For some of us, it will be the worst scene we ever experience. You are sitting in a doctor's office; they enter with a look of practiced concern, and say, "I'm afraid I have some bad news."
The doctor explains your options. Surgery, chemotherapy, radiation, dialysis: all the dizzying vocabulary of serious illness. It is terrifying and your life will never be the same.
If you live in the rich world, however, you should be able to take some small comfort in one thing. As you progress from treatment to treatment, you will be given medicine to manage your pain. You will not have to undergo surgery without anaesthetics, and right up to the end – should it come to that –you will have a range of options to reduce the sheer physical suffering you endure.
Thanks to international drug laws, millions of people across the Global South face serious illness without even that tiny consolation. The structure of international drugs prohibition puts pressure on individual countries to restrict supplies of morphine and other opiate-derived pain medication, meaning that sick people are often simply denied treatment. Ninety percent of the world’s morphine distribution goes to the richest 10 percent of its population. This is the world’s other opioid crisis – the hidden epidemic of poor people forced to suffer and die in needless agony.
The NGO Health Poverty Action recently released a report on the lack of medical provision for pain in India. I spoke to Natalie Sharples, who coordinated the report, to discuss their findings. "India is a particularly telling case," she begins. "It's the world’s number four producer of legal opium, but its provision of morphine for pain relief is one of the lowest in the world."
The figures for India are shocking. During palliative care – when a patient is dying and the only goal is to manage their suffering – the medical system there provides 43 milligrams of morphine per patient, meeting only about 4 percent of actual need. In contrast, Canada, for example, has 68,194 milligrams per patient.
Opiate pain relief is not expensive medication to provide. To manage the pain of a cancer patient with generic drugs can cost between $2 (£1.50) to $5 (£3.80) a month. In fact, the very cheapness of these medications can lessen the incentives for drug companies to provide them. There is simply less money to be made in providing cheap, effective pain relief than in charging patients over-the-odds for more expensive solutions.
This leads to a perverse situation, highlighted by the HPA India report, in which patients who can afford private health care can receive fentanyl patches – a more expensive but far less effective form of pain relief – while poorer Indians are denied the cheap, efficient opiate-derived solutions plentiful in their own country. The same profit motive that led to rampant over-prescription of opioids in the US is leading to the denial of essential medication to poor people across the developing world.
Ultimately, however, this is not about price. It's about the structure of international drugs prohibition. Natalie Sharples continues: "Countries across the world come under enormous pressure to 'crack down on drugs'. That pressure filters down into domestic politics, into state-by-state policy – and eventually right into doctor's offices in cities and villages.
"What our researchers heard over and over again is doctors saying the process for getting a license to prescribe opioid pain relief is so complex, expensive and tedious that it's simply not worth it. Oversight is so strict that doctors can face long prison sentences for even fairly minor clerical errors – so, of course the majority of doctors just avoid it altogether. Wealthy countries with advanced healthcare systems manage to navigate this; they know their patients will demand, and feel entitled to, pain management, so the burden falls massively disproportionately on poorer countries."
This is borne out by the data. India's Narcotic Drugs and Psychotropic Substances Act was passed in 1985, designed to bring the country in line with the 1961 UN Single Convention on Narcotic Drugs – the legal basis for all international drugs prohibition. The effect on the provision of pain relief was catastrophic. By 1997, medical morphine consumption had dropped 97 percent, to just 18 kilograms for the entire country. Of 300 medical colleges in India, only five give training to safely prescribe opioids for palliative care.
Global drug prohibition is monitored by the International Narcotics Control Board (INCB) – the command and control centre of the war on drugs. The INCB is meant to serve a dual purpose, to facilitate access to drugs for medical purposes and to maintain pressure on individual governments to prevent their illicit use. The problem is that countries have pumped billions into the second part of that mission, while neglecting the first.
In order to import opioid painkillers, countries must submit an estimate of what they will need to the INCB for approval. Ask for too much and they risk getting refused and attracting unwanted attention. Most countries base their estimates by looking at past usage. Senegal, for example, has asked the INCB for roughly similar amounts of morphine since the 1960s – despite a massive rise in population and more people surviving to the point where they need to manage chronic conditions and palliative care. In 2013, Senegal applied for just 1 kilogram of morphine – only enough for around 200 patients with advanced cancer.
This pattern is repeated across the world. In 2014, Vyacheslav Apanasenko, a retired admiral in the Russian navy, shot himself with his ceremonial revolver after being denied pain relief for cancer. His suicide note read, "I ask you not to blame anyone except the Health Ministry and the government." The Lancet, a British medical journal, estimated that 40 Russians committed suicide that year because of untreated pain.
When one begins digging into this, the stories are utterly appalling. Children in Nigeria with gas burns covering half their body denied medication; mothers watching their children suffer with cancer, unable to give them anything except a damp cloth on the forehead; people staggering for miles with maggot-infested wounds, only to be given over-the-counter painkillers. If these conditions appeared in a western country there would likely be a revolution – yet they are forced onto the Global South by international drug policy. The line of complicity is direct from the committee rooms of the UN to the streets of the developing world.
Sharples is also keen to highlight the knock-on effects of these policies. "What happens is that because of the restrictions, pain relief only becomes available in very few hospitals dotted around the country," she says. "So, in order to travel to those places, families put themselves in debt. It becomes a massive poverty trap, as people are unable to work, but keep going further into debt. But this is their only chance to access the medication – the alternative is to watch their loved ones suffer. So the effect is not only on the patient themselves, but on families, communities and wider society. It’s an issue for global development.
"An end to international prohibition would mean not only rationalising the processes by which these drugs are provided, so that poor people can access them without systemic block, but also a deep process of undoing the stigma around these essential medications that the propaganda of war on drugs has produced."
In 1998, the UN Office on Drugs and Crime committed itself to moving towards a "drug free world". In 2009, they re-committed themselves to that objective, setting 2019 as a deadline. To see how well that has worked out, click on any news website any day of the week. The world is manifestly not "drug free", and the harms from the trade are increasing.
Perhaps we should also stop and consider that rhetoric around a "drug free world" includes drugs that people actually need. If anything, this might be an indication that it’s time for our entire conversation around "drugs" to grow up. The harms of the global war on drugs are varied and horrific. But a situation where poor people with cancer die in agony, which would be easy and cheap to avoid, must be simply too grotesque to ignore.