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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A tale of two electorates: will rural France vote for Emmanuel Macron?

His chief rival, Marine Le Pen, was campaigning as the “candidate of the forgotten” years before Donald Trump entered politics.

It was a wet night in Paris, but hundreds of people were queuing outside the Antoine Theatre. It was standing room only to see Emmanuel Macron tonight, as it has been for weeks.

The 39-year-old former investment banker gave his usual energetic performance, delivering a well-practised pitch for a progressive, business-friendly and unabashedly pro-European France. His reward: a standing ovation and chants of Macron, président!

This theatre appearance on 8 March was an appropriate stop for a campaign that has been packed with more political drama than a series of House of Cards. Ahead of the first round of voting in the French presidential election on 23 April, the centrist independent has gone from underdog to the man most likely to beat the Front National’s Marine Le Pen. His other main rival, François Fillon of the right-wing Republicans, has been hampered by allegations that he paid his wife and children as parliamentary assistants, despite scant evidence of them doing any work.

Macron, meanwhile, has been attracting support from disenchanted voters on both left and right.

“It’s a new party, a new movement, a new face,” said Claire Ravillo-Albert, a 26-year-old human resources student and ex-Socialist in the queue outside the theatre. “We’re worlds away from the old Socialists and the Republicans here.”

Macron is not a typical outsider, having made millions in banking before serving as an advisor to François Hollande and as economy minister from 2014 to 2016. Nor can his ideas be described as radical. He is “of the left”, he says, but “willing to work with the right”.

For many he seems to embody an enticing alternative to the tired political class. Macron has never run for office before and if successful, would be the youngest president of the modern French republic. Many recruits to his one-year-old party En Marche! are young and relatively new to politics.

“I think he’ll change the French political landscape, and we need that,” said Olivier Assouline, a bank worker in an immaculate grey suit. “He knows business, he knows the state. I think he’s the right person at the right moment,” said the 44-year-old, who previously voted for right-winger Nicolas Sarkozy.

Many queuing for the rally were underwhelmed by Socialist achievements over the past five years – not least the dismal state of the economy – and had little enthusiasm for Fillon, a social conservative and economic Thatcherite.

Macron’s manifesto sticks firmly to the centre-ground. He has promised tax cuts for companies and millions of poor and middle-class families, as well as a few offbeat ideas like a one-off 500-euro grant for each 18-year-old to spend on books and cultural activities.

“With his central positioning, Macron is taking from everywhere – he has the capacity to seduce everyone,” says Frédéric Dabi, deputy director at the polling company IFOP. They estimate that Macron will take half the votes that went to Hollande when he won the last presidential election in 2012, and 17 per cent of those that went to runner-up Sarkozy.

Outside the theatre, the line was split between voters from the left and the right. But there was one word on almost everyone’s lips: Europe. At a time of continental soul-searching, Macron’s converts have chosen a candidate who backs the European Union as a guarantor of peace and celebrates free movement.

“He’s unusual in that he puts that centre-stage,” said Emma, a 27-year-old legal worker who preferred to be identified by her first name only. “Macron offers a good compromise on economic issues. But for me it’s also about Europe, because I think that’s our future.”

With Fillon and Socialist candidate Benoît Hamon both languishing behind in the polls, the second round of the presidential vote, on 7 May, is likely to be a contest between Macron and Le Pen. These are both candidates who claim to have moved beyond left-right politics, and who are both offering opposing visions of France.

This is also a tale of two electorates. Le Pen was campaigning as the “candidate of the forgotten” years before Donald Trump entered politics, traipsing around deindustrialised towns appealing to those who felt left behind by globalisation.

In the queue to see Macron were lawyers, PR consultants, graphic designers; students, gay couples and middle-class Parisians of multiple ethnicities. These are the representatives of a cosmopolitan, successful France. It was hard not to be reminded of the “metropolitan elite” who voted against Brexit.

Macron has called for investment in poorer communities, and his campaign staff pointedly invited onstage a struggling single mother as a warm-up act that night.

Yet his Socialist rival, Benoit Hamon, accuses him of representing only those who are doing pretty well already. It is hard for some to disassociate Macron from his education at the Ecole Nationale d’Administration – university of choice for the political elite – and his career at Rothschild. One infamous incident from early in the campaign sticks in the memory, when he told a pair of workers on strike: “You don’t scare me with your t-shirts. The best way to pay for a suit is to work.” For Macron, work has usually involved wearing a tie.

IFOP figures show him beating Le Pen soundly in when it comes to the voting intentions of executives and managers – 37 per cent to her 18 per cent. But when it comes to manual workers, she takes a hefty 44 per cent to his 17. He would take Paris; she fares better in rural areas and among the unemployed.

If Frédéric Dabi is to be believed, Macron’s bid for the centre-ground could pay off handsomely. But not everyone is convinced.

“He’s the perfect representative of the electorate in the big globalised cities,” the geographer Christophe Guilluy told Le Point magazine in January.

“But it’s the peripheries of France that will decide this presidential election.”