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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Why a Labour split may be in the interests of both sides

Divorce may be the best option, argues Nick Tyrone. 

Despite everything that is currently happening within the Labour Party - the open infighting amongst party officials, the threat of MPs being deselected, an increasingly bitter leadership contest between two people essentially standing on the same policy platform – the idea of a split is being talked down by everyone involved. The Labour Party will “come together” after the leadership election, somehow. The shared notion is that a split would be bad for everyone other than the Tories.

Allow me to play devil’s advocate. What the Corbynistas want is a Labour Party that is doctrinarily pure. However small that parliamentary party might be for the time being is irrelevant. The basic idea is to build up the membership into a mass movement that will then translate into seats in the House of Commons and eventually, government. You go from 500,000 members to a million, to two million, to five million until you have enough to win a general election.

The majority of the parliamentary Labour party meanwhile believe that properly opposing the Tories in government through conventional means, i.e. actually attacking things the Conservatives put forth in parliament, using mass media to gain public trust and then support, is the way forward. Also, that a revitalisation of social democracy is the ideology to go with as opposed to a nebulous form of socialism.

These two ways of looking at and approaching politics not only do not go together, they are diametric opposites. No wonder the infighting is so vicious; there is no middle way between Corbynism and the bulk of the PLP.

I understand that the Labour MPs do not want to give up on their party, but I don’t see how the membership is shifting in their favour any time soon. Most talk around a split understandably comes back to 1981 and the SDP very quickly yet consider this: the most defections the SDP ever achieved were 28. If there was a split now, it would probably involve the vast majority of the PLP, perhaps even 80 per cent of it – a very, very different proposition. There is also clearly a large number of people out there who want a centre-left, socially democratic, socially liberal party – and polls suggest that for whatever reason the Liberal Democrats cannot capitalise on this gap in the market. Some sort of new centre-left party with 150+ MPs and ex-Labour donors to kick it off just might.

Of course, a split could be a total disaster, at least in the short term, and allow the Tories further general election victories over the next decade. But let’s be honest here – given where we are, isn’t that going to happen anyhow? And if a split simply results in what happened in the 1980s recurring, thus eventually leading to a Labour Party capable of winning a general election again, would members of the PLP currently wondering what to do next not consider it worth it just for that?

Nick Tyrone is Chief Executive of Radix, the think tank for the radical centre.