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 Game of Thrones is the perfect show for the modern age

There is something horribly relatable about George R R Martin’s world of Westeros, whose characters have now become part of public myth.

By now, it feels as if George R R Martin – the author of Game of Thrones, narrative sadist and ruiner of all things beautiful and good – has been appointed scriptwriter for the news. I am not the first to observe this. Martin is famous for killing off everyone’s favourite characters and sending his stories careering into pits of bleak uncertainty just when you thought everything might turn out all right. Since Prince became the latest beloved star to die this year, it has become abundantly clear that life is imitating Game of Thrones, and there’s nothing to do but watch the next bit through your fingers and try to avoid spoilers.

The staggeringly popular HBO show based on Martin’s books is in its sixth season, and it is wild, glorious trash. I mean that as a compliment. I love this horrible, problematic show more than I can possibly justify, so I’ve stopped trying. It is hardly a social-justice warrior’s dream, given that it seems to be racing against itself to sexually degrade as many female characters as possible in the space of a 45-minute episode.

The argument for the endless misogynist violence is that it has to be shown, not to titillate viewers, absolutely not, but because that sort of thing just happened back in the murky medieval past. This would be a decent excuse if sexual violence were indeed a thing of the past; or, come to that, if Game of Thrones was actually set in the past, instead of in a fictional fantasy world where there are shape-shifters, zombies and dragons.

There is one aspect, however, in which Game of Thrones has a claim to being the most realistic show on television. Despite the wizards, the wights and the way every character manages to maintain perfect hair even when they’re being pointlessly tortured to death, there is something horribly relatable about Martin’s world of Westeros, whose characters have now become part of public myth. What sets it apart is not the monsters, the nudity or the festering gallons of gratuitous gore, but the overwhelming sense that the plot got run off the rails three books ago and is being steered towards a terrible precipice by a bunch of bickering, power-mad maniacs. This, coincidentally, happens to be the plot of the entire 21st century so far.

Viewers might tune in for what the actor Ian McShane called the “tits and dragons”, but they stay for the unremitting horror. Martin gleefully tramples over all the tropes of conventional sword-and-sorcery fiction. There are no noble quests or heroes’ journeys. Instead, horrible things happen to good people for no reason. Heroism goes extremely unrewarded. The few times injustice does get punished, it happens by accident. Fair maidens are not saved, protagonists are slaughtered at random, and war is always a stupid idea, even though the ­surviving cast members are still trying to solve all their problems by waging it.

Most fans of the show have idly wondered which warring noble house they’d want to be born into. Are you brave and upstanding like the Starks, an entitled aristocrat like the Lannisters, or a mad pirate bastard like the Greyjoys? Personally, I like to think that I’d be at home in Dorne, where knife-fighting and aggressive bisexuality are forms of greeting, but the truth is that I’d have been dead for at least two seasons by now and so would you. And not excitingly dead, either. Not beheaded-by-the-king dead, or burned-as-a-blood-sacrifice-to-the-god-of-fire-by-your-own-father dead. Statistically speaking, we’d be peasants. We probably wouldn’t even get names. We’d just be eating mud and waiting for the war to be over. You know it’s true.

The moral lessons so far are murky but sensible. Dragons are awesome. Men are invariably dreadful. Following religious zealots into battle is a poor life decision. Honour is a made-up concept that will probably get you killed. Most importantly, there are very few truly evil people in the world: instead, there are just stupid people, and scared people, and petty, vindictive people, and sometimes those people get put in charge of armies and nations, and that’s when the rest of us are really buggered. That’s what Game of Thrones is about.

I’m not even confident of a happy ending. I’ve made peace with knowing that my favourite characters are unlikely to make it out of the series alive, and even if they do, it won’t matter, because a giant army of ice zombies is coming to eat the world.

And that’s what makes it brilliant. There are plenty of horrible, sexy things on television, and in these anxious times every novelist worth his advance seems to be turning his hand to grim dystopian fiction. The problem with most dystopias, though, is that they’re too predictable. They serve up worlds where, however awful things get, someone is at least in charge. They are comforting for that reason, in the same way as conspiracy theories are comforting. It is less distressing to believe, for instance, that a secret race of lizard people is managing the destiny of the human race than to believe that nobody is managing it at all.

Stories help us rehearse trauma. They help us prepare for it. You sit down to watch terrible things happening to made-up people and you imagine how you’d cope if that were you, or someone you loved, and even if the answer is “not at all” you find yourself feeling a bit better. Right now, the really frightening prospect is that the world is actually being run by vicious idiots with only half a plan between them who are too busy fighting each other to pay attention to the weather, which is about to kill us all.

That, along with the epic theme music, is why I still love Game of Thrones. It feels like aversion therapy for the brutal randomness of modern politics, with a side order of CGI monsters and a lot of shagging. There you go. I hope that’s given you all the excuse you need to tune in for season six. I did my best. If you need me, I’ll be behind the sofa. 

Laurie Penny is a contributing editor to the New Statesman. She is the author of five books, most recently Unspeakable Things.

This article first appeared in the 28 April 2016 issue of the New Statesman, The new fascism