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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Jeremy Corbyn is not standing down - 172 people cannot drown out democracy

The Labour Party could right now be exploiting a bitter Conservative leadership contest, writes shadow chancellor John McDonnell. 

The shadow chancellor writes exclusively for The New Statesman amid one of the most turbulent weeks in politics this century.

The “coup” taking place in the Labour Party

The instability from Brexit has extended into the Parliamentary Labour Party with members of the shadow cabinet standing down. I would like to thank all of those who have participated with me for their work.

Frustratingly, this has come at the worst possible time for our country. And at a time in which we our party could have used to reset the economic narrative that the Tories planted in the public during the summer of 2010 when our party was in the midst of a leadership contest.

Our party right now could be exploiting a bitter Conservative leadership contest that’ll probably lead to electing a Tory leader who will be responsible for any economic fallout from Brexit. The Tories have peddled lies over the past six years over the management of our economy and the state of the public finance, which the decision last Thursday is sadly exposing.

I strongly believe that if some colleagues are not careful then they may cause irreparable damage to our party and the country. 

The Labour Party changed last September. Jeremy was elected with the largest mandate of any political leader in the history of our country. Our party’s values of democracy and solidarity seem to be asked of the membership and always met. Sadly not by some members of the PLP. 

There are those in our party who could not come to terms with the fact that a quarter of a million members could clearly see that the our party’s broken election model has lead to two back to back defeats and needed replacing. Like the wisdom of crowds, our membership understands that we cant keep going on doing the same thing electorally and getting the same results.

I believe that we can all still work together, but I feel some MPs need to get off their chest what they have been holding back since last Autumn. Maybe then they will hear the message that our membership sent them.

The truth is that Jeremy is not standing down. In the Labour Party our members are sovereign. There was an election held and a decision made, and 172 people cannot outweigh a quarter of a million others. 

It would risk sending the worst possible message we could send as a party to the electorate - that Labour does not respect the democratic process.

The economics of Brexit

The Leave vote delivered an immense shock to the political system creating great instability. Of immediate concern is the deteriorating economic situation. Credible economic forecasters virtually unanimously warned that leaving the European Union would be an enormous shock to the economy. 

The disagreements centred on the severity of the shock, and the long-term damage done. To that initial shock must be added the realisation that there was no plan made for a post-Brexit Britain. 

George Osborne has not secured the foundations of our economy and the market volatility reflects that missed opportunity. With turmoil continuing, and major employers already threatening redundancies, the immediate task is to stabilise markets and reassure investors and savers that financial institutions remain rock solid. 

The measures announced by Bank of England Governor Mark Carney early on Friday morning, and the later statement from the Chancellor, are to be welcomed and we have requested a briefing under Privy Council rules on the financial authorities’ contingency plans. It is also reassuring that George Osborne has now moved a threatened, post-Brexit austerity Budget until at least the Autumn. 

Nonetheless, with a recession now forecast, any attempt to push further austerity measures in response to the crisis would be an act of exceptional economic folly. The Chancellor’s own fiscal targets have long since been missed and simply redoubling the misery of spending cuts and tax rises will not bring them any closer to achievement. 

What is needed in a crisis like this is urgent government action to shore up investment, already falling before the vote. Shovel-ready projects should be brought forward, creating jobs and focused on beginning to rebuild those parts of the country currently most deprived – and where the vote to Leave was strongest. As a country we will get through this crisis, and we will do so when we no longer tolerate a situation in which too many of our people are excluded from even the chance of prosperity.

The referendum result

I have been in consultation with many economist, trade union and business leaders since the early hours of the morning when we learnt the result. I hope to give a speech this Friday going into further details of Labour’s economic response, but the result last Thursday came as a blow to many of us in the Labour Party.

All wings of the Labour movement fought hard, and two-thirds of our voters swung to Remain – the same as the SNP, and far more than the Tories, who split 60:40 for Leave. 

Labour will now be fighting to ensure whatever negotiations now take place, and whatever proposals the government chooses to bring forward, will maintain hard-won protections for working people in this country.

The new Labour leadership inherited the Labour In campaign last year. Obviously as with any campaign we will now have to reassess, but the hard work of the staff who worked on the campaign cannot be questioned. They did a fantastic job. 

Jeremy Corbyn also managed to help get out a larger number of our voters than the other main Westminster leaders across the country. 

But the sad truth is that we lost regardless. We need to learn lessons of the referendum and the General Election campaigns, and question whether the way we campaign as a party needs to be changed. 

It is clear that we cannot fight the next election using the same outdated practises and policies that were in place at the last two general elections, and the recent referendum. 

We cannot continue to do the same things in the same ways and get the same results. Those people who need a Labour government the most cannot afford it.


John McDonnell is Labour MP for Hayes and Harlington and has been shadow chancellor since September 2015.