Pain Cause Exploration 3: Investigating three ways to reduce the global pain burden
Executive Summary
Physical pain represents one of humanity’s universal experiences of suffering. Despite this, some of its most severe and preventable forms receive surprisingly little attention. This is the Happier Lives Institute’s third cause area exploration report about pain (previous ones being Sharma et al., 2020; Dupret et al., 2023). Instead of a wide focus, here we concentrate on three sources of pain. This report identifies where philanthropic resources could most effectively reduce pain-related suffering, evaluates potential interventions, and highlights what we believe are the strongest current opportunities for impact. As a result, we plan to invest more time evaluating palliative care in future work.
The problems
This report focuses on three major sources of pain: lack of access to palliative care, headache disorders, and musculoskeletal pain. The pain associated with these problems is either commonplace and bearable, rare and terrible, or in the case of palliative care, both. In all cases, pain remains essentially untreated.
The harms of untreated pain: commonplace, terrible, or both.
Pain requiring palliative care is both common and terrible. Severe end-of-life pain precedes 41% of all deaths worldwide (Knaul et al., 2025). Where palliative services are unavailable, almost 90% of patients experience substantial, frequently severe, pain (Cleeland et al., 1998; Harding et al., 2011).
Cluster headaches are rare but terribly painful: experienced by about 0.1% of people (San-Juan et al., 2024), yet many describe them as the worst pain of their lives (9.7 on a 0 to 10 scale; Burish et al., 2020). Between 36-64% of sufferers report suicidal thoughts during attacks (Lee et al., 2019).
Painful conditions that lack clear cures, such as back pain and migraines, are among the largest drivers of years lived with disability worldwide. Musculoskeletal pain, especially low back pain, is the leading cause of disability globally. Back and neck pain are estimated to reduce wellbeing by 0.2-1.2 points on a 0-10 scale. Migraines alone affects 15% of the world’s population and are estimated to reduce wellbeing by 0.2 points on a 0-10 scale.
Pain: A highly neglected problem by governments, philanthropy, and research
Duthey et al. (2014) estimates that only about 7.5% of people worldwide receive adequate treatment for serious pain. Bridging this treatment gap demands a mix of research and scaling existing treatments. Yet we observe only a few organisations – which tend to only have low levels of funding – focusing on addressing the problems below.
The neglect of pain as a coherent project to improve people’s lives is as much represented by what we can say as what we can’t: There is no global burden of pain (see Dupret et al., 2023, for more discussion), nor international data on spending on pains (see Section 4), so we can’t even make the same comparisons we can make comparing spending on physical and mental health (e.g., see Bloom’s Global Mental Health report).
Palliative care: In many low- and middle-income countries (LMICs), access to sufficient palliative care is limited. Only 48% of low-income countries had any government funding for palliative care, 54% of lower-middle-income countries, and 65% of upper-middle-income countries compared to 91% in high-income countries (HICs; The WHO Global Atlas of Palliative Care, 2020). The palliative care that does exist is often lacking a critical component of serious pain relief: morphine. Western countries contain ~17% of the world’s population but consume 85% of the world’s morphine supply (INCB, 2023). States report general availability of oral morphine in >50% pharmacies in only 13% of low-income countries, 17% of lower-middle-income countries, and 40% of upper-middle-income countries compared to 80% in HICs (The WHO Global Atlas of Palliative Care, 2020). Need met in LMICs remains far below medically necessary levels (Knaul et al., 2018). Closing the global morphine shortfall is estimated to cost roughly $145 million per year (Knaul et al., 2018), about 0.9% of the $16,514 million in health-directed international assistance targeting HIV/AIDS in 2023 (calculated with IHME’s 2025 DAH data). When it comes to the charities we found, their annual revenue combined only comes to an estimated $6 million.
Headache disorders: Experts estimate that only 13% of migraine sufferers in low-income countries are diagnosed (WHO, 2011). We could not easily find figures for philanthropic funding focused on headache-based disorders in LMICs. We imagine this is small to non-existent. The funding focused on cluster headaches in HICs is also very small, with an estimated lower bound of $2.7 million.
Neck and back pain: Africa has around 12 times fewer physiotherapists per capita than the global average, and roughly 45 times fewer than Europe (World Physiotherapy, 2024). The only international NGO we identified with a clear mandate to improve musculoskeletal health in LMICs was World Spine Care. Their revenue in 2024 was only $0.28 million.
Focused pain relief remains a small and overlooked philanthropic field despite its enormous burden. The largest charity we found focused on this issue had a budget of around $3.5 million annually, with others at $1 million. We think this indicates significant neglectedness and potential for outsized donor impact. We estimate total funding focused on reducing pain-related suffering outside HICs (across palliative care, headache-based disorders, and musculoskeletal pain) is in the single-digit millions or less. This contrasts sharply with the $16,514 million in health-directed international assistance targeting HIV/AIDS in 2023, or the $6,380 million targeting Malaria (calculated with IHME’s 2025 DAH data), which are themselves considered neglected diseases.
Emerging solutions to the biggest unsolved problems in pain
There are effective, affordable, and scalable ways to reduce some of the world’s most intense and common forms of suffering. However, the research here is still very uncertain and more work is needed for any charity to meet our recommended charity status. Of the three areas, we think palliative care is the most promising and the one we plan to do further research in.
1. Palliative care (end-of-life pain)
We found that improving access to palliative care is the most likely to be an actionable and cost-effective opportunity to reduce extreme pain. Rather than treating underlying disease, it focuses on relieving suffering, primarily through provision opioids like morphine. Morphine is inexpensive and can almost completely control even severe cancer- and HIV-related pain. Organisations such as Pallium India, Hospice Africa Uganda, and Douleurs Sans Frontières work to fix the barriers to access – restrictive regulations, poor supply chains, and limited clinician training. Pallium India’s expansion into another state in India could generate 16–108 WELLBYs per $1,000 donated, according to our back-of-the-envelope calculation (BOTEC). Palliative care charities in LMICs that increase general access could be highly cost-effective, so we plan on conducting a more in-depth report on them in order to determine if they can reach our recommended charity status.
2. Headache disorders (migraines and cluster headaches)
Cluster headaches. Very little research targets cluster headache treatments, likely because the affected population is small, leaving many patients to rely on anecdotal guidance online. ClusterFree is a small advocacy and research group working to identify the best treatments for cluster headaches. More research regarding cluster headaches is needed to establish what are the best paths for impact in this area. In this report, we discuss the uncertainties and limitations of advocacy.
Migraines: Simple painkillers (ibuprofen, paracetamol) can stop 1 in 2 migraines (Kirthi et al., 2013; Rabbie et al., 2013), but we know of no organisation focussing on expanding access in LMICs. We are not planning on pursuing this area in the future since NSAIDs are wide-spread and cheap, and it appears hard to make migraine diagnoses. But given the massive pain burden and simple solutions we could be convinced by more research, particularly on the wellbeing benefits of treating migraines in LMICs on wellbeing and more broadly on the prospects of providing greater access to migraine treatment in LMICs.
There are effective, affordable, and
scalable ways to reduce some of the world’s most intense and common forms of
suffering. However, the research here is still very uncertain and more work is
needed for any charity to meet our recommended charity status. Of the three
areas, we think palliative care is the most promising and the one we plan to do
further research in.
3. Musculoskeletal pain (back and neck pain)
Surprisingly few organisations focus on scalable solutions in LMICs. Because this pain is often chronic, long-term use of painkillers risks dependence and loss of efficacy, so we examined non-drug alternatives. Currently, we do not have sufficient data to establish a recommendation in this area. We think further research into the delivery of these non-drug alternatives seems like a promising area of research given the immense scale of the problem.
World Spine Care treats underlying causes through physiotherapy, but the need for skilled labour and repeated visits makes costs relatively high ($44–63 per patient), yielding roughly 15–21 WELLBYs per $1,000 donated according to our BOTEC. Some of World Spine Care’s work involves delivering this care in underserved countries (e.g., Botswana, Ghana, India, Dominican Republic), operating clinics where trained providers are scarce, and building local capacity through training. Currently, this is not as cost-effective as our recommended charities. However, we are interested in further research into the possibility that this model can be scaled using lay practitioners, like has been done with psychotherapy.
A second approach, psychotherapy for chronic pain, aims to help patients live better with persistent pain; our preliminary BOTEC estimates 16–43 WELLBYs created per $1,000 donated. We did not identify organisations currently delivering psychotherapy-for-pain programs in LMICs, so we did not explore this further.
Notes and acknowledgements
Author note: Ben Stewart, Samuel Dupret, and Joel McGuire contributed to the conceptualization, investigation, analysis, data curation, and writing of the project. Michael Plant contributed to the conceptualisation, supervision, and writing.
The views expressed in this document are those of HLI staff and do not necessarily reflect the perspectives of external reviewers.
Reviewer note: We thank Jonathan Leighton from OPIS for feedback on this report.
Charity information note: We thank the staff of Pallium, Hospice Africa Uganda, Douleurs Sans Frontières, World Spine Care, and ClusterFree for answering our many questions.
AI note: We used LLMs to a limited extent to help with the wording of some
paragraphs and to help expedite the graph coding process.