Lotika Rajuwal needed a stronger drug.
The 34-year-old nurse lay on a cot at her home in Nadia, West Bengal, last September. The red tilak (vermillion mark) on her forehead just reached her hair, cropped short after another round of chemotherapy—treatment for acute lymphoblastic leukemia.
Rajuwal tried to ignore the pain in her back and stomach, passing time knitting, and cooking if she felt strong enough to stand. The doctor had been administering tramadol, a narcotic, on her for the past two weeks. But what she needed was much harder to come by in rural India: morphine.
A popular painkiller naturally derived from opium, morphine is a product of the poppy plant. India has been the leading producer of opium for decades, accounting for 90% of the global production, according to a report by the International Narcotics Control Board. In 2011, the country exported 11.6 tonnes of it.
Yet, within its own borders, India's Narcotic Drugs and Psychotropics Act, 1985, has built a difficult obstacle course for health workers and patients trying to access morphine, at times requiring hospitals to have five separate licences. Even though farmers in states such as Uttar Pradesh and Rajasthan continue to grow poppy, only about 4% of Indians who need morphine actually received it in 2008, according to a Human Rights Watch report.
The Opium Wars
In the mid-19th century, India was entangled in two wars between China and Great Britain over opium—wars that strengthened the British empire and allowed legal opium trade without foreign tax.
Opium swept through the world, given as medicine to soldiers during the American Civil War and enjoyed in dens from San Francisco to Southeast Asia. The East India Company had a complete monopoly on opium produced in states such as Bihar and Uttar Pradesh, according to Amar Farooqui, a history professor at the University of Delhi, and author of Smuggling as Subversion, a book on Opium Wars politics.
Even after the West began tackling opium addiction, the British continued to protect their own interests in the colonies. The empire pushed out the Opium Act in 1878 to discourage abuse, but also allowed two groups to continue consumption: Indians who ate opium, and Chinese who smoked opium. In a United Nations document from 1957, researchers said drug addiction in India existed on a larger scale than any other country except, possibly, China.
"The state's approach was not marked by any desire to regulate or restrict opium consumption for medicinal or non-medicinal purposes," Farooqui said. Hence, after independence, the Indian government's policy moved to the other extreme.
At Pallium India, a small hospital in Thiruvananthapuram, Kerala, MR Rajagopal walked at a clip last summer—slowing down only when he got to patients' beds to hold hands and speak quietly with families.
Rajagopal is often described as the father of Indian palliative care, a branch of medicine focused on patients who are chronically ill or at the end of their life.
A large part of palliative care is pain management, which requires opioids such as morphine. So, in his three decades advocating better healthcare in India, Rajagopal has been instrumental in helping his state, Kerala, push back against the national drug policy and gain more access to morphine. In 1998, Kerala successfully amended its state law to make it easier for licensed workers to distribute and administer the drug.
Between patient visits, Rajagopal agreed that the Opium Wars and the British-controlled trade left a legacy of addiction when India achieved independence in 1947. And the fear of addiction drove the new Indian government to bring in unreasonable regulation, he said, especially since oral morphine is rarely addictive.
He said India's burden of pain is an escalating problem in which only 1% of the people who need palliative care and pain management actually get it. And painkillers are part of that problem.
"Over the past many years, we have used between 200 and 300 kilograms of morphine in the country as a whole," Rajagopal said. "If all our cancer patients got morphine, we would need more than 30,000 kilograms of morphine."
States across India have started to lobby for their own policy changes, and expand the facilities that store and offer morphine. Sikkim, West Bengal, and Karnataka have taken steps toward establishing palliative care programs and tapping into morphine supplies, motivated by the 2014 amendment to the national drug policy—easing the legal barriers to procuring and prescribing morphine—and Kerala's track record.
But they have a long way to go.
"West Bengal changed its narcotic regulations in 2012 November," said Rajagopal. "The system continues to be horrendous." The change in West Bengal's regulations allowed more access to non-governmental medical institutions to morphine, besides reducing the number of licences required.
In West Bengal's Nadia district, where Lotika Rajuwal lay suffering last September, patients in rural areas still have little or no access to strong painkillers when they need them. But the district—in the region that was once rich in poppy fields—today has a volunteer palliative care clinic, with doctors trained in Kerala.
Until the facility can access morphine, patients like Rajuwal will continue to suffer.
"I think something stronger for my pain would help me," she said. But, unlike what lawmakers fear, she has no intention of using it forever.
"I just want to stop taking any medicine at all."
Lotika Rajuwal needed a stronger drug.