Introduction for special issue on pain in developing countries

Abstract

The “developing country” categorization has become common in academic settings. There exist, however, several nuances behind these 2 words. There are several ways to classify countries. An exclusively economic classification used by theWorld Bank ranks countries as high, upper-middle, lower-middle, and low-income states. This income-based classification is frequently used to differentiate countries of high from low-to-medium income. Differently, the term “developing country” usually refers not only to a state with developed economy and infrastructure, but also takes into account political stability, gross domestic product, freedom, and a high human developing index (HDI). Human developing index is based on life expectancy, education availability, and access to health care. Human developing index ranges from0 to 1. Indeed,HDI below0.8 is customarily used as an operational definition of developing country. There are more than 120 countries currently classified under the developing country umbrella, including nations with large populations such as China, India, and Brazil. In fact, 4 out of 5 of the 7.7 billion human beings alive today are born, age, and become sick in developing countries. In a way, given these figures, pain occurring in developing countries is the rule rather than the exception in the world. In the present special issue, Sá et al. reported the first metaanalysis of chronic pain prevalence studies from developing countries. Reports from Latin America (n 5 5), Asia (n 5 5), and Africa (n5 2) were included. After adjustment for publication bias, the total prevalence of chronic pain in these regions was estimated tobe18%, similar to previous publications fromdeveloped nations. Interestingly, the authors found a significant effect of the definition of chronic pain used in each of these studies on their final reported prevalence. They also found an effect of the year of publication, where later studies had lower chronic pain prevalence rates compared with those published before 2010. Prevalence of pain was also the subject of Machado et al.’s study. Based on a large multicenter cohort of 15,000 civil servants, the authors reported persistent pain to occur in 62.4% of their sample, being correlated with older age, female sex, excessive drinking, and mood symptoms, among other factors. These data provide insights into the burden of pain in both employed and retired individuals in developing countries and its associated factors. When it comes to pain relief, developing countries lag behind not only in low access to health care, but also in access to education. Both patient and health care provider education are commonly suboptimal in these regions. Despite the fact that the largest proportion of the world population experiencing pain live in developing countries, health care professionals from these areas have faced several challenges when striving for education. This has been mitigated by several initiatives, such as scholarships to attend congresses, free online educational resources, and low/no subscription fees for professionals from these areas to attend international meetings. However, work remains to be performed. Of nearly 6,000 International Association for the Study of Pain members in 2019, affiliates issuing from developing countries were in the minority: Africa, Latin America, and Middle East (regions mainly composed by developing countries) represented 12% of the Association’s members. Similar figures occur in special interest groups, where the proportion of associates from these areas may be below 10% of the total number of members. This proportion discrepancy is also reflected in instances where specific technical or academic credentials are prerequisites to participate, such as for the involvement in international consensuses, task forces, and board activities. In these instances, participation of members from developing countries may range from rare to absent. This could lead to a self-fulfilling prophecy where low income leads to low education and low access to good health care from the patient’s side. From the provider’s end, low access to good quality health care education and research leads to lower representation in high-level scientific and academic settings, which may lead to lower attention to regional particularities by global players and policy makers. A pragmatic way to start change is to look at one’s current medical research environment in a critical way and identify areas that need prioritization. This can be performed in several different ways, one of them being the use of systematic scoping reviews, such as the one reported here by Sharma et al. Their systematic scoping review covered the state of clinical pain research in Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. a Department of Neurology, Pain Center, LIM-62, University of São Paulo, São Paulo, Brazil, b Department of Oncology, Pain Center, Instituto doCâncer do Estado de São Paulo Octavio Frias de Oliveira, São Paulo, Brazil