10 per cent of the world uses 90 per cent of the morphine: this needs to change

Pain relief and palliative care is a human right - and yet global access to drugs is grossly unequal. Change is urgently needed.

10 per cent of the world consumes 90 per cent of the morphine. At first glance that's just another statistic about haves and have nots. But it's more stark than that - particularly if you have cancer in a country where access to pain relief is very limited.

At the heart of the issue is the problem of giving access to drugs and how that's managed. Making drugs available, even under controlled circumstances, is seen in many countries to be facilitating crime and corruption. As a result the legislation in some countries will use language like "addictive drugs" to describe pain relief that people in the developed world see as a basic human necessity, and the only way to avoid a horrific end to many lives: the 12 million people with cancer, but also those with advanced heart, lung or kidney diseases, progressive neurological diseases, HIV/AIDS or tuberculosis.

The various legal and regulatory barriers, mostly relating to prescribing and dispensing of opioids (medications that relieve pain, such as morphine), is just one of the problems. Inevitably there's an issue with costs. Pharmaceutical companies have little interest in producing cheap oral morphine because profits are only marginal. In Ukraine, for example, that means only injectable morphine is available. So patients with chronic cancer pain need painful injections several times per day and may be left without pain relief for hours between. Attitudes among healthcare professionals will vary from country to country. Often there's fear at the possibility of prosecution from prescribing analgesics and a desire to avoid taking any responsibility in a murky area. Even when a law might recognise that controlled medicines are necessary, healthcare staff will be wary of the potential for being investigated and the kinds of disproportionate punishments that might await them.

The under-treatment of cancer pain is a major public health crisis in both developing economies and many parts of the 'under-developed' world. There have been isolated efforts by international organizations to address the problem, but the headline is that little headway has been made. Research led by the European Association for Palliative Care has looked at treatment of cancer pain across 76 countries between 2010 and 2012, showing highly restrictive regulations on what patients can receive in Africa, Asia, the Middle East and Latin and Central America. Expert observers saw that very few countries provided all seven of the opioid medications considered essential for the relief of cancer pain in international guidelines. In many countries, fewer than three of the seven medications are available, and when medications are available they are either entirely unsubsidised or weakly subsidised by government, with limited availability. Restrictions for cancer patients include regulations that limit entitlement to receive prescriptions, limits on duration of prescriptions, restricted dispensing, and large amounts of bureaucracy around the whole prescribing and dispensing process.

Eastern Europe is also a crisis area. Essential opioid medicines are completely unavailable in Lithuania, Tajikistan, Belarus, Albania, Georgia and Ukraine. There are problems elsewhere, including Russia, Montenegro, Macedonia, Bosnia-Herzegovina with regulations that limit physicians' ability to prescribe opioids even for patients in severe pain; arbitrary dosage limits, and intimidating health care providers and pharmacists with severe legal sanctions - all contravening regulations from the WHO and International Narcotic Control Board which recommend that opioids should be available for cancer patients at hospital and community levels and that physicians should be able to prescribe opioids according to the individual needs of each patient.

Legislation makes issues black and white when more debate and education is needed among the decision makers in health care systems. Health policies are needed that integrate palliative care as a normal part of health services, and provide support to relatives during the time of care and after death; excessive restrictions that prevent legitimate access to medications need to be identified and stripped away; and crucially, more attention to providing safe and secure distribution systems that allow staff and patients access to opioids no matter where they are. There's also a lack of training among physicians and staff on the ground treating suffering patients about the issues, and what they can and can't do. A basic knowledge of palliative care needs to be part of undergraduate training for all healthcare workers, along with specialty palliative care programmes for postgrads.

Access to palliative care is a human right, and failure - by governments - to provide palliative care could be seen as constituting cruel or inhuman treatment. More concerted pressure is needed from everyone involved in healthcare worldwide, in policy or delivery, if these basic principles are going to result in changes that are urgently needed.

Professor Sheila Payne is chair of the European Association for Palliative Care, Lancaster University. The Prague Charter, calling for access to palliative care as a human right, can be signed at http://www.eapcnet.eu

A nurse walks with children outside an orphanage and hospital in Addis Ababa. Photograph: Getty Images.
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How English identity politics will shape the 2017 general election

"English" voters are more likely to vote Conservative and Ukip. But the Tories are playing identity politics in Scotland and Wales too. 

Recent polls have challenged some widely shared assumptions about the direction of UK elections. For some time each part of the UK has seemed to be evolving quite distinctly. Different political cultures in each nation were contested by different political parties and with different parties emerging victorious in each.

This view is now being challenged. Early general election surveys that show the Tories leading in Wales and taking up to a third of the vote in Scotland. At first sight, this looks a lot more like 1997 (though less enjoyable for Labour): an increasingly hegemonic mainland party only challenged sporadically and in certain places.

Is this, then, a return to "politics as normal"? Perhaps the Tories are becoming, once again, the Conservative and Unionist Party. Maybe identity politics is getting back into its box post Brexit, the decline of Ukip, and weak support for a second independence referendum. We won’t really know until the election is over. However, I doubt that we’ve seen the back of identity politics. It may actually bite more sharply than ever before.

Although there’s talk about "identity politics" as a new phenomenon, most votes have always been cast on a sense of "who do I identify with?" or "who will stand up for someone like us?" Many voters take little notice of the ideology and policy beloved of activists, often voting against their "objective interests" to support a party they trust. The new "identity politics" simply reflects the breakdown of long-established political identities, which were in turn based on social class and collective experiences. In their place, come new identities based around people, nations and place. Brexit was never really about the technocratic calculation of profit and loss, but about what sort of country we are becoming, and what we want to be. 

Most social democratic parties in Europe are struggling with this change. Labour is no different. At the start of the general election, it faces a perfect storm of changing identities. Its relationship with working-class voters continues to decline. This is not because the working class has disappeared, but because old industries, with their large workplaces, shared communities and strong unions are no longer there to generate a labour identity. 

Labour is badly adrift in England. The English electorate has become increasingly assertive (and increasingly English). The Brexit vote was most strongly endorsed by the voters who felt most intensely English. In the previous year’s general election, it was fear of Scottish National Party influence on a Labour minority government that almost certainly gave the Tories the English seats needed for an overall majority. In that same election, Labour’s support amongst "English only" voters was half its support amongst "British only" voters. The more "English" the voters, the more likely they were to vote Ukip or Conservative. It shouldn’t be a surprise if Ukip voters now go Tory. Those who think that Ukip somehow groomed Labour voters to become Tories are missing the crucial role that identity may be playing.

So strong are these issues that, until recently, it looked as though the next election - whenever it was called - would be an English election - fought almost entirely in English battlegrounds, on English issues, and by a Tory party that was, increasingly, an English National Conservative Party in all but name. Two powerful identity issues are confounding that assumption.

Brexit has brought a distinctly British issue into play. It is enabling the Tories to consolidate support as the Brexit party in England, and at the same time reach many Leave voters in Wales, and maybe Scotland too. This serendipitous consequence of David Cameron’s referendum doesn’t mean the Tories are yet fully transformed. The Conservative Party in England is indeed increasingly focused on England. Its members believe devolution has harmed England and are remarkably sanguine about a break up of the union. But the new ability to appeal to Leave voters outside England is a further problem for Labour. The Brexit issue also cuts both ways. Without a clear appeal cutting through to Leave and Remain voters, Labour will be under pressure from both sides.

North of the border, the Tories seemed to have found - by accident or design - the way to articulate a familial relationship between the party in Scotland and the party in England. Scottish Conservative leader Ruth Davidson appears to combine conservatism, unionism and distance from English politics more successfully than Scottish Labour, which must ride the two horses of "near home rule" and committed unionism. Scottish Labour has a perfectly good call for a reformed union, but it is undermined by the failure of Labour in England to mobilise enough popular support to make the prospect credible.

Identity politics is not, of course, the be all and end all of politics. Plenty of voters do cast their ballots on the traditional tests of leadership, economic competence, and policy. Labour’s campaign will have to make big inroads here too. But, paradoxically, Labour’s best chance of a strong result lies in taking identity politics head on, and not trying to shift the conversation onto bread and butter policy, as the leaked "talking points" seem to suggest. Plenty of voters will worry what Theresa May would do with the untrammelled power she seeks. Challenging her right or ability to speak for the nation, as Keir Starmer has done, is Labour’s best bet.

 

John Denham was a Labour MP from 1992 to 2015, and a Secretary of State 2007 to 2010. He is Director of the Centre for English Identity and Politics at Winchester University

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