The Pan American Health Organization: Its Structure and Role in the Development of a Palliative Care Program for Latin America and the Caribbean

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1 440 Journal of Pain and Symptom Management Vol. 20 No. 6 December 2000 Special Article The Pan American Health Organization: Its Structure and Role in the Development of a Palliative Care Program for Latin America and the Caribbean Liliana De Lima, MS and Eduardo Bruera, MD WHO Collaborating Center in Supportive Care (L.D.L.) and Department of Symptom Control and Palliative Care (E.B.), University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA Abstract In recent years palliative care has emerged as a major public health care issue, both in developed and developing countries. The rising number of cancer deaths as a result of increased tobacco consumption, control of other diseases, lack of preventive programs, and the difficulties of accessing curative treatments in many countries have made palliative care and pain relief the appropriate, and in many cases, the only option for patients with advanced disease. The World Health Organization (WHO) and its Regional Office for the Americas, the Pan American Health Organization (PAHO), have promoted palliative care as a component of their cancer control program. Some health care workers and policy makers are not adequately informed about the role that intergovernmental agencies such as WHO and PAHO play in the health care field. This has led to confusion and, in some cases, misjudgment of the organization. This paper summarizes the structure and role of PAHO and, specifically, its participation in the development of a palliative care program for Latin America and the Caribbean. Many health care professionals, administrators, and policy makers are unaware of the organization s objectives in this area and the tools available to assist in the implementation and development of national programs to care for patients with advanced cancer. The information in this paper is based on data found in the PAHO and WHO web sites, as well as other technical publications from different sources, including individuals not formally associated with WHO or PAHO. J Pain Symptom Manage 2000;20: U.S. Cancer Pain Relief Committee, Key Words World Health Organization, Pan American Health Organization, cancer, cancer pain, palliative care, Latin America, collaborating centers Address reprint requests to: Liliana De Lima, MS, WHO/PAHO Liaison in Supportive Care, M.D. Anderson Cancer Center, 1500 Holcombe Blvd., Box 108, Houston, TX 77030, USA. Accepted for publication: December 21, Introduction Of the eight most common cancers worldwide, five are more prevalent in developing countries. One third of all cancers are preventable and another third are potentially curable, providing they are diagnosed or precursor lesions are treated early. 1 In 1985 there were 595,000 new cancer cases diagnosed in Latin U.S. Cancer Pain Relief Committee, /00/$ see front matter Published by Elsevier, New York, New York PII S (00)

2 Vol. 20 No. 6 December 2000 The PAHO and Palliative Care 441 America and the Caribbean. 2 However, very few resources are allocated in the Latin American and the Caribbean countries to health care. To a great extent the health status of the countries in the Region was the result of the economic and social adjustments adopted by the governments. 3 For over a decade the World Health Organization s (WHO) Global Cancer Control Program has emphasized the following priorities: cancer prevention, cancer detection linked with effective treatment, prevention, and palliative care. 4 Cancer prevention and particularly early detection are currently a major concern in the development of the cancer program in the Americas; however, palliative care has not been fully addressed yet. Recently, the Pan American Health Organization (PAHO) has incorporated a palliative care component in its Cancer Program for the Region. This article gives an overview of the origins of PAHO, discusses the role of WHO and PAHO in policy making in relation to palliative care and advanced cancer care, describes the role of WHO collaborating Centers, and provides general information about the Organization s structure. Origins of the Pan American Health Organization The Pan American Sanitary Bureau originated in a resolution of the Second International Conference of American States (Mexico, January 1902) that recommended that a general convention of representatives of the health organizations of the different American republics be convened. 5 That convention established a permanent directing council the International Sanitary Bureau which was the predecessor of the current Pan American Health Organization. In 1924, the Pan American Sanitary Code, signed in Havana and ratified by the governments of the 21 American Republics, assigned broader functions and responsibilities to the Bureau as the central coordinating agency for international health activities in the Americas. The XII Pan American Sanitary Conference (Caracas, 1947) adopted a reorganization plan whereby the Bureau became the executive agency of the Pan American Sanitary Organization, whose Constitution was officially approved by the Directing Council at its first meeting in Buenos Aires later that year. In 1949, the Pan American Sanitary Organization and the World Health Organization agreed that the Pan American Sanitary Bureau would serve as the Regional Office of the World Health Organization for the Americas. In 1950, the Pan American Sanitary Organization was recognized as a fully autonomous and specialized inter-american organization. Thus, the Organization became a component of both the United Nations and the inter-american systems. The XV Pan American Sanitary Conference (San Juan, Puerto Rico, 1958) changed the name of the Pan American Sanitary Organization to the Pan American Health Organization. The name of the Pan American Sanitary Bureau remained unchanged. Fundamental Purpose The fundamental purpose of PAHO is to promote and coordinate the efforts of the countries of the Region of the Americas to combat disease, lengthen life, and promote the physical and mental health of their people. Structure: Governing Bodies PAHO serves as the health specialized entity of the Organization of American States (OAS), and as the Regional Office for the Americas of the WHO. The headquarters are in Washington, DC, where the health authorities of PAHO s Member Governments meet to set the Organization s technical and administrative policies through its Governing Bodies. PAHO is an inter-governmental agency, responding to a governing body made up of official representatives of member governments. Table 1 summarizes the list of member governments. As an inter-governmental agency, PAHO differs greatly from the structure and function of Non Governmental Organizations (NGOs), such as National Cancer Leagues, the Union Internationale Contre le Cancer (UICC) and the International Association for the Study of Pain (IASP). The difference resides in the fact that while NGOs operate independently from national governments, PAHO can only act upon official request for cooperation from national governments and/or initiatives.

3 442 De Lima and Bruera Vol. 20 No. 6 December 2000 Antigua and Barbuda Argentina Bahamas Barbados Belize Bolivia Brazil Canada Chile Colombia Costa Rica Cuba Dominica Dominican Republic Ecuador El Salvador Grenada Guatemala Table 1 PAHO Member Governments Guyana Haiti Honduras Jamaica Mexico Nicaragua Panama Paraguay Peru Saint Kitts and Nevis Saint Lucia Saint Vincent and Grenadines Surinam Trinidad and Tobago United States of America Uruguay Venezuela The Organization s basic task is to collaborate with Ministries of Health, social security agencies, other government institutions, NGOs, universities, community groups, and many others to strengthen national and local health systems and to improve the health of the Americas. The Pan American Health Organization comprises the following: The Pan American Sanitary Conference the supreme governing body in which each Member Government is represented meets every four years, defines the Organization s general policies, serves as a forum on public health matters, and elects the Director of the Pan American Sanitary Bureau. From 1986 on, the Conference approved PAHO s strategic orientations and program priorities for the coming quadrennium. The Directing Council consisting of one representative of each Member Government meets once a year and acts on behalf of the Conference in years when that body does not meet. It reviews and approves the Organization s program and budget. The Executive Committee composed of representatives of nine Member Governments elected by the Conference or the Council for staggered three-year terms meets twice yearly to consider technical and administrative matters, including the program and budget, and submits its recommendations to the Conference or Council. The Subcommittee on Planning and Programming of the Executive Committee was reorganized in 1984 to enhance the participation of the governments in planning the Organization s activities. It is made up of delegates from seven countries, meets twice yearly, and reports directly to the Executive Committee. The Pan American Sanitary Bureau headed by the Director acts as the Executive Secretariat and carries out the directives of the Governing Bodies. Function In its efforts to improve health, PAHO targets the most vulnerable groups including mothers and children, workers, the poor, the elderly, and refugees and displaced persons. It also helps countries to work together toward common goals in health. Multi-country health ventures are now underway in Central America, the Caribbean, the Andean Region, and the Southern Cone. The Organization also executes projects in conjunction with other United Nations agencies, for international organizations such as the World Bank and Inter-American Development Bank, official development cooperation agencies of various governments, and philanthropic foundations. PAHO strengthens the health sector capacity in the countries to advance their priority programs through intersectoral action, promoting an integral approach to health problems. Budget The Organization has a biennial budget made up of quotas from Member Governments of the Pan American Health Organization, the World Health Organization allocation for the Regional Office of the Americas, and extra-budgetary funds. The Organization recognizes the role of the private for profit and non-profit sectors in the delivery of services, and fosters dialogue and partnerships between them and the Ministries of Health. In addition to its core budget financed by quota contributions from its Member Governments, PAHO also seeks outside funding to help implement special programs and initiatives in response to vital health needs. Voluntary tax-deductible contributions for PAHO health

4 Vol. 20 No. 6 December 2000 The PAHO and Palliative Care 443 and education projects in the Americas may be made to the Pan American Health Organization and Education Foundation (PAHEF). PAHO/WHO Country Offices PAHO has 27 country offices, which are responsible for identifying their priorities according to national needs and the allocation of resources to cover those needs. Table 2 summarizes the list of PAHO/WHO Country Offices. The Central Office in Washington, DC provides the technical support and assistance needed in order to meet those priorities. Because of this, local PAHO office involvement in palliative care varies greatly from country to country. PAHO has encouraged country officials to adopt palliative care as a component of their plan, taking into consideration the limited availability of resources. Division of Disease Prevention and Control (HCP) The Palliative Care Program is a component of the Cancer Control Initiative, which is part of the Non Communicable Diseases Program (HCN), within the Division of Disease Prevention and Control (HCP). The current structure of the Non-Communicable Disease Program within PAHO s organizational structure is summarized in Figure 1. The Division of Disease Prevention and Control promotes and supports the strengthening of national capabilities related to the development of technically feasible, economically viable, and socially acceptable programs for the prevention, control, elimination or eradication of communicable diseases, non-communicable diseases, zoonoses, and foot-and-mouth disease. Non-Communicable Diseases Program (HCN) In recognition of the predominance and increasing trend of non-communicable diseases among causes of morbidity and mortality throughout the Americas, 6 PAHO, early in 1995, established a technical cooperation program (HCN) within the Division of Disease Prevention and Control (HCP). The program places emphasis on technical capacity building, Table 2 PAHO/WHO Country Offices Argentina Bahamas (also directly serves Turks and Caicos Islands) Barbados Caribbean Program Coordination, also directly serves Antigua and Barbuda, Dominica, Grenada, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines; Eastern Caribbean: Anguilla, British Virgin Islands, Montserrat; French Antilles: Guadeloupe, Martinique, St. Martin and St. Bartholomew, French Guiana Belize Bolivia Brazil Chile Colombia Costa Rica Cuba Dominican Republic Ecuador El Salvador Guatemala Guyana Haiti Honduras Jamaica (also directly serves Bermuda and the Cayman Islands) Mexico Nicaragua Panama Paraguay Peru Suriname Trinidad and Tobago United States Mexico Border (Field Office in El Paso, Texas) Uruguay Venezuela (also directly serves Netherlands Antilles) including support for demonstration projects within countries, in the interest of integrating non-communicable disease prevention and control within the context of primary health care. Priorities The changes in the epidemiological profile experienced by a majority of the countries in the Americas requires an adaptation to new priorities that needs to be reflected in the organization of health services and the allocation of resources. In order to assist member countries in this transition, the program on non-communicable diseases has selected key priority areas that are likely to be effective and provide an opportunity to further incorporate strategies that will lead to the reduction of the burden of non-communicable diseases. The program strategy was approved by the 120th Meeting of the Executive Committee of the Directing

5 444 De Lima and Bruera Vol. 20 No. 6 December 2000 Fig. 1. Palliative Care Program within PAHO s Organizational Structure. Divisions: HCP, Disease Prevention and Control; HDP, Division of Health and Human Development; HEP, Division of Health and Environment; HPP, Division of Health Promotion and Protection; HSP, Division of Health Systems and Services Development; HVP, Division of Vaccines and Immunization; SHA, Special Programs for Health Programs. Programs and Special Centers: CAREC, Caribbean Epidemiology Center; INPPAZ, Pan American Institute for Food Protection and Zoonoses; HCA, AIDS program; HCN, Non Communicable Diseases Program; HCT, Communicable Diseases Program; HCV, Veterinary Public Health Program; PANAFTOSA, Pan American Foot and Mouth Disorder. Council. The priority areas and its main components are: 1. Cancer Initiative: National Cancer Control Programs, early detection, RED-PAC, palliative care, cervical cancer, breast cancer. 2. CARMEN: Reduction of non-communicable diseases, prevention of cardiovascular disease.

6 Vol. 20 No. 6 December 2000 The PAHO and Palliative Care Injuries: Prevention of unintentional injuries, intentional injuries, violence and health. 4. TIPS: Technological innovations in prevention and screening for non-communicable diseases, diabetes, hypertension, cervical cancer. Palliative Care The initial Palliative Care Program was promoted by the WHO office in Geneva as a critical component of the Cancer Control Program 7 during the 1980s. It was during this time that a strategy to manage cancer pain, known as the WHO Three Step Analgesic Ladder, was developed by a panel of experts and became recognized as an effective cancer pain treatment approach. This treatment, described in the publications Cancer Pain Relief 8 and Cancer Pain Relief and Palliative Care, 9 has been translated to different languages and widely disseminated throughout the world. Two new publications about palliative care by WHO are now available: Cancer Pain Relief and Palliative Care in Children 10 and Symptom Relief in Terminal Illness. 11 In 1997 PAHO incorporated Palliative Care and Cancer Pain Relief as a component of the Cancer Control Initiative for the Region. 12 Strategy PAHO provides information to assist countries in the adoption of a national policy that will bring about changes in legislation to incorporate palliative care and pain relief as a public health issue, ensuring the availability of appropriate drugs, especially analgesic opioids, 13 as well as a commitment from the Ministries of Health to allocate the necessary resources to implement decentralized palliative care programs. With the assistance of Collaborating Centers and liaison individuals, identification of the legal barriers that impede the adequate utilization of opioid analgesics has been carried out, by providing indepth analysis of the legislation in three different countries. 14,15,16 This analysis is based on the principles established by the Single Convention on Narcotic Drugs 17 and by criteria set by the WHO Cancer Pain Relief Program. 18 Additionally, the Pain and Policy Studies Group/WHO Collaborating Center in Policy & Communications in Cancer Care in Madison, Wisconsin, has monitored the utilization of analgesic opioids in the world and the Region. 19,20,21 The Organization promotes a regional network of groups working in palliative care, which include groups previously supported by WHO s Global Cancer Program, NGOs, public and private institutions, as well as lay organizations. Special efforts are being made to develop an interface between these groups and policy makers. Demonstration Projects One of PAHO s objectives in the Palliative Care Program is to develop field demonstration projects to evaluate cost-effective options for decentralized palliative care programs. These projects will be carried out in countries with the necessary conditions for drug availability and with a decentralized health care system. Three institutions will be selected in three different countries of the region according to the merits of their proposal and the fulfillment of these criteria: Availability of morphine and other opioid analgesics Evidence of the applicant s availability to provide, on its own or in partnership with others, clinical and supportive care needed by patients with advanced cancer and their families Demonstrated commitment of clinical and administrative staff to improve care of persons with cancer and their families, including the involvement of patients and families in determining the courses of treatment Matching support from the country The plan for communication with the community Support from the country s Ministry of Health The extent to which the proposed initiative will be used to leverage broader changes in the health care system and the community Education and Training PAHO trains health workers at all levels through fellowships, courses and seminars, and the strengthening of national training institutions. It leads in the use of advanced com-

7 446 De Lima and Bruera Vol. 20 No. 6 December 2000 munications technologies for information, health promotion, and education, working with journalists in many countries. PAHO has maintained the initial WHO efforts in promoting palliative care and cancer pain relief as a component of the cancer control program. It has done this through courses 22 and by disseminating information throughout country offices, such as the publication of Spanish guidelines on palliative care. 23 Collaborating Centers WHO Collaborating Centers are part of an interinstitutional collaborative network of centers established to provide technical cooperation by supporting the respective WHO Programs at the national, regional, and global levels. 24 The WHO designates as Collaborating Centers and as Regional Focal Points those entities and individuals that, due to their expertise and recognition in a specific area, may provide that technical support. Collaborating Centers are departments or laboratories within academic or research institutions which cooperate with specified Technical Programs according to mutually agreed-upon terms of reference. This agreement is usually for a period of four years. Consideration for renewal is made after submission of annual reports outlining the mutual activities achieved and upon approval by the Regional and Global Program Officers of a proposed plan of work for an additional four years. All WHO Collaborating Centers in the Region of the Americas are known as PAHO/WHO Collaborating Centers. WHO Collaborating Centers form interactive networks corresponding to the various WHO Programs, for implementing research policies and strategies aimed at achieving Health for All. Role of the WHO Collaborating Centers The functions of WHO Collaborating Centers include: training; data collection; dissemination of information; clinical, biological, or toxicological research; product development; development of appropriate technology (i.e., guidelines, manuals, procedures, methodologies, etc.); standardization of terminology, techniques, prophylactic, diagnostic, and therapeutic substances and materials; and provision of consultant services. The Collaborating Centers and Regional Focal Points act entirely as volunteer entities since their activities are not financed by PAHO, but from local sources, and most of the faculty and experts donate a significant portion of their time to the collaborative efforts. Role of the WHO Collaborating Centers in Palliative Care During the initial stages of the development of palliative care initiatives in the world, several Collaborating Centers, such as the WHO Collaborating Center for Palliative Cancer Care in Churchill Hospital in Oxford; the WHO Collaborating Center for Symptom Evaluation in Cancer Care in Madison, Wisconsin; the WHO Collaborating Center for Cancer Pain Research and Education in the Memorial Sloan-Kettering Cancer Center in New York; and the WHO Collaborating Center for Pain Relief at the National Cancer Institute in Milan, Italy, played and important role in the dissemination of the WHO Analgesic Ladder and palliative care recommendations. Recently, two more centers have also been designated as WHO collaborating centers in palliative and supportive care: The WHO Collaborating Center for Policy and Communications in Cancer Care, at the University of Wisconsin, in Madison, and the WHO Collaborating Center in Supportive Cancer Care at the University of Texas, MD Anderson Cancer Center in Houston. A brief description of the role of these WHO/ PAHO Collaborating Centers and addresses and individuals who act as focal points and liaisons for the Region are included in Appendix 1. Some of these collaborating centers have provided support in the Region by promoting a meeting, which has been taking place every two years since 1989, and has been successful in bringing together individuals from different countries. The next meeting will take place in San José, Costa Rica in March Meetings are structured in work groups and the goal is to empower palliative care workers to become agents of change, and to identify possible solutions to common problems. This has resulted in two publications that present diagnostic reports and progresses made in the availability of opioid therapy in Latin America. 25,26 Additionally, the Guidelines on Cancer Pain Management 27 published by the Agency for Health Care Policy and Research from the US Department of Health and Human Services has been translated into Spanish 28 by the WHO Collaborating Center in Supportive Care and widely disseminated throughout the Region.

8 Vol. 20 No. 6 December 2000 The PAHO and Palliative Care 447 Conclusion The terms of cooperation and assistance, plus the limited funds available, determines the way in which PAHO interacts with governments, clinicians, and lay persons. While it operates with less freedom than NGOs, PAHO also has access to high levels of government and is able to assist in the modifications of public policy. It is therefore likely that improvements in Palliative Care for Health Care professionals will be achieved as a continued effort between PAHO and other parties, such as Collaborating Centers, professional associations, and private foundations, as well as public initiatives. Perhaps the main challenge for the future is to guarantee that appropriate coordination of effort takes place, so that minimal duplication exists and resources are allocated most effectively. References 1. Parkin DM. Estimates of the worldwide frequency of twelve major cancers. Bulletin of the World Health Organization 1984;62: Parkin DM, Pisani, P, Ferlay J. Estimates of the worldwide frequency of eighteen major cancers in Int J Cancer 1993;54: Organizacion Panamericana de la Salud, Organizacion Mundial de la Salud. Situacion de la Salud en las Americas: Indicadores Basicos OPS/ HDP/HAD/ Washington: OPS, World Health Organization. Cancer Pain Relief and Palliative Care: Report of a WHO Expert Committee (Technical Report Series 804). Geneva: World Health Organization, Pan American Health Organization. Pro Salute Novi Mundi: A History of the Pan American Health Organization. Washington: PAHO, World Health Organization, Harvard School of Public Health, The World Bank. The Global Burden of Disease: A comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to Murray CJL, Lopez AD, eds. Boston: Harvard University Press, Organización Mundial de la Salud. Programas Nacionales de Lucha Contra el Cáncer: Directrices sobre Política y Gestión. Ginebra: OMS, World Health Organization. Cancer Pain Relief: With a Guide to Opioid Availability, 2 nd ed. Geneva: WHO, World Health Organization. Cancer Pain Relief and Palliative Care. Report of a WHO Expert Committee (WHO Technical Report Series No 804). Geneva: WHO, World Health Organization, International Association for the Study of Pain. Cancer Pain Relief and Palliative Care in Children. Geneva: WHO, World Health Organization. Symptom Relief in Terminal Illness. Geneva: WHO, Pan American Health Organization, Division of Disease Prevention and Control, Program on Non Communicable Diseases. Framework for a Regional Project on Cancer Care in Latin America and the Caribbean. Washington: PAHO, De Lima L. El Empleo de Analgésicos Opiáceos para Aliviar el Dolor del Cáncer. Revista Panamerica de Salud Pública/Pan American Journal of Public Health. 1997; 2: Joranson DE, De Lima, L. Análisis Preliminar de la Legislación Colombiana en Relación a los Principios Internacionales de Disponibilidad de Opioides (Monografía). Madison: University of Wisconsin Pain and Policy Studies Group/WHO Collaborating Center for Policy & Communications in Cancer Care, Joranson DE, De Lima L. Análisis Preliminar de la Legislación Mexicana en Relación a los Principios Internacionales de Disponibilidad de Opioides (Monografía). Madison: University of Wisconsin Pain and Policy Studies Group/WHO Collaborating Center for Policy & Communications in Cancer Care, De Lima, L. Análisis Preliminar de la Legislación Peruana en Relación a los Principios Internacionales de Disponibilidad de Opioides (Monografía). Houston: University of Texas M.D. Anderson Cancer Center/WHO Collaborating Center in Supportive Cancer Care, United Nations. Single Convention on Narcotic Drugs, As amended by the 1972 Protocol. New York: UN, World Health Organization. Cancer Pain Relief: With a Guide to Opioid Availability, 2 nd ed. Geneva: WHO, Joranson DE, Smokowski PR, De Lima L. Tendencias en el Consumo de Opioides en Sur América. Madison: Pain and Policy Studies Group/ WHO Collaborating Center for Policy & Communications in Cancer Care, Joranson DE, Gilson AM, Monterroso M, et al. Opioid Analgesics in Latin America: Legal Requirements, Trends, Recommendations (Monograph). Madison: University of Wisconsin Pain & Policy Studies Group/WHO Collaborating Center for Policy and Communications in Cancer Care, Joranson DE, Gilson AM, Monterroso M, et al. Analgésicos Opioides en América Latina: Tendencias, Requisitos Legales, Recomendaciones (Poster presentation during the Third Latin American Palliative Care and Cancer Pain Relief Meeting in Concepcion, Chile). Madison: University of Wisconsin Pain & Policy Studies Group/WHO Collaborating Center for Policy and Communications in Cancer Care, Organización Panamericana de la Salud, División de Prevención y Control de Enfermedades,

9 448 De Lima and Bruera Vol. 20 No. 6 December 2000 Programa de Enfermedades No Transmisibles. Enfermería en Cuidados Paliativos (informe de reunión). Washington, DC: OPS, Organización Panamericana de la Salud, División de Prevención y Control de Enfermedades, Programa de Enfermedades No Transmisibles. Cuidados Paliativos: Guía para el Manejo Clínico. Washington: OPS, World Health Organization, Office of Research and Development. WHO Collaborating Centers: General Information. Geneva: WHO, Stjernsward J, Bruera E, Joranson D, De Lima L. Opioid availability in Latin America: the Declaration of Florianopolis. J Pain Symptom Manage 1995; 10: De Lima L, Bruera E, Joranson D, et al. Opioid availability in Latin America: the Santo Domingo Report. Progress since the Declaration of Florianopolis. J Pain Symptom Manage 1997;13: Jacox A, Carr DB, Payne R, et al. Management of Cancer Pain. Clinical Practice Guideline No 9. AHCPR Publication No Rockville: Agency for Health Care Policy and Research, US Department of Health and Human Services, Public Health Service, Pain Research Group/WHO Collaborating Center UT M.D. Anderson Cancer Center. Manejo del Dolor por Cáncer. Guia Clínica Práctica No 9. AH- CPR Publication No Houston: UT M.D. Anderson Cancer Center, Appendix 1 WHO Collaborating Centers WHO Collaborating Center for Cancer Pain Relief National Cancer Institute Via Venezia Milan Italy WHO Collaborating Center for Cancer Pain Relief and Quality of Life Saitama Cancer Center 818 Komuro Ina, Saitama 362 Japan WHO/PAHO Collaborating Centers WHO Collaborating Center for Policy & Communications in Cancer Care University of Wisconsin Medical School 600 Highland Avenue Madison, Wisconsin USA WHO Collaborating Center for Quality of Life in Cancer Care Manitoba Cancer Treatment and Research Foundation St. Boniface General Hospital 409 Tache Avenue, Winnipeg, Manitoba R2H 2A6 Canada WHO Collaborating Center in Supportive Cancer Care Pain Research Group The University of Texas M.D. Anderson Cancer Center 1515 Holcombe Boulevard Houston, TX USA WHO Collaborating Center for Cancer Pain Research and Education Memorial Sloan-Kettering Cancer Center 1275 York Ave. New York, NY USA