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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Europe's elections show why liberals should avoid fatalism

France, Germany and the Netherlands suggest there is nothing inevitable about the right's advance.

Humans are unavoidably pattern-seeking creatures. We give meaning to disparate events where little or none may exist. So it is with Brexit and Donald Trump. The proximity of these results led to declarations of liberalism's demise. After decades of progress, the tide was said to have unavoidably turned.

Every election is now treated as another round in the great duel between libralism and populism. In the Netherlands, the perennial nativist Geert Wilders was gifted outsize attention in the belief that he could surf the Brexit-Trump wave to victory. Yet far from triumphing, the Freedom Party finished a distant second, increasing its seats total to 20 (four fewer than in 2010). Wilders' defeat was always more likely than not (and he would have been unable to form a government) but global events gifted him an aura of invincibility.

In France, for several years, Marine Le Pen has been likely to make the final round of the next presidential election. But it was only after Brexit and Trump's election that she was widely seen as a potential victor. As in 2002, the front républicain is likely to defeat the Front National. The winner, however, will not be a conservative but a liberal. According to the post-Trump narrative, Emmanuel Macron's rise should have been impossible. But his surge (albeit one that has left him tied with Le Pen in the first round) suggests liberalism is in better health than suggested.

In Germany, where the far-right Alternative für Deutschland was said to be remorselessly advancing, politics is returning to traditional two-party combat. The election of Martin Schulz has transformed the SPD's fortunes to the point where it could form the next government. As some Labour MPs resign themselves to perpeutal opposition, they could be forgiven for noting what a difference a new leader can make.

2016 will be forever remembered as the year of Brexit and Trump. Yet both events could conceivably have happened in liberalism's supposed heyday. The UK has long been the EU's most reluctant member and, having not joined the euro or the Schengen Zone, already had one foot outside the door. In the US, the conditions for the election of a Trump-like figure have been in place for decades. For all this, Leave only narrowly won and Hillary Clinton won three million more votes than her opponent. Liberalism is neither as weak as it is now thought, nor as strong as it was once thought.

George Eaton is political editor of the New Statesman.