In a telephone interview from Scotland, Dr. Merriman, sometimes called Uganda’s “mother of palliative care,” described the early days of mixing morphine powder imported from Europe in buckets with water boiled on the kitchen stove.
Once cool, it was poured into empty mineral water bottles scrounged from tourist hotels.
She also recalled early opposition from older doctors who equated giving morphine to dying patients with euthanasia.
“You need someone to shout and scream and keep it going,” Dr. Merriman said.
Initially, donors like the Diana, Princess of Wales Memorial Fund and George Soros’s Open Society Institute helped, and the British and American governments provided money to help dying AIDS patients. But those funds slowly dried up as drugs for AIDS became more available.
Some hospitals began mixing their own morphine solutions. Then a morphine shortage occurred in 2010 following price squabbling between the health ministry and private wholesalers.
In 2011 the national drug warehouse was made the sole legal importer of morphine powder, and Hospice Africa was asked to mix solution for the whole country.
Treat the Pain stepped in to help. Its founder, Dr. O’Brien, a former epidemiologist at the Clinton Health Access Initiative, said she created the nonprofit after reading a 2007 New York Times series describing how millions died without pain relief and hearing an H.I.V. doctor describe his patients screaming in pain.
The nonprofit, which is now part of the American Cancer Society, paid about $100,000 for machines to sterilize water, make plastic bottles, fill them and attach labels.
Further mechanization is needed. On a recent visit to the operation, a pharmacist whisked powder and water together in what looked like a 40-gallon pasta pot, and medical students screwed caps onto the bottles.
The line can churn out 5,400 bottles a day, “and everything is automated except putting the caps on,” said Christopher Ntege, the chief pharmacist. “That is a small challenge compared to what we faced before.”
Despite its imperfections, the Ugandan model inspires others.
“Many countries come here to learn how they should rewrite their laws and medical policies,” said Dr. Emmanuel B.K. Luyirika, executive director of the African Palliative Care Association, an advocacy group. “This is a low-cost initiative that should be used everywhere.”
The health ministries of about 20 countries now use inexpensive morphine, Dr. Merriman estimated. But it is often available only in hospitals in the capital.
Efforts like these in Africa, Asia and Latin America “have laid the groundwork in the last twelve years for what could happen,” said Dr. Kathleen M. Foley, a palliative care specialist at Memorial Sloan Kettering Cancer Center.
“But it hasn’t moved faster because of poverty, lack of infrastructure, and the fact that palliative care is a new field and specialists aren’t paid by their governments to do the work.”
Now, she added, “I’m increasingly concerned that we’re losing the battle because of this panic. Overdose deaths are taking all the oxygen.”