Every day in his work at the regional cancer centre in Rohtak, in the north Indian state of Haryana, Dr Ashok Chauhan sees patients in the agonising pain that accompanies the final stages of cancer.
Most of them are too sick to be cured, so Dr Chauhan and his colleagues try to do the only thing they can – provide relief from the intense suffering.
To do this he needs morphine, a drug that has been the gold standard of relief from severe pain for centuries and which India produces in huge quantities.
The problem is that this centre, like many others in India, has run out of the drug and all Dr Chauhan can do is send the patients or their relatives to the nearest supplier in Delhi – ovber three hours away by road.
“It’s very sad. We are as frustrated as the patients,” said Dr Chauhan. “When they have to travel to Delhi to get it, it adds to their misery.”
The acute shortage of oral morphine in Haryana and many other Indian states is a result of complex Indian narcotics laws that are based on rules for the sale of opium that date back to the time of the British Raj.
In a report published last October, Human Rights Watch estimated that up to seven million Indians with diseases such as tuberculosis, Aids and cancer suffer excruciating pain unnecessarily every year because of restrictions on morphine and the lack of palliative care.
“India is one of the world’s largest legal producers of opium, the raw material for morphine,” said Diederik Lohman, a senior health and human rights researcher at Human Rights Watch.
“But almost all of it is exported while millions of Indians who need it suffer needlessly.”
India emerged as one of the world’s biggest producers of opium in the late 1700s when the British began to cultivate the opium poppy on the subcontinent so it could ship vast amounts of the drug to China to ease a trade deficit.
The British brought production of the drug under central government control and placed internal taxes, or excise duties, on the opium so as to limit domestic consumption in India.
On independence in 1947, India inherited this system and continued to grow opium, which was by then mainly used to produce medical morphine at home and abroad.
But in 1985, as part of global efforts to curb the illegal narcotics trade, India enacted a law that tightened rules on the growth of opium and the production, sale and procurement of morphine.
Suddenly, Indian hospitals and pharmacies had to obtain five licences – including from the excise department – to buy and store the drug, and violations were to be punished by mandatory jail time.
The result was that morphine treatment virtually disappeared overnight.
“It’s an unintended consequence of the global war on drugs,” said Mr Lohman.
In 1998, the government realised that the law was preventing its citizens from receiving the care they needed, so it drafted a new one to simplify the procedure.
However, more than a decade later, only 14 of India’s 28 states and one of its seven union territories – Delhi – have enacted the law. Haryana has not.
Regional cancer centres such as the one in Rohtak, which are funded by the federal government, also come under the new rules, but that still does not guarantee an uninterrupted supply of morphine.
Because other hospitals and pharmacies are not covered by the new rules, there are no alternative sources when the cancer centres’ stocks run out.
And even in some states where the new law – under which only one licence is required – has been adopted, there is still no morphine.
Part of the problem, say palliative care experts, is that years of unavailability have meant most doctors are unsure how to prescribe the drug.
This coupled with the fact that many medical schools still emphasise the negative effects of morphine – such as addiction and respiratory failure – over the positive ones, means hospitals often do not demand the drug.
“It’s something in a textbook, it’s not reality.
“The doctors don’t know it and therefore they don’t use it,” said Dr MR Rajagopal, chairman of Pallium India, a Kerala-based charity that provides palliative care.
Dr Rajagopal, who also runs workshops across India to educate doctors on pain relief, said only a handful of India’s 300-odd medical colleges teach palliative care as part of the curriculum. “The idea in India is that if you have cancer and it can be cured you will suffer until it is cured. If it cannot be cured, you will suffer until the end.”
And while the cost of the drug – less than US2 cents (Dh7 fils) a tablet – means that most Indians who need it can afford it, the price also deters pharmacies from stocking it, as they do not want to waste time applying for licences for a drug that produces tiny returns.
Thus, although the roads leading to the cancer centre in Rohtak are lined with chemist shops, none of them sell the small blue tablets that could give the terminal patients the relief they need.
On a recent day, five people had been in to get their monthly supply of morphine, but all had left empty-handed.
The doctors say the patients and their families, most of whom are poor farmers, accept the fact that they will have to travel for hours to Delhi.
“After all,” says Dr Vivek Kaushal, one of the senior doctors at the centre, “when you are in that much pain you will go to any lengths to get the medicine you need."
February 8, 2010
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