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

A nurse walks with children outside an orphanage and hospital in Addis Ababa. Photograph: Getty Images.
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Does the UK care enough about climate change to admit it is part of the problem?

The government’s energy policies make can make it hard to decipher its commitment to emissions reduction.

“People tell me it’s ridiculous to be flying for a climate change project but you have to get real with it, I mean I can’t cycle across the Southern ocean,” says Daniel Price, an environmental scientist from London. As founder of Pole-to-Paris, Price is about to complete a 17,000km bike ride from the Antarctic to the Arc de Triomphe.

Price came up with the idea in an effort to raise public awareness of COP21, the UN Climate Change Conference taking place in Paris next week. During the trip he’s faced a succession of set-backs: from the discovery that boats were prohibitively expensive, to diplomatic tensions scuppering his Russian visa plans. Yet the darkest moments were when he became overwhelmed by the magnitude of his own mission. “There were difficult times when I just thought, ‘What is the point of this’?” he says. “Cycling round the world is nowhere near enough to engage people.” 

As world leaders descend on Paris, many questions remain unanswered. Not least how much support developing nations will receive in tackling the effects of climate change. New research commissioned by Oxfam claims that such costs could rise to £1.7tn a year by 2050. But with cuts kicking in at home, the need to deliver “climate justice” abroad feels like a bigger ask than ever.

So does Britain really care enough about climate change to accept its full part in this burden? The government’s energy policies make can make it hard to decipher its commitment to emissions reduction. In September, however, it did pledge £5.8bn from the foreign aid fund to helping poorer nations combat climate change (twice that promised by China and the United States). And there’s evidence to suggest that we, as a public, may also care more than we think.

In America attitudes are much darker; in the dismissive words of Donald Trump “It’s called the weather”. Not least since, as a recent study proves, over the last twenty years corporations have systematically spread scepticism about the science. “The contrarian efforts have been so effective," says the author Justin Farrell, a Yale sociologist, "that they have made it difficult for ordinary Americans to even know who to trust.” 

And what about in China, the earth's biggest polluter? Single-party rule and the resulting lack of public discussion would seem to be favouring action on the environment. The government has recently promised to reach "peak" emissions by 2030, to quadruple solar installations, and to commit $3.1bn to help low-income countries adapt to the changing world. Christiana Figueres, the UN’s chief climate official, has even lauded the country for taking “undisputed leadership” on climate change mitigation.

Yet this surge of policy could mask the most troubling reality of all: that, when it comes to climate change, the Chinese are the least concerned citizenship in the world. Only 18 per cent of Chinese see the issue as a very serious problem, down 23 percentage points from five years ago, and 36 points behind the global median.

A new study by political economist Dr Alex Lo has concluded that the country’s reduced political debate could be to blame for the lack of concern. “In China popular environmentalism is biased towards immediate environmental threats”, such as desertification and pollution, Lo writes, “giving little impetus to a morally driven climate change movement”.

For the international community, all is well and good as long as the Chinese government continues along its current trajectory. But without an engaged public to hold it to account there’s always a chance its promises may fade into thin air.

So perhaps the UK’s tendency to moan about how hard it is to care about the (seemingly) remote impacts of climate change isn’t all bad. At least we know it is something worth moaning about. And perhaps we care more than we let on to each other.

Statistics published this summer by the Department of Energy and Climate Change reveal that three quarters of the British public support subsidies for renewable energy, despite only 10 per cent thinking that the figure is that high. “Even if the public think the consensus is not there, there are encouraging signs that it is,” says Liz Callegari, Head of Campaigns at WWF. “Concern for climate change is growing.”

As Price puts it, “You can think of climate change as this kind of marathon effort that we have to address and in Paris we just have to get people walking across the start line together”. Maybe then we will all be ready to run.

India Bourke is the New Statesman's editorial assistant.