The story of one mans pregnancy: It felt joyous, amazing and brilliant

Pregnancy is increasingly common among trans men. For Jason Barker, who has made a film about the experience, it changed his life

Its hard to perform a somersault at 36 weeks pregnant. Towards the end of his debut feature film, Jason Barker is swimming in the London Fields lido in east London, a short walk from the flat he shares with his partner, Tracey. The screen is rinsed blue. Barker dances, makes a star. And then, very slowly, he turns full height in the water, his Hawaiian swim shorts flapping, his stomach a perfect, firm dome.

This is the viewers first sight of Barkers pregnant belly in A Deal With the Universe, which premieres at the BFI Flare festival next week. And after seven years in which he and Tracey tried to conceive, it is a moment of pure levity and joy. That swimming stuff that you see? he says. It felt like the first time I could ever say, Yeah! I actually like this body. Love it. Its brilliant.

Barker was born female. He transitioned roughly 20 years ago, at 26, soon after he met Tracey though, as Barker says, before and after dont really work in this story. The process of transitioning was gradual, without hard edges. The two of them hoped to start a family, but after a few years of Tracey trying to conceive with her own eggs, in 2003 they resorted to plan B. Tracey would be impregnated; Barker, who had undergone chest surgery but kept his ovaries, would supply the eggs. He bought a new camera to document it. Soon they would have a baby and a film.

So Barker stopped taking testosterone. He delayed an appointment to discuss a hysterectomy. Well, it was just a short film. Not too disruptive. But the filming went on and on and Barker ended up telling a very different story to the one he planned. The pregnancy he chronicled was not Traceys, but his own. And it changed his sense of who he was.

Pregnancy among transgender men is increasingly common. Sally Hines, a professor at the University of Leeds who is leading a three-year research project into the subject, says: In the UK, if you look at how many people are accessing blogs and online forums and support groups, asking about healthcare because they are pregnant, or young guys thinking about the future There is lots of anecdotal evidence that more people are doing it. When something becomes visible, more people think its possible.

But 10 years after Thomas Beatie, from Hawaii, made headlines with his combination of beard and baby bump the first publicised case of a legal male, in a traditional marriage to a woman, to give birth the data remains scant. In Australia, 54 people who identified as men gave birth in 2014, according to Medicare statistics. In the UK, the Office for National Statistics collects no information on the gender of the birthing parent; neither does the NHS. Last year, British newspapers including the Sun and the Independent hailed Hayden Cross as Britains first pregnant man. Soon afterwards, they had to hail another man, Scott Parker, after he got in touch to say that he had given birth a few months earlier.

There have been about six first pregnant men, Barker notes wryly. His son turns eight this year.

And yet the idea of transmasculine pregnancy as a novelty holds sway. Each birth is greeted as the first. It is perennially surprising, and I wonder if this is because it is conceived by cis people as a double-edged contradiction that undermines both the common conception of pregnancy as inherently female and the sense of a completed transition as if a trans man carrying a child constitutes a sort of U-turn. But, as Hines says, Transition is not a straightforward A to B Pregnancy is not an interruption, just another part of a long and complex journey.

Barker, whose son is now seven. Photograph: David Levene for the Guardian

Barkers film begins with him prizing a state of heightened masculinity. When Tracey cant conceive, he longs for a penis and testicles. He strikes muscular poses while washing the windows of their caravan, and the thought of his eggs entering her makes him feel like cock of the walk. He says it in a way that emphasises the pun. But, as the film progresses, a subtler story emerges.

I had this fantasy picture, he says. I thought, Ill have a baby, and that night Ill go and have a pint, and about two weeks after that Ill start on the testosterone again Job done. Pregnancy was a transient state, a strange bit of my life, after which normality would be restored.

But, pretty quickly, the film begins to transmit more mixed messages. As soon as he is pregnant, Jason appears in a pair of denim dungarees, that classic of 1970s maternitywear. In labour, he looks forlorn in a cerise nightie with a cute animal motif. He laughs when I ask why, in pregnancy, he resorted to these conventional cues for femininity. You just grow so massive and youve got nothing! he says. Retailers of pregnancy clothing arent exactly teeming with options for trans men. Tracey went to New Look and bought a load of maternity trousers, but even the combats were embroidered with flowers. She had to get a needle and unpick them.

In pregnancy, Barker mostly passed as a fat bloke. No one offered him a seat on the bus. No one batted an eyelid when, dressed in jeans and a cardie, he walked along the canal towpath to Nandos two days before giving birth. He was both in plain sight and, owing to the relative rarity of pregnant men, hidden. In an antenatal class, when the teacher instructed all the pregnant folks to feel their hips, and he obeyed, the man beside him gave a nudge and said: I dont think we have to bother, mate!

For as long as he could remember, Barker had had a body that didnt fit. And now youre here, he tells his son in the film, and I cant think like that any more.

It would be easy to imagine pregnancy as a time of heightened gender dysphoria for trans men. I had expected most people to have more dissonance with their body during pregnancy, says Alexis Hoffkling, a researcher and medical student at the University of California, San Francisco who is trans herself. A few years ago, she started interviewing trans men who had been pregnant and found that while some had a lot harder time with their bodies [others] felt empowered. Some found it masculinising. They were more like a fat dude than they had ever felt before. As their body got bigger, they felt stronger.

When Barker began to piece together the 25 hours of tape he had recorded over eight years of trying to start a family, a worry began to form. The proper story, he thought, would be that somebody keeps their gender identity regardless. Im a man and Im pregnant but Im still a man, and this is a mans pregnant tummy. But for me, it felt really different.

Barker says he is naturally a very binary person. Ive been ever so serious about gender in my life. That its this thing you have to be fully committed to. Because my generation of trans people had to be fully committed in order to access treatment. It took a while, but slowly he began to let go of his self-interrogation, what he calls the whole pregnant man thing. He stops to think. The closest comparison, he says, is that being pregnant was like watching Mo Farah run. He is so graceful. Hes not having to go, Im trying to run! like the rest of us. And thats how it felt for me: Wow. Im just doing this. It felt joyous and amazing and brilliant.

In the same way that Barker would always stand up for his friends against transphobic strangers, now he felt compelled to protect his pregnant body against his own sense of incongruence. I would defend that body. That body is a beautiful thing because of what its doing and what its done, he says. The body was all about my kid.

So, in a way, it was a selfless body? It didnt feel right when Barker was its sole occupant, but when it acquired another, an other, it became a better fit? I wonder if Barker felt less male when pregnant. But he says only: Honestly, I had a really lovely time.

Im going to ask you a very personal question, he says, leaning forward. When people talk about getting broody again, its pretty ick, isnt it? Its icky because none of us likes to think we are ruled by our hormones?

Thats true, I say. But, speaking personally, I did get broody again.

Yes, so did I! he exclaims, delighted. He and Tracey knew that they wouldnt try for another child, because it had taken them a decade to conceive and they didnt want to lose their sons infancy in endless rounds of IVF. But for a long time after the birth, Barker lived with a sort of second, shadow baby.

Id have these fantasies that somehow, a few months later, theyd say, Just a minute! We think theres a twin in there! Id think about it all the time, that I was somehow accidentally pregnant and nobody knew. Kangaroos do it, Id think. Would there possibly be a way? Theyd say, We dont know how its happened but its like your body stored it. And Id be, Well, there you go! A miracle!, he says.

He never had the hysterectomy. He hasnt taken testosterone in 15 years, since he and Tracey embarked on their plan B.

Barker and his partner Tracey. Photograph: Sara Davidmann/A Deal With the Universe/BFI

There is, as yet, no guidebook to pregnancy for trans men, though Barkers film will fortify others who wish to follow in his footsteps. There is a memoir, Wheres the Mother? Stories from a Transgender Dad, by Trevor MacDonald, who lives in Manitoba, Canada, and who carried his own children, now three and seven. MacDonald founded a Facebook group on birthing and breast- or chestfeeding for men.

The questions that come up repeatedly are practical ones. What is the impact of testosterone on a trans mans chances of conceiving? (Barker took it for three years.) How does chest surgery affect lactation? (This subject is off-limits for Barker, but MacDonald fed his own children and became the first openly trans volunteer at La Leche League, the breastfeeding support group, after they initially told him it was inappropriate for them to help him. From his own research conversations with trans men, he knows that some found nursing reduced their experience of gender dysphoria around their breasts: It seemed to have to do with those body parts serving a purpose that they otherwise didnt, he says.)

Once, in hospital, the nurses called Barker Mum. But after racking his brains, that is the single misstep he can recall. MacDonald says he is amazed that Barker had such a smooth experience with his healthcare providers. There are plenty of stories of those who dont specimen bottles routinely given to thin female partners instead of the pregnant man, and so on.

Registering the birth was a hurdle, though. Barker had no choice but to officially be his sons mother. As well as his name, he included his birth name under the designation AKA, because he dreaded some kind of clerical error that would make the baby not mine. That sounds completely paranoid, he says, but growing up with section 28 had given him the idea of not thinking that you deserve to be spoken about, do certain jobs or have certain things. And those things included, presumably, a child.

Mostly, though, parenthood has been free of administrative challenges. In fact, Being out and about as a dad with a small baby attracted more attention than being a pregnant man did! he says. Barker is a writer, but he is also his sons prime carer. I remember him crying on a bus and a woman shouted, Not as easy as you thought, was it? Also I once shocked the whole Stay and Play when I told them that my partner had gone back to work two weeks after the baby was born.

Their little boy has grown up with an understanding of his family, how he came about. Ever since he was born, they have told it to him almost like a bedtime story. (He has heard it so often, he sometimes rebukes his dad for boasting about being trans.) Discussing Harry Potter one day, Barkers son wanted to know which of the characters Barker would be if he could choose anyone. Hagrid, Barker replied. In the films, the hirsute, giant gamekeeper is played by Robbie Coltrane. Well, youve already got the beard, his son said, appreciatively.

A film needs an arc, of course to end somewhere other than where it started. Barkers worry about this, when he began to edit the footage last year, was, My God, will somebody think Im cured [of being trans]? Its a horrible thought, he says. Its all right for Tracey, his indomitable partner, whose eyes continue to sparkle even through a mastectomy for breast cancer. She didnt need an arc. She could just be brilliant all the way.

I think my arc, he says, is going from somebody who thinks being an ordinary man is the best thing you can be to somebody who sees a different way of being. To a certain extent its about femininity, he says, tapping the table as if hes put his finger on it. Id pushed [it] away from a really young age, and I think its about bringing some of that back. And you realise how undervalued this work is And it does make you think, What was I pushing away? What was I scared of?

Its about vulnerability, I think, he says, and it is a surprise to hear him say it, because the quality he most wants to surface in the film is resilience. Of course, the two go together, and Barkers story is about both of those things, and the personal regrowth that can come from giving birth. He not only challenged boundaries in the world around him, but in his own understanding of himself.

A Deal with the Universe is at BFI Flare: London LGBTQ+ film festival on 26 March at BFI Southbank

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I have prostate cancer. But I am happy | George Monbiot

The three principles that define a good life will protect me from despair, says Guardian columnist George Monbiot

It came, as these things often do, like a gunshot on a quiet street: shocking and disorienting. In early December, my urine turned brown. The following day I felt feverish and found it hard to pee. I soon realised I had a urinary tract infection. It was unpleasant, but seemed to be no big deal. Now I know that it might havesavedmy life.

The doctor told me this infection was unusual in a man of my age, and hinted at an underlying condition. So I had a blood test, which revealed that my prostate-specific antigen (PSA) levels were off the scale. An MRI scan and a mortifying biopsy confirmed my suspicions. Prostate cancer: all the smart young men have itthisseason.

On Monday, I go into surgery. The prostate gland is buried deep in the body, so removing it is a major operation: there are six entry points and it takes four hours. The procedure will hack at the roots of my manhood. Because of the damage that will be caused to the surrounding nerves, theres a high risk of permanent erectile dysfunction. Because the urethra needs to be cut and reattached to the bladder, I will almost certainly suffer urinary incontinence for a few months, and possibly permanently. Because the removal of part of the urethra retracts the penis, it appears to shrink, at least until it can be stretched back into shape.

I was offered a choice: radical surgery or brachytherapy. This means implanting radioactive seeds in the parts of the prostate affected by cancer. Brachytherapy has fewer side effects, and recovery is much faster. But theres a catch. If it fails to eliminate the cancer, theres nothing more that can be done. This treatment sticks the prostate gland to the bowel and bladder, making surgery extremely difficult. Once youve had one dose of radiation, they wont give you another. I was told that the chances of brachytherapy working in my case were between 70 and 80%. The odds were worse, in other words, than playing Russian roulette (which, with one bullet in a six-chambered revolver, gives you 83%). Though I have a tendency to embrace risk, this was not an attractive option.

It would be easy to curse my luck and start to ask, Why me? I have never smoked and hardly drink; I have a ridiculously healthy diet and follow a severe fitness regime. Im 20 or 30 years younger than most of the men I see in the waiting rooms. In other words, I would have had a lower risk of prostate cancer only if I had been female. And yet I am happy. In fact, Im happier than I was before my diagnosis. How can this be?

The reason is that Ive sought to apply the three principles which, I believe, sit at the heart of a good life. The first is the most important: imagine how much worse it could be, rather than how much better.

When you are diagnosed with prostate cancer, your condition is ranked on the Gleason Score, which measures its level of aggression. Mine is graded at seven out of 10. But this doesnt tell me where I stand in general. I needed another index to assess the severity of my condition, so I invented one: the Shitstorm Scale. How does my situation compare to those of people I know, who contend with other medical problems or family tragedies? How does it compare to what might have been, had the cancer not been caught while it was still apparently confined to the prostate gland? How does it compare to innumerable other disasters that could have befallen me?

When I completed the exercise, I realised that this bad luck, far from being a cause of woe, is a reminder of how lucky I am. I have the love of my family and friends. I have the support of those with whom I work. I have the NHS. My Shitstorm Score is a mere two out of 10.

The tragedy of our times is that, rather than apply the most useful of English proverbs cheer up, it could be worse we are constantly induced to imagine how much better things could be. The rich lists and power lists with which the newspapers are filled, our wall-to-wall celebrity culture, the invidious billions spent on marketing and advertising, create an infrastructure of comparison that ensures we see ourselves as deprived of what others possess. It is a formula for misery.

The second principle is this: change what you can change, accept what you cant. This is not a formula for passivity Ive spent my working life trying to alter outcomes that might have seemed immovable to other people. The theme of my latest book is that political failure is, at heart, a failure of imagination. But sometimes we simply have to accept an obstacle as insuperable. Fatalism in these circumstances is protective. I accept that my lap is in the lap of the gods.

So I will not rage against the morbidity this surgery might cause. I wont find myself following Groucho Marx who, at the age of 81, magnificently lamented: Im going to Iowa to collect an award. Then Im appearing at Carnegie Hall, its sold out. Then Im sailing to France to pick up an honour from the French government. Id give it all up for one erection. And today theres Viagra.

The third principle is this: do not let fear rule your life. Fear hems us in, stops us from thinking clearly, and prevents us from either challenging oppression or engaging calmly with the impersonal fates. When I was told that this operation had an 80% chance of success, my first thought was thats roughly the same as one of my kayaking trips. And about twice as good as the chance of emerging from those investigations in West Papua and the Amazon.

There are, I believe, three steps to overcoming fear: name it, normalise it, socialise it. For too long, cancer has been locked in the drawer labelled Things We Dont Talk About. When we call it the Big C, it becomes, as the term suggests, not smaller, but larger in our minds. He Who Must Not Be Named is diminished by being identified, and diminished further when he becomes a topic of daily conversation.

The super-volunteer Jeanne Chattoe, whom I interviewed recently for another column, reminded me that, just 25 years ago, breast cancer was a taboo subject. Thanks to the amazing advocacy of its victims, this is almost impossible to imagine today. Now we need to do the same for other cancers. Let there be no moreterriblesecrets.

So I have sought to discuss my prostate cancer as I would discuss any other issue. I make no apologies for subjecting you to the grisly details: the more familiar they become, the less horrifying. In doing so, I socialise my condition. Last month, I discussed the remarkable evidence suggesting that a caring community enhances recovery and reduces mortality. In talking about my cancer with family and friends, I feel the love that I know will get me through this. The old strategy of suffering in silence could not have been more misguided.

I had intended to use this column to urge men to get themselves tested. But since my diagnosis, weve discovered two things. The first is that prostate cancer has overtaken breast cancer to become the third biggest cancer killer in the UK. The second is that the standard assessment (the PSA blood test) is of limited use. As prostate cancer in its early stages is likely to produce no symptoms, its hard to see what men can do to protect themselves. That urinary tract infection was a remarkably lucky break.

Instead, I urge you to support the efforts led by Prostate Cancer UK to develop a better test. Breast cancer has attracted twice as much money and research as prostate cancer, not because (as the Daily Mail suggests) men are the victims of injustice, but because womens advocacy has been so effective. Campaigns such as Men United and the Movember Foundation have sought to bridge this gap, but theres a long way to go. Prostate cancer is discriminatory: for reasons unknown, black men are twice as likely to suffer it as white men. Finding better tests and treatments is a matter of both urgencyand equity.

I will ride this out. I will own this disease, but I wont be defined by it: I will not be prostrated by my prostate. I will be gone for a few weeks but when I return, I do solemnly swear I will still be the argumentative old git with whom you are familiar.

George Monbiot is a Guardian columnist

Prostate Cancer UK can be contacted on 0800 0748383

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Yes, bacon really is killing us

The long read: Decades of research proves that chemicals used to make bacon do cause cancer. So how did the meat industry convince us it was safe?

There was a little cafe I used to go to that did the best bacon sandwiches. They came in a soft and pillowy white bap. The bacon, thick-cut from a local butcher, was midway between crispy and chewy. Ketchup and HP sauce were served in miniature jars with the sandwich, so you could dab on the exact amount you liked. That was all there was to it: just bread and bacon and sauce. Eating one of these sandwiches, as I did every few weeks, with a cup of strong coffee, felt like an uncomplicated pleasure.

And then, all of a sudden, the bacon sandwich stopped being quite so comforting. For a few weeks in October 2015, half the people I knew were talking about the news that eating bacon was now a proven cause of cancer. You couldnt miss the story: it was splashed large in every newspaper and all over the web. As one journalist wrote in Wired, Perhaps no two words together are more likely to set the internet aflame than BACON and CANCER. The BBC website announced, matter-of-factly, that Processed meats do cause cancer, while the Sun went with Banger out of Order and Killer in the Kitchen.

The source of the story was an announcement from the World Health Organization that processed meats were now classified as a group 1 carcinogen, meaning scientists were certain that there was sufficient evidence that they caused cancer, particularly colon cancer. The warning applied not just to British bacon but to Italian salami, Spanish chorizo, German bratwurst and myriad other foods.

Health scares are ten-a-penny, but this one was very hard to ignore. The WHO announcement came on advice from 22 cancer experts from 10 countries, who reviewed more than 400 studies on processed meat covering epidemiological data from hundreds of thousands of people. It was now possible to say that eat less processed meat, much like eat more vegetables, had become one of the very few absolutely incontrovertible pieces of evidence-based diet advice not simply another high-profile nutrition fad. As every news report highlighted, processed meat was now in a group of 120 proven carcinogens, alongside alcohol, asbestos and tobacco leading to a great many headlines blaring that bacon was as deadly as smoking.

The WHO advised that consuming 50g of processed meat a day equivalent to just a couple of rashers of bacon or one hotdog would raise the risk of getting bowel cancer by 18% over a lifetime. (Eating larger amounts raises your risk more.) Learning that your own risk of cancer has increased from something like 5% to something like 6% may not be frightening enough to put you off bacon sandwiches for ever. But learning that consumption of processed meat causes an additional 34,000 worldwide cancer deaths a year is much more chilling. According to Cancer Research UK, if no one ate processed or red meat in Britain, there would be 8,800 fewer cases of cancer. (That is four times the number of people killed annually on Britains roads.)

The news felt especially shocking because both ham and bacon are quintessentially British foods. Nearly a quarter of the adult population in Britain eats a ham sandwich for lunch on any given day, according to data from 2012 gathered by researchers Luke Yates and Alan Warde. To many consumers, bacon is not just a food; it is a repository of childhood memories, a totem of home. Surveys indicate that the smell of frying bacon is one of our favourite scents in the UK, along with cut grass and fresh bread. To be told that bacon had given millions of people cancer was a bit like finding out your granny had been secretly sprinkling arsenic on your morning toast.

Vegetarians might point out that the bacon sandwich should never have been seen as comforting. It is certainly no comfort for the pigs, most of whom are kept in squalid, cramped conditions. But for the rest of us, it was alarming to be told that these beloved foods might be contributing to thousands of needless human deaths. In the weeks following news of the WHO report, sales of bacon and sausages fell dramatically. British supermarkets reported a 3m drop in sales in just a fortnight. (It was very detrimental, said Kirsty Adams, the product developer for meat at Marks and Spencer.)

But just when it looked as if this may be #Bacongeddon (one of many agonised bacon-related hashtags trending in October 2015), a second wave of stories flooded in. Their message was: panic over. For one thing, the analogy between bacon and smoking was misleading. Smoking tobacco and eating processed meat are both dangerous, but not on the same scale. To put it in context, around 86% of lung cancers are linked to smoking, whereas it seems that just 21% of bowel cancers can be attributed to eating processed or red meat. A few weeks after publishing the report, the WHO issued a clarification insisting it was not telling consumers to stop eating processed meat.

Meanwhile, the meat industry was busily insisting that there was nothing to see here. The North American Meat Institute, an industry lobby group, called the report dramatic and alarmist overreach. A whole tranche of articles insisted in a commonsense tone that it would be premature and foolish to ditch our meaty fry-ups just because of a little cancer scare.

Nearly three years on, it feels like business as usual for processed meats. Many of us seem to have got over our initial sense of alarm. Sales of bacon in the UK are buoyant, having risen 5% in the two years up to mid-2016. When I interviewed a product developer for Sainsburys supermarket last year, she said that one of the quickest ways to get British consumers to try a new product now was to add chorizo to it.

And yet the evidence linking bacon to cancer is stronger than ever. In January, a new large-scale study using data from 262,195 British women suggested that consuming just 9g of bacon a day less than a rasher could significantly raise the risk of developing breast cancer later in life. The studys lead author, Jill Pell from the Institute of Health and Wellbeing at Glasgow University, told me that while it can be counterproductive to push for total abstinence, the scientific evidence suggests it would be misleading for health authorities to set any safe dose for processed meat other than zero.

The real scandal of bacon, however, is that it didnt have to be anything like so damaging to our health. The part of the story we havent been told including by the WHO is that there were always other ways to manufacture these products that would make them significantly less carcinogenic. The fact that this is so little known is tribute to the power of the meat industry, which has for the past 40 years been engaged in a campaign of cover-ups and misdirection to rival the dirty tricks of Big Tobacco.

How do you choose a pack of bacon in a shop, assuming you are a meat eater? First, you opt for either the crispy fat of streaky or the leanness of back. Then you decide between smoked or unsmoked each version has its passionate defenders (I am of the unsmoked persuasion). Maybe you seek out a packet made from free-range or organic meat, or maybe your budget is squeezed and you search for any bacon on special offer. Either way, before you put the pack in your basket, you have one last look, to check if the meat is pink enough.

Since we eat with our eyes, the main way we judge the quality of cured meats is pinkness. Yet it is this very colour that we should be suspicious of, as the French journalist Guillaume Coudray explains in a book published in France last year called Cochonneries, a word that means both piggeries and rubbish or junk food. The subtitle is How Charcuterie Became a Poison. Cochonneries reads like a crime novel, in which the processed meat industry is the perpetrator and ordinary consumers are the victims.

The pinkness of bacon or cooked ham, or salami is a sign that it has been treated with chemicals, more specifically with nitrates and nitrites. It is the use of these chemicals that is widely believed to be the reason why processed meat is much more carcinogenic than unprocessed meat. Coudray argues that we should speak not of processed meat but nitro-meat.

Prosciutto di Parma has been produced without nitrates since 1993. Photograph: Stefano Rellandini/Reuters

Pure insane crazy madness is how Coudray described the continuing use of nitrates and nitrites in processed meats, in an email to me. The madness, in his view, is that it is possible to make bacon and ham in ways that would be less carcinogenic. The most basic way to cure any meat is to salt it either with a dry salt rub or a wet brine and to wait for time to do the rest. Coudray notes that ham and bacon manufacturers claim this old-fashioned way of curing isnt safe. But the real reason they reject it is cost: it takes much longer for processed meats to develop their flavour this way, which cuts into profits.

There is much confusion about what processed meat actually means, a confusion encouraged by the bacon industry, which benefits from us thinking there is no difference between a freshly minced lamb kofta and a pizza smothered in nitrate-cured pepperoni. Technically, processed meat means pork or beef that has been salted and cured, with or without smoking. A fresh pound of beef mince isnt processed. A hard stick of cured salami is.

The health risk of bacon is largely to do with two food additives: potassium nitrate (also known as saltpetre) and sodium nitrite. It is these that give salamis, bacons and cooked hams their alluring pink colour. Saltpetre sometimes called sal prunella has been used in some recipes for salted meats since ancient times. As Jane Grigson explains in Charcuterie and French Pork Cookery, saltpetre was traditionally used when brining hams to give them an attractive rosy appearance when otherwise it would be a murky greyish brown.

In earlier centuries, bacon-makers who used saltpetre did not understand that it converts to nitrite as the meat cures. It is this nitrite that allows the bacteria responsible for cured flavour to emerge quicker, by inhibiting the growth of other bacteria. But in the early 20th century, the meat industry found that the production of cured meats could be streamlined by adding sodium nitrite to the pork in pure form. In trade journals of the 1960s, the firms who sold nitrite powders to ham-makers spoke quite openly about how the main advantage was to increase profit margins by speeding up production. One French brand of sodium nitrite from the 60s was called Vitorose or quick-pink.

Nitro-chemicals have been less of a boon to consumers. In and of themselves, these chemicals are not carcinogenic. After all, nitrate is naturally present in many green vegetables, including celery and spinach, something that bacon manufacturers often jubilantly point out. As one British bacon-maker told me, Theres nitrate in lettuce and no one is telling us not to eat that!

But something different happens when nitrates are used in meat processing. When nitrates interact with certain components in red meat (haem iron, amines and amides), they form N-nitroso compounds, which cause cancer. The best known of these compounds is nitrosamine. This, as Guillaume Coudray explained to me in an email, is known to be carcinogenic even at a very low dose. Any time someone eats bacon, ham or other processed meat, their gut receives a dose of nitrosamines, which damage the cells in the lining of the bowel, and can lead to cancer.

You would not know it from the way bacon is sold, but scientists have known nitrosamines are carcinogenic for a very long time. More than 60 years ago, in 1956, two British researchers called Peter Magee and John Barnes found that when rats were fed dimethyl nitrosamine, they developed malignant liver tumours. By the 1970s, animal studies showed that small, repeated doses of nitrosamines and nitrosamides exactly the kind of regular dose a person might have when eating a daily breakfast of bacon were found to cause tumours in many organs including the liver, stomach, oesophagus, intestines, bladder, brain, lungs and kidneys.

Just because something is a carcinogen in rats and other mammals does not mean it will cause cancer in humans, but as far back as 1976, cancer scientist William Lijinsky argued that we must assume that these N-nitroso compounds found in meats such as bacon were also carcinogens for man. In the years since, researchers have gathered a massive body of evidence to lend weight to that assumption. In 1994, to take just one paper among hundreds on nitrosamines and cancer, two American epidemiologists found that eating hotdogs one or more times a week was associated with higher rates of childhood brain cancer, particularly for children who also had few vitamins in their diets.

In 1993, Parma ham producers in Italy made a collective decision to remove nitrates from their products and revert to using only salt, as in the old days. For the past 25 years, no nitrates or nitrites have been used in any Prosciutto di Parma. Even without nitrate or nitrite, the Parma ham stays a deep rosy-pink colour. We now know that the colour in Parma ham is totally harmless, a result of the enzyme reactions during the hams 18-month ageing process.

Slow-cured, nitrate-free, artisan hams are one thing, but what about mass-market meats? Eighteen months would be a long time to wait on hotdogs, as the food science expert Harold McGee comments. But there have always been recipes for nitrate-free bacon using nothing but salt and herbs. John Gower of Quiet Waters Farm, a pork producer who advises many British manufacturers of cured meats, confirms that nitrate is not a necessary ingredient in bacon: Its generally accepted that solid muscle products, as opposed to chopped meat products like salami, dont require the addition of nitrate for safety reasons.

Bacon is proof, if it were needed, that we cling to old comforts long after they have been proven harmful. The attachment of producers to nitrates in bacon is mostly cultural, says Gower. Bacon cured by traditional methods without nitrates and nitrites will lack what Gower calls that hard-to-define tang, that delicious almost metallic taste that makes bacon taste of bacon to British consumers. Bacon without nitrates, says Gower, is nothing but salt pork.

Given the harm of nitro-meat has been known for so long, the obvious question is why more has not been done to protect us from it. Corinna Hawkes, a professor of Food Policy at City University in London, has been predicting for years that processed meats will be the next sugar a food so harmful that there will be demands for government agencies to step in and protect us. Some day soon, Hawkes believes, consumers will finally wake up to the clear links between cancer and processed meat and say Why didnt someone tell me about this?

The most amazing thing about the bacon panic of 2015 was that it took so long for official public health advice to turn against processed meat. It could have happened 40 years earlier. The only time that the processed meat industry has looked seriously vulnerable was during the 1970s, a decade that saw the so-called war on nitrates in the US. In an era of Ralph Nader-style consumer activism, there was a gathering mood in favour of protecting shoppers against bacon which one prominent public health scientist called the most dangerous food in the supermarket. In 1973, Leo Freedman, the chief toxicologist of the US Food and Drug Administration, confirmed to the New York Times that nitrosamines are a carcinogen for humans although he also mentioned that he liked bacon as well as anybody.

The US meat industry realised it had to act fast to protect bacon against the cancer charge. The first attempts to fight back were simply to ridicule the scientists for over-reacting. In a 1975 article titled Factual look at bacon scare, Farmers Weekly insisted that a medium-weight man would have to consume more than 11 tonnes of bacon every single day to run the faintest risk of cancer. This was an outrageous fabrication.

But soon the meat lobby came up with a cleverer form of diversion. The AMI the American Meat Institute started to make the argument that the nitrate was only there for the consumers own safety, to ward off botulism a potentially fatal toxin sometimes produced by poorly preserved foods. The scientific director of the AMI argued that a single cup of botulism would be enough to wipe out every human on the planet. So, far from harming lives, bacon was actually saving them.

In 1977, the FDA and the US Department of Agriculture gave the meat industry three months to prove that nitrate and nitrite in bacon caused no harm. Without a satisfactory response, Coudray writes, these additives would have to be replaced 36 months later with non-carcinogenic methods. The meat industry could not prove that nitrosamines were not carcinogenic because it was already known that they were. Instead, the argument was made that nitrates and nitrites were utterly essential for the making of bacon, because without them bacon would cause thousands of deaths from botulism. In 1978, in response to the FDAs challenge, Richard Lyng, director of the AMI, argued that nitrites are to processed meat as yeast is to bread.

The meat industrys tactics in defending bacon have been right out of the tobacco industrys playbook, according to Marion Nestle, professor of nutrition and food studies at New York University. The first move is: attack the science. By the 1980s, the AMI was financing a group of scientists based at the University of Wisconsin. These meat researchers published a stream of articles casting doubt on the harmfulness of nitrates and exaggerating the risk from botulism of non-nitrated hams.

Does making ham without nitrite lead to botulism? If so, it is a little strange that in the 25 years that Parma ham has been made without nitrites, there has not been a single case of botulism associated with it. Almost all the cases of botulism from preserved food which are extremely rare have been the result of imperfectly preserved vegetables, such as bottled green beans, peas and mushrooms. The botulism argument was a smokescreen. The more that consumers could be made to feel that the harmfulness of nitrate and nitrite in bacon and ham was still a matter of debate, the more they could be encouraged to calm down and keep buying bacon.

A bacon sandwich at a diner in Michigan. Photograph: Molly Riley/Reuters

The botulism pretext was very effective. The AMI managed to get the FDA to keep delaying its three-month ultimatum on nitrites until a new FDA commissioner was appointed in 1980 one more sympathetic to hotdogs. The nitrite ban was shelved. The only concession the industry had made was to limit the percentage of nitrites added to processed meat and to agree to add vitamin C, which would supposedly mitigate the formation of nitrosamines, although it does nothing to prevent the formation of another known carcinogen, nitrosyl-haem.

Over the years, the messages challenging the dangers of bacon have become ever more outlandish. An explainer article by the Meat Science and Muscle Biology lab at the University of Wisconsin argues that sodium nitrite is in fact critical for maintaining human health by controlling blood pressure, preventing memory loss, and accelerating wound healing. A French meat industry website,, argues that the use of the right dose of nitrites in ham guarantees healthy and safe products, and insists that ham is an excellent food for children.

The bacon lobby has also found surprising allies among the natural foods brigade. Type nitrate cancer bacon into Google, and you will find a number of healthy eating articles, some of them written by advocates of the Paleo diet, arguing that bacon is actually a much-maligned health food. The writers often mention that vegetables are the primary source of nitrates, and that human saliva is high in nitrite. One widely shared article claims that giving up bacon would be as absurd as attempting to stop swallowing. Out of the mass of stuff on the internet defending the healthiness of bacon, it can be hard to tell which writers have fallen under the sway of the meat lobby, and which are simply clueless nutrition experts who dont know any better.

Either way, this misinformation has the potential to make thousands of people unwell. The mystifying part is why the rest of us have been so willing to accept the cover-up.

Our deepening knowledge of its harm has done very little to damage the comforting cultural associations of bacon. While I was researching this article, I felt a rising disgust at the repeated dishonesty of the processed meat industry. I thought about hospital wards and the horrible pain and indignity of bowel cancer. But then I remembered being in the kitchen with my father as a child on a Sunday morning, watching him fry bacon. When all the bacon was cooked, he would take a few squares of bread and fry them in the meaty fat until they had soaked up all its goodness.

In theory, our habit of eating salted and cured meats should have died out as soon as home refrigerators became widespread in the mid-20th century. But tastes in food are seldom rational, and millions of us are still hooked on the salty, smoky, umami savour of sizzling bacon.

We are sentimental about bacon in a way we never were with cigarettes, and this stops us from thinking straight. The widespread willingness to forgive pink, nitrated bacon for causing cancer illustrates how torn we feel when something beloved in our culture is proven to be detrimental to health. Our brains cant cope with the horrid feeling that bacon is not what we thought it was, and so we turn our anger outwards to the health gurus warning us of its hazards. The reaction of many consumers to the WHO report of 2015 was: hands off my bacon!

In 2010, the EU considered banning the use of nitrates in organic meats. Perhaps surprisingly, the British organic bacon industry vigorously opposed the proposed nitrates ban. Richard Jacobs, the late chief executive of Organic Farmers & Growers, an industry body, said that prohibiting nitrate and nitrite would have meant the collapse of a growing market for organic bacon.

Organic bacon produced with nitrates sounds like a contradiction in terms, given that most consumers of organic food buy it out of concerns for food safety. Having gone to the trouble of rearing pigs using free-range methods and giving them only organic feed, why would you then cure the meat in ways that make it carcinogenic? In Denmark, all organic bacon is nitrate-free. But the UK organic industry insisted that British shoppers would be unlikely to accept bacon that was greyish.

Then again, the slowness of consumers to lose our faith in pink bacon may partly be a response to the confusing way that the health message has been communicated to us. When it comes to processed meat, we have been misled not just by wild exaggerations of the food industry but by the caution of science.

On the WHO website, the harmfulness of nitrite-treated meats is explained so opaquely you could miss it altogether. In the middle of a paragraph on what makes red meat and processed meat increase the risk of cancer, it says: For instance, carcinogenic chemicals that form during meat processing include N-nitroso compounds. What this means, in plain English, is that nitrites make bacon more carcinogenic. But instead of spelling this out, the WHO moves swiftly on to the question of how both red and processed meats might cause cancer, after adding that it is not yet fully understood how cancer risk is increased.

The typical British sausages does not fall into the processed meat category. Photograph: Julian Smith/AAP

This caution has kept us as consumers unnecessarily in the dark. Consider sausages. For years, I believed that the unhealthiest part in a cooked English breakfast was the sausage, rather than the bacon. Before I started to research this article, Id have sworn that sausages fell squarely into the processed meat category. They are wrongly listed as such on the NHS website.

But the average British sausage as opposed to a hard sausage like a French saucisson is not cured, being made of nothing but fresh meat, breadcrumbs, herbs, salt and E223, a preservative that is non-carcinogenic. After much questioning, two expert spokespeople for the US National Cancer Institute confirmed to me that one might consider fresh sausages to be red meat and not processed meat, and thus only a probable carcinogen. (To me, the fact that most sausages are not processed meat was deeply cheering, and set me dancing around the kitchen with glee thinking about toad in the hole.)

In general, if you ask a cancer scientist to distinguish between the risks of eating different types of meat, they become understandably cagey. The two experts at the National Cancer Institute told me that meats containing nitrites and nitrates have consistently been associated with increased risk of colon cancer in human studies. But they added that it is difficult to separate nitrosamines from other possible carcinogens that may be present in processed meats like bacon. These other suspects include haem iron a substance that is abundant in all red meat, processed or not and heterocyclic amines: chemicals that form in meat during cooking. A piece of crispy, overcooked bacon will contain multiple carcinogens, and not all are due to the nitrates.

The problem with this reasoning, as I see it, is that it cant account for why processed meat is so much more closely linked to cancer than cooked red meat. For that, there remains no plausible explanation except for nitrates and nitrites. But looking for clear confirmation of this in the data is tricky, given that humans do not eat in labs under clinical observation.

Most of what we know about processed meat and cancer in humans comes from epidemiology the study of disease across whole populations. But epidemiologists do not ask the kind of detailed questions about food that the people who eat that food may like answers to. The epidemiological data based on surveys of what people eat is now devastatingly clear that diets high in processed meats lead to a higher incidence of cancer. But it cant tell us how or why or which meats are the best or worst. As Corinna Hawkes of City University comments, The researchers dont ask you if you are eating artisanal charcuterie from the local Italian deli or the cheapest hotdogs on the planet.

I would love to see data comparing the cancer risk of eating nitrate-free Parma ham with that of traditional bacon, but no epidemiologist has yet done such a study. The closest anyone has come was a French study from 2015, which found that consumption of nitrosylated haem iron as found in processed meats had a more direct association with colon cancer than the haem iron that is present in fresh red meat.

It may be possible that epidemiologists have not asked people more detailed questions about what kind of processed meats they eat because they assume there is no mass-market alternative to bacon made without nitrates or nitrites. But this is about to change.

The technology now exists to make the pink meats we love in a less damaging form, which raises the question of why the old kind is still so freely sold. Ever since the war on nitrates of the 1970s, US consumers have been more savvy about nitrates than those in Europe, and there is a lot of nitrate-free bacon on the market. The trouble, as Jill Pell remarks, is that most of the bacon labelled as nitrate-free in the US isnt nitrate-free. Its made with nitrates taken from celery extract, which may be natural, but produces exactly the same N-nitroso compounds in the meat. Under EU regulation, this bacon would not be allowed to be labelled nitrate-free.

Its the worst con Ive ever seen in my entire life, says Denis Lynn, the chair of Finnebrogue Artisan, a Northern Irish company that makes sausages for many UK supermarkets, including Marks & Spencer. For years, Lynn had been hoping to diversify into bacon and ham but, he says, I wasnt going to do it until we found a way to do it without nitrates.

When Lynn heard about a new process, developed in Spain, for making perfectly pink, nitrate-free bacon, he assumed it was another blind alley. In 2009, Juan de Dios Hernandez Canovas, a food scientist and the head of the food tech company Prosur, found that if he added certain fruit extracts to fresh pork, it stayed pink for a surprisingly long time.

In January 2018, Finnebrogue used this technology to launch genuinely nitrate-free bacon and ham in the UK. It is sold in Sainsburys and Waitrose as Naked Bacon and Naked Ham, and in M&S as nitrate-free bacon. Kirsty Adams, who oversaw its launch at M&S, explains that its not really cured. Its more like a fresh salted pork injected with a fruit and vegetable extract, and is more perishable than an old-fashioned flitch of bacon but that doesnt matter, given that it is kept in a fridge. Because it is quick to produce, this is much more economically viable to make than some of the other nitrate-free options, such as slow-cured Parma ham. The bacon currently sells in Waitrose for 3 a pack, which is not the cheapest, but not prohibitive either.

I tried some of the Finnebrogue nitrate-free bacon from M&S. The back bacon tasted pleasant and mild, with a slight fruitiness. It didnt have the toothsome texture or smoky depth of a rasher of butchers dry-cured bacon, but Id happily buy it again as an alternative to nitro-meat. None of my family noticed the difference in a spaghetti amatriciana.

Nitrate-free bacon still sounds a bit fancy and niche, but there shouldnt be anything niche about the desire to eat food that doesnt raise your risk of cancer. Lynn says that when he first approached Prosur about the fruit extract, he asked how much they had sold to the other big bacon manufacturers during the two years they had been offering it in the UK. The answer was none. None of the big guys wanted to take it, claims Lynn. They said: It will make our other processed meats look dodgy.

But it also remains to be seen how much consumer demand there will be for nitrate-free bacon. For all the noise about bacon and cancer, it isnt easy to disentangle at a personal level just what kind of risk we are at when we eat a bacon sandwich. OK, so 34,000 people may die each year because of processed meat in their diet, but the odds are that it wont be you. I asked a series of cancer scientists whether they personally ate processed meat, and they all gave slightly different answers. Jill Pell said she was mostly vegetarian and ate processed meats very rarely. But when I asked Fabrice Pierre, a French expert on colon cancer and meat, if he eats ham, he replied: Yes, of course. But with vegetables at the same meal. (Pierres research at the Toxalim lab has shown him that some of the carcinogenic effects of ham can be offset by eating vegetables.)

Our endless doubt and confusion about what we should be eating have been a gift to the bacon industry. The cover-up about the harm of meat cured with nitrate has been helped along by the scepticism many of us feel about all diet advice. At the height of the great bacon scare of 2015, lots of intelligent voices were saying that it was safe to ignore the new classification of processed meats as carcinogenic, because you cant trust anything these nutritionists say. Meanwhile, millions of consumers of ham and bacon, many of them children, are left unprotected. Perhaps the most extraordinary thing about this controversy is how little public outrage it has generated. Despite everything, most of us still treat bacon as a dear old friend.

In an ideal world, we would all we eating diets lower in meat, processed or otherwise, for the sake of sustainability and animal welfare as much as health. But in the world we actually live in, processed meats are still a normal, staple protein for millions of people who cant afford to swap a value pack of frying bacon for a few slivers of Prosciutto di Parma. Around half of all meat eaten in developed countries is now processed, according to researcher John Kearney, making it a far more universal habit than smoking.

The real victims in all this are not people like me who enjoy the occasional bacon-on-sourdough in a hipster cafe. The people who will be worst affected are those many on low incomes for whom the cancer risk from bacon is compounded by other risk factors such as eating low-fibre diets with few vegetables or wholegrains. In his book, Coudray points out that in coming years, millions more poor consumers will be affected by preventable colon cancer, as westernised processed meats conquer the developing world.

Last month, Michele Rivasi, a French MEP, launched a campaign in collaboration with Coudray demanding a ban of nitrites from all meat products across Europe. Given how vigorously the bacon industry has fought its corner thus far, a total ban on nitrites looks unlikely.

But there are other things that could be done about the risk of nitrites in bacon, short of an absolute veto. Better information would be a start. As Corinna Hawkes points out, it is surprising that there hasnt been more of an effort from government to inform people about the risks of eating ham and bacon, perhaps through warning labels on processed meats. But where is the British politician brave enough to cast doubt on bacon?

Follow the Long Read on Twitter at @gdnlongread, or sign up to the long read weekly email here.

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NFL concussion: researchers hope blood tests can better detect head trauma

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In the second quarter of an NFL game on Thursday night, the Baltimore Ravens quarterback Joe Flacco slid to gain a first down. The 233lb Miami Dolphins linebacker Kiko Alonso flew into him, ploughing shoulder-first into his head.

Such was the force of the hit, Flaccos helmet flew off. He walked from the field but he was dazed and bleeding from one ear. There was little doubt he had suffered a concussion.

It was an extreme example of the brutal reality of football. Many head injuries caused by the game, however, are harder to detect, the product of collisions repeated over time. Some researchers think a blood test may soon be one way of detecting such problems.

At this point there are probably as many as 20 to 25 incredibly insightful biomarkers for brain health, said Kevin Hrusovsky, chief executive of Quanterix, a startup that is one of a handful of companies seeking to develop standardized blood tests to detect concussions.

We are hopeful we will be able to transform brain health in the way weve transformed cardiac health and even cancer health.

Researchers at Quanterix and other companies hope blood tests will soon look for evidence of Alzheimers or dementia, much as standard cholesterol tests now help to assess heart problems.

I think about [such tests] every minute of every day, said Robert Stern, a researcher at Boston University who co-authored a landmark study that found the degenerative disease chronic traumatic encephalopathy (CTE) in the brains of 110 of 111 dead NFL players.

Since the 1920s, researchers have known that repeated blows to the head can result in cognitive degeneration. Recent research has shown how severe such damage can be. However, because CTE in particular can only be diagnosed after death, it is almost impossible to know how many people have it.

Theres been tremendous advances over the last two years with regard to fluid biomarkers and Alzheimers disease, said Stern. We can then exploit whats being done in that area for CTE.

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Blood tests for concussive injury could help manage neurodegenerative diseases, for example, answering with more certainty questions about how long an athlete should stay out of play; whether a person is predisposed for neurodegenerative disease; or whether disease is advancing. Stern and others hope the technology will eventually help ordinary people too, such as car accident victims.

There is still disagreement on how tests for concussion, and then neurodegeneration, might be applied. Stern sees a blood test as the first in a series of more specific panels, the way a breast cancer patient might first receive a mammogram, then a biopsy. Hrusovsky hopes degenerative diseases will be found in one blood test hopefully, of course, one developed by his company.

Neurologists currently rely on a series of cognitive tests to see whether symptoms of traumatic brain injury are present. Perhaps that is why Quanterixs work has caught the imagination of the public and the attention of the NFL. Through a partnership with General Electric, the league has given Quanterix $800,000 to continue the research, Bloomberg BusinessWeek reported.

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One drug dealer, two corrupt cops and a risky FBI sting

The long read: Davon Mayer was a smalltime dealer in west Baltimore who made an illicit deal with local police. When they turned on him, he decided to get out but escaping that life would not prove as easy as falling into it

On a humid summer day in 2004, Davon Mayer stepped out of his house on Bennett Place in the heart of Baltimore. Sixteen years old, Davon was short, plump and baby-faced, still more of a kid than an adolescent. Like many other boys in his neighbourhood, he had long since stopped going to school and was dealing drugs full-time.

On any other day, Davon would have been busy by this hour, trading vials of crack for cash on the pavement, keeping an eye out for the police. But this morning, he was on his way to meet with a narcotics detective named William King. Weeks earlier, the detective had arrested Davon after catching him selling drugs. He had taken Davon to the police station and then let him go, asking that Davon call him. When Davon failed to call, King had paid him a visit to let him know he wasnt playing around.

As Davon walked to a nearby strip mall where King had arranged to meet, his mind was weighed down by anxiety. What could a city detective possibly want from a small-time drug dealer such as himself? The only answer Davon could think of was that King wanted him to become an informant. The more Davon dwelled on that possibility, the more panicked he got. Where he came from, there was nothing worse than helping the police. To snitch on fellow drug dealers was to invite death.

He got to the malls parking lot and saw Kings pickup truck. King was sitting behind the wheel, dressed in sweatpants and a T-shirt. He asked Davon to get in the back seat and turned on the engine. I have been watching you, King said, as they drove around. I like the way you do business.

Growing up, Davons parents werent around much. His father, Marvin Bunk Nutter, spent much of his sons childhood in jail on robbery and murder charges. Davons mother, Tonya, spent some of those years in jail, too, for drug possession, and the rest on the streets, sustaining her crack addiction with prostitution. Davon reserved the word Ma for his grandmother, Norma, who had raised him, along with his sister and a cousin.

Norma was a small woman with a big presence, a matriarch to the entire block. She had fought her own battle with drug addiction when she was younger; at one point, her kids had been taken away by social services. When she finally overcame her addiction, she committed herself to discipline and order, toiling from morning till night to take care of her husband, a factory worker, and three grandkids. The entire block could be dirty and dishevelled but the front of 947 Bennett Place was always spick and span.

What Davon didnt know at the time was that Norma couldnt remain insulated from the world of drug dealing herself. Even though her husband earned enough for her to be able to feed and clothe the kids, she struggled to find the money to take care of their wants toys for Christmas, gifts on birthdays, an occasional afternoon out to the movies. And so she had to make a few bucks on her own. There were drug dealers in the neighbourhood who trusted Norma to keep their money safe for them, to provide a place where it wouldnt be stolen or discovered in a police raid. Dealers usually paid her a small amount for the service.

Davon Mayers old neighborhood in west Baltimore. Photograph: JM Giordano for the Guardian

Despite Normas best efforts, by the time Davon was about 11, he began to feel the pull of the drug business. He was growing more and more conscious of all the things he wanted that his grandmother couldnt give him. All the boys he knew in the neighbourhood seemed to own a pair of Nike Air Jordan sneakers, but not even in his wildest dreams could he ask Norma for the $100 it would cost to buy a pair.

Davon told a friend, AC, who worked for a dealer in west Baltimore, that he wanted to make some money. One morning, AC took Davon to see one of the dealers men, LJ, outside a row of apartment buildings on Pennsylvania Avenue. Davon felt himself trembling a little as LJ looked him over from head to toe. Then he handed Davon a sandwich bag with 50 vials of crack, each capped with a purple top.

Davon slid the pack of vials into his pocket as LJ and AC walked off. He stood nervously in the fenced passageway leading to the door of the apartment building, wondering what he would do if the cops came. Minutes later, a young woman with a sickly pallor came out of the apartment building; recognising him right away as the seller, she asked him for a vial. After Davon had sold to her, he turned around to find a crowd of at least a dozen other buyers waiting on the sidewalk. The pack was gone within minutes.

LJ gave him another pack, which Davon dispensed with in short order. At the end of his first days work, Davon had $750 in dollar bills. It was more cash than he had seen before. He was allowed to keep $75. Walking back to Bennett Place, Davon felt a sense of exhilaration.

Over the summer, as Davons shoebox savings grew, he couldnt resist the Jordans, deluding himself that they would somehow escape notice at home. But one night, when he was sitting in the living room talking on the phone, his mother Tonya overheard him bragging about the sneakers.

Davon, where did you get these shoes from? Tonya asked him.

I got them from Bunk, he answered, without skipping a beat. His father had got out of jail the previous year, and came around every few days.

Tonya didnt believe him. She called Bunk, and he came over the next day to take the shoes away and give Davon a beating. He warned Davon to stay off the streets. But Davon was back on Pennsylvania Avenue the very next day. He was hooked on the money he was making. A few weeks later, he packed up his things and left home.

As he built up a reputation for hard work, Davons boss gave him more drugs to sell and his earnings went up to more than $500 a day. He had moved into the apartment building where hed been selling drugs, living with an addict named Lisa who let him stay in a spare bedroom in exchange for her daily fix of crack. At night, he would lie on the floor of his bare room, longing for the comfort of the bed he had left behind at Normas house. Sometimes, staring out of the window, he would feel so overcome by loneliness that he would break down and cry.

One afternoon in August 2000, Davon was caught selling drugs by police. He felt a tingle of excitement as he was marched into a police van. He would finally be able to brag about having been to jail. The price of this glory would be minimal, too: as a minor, he expected to be let off lightly.

Davon was released later that day, returning home with his mother. Over the next few days, he mulled over whether to return to Pennsylvania Avenue. He didnt want to go to prison and decided he was better off going to school, which was about to reopen after the summer break. He was also concerned about Norma, who had been diagnosed with breast cancer.

From the very first day of school, Davon felt a restlessness that quickly transformed into a yearning for his old life. At school, the popular kids were much better dressed than he was. The girls he liked paid him no attention. Davon felt he had taken a big step down in status.

Police on patrol in Baltimore. Photograph: Rob Carr/AP

Frustrated, he decided to dip his toe back into the drug business. After school let out in the afternoon, he would go over to a street three blocks from Bennett Place and hustle for a couple of hours before coming home. By the winter, he had saved enough money to buy his first car, an old Grand Marquis. He didnt want Tonya or Norma to see it, so he parked it a few blocks away and walked the rest of the way home.

Throughout the summer and autumn of 2001, Normas health worsened. She would spend most of her time in bed. One day in November, after Davon had started in 10th grade, he went into Normas bedroom to check on her. She looked like she was napping, but he touched her, and she was cold.

Two years later, Davon lost another family member, when his father was shot in a revenge killing. That night, for the first time in his life, Davon got drunk. Sitting by himself, he wept uncontrollably, although he would never quite understand why he felt so much grief over the loss of a father who had barely been present in his life.

By this point, Davon had long since quit school and his drug-dealing career was taking off. He had seen smalltime dealers in his neighbourhood remain stuck at the bottom of the pyramid, and he hustled day and night to move up. Once he realised there was more money to be made from selling heroin than crack, he branched out into a neighbourhood west of Bennett Place. He was making more than $1,500 a day.

When Davon was arrested and let off by the narcotics detective William King in the summer of 2004, he had no idea what King wanted. Now, weeks later, sitting in the back of Kings pickup truck, he silently took in Kings compliment on how he did business, trying to divine Kings intentions. He wasnt used to hearing praise from a cop.

Softly spoken and reserved, King did not have the kind of intimidating presence that some of his colleagues did. But after joining Baltimores narcotics squad in the late 1990s, he had quickly gained respect for his skill at cultivating informants and collecting intelligence. King usually worked with a partner named Antonio Murray, who was shorter and stockier in physique, and more aggressive. The duo were feared by drug dealers, who knew that King and Murray didnt mind bending the rules if it suited them.

After driving around for a few minutes, going nowhere in particular, King finally came to the point. If Davon could tell him where other dealers in the area were hiding their stash, he would raid them. So far, it sounded exactly like what Davon had been worrying about the detective wanted him to be an informant. But King went on. After the raids, he would turn only some of the confiscated drugs over to the authorities. The rest he would sell to Davon wholesale, at a price significantly lower than the market rate.

Davon studied Kings face in the rear view mirror. Was this a set up? He saw nothing in Kings expression to make him doubt that the proposition was serious. As the seconds passed, Davon was overcome with the giddy realisation that if this arrangement actually worked out, it could catapult him into the stratosphere of Baltimores drug trade.

Absolutely, Davon said finally. Absolutely.

A few days later, Davon got a phone call from King telling him to come to the parking lot of a McDonalds in east Baltimore. When Davon arrived, he recognised Kings black SUV. He had expected King to be alone but his partner, Murray, was in the car, too.

In the back of the truck were four or five boxes, filled with plastic bags of marijuana. There were four different grades, King told him, 5kg (12lb) in all. King wanted to know if Davon could take the marijuana and wholesale it.

Ive got to advertise it first, Davon said. Ill need a sample.

Davon left the parking lot with four Ziploc bags containing the different kinds of weed, and told King that he would call him. He met with a dealer in his neighbourhood, and they settled on a price of $12,000 for all of it. A couple of days later, the dealer brought the cash over to Davons house, handing it to him in the presence of Tonya, who had long given up on trying to stop her son from selling drugs.

Once again, Davon met King and Murray at the McDonalds. He had negotiated them down to a purchase price of $7,000 for the drugs. Davon transferred the boxes from the back of the SUV into his car, and drove out of the parking lot, experiencing a sense of security he had never imagined he would feel under the gaze of two police officers.

Davon Mayer between the business centre and the Rite Aid where he met Detective King for the first time. Photograph: JM Giordano for the Guardian

In the weeks following the marijuana deal, King began calling Davon every few days. They would meet at the Rite Aide parking lot, across from the western district police station. King would hand Davon whatever drugs he and Murray had confiscated typically crack or heroin, occasionally marijuana. Davon would take the drugs back to Bennett Place or Pennsylvania Avenue and offload them as quickly as he could.

Davon could usually guess who King and Murray had seized particular batches from. He had been in the business long enough to know which dealers were selling what line of vials the red tops, purple tops, green tops, blue tops. To reduce the risk of being linked to King and Murray, Davon would repackage the drugs before selling them.

Once the drugs were sold, he would text King to let him know that he was coming over to deliver the money. Within weeks, both of them had got so comfortable with the arrangement that there were times when they didnt even meet in person. Davon would simply walk over to the parking lot, get into the unlocked SUV and drop off money for King, or collect the drugs King had left for him while King worked his shift at the police station less than 200 yards away.

King was not a man of expensive tastes, but he was bad at managing his money. By the middle of 2004, even with the cash that was rolling in from the secret venture that he and Murray were running on the side, King fell behind on the monthly payment toward his SUV. By comparison, Davons finances were remarkably robust. He sensed an undertone of jealousy in the comments King made when he showed up wearing a new shirt or a new pair of shoes. Somebodys looking good these days, King would say.

Toward the end of the summer, King became desperate to make more money. He and Murray were not having as much luck as before in making seizures, as their raids had already put some smaller dealers, the softer targets, out of business. They began to turn up the heat on Davon, secretly keeping track of who he was meeting with. They often showed him pictures of dealers that they knew to be among his friends and associates.

Do you know this guy? King asked one day about a particular dealer.

Yeah, Davon answered uneasily.

Well, I want him, King said.

I cant help you with that, Davon replied.

Well, when they go down, youll go down with them. And we cant do nothing to help you, King told him.

Davon had entered into the partnership believing it was a deal between equals. The veiled threats from King broke that illusion. The difference between a drug dealer like himself and a pair of drug-dealing cops, he realised, was that they could operate with impunity where he couldnt. When King and Murray began actively targeting Davons friends in the drug world, he interpreted it as a warning.

Things were about to get worse. One autumn evening, police picked Davon up as part of a street sweep operation a few blocks from Bennett Place. He was taken to the western district police station, where he found himself in an interrogation room with King. The detective looked at him with an even gaze, as if he were facing a stranger.

You want to stop yourself from going down with the others? King asked. You will tell us who the bosses are. Tell us whos who here and whats going on.

I cant help you with that, Davon said.

Davon was released without charge, but Kings threat could not have been any clearer.

When he got home, Davon began looking for a way to overcome the sense of powerlessness he had experienced. Not long after, he looked up the website for the FBIs Baltimore field office. Over the following days, he called the number a few times but always hung up at the last minute, worried about the possible consequences for himself if he reported the matter to the FBI. Turning it over in his mind, he finally concluded that the legal risk he faced would be minimal because he was 17 still a minor.

He called the number again. This time, he didnt hang up.

One day in November, Davon approached a silver Buick parked in Lexington Terrace, a neighbourhood of housing projects and row houses similar to his own. A tall FBI agent named Richard Wolf was sitting inside with a colleague, the only two white faces on the street. Davon glanced at them through the window and climbed on to the back seat.

Davon told the agents how he had been recruited by King and what he had been doing for the cop since the summer. Wolf wanted to know why he had decided to turn on his former partners. I dont trust King, Davon said. He was worried that the detective could put him in jail whenever he pleased, if Davon didnt do his bidding. And there was another reason he had contacted the FBI, he explained. He wanted to get out of selling drugs for the sake of his newborn daughter. Becoming an informant, he reasoned, could give him a safe exit from the world of dealing.

Wolf was struck by how self-assured Davon was. As a special agent, he knew it often took some coaxing to help whistleblowers and informants overcome their nervousness. But Davon didnt seem nervous at all. Wolf proceeded to lay down a condition: Davon would be paid to help the FBI develop a case against King and Murray, but he would have to stop hustling. If he got caught dealing drugs while working as an informant, he could face federal charges. Davon nodded.

Every year, the FBI investigates dozens of complaints of corruption by public employees. Since turf battles between the FBI and local law enforcement agencies around the country are not uncommon, federal agents tasked with investigating police officers have to be especially careful about pursuing charges of wrongdoing, lest they be perceived as pushing a hidden political agenda. The agents must also restrict knowledge of their investigation to an unusually small circle, since a cop, especially a guilty one, would be more likely to sniff out an ongoing probe and move to cover their tracks. Wolf, who was joined by a fellow agent named Wendy Munoz, was keenly aware of these sensitivities as he followed up on the information Davon had provided.

The first step toward building the case was to collect evidence of a drug deal between King and Davon. It was Davon who came up with the plan. He would tip King off to a stash of crack hidden in an alley off Bennett Place, enabling King to confiscate the stash and give it to Davon to sell. But this time the crack would have to be fake, since the FBI couldnt knowingly allow real drugs to be exchanged for money.

Through a Baltimore police sergeant, Wolf got hold of a recipe for baking a fake crack pie, which involved mixing Anbesol, the pain-relief medication, with baking soda and water, and heating it in the microwave. The resulting product was meant to have the yellowish colour and the grainy texture of crack. But when Wolf and Munoz attempted the recipe, in the FBIs office kitchen, the results left something to be desired. What they had made looked nothing like crack.

Wolf called the sergeant again to tell him, with some embarrassment, that the recipe hadnt worked. The sergeant gave him an easier alternative: macadamia nuts. Wolf went out and bought a bag of macadamias from the store, and Munoz spent hours splitting them into slivers with her fingernails. The agents made up 160 yellow plastic baggies and showed them to Davon, who gave his enthusiastic approval. In casual handling, he said, the bags could easily pass off as the real thing.

Drugs and cash seized by Baltimore police. Photograph: Rob Carr/AP

A week later, on 30 December 2004, the agents met Davon again. He put the bags of fake crack in a McDonalds paper bag and stashed it in the alley. At 11.50am, King parked his car near Bennett Place, entered the alley and phoned Davon, who guided him to the stash. Davon and the agents heard rustling noises as King searched. I got it, he said, finally. I got it.

Shortly after noon, Davon walked over from Wolfs car to meet King at the Rite Aid parking lot, across from the police station. In his trouser pocket was a digital recorder. King handed him the McDonalds bag. He wanted the crack sold as quickly as possible. Need some money, King said.

A few hours later, Davon met up with the agents again and gave them the bag. Wolf gave him $750, all in crumpled singles and five- and 10-dollar bills, as would be expected if the money had come from peddling crack on the street. Near the bottom of each bill, Wolf had scribbled his initials RJW with an ultraviolet pen. Davon gave King another call.

I got that dough, he said.

You for real? King said, surprised that the crack had sold so quickly.

The shit jumped off, Davon said.

Minutes later, he met up with King and delivered the cash.

By mid-February, the FBI had received court authorisation to tap King and Murrays phones. From the calls, the FBI agents could deduce that the detectives were forcing dealers they nabbed into their vehicle and, after talking to them, letting them out. But Wolf and Munoz had no evidence of what was transpiring inside the Chevrolet Lumina. They needed a microphone in the car.

One night in late March, after King and Murray had ended their shift, leaving the Lumina in the Rite Aid parking lot by the police station, FBI agents drove up in an identical Lumina and parked it next to King and Murrays vehicle. Next, they swiftly unlocked King and Murrays and drove it away, leaving the decoy in place. To a casual observer inside the police station, which the agents knew was staffed 24 hours a day, nothing would have looked amiss. A couple of hours later, the agents brought King and Murrays car back to the lot now rigged with microphones and GPS trackers and drove away the stand-in car.

Now the FBI began listening in on conversations King and Murray were having with dealers picked up from the street. Some of the dealers appeared to know what to expect, thanks to the reputation the cops had earned. Threatened with arrest, the dealers surrendered their cash and drugs meekly, sometimes pleading to get a few dollars back.

By early May 2005, Wolf and Munoz along with other officials were convinced they had enough evidence to wrap up the investigation. Later that month, the FBI invited King and Murrays squad to their office for a meeting whose stated goal was to form a taskforce aimed at fighting drugs in Baltimore. As soon as King and Murray got there, agents put them in handcuffs and informed them that they were being arrested on federal drug charges. In separate interviews with the two men, agents played back recordings of the some of the incriminating phone calls. King listened, crestfallen. I really think I should have my attorney, he said, nervously. Dont you think I should have my attorney?

When the case went to trial in March 2006, Davon was one of the first witnesses to take the stand. King and Murray watched from across the courtroom as Davon described how their partnership began and what he did to enable the FBIs sting operation. Up to that moment, Davon hadnt shared the secret of his collaboration with anybody, not even his girlfriend, Keisha.

After word got out about his appearance in court, the FBI moved Davon to a hotel in a suburb of Baltimore for his own safety. He got threatening phone calls. Keisha was stopped on the street by gang members. Tell him were going to kill him, they said. Even Tonya, who was still living at Bennett Place, was angry that her son had helped the feds. He had violated a sacrosanct rule of where he had grown up: you never work with the police, because law enforcement can never be your friend.

As the trial proceeded, the evidence against King and Murray mounted. Since the duo were carrying police-issued guns while shaking down dealers for drugs and cash, the jury found them guilty on multiple counts of armed robbery, in addition to several other counts of extortion and possession of drugs with intent to distribute. The judge sentenced the men to a combined 454 years in prison.

Throughout the investigation and the run-up to the trial, Davon had not thought much about what would happen after it was all over. He had vaguely imagined getting a lot more help from the government, taking his cue from movies in which the FBI relocated witnesses and bought them houses. The reality was somewhat different. After the trial ended, the FBI helped Davon to move into a rental apartment, giving him $1,500 to put down as a deposit. As the case was over, Wolf explained to Davon, the bureau could no longer justify paying him as an informant.

He was now on his own, without much cash to support himself. At one point, he had made a substantial amount of money dealing drugs, but he had ultimately squandered it, and now had nothing to show for the drug-dealing career he had had: no house, car or significant savings.

Davon Mayer on the steps of his old home in west Baltimore Photograph: JM Giordano for the Guardian

Davons girlfriend, Keisha, worked for the county government and had a daughter from a previous relationship. Davon didnt want to be financially dependent on her, and he eventually found work at a Wal-Mart, making $9 an hour unloading trucks at the stores warehouse. After all those years of making quick money, the backbreaking labour was an unpleasant dose of reality. The inside of the trucks felt like an oven. The Wal-Mart was more than 20 miles from where he lived, and since he no longer had a car, he had to pay an acquaintance a few dollars a day to take him to work. He had to ask Keisha to pick him up at the end of his shift. It felt humiliating. Of the $1,300 or so he made a month, more than $1,000 went toward paying rent and bills. How do people survive off of this? he asked Keisha.

As the months passed, he felt his patience for this new way of life depleting. The only way out, Davon decided, was to get back into hustling. But he had no capital to invest and there was no way anybody would front him drugs.

Bit by bit, he saved up a few hundred dollars. Then he called his grandfather, Ford, who reluctantly helped him re-establish contact with a couple of suppliers. Davon began selling to dealers who had bought from him before but didnt know his real name. Within weeks, he was back to making $300-$400 for work that took no more than a few minutes. Shortly after, he quit working at Wal-Mart. The job was slowing down the hustle, he told me.

When the lease on his apartment ended, he moved in with Keisha, but he kept her in the dark about the extent to which he had resumed his drug dealing. The black hole had pulled him back in.

In January 2009, Keisha and Davon had a baby girl, who they named Daylyn. Up until this point, Keisha had downplayed the consequences of his drug dealing in her mind, accepting it as something he simply couldnt get out of. But now, after having become the mother of his child, and after Davon had another close call with the police, she gave him an ultimatum. You have to make a choice, she said. The streets or family. You cant have both.

Davon had already lost his grandmother Norma, and his mother had died earlier that year. The only family he had left was Keisha. He agreed to give up his drug dealing. Over the next year-and-a-half, Davon began making a small income by working at bars and giving haircuts on the side. He and Keisha divided the household expenses down the middle. The house was in Keishas name; Davon paid her a part of the mortgage in the form of rent. Then, one day in the fall of 2011, after weeks of growing increasingly distant and quiet, he told Keisha he didnt have the money that month.

What happened to your paycheck? You just got paid, she asked. He admitted that he had given the money to a dealer, but the guy had been arrested. The money was gone.

Keisha was furious. She was convinced that Davon was incapable of shaking his addiction to the easy money that drug dealing brought. Im not going to live like this anymore, she said. She told him he was going to have to find another place to live. Davon knew that it wasnt an empty threat. He had to make a lasting change.

A week before Thanksgiving in 2011, I met up with Davon at a mall in Towson, Maryland, about 25 miles from Baltimore. I had made contact with him earlier that year after learning about the King and Murray investigation, which had left me wondering how things had turned out for him since. When I made my way through a throng of holiday shoppers into the restaurant, Davon rose from the table where he was seated with Keisha and Daylyn, and greeted me with a handshake, flashing a grin that revealed two gleaming gold teeth. Although he was nearing his 26th birthday, he still looked boyish.

He described how poor he felt now every time he walked into a mall with Keisha. I used to spend $1,000 at a mall in the blink of an eye, he said. He ruminated about how things might have turned out if he had chosen to continue working with King and Murray instead of going to the FBI. I know if I had chosen to go down the path that I was on, and if I werent in jail right now, I would be at the top of the game, he told me. I would be untouchable right now.

We stayed in touch over the following months, and in March 2012, Davon got a job with a company specialising in lead and asbestos abatement. The work was gruelling but Davon seemed happy. But keeping the past at bay had not been easy, he told me one day that spring when we met up for lunch at a mall in Columbia. Some of his old friends kept asking him to join them. I get offers all the time, he said. Because I still know guys who are pretty high up. They think that I know how to avoid a lot of stuff with the police. That I got some kind of deal. His bond with both his daughters had been growing stronger each day, he told me. Thats what kept him straight.

Reporters are supposed to stay neutral about their subjects, but the more I got to know Davon, the more I slipped into the role of a supportive confidante. As we continued to meet over the next two years, I began rooting for his success, not least because I wanted to see his story end in redemption and hope rather than failure. He would call me every few weeks to share his dreams of starting his own business one day.

When I was at the beach on Memorial Day weekend in 2013, he called me to tell me that his cousin and that cousins one-year-old child had been murdered in downtown Baltimore. He was immensely troubled by this news. A few months later, Keisha called me to tell me that Davon had suffered a panic attack. He had called her from the highway crying hysterically and saying that he was lost. He had managed to drive to the nearest hospital, which transferred him to a psychiatric ward.

When Davon was released three days later, his mental health was still fragile. He often called me for support, and I worried that he would unravel. I urged him to look into college. He passed a test for admission into preparation classes for a high-school equivalency qualification from Baltimore City Community College. Davon was short of money, and despite knowing that I was about to breach the barrier that is supposed to always keep a reporter separate from his subject, I paid the $80 fee he needed to register in the fall.

After he began attending class, he returned to his optimistic self. In December, I lent him $150 so that he could take his exams. He scored one of the highest in his class, and sent me a joyous text in January to say that he had been accepted into the ITT Technical Institute in Baltimore county to pursue an associate degree in network systems administration. While taking courses toward that degree over the next year, he began working as a contractor specialising in hooking up internet cables and other infrastructure for computer networks at government departments and private businesses. For the first time in his life, he had what he saw as a viable career.

In our conversations over the past two years, during which Davon continued to thrive, we had occasion to reflect on his lifes arc. The endless hours he spent telling me about his childhood and teenage years appeared to have given him an understanding of his story that he had never had before an appreciation of the complex interplay between the circumstances he found himself in at various points in his life and the choices he had made along the way. He might not have become a drug dealer if he hadnt grown up on Bennett Place. Nor would he have considered giving up that career if circumstances hadnt led him to become an FBI informant. Yet, without Keisha to hold him to account and to a lesser extent, my desire to tell a story I had always imagined to be one of redemption he could have easily slipped back into the black hole. The more perspective he gained about his own journey, the more he realised how impossible it was for many with his kind of background to climb out of their situation.

One morning not long ago, Davon took time out to give me a tour of his old neighbourhood. We walked down Bennett Place, past boarded-up houses. The sidewalks were deserted, and there were no signs of drug activity anywhere. We sat on the steps of a townhouse a couple of doors down from the one he had grown up in. It saddened him to think that there were so many like him on these streets who had suffered what he had but didnt have a way out.

I hate it when people say you have a choice, he said. It angers me. What choice do you have when your mother is out prostituting herself to feed her drug habit and your father is out murdering people?

We walked toward my car. He turned back to take another look at his grandfathers townhouse. Thats our house, he said. His plan was to buy it and turn it into a safe space for teenagers, off the streets. It would just be for the community, he said. You dont have a place to stay? You can come here. That would make my grandmother proud.

Main photograph: JM Giordano for the Guardian

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More than 25 million people dying in agony without morphine every year

Concern over illicit use and addiction is putting morphine out of reach for millions of patients globally who need it for pain relief

More than 25 million people, including 2.5 million children, die in agony every year around the world, for want of morphine or other palliative care, according to a major investigation.

Poor people cannot get pain relief in many countries of the world because their needs are overlooked or the authorities are so worried about the potential illicit use of addictive opioids that they will not allow their importation.

Staring into this access abyss, one sees the depth of extreme suffering in the cruel face of poverty and inequity, says a special report from a commission set up by the Lancet medical journal.

In Haiti, for instance, says the report, there are no nursing homes or hospices for the dying and most have to suffer without pain relief at home.

Patients in pain from trauma or malignancy are treated with medications like ibuprofen and acetaminophen, says testimony from Antonia P Eyssallenne of the University of Miami School of Medicine. Moreover, nurses are uncomfortable giving high doses of narcotics even if ordered to do so for fear of being responsible for the patients death, even if the patient is terminal.

Death in Haiti is cruel, raw, and devastatingly premature. There is often no explanation, no sympathy, and no peace, especially for the poor.

A doctor in Kerala, India, which has a palliative care service, told of the arrival of a man in agony from lung cancer. We put Mr S on morphine, among other things. A couple of hours later, he surveyed himself with disbelief. He had neither hoped nor conceived of the possibility that this kind of relief was possible, said Dr M R Rajagopal.

But when he returned, morphine stocks were out. Mr S told us with outward calm, I shall come again next Wednesday. I will bring a piece of rope with me. If the tablets are still not here, I am going to hang myself from that tree. He pointed to the window. I believed he meant what he said.

The commissions three-year inquiry found that nearly half of all deaths globally 25.5 million a year involve serious suffering for want of pain relief and palliative care. A further 35.5 million people live with chronic pain and distress. Of the 61 million total, 5.3 million are children. More than 80% of the suffering takes place in low and middle-income countries.

Jim Yong Kim, president of the World Bank, said things had to change. Failure of health systems in poor countries is a major reason that patients need palliative care in the first place. More than 90% of these child deaths are from avoidable causes. We can and will change both these dire situations.

Morphine is hard to obtain in some countries and virtually unobtainable in others. Mexico meets 36% of its need, China meets 16%, India 4% and Nigeria 0.2%. In some of the worlds poorest countries, such as Haiti, Afghanistan and many countries in Africa, oral morphine in palliative care is virtually non-existent.

Oral and injectable morphine is out of patent, but costs vary widely and it is cheaper in affluent countries like the USA than in poor countries. A second issue is opiophobia the fear that allowing the drugs to be used in hospitals will lead to addiction and crime in the community.

The world suffers a deplorable pain crisis: little to no access to morphine for tens of millions of adults and children in poor countries who live and die in horrendous and preventable pain, says Professor Felicia Knaul, co-chair of the commission from the University of Miami, calling it one of the worlds most striking injustices.

Knaul says she only realised that many people suffered without pain relief when she was working to improve access to cancer treatment in low-income countries. I was shocked. I had no idea. When people were showing me the data I thought it cant be in this world, she told the Guardian.

She had also experienced the need for morphine herself after a mastectomy for breast cancer. When I woke up I couldnt breathe because the pain was so bad. If they hadnt arrived with the morphine I dont know how I would have got through it. And as a young girl in Mexico, she had to watch her father suffer as he died without pain relief.

I dont think that we have cared enough about poor people who have pain, she said. It doesnt make them live any longer. It doesnt make them more productive. It is simply the human right of not suffering any more pain and we dont care about that for people who are poor.

The commission recommends that all countries put in place a relatively inexpensive package of effective palliative care for end of life conditions that cause suffering, including HIV, cancers, heart disease, injuries and dementia.

One of their most emphatic recommendations, says Knaul, is that immediate-release, off-patent, morphine that can cost just pennies should be made available in both oral and injectable formulations for any patient with medical need. The disparity and access abyss between the haves and have-nots is a medical, public health and moral injustice that can be effectively addressed by the commissions recommendations.

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