Rwanda avoids US-style opioids crisis by making own morphine
BUSHEKELI, RWANDA >> It was something, the silence. Nothing but the puff of her breath and the scuff of her slip-on shoes as Madeleine Mukantagara walked through the fields to her first patient of the day. Piercing cries once echoed down the hill to the road below. What she carried in her bag had calmed them.
For 15 years, her patient Vestine Uwizeyimana had been in unrelenting pain as disease wore away her spine. She could no longer walk and could barely turn over in bed. Her life narrowed to a small, dark room with a dirt-floor in rural Rwanda, prayer beads hanging on the wall by her side.
A year ago, relief came in the form of liquid morphine, locally produced as part of Rwanda’s groundbreaking effort to address one of the world’s great inequities: As thousands die from addiction in rich countries awash with prescription painkillers, millions of people writhe in agony in the poorest nations with no access to opioids at all.
Companies don’t make money selling cheap, generic morphine to the poor and dying, and most people in sub-Saharan Africa cannot afford the expensive formulations like oxycodone and fentanyl, prescribed so abundantly in richer nations that thousands became addicted to them.
Rwanda’s answer: plastic bottles of morphine, produced for pennies and delivered to homes across the country by community health workers like Mukantagara. It is proof, advocates say, that the opioid trade doesn’t have to be guided by how much money can be made.
“Without this medicine I think I would die,” said Uwizeyimana, 22.
When Mukantagara arrived, she smiled.
The small-scale production of liquid morphine that began in neighboring Uganda years ago is now being taken significantly further in Rwanda. It aims to be the first low- or middleincome country to make palliative care — or the easing of pain from life-threatening illness — available to all citizens, and for free.
As a palliative care worker, Mukantagara has long been a witness to death. She watched her sister die of cancer decades ago, in agony without relief.
The 56-year-old nurse settled on the edge of Uwizeyimana’s bed, and they began with prayer. Uwizeyimana was feeling better. “Now I think everything is possible,” she said. They held hands and prayed again, in whispers. Uwizeyimana closed her eyes.
As her visitors left Uwizeyimana blessed them, wishing for them what she might never have herself. May you get married, if you are not, she said. May you have children.
“It is hard to estimate how long someone will live,” Mukantagara said, walking away. Uwizeyimana is not the youngest among the 70 patients she sees. Many have cancer. Some have HIV. A few have both.
She attends patients’ funerals and thanks grieving families for their care. To relax, she sings in her church choir, and in her office by the hospital chapel she hums along with the hymns. A psychologist colleague offers her counseling.
The work is never easy, she said. But with morphine, at least, there is a chance for death with dignity.
Twenty-five years ago, the killing of some 800,000 ethnic Tutsis and moderate ethnic Hutus left this small country with an intimate knowledge of pain. Those who survived, struggled to recover from ghastly machete wounds and the cruelest of amputations.
With the health system shattered, there was little to ease the agony.
As Rwanda rebuilt itself, resilience was essential. Pain was to be endured, ideally without showing suffering; if you did, some said, you were not strong.
But medical advances meant more people were living into old age and facing diseases such as cancer. Some thought their pain was punishment from
God for past sins, recalled Dr. Christian Ntizimira, one of Rwanda’s most outspoken advocates for palliative care. At the same time, health workers treating Rwandans in the late stages of AIDS pleaded for a way to ease their pain.
Many doctors were ignorant of morphine or scared to use it. When Ntizimira was hesitant to prescribe it, early in his career, a mother fell to her knees in front of him and pleaded for mercy for her son. Ntizimira was ashamed.
“I went home and questioned myself: ‘Why study so many years if I can’t help someone in pain?’” he recalled. “I didn’t sleep that night.”
In much of the world, the use of opioids was exploding. Consumption has tripled since 1997, according to the International Narcotics Control Board. But the increase was in expensive formulations that are profitable for pharmaceutical companies, according to an AP analysis of INCB data. The use of morphine, the cheapest and most reliable painkiller, stagnated.
Administration of morphine for hospice patients is undisputed — in 2016, when the U.S. Centers for Disease Control called on doctors to cut back on the flood of opioid prescriptions that fed the addiction crisis, it specifically exempted end-of-life patients.