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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On World Aids Day, let’s end the stigma around HIV for good

Advances in treatment mean that being HIV positive is no longer a death sentence, but attitudes still lag behind.

Stigma is a dangerous human construct, principally based on unfounded prejudices. None more so than the stigma surrounding HIV. The condition has been a recognised health issue in the UK for more than 30 years, and the advances in treatment have been staggering. Unfortunately attitudes seem to have remained in the 1980s.

A recent Terrence Higgins Trust poll asked people who are living with HIV for words that they have heard to describe their health condition. “AIDS”, “riddled”, “dirty”, “disgusting”, “promiscuous”, “dirty”, “deserved”, “unclean”, “diseased” – were the most cited.

Imagine turning to someone, who lets say has a long term health condition like high blood pressure, and branding them “lazy”, “fat”, “deserving”. Or someone who has just been diagnosed with diabetes being dismissed as “greed”. Of course, I’m not saying that these health conditions are without their own stigma. Rather I doubt that Charlie Sheen would have been subjected to such a vitriolic witch hunt, had it transpired he had either of those.

Once the nausea of that coverage subsided, it was telling to note the absent voices from most of the media debate around HIV and stigma. The thing that struck most was the total lack of understanding of the condition, the treatment, and the lack of representation of those who are living with HIV.

There was little written about the stigma women living with HIV face. That which those within the black African community, or the trans community, or the over 50s – the first generation of people living into old age with HIV – are subjected to.

Such is the stigma and the shame of HIV in black African communities that it can divide families. HIV positive people can be asked to leave home, resulting in separation from their family and isolation from their community. We know of a woman from the black African community who felt so stigmatised for not breastfeeding her baby – due to her HIV treatment – that she stopped her drug regime. She died unnecessarily of an Aids-related illness. After her death, her medication was found in the attic.

While living with HIV can be stressful for all ages, ageing with HIV can introduce challenges to mental health and quality of life. When compared to their peers, older people living with HIV are disadvantaged in a wide range of ways – from poorer health, to social care and financial security. We’ve found that older people fear that social care services will be prejudiced about their HIV diagnosis. One man shared that he feared hugely going into a home – the attitudes towards HIV that he might find, and ignorance from the staff. This fear is rooted in many people’s historic and continued experience of HIV-related discrimination.  

Often considered to be a lower risk group than gay men, women are sometimes forgotten in HIV discourse and yet women are stigmatised as much as any other with HIV. Women living with the condition face a unique stigma. Some are mothers and have been accused of being “irresponsible” and “putting children at risk”.

For the record, taking antiretroviral medication (ART) lowers the amount of virus in your blood to “undetectable” levels. When the level of HIV in your blood is so low that it can’t be picked-up in tests it is undetectable. This means there is an extremely low risk of passing on HIV.

Because of ART, undetectable women have a very low risk of passing on HIV to their babies. New-borns are given their own short course of ART to further reduce their risk of developing HIV, and undergo a series of tests during the first 18 months of life.

Many transgender people are on a difficult gender journey, which includes lots of access to GPs for onward referrals to specialists, and still they worry about HIV stigma. Some deny their HIV status in settings where possible, as they look at it as a barrier to achieving their goal. Gender specialist clinics are embedded in mental health departments, and some positive trans people worry that the stigma of diagnosis might be seen as an indicator of promiscuity, which they feel might work against their cases.

And what of stigma in the gay community? The poll mentioned earlier found that of 410 gay men living with HIV, 77 per cent experience stigma – with more than two thirds experiencing this most from within the gay community.

Those gay men who take the plunge and live openly with their status are often heckled, and sent abuse on dating apps like Grindr, even receiving messages that they shouldn’t be using it because “they’ll infect others”. It’s all too easy in the digital age for stigma to persist, and ignorance to remain faceless.

Stigma is best countered with fact. But there’s a clear lack of education amongst many – both positive and negative. Growing up with sex and relationship education lessons that only teach the reproduction cycle is not enough. Young people should be given clear and detailed information about the risks of HIV, but also how living with HIV in the UK has changed, and it is now an entirely manageable health condition.

Officially, stigma is defined as a mark of disgrace associated with a particular circumstance, quality, or person. Let’s turn that around today, and use the red ribbon to stop stigma. Let’s use it a mark of solidarity, compassion and understanding.

Let’s start a conversation about how we speak and write about HIV. Let’s stand together, today of all days against HIV stigma. Start now – join the solidarity on social media by taking a selfie with your red ribbon and #StopStigma.