Rwanda doesn't have access to costly opioids from big pharmaceutical companies, so the African country has come up with a solution.
In this photo taken Tuesday, Nov. 5, 2019, palliative care nurse Madeleine Mukantagara, 56, left, prays with Vestine Uwizeyimana, 22, right, who has spinal degenerative disease and is taking oral liquid morphine for her pain, as she visits to check on her health at her home in the village of Bushekeli, near Kibogora, in western Rwanda.
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. 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.
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.As Rwanda rebuilt itself, resilience was essential.
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.
A major study by the Lancet Commission on Global Access to Palliative Care and Pain Relief recently described the inequality between rich and poor countries as a “broad and deep abyss.” Commercially made morphine is on average nearly six times more expensive in many low- and middle- income counties than it is in wealthy ones, the INCB has reported, and the price varies wildly from place to place. Experts attribute it in part to small countries with low opioid consumption lacking the negotiating power to import drugs at bulk prices, particularly for controlled narcotics that require international authorizations that tack on cost.
The Ugandan operation, though much praised, remains limited in reach. Its existence outside the government health system is precarious, relying so much on donor support that it nearly shut down this year, founder Dr. Anne Merriman said. The bottles of liquid morphine are distributed to hospitals and pharmacies, where they are kept under lock and key until community workers like Mukantagara retrieve them. Then they are carried to the homes of the suffering even in some of Rwanda’s most rural areas, along footpaths between rolling bean fields and banana plants.
Even in Rwanda, doctors at first were hesitant to prescribe morphine for Ange Mucyo Izere, a 6-year-old girl who is undergoing chemotherapy for bone cancer.The girl began sipping doses of the liquid morphine in October and has been transformed. She took a visitor’s smartphone and began snapping photos, then struck poses for a camera.
It is a key distinction. Critics say for-profit drug makers have blurred that line, seizing on the good intentions of hospice advocacy to market opioids to patients with common chronic conditions. It is hard for people to tell now when opioids are appropriate and when the risks outweigh the benefits, said Lukas Radbruch, a German doctor and professor of palliative medicine.
Rep. Katherine Clark, D-Massachusetts, who authored the report, said she understands the need to address the global scourge of untreated pain. But she said the international health community cannot turn the reins over to the for-profit pharmaceutical industry that is already widely blamed for causing one epidemic.
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