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While the US suffers from a surfeit of mis-prescribed opioids causing unnecessary addiction and death, the bigger problem elsewhere is the lack of access to cheap drugs that would allow the sick to suffer less or die with dignity.

The Lancet Commission on palliative care, which published its findings last week, showed that while the use of analgesics more than doubled over the past decade, there was almost no change outside North America and western and central Europe.

More than 5bn people had little or no access to drugs like codeine and morphine despite the growing burden of cancer and other conditions. In the US, opioid overdoses killed 67,000 in 2016-17, making their abuse the leading cause of mortality for people under 50.

This “pain divide” is caused by factors such as an absence of training and awareness in medical professionals; limited financial resources; international trade controls and onerous regulation, not to mention fears of criminal prosecution, addiction and diversion.

“We have to speak about two crises,” says Felicia Marie Knaul from the University of Miami, a leading researcher on the commission. “A neglected pain crisis that affects the poor much more than the rich, and a very serious issue in a small number of countries of an opioid crisis. Regulation has focused more on limiting misuse, and non-medical use than guaranteeing access to pain relief. We call for a balanced approach.”


Three questions

We spoke to Natalia Kanem, new head of the United Nations Population Fund

What is the key message from your annual State of the World Population report out this week?

That economic inequality is reinforcing of and reinforced by reproductive health inequality. Not having very basic access to family planning for women leads to a societal inequality which does not bode well for peace. The life prospects, the essence of hope that tomorrow is going to be better, is [threatened]. The value of education to them opens doors so they can enter the labour force, have the respect of the community, and run for office. We’re concerned about retrogression.

What is your strategy as head of the agency?

We have three aims, to get to zero. Zero death in childbirth; zero unmet need for family planning — anyone who wants it has a method of their choice, at their location, at an affordable price; and zero violence against women and girls . . . including female genital mutilation. These are wounds to society that really have to be healed and prevented. We have lots to do and we feel [a need for] rapidity and urgency.

What is your message to Donald Trump after he stopped funding UNFPA?

My message would be to inform and accurately depict the work of UNFPA. We are in fact among the most effective champions of women's reproductive health and we do so from a rights framework. We felt a lot of sadness at the claim — which is erroneous — of coercive tactics. We defend the rights of women. We feel the money the US was contributing — almost $70m — was put to extremely good to use to save lives, to help women in refugee camps. We think this is such a worthy endeavour and every country has to show solidarity.

Watch our full discussion with Natalia Kanem on Facebook.


Chartwatch

Child mortality In 2016, 5.6m children died before their fifth birthday — almost half in their first month of life. 15,000 die every day, mostly from preventable causes, according to new UN data. Regional disparities are strong: One in 13 children in sub-Saharan Africa die before they are five, compared with one out of 189 in richer countries. (UNCME)


News round-up

Pollution peril Pollution kills more than nine million people a year — and 92 per cent of these deaths are in the world's poorest countries. Deaths from polluted water and dirty household air are falling, while those associated with industrialisation are rising. India (2.5m) and China (1.8m) are the most affected. (The Lancet, FT)

Health leadership The World Health Summit in Berlin called on governments to intensify efforts on global health; strengthen investments in health security to prevent pandemics; and protect workers in conflict zones. Philanthropy is no substitute, Bill Gates told the FT: “Compared to government aid money, it’s not the same order of magnitude.”(World Health Summit, FT)

Plague fears Cases of plague in Madagascar topped 1,000 with almost 100 deaths. The disease seems to us a medieval affliction but — largely due to poverty — it has never fully disappeared . (Reuters, FT, NPR) 

Gene therapy Likely FDA approval of a treatment developed by Spark Therapeutics has big implications for the way we fight illness and disease, essentially helping the body fix itself. But one-shot treatments come at a price: could this be the first million dollar drug? (FT, Stat)

Superbug struggle A new project will map the spread of disease associated with antimicrobial resistance and add the data to the Global Burden of Disease database. Drug resistant infections kill 700,000 people each year. (Cidrap, CNBC) 

Pharma Iraq row US veterans are suing AstraZeneca, General Electric, Johnson & Johnson, Pfizer and Roche, accusing them in effect of funding an Iraqi terrorist militia. The lawsuit accuses the companies of bribing Iraqi health officials who were under the control of the Mahdi Army. (FT) 

Drug price ding dong With action from the White House yet to materialise, US states are developing their own drug price policies, prompting battles with the likes of the Association for Accessible Medicines, the trade group for generic drugmakers. (FT)

US drug tsar withdraws Tom Marino, President Trump's nominee for drug tsar, withdrew his name after allegations he helped undermine the government's fight to stop drug companies selling various opioids. Former pharma exec Alex Azar is tipped to become health secretary after Tom Price stepped down over his use of private jets on official business. (FT, Politico)

Rise of the robots Japan is increasingly focused on robotic solutions to its demographic crisis and a looming shortfall of care workers. Lifting and chatting robots are already being deployed and future developments include self-driving toilets and mattresses with artificial intelligence. (FT)

Medical tourism eastern Europe is fast becoming a destination for medical tourism. Hungary has a specialism in dental services, the Czech Republic is popular for cataract surgery and Poland is well known for its plastic surgeons. (FT)

Obesity in India Improved standards of living, more automation and better transport are some of the factors that have turned India from a country known for malnutrition to one of obesity. By 2025 it could also be the diabetic capital of the world: more than 65m already suffer from the disease. (CNN)

Health trackers A new resource from UK health authorities combines indicators such as child obesity, drug treatment and sexual health to help policymakers and support local decisions about resources. The BBC launched a database to track hospital performance amid reports of NHS targets not being met. (Public Health England, BBC)

Virtual virtues Virtual reality technology is being used to train surgeons in simulated surgery environments and also to break American opioid addiction. (BBC video, Mosaic audio)


Best from the Journals

Dealing with Ebola Lessons from the west African Ebola epidemic include the need for improved hydration; better monitoring of vital signs; biochemical testing; improved staffing; and better availability of pain relief. Broader lessons can be applied to other epidemics. (The Lancet, Telegraph)

Public services Safe water, drainage, and sanitation are essential for public health. Governments must act to to make these services more resilient. (BMJ)

Magic mushrooms A study indicating that psilocybin — the psychedelic ingredient found in “magic” mushrooms — can help treat depression adds to others that show beneficial effects for other psychiatric conditions such as anxiety and alcohol abuse. (Nature) 

Exercise and age Older people can 'drop a decade' with regular exercise. (BMJ)

Self-harm shock A study charts an alarming 68 per cent rise in self-harm among 13-16 year old girls in the UK from 2011 to 2014. Children and adolescents who self-harm are much more likely to die at a young age. The likelihood of referral for help is lowest in poorer areas — the very places where incidence of self-harm is highest. (BMJ)


Podcast of the week

Healthy hearts What is the best way for doctors to educate patients about diet and exercise? (BMJ, 16m)


In case you missed it

Previous edition: World Bank says ‘go big, go fast’ to stub out tobacco

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Final thought

Menopause What if the menopause were something women thought positively about or could discuss openly without fear of derision? (The Conversation)

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