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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The promises of Brexit can't be kept. You can only decide which bits to betray

Vote Leave's great success was in presenting a menu of contradictory options as if they could all be secured. 

If Britain leaves the European Union but retains its membership of the single market and the customs union, has it really left? Barry Gardiner doesn’t think so. Labour’s shadow trade secretary, writing for the Guardian, argues that to satisfy those who voted Leave, Britain must regain control of its own borders – forcing it out of the single market in order to lose free movement rights – and its own laws, forcing it out of both the customs union and single market to avoid regulatory harmonisation.

Jeremy Corbyn has argued that single market membership and EU membership are one and the same, as has Caroline Flint. They have kept the options open on the customs union. Are they right?

As I wrote yesterday, it’s hard to explain what drove Britain’s Brexit vote without conceding that objections to the rules of the single market played a significant role. Gardiner is undoubtedly right to say that two of the biggest drivers of the vote were control over borders and laws, both of which cannot be achieved while remaining within the single market. Neither can the third biggest driver, which was more money for public services in general and the NHS in particular – that £350m a week. Because if the United Kingdom retains its single market membership, it will continue to “send money to Brussels”.

There’s a “but” coming, though, and it’s a big one. The first problem is that while the majority of people who voted to leave did so for reasons that cannot be fulfilled if we remain in the single market, those votes weren’t enough to take Britain out of the European Union. Leave only triumphed because it also secured the votes of people who thought it would take the country out of the political project but would retain a Norway-style arrangement.

The second is that those three big mandates cannot be reconciled with each other. If the United Kingdom leaves the single market and the customs union, then the promise of more money for the NHS will be difficult, perhaps impossible, to deliver, at least not in the way that people envisaged. (When people said they wanted £350m extra in the NHS, they didn’t mean “in order to pay for drugs that are more expensive, to recoup the cost of our new regulatory regime and to plug the recruitment gap left by EU citizens with high-priced locums”. They meant that the NHS would do everything it does now and more, not run to stand still.)

The great success of Vote Leave was in presenting a whole menu of contradictory options as if they could be served on one dish. But you cannot have the Extra Hot and the Lemon & Herb on the same piece of chicken. You have to choose. The big failure of the political class has been not to advocate for one of those options over the other. (Theresa May has effectively been running on a ticket of “Extra Hot, Lemon & Herb, and the French will pay for it”.)

You cannot have a Brexit that unlocks trade deals with India and the rest of the BRICS (five major emerging national economies) and reduce the uncontrolled flow of people from elsewhere around the world to the UK. You can’t have a more generously-funded public realm and pursue a Brexit that makes everyone poorer. You have to choose. 

Stephen Bush is special correspondent at the New Statesman. His daily briefing, Morning Call, provides a quick and essential guide to domestic and global politics.