Rwanda avoids US-style opioids crisis by making own morphine

It was something, the silence. Nothing but 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. Her life narrowed to a 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 in the poorest nations have no access to opioids at all.

Companies don't make money selling generic morphine to the dying, and most in sub-Saharan Africa cannot afford the expensive formulations like oxycodone, 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 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.

As a palliative care worker, Mukantagara, 56, has long been a witness to death. She watched her sister die of cancer decades ago, in agony without relief.

She settled on the edge of Uwizeyimana's bed. Uwizeyimana was feeling better.

Now I think everything is possible, she said. They held hands and prayed. Uwizeyimana is not the youngest among the 70 patients Mukantagara sees. Many have cancer. Some have HIV. A few have both.

The work is never easy, she said. But with morphine 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 country with an intimate knowledge of pain. Those who survived struggled to recover from ghastly machete wounds and cruel amputations.

As Rwanda rebuilt itself, resilience was essential. Pain was to be endured, ideally without showing suffering.

But medical advances meant more people began living into old age and facing diseases such as cancer. Some thought their pain was punishment from God, recalled