
Closing by Sir George Alleyne,
Director Emeritus of the Pan American Health Organization
HE Ambassador Cheryl Spencer: Our vision is a world free from health related suffering. For our attendees all over the world, please introduce yourselves and your organizations in the chat and put your questions in the Q&A and we’ll try to get to them if there’s time and if not, we’ll respond to them by email. So it’s now my honor to introduce my friend, colleague and IHPC board member Dr. Dingle Spence. Dr. Dingle Spence is a Jamaican physician with training in clinical oncology and palliative medicine. She’s co-founder of the Jamaica Cancer Care and Research Institute and co-founder and president elect of the Caribbean Palliative Care Association. And I’ll be back in a bit to introduce some of the other speakers, but in the meantime, Dingle the floor is yours.
CARIPALCA, Dr. Dingle Spence, President:: Good morning, good afternoon, good evening to everybody, and thank you so much for joining us. It’s my pleasure now to introduce her. Excellent to the ambassador, Cheryl K. Spencer, our permanent Jamaican representative to the United Nations, Ambassador Spence said. The floor is yours. Thank you.
HE Ambassador Cheryl Spencer:Thank you very much, Dr. Linda Spencer. Thank you. Also to Dr. Katherine Pettus, Chair Stars George Allen, director emeritus of the Pan American Health Organization. Dr. Dingle Spence, President-Elect Caribbean Palliative Care Association. Dr. Katherine Pettus, Senior Advocacy and Partnerships Director, International Association for Hospice and Palliative Care. Representatives of the UNODC. Colleagues from the Ministry of Health and Wellness of Jamaica. Excellencies, Distinguished Ladies and Gentlemen, it is indeed a pleasure for me to deliver opening remarks on behalf of the government of Jamaica on this very important side event. One note in the W.H.O. literature, a simple sentence that says palliative care is not passive care, therefore must be available at all levels of care needs at the life limiting, life threatening or life prolonging level, thus improving the quality of life of persons. At the bystander of this is access to essential medicines such as morphine, which is recognized as the gold standard for pain relief, noting that the control of pain is a priority for treatment in palliative care. That is why this discussion today, which aims to examine and highlight the disparities in access and availability of those essential medicines in the Caribbean region, is so critically important.
According to statistics, an estimated 40 million people are in need of palliative care. Seventy eight percent of whom live in low and middle income countries and within the context of a high percentage of children, Jamaica remains concerned that the availability of international controlled substances for medical and scientific purposes remain from low to non-existent in many parts of the world. The Caribbean included this disparity also exists even among the latter countries themselves. The COVID 19 pandemic has further exacerbated the challenges to access and availability of essential medicines, including for pain and palliative care, through disruption in the medicines supply chain. Needless to say, that access and availability of medicines are important to achieving the health outcomes under the Agenda 2030 for sustainable development, in particular Goal three, as well as the right to health. It is recognized here that there are several barriers to equitable access, including, inter alia, lack of awareness among policymakers and health professionals on palliative care, culture and social considerations, misconceptions regarding palliative care, and linkages to increased substance abuse.
This year, 2022 marks an important milestone the 45th anniversary of the development of the W.H.O. model list of essential medicines. Jamaica is therefore delighted that being a member of the commission during this period. We are also pleased to have witnessed the official launch of the Joint Call for Action on scaling up the implementation of international drug policy commitments on improving availability of and access to controlled substances for medical and scientific purposes, which was held on the opening day of this session of the CND. Further, there is a critical need for stronger and renewed thrust for addressing barriers to access in accordance with, inter alia, the 2016 UNGASS Outcome Document. In 2021, Jamaica was pleased to have led on the resolution in the WTO on strengthening nursing and midwifery, which reaffirmed the importance of investing in the health workforce. Greater investments in education and training of health professionals, including embedding palliative care in core curriculum, will be a positive step in the right direction. And in that connection, we are now embarking on a primary health care reform agenda in Jamaica that includes the definition and implementation of palliative care services in primary care centers. The buildout of these areas of care indicates our appreciation of the need. Further to this, the Health and Wellness Ministry will support the launch of a diploma course in palliative care at the University of the West Indies to ensure Academy of Train Health and Care Workers. We also recognize that a small island, developing states, we grew up with stark realities of capacity constraints, especially human and financial constraints. It is therefore essential that this issue be kept at the forefront of the political agenda and the countries in the region work together in collaboration with partners such as Apple, including through the Powerful Strategic Fund for Essential Medicines, with a view to increasing access. Please rest assured of the governmental Jamaica’s commitment to continuing to emphasize the importance of the implementation of our joint commitment based on the principle of common and shared responsibility, which in this instance is to increase access and availability of medicines for the most vulnerable.
In closing, I wish to thank the panelists reflecting the keen interest of civil society. We thank the UNODC. We and along with the commitment to addressing this important issue and of course, sincerely to Dr. Spence for her efforts and her initiative in seeking to highlight this concern. We owe it to millions of persons in need of palliative care to find and explore avenues to provide much needed medicines to reduce pain and suffering. Thank you!
IAHPC, Dr. Katherine Pettus, Moderator: Thank you, your excellency, it’s a great honor to have you with us today. And now it’s my honor to introduce Dr. Karen Cox, family physician working in palliative care in Trinidad and Tobago. She is a member of Carib Pulka and the Palliative Care Society of Trinidad and Tobago. Dr. Karen, the floor is yours.
CARIPALCA, Dr. Karen Cox, Family Physician: It’s an honor to be here on this platform today, representing the Caribbean Palliative Care Association next line. So who are we? Carib Pulka is a regional palliative care association, and we represent the people of the Caribbean community, and our mandate is to ensure that the people of our region experiencing health related suffering have a voice. We exist to promote palliative care development, education and to advocate for palliative care on national, regional and global platforms like this. So the W.H.O. Public Health Strategy for Palliative Care acknowledges that medicine availability is a key component, and our advocacy today centers around that access to medicines, specifically access to control, essential medicines. And what do we mean by essential medicines? These are medicines that satisfy the priority health needs of a population and for our patients dying of cancer and other illnesses, the priority need is pain relief and relief of suffering. The WHO identifies three key players three drugs: codeine, fentanyl patches, and morphine as the main essential opioids. We’re focusing particularly on morphine today, as it’s a global strong opioid of choice for cancer pain relief. So the unavailability or inaccessibility of essential medicines results in health related suffering, and this is what suffering looks like or can sound like. And it means the patient experiencing unrelenting distress suffers is suffering on the side of the relative who bears witness to this and often the family. Sorry, the health professional, if he has no access to drugs to relieve this distress also suffers slide. So recognizing the importance of these essential drugs in our region, we did a quick survey of practitioners on the ground in six Caribbean territories asking: What’s out there? What do you have access to? And we found that there were several worrying findings.
Three of the six countries had no access to immediate release of morphine. And to highlight this, this is quick acting morphine. This is the gold standard for severe acute pain. So this is an untenable situation. Many of the countries reported frequent stock outs of various formulations, restricted formulations so really difficult to treat doses when you only have one strength, scarce alternatives, often at a cost. And if you’re a patient in the community from a central dispensing hospital, challenge in accessing these medicines, particularly in an emergency or after hours. And they were quite wide disparities among the countries we looked at. Jamaica seemed to fare perhaps the best and Dr. Spence will speak to that later. At the other end of the spectrum we had Guyana was really poor formulary availability. If you have only injectable morphine and slow release morphine, what that can look like is either you have to take yourself to a hospital as a patient in pain to receive an injection or the difference between slow release and quick acting is you wait 90 minutes for pain relief as opposed to 50 minutes. And that is unacceptable when oral morphine is quick and effective and cheap. Some countries had more stringent regulations in terms of who could prescribe and where the drugs are available, and then the repeated issue of stock outs in these Trinidad and Tobago.
There were multiple barriers. These are some that that my colleagues identified, a main one was the feeling that palliative care did not feature on the government agenda. It’s not a priority. Five of the six countries had no national palliative care policy, and so political will to ensure the necessary frameworks were lacking. The frequent stock outs make us think that there’s inadequate, inaccurate story forecasting of our estimates. And we recognize that these are drugs of abuse and diversion potential. But if regulations are so stringent that a patient in pain cannot get relief, then something needs to change. Morphine is an old and cheap drug. So the low profit margins for private pharma make it unattractive? And that’s another challenge. And the last to really speak to the need for ongoing education profession. Health professionals receive very little training around prescribing and managing opioids, and stigma persists not only among the layperson but also among health professionals and colleagues. So a lot of work is needed to change this.
So in summary, there’s still really poor access in some areas of the Caribbean. And if we accept that pain relief as a basic human right, then I think we have a responsibility, a moral responsibility to change the situation. Thank you. I would like to hand you over now to my colleague Salim. India is a palliative care nurse trained at some Christopher’s hospice in the UK, and she is currently the lead palliative care nurse and Beacon Foundation in Guyana.
Beacon Hospice Foundation, Bibi Salim, Head Nurse: Greetings from Guyana. I will attempt to shed some light on the availability and accessibility of the opioids in Guyana. I would like to give a little background of our country. We are the only English speaking country in South America. And as such, we became one of the founding members of the Caribbean community. Ghana is large, its 83,000 square miles, and it is divided into 10 administrative regions. So the Beacon Foundation, which is a non-governmental charitable organization that offers domiciliary palliative care to cancer patients in Ghana. We are only able to service five of these administrative regions, and this is all due to the fact that the other areas are very difficult to access. So straight away, you can see that there is the accessibility to these areas of make it difficult for these patients to have the kind of treatment they really need.
The opioids that are available on the Ghana drug formulary are tablets, morphine charged milligrams that is they sole release. Also, the 10 mg we have tramadol tabs, codeine, and liquid morphine, which is only available in the private hospitals. We have injection [missing], morphine 10 and 15, and the injection fentanyl, which is also only available at the major hospital. The Beacon Foundation, which gets most all of its opioids from the government, can only access the tabs of morphine whenever it’s available, which we will show a little later has been stopped a few times. The tabs of morphine or the more codeine, tramadol and morphine injection are better than injection. Those are what we have to work with. So the drugs that are issued to the beacon population will give you an indication between 2018 and 2021 what we had to deal with. We would have made requisition one hundred and thirty nine times, of 80 of those, which is 58 percent of the times we would have ordered. We did not. We only received the opioids of the 80 times that we receive, 16 or 20 percent of those times., the request amount was not received and 50 percent of the times we received, we were stocked out.
So straight away, you can see our patients are going to go to a lot of suffering because they can’t access the most important medication. No, the barriers to all of this is the quantification number is not accurate to usage, which means that the number, the amount that is being ordered by the Manager Materials Management Unit of the Ministry of Health is not accurate. So the amount of medication that is actually being used in the system not only for palliative care but for all other services. There is also the over utilization of opioid in the departments such as surgery, especially the post-op areas where most of the surgeons now prefer to use the morphine rather than using the other painkillers that can actually work and leave the opioids for patients who have cancer. There is also the inaccessibility to remote areas. If you would have looked at the map of Ghana, you will see that we have with administrative regions like region one. That’s right at the tip of Ghana. Those are mountainous area region seven, region eight. Those areas are very difficult for us to service. We service regions two, three, four, five, six and 10, which is easily accessible to us because we can drive and get there. But the other areas you either go by boat or you have to go by plane, which because we are an NGO means it’s impossible for us to access those areas. The unavailability of the primary health care facilities as the health centers in the health post, and we convene as an NGO, so we are not included in the Ministry of Health budget.
So, I would like to introduce Miss Verna Edwards, who is the scientific officer of the Ministry of Public Health and Wellness in Jamaica.
DPharm, Verna Edwards: Greetings, everyone. I will be presenting on challenges of opiate availability in Jamaica. My objectives include introduction to the island of Jamaica, barriers to access and availability of opioids, our legislation and regulatory framework, and then I will conclude.
Jamaica is an English speaking island in the Caribbean. We have a population of approximately three million people and we have four health regions with 24 public hospitals and one university hospital. So what is unique about Jamaica? In June 2008, two representatives from Jamaica, Dr. Linda Spence of the Hope Institute Hospital and Verna Edwards from the Ministry of Health and Wellness were awarded an International Pain Policy Fellowship by the University of Wisconsin. The focus of the fellowship was to improve availability and accessibility of opioids in Jamaica. So prior to us starting the fellowship, we did a survey and we identified several barriers to access and availability of opioids. Some of the barriers we identified were availability of stock, appropriate use of opioids for the management of cancer pain. Should the drug be used as needed? Or should we be prescribing a drug that, if patient takes it around the clock? A common cultural misperception about the use of opioids that these drugs were dangerous? Use of opioids relating to death are dying, and we saw where persons would be afraid of actually taking the drug–just denying themself the care they need to relieve the pain. We also saw the need for training of healthcare providers.
I’ve listed [on slides] all the opioids we have in Jamaica. We have codeine injection and sirup. We have morphine in all presentations. We have powder tablets. Immediate release and long acting. We have the morphine injection. We have fentanyl patch. And we also have fentanyl injection, which has been very useful in surgery. Along with palliative care, we have stated in which we are using less of and we have oxycodone, which was actually added during our fellowship. So you can see from this slide that since we completed a fellowship in 2012, we have been able to maintain good stock levels of morphine in Jamaica. However, during the COVID experience over the last two years, we have been having challenges with our immediate release tablets. So what we have been doing is we have been using the powder to make the sirup and this is made in the public sector hospitals where we we make the sirup so that doctors can prescribe the immediate release.
So I am a regulator in the Ministry of Health and Wellness, and I was in the position for over 10 years. So the Ministry of Health and Wellness Standards and Regulation Division is responsible for regulating the importation, storage and distribution of controlled substances, including including opioids, to various legislations. So we have the Food and Drug Act and regulations, and it does speak to controlled drugs and under the act we register drugs. We have the Dangerous Drug Act and so we have several legislation. So the framework speaks to authorization of our health professional doctors and pharmacies. We have permits. We have our covered prescriptions, [missing], and we do our submission of annual estimates.
So in conclusion, what has the fellowship done for Jamaica? We have been able to improve the knowledge and awareness of and use of opioids to relieve pain and suffering of our people in Jamaica. Straightening out the legislations and health system to improve access and availability of opioids, and we proposed the development of a regional pain management policy. In closing, thank you for listening, and we leave with the code: somewhere along the way, we must learn that there’s nothing greater than to do something for others. Thank you.
We will now move to introduce our patient. We will now show a video of a patient experience, Ms. [sic] Lawrence is a woman in her early 50s and works as a secretary in a government agency. In late 2021, she was diagnosed with pancreatic cancer and is currently being treated at the Hoop Institute Hospital in Jamaica. We now present this video. Thank you.
Ms. Laurence, Patient (video): Last year, I was diagnosed with pancreatic cancer. I was treated and now treated at the Hope Institution. .. I can’t tell you, it was terrible. The pain was bad, I couldn’t stand, I couldn’t sit, it was terrible. What Hope does is help me address the pain, with a tablet and patch, but it’s not effective like the tablet or liquid. With the morphine, you can get an effect in less than 5 minutes and don’t feel the pain anymore. So, I prefer the morphine more than the patch, even if the patch is still useful. Now, I can stand up, I can sit, and when the pain starts I just take the morphine. The morphine, it just gives me relief, it just gives me hope.
Again, the patch, I don’t know how much it helps. But the morphine–and just the morphine–it helps so much.
CARIPALCA, Dr. Dingle Spence, President:: So, I’m Dingle Spence and I’ve been introduced already, and I want to continue to talk about the disparities in access to opioids and offer some potential solution to the situation that we’re facing. So my objectives to give you another brief introduction to the disparities to opioid access in the region, and then to continue to talk about an initiative that has worked in Jamaica, and then to offer two potential solutions to help move member states forward with concrete action.
So here we are in the Caribbean again: and we’ve seen this map a couple of times today. We have a large population of 44 million, six million English speaking people. And as you can see, we do have the Caribbean community otherwise known as CARICOM, the members of which you can see on the right of the slide. So this graph is really why we’re here today. This is looking at their morphine consumption in the Pan American Health Region region of the Americas, including the Caribbean, and that Green Line that you can see is what we call the global mean The global mean is 4.6 milligrams per person of morphine consumption. And if you look carefully, you will see in fact, only one country in in the CARICOM region actually touches the global mean. Everybody else is very, very, very far below, including countries in South America, Central America and certainly pretty much all of us in the Caribbean region. So that is really a desperate situation, and it means that there’s an awful lot of people suffering out there in pain and distress.
So I wanted to share again and continue on from my colleague, Mrs. Edward’s talk about how we manage to improve access and availability of morphine in Jamaica. And if a two second story, I came home to Jamaica here and in end of 2002, and by the beginning of 2003, I had used all of the morphine in Jamaica by prescribing it correctly as I had been trained. I then met Mrs. Edwards at the Ministry of Health and we we made an emergency order to the International Narcotics Control Board, and we were able to bring more medicine into the country. We then were very fortunate to embark on the fellowship that you have heard, and we are so proud to be able to increase medicine access in our country. So how did we do that? Well, you have heard from Verna about the regulatory framework and the policies that are required to govern the distribution and accessibility of these medicines. That, of course, has been mentioned before the medicine, availability and education piece, but cannot be separated. So we actually embarked on a very intensive education campaign. We went through all 24 public hospitals in the island. We interviewed people we gave talks to a wide range of health care practitioners. And partly also what was successful is that we were able to bring to the table a wide range of people like policy makers, pharmacy practitioners, and sometimes in fact, users as well, to do education and training. We were able to develop a chart that was put on hospital ward walls so that people could have a quick reference. So we can’t do without education, obviously.
Then we were very proud also to be able to increase the availability of medicines. We found a cheaper source of powder; as you heard that powder is used and compounded into the liquid on the bench, but not all the public pharmacies can do that. So we were then also able to bring in supplies of immediate release morphine tablets both in public and private sectors, so that there were no difficulties in having to compound the power on the bench into the sirup. And although we still have issues with distribution in our more rural sectors, in the central part, we do now have access to these medicines, although, as we have said, covid has made it difficult in recent years.
So what can we do as a region to enable change? I want to speak to the implementation side. How do we actually do it on the ground? So we already have regional groups, we have CARICOM, we have the public health agency that you’ve heard about today, and we of course, have our regional academic institution that many of our islands, the University of the West Indies. So I’m going to offer a couple of solutions. I think the model of the pain policy scholarship that myself and Bernie Edwards went through and you can have seen from the graph the changes we were able to put in place. This is an excellent model, and I think that we can translate our own equivalent into the Caribbean. We have many small island developing nations, and we’re likely to need an individual approach to help support each island in its own efforts. I think one of the most important things is to enable real change on the ground, and this means bringing people together around the table. COVID has taught us that we can do an awful lot in the virtual arena. What we need to do is help individual countries formulate their action plan and support them as they move through in the way that we did here, and I have no doubt that that can bring success. And then, of course, we have the Pan-American Health Organization Strategic Fund, which is a regional mechanism for pooled procurement of essential medicines. As has been said already, morphine is inexpensive, it is generic and also has been mentioned that there’s very little interest from private sector to be bringing these things into the country. So is there a way that we can work together in the region using the connections we already have building on those? I think one of the things that the strategic fund offers is the five pillars that you see there: technical cooperation, which is what we’re talking about pooled procurement, building capacity, quality assurance of the medicines that are being dispensed and provided, and there are innovative financing mechanisms available as well. So to me, if we have a fellowship policy approach which brings people to the table who are actual end users, people who are working on the ground, bring the region together in a way that we can access these these things, we shouldn’t just see them on a slide: this is real. We can do this! We already accessed HPV vaccination. We access antiretrovirals in this way. So why can we not access these essential medicines that we need for managing pain and suffering?
I’m just going to finish with showing you these pictures. The Caribbean Palliative Care Association came into being in 2016, but we started with a very important meeting in Jamaica in 2015, and I want to just introduce the people on the left hand side as this will segue into the closing remarks. So they’re on that on the right of that picture. Kim Cleary, who was in fact the mentor to myself and Ben Edwards in the Pain Policy Fellowship and I believe is on the call with us today. Thank you, Jim, for all the support you have given us. Next to him is Dr. Fenton Ferguson, who is the minister of Health at the time and was very supportive of our initiative. Then we have Liliana de Lima, the executive director of the International Association of Hospice and Palliative Care, who has been a friend and colleague and fervent supporter of all we do globally and also in particular in the region. And then on her to her right is Professor St. George Alleyne, who I would now like to formally introduce to give the closing remarks. Prof, what can I say? Professor is and actually an old old old family friend; probably knew me when I was in utero. He is the director emeritus of [missing], he’s a Barbadian national, he’s a graduate of the University of the West Indies. And if I was to go through his CV, that would take up the rest of the webinar. So I’m going to now hand over to George to give us the closing remarks. Thank you.
Pan American Health Organization, Sir George Alleyne, Director Emeritus: Thank you very much for having me along with you. As you say, 2015 is a long way. And in some ways it has been a productive ride. I want to congratulate Dr. Spence actually being one of the leading lights in this area and galvanizing people to act. We have heard the ambassador give a tour de force and setting out the international problems that attend a lack of appropriate opioid use in the world as a whole and of the Caribbean, both the political technical aspects of it, and we heard from participants about the many problems that occurred. We heard a so very touching video from a patient attesting to the value of pain relief. And we’ve heard a repetition of the barriers that occurred. And then when Dingle first asked me to participate and also reflect on what I’ve heard this morning, I reflected on the nature and the possible solution to the problem. I think all of us are ready to do implement some of the solutions to the problem. I think one of the first things that struck me in 2015 and through the last seven years has been accentuated is the whole idea of the inequity, even in the Caribbean, as gross inequity in the availability of painkilling pain relieving of painkilling drugs. And one conclusion that I’ve come is that the availability of these drugs and the attention to the relieving suffering, health related suffering. This should be one of the indicators of the efficient functioning of any health system. And I think when we speak about the strength of the health systems, we have to introduce this as one of the indicators of how a health system really functions: if the system functions to the benefit of the population it serves, then we should see this as one of the indicators of the efficiency and effectiveness of that system. It’s not only inequity in other areas, but inequity in this particular area, I think should be one of the indicators of the efficiency of a good health system.
In one of the other areas that has worried me, and I have heard echoes of this atmosphere, is a conflation of the problem in the Caribbean and unavailability of all opioids with the problem of the United States, the overuse of opioids, I have found sometimes in discussion that these two things tend to get conflated and we must resist that as vigorously, vigorously as we can. It can be a problem. There may be people in the Caribbean who use opioids unnecessarily, but that is not the problem. The problem is the lack of availability and the inequity in the utilization of these drugs. One of the other areas that has concerned me and is concern over the years and more increasingly now is this view in the Caribbean and various places, there is some value in redemptive suffering. There’s some value to suffering–that people should suffer. It is a mark of character. It is a marker of some deeper spiritual value, as it were, is that you should suffer. And in the final analysis, you would believe of your suffering in the hereafter. This idea of redemptive suffering and somehow that we’ve got to [suffer] in various places. I speak not only of the technical education institutions, but also in religious institutions that there is no value in redemptive suffering. So there is no need of people to suffer in there at various times in their lives.
The other thing that has always struck me is almost the equation of palliative care with terminal care. There are other places in the care spectrum along which you would need to have pain relief, pain relief. So the idea that it’s only at the end of life, only in terminal illness that you need attention for care. The other thing that has struck me is the fear among the medical profession. Some fear of overuse. Some fear that patients may become addicted to drugs. You have an 80 year old gentleman or 80 year old lady with pancreatic cancer. And you fear that that person might become addicted to drugs. So therefore that person continues to suffer now, or what can be done? I think this morning seminar has shed a ray of light on the possibilities of addressing this issue. What is this shown? There is a small dedicated band of individuals who are committed to addressing this problem. And I heard in the voice of the ambassador the conviction that at her level there is something that she can do also to address this problem. So in the light of this seeking this committed band of individuals, let me argue for the search for what I call political entrepreneurs, what to call a champion. It would be good in the presentation of this, for the person to have the power to change the ideation of those in power. It will be good to seek out and have some champions commit to putting forward this cause in various locations.
So is there some light? I say yes, there is light in that. There is this committed group, a group of people [through which] there has been progress. There has been a concerted and effective action as there have been some progress. Yes, in the sense that there are more people at various levels who are aware of the problem, but there’s still a lot to be done. But I have a comfort from the words of Margaret Mead, who said never doubt that a small group of individuals cannot change the world. Indeed, as she went on to say, it is the only thing that ever has changed the world. This concerted action of a small group of committed individuals. So once again, congratulations for pointing out the problem. Congratulations for showing that there are solutions to the problem. And congratulations or the commitment of this small group of people advancing the cause. Thank you very much, Dingle.
CARIPALCA, Dr. Dingle Spence, President:: Thank you very much for joining us today, George. Over to you, Katherine.
IAHPC, Dr. Katherine Pettus, Moderator: Thank you. Dingle, just to ask a question and put you on the spot: one of the big concerns at the CND is the issue of diversion and misuse. And so how does Jamaica, and the way that you’ve been able to increase access, handle preventing diversion and misuse?
CARIPALCA, Dr. Dingle Spence, President:: Well as you have heard, we obviously do have more morphine in the system now. But I think what we actually have very little diversion and abuse in Jamaica, and I think we have a very tight regulatory framework thanks to the standards and regulations division in our ministry, and those have been strengthened over the years. So as better pointed out, only original prescriptions can be filled. I believe there is now a network between the pharmacies that dispense controlled medicines, that they’re aware that when a prescription is filled so that people cannot go to multiple pharmacies with multiple prescriptions. We’re also very fortunate that culturally it’s not really an issue. We have other drug issues, but addiction to painkillers or diversion of painkillers in our particular cultural setting, fortunately, is not a huge issue. But I will say again, the regulatory framework in the country is what keeps things safe. Thank you.
IAHPC, Dr. Katherine Pettus, Moderator: Thank you, and so then you could recommend that as a model to other countries?
CARIPALCA, Dr. Dingle Spence, President:: Absolutely, and that’s what we’re talking about with the Fellowship that helps us look at what we have on the ground and changing things, if necessary.
IAHPC, Dr. Katherine Pettus, Moderator: Well, we’re at our hour and thanks to the Waltham Center for hosting this, for the platform to the Vienna NGO Committee on Drugs for Co-hosting and the U.N. Office of Drugs and Crime and to Carib Pulka and all the wonderful speakers to Your Excellency, Ambassador Spencer and to everybody. So thank you and we’ve got a lot of work to do, but we’ve been talking about that. It seemed eons and ongoing steps to make this all happened. So have a wonderful rest of the day