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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For a mayor who will help make Londoners healthier, vote for Tessa Jowell

The surgeon, former Labour health minister and chairman of the London Health Commission, Ara Darzi, backs Tessa Jowell to be Labour's candidate for London mayor.

London’s mayor matters. As the world’s preeminent city, London possesses an enormous wealth of assets: energetic and enterprising people, successful businesses, a strong public sector, good infrastructure and more parks and green spaces than any other capital city.

Yet these aren’t put to work to promote the health of Londoners. Indeed, quite the opposite: right now, London faces a public health emergency.

More than a million Londoners still smoke tobacco, with 67 children lighting up for the first time every day. London’s air quality is silently killing us. We have the dirtiest air in Europe, causing more than 4,000 premature deaths every year.

Nearly four million Londoners are obese or overweight – and just 13% of us walk or cycle to school or work, despite half of us living close enough to do so. All Londoners should be ashamed that we have the highest rate of childhood obesity of any major global city.

It’s often been said that we don’t value our health until we lose it. As a cancer surgeon, I am certain that is true. And I know that London can do better. 

For that reason, twice in the past decade, I’ve led movements of Londoners working together to improve health and to improve the NHS. Healthcare for London gave our prescription for a better NHS in the capital. And Better Health for London showed how Londoners could be helped to better health, as well as better healthcare.

In my time championing health in London, I’ve never met a politician more committed to doing the right thing for Londoners’ health than Tessa Jowell. That’s why I’m backing her as Labour’s choice for mayor. We need a mayor who will deliver real change, and Tessa will be that mayor.  

When she invited me to discuss Better Health for London, she had the courage to commit to doing what is right, no matter how hard the politics. Above all, she wanted to know how many lives would be saved or improved, and what she could do to help.

In Tessa, I see extraordinary passion, boundless energy and unwavering determination to help others.

For all Londoners, the healthiest choice isn’t always easy and isn’t always obvious. Every day, we make hundreds of choices that affect our health – how we get to and from school or work, what we choose to eat, how we spend our free time.

As mayor, Tessa Jowell will help Londoners by making each of those individual decisions that bit easier. And in that difference is everything: making small changes individually will make a huge difference collectively.  

Tessa is committed to helping London’s children in their early years – just as she did in government by delivering Sure Start. Tessa will tackle London’s childhood obesity epidemic by getting children moving just as she did with the Olympics. Tessa will make London a walking city – helping all of us to healthier lifestyles.

And yes, she’s got the guts to make our parks and public places smoke free, helping adults to choose to stop smoking and preventing children from starting.   

The real test of leadership is not to dream up great ideas or make grand speeches. It is to build coalitions to make change happen. It is to deliver real improvements to daily life. Only Tessa has the track record of delivery – from the Olympics to Sure Start.   

Like many in our capital, I am a Londoner by choice. I am here because I believe that London is the greatest city in the world – and is bursting with potential to be even greater.

The Labour party now has a crucial choice to make. London needs Labour to choose Tessa, to give Londoners the chance to choose better health.