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 Dr. Christian Ntizimira, a palliative care advocate.
Yet many doctors remained reluctant to use opioids.
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.
The use of morphine for hospice patients is undisputed -- when the U.S. Centers for Disease Control issued guidelines in 2016 calling on doctors to cut back on the flood of prescriptions that fed the addiction crisis, it exempted end-of-life patients.
The problem in the United States took hold when companies began campaigning for opioids to be used for chronic conditions like back pain — patients who could be customers for decades, said Dr. Anna Lembke, a Stanford University professor who has been a witness against pharmaceutical companies.
“What makes me mad is the confusion this causes,” said Lukas Radbruch, a German doctor and professor of palliative medicine, who fears the American addiction crisis is causing a backlash and the poorest people in the world will suffer.
The INCB reported that some 90 percent of opioids are consumed by the richest nations, where just 17% of people live. In developing nations, cost, onerous regulation and culture aversion to opioids prevents most from accessing them even on their deathbeds.
“People should have medication like an American person,”said Diane Mukasahaha, Rwanda’s coordinator of palliative care. “We all are human beings. The body is the same.”
Stefano Berterame, chief of the narcotic control for the INCB secretariat, said the agency has implored pharmaceutical companies to help.
Commercially made morphine is on average nearly six times more expensive in many poor counties than it is in wealthy ones, the INCB has reported. Experts attribute it in part to countries with low opioid consumption lacking the negotiating power to import drugs at bulk prices.
So a some African countries -- Rwanda, Kenya, Malawi -- began to make morphine on their own. They looked to Uganda, where the nonprofit Hospice Africa Uganda was making liquid morphine in a process so basic it was mixed for two decades at a kitchen sink.
But the Ugandan operation relies so much on donor support that it nearly shut down this year, founder Dr. Anne Merriman said.
By putting production and distribution under government control and covering the costs for patients, Rwanda has become the new model for Africa. The liquid is produced from imported powder, said Richard Niwenshuti Gatera, a pharmacist and director of the production facility.
Like all opioids, morphine can be addictive. But the government has control over the supply to prevent what happened in the United States, pills were shipped to tiny towns in quantities far exceeding justifiable medical need, said Meg O’Brien, whose Treat the Pain organization helps poor nations produce morphine. The drug is reserved for the sickest people and there is no marketing effort to expand use.
There have been no reports of abuse, said Mukasahaha.
The movement is spreading slowly across Africa: Twenty-two of 54 countries now have affordable morphine, according to Hospice Africa Uganda.
At a rural home, Mukantagara carried a bottle to 52-year-old Faina Nyirabaguiza, who has cancer. Each of her movements signaled pain. She settled on a wooden bench, rubbing her wrist.
Mukantagara poured the green liquid into the bottle cap. Nyirabaguiza drank three.
“Maybe it will help me,” she said. “My wish is to die. Really, I’m suffering.”
On the nurse’s ride back to the hospital, her vehicle passed a pickup truck with a coffin in the back. Women ran alongside it and sang.