Dying a painless death SLUG: India palliative care REPORTER: Gayatri Parameswaran DATE: INTRO; Thousands of patients in India

experience unnecessary pain because access to morphine is restricted. Morphine, which comes from opium, is one of the most effective painkillers. India grows opium poppies, and produces opium for the international pharmaceutical market. But terminally ill patients in more than half the country are not getting it. The strict government regulations were created out of fears of illicit drug use and addiction. But in recent years Kerala in the south of the country has become to the fist state to relax the rules and has started using morphine for patients who are dying. Despite having less than three per cent of the country's population, it hosts 2/3rds of the country's palliative care centres. Gayatri Parameswaran travelled to find out more. TEXT SFX 1: Hospital room ambient 34-year old Raj Mohan is in his ward at the palliative care unit in a hospital in Trivandrum, Kerala. His left leg was amputated a couple of months ago. From the operation, doctors found out that he also suffers from cancer. Raj Mohan clip 1 [Male/ Tamil, 00:35]: I am ill. I have nodules all over my body. The doctor called it cancer nodules. I have nodules on my head and my buttocks as well. Apart from that, I have fever. I can't eat. Rajmohan had to travel about 100 kilometers from his village to this hospital. He lives in neighbouring Tamil Nadu state, where he couldn't find any doctor who would prescribe him morphine -- the only drug which will ease his pain at this stage.

In 2009, Human Rights Watch found that many major hospitals in India do not provide cancer patients with morphine. Under laws created in the 1980s morphine is strictly regulated in the country out of fears of drug abuse. But Dr MR Rajagopal, a pioneer of palliative care in India, says the laws have affectively stopped people from getting access to morphine. Dr Rajagopal clip 1 [Male/English, 02:30]: Any doctor could prescribe it but you cant buy it from anywhere because the pharmacists stopped stocking it. By those regulations, if you are found in unlawful possession of more than two grams, you would be liable for a minimum imprisonment, rigorous imprisonment, of ten years. Which means that if a pharmacist makes an error in his calculations and is found in possession of three grams of morphine, the judge will have no option but to give him rigorous imprisonment for ten years. So the pharmacists stopped stocking it. And...then there are so many licenses necessary. In most states in India each state has its own narcotic regulations in most states you need anywhere from three to four different licenses to be able to use it. With complicated license procedures, the morphine consumption came down. Dr Rajagopal clip 2: The regulations also had a secondary ripple effect. Because hospitals stopped using it, doctors and other professionals became more and more unfamiliar with the drug. So much so, today, we have a generation of doctors who have not seen a tablet of morphine. Based on a proposal made by Indian Association of Palliative Care, in 1998 the Indian government ordered all states to simplify their narcotics law. But until now only less than half of the countrys states and union territories have simplified narcotics regulations which allow doctors to prescribe morphine, pharmacists to stock it and patients to access it with ease. Dr Rajagopal explains why. Dr Rajagopal clip 3 [Male/English, 01:20]: The lack of awareness, the attitude of the professionals and the healthcare industry as a whole are the major negative factors. When I say the healthcare industry, what I mean is palliative care doesnt necessarily mean adequate profit for the industry because most of palliative care is a low cost thing. Yes, I suppose one could make a profit out of it, but not as much as you could make out of, say, inappropriate intensive care or inappropriate chemotherapy, which would carry a much better profit margin. So, it doesnt suit the system as a whole. This results in more patients dying with terminal illness in pain.

For the last twenty years, Dr Rajagopal and his NGO Pallium India have been busy spreading awareness about the medical use of morphine to ordinary people as well as health professionals and providing it free of cost to the needy. Kerala now has 140 palliative care units and now provides two-thirds of Indias palliative services. Dr Rajagopal is really proud about his work. Dr Rajagopal clip 4 [Male/English, 00:45]: One huge sense of personal privilege, a privilege to be where I am. The satisfaction that comes out of it. Out of making such a huge difference to peoples lives. Thats a great reward. We got this very great kick, a high, from seeing people so visibly relieved. Somebody coming begging to be killed and in an hour sitting up and having a cup of tea. And this was really a powerful reward for all the difficulties that were there. SFX2: Ambient walking to patients room Back to the hospital in Kerala. Rajmohan is happy because for the first time after the operation, he is pain-free. Rajmohan clip 2 [Male/Tamil, 01:00]: I used to be in a lot of pain all over my body for the last three months. I used to lie wailing in pain. Then the doctor in my village called up this hospital and they asked me to come here and promised they would help. I said I dont have any money to pay for the treatment. Ive spent all my money treating this disease. I dont have a penny left. So I begged them for a favor. They agreed and I came here. Before this, I used to go to the pharmacist and buy painkillers. It would give me relief for a few minutes but then I would suffer again. But since yesterday, I dont experience any pain. This is Gayatri Parameswaran in Trivandrum, Kerala, for Asia Calling.