There’s an article in the New York Times about the problems faced by doctors in India who want to prescribe morphine to terminally ill patients, especially those who are suffering from cancer.
The centerpiece of the article is a Dr. Rajagopal, who runs a palliative care clinic in Kerala, the one Indian state where morphine tends to be accessible. Dr. Rajagopal has been lobbying to make morphine more accessible to ordinary Indians nationwide.
About 1.6 million Indians endure cancer pain each year. Because of tobacco and betel nut chewing, India leads the world in mouth and head tumors, and has high rates of lung, breast and cervical cancer. Tens of thousands also die in pain from AIDS, burns or accidents.
But only a tiny fraction — Dr. Rajagopal estimates 0.4 percent — get relief.
Clinics dispensing morphine are so scarce that some patients live 500 miles from the nearest. Calcutta, a city of 14 million, has only one. (link)
Ironically, India grows the poppies from which much of the morphine used in western countries is derived. But government regulations (a highly familiar villain, in the Indian context) make it virtually impossible for ordinary people who are seriously ill to get access to it:
Elsewhere, the state laws enforcing the Narcotic Drugs and Psychotropic Substances Act, passed in 1985 to curb drug trafficking, are complex and harsh. The book outlining them is 1,642 pages, and even minor infractions can mean 10-year sentences. Legal morphine use in India plummeted 97 percent after 1985, reaching a low of 40 pounds in 1997. It has since crept up.
“India is a regulatory morass,†said David E. Joranson, director of the Pain & Policy Studies Group at the University of Wisconsin medical school. “It is controlled by the Ministry of Finance, and the rules are based on excise regulations that go back to the British Raj.â€
Each shipment requires five licenses. Pills must be locked in two-key cabinets. When patients die, families must return unused pills — sometimes a struggle in a country where the dead may be cremated with their medicines.
Many pharmacists just cannot be bothered.(link)
Obviously, simplifying the regulatory process would help this situation a great deal. One would obviously still want tight control and monitoring of the morphine that is dispensed, but not so much that it discourages the use of the drug where it could be of help.
There is some hope. At the end of the Times piece, the reporter describes an interview with Dr. Anbumani Ramadoss, a Cabinet Minister at the Ministry of Health and Family Affairs, who has expressed support in Parliament for greater emphasis on pain relief in the Indian health system.
Does anyone have personal experience (i.e., with friends or family) of trying to get access to painkillers or palliative care in the Indian health system?
I had realized this irony earlier when reading the CIA World Factbook entry for India:
I remember thinking that: 1. People chew tobacco. 2. People get cancer. 3. People don’t/can’t get cured. 4. People are in pain. 5. People can’t get morphine to ease the pain.
Instead, people might as well chew opium instead of tobacco and have a happier and more mellow time all round.
Instead, people might as well chew opium instead of tobacco and have a happier and more mellow time all round.
On a related note, as I was reading the Times piece I was wondering about whether village/folk doctors (Hakims) dispense unlicensed bhang as a painkiller…
Yes, Cancer like amny others is still the rich mans disease in India. The bureaucratic system is also terrible. By the time a bill is passed in the senate for easy presciption of morphine, there will be other laws which will make it impossible for the rightful people to obtain some.
how is cancer a “rich mans disease”. i would imagine poor people can get the big C just as easily as anyone else.
I don’t know if this statement was intended to be sarcastic, but cancer is not strongly correlated with prosperity in India (not as much as diabetes). The Cancer Institute in Madras gets a very wide spectrum of social strata, from all sorts of causes. That said, there may be some correlation with prosperity based on the causes – cigarette smoking more prosperous than beedi smoking slightly more prosperous than chewing or snuffing tobacco. And then there’s the whole crowd of patients who never used tobacco in any form, where one really cannot see any stratification of prosperity levels.
I think she means only the rich can afford the treatment.
one of my relatives, backed by family USD, receiving “rich persons” cancer treatment in india, got really bad treatment from her doctor. ended up dying when another relative in the US had the same problem, and lived. and, this was in a tricked out “high quality” hospital. its scary what it would be like to be poor out there.
Puli, It is difficult to comapre the 2 scenarios. Even though they got the same treatment and had the same disease, the one who lived may have a good resistance power. This depends on climate, diet, excercise and also genetic make up. Hence you cannot compare these two cases by saying that the relative died because she got her treatment in India and not the US.
the aunts kids told some of our doctor relatives in the us what treatment she was getting, and the advice she was getting. they said that the advice and treatment was “incompetant and wrong” and if the doctor was in the us, they could “sue them into the ground”
Well it is not surprising how doctors differ in their approaches! A doctor who has just “heard” about a case will obviously have a different opinion than a doctor who has actually seen the patient! The US doctor cannot guarantee that if your relative had her treatment in the US as opposed to India she would have lived!
dont want to go into any more details of this, but some of the stuff was just openly messed up.
I know for a fact that credentialing and continuing education requirements in the US are VASTLY greater than in India. The threat of being sued also helps keep physician quality pretty high in the US. So, on average, I would agree with you, Puli. That said, you couldn’t rule out individual differences in any specific case. Sometimes, the same decision by the same physician leads to different results in different patients.
Wrd!
in addition to #10 and #12, it should also be mentioned that india these days is big into medical tourism. methinks perhaps the best doctors go where the money takes them, a.k.a. where the foreigners are. which might be another reason for substandard treatments, even in big hospitals.
also, wrt #3:
did you mean parliament? there’s no senate in india.
Amardeep, I dont know if this can be classified as an urban legend but I heard that many “nannies”/ayahs use opium as a way to keep their charges under control…..
You definitely have a point that palliative care is lagging in India .The other area of medicine that is neglected is trauma care ( ER type )
Re: quality of medical treatment in India :usually you get what you can pay for. I have some medical professionals in the family and I know for a fact that for example: cardiology treatments in India are equivalent to the best in the West in some hospitals.To be noted: these are the type of 5 star hospitals that cater to a large number of medical tourists as well as the well -off patients .$ to rupee the conversion rate still works in India’s favor. Other treatments available that are totally on par with what you get here are fertility treatments and standard stuff like hip replacement surgeries. Of course, there are always cases where there is malpractice which I think is the case anywhere in the world
i would go LIVID if someone drugged my kids…
Again,I want to emphasize that this may be an urban legend ….evidently very mild doses of opium are used in rural areas as a palliative /sophoric for kids ….
that wouldnt make me go mildly livid. there would be hell to pay. heads would roll.
Up until the creation of the FDA, a lot of kids’ medicines in the US contained alcohol or even codeine, for the same reasons. Scary!
Was this during the Raj? Those wiley ayahs creating an entire generation of sleepy, smack addicted little sahibs/memsahibs…
I am sure that if its a legend it started then …. the lady who used to cook for my mom swore that it happened in her village in the 70s….
No wonder its been so difficult to score some percocet-equivalent when travelling over there. Shoot.
This article has got me all confused. Getting opium and heroin and every other kind of drug is a breeze in India. Who bothers with a prescription? I just don’t understand. Is this about super-rich people trying to do things within the system and complaining that it’s too hard? Of course it is, that’s why India’s got such a bustling black market–for everything.
Doctors trying to prescribe? Prescription? I never heard of such a thing.
Harbeer, you’ve never heard of a prescription?
Very true all this. My father died of cancer a few years ago in Calcutta but was able to get morphine towards the end. This was in part because my sister was a Doctor at the one center that the NYT mentions (its called the Thakurpukur Center) and for a while I think even headed a division there. Despite having this fabulous inside connection (and I insist that there is absolutely zero bribery at this center) which works wonders in India as we all know, I still remember the papers and then the number of locks and keys that opened drawers then cupboards and then a small steel almirah that housed a few precious small bottles. I think this really is a case of scarcity of funds and resource allocation and perhaps not so much a matter poor people being screwed. Morphine is expensive, its a poor country, the govt. has to realize this and try to spend more on palliative care.
There is nothing unlicensed about bhaang in India. I have seen ‘Government Bhaang Center’ in Bhopal, M.P. I only wish I got like a videshi and took pics of it. I also mildly wish I’d bought it and obtained a receipt of the thing!
But amazing about the morphine handling laws. Kills drug trade, also patients with pain. But who cares, the system is usually made to work like Round-up – torch it all!
Sorry, ignorant question: what exactly is bhaang?
@Puliogre in da USA, pingpong ,Shodan
Yes Shodan, i did mean that only the rich can afford to atleast get some treatment for the dreaded disease. Not only in India, the scenario is the same in the US.
Sorry, ignorant question: what exactly is bhaang?
Sarah, it is usually spelled “bhang”. It’s an opiate that goes into a drink people commonly imbibe on holidays like Holi. As I understand it, it contains opium, not cannabis; I think Wikipedia might be wrong.
That sounds really, really pleasant…
I could be wrong, but I thought that bhang was made from marijuana leaves. So, wouldn’t that imply it contains cannabis and not opium? And yes, there are government shops in U.P. that sell bhang – it’s used in drinks during Shivratri (a religious festival) too.
hmm, well i’ve never had it in India, but the American campus version most certainly contained a fat-reduced THC derivative. No substitute for morphine, though, for palliative care.
There’s an American campus version? Damn. Clearly I went to the wrong college. OK, time to stop derailing the thread.
This is absolutely true. My grandmother is on Medicare. When she was diagnosed with stage 4 small-cell carcinoma lung cancer, Medicare denied her access to chemotherapy because they said she was too far advanced. They were perfectly willing to let her die. My grandparents are particularly poor– just average working class retirees– but they certainly can’t come up with the cost of chemo out of pocket. I am livid just typing this.
The drug companies are taking advantage of the dearth of care to recruit subjects for their drug studies. My grammy happened to get lucky and qualify for one; the drug being tested turned out to be extremely effective on people with a specific genetic mutation she happens to have, and she’s still going strong nearly three years after they told her she had 4 months to live. But if she hadn’t gotten lucky… the system would have left her for dead.
i found this related article truly heartbreaking in so many ways.
That should say not particularly poor.
cancer can affect anyone, but the reason why cancer might be considered a “rich man’s disease” is because the biggest killer of people in the developing world (which is most of the world) is NOT cancer–it’s infectious disease (like malaria, HIV/AIDS, etc) and the thing that kills the most children outside the western world is diarrhea, presumably from infectious disease.
cancer can affect people of all ages, but one theory is that it happens when one is past their reproductive prime, and from an evolutionary standpoint, the body doesn’t function the way it once did because it no longer has that “need” to protect itself from death. anyways, so though some children get cancer, it primarily is a disease of the old.
that is, you have to live long enough to get it. many poor people in developing countries don’t live that long. there’s a disproportionate amount of funding spent on cancer research and cancer cures, while research on infectious diseases and their cures aren’t quite as robust since making drugs and such wouldn’t be profitable to pharmaceutical companies–hence less incentive to find cures.
Having lived now on 3 continents, I cna say one ting: Quality of medical care in India (when you have even moderate money and/or medicare) is absolutelyu great – even better than the cedar sinai variety. I have vsiisted (thanks to a congenital issue) most major hospitals everywhere and I have come to rely on many in India, esp. Lilavati Hospital and Breach Candy in Bombay. When I last stayed there, the kindest nurses with broadest smiles really eased my pain and anxiety. In New York, was left to languish in a no man’s land somewhere betwixt Admissions and the Doctors’s office. This was with full corporate insurabce and multiple personal calls from my Doctor to the hospital. The pain was severe anmd I ended up fainting. The care I eventually got was FIRST CLASS —technically, but where was the car that makes it human?
Now cancer is another beast. It is too unknown and the variability is huge. IN the end, each doctor is an alchemist. I am particularlyu impressed that in India some of the brightest hit medschool and work in rural areas and government hospitals. The car is not great here not because of the doctors who are great but lack of infrastructure.