Dying in Pain in the Global South



All of us have been close to the pain of a loved one at one point or another: a grandmother with cancer at home, a father in a cancer treatment center, a brother undergoing radiation or chemotherapy treatment. The sharp pain is there, but they don’t complain. They just furrow their brow. In the best case they moan. Pain medication arrives. A dosis every four hours. If the pain increases they call the nurse. We no longer hope for them to get better; we prefer the guilt of hoping they die in peace, because we know that this would be their relief: the hope that their last moments are pain free.

And this is not just cancer. Other chronic diseases are increasing the need for pain medication based on opiates, such as morphine, and other less strong medications, including codeine and tramadol.

Photo by: Flickr Creative Commons via  Reavel .

Photo by: Flickr Creative Commons via Reavel.

Access to medication to alleviate symptoms and pain is an essential element of palliative care. Palliative care seeks to improve the quality of life of patients facing chronic or terminal illnesses, alleviating their pain and other types of physical, psychosocial and spiritual problems. Far from a refined commodity in certain health systems, they have been recognized as a requirement of human rights. Various documents written by UN Special Rapporteurs against torture and the right to health, emphasized that the lack of access to medication to treat pain violates fundamental rights to health and the protection from cruel, inhuman, and degrading treatment. Flickr Creative Commons via Reavel

In spite of the imminent increment in its demand and importance as a human rights issue, access to opiate based medications is still limited in the global South. Although the administration of morphine forms part of the list of essential medications recommended by the World Health Organization, and its production is relatively inexpensive, as there are no patents, its access is generally restricted.

According to the numbers provided by the Pain & Policy Studies Groupregarding information offered by the The International Narcotics Control Board(INCB) on global consumption of morphine, or consumption per person in 2013, countries like Austria, Canada, Denmark, United States, and New Zealand make up the largest portion of consumption in the world. Other countries, the majority European, including Switzerland, Australia, the United Kingdom, France, and Iceland, also registered high levels of consumption, above the global average of 6.27mg per capita. In Latin America, the country with the highest consumption level is Argentina, which is close to the world average. All other countries in the region are below the average. The following map shows worldwide morphine consumption in the world for the year 2013. Countries marked in dark blue are those with the highest consumption.

According to a ‘Global Access to Pain Relief’, survey, more than 5 billion people live in countries with Little or zero access to pain treatment, including 5.5 million terminal cancer patients. The following map highlights the countries with the greatest number of people that die without access to pain treatment. Countries marked in dark blue are those with the greatest number of deaths without access to pain treatment.

In Latin America, various difficulties impede peoples’ access to this type of medications. Lack of knowledge on the part of doctors and healthcare providers regarding pain treatment contributes to the low prescription of this medication. For many doctors who were trained to heal, the idea of thinking about palliative care for death does not make sense. Only in two countries in the region, Chile and Cuba, is palliative care included in university curriculum as part of training in healthcare. Medical prejudice against opiates, fearing that their consumption will become addictive, is another reason that doctors do not prescribe them, even though it is demonstrated that addiction occurs in very few cases, and, even if it does, given the terminal nature of the illness, this is irrelevant.  Although there are debates regarding the use of opiates for illnesses other than cancer, their use for the treatment of cancer and terminal illnesses is generally accepted. Patients and their families also have the same prejudice, fearing a prescription for opiates due to the myths regarding their use.

The restrictive anti-drug policies in the world have also played a role. The international drug control regime incorporates obligations to guarantee access for medical uses, but in practice, States adopt controls to prevent traffic and unlawful use, which often are excessive for controlled substances. In the majority of Latin American countries, it is common for these medications to be prescribed only by special order, issued by central health offices, and their transportation requires reinforced security measures. All of this increases the cost of distribution. Although there are efforts within the United Nations to change this policy, the results of these efforts are still tepid.

Frequently, States import or acquire less medication than required because they calculate the consumption based on historical data that does not represent the real need of patients. There are also no effective distribution mechanisms for these medications within countries, which means that the little access to opiates that exists is concentrated in urban centers.

Pain relief should not be a luxury of developed countries. More than an economic issue, the difficulty is in the absence of knowledge and training of medical professionals, prejudice against their prescription, and excessive barriers that States and anti-narcotic agencies impose on their distribution.

A world without pain is possible. Medications to address the pain exist, are produced at a reasonable price. States and medical professionals can do much to reduce the gap that impedes access to these medications and make death a more dignified and humane process. Fear and prejudice cannot continue to be the guide for the construction of policies regarding access to opiates in the world. Not unless we want to continue to die in pain.


*Diana Guarnizo is a researcher and social rights coordinator, Center for Law, Justice and Society (Dejusticia).