The influence of colonialism on the pain relief access abyss

This blog post was originally published by the EAPC blog and is available here.

Screams of pain punctuate households worldwide, but disproportionately more so in low and middle income countries.

Our home witnessed this for two years as my adoptive mother was ravaged by cancer. She was finally administered pentazocine two days before she died. It barely made a dent on the pain emanating from a backbone broken by cancer. As she took her last breath, we exhaled in guilty, tearful relief.

Twenty three years later, my biological mother lay dying of interstitial lung disease and needed oral morphine to ease her breathlessness. Despite working for a WHO Collaborating Centre for Training and Policy on Access to Pain Relief, getting access to these pills in the most populated state in India was a nightmare. Ironically, the same state where the only government-run opium and alkaloids factory is located. A local doctor reluctantly prescribed oral morphine, which was then sent from Kerala – an approximate distance of 1952 kms.

How did we reach a point where one of the oldest medicines in the world is so hard to access in a country where it has been cultivated and used medically for centuries? And what causes the access abyss [1] between the global north, primarily erstwhile colonisers, and the global south, entirely comprised of previously colonised countries?

Opium’s use throughout history has been extensively documented. But its entry into the arena as a feared and controversial ‘drug’ only happened in the 19th century.

Papaver somniferum, the opium poppy, transformed from traditional medicine used in small quantities into a currency of political economy alongside another main character—the deceptively innocent Camellia sinensis, or tea. These plants triggered a series of events that shifted the global power balance. Amitav Ghosh’s ‘Smoke and Ashes’ dives deep into how this came to be and illuminates some dark corners of colonial legacy. 

Under the Dutch and subsequently the British, opium travelled from India across South East Asia to China. It fueled Empire. The British East India Company became the world’s largest cartel and established a narco-state. When the Chinese tried to stop the trade, the British went to war under false pretenses of protecting free trade. They enforced legalisation, causing unfathomable harm to the local population of China and indentured labour in India.

In the post second World War era, after colonial entities withdrew from most colonies, they framed a new paradigm around controlled substances, within which they created international laws that served to ensure the power balance remained skewed.

While the United Nations Single Convention (1961) – which is still in use – allegedly seeks balance between the prevention of illicit use and access for medical and scientific purposes, it disproportionately focuses on control. Accountability lies with countries that grow, produce, manufacture and supply these substances. Effectively, what was previously a source of astronomical profit to colonialists is now regulated with harsh punitive measures in the very countries that were exploited. Katherine Pettus’s ‘Structural Imperialism and the Pandemic of Untreated Pain in the Asia Region’ [2] explores this in vivid detail.

Draconian laws that stemmed from the ‘war on drugs’ gatekeep access to opioids for pain relief. In India, it took nineteen years of relentless advocacy [4,5] by civil society to amend the Narcotic Drugs and Psychotropic Substances ACT of 1985, which was one of the greatest barriers to pain relief.

While the overdose crisis in the United States of America is an enormous tragedy, it overshadows the other opioid crisis that afflicts 80% of the world – that of inadequate access to pain relief. The dominant narrative makes millions in agony invisible, once again underscoring the disparate value placed on life in different parts of the world. This is also reflected in academia, in studies like the one done by Dobson and Blackhall [6] that question whether all people with life-limiting illnesses should be screened for misuse.

This remains a contentious topic, often viewed as a harm vs. value debate. What is harmful and what is valuable cannot centre around the needs of high-income communities but must be refocused through a postcolonial lens where the patient and their needs—in any part of the world—is the driver of policy and action.

Pain relief and palliative care must be urgently reimagined through a new framework—one that includes the countries with the highest unmet needs at the table.