Chronic Pain in Maputo, Mozambique: New Insights

bs_bs_banner Pain Medicine 2013; 14: 551–553 Wiley Periodicals, Inc. Chronic Pain in Maputo, Mozambique: New Insights pme_1429 551..553 Historical data regarding the African continent have remained obscure to the rest of the world for a long period of time. We may state that Africa is much more than a single country and much less than the more than 50 territorial entities divided by artificial frontiers imposed by Europe [1]. Mozambique is a country on the East coast of Austral Africa that has been experiencing profound changes over the last 50 years. It achieved its independence from Portugal in 1975 after a prolonged and bloody war and then had a civil war between the socialist government (Frelimo) and the opposition (RENAMO). These were the last decades in Mozambique: a poor country struggling for social, political, and economic stabilization [2,3]. The estimated population in Mozambique is 20,069.738 million and Maputo is its main city. Regarding the social indicators, the rate of illiteracy is about 50.4%. The life expectancy of a Mozambican is 49.4 years [2]. The prevalence of HIV/AIDS in the Maputo region is about 13.0% [4]. Regarding religion, 28.4% of the population declares itself Catholic, 17.9% Muslim, 10.9% Protestant and Evangelical, and 2.1% animist. Even with the expansion of the Christian and Islamic influence, the bases of society are estimated to be anchored on traditional animist religion [2,3]. The Pain Unit of the Central Hospital of Maputo The Pain Unit of the Central Hospital of Maputo was implanted in 1996 with the help of a French nongovernmental organization (NGO) with humanitarian objectives called “Douleur sans Frontières”, created in 1996 by French doctors based on other NGOs such as Médicins Du Monde and Médicins sans Frontières, in order to export knowledge about pain to underprivileged world locations. This NGO acts on different fronts, such as Cambodia, Haiti, and Africa, sponsoring Units for the Treatment of Pain. In 2003, it was recognized as a public utility entity by the Conseil D’Etat Français [5,6]. harmony in social relations or with one’s relatives, ancestors, or deities. The figure of the healer symbolizes the treatment of these ills by means of herbs, prayers, or sacrifices. The spectrum of the activities of traditional doctors involves a diagnosis (divination) and treatment (with mixtures of plant products, skin cuts at points considered vulnerable called scarifications, or expulsion of spirits) [7–9]. Today, traditional doctors have a Department of the Health Ministry for Traditional Medicine activities. They are represented by the Association of Traditional Doctors of Mozambique (AMETRAMO). Objectives The objective of the present study was to describe and analyze the epidemiological, emotional aspects, and the religious practices of patients with chronic pain treated at the Pain Unit of the Central Hospital of Maputo, Mozambique. Methods A cross-sectional descriptive study was conducted by the Pain Unit of the Central Hospital of Maputo, Mozambique, and University of São Paulo, Brazil. During a period of 2 months (2010-11), all patients attending ambulatory visits at the Pain Unit of the Central Hospital of Maputo were interviewed. We selected patients older than 18 years with the presence of chronic pain according to IASP criteria [10], who gave written informed consent to participate. A questionnaire regarding gender, ethnic group, religion, diagnosis and intensity of pain, and traditional and alternative treatments was applied. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria were used to define depression and anxiety. Data were entered and analyzed using SPSS by the Department of Statistics of the School of Medicine of Ribeirao Preto University of São Paulo. The study was approved by the National Bioethics Committee for Health of Mozambique and subjects were identified only by number. Results Health, Disease, and Traditional Medicine in Mozambique In Mozambique, the predominant system of interpretation of misfortune, health, and disease in the population of Mozambique involves an association with the traditional religions of the region, which influences the moral values and conducts of society. Physical ills may represent dis- A total of 123 patients were interviewed over a period of 2 months and 118 were included. Of these, 79 (66.9%) were women and 39 (33.1%) were men. The mean age was 52.4 years, with a standard deviation of 13.7. One hundred and seven patients (90.7%) were black and 11 (9.3%) white and Asian. Thirty-six (30.5%) had up to 4 years of schooling. 551 Downloaded from https://academic.oup.com/painmedicine/article-abstract/14/4/551/1825549 by guest on 23 May 2020 Introduction Ferreira et al. Regarding the religious aspects, 30 (25.4%) patients were Catholic, 35 (29.7%) were Evangelical, 10 (8.5%) were Muslims, 3 (2.5%) practiced traditional religions, and 40 (33.9%) were atheist or had other religion. In addition to their treatment at the Pain Unit, 58 patients (49.2%) also received some type of treatment from local healers. These treatments were based on scarification (cuts in the skin) (44—37.3%) and on phytotherapy based on medicinal herbs (17—14.4%). Discussion The epidemiological data obtained seem to agree with the data from previously published studies for patients with chronic pain, with a predominance among women and a prevalence in the mean age range of 52 years. The main types of pain corresponded to osteomuscular and neuropathic pain, with emphasis on back pain, also in agreement with previous studies [11–13]. The prevalence of HIV/AIDS was within the expected rates for this region (13.6%), according to Barreto [4]. Despite the low prevalence of traditional/animist religions observed in the interviews, 49.2% of the patients seek alternative treatments with healers/traditional religions. These data appear to be correlated with the vision of health-disease-cure of the Mozambique population. According to this holistic perspective, it is not enough to treat the disease to cure the patient. It is necessary to re-establish the social equilibrium, including harmony with one’s ancestors. Thus, disease is not the opposite of health. We frequently think that the population of Mozambique looks for healers due to an insufficient number of doctors, or due to lack of family money. However, treatment with a “nyanga” (healer) may be as expensive as that with a doctor, or even more expensive. On this basis, we cannot consider a healer to be a doctor “for the poor” or for classes of a lower intellectual level [7]. On the other hand, the prevalence of depressive disorders is below the expected level for patients with chronic pain (33.1%) [14]. Maruta detected a 55% prevalence of depressive disorders in patients with chronic pain [15]. We do not know for sure if the impact of a chronic disease may be lower in this population or if these people are simply more likely to “numb” their feelings. In this case, we 552 may explain these results based on the cultural aspects involved. Religions function socially as a set of beliefs and practices that guide a group philosophically, justifying the causes of misfortune and re-establishing the hope for a resolution of problems. Thus, they weave their relation with the painful phenomenon either by justifying suffering or by relieving the anguish related to the latter [5]. Rites and ceremonies of passage are present in tribal or traditional societies, with more symbolic force than in modern capitalist societies. This may perhaps be the reality for some African societies [16]. A study of the subjective aspects of pain conducted in sub-Saharan Africa demonstrated, on the basis of the perception of the nurses involved in the treatment of pain, that “African men tend to express less their pain verbally, perhaps because they believe that this is an act of weakness.” “Suffering in silence” seems to be encouraged as a synonym of strength [17]. Perhaps, this is the great contrast with the American, capitalist, culture, in which the role of disease and loss has another connotation. Characteristics such as low tolerance of frustration, low pain threshold, and abuse of analgesics are frequent. This type of more hedonistic vision linked to man and to his ability to solve all physical problems (man as an infallible being) determines his relation with suffering and pain in a very peculiar manner. Therefore, as pain has a cultural basis, it is necessary to contextualize all those involved in this process, acting in a social reality, weaving the web of relations that cause pain to be an experience with a meaning to be sought [16]. KAREN FERREIRA, MD* MARIA TERESA SCHWALBACH, MD† JOÃO SCHWALBACH, MD† JOSE SPECIALI, PhD* *Department of Neurosciences and of Behaviour Sciences, Division of Neurology, University of São Paulo, Ribeirao Preto, São Paulo, Brazil † Pain Unit, Central Hospital of Maputo, Maputo, Mozambique References 1 Mazrui A, Wondji C. General History of Africa: Africa since 1935. Paris: UNESCO; 2010. 2 Fry P. Mozambique: Ensaios. Rio de Janeiro: Ed UFRJ; 2001. 3 Mozambique National Institute of Statistics. Data census. 2007. Available at: http://www. portaldogoverno.gov.mz (accessed July 10, 2011). 4 Barreto A. Impacto Demográfico do HIV/SIDA em Mozambique. Maputo: UEM; 2002. 5 Schwalbach T. Archives of Pain Unit of the Central Hospital of Maputo, Mozambique. 2009. Downloaded from https://academic.oup.com/painmedicine/article-abstract/14/4/551/1825549 by guest on 23 May 2020 Forty patients (33.9%) had a diagnosis of osteomuscular pain, 40 (33.9%) had neuropathic pain, 17 (14.4%) had oncologic pain, 16 (13.6%) had pain related to HIV/AIDS, and 5 (5.9%) had other kind of pain, like visceral and myofascial pain. Thirty-nine (33.1%) patients had back pain, including radicular (lumbar disc herniation and degenerative disc disease) and mechanical pain (muscle spasm). Mean visual analog scale before treatment was 8.37, and after treatment at Pain Unit was 4.75. 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