Narcotics incite fear: doctors fear addicting patients, and law enforcement officials fear drug crime. And hence many governments, especially in the poorer regions like Africa, proclaim wholesale ban on drugs like morphine.
And it is the hapless poorer sections which pay a heavy price. People die a very painful death.
AdvertisementEsther Walker, a British nurse working in Sierra Leone, while giving a lecture on palliative care at the national medical school, asked her students, "Who has seen someone die peacefully in Sierra Leone?"
"Not one had," she said.
Often, the government elite who can afford medicine for themselves are indifferent to the sufferings of the poor, critics charge.
The World Health Organization (WHO) estimates that 4.8 million people a year with moderate to severe cancer pain receive no appropriate treatment. Nor do another 1.4 million with late-stage AIDS. For other causes of lingering pain — burns, car accidents, gunshots, diabetic nerve damage, sickle-cell disease and so on — it issues no estimates but believes that millions go untreated.
Figures gathered by the International Narcotics Control Board, a United Nations agency, make it clear: citizens of rich nations suffer less. Six countries — the United States, Canada, France, Germany, Britain and Australia — consume 79 percent of the world's morphine, according to a 2005 estimate. The poor and middle-income countries where 80 percent of the world's people live consumed only about 6 percent.
Some countries imported virtually none. "Even if the president gets cancer pain, he will get no analgesia," said Willem Scholten, a WHO official who studies the issue.
To complicate the issue further, many African countries have had a horrid history of drub abuse. Like in Sierra Leone where child soldiers were hardened with mysterious drugs with names like gunpowder and brown-brown, along with glue and alcohol.
Net result morphine is looked upon with such distrust that those who need them most are denied access. Even babies suffer.
Like Momoh Sesay of Sierra Leone, who tumbled into a cooking pot of boiling water. He was only given saline washes, and his dead skin was scrubbed off with debridement, a painful procedure. In New York, he would have had morphine.
So probably would Abdulaziz Sankoh, 7, in another bed, who has sickle cell disease. He moans at night when twisted blood cells clump together and jam the arteries in his spindly legs, slowly killing his bone marrow.
As would Musa Shariff, an 8-month-old boy whose scalp is so swollen by meningitis that his eyelids cannot close.
That flies in the face of Western medicine, which allows careful use even in premature infants.
But many government officials in Africa seem to think that scarce funds must go to the top five causes of death - diarrhea, pneumonia, tuberculosis, malaria and sexually transmitted diseases.
"I'm not saying that palliative care doesn't top the list, too," said Wiltshire C. N. Johnson, the chief of the enforcement arm of the National Pharmacy Board of Sierra Leon. "But it's officially a very small percentage of the requirement."
But then critics note that often the government elite who can afford medicine for themselves are indifferent to the sufferings of the poor.
Actually there were about half the six million cancer deaths worldwide last year were in poor countries, and most diagnoses were made late, when death was inevitable. But first, there was agony. About 80 percent of all cancer victims suffer severe pain, the W.H.O. estimates, as do half of those dying of AIDS.
At pain conferences, doctors from Africa describe patients whose pain is so bad that they have chosen other remedies: hanging themselves or throwing themselves in front of trucks.
Actually morphine's raw ingredient — opium — is not in short supply. Poppies are grown for heroin, of course, in Afghanistan and elsewhere. But vast fields for morphine and codeine are also grown in India, Turkey, France, Australia and other countries.
Nor is it expensive, even by the standards of developing nations. One hospice in Uganda, for example, mixes its own liquid morphine so cheaply that a three-week supply costs less than a loaf of bread.
Also doctors in developing countries often have beliefs about narcotics that prevailed in Western medical schools decades ago — that they are inevitably addictive, carry high risks of killing patients and must be used sparingly, even if patients suffer.
Pain experts argue that it is cruel to deny them to the dying and that patients who recover from pain can usually be weaned off. Withdrawal symptoms are inevitable, they say — as they are if a diabetic stops insulin. But the benefits outweigh the risks.
"Pain relief hasn't been given as much attention as the war on drugs has," regretted an expert.