The root of the word morphine is Morpheus, the Greek god of dreams. Neil Gaiman’s contemporary reimagining of the character in his magnum opus Sandman likewise thrusts upon us a gothic titular figure, constantly morose, deeply troubled, and yet a benevolent god of dreams that embodies everything human. Perhaps it should be no surprise then that in the modern world this character’s namesake, morphine, the gold standard of medically prescribed painkillers (Ruiz-Garcia and Lopez-Briz 2008), offers a similarly troubling medical story, evoking in equal measure the contingent histories of pleasure and war, relief and addiction, commerce and regulation.
In few places is this more apparent than in India. Legal opium is grown throughout certain regions of the country for the sole purpose of pharmaceutical production, yet irrespective of this robust industrial production, very little morphine is used within the country’s own hospitals (Rajagopal and Joranson 2007). This is a story that involves both the everyday impacts of restrictive regulation, and a local palliative care movement intent on widening access to the drug.
The everyday life of morphine in medicine
It’s a Tuesday afternoon; volunteers trickle into a palliative care center in South India which they co-run with three other doctors. Big smiles and warm welcomes are exchanged as they take up their positions in the clinic. The volunteer at the new patient registration desk receives a patient’s treatment books from them, while another sifts through the organization’s accounts. A few other volunteers are huddled at the end of the room, sorting out all the medicines to be given free of charge to the incoming patients. One by one the patient’s treatment books are matched with the corresponding case sheets kept within the clinic. A list of patients is drawn up, separating those who need to consult the doctor and those who just need a resupply of medicines.
Half an hour passes and a quick shout from the doctor indicates his need to access the cupboard containing morphine. The more relaxed atmosphere evaporates to be replaced by one of attention and haste, the prevailing conviviality quickly subsumed by a serious atmosphere with a distinct edge of fear. Immediately, there is the grating clang of steel desks being drawn open, the ominous clinks of several iron keys juggling in hands, and the familiar thud of large ledgers being laid out.
The tablets for the patient are packaged into small polythene bags. Strict regimens of drug administration are explained and re-explained. The patient and the doctor are then made to sign the two ledgers, one to log the disbursement of the drug and another to account for the number of oral morphine tablets left for circulation at the establishment.
Over one thousand miles away in North India, a young man enters the palliative care department of a major regional cancer center. His grandfather had been taken under the care of its sole doctor following a diagnosis of advanced pancreatic cancer for which he has been prescribed a course of codeine. This department consists of a single room, its lone doctor having come to occupy it when it was established in mid-2019. The dimensions are measured in horizontal and vertical lines, windows interspersing the whitewashed walls, the furnishing sparse—a desk sitting beside the door, and at each end of the room an examination table.
The doctor explains that later this month he will advance the patient’s treatment by performing coeliac plexus nucleolysis. This is a surgical procedure that destroys the bundle of nerves lying behind the stomach that are responsible for transmitting pain from the diseased tissue. In part, this intervention is defined according to the doctor’s personal history—before being recruited into palliative care he had been an anesthetist, a route into the specialism common in the Indian medical system. As such, he retains a proclivity (and skill) for such procedures.
But this reveals something more. For, despite morphine’s association with palliative care, in this instance the drug is not immediately offered. Nor indeed is it stored in this room, nor the pharmacy across the hallway, stocked instead with chemotherapeutic drugs and tramadol, an opioid considered weaker. Pushed on why, he explained: “[Because] somebody might take it for their own use, for intoxication. So, we will plan, in such a way that, who is writing [a prescription], it should not be available to him… If I have drug in my box here [pointing to the cupboard next to his desk], I can write it and take it from there and give it to somebody.” Yet, he concedes, morphine is a “wonderful” drug. With it, he says, he has everything he needs to combat pain.
There is therefore a particularity to this object, a particularity that is couched uncomfortably between a meticulous and overbearing regulatory gaze and an acceptance from many within the medical establishment around its undoubted ability to ease severe pain. In India, this has made morphine access a key regulatory aim for the palliative care movement. As such, to write about morphine is to necessarily also discuss palliative care.
Palliative care in India
Palliative care has no therapeutic logic. Its practitioners and advocates do not aim to cure disease. For a long time, and often to the detriment of people’s wellbeing, they suggest, allopathic medicine has focused too intensely on prolonging life. Palliative care, by contrast, is a medical specialty concerned with the end of a person’s life and is exclusively symptomatic (rather than curative) in its focus. Practitioners espouse an ethos not of healing but of making comfortable. It is thus a mode of care with a complicated relationship to the colonial and industrial trajectories of “modern” medicine. It has roots in a Christian missionary ethos, yet it simultaneously opposes the medical-industrial complex that binds attempts to treat disease with the financial interests of producers of healthcare technologies.
These characteristics have given the specialty a certain pattern in India, where it is actively being incorporated into the wider medical system. Healthcare institutions can be difficult to access and overcrowded; government medical hospitals struggle to deal with patient numbers far in excess of that for which they were built, serving often wide and diverse geographical areas. Yet the country also has a thriving private system existing in parallel, carrying out medical technical procedures in an environment as advanced as anywhere in the world.
This private landscape is highly competitive and rewards those procedures with quick patient turnaround and high financial costs. Palliative care therefore fits poorly within these institutions dominated by the profit imperative. It is therefore within government medical institutions and NGOs that palliative care is gaining a foothold. But this is highly variable across the country. In the southern state of Kerala, palliative care enjoys the largest coverage as care delivery is based on a close logic of collaboration between the civil society, local communities, and the state (Kumar 2007). In northern India, particularly outside the major cities, palliative care is harder to access and where available it is largely indexed solely by the distribution of oral morphine. Yet this is a drug that, as we have written, can be highly difficult to access. One reason is the profit logic that we have described.
Delineating the lack of access to morphine
Drug scarcity also happens at the conjuncture of regulation and need. In the case of India, the former likewise exerts an undue influence on the drug’s availability. The prohibitory ethos prevalent in early 20th-century legal discourse, the War on Drugs, and the current opioid crisis in the global north can be read in the restrictive legislation that governs the movements of this drug (Kunnukattil Shaji 2021). These events cast a long shadow over the people in pain in the global south who need medical opiates, yet for whom they remain largely unavailable (be that through material scarcity or a lack of access).
Despite the variability in provision over the country, this regulatory concern is a pervasive feature. The regulation along with the social fear induced by reported increases in synthetic drug use (Krishnan 2022; Louis 2023; Philip 2023) often manifests as increased fear amongst medical personnel in administering morphine. As such, it cannot be reduced to being somehow “irrational” (Willmott et al. 2018). Rather, the lack of accessibility of morphine is a problem with deep social and historical roots (Krakauer et al. 2010, Surawy Stepney 2022).
In this manner, morphine’s availability follows a familiar pattern to pharmaceuticals more generally. The circulation of pharmaceuticals in particular local settings increasingly depends on specific political configurations that enforce different administrative and regulatory mechanisms. They engender a politics of inclusion and exclusion as to who is to receive these drugs and who cannot, both individually and collectively (Lakoff 2008). But where an opiate like morphine is notionally available, it nevertheless appears in ways distinct from most other drugs (Surawy Stepney 2022). This can be seen in our accounts from both the north and south of the country. As the clinical scenes displayed above demonstrate, discourses of diversion are a common feature to discussions around opiate availability in both the north and south, and, despite limited evidence of such illicit movement, manifest themselves in everyday objects such as keys, cabinets, and logbooks that typify the strict accounting of morphine’s whereabouts and its secure storage. Like Gaiman’s Morpheus, morphine retains its sense of fear and permanence even as its relieving properties are acknowledged.
This set of material practices renders the drug highly difficult to access even within palliative settings, thus transforming the “care” within palliative care. Palliative care and morphine access therefore remain necessary to write together, vagaries in the latter informing what Veena Das and Ranendra K. Das (2006) have termed “local ecologies” of care—hybrid and dynamic forms of care that are neither reducible to international regimes nor to their local and particular counterparts. Pain relief and palliative care remains chronically unattended to, as access to it is mired under a bevy of regulatory oversight. The danger of this “access abyss” (Knaul et al. 2018) widening is indeed a painful prospect.
Das, Veena, and Ranendra K. Das. 2006. “Pharmaceuticals in Urban Ecologies.” Global Pharmaceuticals, 171–205.
Knaul, Felicia Marie, Paul E. Farmer, Eric L. Krakauer, Liliana De Lima, Afsan Bhadelia, Xiaoxiao Jiang Kwete, Héctor Arreola-Ornelas, et al. 2018. “Alleviating the Access Abyss in Palliative Care and Pain Relief—an Imperative of Universal Health Coverage: The Lancet Commission Report.” The Lancet 391 (10128): 1391–1454. https://doi.org/10.1016/S0140-6736(17)32513-8.
Krakauer, Eric L., Roberto Wenk, Rosa Buitrago, Philip Jenkins, and Willem Scholten. 2010. “Opioid Inaccessibility and Its Human Consequences: Reports from the Field.” Journal of Pain & Palliative Care Pharmacotherapy 24 (3): 239–43. https://doi.org/10.3109/15360288.2010.501852.
Krishnan, Murali. 2022. “Is India on the Brink of a Drug and Alcohol Abuse Crisis? – DW – 12/27/2022.” Dw.Com. 2022. https://www.dw.com/en/is-india-on-the-brink-of-a-drug-and-alcohol-abuse-crisis/a-64217066.
Kumar, Suresh K. 2007. “Kerala, India: A Regional Community-Based Palliative Care Model.” Journal of Pain and Symptom Management 33 (5): 623–27.
Kunnukattil Shaji, Nishanth. 2021. “Grappling with Morphine: A Local History of Painkiller Use in Kerala, India.” Canadian Bulletin of Medical History 38 (S1): S118–42.
Lakoff, Andrew. 2008. “29 The Right Patients for the Drug: Pharmaceutical Circuits and the Codification of Illness.” The Handbook of Science and Technology Studies, 741.
Louis, Arul. 2023. “India Taking Steps to Counter Manufacture of Illegal Synthetic Drugs: INCB.” March 10, 2023. https://www.business-standard.com/article/current-affairs/india-taking-steps-to-counter-manufacture-of-illegal-synthetic-drugs-incb-123031000043_1.html.
Philip, Shaju. 2023. “Alarming Spike in Drug Abuse in Kerala as Police Cases Jumped 333% Last Year.” The Indian Express (blog). January 30, 2023. https://indianexpress.com/article/india/kerala/alarming-spike-drug-abuse-kerala-police-cases-last-year-8413461/.
Rajagopal, M. R., and David E. Joranson. 2007. “India: Opioid Availability—an Update.” Journal of Pain and Symptom Management 33 (5): 615–22.
Ruiz-Garcia, Vicente, and Eduardo Lopez-Briz. 2008. “Morphine Remains Gold Standard in Breakthrough Cancer Pain.” BMJ 337 (December): a3104. https://doi.org/10.1136/bmj.a3104.Surawy Stepney, N. 2022. “No Morphine in India: The Material, Symbolic, and Alternate Circulations of an ‘Absent’ Drug.” Unpublished Doctoral Thesis. King’s College London
Willmott, Lindy, Ben White, Donella Piper, Patsy Yates, Geoffrey Mitchell, and David Currow. 2018. “Providing Palliative Care at the End of Life: Should Health Professionals Fear Regulation?” SSRN Scholarly Paper 3274384. Rochester, NY: Social Science Research Network. https://papers.ssrn.com/abstract=3274384.