Data from the International Narcotics Control Board¹³ shows the following figures for narcotic consumption in Uganda, 2002: codeine 27 kg (down from 83kg, 1998); morphine 9 kg (up from 2 kg, 1993); pethidine 8 kg (as in 1998, but down from 22kg in 2001).

For the years 2000-2002, the average defined daily dose consumption of morphine for statistical purposes (S-DDD)¹⁴ in Uganda was 4. This compares with other African countries as follows: Swaziland 1; Egypt 2; Zimbabwe 13; Botswana 53; Namibia 73; South Africa 103. Twenty nine countries reported no morphine consumption during 2000-2002 (Table 4).

Morphine for cancer and HIV/AIDS patients is provided free of charge by the government. In March 2004, a Statutory Instrument¹⁵ was signed by the Minister of Health authorizing palliative care nurses and clinical officers to prescribe morphine as part of their clinical practice: a ground-breaking innovation.

Morphine is supplied by HAU in tablet and liquid forms. The slow-release morphine tablets (MST) – donated by NAPP (UK) - are in 10mg and 30mg strengths. Liquid (oral) morphine is the most frequent form of pain control and is prepared in 1mg, 10mg and 20mg per ml. strengths. Pharmacist Peter Mikajjo comments:

We prepare [liquid morphine] in a very simple way whereby it cannot take a lot of time and cannot be costly. Morphine is prepared out of morphine powder: there are actually two types – either morphine sulphate or morphine hydrochloride – but basically we are using morphine sulphate and we prepare enough that can be used in a week.¹⁶

HAU founder Anne Merriman is clear about the role played by morphine in palliative care:

I think support care can be put in if you don’t have morphine but I don’t think palliative care is there… When I met Dame Cicely a few years back, I said to her “You know something: there was support care in Uganda before I went, and there were really caring people doing it”. And she said “that’s why I started the modern hospice movement. The support care was there – people were dying with people caring for them - but they weren’t controlling pain;

Table 4 Average daily consumption of defined daily doses (for statistical purposes) of morphine per million inhabitants, 2000-2002: countries of Africa

Source: International Narcotics Control Board. Narcotic Drugs: estimated world requirements for 2004. Statistics for 2002. New York: United Nations, 2004.

that’s why I started it, and that’s the difference I made.” So my definition now is: support care without pain control is support care; pain control without support care is anaesthesiology… to have palliative care you have to have pain control plus support care.¹⁷

A key contributor to the debate surrounding morphine has been Jack Jagwe, who describes his role as follows:

My role in Hospice Africa Uganda is that of the senior advisor on policy, drugs and advocacy. Policy concerns how palliative care relates to Government health policies so that we don’t have any conflict. The second one is about drugs, how to access palliative care drugs and most specifically the availability of morphine to patients in palliative care. And the third one is advocacy - to try and convince Government and top health policy makers about the value of having palliative care for so many patients in our country who are dying from HIV/AIDS and cancer.

First of all: I’m a physician by training, and I’ve been in the Government services for 30 years ’til my retirement - and I got interested when Dr Anne Merriman came to Uganda in 1993. By then I was the Deputy Director of Medical Services in charge of clinical services and also in charge of essential grants in the country. That’s when she came and mentioned that we should have drugs like morphine available for these people. And after that, when I retired officially from the Government, I became Chairman of the National Drug Regulatory Body in Uganda. Since then I’ve been interested in palliative care and in 1998 when she organised a national workshop I was appointed Chairman of a task force which worked out a national policy on palliative care. That draft was thoroughly discussed and eventually submitted to the Ministry of Health and it was incorporated into the Health Strategic Plan of 2001-2005.¹⁸

If morphine is required by patients in the Kitovu Mobile Home Care programme, a referral is made to the programme doctor. Once the doctor prescribes the morphine, the patient or a family member can collect the medicine from nurses at a nearby centre.