MR. KOJO NNAMDIIt's an unexpected byproduct of the global war on drugs, millions of people in Africa, Asia and Eastern Europe at the N stages of cancer and aids suffering needlessly without access to legal pain medication. Two hundred years after researchers first developed powerful pain killers from poppy plants, morphine and other opiates are still the best and cheapest way to treat acute pain. But many governments around the world have such stringent drug control policies that doctors are either unable or unwilling to prescribe them.

MR. KOJO NNAMDIIn the new documentary "Freedom From Pain," journalist Peter Klein explores the complex politics of the war on drugs and the human side of a manmade shortage. Peter Klein is director of the International Reporting Program at the University of British Columbia Graduate School of Journalism. He joins us from studios at the University in Vancouver. Peter Klein, thank you for joining us.

MR. PETER KLEIN(unintelligible) ...

NNAMDIAlso joining us by telephone from Wisconsin is Dr. James Cleary, professor of medicine and director of palliative medicine at the University of Wisconsin School of Medicine and Public Health. James Cleary, thank you for joining us.

DR. JAMES CLEARYThank you very much, a pleasure to be with you.

NNAMDIPeter, according to the international narcotics control board, only 10 percent of legal pain drugs are consumed in the developing world, 94 percent of the world's morphine supply is consumed in North America and Europe. Even as health researchers are warning that cancer and other afflictions are on the rise in the developing world, this is a story of a shortage. But it's really a story of a manmade shortage. Could you, please, explain?

KLEINYou know, one of the surprising things to me is how little most people know about this story, including myself. I've covered global health issues for almost two decades now and I've never heard of this. A friend of mine who works for Medecins Sans Frontieres, had mentioned this in passing to me about a year and a half ago and my ears perked up. I said, how is that possible? And we discussed it. And I think one of the issues is that it's -- you know, the enemy is not a particular country, it's not a particular company, it's not even a particular industry.

KLEINIt's bureaucracy and it's sort of -- it's inertia. And I think that's one of the reasons that this thing has gone on for so long without really, certainly, the broader public and even many people in the medical community being aware of this problem.

NNAMDIThe statistics are shocking. The images in the documentary are also very disturbing. You who have been looking at this thing say that you only came across the story, most of us have never heard about it. How did you come across this story?

KLEINWell, as I say, I was talking to Dr. Darin Portnoy who's done a lot of work with MSF about a year and a half ago, and as I often do, I asked him, what is the topic that we journalists are missing? You know, you sit around with your friends and say those journalists are getting this story wrong. What is that story?

KLEINAnd I was surprised. I thought he was going to, you know, throw out cholera or AIDS or malaria or TB or -- you know, there's so many important global health issues. But he said, no, you know, people are actually aware of these issues and some of these other issues are getting funding. But we go to these hospitals in the developing world and as we found not only in the developing world and -- people are just suffering. And it's this human rights issue that is in the shadows and that's really what struck me as an important story to tell.

NNAMDI800-433-8850 is our number if you'd like to join this conversation. Do you see this as a human rights issue? Should the global shortage of pain medication be viewed as a human rights issue? 800-433-8850, send us a tweet at kojoshow, e-mail to kojo@wamu.org or go to our website, kojoshow.org, to join the conversation with Peter Klein, producer of "Freedom From Pain," a documentary on the worldwide shortage of pain medication.

NNAMDIIt airs this Wednesday, July 20, on the program "People and Power," on Al-Jazeera English. Also joining us by telephone is Dr. James Cleary, professor of medicine and director of Palliative Medicine at the University of Wisconsin School of Medicine and Public Health.

NNAMDIDr. Cleary, you're an expert on palliative care and cancer treatment. You've been working on these issues in different parts of the world. How different are the treatments and the broader experience of patients in a place like the U.S. compared to, say, the Ukraine or India?

CLEARYSo remarkably different. If we look at the statistics provided by the International Narcotic Control Board, in the United States, we consume something like 600 milligrams of morphine equivalents. We calculate it all out so that we standardize it. We're at about 600 milligrams of morphine equivalents per person per year.

CLEARYIn countries -- developing countries, some it's less than one milligram per person per year. In others, it's down to decimal point .01 milligrams of morphine per year. So the availability of these drugs is extremely different between the United States, Australia, England, Europe and between developing countries.

NNAMDIWhy is that important?

CLEARYI think pain relief is actually an essential human right and as we see in the documentary, we have people from human rights watch even making the comparison with torture. But us not providing -- society not providing an adequate pain relief for people who have advanced disease such cancer, AIDS, that's a form of torture.

CLEARYThere is no relief from this and this is something that we should be doing. In actual fact, in 1961, the United Nations in its single convention on narcotic drugs says that these are indispensable for the treatment of pain. But we've got caught up in this war on drugs, the avoidance, how do we prevent abuse and we've neglected to actually treat people's pain. And I'd say this is one of the most neglected global health areas.

NNAMDIPeter Klein, when we talk about this war on drugs and when we talk about the unforeseen consequences, we almost always focus on the U.S. and the Western world and the way that our demand for drugs fuels violence and wars over turf. This is different. How is this linked to the war on drugs?

KLEINWell, the U.N. Office of Drugs Crimes basically oversees the global war on drugs. And of course, the war on drugs extends well beyond the borders of the United States. There are drug abuse problems and drug production problems all over the world and so they work directly with these countries to help them help individual countries address their own drug problems, both on the supply and the demand side and, of course, on the criminal side.

KLEINAnd, of course, that's important work that's being done. But it is -- as Diederik Lohman from the Human Rights Watch pointed out, it's a blunt axe. It may solve -- it may address one issue, but in the process, there is this collateral damage, which is that if you curtail -- for instance, in India that we looked at, if you go to India and say, you know, you have to have really, really strict controls on opiates and they comply and they go overbroad, you then restrict opiates for medical purposes as well.

KLEINWhich is exactly what we've seen in almost all the states in India and it's really taken extremely aggressive efforts by a handful of doctors there in individual states like in Kerala to say, listen, we have to loosen those rules and allow for opiates for medical purposes even while we keep it, you know, curtailed for illicit means.

KLEINBut that's an extra step that has to be done. And up until recently, the United Nations and the global war on drugs community have really not recognized this as an issue because, of course, they had other issues to deal with and they have a very challenging problem of dealing with the war on drugs.

NNAMDIWell, I want to underscore that for a second because we're not talking here about Western pharmaceutical companies denying something to poor consumers. This is actually a story of governments in places like India, in places like Vietnam with a profound aversion to allowing legal opiates. What is the source of that profound aversion? Is it our war on drugs?

KLEINNo, you're absolutely right. I mean, you know, you often hear these stories of global health where, you know, a company may have the patent on a HIV -- on an anti-retroviral and they don't want to reduce the price because they want to maintain their profits and not allowing it to get to the developing world. That's a common narrative in these global health stories.

KLEINThat's not the case here. There's no patents on morphine. It's been around for a long time. It's relatively easy to make. It's certainly very cheap to make. It is this fear of -- and it's really -- it's a different problem in different countries.

KLEINLike in India, for instance, they have -- they've just established such strict rules, really blanket rules, that nobody wants to deal with the bureaucracy so there's all this paperwork the doctors and pharmacists need to fill out if .1 milligrams of morphine go missing in India. A doctor is liable for that and they can actually, literally, go to jail if a negligible amount of morphine gets missing.

KLEINSo the effect is that most doctors don't want to deal with it. In other countries like Ukraine, where there is a legacy of drug abuse and they do have a serious drug abuse problem, there is aggressive effort to curtail any access to morphine. So therefore, they've established these very strict rules, which have had this sort of splatter effect into the medical community.

NNAMDIAnd Jim Cleary, what has been the consequence of this lack of access to morphine in that part of the world? What has been the consequence for patients in pain? What kind of scale are we talking about? What kind of suffering are we talking about?

CLEARYWell, many people will refer to cancer pain as being one of the worst sorts of pain, that we can actually refer as severe level of pain of 10 on a zero to 10 scale. The worst pain you can imagine applying to millions of people around the world as they approach the end of their life.

CLEARYBut it impacts those people. It impacts young children having burn dressings in hospitals over in Kenya. And I recall being in a hospital where a child was having burn dressings and just screaming. In the movie -- in the documentary, we have (word?) who keeps a gun under his pillow for the day when the pain becomes unbearable.

CLEARYHe's left his home and family because he doesn't want his family to see him cry. These are the sorts of implications that are facing people as they approach the end of life and it is very tragic. It's very sad and it's something we can correct with a cheap medication, morphine.

NNAMDIPeter Klein, this might be a bit of a cringe inducing question, but I'm curious. What is it like to be present as a journalist doing a medical visit for someone who is dying a painful death from breast cancer?

KLEINIt's -- there's no question, it's extremely difficult. I mean, I went through watching my own father pass away and knowing the, you know, the valiant efforts specifically to address his pain issues 15 some odd years ago, more than that. And when I compare what I saw in, you know, in Hutson (sp?) , Uganda, people with the same disease my father had, cancer, in such excruciating pain with, you know, not just metastasized tumors, but infected tumors with -- I mean, I don't -- it's lunchtime. I don't want to describe it in too much detail.

KLEINBut, I mean, really horrific images. And, you know, I mean, one of the things that I think a lot of people who deal with global health say is the smell. The smell stays with you and that smell -- literally, I went with my grad students and several of my grad students have said they've woken up thinking of this smell. It really comes back. It's difficult.

NNAMDIWell, were you aware that the war on drugs was having this effect in developing countries? If so, tell us what you think, 800-433-8850. Here is Rupa, in Annapolis, Md. Rupa, you're on the air. Go ahead please.

RUPAGood afternoon, Kojo. I really enjoy your show. I'm a physician, an internist, practicing in Maryland and I'm from India and I heard all the comments about the government control in India. But I think a real issue is to write a prescription. There's a real taboo about prescribing narcotics or pain medications. I've heard of relatives who couldn't get morphine because doctors would be labeled as death doctors when they get prescriptions. So I don't think it's just so much of control and lots of paperwork.

RUPAI think, just as in America, prescribing narcotics and all of that is controlled, but physicians actually under-prescribe pain medications even when they're needed. And I'm not so sure there's a hospice system in India, which is one of the, you know, most common ways to prescribe pain medications to dying patients in pain. And I don't know if there's a system there so I think it's more than just lack of medication. I think you have to look at it from the physician prescribing practices.

NNAMDII'd like to have first Jim Cleary and then Peter Klein respond to you, Rupa. Jim Cleary, you first.

CLEARYSure. Let me -- so India is developing a palliative care network and one of the strongest areas of growth is Kerala and we see that with Dr. Roger Capal (sp?) in the documentary. I would say that it is regulations, it is physician practice. It's also drug availability and we need to correct all three things at the same time.

CLEARYWe need to educate physicians and clinicians, the society, that these are reasonable drugs. We need to make sure they're available so that when physicians do start prescribing that they are available. There's nothing worse than starting patients on these medicines and having stock outs. And then we also need to make sure the regulations are in place. And let me finish by saying that this is a balanced approach. We're not saying that we make these liberally available and that abuse is rampant. We're saying we need to do this in a balanced manner that actually reduces the risk of misuse and abuse.

NNAMDIWith Peter Klein, Rupa also referred to the possible stigma that could be attached to physicians who prescribe this as narcotics-providing physicians in a culture in which providing narcotics, at this point, does not seem to be acceptable among people culturally. Or is it that stigma comes from the government's association of narcotics with the stigma?

KLEINI think it's a vicious circle. I think a lot of patients, not just in India, but in many parts of the world, associate being prescribed morphine with the end of life and so there is that stigma. There's other, you know, just general fears of opiates. There's even fears of addiction, which, you know, may be less of an issue, obviously, if you're dying. But in general, there really aren't dramatic addiction problems with properly prescribed titrated morphine.

KLEINBut the -- so it's a supply problem and it's a demand problem. A lot of patients aren't asking for it so there's not a lot of demand. A lot of doctors aren't willing to supply it because of all the bureaucracy around it so they don't offer it to their patients. So it really is -- it's a scenario where, you know, there is this -- as Jim Cleary points, there is a fairly simple solution here that a lot of people, both on the patient and the doctor side, are ignoring and that's really where -- why I think it's important for us as journalists to go out there and let people know. Not just, you know, our audiences in Europe and in North America, but, you know, fortunately this program, this Al-Jazeera program, is airing all over the world.

KLEINSo hopefully people in those countries, in India and Ukraine and Uganda and other countries we went to, that we've researched, will see these stories and realize -- maybe they'll know someone who's dying and never even thought about asking for morphine. If there's more demand, hopefully there will be more supply.

NNAMDIPeter Klein is the producer of "Freedom from Pain." It's a documentary on the worldwide shortage of pain medication. It airs this Wednesday, July 20, on the program "People and Power" on Al-Jazeera English. He's also director of the International Reporting Program at the University of British Columbia Graduate School of Journalism.

NNAMDIHe joins us along with Dr. James Cleary, professor of medicine and director of Palliative Medicine at the University of Wisconsin School of Medicine and Public Health. Jim Cleary, the global public community has tended to focus on diseases that can be spread from person to person, such as AIDS or TB, but there seems to be a growing recognition of the importance of non-communicable diseases like mental illness, like cancer, which seem to be affecting health outcomes and developing countries a lot more.

CLEARYYes, there is this growing issue of non-communicable diseases and it's estimated by 2020 that the non-communicable diseases will be the major cause of death around the world. Already many of the deaths from non-communicable disease are taking place in developing countries, up to 80 percent. So we have a real problem and this is just the tip of the iceberg that we're seeing at the moment. So there's a real effort. There's a U.N. summit in New York in September, which is a global leaders' summit.

CLEARYWe're very hopeful that our President Obama will go and represent the United States at this meeting and actually make a commitment to improve the situation with non-communicable diseases and particularly with pain relief. We see that, again, as a neglected global health issue and we need the nations of the world to stand up and say this is an important issue that we need to address.

NNAMDIHere's Nancy in Baltimore, Md. Nancy, you're on the air. Go ahead, please.

NANCYYes. I've been dealing with a family member that's had chronic pain from a failed spinal fusion for the last five years. And the pain management community and doctors live in such fear of prescribing higher levels of narcotic pain medicine. My experience is because they're -- all they're looking at is for the license. And I've had a doctor tell me that, yes, he needs higher doses, but good luck finding a doctor that is willing to prescribe it. And for the past five years, we've been (unintelligible) the E.R., the emergency room because the doctors are under-treating for pain. And in this country, I know there's 74 million people that are being under-treated for pain because of doctor's fear.

NNAMDINancy, do you see this as a human rights issue?

NANCYYes.

NNAMDIAnd Peter Klein...

NANCYAnd (unintelligible) people living in chronic pain and they told him that the best treatment - before the war on drugs, he would be able to get the level of pain medicine he needs to have. Doctors live in such fear and all they're worried about is their license. They're not prescribing what patients need and they (unintelligible) .

NNAMDIPeter Klein, this documentary also features some heroes, especially doctors who are trying to figure out how to help patients without a key weapon in their arsenal.

KLEINThere's no question. I mean, I think what happens -- I think Jim Cleary is one of the heroes. Doctors who deal with these issues on a regular basis, you know, they get frustrated and finally they say, we have to do something. And indeed, Dr. Roger Capal has done that and said, you know what, I can't stand by and watch this anymore. And he really pushed -- I mean, he went to the legislatures and really pushed for changes there.

KLEINIn Uganda, Dr. Ann Merrimen (sp?) who is really a fascinating woman. We didn't get too detailed into her story in this particular documentary, but we have a follow-up project and we're going to have a bigger paying multi-media project on internationalreporting.org, our website. There's some people who have really done some amazing work.

NNAMDIPeter Klein, is producer of "Freedom from Pain," a documentary on the worldwide shortage of pain medication. It airs this Wednesday, July 20, on the program "People and Power" on Al-Jazeera English. He's also director of the International Reporting Program at the University of British Columbia Graduate School of Journalism. Peter Klein, thank you for joining us.

KLEINThank you.

NNAMDIDr. James Cleary is a professor of medicine and director of Palliative Medicine at the University of Wisconsin School of Medicine and Public Health. Jim Cleary, thank you for joining us.

CLEARYThank you very much, Kojo.

NNAMDIAnd thank you all for listening. I'm Kojo Nnamdi.

NNAMDIComing up tomorrow on "The Kojo Nnamdi Show," a curfew enforced by police rather than parents. Montgomery Country enters the debate over keeping kids home at night. Plus, from its roots in ancient China to its popularity in vending machines today, we explore the world of tea. "The Kojo Nnamdi Show," noon until 2:00 tomorrow on WAMU 88.5.