Nagesh Simha knows about pain. He has had three kidney transplants, one of which led to such severe complications that he had to have both hips replaced. But when he's not a patient, he's a surgeon, supervising a cancer hospice in Bangalore - where he sees patients in what he calls the "catastrophic pain" that frequently accompanies the disease.
As a patient, Dr. Simha knows what opiates can do: the blessed relief from pain that cheap, simple drugs such as morphine can provide. And as a palliative-care physician, he knows that tragically few Indians who need that relief will get it.
"It's pathetic," said Dr. Simha, president-elect of the Indian Association of Palliative Care. "If there was any political will, this thing could be fixed in a week, and fixed very cheaply."
Drugs to control the severe pain of people with diseases such as cancer cost as little as two cents for a 10-milligram tablet, and India is one of the world's major producers. However, nearly all those drugs are exported. Due to a combination of bad laws, bungled bureaucracy and poor physician training, up to seven million Indians each year needlessly suffer acute pain, according to a report released yesterday by Human Rights Watch.
"India has many well-trained, sophisticated doctors at cancer hospitals who could easily treat pain but they don't have access to morphine and/or they have had no training on pain management," said Diederik Lohman, author of the report.
Eighteen of 29 main cancer centres do not have personnel trained to administer morphine and other strong pain medications. Morphine is available in even fewer AIDS-treatment centres, TB facilities and primary-health centres. Neither pain management nor palliative care is taught in the standard Indian medical school curriculum.
The report provokes the question of whether, with so many critical primary health- care problems, palliative care is a luxury India can afford to worry about. Mr. Lohman countered that the difference is that the pain problem could be quickly and easily solved. "You can't say that until malnutrition is solved in India you're not going to do anything else ... It would take very little to make morphine available and train doctors how to use it."
India's failure to provide pain management originates in excessively complex drug laws - which reflect, in part, a worldwide paranoia about the use of opiates, Mr. Lohman said - but here the problem has been exacerbated by a vast, slow-moving bureaucracy. In 1985, India introduced legislation to control illicit opiate use, but the law inadvertently made it extremely difficult for legitimate users to get access. Morphine treatment virtually disappeared overnight. Finally, in 1998, the central government drafted new regulation and suggested states use it, but two-thirds have yet to do so.
Because doctors are not trained in using the drugs, they do not create any demand for change, and continue to hold misconceptions about the potential for addiction and misuse of morphine.
Patients told Human Rights Watch that doctors ignored their pain, dismissed it as inevitable or offered acetaminophen; doctors described avoiding patients with pain because they had no way to help. Dr. Nagesh said those doctors were a minority - most simply had no concept of how great their patients suffering was, or how easily they could mitigate it. "The biggest obstacle is the medical profession itself.