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Pain-relief shortage in poorer countries ‘due to stigma of US opioids crisis’ | Global development

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Patients suffering chronic pain are being denied treatment in low-income countries because of restrictive laws and concerns about opioid addiction, which have been fuelled by the crisis engulfing the US.

Palliative doctors, who say there is a huge unmet need for pain-relief drugs in poorer countries, have called for laws to be relaxed and for the stigma around opioids to be addressed.

Only 17% of the morphine produced worldwide in 2020 for medical purposes was consumed in low- and middle-income countries, despite them being home to close to 83% of the global population, according to the latest figures from the International Narcotics Control Board, which monitors drug use. It said the imbalance in usage has barely changed in 20 years.

A 2017 Lancet commission study found that Haiti received an annual average of just 5mg of morphine-equivalent opioids for each patient requiring palliative care – 0.8% of what is needed – compared with the US, which received 55,000mg for each patient, more than 3,000% of the required amount.

“What I witness myself every day are people who have been on disease-specific treatment going through pain and suffering through weeks, months or years,” said Dr MR Rajagopal, the chairman of Pallium India, a palliative care charity based in Kerala. “At least 96% of them in my country eventually are denied pain relief. I have seen several people with scars around the neck from attempting to kill themselves by hanging.”

Rajagopal said very few patients reached palliative care clinics where they could finally access pain-relief drugs suitable for their conditions and that doctors were often scared to prescribe them.

Biochemist Denys Rukarata tests locally produced oral liquid morphine for purity at the Pharmaceutical Laboratory of Rwanda.
Biochemist Denys Rukarata tests locally produced oral liquid morphine for purity at the Pharmaceutical Laboratory of Rwanda. Photograph: Ben Curtis/AP

He said draconian laws grew out of a 1961 international treaty that emphasised the control of opioids in order to stop drug abuse. The resulting global “war on drugs”, which effectively criminalised production and supply even in medical contexts, led hospitals and pharmacies to stop stocking opioids. The result, he said, was that India’s use of opioids dropped from 600kg a year in 1985 to 17kg in 1997.

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A common condition

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The human toll of non-communicable diseases (NCDs) is huge and rising. These illnesses end the lives of approximately 41 million of the 56 million people who die every year – and three quarters of them are in the developing world.

NCDs are simply that; unlike, say, a virus, you can’t catch them. Instead, they are caused by a combination of genetic, physiological, environmental and behavioural factors. The main types are cancers, chronic respiratory illnesses, diabetes and cardiovascular disease – heart attacks and stroke. Approximately 80% are preventable, and all are on the rise, spreading inexorably around the world as ageing populations and lifestyles pushed by economic growth and urbanisation make being unhealthy a global phenomenon.

NCDs, once seen as illnesses of the wealthy, now have a grip on the poor. Disease, disability and death are perfectly designed to create and widen inequality – and being poor makes it less likely you will be diagnosed accurately or treated.

Investment in tackling these common and chronic conditions that kill 71% of us is incredibly low, while the cost to families, economies and communities is staggeringly high.

In low-income countries NCDs – typically slow and debilitating illnesses – are seeing a fraction of the money needed being invested or donated. Attention remains focused on the threats from communicable diseases, yet cancer death rates have long sped past the death toll from malaria, TB and HIV/Aids combined.

‘A common condition’ is a new Guardian series reporting on NCDs in the developing world: their prevalence, the solutions, the causes and consequences, telling the stories of people living with these illnesses.

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He said advocacy efforts had helped relax regulations in Kerala and other parts of India, but that still only 350kg of opioids a year were being consumed, whereas he estimated that 30,000kg were now needed.

Gary Rodin, who is the director of the Toronto-based Global Institute of Psychosocial, Palliative and End-of-Life Care and has carried out research into habits of prescribing opioids, said the increase in rates of diseases such as cancer and diabetes in low- and middle-income countries demanded greater emphasis on relieving pain and psychological distress.

“Maybe 100 years ago that would have been a large part of medicine. As medicine has gotten more specialised and technologised, people have paid more attention to Cat scans and MRIs and blood tests than they have to the suffering of the patient. They haven’t asked enough about the suffering,” he said.

That has resulted in more aggressive chemotherapy treatment, Rodin said, even at stages when it is unlikely to work and when the body struggles to handle it.

“Suicide rates are very high in advanced disease. Psychological distress is very common; family distress is very common. There are lots of approaches which we have evidence will help, but we don’t do nearly enough to support that.”

OxyContin maker Purdue Pharma has had to settle thousands of lawsuits over its role in the US opioid crisis.
OxyContin maker Purdue Pharma has had to settle thousands of lawsuits over its role in the US opioid crisis. Photograph: Toby Talbot/AP

Palliative care can be a cheaper way to ease the suffering of terminally ill patients and could be made more available by relaxing laws and training healthcare workers to administer painkillers and ease psychological distress, Rodin said.

Julia Downing, the chief executive of the International Children’s Palliative Care Network, said neglecting a patient’s pain can have a significant impact on their quality of life.

“The implications are quite broad … If they’re unable to work, the family will become poorer and poorer, and then they can’t pay for school fees, so the children can’t go to school. The impact of having people whose pain is not controlled goes far beyond just that individual themselves,” she said.

Rajagopal said the US opioid crisis has affected how opioids are viewed globally, fuelling fears among doctors that patients who are prescribed them will become addicted. However, he said, addiction in the US was specific to that context, where pharmaceutical companies aggressively marketed opioids.

In the US, the CDC estimates that 75,673 deaths were caused by opioid overdose in the 12-month period ending in April 2021.
In the US, the CDC estimates that 75,673 deaths were caused by opioid overdose in the 12-month period ending in April 2021. Photograph: Spencer Platt/Getty Images

“Pain is not visible. It happens in hospital beds or patients’ rooms and is not visible to the world. Addiction, on the other hand, is very visible in headlines which quote the US epidemic and overdose deaths. No one talks about the western European success over decades; all the news is about the opioid crisis in the USA. This means that when we try to have discussions, our work becomes harder because many minds are primed against opioids,” said Rajagopal.

Downing said progress has been made in Uganda, India and Kenya but more needed to be done not just on legislation but also on training medical staff.

Zipporah Ali, a Kenyan palliative care doctor, said some progress has been made in her country to relax opioid laws.

“There was a time a patient came to me in so much pain with a neck tumour that was so swollen, he just wanted to die. But I started him on treatment with high doses of pain management and steroids. The next week in the hospital he came and grabbed me to say: ‘Thank you. I don’t want to die any more.’” said Ali. “We are not curing the disease, but it can make you comfortable.”

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Nancy Pelosi: Pelosi’s visit to Taiwan revives the debate on international recognition of the island | International

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Nancy Pelosi’s brief and controversial visit to Taiwan could not have incited more contrasting reactions from the governments on either side of the Formosa Strait. President Tsai Ing-wen’s administration received the speaker of the United States House of Representatives with everything but a fireworks show, projecting flamboyant welcome messages on the island’s tallest building. Beijing, on the other hand, responded to what it considered a “blatant provocation” with a week of unprecedented military exercises. The superpower has also cut ties with Washington on key topics and recently published the first official report on Taiwan in two decades. Its aggressive reaction has brought to the forefront the debate about international recognition of the island, which functions as a state but is recognized by only 14 countries.

“My friends and I were very excited for a figure like this to come. It’s good to attract attention,” says Sun Hui’an by phone. “We are used to threats from China. We can’t let it dictate our lives,” adds the 29-year-old nurse.

Formosa was the place to which nationalist leaders and around a million people fled after the victory of the Communist Army in 1949 in the civil war. While in mainland China Mao Zedong declared the founding of the People’s Republic, Chiang Kai-shek, the leader of the Kuomintang (the formation that had presided over the country between 1927 and 1949), established a government in exile in Taiwan. Not until the 1970s did the United Nations and most Western countries began to recognize Beijing as the legitimate government of China, to the detriment of Taipei.

Taiwan is not a special administrative region of China like Hong Kong and Macau. It has a democratic government, a constitution and an army of 300,000 soldiers. It ranks as the 21st largest economy in the world, and it is the leading producer in the semiconductor industry. In 2019, it became the first place in Asia to legalize marriage between same-sex couples.

For the Chinese government, the island is a headache. The Asian giant considers Taiwan an inalienable part of its territory, whose “reunification” is, in the words of President Xi Jinping, “a historic mission of the Communist Party.” In recent years, especially since Tsai Ing-wen assumed the presidency in 2016, Chinese authorities have spoken with increasing assertiveness about a future unification, for which they have not ruled out the use of force. The rapport between the Tsai Administration and the United States, as evidenced by the recent visit of the American politician, has infuriated Beijing. On Wednesday, China published the first white paper on Taiwan in 22 years, drawing far more red lines than previous publications from 1993 and 2000.

Beijing’s discourse has never quite caught on across the strait. The two main Taiwanese parliamentary groups hold two radically opposed ideas about nationalism. While the Blue Coalition, led by the Kuomintang (KMT), aspires to an eventual unification with the People’s Republic, the Green Coalition, led by the Democratic Progressive Party (PDP), prefers to distance the island from Beijing.

Xulio Ríos, director of the Chinese Policy Observatory, points out that, however, that “the nuances are important”: “In the KMT there is everything from an intense blue –which defends unification and the idea of China – to a sky-blue, which understands that there are two different realities on both sides of the strait. The PDP advocated for independence, but today it does not defend it so aggressively and is committed to maintaining the status quo.”

Although historically opposed, the Kuomintang and the Chinese Communist Party (CCP) have sometimes found ways to collaborate and prevent secession. KMT Vice Chairman Andrew Hsia is currently on a 17-day trip to the mainland to boost cross-border communication. “The cooperation between the KMT and the CCP really picked up momentum in 2008, with the victory of Ma Ying-jeou [KMT] in the elections. This made possible a rapprochement between the business and political elites of the mainland and Taiwan,” says Ríos.

Maintaining the status quo

That approach was cut short in 2014, when a group of protesters occupied parliament to denounce the approval, without bipartisan debate, of a controversial trade agreement with China. “The Sunflower Movement put the brakes on a whole process of rapprochement, which had generated the expectation of a possibility of peaceful unification through dialogue,” says Ríos. “After PDP’s victory with an absolute majority in 2016 is completely the opposite, a completely opposite path opened,” he adds.

Despite the two trends, the surveys carried out biannually by the Center for Electoral Studies of National Chengchi University (Taipei) since 1994 show that the vast majority of the 23 million Taiwanese are committed to maintaining the status quo. In its latest poll, from July, those in favor of unification are few (1.3%) and falling, while those in favor of declaring independence (5.1%) have also lost steam.

“My parents and I share the same opinion: we don’t care who rules Taiwan, but we don’t want to lose our freedoms. My grandparents and my parents had hopes for the principle of one country, two systems, but after what happened in Hong Kong we know that it is not viable,” says Wu, 32, who prefers to identify himself with a pseudonym.

Deng Xiaoping devised the one country, two systems model in the late 1980s. The goal was to ensure conformity to the idea that there is but one China, while ensuring that those areas that had developed their own economic systems could keep them under Chinese rule. The idea, originally conceived for Taiwan, has never been accepted by the island’s political parties.

Taiwanese fear that the idea’s acceptance will bring an erosion of democracy. China had agreed with the United Kingdom to guarantee Hong Kong’s system of freedoms until 2047. But after the 2019 protests, Beijing has become intransigent, with the approval of the draconian National Security Law and with an electoral reform that ended up placing Beijing-backed candidate John Lee as head of government in May.

“Once you visit the Chinese mainland, if you are green, you turn dark green. If you are blue, you go green,” Wu says, summarizing the Taiwanese’s misgivings. But given the obvious difference in opinion that has persisted in high political circles, the most intelligent response seems to be the one reflected by the polls. When asked what he would choose between preserving the status quo or moving towards complete autonomy from Beijing, Wu does not hesitate: “Independence does not deserve a war.”

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‘The Taliban no longer wanted to kill me. Now they wanted to marry me’ | Women’s rights and gender equality

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The day the Taliban entered my city last August, I started to receive renewed threats from Taliban commanders who wanted to punish me for my work as a news journalist. I was forced to leave my home that day, amid the loud explosions of an ongoing battle, hiding under a burqa, and praying to survive the journey.

What I did not know then was that this journey would continue for the next year.

Every few weeks, I moved from province to province, sometimes living in the heart of cities, other times hiding out in remote villages. In the first few days, I stayed at my uncle’s house in Sari Pul province, but once the local Taliban learned he was harbouring a fugitive, we had to leave in the middle of the night.

I went to Mazar-i-Sharif city in Balkh, and then took the road to Kabul, passing through Samangan, Baghlan and Parwan provinces. We were stopped at checkpoints in every province, and every time my heart would pound inside my chest. Luckily, I was under a chadari [the full Afghan burqa] and passed through checkpoints undetected.

In Kabul, the very air had shifted; there was fear and dread, alongside celebrations, as Taliban fighters from all over the country gathered in the capital. With the help of some friends, I was moved to a safe house, where I spent the next three months attempting to find ways to leave the country, but seldom even leaving the compound I was hiding in. The Taliban would launch random raids in the neighbourhood, looking for fugitives like me.

Somehow, our compound evaded suspicion, but when the number of raids increased, I knew I would have to leave Kabul soon.

In December 2021, I heard the news that my cousin had been killed by the Taliban. He was a policeman and often clashed with the Taliban during the years of conflict. Like me, he had been hiding for months, looking for a way to leave the country, but was caught and killed. I broke down, not just in grief over his loss, but also in incredible pain over what my life had turned into.

I decided to go back to my province, but did not go home because I didn’t want to risk my family’s lives. I hid at the home of another relative, but being so close to my family again made me homesick. I yearned for my mother’s embrace; I hadn’t seen her in months.

One day, I met my mother in a crowded marketplace. We hugged each other tight, and I cried, but she gave me strength. I knew I couldn’t give up now.

Over the next few months, I started weaving carpets to help support myself and my family. Since the Taliban takeover, we had not only lost income but my life in exile was costing my parents, who had already sacrificed so much to raise me and now had to support me. It was hard labour, and I developed rashes and sores on my hands, but it helped my family and took my mind off the threats I was still receiving.

Then the threats from the Taliban changed. They no longer wanted to kill me. They wanted me to marry one of their commanders. They reached out to my parents and community elders, pressuring them to give me away in marriage.

I couldn’t believe it was now happening to me. In the past, I covered stories of the Taliban imposing forced marriages on young girls. Now I was one of the women I had reported about last year.

When I refused, they sent me photos of AK-47s and pistols, threatening to kidnap me, and kill my parents. I blocked their numbers and deleted WhatsApp but they still found ways to send me threats. Eventually, I took out my sim card and broke it into pieces. I was terrified of what they would do to me, or worse, to my family.

So in July, with the help of friends, I made one more attempt to leave the country. First, with the help of my father, I moved to Mazar-i-Sharif, and then we took the road to Kabul again. I carried medical certificates, and every time we were stopped, we would say I was going to Kabul for treatment. I was nervous throughout the journey because the Taliban were more brutal than before.

Eventually we made it to Kabul, where I met with other women like myself. Together, under the pretext of seeking medical help, we were able to get on a flight leaving for a neighbouring country.

I am somewhat safer now, but not out of danger. I barely sleep because I fear for my family, who are still in Afghanistan. They are already being shamed because I ran away. A young unmarried daughter leaving by herself is considered very dishonourable in Afghan culture.

But I am fortunate in the support I have received from my parents, at great personal risk. They always prioritised my passion, my happiness, and now my security and future. Contrary to popular belief, many Afghan fathers would, like mine, rather face societal dishonour and threats than deny their daughters opportunities for a better future.

I appeal to our international allies to empower such Afghan families, particularly the women. We worked so hard to attain values of equality and freedom and have lost the most in the last year. But we are still resisting, and we are seeking allies to support us and amplify our voices.

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New Evidence Suggests Archaeologist Howard Carter Stole Tutankhamun’s Treasure

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This year marks the 100th anniversary of the discovery by Carter and his team of the tomb of the boy king, which was filled with thrones, chariots and lots of other objects Egyptians believed were needed in the next world.

Archaeologist Howard Carter, who discovered Tutankhamn’s tomb in 1922, stole some of the treasures found in the 3,300-year-old burial place, a previously unpublished letter sent to the archaeologist by a scholar from his team shows.

According to Bob Brier, a leading Egyptologist at Long Island University, rumors have long been circulating about Carter stealing treasures. “But now there’s no doubt about it,” Brier reportedly said.

Correspondence between Carter and members of his excavation team remains in a private collection but it will be published by Oxford University Press in Brier’s forthcoming book, ‘Tutankhamun and the Tomb that Changed the World’.

Carter gave British philologist Sir Alan Gardiner, who was enlisted by the archaeologist to translate hieroglyphs found in the tomb, a “whm amulet”, used for offerings to the dead, telling him that the amulet had not come from the tomb. Later, Gardiner showed the amulet to Rex Engelbach, who was the British director of the Egyptian Museum in Cairo at the time, and was told that it had actually come from the Tutankhamun’s tomb because it matched other examples which all had been made from the same mould.

In 1934, Gardiner wrote to Carter: “The whm amulet you showed me has been undoubtedly stolen from the tomb of Tutankhamun…I deeply regret having been placed in so awkward a position…I naturally did not tell Engelbach that I obtained the amulet from you.”

In 1922, Carter and his financial donor, Lord Carnarvon, discovered the tomb of the boy king, filled with thousands of objects, including thrones and chariots, that were believed to be needed in the next world. Within the next decade, Carter supervised the removal of those objects and their transportation down the Nile to Cairo where they were put on display in the Egyptian Museum.



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