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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Brexit would jeopardise the rights of working women

Europe isn’t perfect, but without it millions of women and millions of trade unionists would be at risk of Tory deregulation. 

One of the most important arguments in favour of staying in the EU is the protections that membership affords working people.

Whether it’s equal rights for part-time workers, the agency workers directive or limits on the length of the working week, we all owe the European Union and its Social Charter – campaigned for by a generation of trade unionists from across the continent – a great deal.

Outside of Europe British workers would find themselves worse off both in terms of their pay packets and the rights that they rely on. Add to that the reality that outside the EU risks being a place with lower public spending thanks to a troubled economy and rising privatisation of our public services, you can understand why the vast majority of British trade unions are recommending that their members vote to remain.

And for working women, the choice is starker still, because women have that much more to lose when rights and protections are stripped from the workplace.

Just think what EU law guarantees for all working people through the social charter, and how losing these rights (and putting the Brexit bunch in charge) would impact on things we’ve all come to rely on like maternity pay and guaranteed holiday pay.

Think about how much harder the struggle for equal pay will be if it’s not underpinned by EU law.

Think about how a Boris Johnson led Tory government – outside of Europe, on the fringes of global influence and under increasing pressure from UKIP to withdraw even further from the modern world – would attack your working conditions.

The Tory right – fresh from dragging our country out of Europe and away from regulations that help keep us safe at work aren’t going to stop there. Their next port of call will be other sources of what they deem “red tape” – like equal rights legislation that helps ensure women have all the same opportunities afforded to their male colleagues.

That’s something that matters to me as a trade unionist and as a woman.

It’s something that matters to me as Assistant General Secretary of a union with more than a million female members – UNISON, the biggest membership organisation for women in the country.

It matters to me as President of the TUC – when most trade unionists are women and when we have the first female TUC General Secretary in Frances O’Grady.

But most of all it matters to me because of the stories of all of the women I’ve met and am proud to represent who benefit every single day from Europe-wide protection of their rights.

What we face is the risk of losing those rights to a cynical and desperate campaign based around false promises and rhetoric from the Brexiteers. What we need in this campaign is some straightforward honesty. So here’s my position in a single sentence: Europe isn’t perfect, but without it millions of women and millions of trade unionists would be at risk.

I won’t stand for that. Neither should you. And neither should they either.

Liz Snape is Assistant General Secretary of UNISON and President of the TUC