KAMPALA, Uganda — Pain is only the latest woe in John Bizimungu’s life.
Rwandan by birth, he has lived here as a refugee since his family was slaughtered in the 1994 genocide. A cobbler, Mr. Bizimungu used to walk the streets asking people if he could fix their shoes.
Now, at 75 and on crutches, he sits at home hoping customers will drop by. But at least the searing pain from the cancer that has twisted his right foot is under control.
“Oh! Grateful? I am so, so, so, so grateful for the morphine!” he said, waving his hands and rocking back in his chair. “Without it, I would be dead.”
Mr. Bizimungu’s morphine is an opioid, closely related to the painkillers now killing 60,000 Americans a year — a situation President Trump recently declared a “health emergency.”
The cobbler’s desperate need exemplifies a problem that deeply worries palliative care experts: how they can help the 25 million people who die in agony each year in poor and middle-income countries without risking an American-style overdose epidemic abroad or triggering opposition from Western legislators and philanthropists for whom “opioid” has become a dirty word.
The American delegation to the International Narcotics Control Board, a United Nations agency, “uses frightening war-on-drugs rhetoric,” said Meg O’Brien, the founder of Treat the Pain, an advocacy group devoted to bringing palliative care to poor countries.
“That has a chilling effect on developing countries,” she said. “But it’s ridiculous — the U.S. also has an obesity epidemic, but no one is proposing that we withhold food aid from South Sudan.”
Uganda has implemented an innovative solution. Here, liquid morphine is produced by a private charity overseen by the government. And with doctors in short supply, the law lets even nurses prescribe morphine after specialized training.
About 11 percent of Ugandans needing morphine get it. Inadequate as that is, it makes Uganda a standout not just in Africa, but in the world.
Yet there is very little opioid abuse here; alcohol, marijuana and khat are far bigger problems.
No Relief in Sight
A recent major study by The Lancet Commission on Global Access to Palliative Care and Pain Relief described a “broad and deep abyss” in access to painkillers between rich countries and poor ones.
The United States, the report said, produces or imports 31 times as much narcotic pain-relievers it needs whether in legal or illegal form: morphine, hydrocodone, heroin, methadone, fentanyl and so on.
Haiti, by contrast, gets slightly less than 1 percent of what it needs. And Nigeria, on a per-capita basis, gets only a quarter of what Haiti gets: 0.2 percent of its need.
Even in big countries with domestic pharmaceutical industries, citizens still get shortchanged on pain relief, the report said. India and Indonesia, the second- and fourth-most populous countries on the planet, each supply only 4 percent of their own needs. Russia is at 8 percent. China, at 16 percent, barely beats Uganda.
“Each country has its own barriers,” said Dr. James F. Cleary, director of pain and policy studies at the University of Wisconsin’s medical school and a member of the commission that produced the Lancet study.
In some countries, doctors get no palliative care training; in others, legislators or the police oppose importing narcotics or deliberately make prescribing them difficult because of what the report deems “opiophobia.”
Pharmaceutical companies are uninterested in selling the generic morphine needed by poor countries because it is cheap and yields little profit.
Enough morphine to treat the entire world for end-of-life suffering would cost only $145 million a year, the Lancet report found.
Moreover, to treat all the children underage 15 needing it — for severe burns, surgery, car accidents, pain from sickle cell disease, cancerous tumors crushing spinal cords and so on — would cost a mere $1 million.
“This is a pittance,” the authors wrote, “compared with the $100 billion a year the world’s governments spend on enforcing global prohibition of drug use.”
Some pharmaceutical companies do try to market patented time-release oxycodone and other highly profitable opioids in middle-income countries — but governments are often wary because of the epidemic of drug abuse that has swept the United States.
“You only have to see one Time magazine cover, and countries say, ‘This isn’t something we want,’” Dr. Cleary said.
Demand for pain relief “needs a champion in each country,” said Felicia Marie Knaul, a health economist at the University of Miami and lead author of the Lancet report.
“Most people don’t want to talk about pain and dying,” she said. “And what makes it different from cancer is that the people who need it most are right about to die, and then they can’t speak out.”
How Uganda Succeeded
Uganda has had a national pain-relief policy since the mid-1990s. It succeeded for several reasons:
• The policy had outspoken local champions: Dr. Anne Merriman, a former missionary nun who in 1993 founded Hospice Africa Uganda to care for the terminally ill; Rose Kiwanuka, the first nurse trained in palliative care in this country, who now heads the Palliative Care Association of Uganda; and Dr. Jack Jagwe, a health ministry official who recognized the need.
(Like much of Africa, Uganda was in the grip of an AIDS epidemic in 1993 that seemed unstoppable because antiretroviral drugs then cost $12,000 a year. Many victims died screaming in pain from cryptococcal meningitis, Kaposi’s sarcoma or other opportunistic infections.)