Morphine: The cheap, effective pain-relief drug denied to millions

 

By Joanne Silberner PRI's The World

In the UK and US, patients who need morphine get it - it's a different story elsewhere

It's cheap, effective and easy to administer - so why are millions of people around the world dying in pain, without access to morphine?

In an open ward at Mulago Hospital in Uganda's capital city, Kampala, an elderly woman named Joyce lies in the fifth bed on the left.

She has twisted the sheets around herself, her face contorted by pain. Joyce's husband, thin and birdlike, hovers over her.

Joyce has cancer - it has spread throughout her body - and until a few days ago, she was on morphine. Then it ran out.

"She's consistently had pain," says a nurse. "And she describes the pain to be deep - kind of into her bones."

The Ugandan government makes and distributes its own morphine for use in hospitals, but poor management means the supply is erratic.

"We're in a very difficult situation," says Lesley Henson, a British pain specialist on duty at Mulago Hospital. They have patients whose pain has been kept under control with morphine - but they are running out it.

In many ways, morphine is an excellent drug for use in developing countries. It is cheap, effective, and simple and easy to administer by mouth.

Yet according to the World Health Organization, every year more than five million people with cancer die in pain, without access to morphine.

"The fact that what stands between them and the relief of that pain is a drug that costs $2 [£1.25] a week, I think is just really unconscionable," says Meg O'Brien, head of The Global Access to Pain Relief Initiative, a non-profit organisation that advocates for greater access to morphine.

O'Brien says in well-off countries, like the UK and United States, there is enough morphine to treat 100% of people in pain - but in low-income countries, it's just 8%.

In many low- and middle-income countries - 150, by some counts - morphine is all but impossible to get. Some governments don't provide it, or strictly limit it, because of concerns that it will be diverted to produce heroin.

And many doctors are reluctant to prescribe morphine, fearing their patients will become addicted.

In India, whether you can get morphine depends largely on where you are treated.

Tata Memorial Hospital, a modern and well-equipped medical centre in Mumbai, has no problem getting morphine for patients.

"We have all the medicines necessary," says Dr Mary Ann Muckaden, head of pain relief at the hospital. "We never run out."

But in other parts of the country, it's a different story. Muckaden estimates only 1% to 2% of Indians with cancer pain get morphine.

Dinesh Kumar Yadav, 28, has come to Tata Memorial - a 30-hour bus ride from his home - to get morphine for his wife.

He tells me she is bedridden with pain but can't get morphine in the north Indian state where they live.

Dr Muckaden says part of the problem is a stifling bureaucracy.

"Many physicians in the north, they don't want to go through the rigorous licensing to store morphine," she explains.

A morphine-use map of the world

• $2 (£1.25) - cost per week per patient
• 100% - percentage of people in UK and US who have access to morphine, if they need it
• 8% - percentage in the developing world who get morphine when required
• 20% of the world's painful deaths are in sub-Saharan Africa, but only 1% of morphine use

Source: GAPRI

There is a place in India where there are no barriers to morphine. But even at the CIPLA Palliative Care Centre in the city of Pune, in Maharashtra state, there are still challenges.

You don't see the challenges when you walk through the cool courtyard gardens with fountains and manicured walkways, or in the beautiful whitewashed buildings with large airy wards, each named after a flower.

"This is heaven on earth," says Asha Dikshit, whose mother came here last year in the last stages of breast cancer.

"She was in agony. Her shoulder had dislocated. It could not be fixed back," says Dikshit. "She had pain in the back, and sometimes there were hallucinations."

But she says her mother died - peacefully - on morphine.

 

Making morphine

• Comes from the opium poppy
• Discovered in 1804
• First marketed for pain relief in 1817
• Recommended by WHO for pain relief under certain conditions

• Morphine and cancer in the UK

Every patient here has cancer, and the care is free. The Indian generic drug manufacturer CIPLA supplies the morphine and pays all the other expenses.

But even with all the centre offers, the occupancy rate runs at only about 60%. One big reason, says director Priya Kulkarni, is a result of patients' own concerns about morphine. They often think morphine equals death, and they recoil when doctors suggest it.

Kulkarni says many local oncologists don't want to send patients here for that reason.

"They don't want to give up when it comes to giving them hope," she says. "And saying something like, 'I am going to refer you to a palliative specialist,' is indirectly saying 'There is nothing more I can do for you.'"

Despite all the obstacles to the use of morphine in the developing world, Kulkarni and others say things are starting to move in their direction.

In low-income countries, morphine consumption is up tenfold since 1995, according to the International Narcotics Control Board. And several countries where not many years ago there was no morphine - like Uganda - at least have some today, even if the supply is unreliable.

Back at the hospital in Kampala - where the pharmacy ran out of morphine and Joyce, the cancer patient, had to go without - palliative care specialist Leslie Henson finds a bit of luck. After leaving her patient, she steps into an office, glances at a bookshelf, and sees a forgotten bottle of morphine. It's enough to treat two or three people.

"Hopefully, we'll go take this to her and see what we can do," she says as she troops back to Joyce's room.

Soon, a doctor administers the morphine.

Joyce smiles. Her face untwists. And her husband looks ecstatic.

I ask Joyce if she's glad to get the morphine. Her husband answers. "Very much, indeed."

Other people in the hospital will remain in pain - there is not enough morphine to go around - but for the next few hours, at least, Joyce will be pain-free.

Blacklisting is the scandal that now demands action

 

Thousands have been driven out of work in Britain by corporate spying outfits. It's an outrage that calls for more than an inquiry 

• Seumas Milne
• The Guardian, Tuesday 4 December 2012 22.20 GMT

'Workers across Britain have been systematically and illegally forced into unemployment by some of the country's biggest companies.' Illustration by Matt Kenyon

 

As in the phone-hacking scandal, the evidence of illegality, surveillance and conspiracy is incontrovertible. In both cases, the number of victims already runs into thousands. And household names are deeply tied up in both controversies – though as targets in one and perpetrators in the other.

But when it comes to the blacklisting scandal, the damage can't only be measured in distress and invasion of privacy. Its impact has already been felt in years of enforced joblessness, millions of pounds in lost income, family and psychological breakdown, emigration and suicides.
It's now clear that workers across Britain have been systematically and illegally forced into unemployment for trade union activity – often on publicly funded projects and in collusion with the police and security services – by some of the country's biggest companies, using secret lists drawn up by corporate spying agencies.

Liberty has equated blacklisting with phone hacking, insisting that the "consequences for our democracy are just as grave". Keith Ewing, professor of public law at King's College London, calls it the "worst human rights abuse in relation to workers" in Britain in half a century.

But whereas David Cameron ordered a public inquiry into hacking, he rejected any investigation of blacklisting out of hand. And while a mainly anti-union media has largely ignored the scandal, all the signs are that it's continuing right now, in flagship public projects such as the £15bn Crossrail network across the south-east.

Thanks to leaks, tribunals, evidence to MPs and an information commissioner's raid, we now know that one of those private espionage outfits, the Consulting Association, had 3,213 names on its blacklist before it was shut down in 2009. Most were construction workers, based at sites from Clwyd to Croydon, but they also included environmental activists.

For an annual subscription of £3,500, 44 construction and outsourcing giants such as Balfour Beatty, Carillion, Sir Robert McAlpine and Wimpey paid £2.20 a shot for "intelligence" on the 40,000 names a year they ran past the association's database.

For that they could have access to such gems as "keeps extremely interesting company", "union activity", "brought in H&S issues", "politically motivated", "troublemaker", "recently seen at a leftwing meeting" and "girlfriend … involved in several marriages of convenience". Mostly, workers were branded "involved in dispute" or "company given details and not employed".

Through this covert power, building workers were driven on to the dole during a construction boom. Both Dave Smith, an engineer, and Steve Acheson, an electrician, were sacked from one major construction job after another after raising health and safety concerns (asbestos and lack of drying facilities) over a decade ago. They have never been able to work in the trade for more than a few weeks ever since.

Their cards had been marked by blacklisters. "Those people ruined my life," Acheson says. For some workers, they destroyed it. After hundreds involved in disputes on London's Jubilee line extension were blacklisted in 2000, at least two who were unable to find work committed suicide.

The Consulting Association, which used material the Information Commissioner's office said "could only be supplied by the police or security services", was fined £5,000 for breaching data protection law (paid by the Conservative donor Sir Robert McAlpine). Blacklisting was formally outlawed in 2010, but covert arrangements are by their nature difficult to expose.

Corporate managers who have been revealed to have been up to their necks in blacklisting are now running major publicly funded projects – including Crossrail and the Carillion-run PFI Great Western Hospital in Swindon – that are the focus of new blacklisting and bullying disputes.

Last week, Ian Kerr, the man who headed the Consulting Association, spoke in public for the first time, telling MPs there had been an "awful lot of discussion" between Crossrail contractors and his outfit, as well as those at the Olympic Park, Wembley stadium and other public construction projects. "Like it or not," he declared, blacklisting "will always be there".

Of course blacklisting isn't new. Throughout the cold war, the virulently rightwing Economic League ran a similar corporate espionage outfit, from where Kerr brought his database. And more recently civil servants, police and corporations have been shown to work hand in glove against climate change and other environmental activists.

Nor is blacklisting confined to construction, where unions still have real power. But in a deregulated economy – where union weakness has helped slash the share of wages in national income and an anti-union firm such as Starbucks can announce it's cutting staff benefits on the day it's in the public dock for tax dodging – this ugly corporate victimisation isn't just an outrage against civil liberties.

It's also a block on the revival of union organisation essential to turning the tide of inequality – and the defence of those paying the price of a failed economic model. Labour, which took 11 years to put its own ban on blacklisting into law out of deference to big business, now needs to commit to tougher rights at work. The scandal of corporate blacklisting doesn't just demand a public inquiry and compensation, but a real shift of direction on power in the workplace.

Drugs are taken for pleasure – realise this and we can start to reduce harm

 

The web-based Net Pleasure Index is an attempt to gather information about a much-ignored element of drug-taking

• David Nutt
• guardian.co.uk, Monday 3 December 2012 12.36 GMT

'The fact that there are so many users of illicit drugs means that the pleasures must often be seen to outweigh the pain, just as they do for alcohol and tobacco.' Photograph: Scott Houston/Sygma

 

The mainstream penalty-driven approach to drugs control is both morally and intellectually flawed. Morally, it ignores the use and, in some cases, promotion of drugs such as alcohol and tobacco that are much more harmful than most "illicit" drugs. Intellectually, it ignores the reasons people choose to take drugs, and why they value them. One of the most important motivations for taking drugs, which cannot easily be acknowledged by the authorities, is personal pleasure.

The UK government position seems predicated on the view that all drug users are addicts, enslaved to their drug of choice by virtue of a lack of moral fibre. In fact, we know that even for the most addictive drugs – heroin, crack cocaine and crystal methamphetamine – most users do not become addicted. And of course at the initiation of use people are not addicted, with almost everyone who tries out a drug doing so through personal choice rather than being made to by dealers; so there is clearly a lot of choice in the use of drugs.

There are several reasons for people choosing to try drugs. For "legal" drugs particularly alcohol and tobacco, that most people find unpleasant to start with, the choice to use is largely driven by fashion, manifesting through peer pressure. With alcohol, the drinks industry has marketed less aversive mixtures (alcopops) to help people overcome the taste of alcohol. It also engages in massive sexually orientated advertising to induce use, much of this illegally targeted at underage drinkers via social media sites.

In the UK last year half of all 15- to 16-year-olds were intoxicated on alcohol at least once a month, despite the drinking age being 18. This behaviour is de facto "illegal" though the government turns a blind eye, which means that many are addicted to alcohol before they are able to legally purchase it. For "illicit" drugs the choice to use is more complex, as the risk of being caught and getting a criminal record needs to be taken into consideration. Yet up to 50% of young people break the law to use these at some stage in their lives. To better deal with the consequences of this use – for example up to 5% of regular cannabis users may be dependent — we need better information about the reasons for use.

In some cases illicit drug-taking is about challenging authority, but in most cases it's about psychological exploration, often driven by positive comments and encouragement from friends. Then, once the hurdle of "breaking the law" has been overcome, the value of the drug in terms of personal pleasure and positive social engagement can be weighed against the risks of being caught. For a sizeable minority of users "illicit" drugs are taken to reduce pain and suffering (eg cannabis for multiple sclerosis, psilocybin for cluster headaches). Similarly, alcohol is often used to reduce anxiety and deaden sadness.

The fact that there are so many users of "illicit" drugs such as cannabis, MDMA and ketamine means that the pleasures must often be seen to outweigh the pain, just as they do for alcohol and tobacco. Until we properly understand the personal value of all drugs (including alcohol and tobacco), harm- and use-reduction policies are bound to fail.

In some countries even admitting that there might be a value in drug use is effectively barred from public discourse. In order to start an honest dialogue with people who use drugs we need to balance the focus on drugs-related harms by exploring pleasure, which is what motivates most people who use drugs, including alcohol.

The new web-based Net Pleasure Index, part of the 2013 Global Drug Survey is an attempt to gather this information for a wide range of drugs. It is aimed at the recreational rather than addicted user of alcohol and other drugs (tobacco users rarely admit to any pleasure, as they are mostly dependent).
Along with questions on drug policy and prescription drug use, the data it generates will help decision-making by government and individual users about the relative likelihood of new "legal highs" becoming a problem and help us better understand what motivates the use of different drugs. It will also guide advice on websites such as the Independent Scientific Committee on Drugs (ISCD) and aid harm-sation educational approaches such as the Global Drug Survey drugs meter.

If you are one the 90% of the UK population who use some sort of drug then please take the time to join the 13,000 people who have already taken part in this year's Global Drug Survey and give us your insights.

Borussia Dortmund boss attacks Premier League's oligarch owners

 

• Chief executive says English game is losing its soul
• Germany's cheap tickets and standing areas show the way

• David Conn in Dortmund
• The Guardian, Sunday 2 December 2012 21.00 GMT

Borussia Dortmund's chief executive, Hans-Joachim Watzke, says that links between fans and clubs in Germany are now stronger than they are in England. Photograph: Gary Calton for the Guardian

 

The chief executive of Borussia Dortmund, who play Manchester City in the Champions League on Tuesday, has launched a passionate defence of German football principles and attacked English clubs' ownership by rich men from overseas.

Hans-Joachim Watzke described German football as "romantic" for retaining its "50% plus one" rule, which requires Bundesliga clubs to be owned by their members. He questioned the ethos and sustainability of Premier League clubs' ownership, including City being owned and funded by Sheikh Mansour of Abu Dhabi.

Of City, a club he visited for last month's 1-1 draw in the first match between the two, Watzke said: "I am a little bit romantic, and that is not romantic. In England people seem not to be interested in this – at Liverpool they are fine for the club to belong to an American. But the German is romantic: when there is a club, he wants to have the feeling it is my club, not the club of Qatar or Abu Dhabi."

Watzke was a prominent supporter of the 50% plus one rule when it was challenged last year by Martin Kind, the president of Hannover. Dortmund are floated on the stock market, but the members elect the president and four members of the club's supervisory board – and also vote to decide major issues of club policy.

"I was the biggest opponent of changing the rule," Watzke said in an interview with the Guardian at Dortmund's Signal Iduna stadium in the build-up to the City match. "Germans want to have that sense of belonging. When you give [the supporters] the feeling that they are your customers, you have lost. In Germany, we want everybody to feel it is their club, and that is really important."

All 36 Bundesliga clubs are owned or controlled by their members, except the historic exceptions of Wolfsburg, owned by Volkswagen, Bayer Leverkeusen, owned by the pharmacy giant Bayer, and Hoffenheim, which is now funded by a single very wealthy entrepreneur, Dietmar Hopp.

Apart from those three and Kind's Hannover, the remaining 32 voted to keep the 50% plus one rule, which was introduced in 2001 when the Bundesliga clubs broke away to run the league competition independently from the German Football Association, the DFB.

"In former times in England I think the relationship between the club and supporters was very strong," Watzke argued. "Our people come to the stadium like they are going to their family. Here, the supporters say: it's ours, it's my club."

Watzke, himself a lifelong supporter of Dortmund, who drew 1-1 with runaway Bundesliga leaders Bayern Munich on Saturday, linked the system of member-ownership and control to the maintenance of affordable tickets and standing areas at top flight German football.

At Dortmund, the 25,000 fans who form the famous "Yellow Wall" standing area in the Signal Iduna stadium's south stand pay just €190 (£154) for a season ticket for the 17 home Bundesliga matches. Season tickets that also include entry to the first three Champions League group games cost slightly more at €220, working out at exactly €11 for each match.

"Here, it is our way to have cheap tickets, so young people can come," Watzke said. "We would make €5m more a season if we had seats, but there was no question to do it, because it is our culture. In England it is a lot more expensive. Football is more than a business."

Watzke argued that Dortmund, who top the group of City, Real Madrid and Ajax while the English champions cannot qualify for the knockout stages, have been able to compete with such clubs thanks to sensible management, coaching and player recruitment, despite not having the resources of a rich individual such as Sheikh Mansour backing the club.

"Everybody told me you cannot play in the Champions League against clubs like Manchester, they have more money. But we are trying to do it ourselves, in our way.

"There are a lot of ways to Rome," he said. "Chelsea have won the Champions League. But Chelsea's question is: what happens after [Roman] Abramovich?"

More to getting your eye in than meets the eye

The position of the eyes in the stance is the key to balance while batting, and balance, in turn, is the key to dominating

 

Martin Crowe in Cricinfo

December 3, 2012

Ricky Ponting's retirement brings to an end a dominant era of Australian cricket, from 1995 to 2010. The Aussie juggernaut that slayed all before it was born under Allan Border, started up properly under Mark Taylor, sped along swimmingly under Steve Waugh, and came to its conclusion under Ponting. That brutally dominating team was propped up by a multitude of true modern-day greats: Matthew Hayden, the Waughs, Adam Gilchrist, Shane Warne, Glenn McGrath and Ponting. Australia now solely relies overwhelmingly on Michael Clarke; while Ponting had massive support, Clarke is alone. The dominant era is done.

 

For me, as a pupil of the finer points of batting, the single most significant fundamental in the success of Ponting, Clarke and those before them is the balance of the head at the moment the ball is released. The position of the eyes is the absolute key to true balance. Both eyes need to be level, still, and looking directly at the bowler's hand. Any deviation from that position and the batsman's balance is affected.

 

When a batsman sets himself into his stance, it doesn't mean that that position is retained right through to when the ball is released. Often batsmen will lose a still, level, aligned position a split second before the ball is released, resulting in losing the proper balance needed at the crease. Often they never get into the right position to start with, being too "closed off" and not looking at the bowler with square and level eyes.

 

Sachin Tendulkar has the perfect head position, as does Virender Sehwag, as did Rahul Dravid and VVS Laxman. Sourav Ganguly was a bit hit and miss with his. Jacques Kallis, Hashim Amla, Graeme Smith and AB de Villiers all have it, but only at the last minute, as their stances are adjusted just prior to delivery. The South Africans get into the right position at the right time; the Indians are naturally always there.

 

For Australia, Ponting, Clarke and the Waughs all had very natural positions too. The naturalness I refer to is the fact that they all start with the bat down, tapping away with a natural lift as the ball is delivered. The South Africans prefer to hold their bats off the ground.

 

Brian Lara never quite got his eyes level. His stance was slightly closed and his left eye not always level with his right, but he hardly missed a ball. Ultimately he moved beautifully, lifted the bat naturally and fluently, and had an eye like a hawk. Shivnarine Chanderpaul has an open stance to enable his eyes and head the best position. He executes this perfectly, illustrating that it's better that the stance and body position be more "open" than "closed".

 

Kevin Pietersen has an excellent starting position but he moves a lot as the bowler delivers and sometimes gets stuck early. His problem with left-arm spin is simply that he doesn't hold the balanced position long or late enough. The slower the bowler, the more disciplined the batsman needs to be to wait. At times Pietersen moves a fraction too early and gets his eyes slightly out of line. His tall body leans to the off, which causes his feet to get stuck, so from there it's all hands.

 

Alastair Cook has a fine set-up, allowing his tall frame the best head position and maintaining his balance until the ball is released. When he loses form, it's because the balance is slightly off.

Throughout New Zealand the coaching has been to stand erect and side-on. This has put almost every batsman in the wrong position. Ross Taylor and Kane Williamson are the best at keeping the head position level, but Williamson prefers to lift his bat high when facing quicks, as opposed to when he faces spin; and when he lifts, he takes his eyes slightly off the proper, level position.

 

Those who hold their bats up in their stance often get into trouble. When the bat is held up, the top hand is set into a too side-on position, and this pushes the head to look at mid-off, not the bowler. Therefore the eyes are not level and are out of line. You can best tell by the position of the nose: a right-hander whose head is not in the perfect position is only half looking at the bowler, so to say; the nose will point to mid-off - a sure indicator that the balance is not perfect.

 

From there the body falls to the off side, the front foot lands early, and the body shapes to play to the off side. The bat comes through as only half a bat. What feels like a straight push can easily end in an outside edge. A straight ball can be hard to locate with the bat as the front foot is in the way, and the potential for an lbw is created.

 

It all comes back to the proper position of the eyes. Ponting had it perfect most of the time. But when he didn't and the body "fell" early and the front foot landed early and he started to push early, especially early in his innings, he had a problem now and then. His only flaw, which was also a great strength in attack when he was flowing along, was that the higher his bat was lifted early, the more the body struggled to hold the balanced position. Still, for Ponting this was rare. In the last two years, though, his balance has let him down. His head and eyes have fallen slightly outside his proper line of sight, and he has got stuck and gone searching with his hands.

 

Tendulkar has a similar problem at present but it stems from his back foot being rooted to the spot, so when his front foot lands without movement from his back foot, he becomes closed off and the eyes are slightly out of position.

 

Balance is everything: the feet moving together, the bat held down to centre the body, the head and eyes in a level, still hold. Holding that balanced position to the point when the ball is released is the single most important fundamental to batting, and ultimately to dominating.

 

Martin Crowe, one of the leading batsmen of the late '80s, played 77 Tests for New Zealand

Smell: The secret of true love

New research about our sensory systems shows that the nose is central to the way we form relationships


Love, according to romantics, can have a dramatic effect on the senses: striking lovers blind, deaf or rendering them tongue-tied. But the simple answer to the question of whether any relationship is "the one" seems to be that your ideal man or woman gets up your nose. New research suggests a sense of smell is vital for a good long-term relationship.

In the new study, reported in the journal Biological Psychology, researchers looked for the first time at the effect of being born without a sense on smell on men and women's relationships.
The research involved analysing data on men and women aged 18 to 46 with no sense of smell and comparing it with information gleaned from a healthy control group. The results showed that men and women who were unable to smell had higher levels of social insecurity, although this manifested itself in different ways.

In men, but not in women, it led to fewer relationships. The men with a faulty sense of smell averaged two partners compared with 10 for healthy men.

One theory is that the lack of a sense of smell may make men less adventurous. They may have more problems assessing and communicating with other people. They may also be concerned about how they are perceived by others, and worry about their own body odour.

The two groups of women had the same average number of sexual partners – four. But the women who couldn't smell well lacked confidence in their partners: they were around 20 per cent less secure in their relationship than the women in the control group. Lacking a sense of smell had no impact on their relationships with close friends, suggesting that smell plays a role for women specifically when it comes to their partners.

Research is increasingly showing that olfaction, one of the oldest sensory systems but probably the least understood, has an important role in a large number of areas. According to one study, women are more concerned about the smell than about the look of a potential mate, while men are the opposite. One study found that 13 per cent of men and 52 per cent of women have slept dressed in the clothing of another person, usually their partner, because of the smell.

"The sense of smell provides social information about others," say the researchers from the University of Dresden. "Its absence is related with reduced social security in men and women, and affects partnership. Men exhibit much less explorative sexual behaviour and women are affected in a way that they feel less secure about their partner. Our results show the importance of the sense of smell for social behaviour."

The role of smell as a trigger for arousal in men features widely in fiction, from Patrick Süskind's Perfume: The Story of a Murderer to Al Pacino's lead role in Scent of a Woman, where blind Colonel Frank Slade can name or describe the appearance of women by their perfume alone.
Phillip Hodson, a psychotherapist and author of How 'Perfect' Is Your Partner?, described the new study as "a very astute piece of work". "Instead of testing pheromones – which control moths but may not control humans – they've studied the smell-disabled to see how they differ from the rest. And both sexes with faulty noses appear to be less than sexually confident. "We know the nose is a sexually interactive organ: it tends to run when we get aroused and often people sneeze when extremely excited," he said. "The French take the subject so seriously they even have a word for the scent of a woman when perfume is mingled with body oil: her cassolette."

An Alternative view on Modi's Gujarat

Illustration by Sorit            Opportunity Costs Of A Leader             The Gujarat model dispossessed and polarised millions, and scotched debate. Would India take it to heart? Suchitra Balasubrahmanyan

I moved to Delhi some three weeks ago after spending over three decades of my life in
Ahmedabad, prepared to be quizzed about the impending elections in Gujarat and whether the present government is likely to return to power for the third consecutive term; hear praise for peace returning to Gujarat after the violence of 2002, since no incidents of violence have taken place since then; and hear about Gujarat’s astonishing economic development and the prospect of the state’s leadership moving from Gandhinagar to New Delhi. I get all that.

But I also wonder if the people who ask me these questions realise that the Gujarat development model is inextricably linked with a certain set of ideologies, ambitions and aspirations which facilitate and sustain it?

In some ways, Gujarat is a microcosm of India. It has a great diversity of religions, castes and communities. The percentage of Muslim minorities in the state is just slightly lower than the national average. Dalits and adivasis together form about a fifth of Gujarati society, just as in the rest of India. (However, the Dalit-adivasi ratio is quite different). And all these communities, along with fisherfolk, pastoralists and the landless poor, have paid the price for helping realise the economic dreams of the state’s expanding, ambitious middle classes. Common property resources—coastal land, rivers and pastoral lands in rural areas—have been systematically taken over to make way for special economic zones and large industrial and infrastructure projects. Lakes and riverfronts have been gated and redeveloped as entertainment zones and real estate for the urban elite, dispossessing the poor, marginalised and the voiceless.

What is the worldview that underpins the shaping of such a socio-economic order? I am neither a political analyst nor a sociologist, just a teacher of design and I speak from direct experience. This is a development model, it’s plain to see, whose motive force is the ambition of the Gujarati middle class, made possible through large-scale dispossession and sustained only by denying dissent.

Anyone raising issues of equity, justice or sustainability associated with such a model of development is likely to be branded antediluvian at best and ‘outsider’, anti-Gujarat and pseudo-secularist at worst. Either way, dissenting views would find no space in the local media or in public discourse.
Since the 1980s, episodes of caste and communal violence have sharpened spatial segregation of communities, resulting in Muslim and Dalit ghettoes and upper-caste enclaves and declining social interaction. Muslims increasingly send their children to schools run by their community in their own localities. Within the municipal school system, they prefer the Urdu medium of instruction, while Gujarati medium schools are attended overwhelmingly by Dalit children. Schools are spaces for shared childhoods leading to adult bonds of friendship and understanding within accepted traditional social boundaries, but such spaces are no longer available. So it’s not Muslims and Dalits who are victims of social polarisation, but Gujarati society as a whole.

Anyone raising issues of equity or justice vis-a-vis the Gujarat model of development would be branded antediluvian at best, and anti-Gujarat ‘outsiders’ at worst.

After three decades of caste and communal violence, and almost fifteen years of the present political regime, we now have a generation of young Gujarati adults who know no other social order, no other way of being. The lack of access to diverse views through the media or public debate breeds intolerant parochialism and uncritical acceptance of the mirage of miraculous growth-rate figures. Perhaps, the middle class elsewhere is no different in its aspirations for a Gujarat style of development. But they might like to take a moment to consider the kind of social order that will inevitably accompany it and the political sanction it will receive. Would that be their idea of India? Significantly, cases related to the murder of an activist protesting against illegal mining in south-western Gujarat (he was murdered right outside the Gujarat High Court) and the blocking of community access to a river by a prominent industrial house are now before the Supreme Court. It is worth remembering that in the thousands of cases related to the 2002 riots that were closed in local courts, the process of bringing the perpetrators of communal carnage to justice had restarted only on the intervention of the SC. What will happen to democratic institutions of checks and balances if a Gujarati worldview were to be established nationally is anyone’s guess.

As a university teacher I can attest, as will other colleagues in design, architecture and management institutes in Ahmedabad, how difficult it is to even discuss ideas like secularism or social justice in the classroom, or to debate whether or not the state’s development model is socially and economically sustainable, or the human costs involved. Yet, I remain optimistic, happy with small signs that there is some intuitive goodness, even courage, in young people that shines through my experiences with students. This year, Id was celebrated at roughly the same time as the festival of Rakshabandhan. In a classroom assignment, students were asked to observe the social geography of the old parts of Ahmedabad. One student, a young woman, reported her observations of a side-lane flanked on one side by a Muslim mohalla and on the other by a Jain pol. Id decorations lined the mohalla-side of the road and rakhis were displayed for sale on the opposite side. She said she was really happy to see this, that the two communities could celebrate their festivals side by side. In another classroom project, architecture students were asked to visualise designs for the disputed Ramjanmabhoomi site, in accordance with the Allahabad High Court ruling. Each student in the class offered designs which, while complying with the ruling, brought the irreconcilable communities together, using the space creatively to resolve the differences.

While young people often echo the prejudice and parochialism that surrounds them, when given a chance to experience reality freely and to relate in a human way, they respond positively. Left to themselves, they can intuitively feel the rich web of their environment and respond humanely. But these impulses need nurturing, they need space to breathe and expand and be expressed. In Gujarat, and also in the rest of India.

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(Suchitra Balasubrahmanyan teaches at the School of Design, Ambedkar University, Delhi, and co-authored Ahmedabad: From Royal City to Megacity, Penguin 2011)