LEAD IN:

A choir without a voice is set to tour Europe to raise awareness of the plight of throat cancer patients.

The group, fitted with artificial voice boxes, call themselves "Shout at Cancer" because they're fighting back against the cancer which robbed them of their ability to speak.

STORY-LINE:

Thanks to this choir, these people are able to 'shout' again and they're aiming to 'let it all out' as loudly as they possibly can.

The words of the song by the 1980s pop band "Tears for Fears" is special to them and they've named themselves "Shout at Cancer" because of it.

Here the choir's been given the opportunity of performing at the Royal College of Surgeons in London.

They're all on a mission to make people, including doctors, aware of how isolating and difficult it is to have throat cancer.

While most physicians understand the trauma of having cancer, not not everyone understands what it's like to live after having your voice taken away.

Apart from a few specialist voices, everyone here has had an operation to have their larynx cut out and their windpipe brought through to a hole made in the front of their throats.

The laryngectomy is a complex operation which takes several hours.

Afterwards breathing is never the same again.

Patients have to master the technique of using a valve which becomes a permanent reminder of the cancer.

To speak, patients have to draw air through the hole in their windpipe and use the valve to trap the air into the mouth.

This allows them to manipulate the air to form what doctors call a 'valve voice'.

Margaret Young discovered she had thyroid cancer over seven years ago, she thought it had been treated, but it spread and before Christmas two years ago she discovered it had metasticised.

It would not have occurred to Young to join a choir before her cancer, but she was persuaded to do it by a speech therapist who'd heard about "Shout at Cancer".

She remembers: "They kept saying I should join the choir, but I've never been able to sing, so they fooled me by saying, well you don't really have to sing, it's just speech therapy and well, they lied, because we do sing and that's how I've ended up in the choir. But it's nice to meet other people in the same position because you can become very isolated, it would be easy to become isolated."

Andrew Beaumont was among the first members of the choir.

He, like Young, had his voice box removed when his cancer spread.

Beaumont is a vigorous advocate for the charity: "It is absolutely essential, it stretches the tonal range one is able to create and apart from the social side, the sense of community and a sense of purpose. You know it's very important to have a sense of purpose in all things and this charity is unique in doing that for laryngectomees."

Shout at Cancer is also a charity which helps to fund the choir.

Thomas Moors is the co-founder and one of an array of medical experts from scientists, voice therapists, musicians and surgeons who are raising money to spearhead new research.

They want a scientific enquiry into how music therapy can be used aid voice exercises for people who have had laryngectomies and examine how it can be used to ensure they're not isolated by the rest of society.

Although there are published studies physical problems experienced by laryngectomees, there is little research on their their emotional welfare or the psychosocial implications of the operation.

An additional problem is that most laryngectomees are nearing retirement which means they are more easily isolated.

Evangelos Himonides from University College London is among the scientists aiming to use music as a tool to help survivors of throat cancer.

"There's nothing about all the psychosocial factors that are part of this game and anything that is to do with how we can foster the development of these people, how we can enable their engagement and how we can help them gain the confidence and the support structures and all the different understandings that need to be in place, so that they can return back to society, they can relinquish the stigma that is connected to this."

The charity says there is simply not enough research, or progress into using new technologies because the number of laryngectomies each year are relatively few.

Here in the UK there are fewer than 1,800 operations a year according to "Shout at Cancer".

During the concert, choir member Jean Cooper reads her testimonial: "I thought I would never talk again and I did, I thought I would never sing again and I have. Now I know I can do anything and I will, I am me again."

Though the sentiment is personal, her experience is shared by the rest of the choir.

As well as conducting, Dr. Thomas Moors is the choir's director and cofounder of Shout at Cancer.

He is hoping the choir will make people sit up and understand the needs of people surviving throat cancer - better social support, better voice training services and even research into better technology.

Moors says: "Up to thirty percent, forty percent of them get into social isolation because of the effect on their voice and psychological affects. Does it have an effect by them joining the choir, yes. As soon as they do it, after their first concert, but (also) going and preparing and meeting up and having the group effect and enjoying the music and the sound they are producing together, it has an amazingly uplifting effect on them and they are the best ambassadors for this project themselves, because they go out and they spread the word and they are so enthusiastic about it that sometimes I even have to ask them to shut up. (laughs)."

As well as planning a number of Christmas concerts, next spring the choir will travel Brussels and Barcelona to spread their message.

AP TELEVISION - Music/video/performance rights must be cleared

London, UK - 5 October 2016

1. Mid of Shout at Cancer choir who've all had laryngectomies rehearsing their signature tune "Shout" by Tears for Fears

2. Close tilt down over the shoulder of charity founder Dr. Thomas Moors with choir in background

3. Close of concert pianist

4. Mid of choir

5. Close of pianist

6. Close of musical score

7. Wide of choir

8. Close of people in audience

9. Mid of audience

10. Wide pan from choir to audience applauding

11. UPSOUND: (English) Margaret Young, choir member, Shout at Cancer (shows wide of Margaret Young reading composition)

"It's gone, the box, the vocal chords, they took it all away. If I am mid sentence and I stop, it's not by choice. So I'll ask you again in a different way: can you hear my voice?"

12. Mid of audience applauding

13. SOUNDBITE: (English) Margaret Young, choir member, Shout at Cancer

"They kept saying I should join the choir, but I've never been able to sing, so they fooled my by saying, well you don't really have to sing, it's just speech therapy and well, they lied, because we do sing and that's how I've ended up in the choir. But it's nice to meet other people in the same position because you can become very isolated, it would be easy to become isolated."

14. Close of choir member pressing their speech valve

15. Close of Dr Thomas Moors directing choir with professional mezzo soprano La Verne Williams in the background

16. Close of speech valve on choir member

17. Tracking shot of Moors' hands

18. Various of choir members rehearsing "We Will Rock You" by Queen

19. Close tilt up of Andrew Beaumont pressing his speech valve to his face during singing

20. Mid rear view of choir during rehearsal

21. SOUNDBITE: (English) Andrew Beaumont, choir member, Shout at Cancer:

"It is absolutely essential, it stretches the tonal range one is able to create and apart from the social side, the sense of community and a sense of purpose. You know it's very important to have a sense of purpose in all things and this charity is unique in doing that for laryngectomees."

22. Close pan of audience (of surgeons and voice therapists) listening to La Verne Williams explain the use of vocal exercise

23. Close pan up of pianist playing "Brussels" by Jaques Brel accompanied by choir including Williams

24. Mid zoom out of Williams to reveal whole choir

25. Various of choristers singing accompaniment to Brussels

26. SOUNDBITE: (English) Evangelos Himonides, senior lecturer, University College London:

"There's nothing about all the psychosocial factors that are part of this game and anything that has to do with how we can foster the development of these people, how we can enable their engagement and how we can help them gain the confidence and the support structures and all the different understandings that need to be in place, so that they can return back to society, they can relinquish the stigma that is connected to this."

27. UPSOUND: (English) Jean Cooper, choir member, Shout at Cancer (reading her Testimonial during concert)

"I thought I would never talk again and I did, I thought I would never sing again and I have. Now I know I can do anything and I will, I am me again."

28. SOUNDBITE: (English) Dr. Thomas Moors, director, founder, Shout at Cancer:

"Up to thirty percent, forty percent of them get into social isolation because of the effect on their voice and psychological affects. Does it have an effect by them joining the choir, yes. As soon as they do it, after their first concert, but (also) going and preparing and meeting up and having the group effect and enjoying the music and the sound they are producing together, it has an amazingly uplifting effect on them and they are the best ambassadors for this project themselves, because they go out and they spread the word and they are so enthusiastic about it that sometimes I even have to ask them to shut up. (laughs)."

29. Various of choir singing their own composition for the Paralympians " Together we shout … Louder!"

FOR CLEAN VERSION SEE STORY NUMBER: 4061046

LEAD IN:

A choir without a voice is set to tour Europe to raise awareness of the plight of throat cancer patients.

The group, fitted with artificial voice boxes, call themselves "Shout at Cancer" because they're fighting back against the cancer which robbed them of their ability to speak.

STORY-LINE:

Thanks to this choir, these people are able to 'shout' again and they're aiming to 'let it all out' as loudly as they possibly can.

The words of the song by the 1980s pop band "Tears for Fears" is special to them and they've named themselves "Shout at Cancer" because of it.

Here the choir's been given the opportunity of performing at the Royal College of Surgeons in London.

They're all on a mission to make people, including doctors, aware of how isolating and difficult it is to have throat cancer.

While most physicians understand the trauma of having cancer, not not everyone understands what it's like to live after having your voice taken away.

Apart from a few specialist voices, everyone here has had an operation to have their larynx cut out and their windpipe brought through to a hole made in the front of their throats.

The laryngectomy is a complex operation which takes several hours.

Afterwards breathing is never the same again.

Patients have to master the technique of using a valve which becomes a permanent reminder of the cancer.

To speak, patients have to draw air through the hole in their windpipe and use the valve to trap the air into the mouth.

This allows them to manipulate the air to form what doctors call a 'valve voice'.

Margaret Young discovered she had thyroid cancer over seven years ago, she thought it had been treated, but it spread and before Christmas two years ago she discovered it had metasticised.

It would not have occurred to Young to join a choir before her cancer, but she was persuaded to do it by a speech therapist who'd heard about "Shout at Cancer".

She remembers: "They kept saying I should join the choir, but I've never been able to sing, so they fooled me by saying, well you don't really have to sing, it's just speech therapy and well, they lied, because we do sing and that's how I've ended up in the choir. But it's nice to meet other people in the same position because you can become very isolated, it would be easy to become isolated."

Andrew Beaumont was among the first members of the choir.

He, like Young, had his voice box removed when his cancer spread.

Beaumont is a vigorous advocate for the charity: "It is absolutely essential, it stretches the tonal range one is able to create and apart from the social side, the sense of community and a sense of purpose. You know it's very important to have a sense of purpose in all things and this charity is unique in doing that for laryngectomees."

Shout at Cancer is also a charity which helps to fund the choir.

Thomas Moors is the co-founder and one of an array of medical experts from scientists, voice therapists, musicians and surgeons who are raising money to spearhead new research.

They want a scientific enquiry into how music therapy can be used aid voice exercises for people who have had laryngectomies and examine how it can be used to ensure they're not isolated by the rest of society.

Although there are published studies physical problems experienced by laryngectomees, there is little research on their their emotional welfare or the psychosocial implications of the operation.

An additional problem is that most laryngectomees are nearing retirement which means they are more easily isolated.

Evangelos Himonides from University College London is among the scientists aiming to use music as a tool to help survivors of throat cancer.

"There's nothing about all the psychosocial factors that are part of this game and anything that is to do with how we can foster the development of these people, how we can enable their engagement and how we can help them gain the confidence and the support structures and all the different understandings that need to be in place, so that they can return back to society, they can relinquish the stigma that is connected to this."

The charity says there is simply not enough research, or progress into using new technologies because the number of laryngectomies each year are relatively few.

Here in the UK there are fewer than 1,800 operations a year according to "Shout at Cancer".

During the concert, choir member Jean Cooper reads her testimonial: "I thought I would never talk again and I did, I thought I would never sing again and I have. Now I know I can do anything and I will, I am me again."

Though the sentiment is personal, her experience is shared by the rest of the choir.

As well as conducting, Dr. Thomas Moors is the choir's director and cofounder of Shout at Cancer.

He is hoping the choir will make people sit up and understand the needs of people surviving throat cancer - better social support, better voice training services and even research into better technology.

Moors says: "Up to thirty percent, forty percent of them get into social isolation because of the effect on their voice and psychological affects. Does it have an effect by them joining the choir, yes. As soon as they do it, after their first concert, but (also) going and preparing and meeting up and having the group effect and enjoying the music and the sound they are producing together, it has an amazingly uplifting effect on them and they are the best ambassadors for this project themselves, because they go out and they spread the word and they are so enthusiastic about it that sometimes I even have to ask them to shut up. (laughs)."

As well as planning a number of Christmas concerts, next spring the choir will travel Brussels and Barcelona to spread their message.

Music/video/performance rights must be cleared

London, UK - 5 October 2016

1. Mid of Shout at Cancer choir who've all had laryngectomies rehearsing their signature tune "Shout" by Tears for Fears

2. Close tilt down over the shoulder of charity founder Dr. Thomas Moors with choir in background

3. Close of concert pianist

4. Mid of choir

5. Close of pianist

6. Close of musical score

7. Wide of choir

8. Close of people in audience

9. Mid of audience

10. Wide pan from choir to audience applauding

11. UPSOUND: (English) Margaret Young, choir member, Shout at Cancer (shows wide of Margaret Young reading composition)

"It's gone, the box, the vocal chords, they took it all away. If I am mid sentence and I stop, it's not by choice. So I'll ask you again in a different way: can you hear my voice?"

12. Mid of audience applauding

13. SOUNDBITE: (English) Margaret Young, choir member, Shout at Cancer

"They kept saying I should join the choir, but I've never been able to sing, so they fooled my by saying, well you don't really have to sing, it's just speech therapy and well, they lied, because we do sing and that's how I've ended up in the choir. But it's nice to meet other people in the same position because you can become very isolated, it would be easy to become isolated."

14. Close of choir member pressing their speech valve

15. Close of Dr Thomas Moors directing choir with professional mezzo soprano La Verne Williams in the background

16. Close of speech valve on choir member

17. Tracking shot of Moors' hands

18. Various of choir members rehearsing "We Will Rock You" by Queen

19. Close tilt up of Andrew Beaumont pressing his speech valve to his face during singing

20. Mid rear view of choir during rehearsal

21. SOUNDBITE: (English) Andrew Beaumont, choir member, Shout at Cancer:

"It is absolutely essential, it stretches the tonal range one is able to create and apart from the social side, the sense of community and a sense of purpose. You know it's very important to have a sense of purpose in all things and this charity is unique in doing that for laryngectomees."

22. Close pan of audience (of surgeons and voice therapists) listening to La Verne Williams explain the use of vocal exercise

23. Close pan up of pianist playing "Brussels" by Jaques Brel accompanied by choir including Williams

24. Mid zoom out of Williams to reveal whole choir

25. Various of choristers singing accompaniment to Brussels

26. SOUNDBITE: (English) Evangelos Himonides, senior lecturer, University College London:

"There's nothing about all the psychosocial factors that are part of this game and anything that has to do with how we can foster the development of these people, how we can enable their engagement and how we can help them gain the confidence and the support structures and all the different understandings that need to be in place, so that they can return back to society, they can relinquish the stigma that is connected to this."

27. UPSOUND: (English) Jean Cooper, choir member, Shout at Cancer (reading her Testimonial during concert)

"I thought I would never talk again and I did, I thought I would never sing again and I have. Now I know I can do anything and I will, I am me again."

28. SOUNDBITE: (English) Dr. Thomas Moors, director, founder, Shout at Cancer:

"Up to thirty percent, forty percent of them get into social isolation because of the effect on their voice and psychological affects. Does it have an effect by them joining the choir, yes. As soon as they do it, after their first concert, but (also) going and preparing and meeting up and having the group effect and enjoying the music and the sound they are producing together, it has an amazingly uplifting effect on them and they are the best ambassadors for this project themselves, because they go out and they spread the word and they are so enthusiastic about it that sometimes I even have to ask them to shut up. (laughs)."

29. Various of choir singing their own composition for the Paralympians " Together we shout … Louder!"

On the rolling hills of Rwanda, a nurse is on an urgent mission, by foot, to bring relief to a patient suffering from severe pain. In her bag she carries liquid morphine.

For 15 years, Vestine Uwizeyimana had been in unrelenting agony, as disease caused her spine to disintegrate.

She could no longer walk and could barely turn over in bed without whimpering.

At times she could not eat, talk, even recognise loved ones.

Her life narrowed to a small, dark room in a dirt-floor home in rural Rwanda, a rosary hanging on the wall by her side.

Her cries could be heard by passers-by on the road down the hill from her home.

A year ago, relief came in the form of liquid morphine.

The drug, locally produced, is part of a groundbreaking effort by Rwanda to address the world's other opioid crisis, in which millions of people in developing countries are without strong painkillers to calm suffering so intense that some cannot help but scream.

The Associated Press followed the morphine solution from its creation in a modest one-room production plant, to its distribution to patients living on the green hills along Lake Kivu and in the capital, Kigali.

The region is of little interest to the for-profit drug manufacturers that are blamed for rampant opioid addiction in the United States.

Their neglect of sub-Saharan Africa, where most countries are still too poor to be attractive markets for expensive formulations like oxycodone, is now seen as a kind of blessing.

Born of desperation, in the drug makers' absence, a solution has been found that some health experts say could be a model for the world.

With little risk of addiction, and at low cost, the production of liquid morphine that began on a small scale in neighbouring Uganda years ago is now being taken significantly further in Rwanda.

It aims to be the first low or middle-income country to make palliative care, or the easing of pain from life-limiting disease, available to all citizens via universal health care, and for free.

The final steps toward that goal are made on footpaths between rolling bean fields and banana plants as community health workers with bottles of morphine visit homes across Rwanda, bringing relief that many in Africa once considered out of reach.

Uwizeyimana greeted the arrival of health worker Madeleine Mukantagara with a smile.

The 56-year-old nurse settled on the edge of the bed, and they began with prayer.

Then there were questions and checking of vital signs.

Uwizeyimana was feeling better.

They held hands and prayed again, in whispers.

Uwizeyimana closed her eyes.

"The hardest thing about my job is seeing someone who was normal before now approaching the end of their lives, step by step" Mukantagara said as a tear dropped from the corner of her eye.

Uwizeyimana is not the youngest among the 70 patients she sees.

Many have cancer, some have HIV and few have both.

As a palliative care worker, Mukantagara has long been a witness to death.

She watched her sister die of cancer decades ago, in agony, without relief.

Now she attends patients' funerals and thanks grieving families for their care and support.

To relax, she sings in her church choir, and in her office across from the hospital chapel she hums along with the hymns.

A psychologist colleague offers her counseling.

The work is never easy, she said. But with the morphine, at least, there is a chance for death with dignity.

Twenty-five years ago, Rwanda's genocide offered nothing of the sort.

The killing of some 800-thousand ethnic Tutsis and moderate ethnic Hutus over roughly 100 days left the small country with an intimate knowledge of pain.

Those who survived, sometimes hidden under bodies of the dead, struggled to recover from ghastly machete wounds and the cruellest of amputations.

With the health care system shattered, little or no pain medication was available.

As Rwanda rebuilt itself, resilience was essential.

Pain was to be borne, ideally without showing suffering. If you did, some said, you were not strong.

But the culture began to change.

As the country drew global attention for advances in health care people were living longer, into their 70s or 80s, and more were dying from diseases such as cancer, heart disease and diabetes.

Rwanda is quietly becoming the new model for Africa, putting liquid morphine production and distribution under strict government control, making it sustainable.

The country's health insurance system covers the drug's cost for patients.

At each hospital, teams are trained in palliative care.

The health workers who prescribe morphine, including nurses and midwives, are taught to differentiate between chronic life-limiting diseases, which can be treated with morphine, and chronic pain, which cannot, at least not without risk.

It is a key distinction.

Critics say for-profit drug makers have blurred that line in richer countries like the US, where untold numbers of people have become addicted to opioids after receiving prescriptions for chronic pain such as osteoarthritis.

Past assurances that addiction was no danger have been revealed as lies.

The resulting confusion over opioid use has caused dismay among health workers in Rwanda and elsewhere in Africa who now must work even harder to press for pain relief.

Even before the US crisis many local doctors were wary of morphine because of fears of abuse and hesitated to prescribe it, they said.

Now that "opiophobia" has deepened.

The situation worsened when the World Health Organization, under pressure from US lawmakers appalled by the addiction crisis, rescinded key guidelines on prescribing opioids amid accusations that they had been influenced by drug makers.

WHO now plans to revise them.

The misunderstandings frustrate Diane Mukasahaha, Rwanda's national coordinator of palliative care.

"Without pain management there is no human right. If people are dying and are in torture of pain that country or that community are not observing human rights regulations," she said, recalling patients without morphine who were near starvation because they couldn't bear to eat.

And yet while the global consumption of opioids has more than tripled since 1997 the increase has been in the use of expensive formulations such as oxycodone and fentanyl, mostly in rich countries where pharmaceutical companies market the drugs, according to a report this year by the International Narcotics Control Board (INCB) that tracked progress in morphine availability in the developing world.

There is enough morphine in the world to treat all who truly need it, the INCB report said, but more than 90 per cent is consumed by the wealthiest countries.

With morphine six times more expensive, on average, in many low and middle-income countries than in wealthy ones and with prices varying wildly, the INCB has told drug companies they should ensure low-cost pain medications as a social responsibility.

And so a growing number of African countries are stepping up to make and distribute morphine, usually in a non-profit and government collaboration.

Kenya is one, Malawi another, but many countries are far behind, without morphine on their essential medicines lists or even a policy on pain relief.

While 22 of Africa's 54 countries now have affordable liquid morphine, according to Hospice Africa Uganda, consumption is still badly limited by challenges such as poor logistics and lack of funding.

While acknowledging Rwanda's achievements, Mukasahaha said more work is needed.

The country's goal of reaching everyone who needs palliative care by 2020 is just weeks away but not everyone benefits from home visits by community health workers, she said. The training of those workers, thousands in all, goes on.

Later that day she visited one of Rwanda's youngest palliative care patients, a 6-year-old girl with bone cancer named Ange Mucyo Izere.

"She was not able to sleep, talk, pray. Now she even accepts chemotherapy," said her mother, Joselyne Mukanyabyenda.

The girl began sipping doses of the liquid morphine in October, and she has been transformed.

During Mukasahaha's visit to her Kigali home she took a visitor's smartphone and began snapping photos, then struck poses for a camera, suddenly emboldened.

Now Rwanda's liquid morphine is made three times a week, about 200 bottles at a time, in a room where a handful of workers in protective scrubs are checked before leaving to prevent the drug being smuggled out.

Health authorities in the capital request how much morphine is needed.

The bottles are sent to Kigali and distributed to hospitals and district pharmacies, where they are kept under lock and key.

The government tracks how much is used.

The oversight leaves little room for abuse or influence by for-profit drug companies, but few are around.

Just one drug maker had a presence at the African palliative care conference, attendees recalled.

Experts estimate it would cost only 145 million dollars a year to make enough morphine to ease end-of-life suffering for all, worldwide.

But there is limited interest in making sure poor people can access that cheaper, more reliable form of pain relief, according to the Opioid Price Watch, which tracks how accessible opioids are around the world.

Faina Nyirabaguiza is 52.

Each of her movements signaled pain.

She walked slowly.

She settled on a wooden bench and folded over herself, rubbing her wrist with her thumb.

The visiting nurse, Mukantagara, increased her morphine dosage on the spot.

She poured the liquid into the bottle cap.

Nyirabaguiza drank three, one after another.

"Now that the dose is up, maybe it will help me," she said, her eyes fixed on the floor.

"My wish is to die. Really, I'm suffering."

Her husband, Felicien Musemihari, was quiet.

"According to what we read, there is heaven. And heaven is better than earth," he said finally.

"Better to leave this world and we'll meet there."

They prayed.

Nyirabaguiza closed her eyes.

Mukantagara's hand was on her back, soothing.

Bushekeli, Rwanda - 5 November 2019

1. Various of nurse Madeleine Mukantagara on foot to meet patient in Bushekeli community

2. Various of patient Vestine Uwizeyimana in bed

3. Madeleine with liquid morphine bottle

4. Close of liquid morphine bottle

5. SOUNDBITE (Kinyarwanda) Vestine Uwizeyimana, 22, spinal degenerative disease patient:

"When I would cry in pain people could hear me up on the main road. It was difficult to talk and eat and often I couldn't recognise people. But since taking the medicine I can eat, talk and recognise people and sometimes I can turn in my bed. I am still sick but somehow, I am better because of the morphine."

6. Various of Madeleine and Vestine praying together

Ruesero (a village near the Kibogora District Hospital), Rwanda - 5 November 2019

7. SOUNDBITE (Kinyarwanda) Madeleine Mukantagara, 56, nurse from Kibogora District Hospital:

"The hardest thing about my job is seeing someone who was normal before now, approaching the end of their lives, step by step."

Kigali, Rwanda - 6 November 2019

8. Various general views of Kigali

Kibogora, Rwanda - 4 November 2019

9. People waiting outside pharmacy at Kibogora District Hospital

10. Young boy outside a pharmacy at the hospital

Kigali, Rwanda - 6 November 2019

11. Medical director Diane Mukasahaha of Rwanda Biomedical Center high fiving Ange Mucyo Izere, 6, bone marrow cancer patient at her home

12. Diane Mukasahaha hugging Ange

13. UPSOUND (English) Diane Mukasahaha, National Palliative Care Program Director, Rwanda Biomedical Center: "She has cancer. She has B-cell ALL (Acute lymphoblastic leukemia)"

14. Ange listening to music on her mother's phone.

15. UPSOUND (English) Diane Mukasahaha, National Palliative Care Program Director, Rwanda Biomedical Center: "Yes according to the mum, before getting morphine, the baby (Ange) was in severe pain and she was not even able to take her other medication because of the pain."

16. Ange taking pictures with her mother's mobile phone

17. Various of Ange

18. SOUNDBITE (English) Diane Mukasahaha, National Palliative Care Program Director, Rwanda Biomedical Center:

"Without pain management there is no human right. If people are dying in torture of pain, that country, that community is not observing human right regulations."

Butare, Rwanda - 7 November 2019

19. Richard Niwenshuti Gatera (in white coat), pharmacist and director of the medicine production unit in Butare, walking into laboratory where liquid morphine is made

20. Richard walking past plaque commemorating staff killed during the 1994 Rwandan genocide at laboratory

21. Close of plaque

22. Richard speaking with the staff that produce the liquid morphine

23. Various of liquid morphine being produced

Ruesero (a village near the Kibogora District Hospital), Rwanda - 5 November 2019

24. Madeleine Mukantagara, 56, nurse, from Kibogora District Hospital greeted by Felicien Musemihari whose wife Faina Nyirabaguiza, 52, has cervical cancer

25. Children of Felicien and Faina

26. Various of Madeleine giving Faina liquid morphine

27. UPSOUND (Kinyarwanda) Faina Nyirabaguiza, 52, cervical cancer sufferer

"I am taking the medicine now, but I am still suffering. Now when the dose is increased maybe it will help me, I don't know. But my wish will be to die. Even if this medicine helps ease my mind, I am really suffering, I just want to pass away."

28. UPSOUND (Kinyarwanda) Felicien Musemihari, Faina's husband: "My wish is for my wife to be able to pass on to go to heaven because I know one day when I too pass, we will be able to meet there again. So my wish is that it is better for her to leave this world."

29. Liquid morphine on the table

30. Various of Mukantagara and the family praying

LEADIN:

The world's first memory-powered Christmas tree is helping people to remember loved ones over the festive period.

Terminal illness charity Marie Curie has installed the tree in London which reacts and grows brighter as people share memories on social media.

STORYLINE:

This beautiful Christmas tree is powered by memories.

Christmas can be a hard time for people who have lost loved ones and the terminal illness charity Marie Curie wants to shine a light on the happy memories.

Dwarfed, but not outshone, by the London Eye wheel the tree glows blue in response to memories shared on Twitter or Instagram using the hashtag #lightupxmas.

Every social media interaction makes the tree glow ever so slightly brighter.

Sisters Rachel Powell, Lisa Thomas and Sally Keenan from Cardiff, Wales have come to London's South Bank to remember their parents Helen and Terry Radford.

In 2008 their dad was diagnosed with terminal cancer and died shortly afterwards. In 2014 their mum was also diagnosed with terminal cancer. Both received support from the Marie Curie charity.

Lisa Thomas is taking a photo of her sisters under the tree and lighting in blue in memory of her parents.

Rachel Powell says: "It just reminds you of the good memories as well, because sometimes it's quite hard because you have the painful memories so it kind of reminds you of the happy times as well which helps."

Her sister Lisa Thomas adds: "And the more memories that you have, and the more that you tweet, the more the tree lights up which makes such a difference then when you're actually stood here looking at it and you're viewing it for yourself in person it's brilliant."

This is the last family photo of the Radfords in 2007 at a family barbecue to celebrate Powell's graduation from university.

Sally Keenan says: "It's just a lovely thing to do at Christmas time for us to come and just be thoughtful, and a place to sit and a place to talk, maybe have a little cry and just to remember all our loved ones that we've lost and obviously different families as well."

Marie Curie is calling it the world's first memory powered Christmas tree.

Because Christmas is traditionally a time for family to come together, it can also be a particularly difficult time for people with loved ones with terminal illness or who have passed away. Marie Curie wanted to reflect this and so installed the seven metre tall memory tree.

Marie Faulkner, social media manager at Marie Curie explains what sort of memories people have been sharing.

She says: "We've had everything from my dad's delicious roast potatoes to people maybe highlighting a particular person that they've lost. I tweeted about my granny Molly and our notorious family home videos that she would appear in. We're getting all sorts really, but they're really happy and positive."

In support of the charity the London Eye has changed from red to yellow - the charity's official colour.

The tree lit up for the first time on 4 December and people arrived to see it and watch a choir performing Christmas hits.

Paul Sims' mother died when he was a teenager. He says: "Yeah I'm remembering my mum. My mum died when I was 17 and actually Christmas hasn't been the same since then."

"It is a very important time to remember who has come before us and especially for my mum, remembering what she came to do, what she did for us as a family and how much she loved us and cared about us," he adds.

Helen Swanton's father died of cancer and she wants to remember him over Christmas. "I think it's a time when families either get together or maybe they don't get together and it does make you think about people who should be there but aren't there with you. So yes, it's a special time."

Jessica Gill is remembering a close family friend. "I would say the person I would remember is a really close family friend of ours who passed away a few years ago. Really healthy man, father, husband, and best friend to many. So I would be remembering him around this time of year and his family."

Anybody can tweet or make an Instagram post by using the hashtag #lightupxmas.

Over the 12 days of Christmas Marie Curie Nurses in the UK will care for more than 2,000 people in their own homes, helping families be together and make special memories through Christmas.

Marie Curie is the UK's leading charity for people with any terminal illness.

London, UK - 4 December, 2017

1. Wide of Marie Curie memory tree with London Eye in background

2. Close of star on tree

3. Mid of tree flashing blue after memory is tweeted

4. Pull focus of lights

5. Wide of London's South Bank and the London Eye

6. Low angle pan right of tree and London Eye

7. Over the shoulder of Lisa Thomas taking a photograph of her sisters Rachel Powell (right) and Sally Keenan

8. Close of Lisa Thomas

9. Low angle of same

10. Various of Instagram on phone typing #lightupxmas

11. Close of lights on tree glowing blue in response

12. SOUNDBITE: (English) Rachel Powell, lost her father and mother to cancer

"It just reminds you of the good memories as well, because sometimes it's quite hard because you have the painful memories so it kind of reminds you of the happy times as well which helps."

SOUNDBITE: (English) Lisa Thomas, lost her father and mother to cancer

"And the more memories that you have, and the more that you tweet, the more the tree lights up which makes such a difference then when you're actually stood here looking at it and you're viewing it for yourself in person it's brilliant."

Handout: Rachel Powell - only to be used in connection with this story

Cardiff, Wales - August 2007

13. Family photo of (left to right) Helen Radford, Sally Keenan, Rachel Powell, Lisa Thomas and Terry Radford

London, UK - 4 December, 2017

14. Mid of sisters hugging each other

15. SOUNDBITE: (English) Sally Keenan, lost her father and mother to cancer

"It's just a lovely thing to do at Christmas time for us to come and just be thoughtful, and a place to sit and a place to talk, maybe have a little cry and just to remember all our loved ones that we've lost and obviously different families as well."

16. Mid of man tweeting

17. Close of Twitter with the hashtag lightupxmas

18. Mid of tweet being sent and the tree glowing blue in response

19. Close of Twitter feed with tweet reading: (English) "I remember my grandad prepping a fresh turkey every year he'd come to stay at xmas. My sister had to hold the bag of guts and feathers as he trimmed, plucked and gutted. He was a badass. #lightupxmas."

20. Close tilt down of Marie Faulkner tweeting

21. Close of tweet reading: (English) "This Christmas I'll be thinking of my granny Molly who would #lightupxmas"

22. Low angle of Faulkner sending tweet and tree turning blue

23. SOUNDBITE: (English) Marie Faulkner, social media manager, Marie Curie

"We've had everything from my dad's delicious roast potatoes to people maybe highlighting a particular person that they've lost. I tweeted about my granny Molly and our notorious family home videos that she would appear in. We're getting all sorts really, but they're really happy and positive."

24. Mid of person tweeting memory

25. Close of screen reading: (English) "Made it down to the amazing @mariecurie tree. I'm remembering my nan and spending Christmas with her."

26. Mid of tweet being sent

27. Close of tree lights turning blue

28. Close pull focus of star on tree

29. SOUNDBITE: (English) Paul Sims, vox pop

"Yeah I'm remembering my mum. My mum died when I was 17 and actually Christmas hasn't been the same since then."

30. Wide of tree turning blue

31. SOUNDBITE: (English) Paul Sims, vox pop

"It is a very important time to remember who has come before us and especially for my mum, remembering what she came to do, what she did for us as a family and how much she loved us and cared about us."

32. SOUNDBITE: (English) Helen Swanton, vox pop

"I think you do, I think it's a time when families either get together or maybe they don't get together and it does make you think about people who should be there but aren't there with you. So yeah, it's a special time."

33. SOUNDBITE: (English) Jessica Gill, vox pop

"I would say the person I would remember is a really close family friend of ours who passed away a few years ago. Really healthy man, father, husband, and best friend to many. So I would be remembering him around this time of year and his family."

34. Wide of choir singing 'It's beginning to look a lot like Christmas'

35. Mid pan left of choir

36. Mid of choir's director

37. Wide low angle of tree and London Eye

LEADIN:

The world's first memory-powered Christmas tree is helping people to remember loved ones over the festive period.

Terminal illness charity Marie Curie has installed the tree in London which reacts and grows brighter as people share memories on social media.

STORYLINE:

This beautiful Christmas tree is powered by memories.

Christmas can be a hard time for people who have lost loved ones and the terminal illness charity Marie Curie wants to shine a light on the happy memories.

Dwarfed, but not outshone, by the London Eye wheel the tree glows blue in response to memories shared on Twitter or Instagram using the hashtag #lightupxmas.

Every social media interaction makes the tree glow ever so slightly brighter.

Sisters Rachel Powell, Lisa Thomas and Sally Keenan from Cardiff, Wales have come to London's South Bank to remember their parents Helen and Terry Radford.

In 2008 their dad was diagnosed with terminal cancer and died shortly afterwards. In 2014 their mum was also diagnosed with terminal cancer. Both received support from the Marie Curie charity.

Lisa Thomas is taking a photo of her sisters under the tree and lighting in blue in memory of her parents.

Rachel Powell says: "It just reminds you of the good memories as well, because sometimes it's quite hard because you have the painful memories so it kind of reminds you of the happy times as well which helps."

Her sister Lisa Thomas adds: "And the more memories that you have, and the more that you tweet, the more the tree lights up which makes such a difference then when you're actually stood here looking at it and you're viewing it for yourself in person it's brilliant."

This is the last family photo of the Radfords in 2007 at a family barbecue to celebrate Powell's graduation from university.

Sally Keenan says: "It's just a lovely thing to do at Christmas time for us to come and just be thoughtful, and a place to sit and a place to talk, maybe have a little cry and just to remember all our loved ones that we've lost and obviously different families as well."

Marie Curie is calling it the world's first memory powered Christmas tree.

Because Christmas is traditionally a time for family to come together, it can also be a particularly difficult time for people with loved ones with terminal illness or who have passed away. Marie Curie wanted to reflect this and so installed the seven metre tall memory tree.

Marie Faulkner, social media manager at Marie Curie explains what sort of memories people have been sharing.

She says: "We've had everything from my dad's delicious roast potatoes to people maybe highlighting a particular person that they've lost. I tweeted about my granny Molly and our notorious family home videos that she would appear in. We're getting all sorts really, but they're really happy and positive."

In support of the charity the London Eye has changed from red to yellow - the charity's official colour.

The tree lit up for the first time on 4 December and people arrived to see it and watch a choir performing Christmas hits.

Paul Sims' mother died when he was a teenager. He says: "Yeah I'm remembering my mum. My mum died when I was 17 and actually Christmas hasn't been the same since then."

"It is a very important time to remember who has come before us and especially for my mum, remembering what she came to do, what she did for us as a family and how much she loved us and cared about us," he adds.

Helen Swanton's father died of cancer and she wants to remember him over Christmas. "I think it's a time when families either get together or maybe they don't get together and it does make you think about people who should be there but aren't there with you. So yes, it's a special time."

Jessica Gill is remembering a close family friend. "I would say the person I would remember is a really close family friend of ours who passed away a few years ago. Really healthy man, father, husband, and best friend to many. So I would be remembering him around this time of year and his family."

Anybody can tweet or make an Instagram post by using the hashtag #lightupxmas.

Over the 12 days of Christmas Marie Curie Nurses in the UK will care for more than 2,000 people in their own homes, helping families be together and make special memories through Christmas.

Marie Curie is the UK's leading charity for people with any terminal illness.

London, UK - 4 December, 2017

1. Wide of Marie Curie memory tree with London Eye in background

2. Close of star on tree

3. Mid of tree flashing blue after memory is tweeted

4. Pull focus of lights

5. Wide of London's South Bank and the London Eye

6. Low angle pan right of tree and London Eye

7. Over the shoulder of Lisa Thomas taking a photograph of her sisters Rachel Powell (right) and Sally Keenan

8. Close of Lisa Thomas

9. Low angle of same

10. Various of Instagram on phone typing #lightupxmas

11. Close of lights on tree glowing blue in response

12. SOUNDBITE: (English) Rachel Powell, lost her father and mother to cancer

"It just reminds you of the good memories as well, because sometimes it's quite hard because you have the painful memories so it kind of reminds you of the happy times as well which helps."

SOUNDBITE: (English) Lisa Thomas, lost her father and mother to cancer

"And the more memories that you have, and the more that you tweet, the more the tree lights up which makes such a difference then when you're actually stood here looking at it and you're viewing it for yourself in person it's brilliant."

Handout: Rachel Powell - only to be used in connection with this story

Cardiff, Wales - August 2007

13. Family photo of (left to right) Helen Radford, Sally Keenan, Rachel Powell, Lisa Thomas and Terry Radford

Associated Press

London, UK - 4 December, 2017

14. Mid of sisters hugging each other

15. SOUNDBITE: (English) Sally Keenan, lost her father and mother to cancer

"It's just a lovely thing to do at Christmas time for us to come and just be thoughtful, and a place to sit and a place to talk, maybe have a little cry and just to remember all our loved ones that we've lost and obviously different families as well."

16. Mid of man tweeting

17. Close of Twitter with the hashtag lightupxmas

18. Mid of tweet being sent and the tree glowing blue in response

19. Close of Twitter feed with tweet reading: (English) "I remember my grandad prepping a fresh turkey every year he'd come to stay at xmas. My sister had to hold the bag of guts and feathers as he trimmed, plucked and gutted. He was a badass. #lightupxmas."

20. Close tilt down of Marie Faulkner tweeting

21. Close of tweet reading: (English) "This Christmas I'll be thinking of my granny Molly who would #lightupxmas"

22. Low angle of Faulkner sending tweet and tree turning blue

23. SOUNDBITE: (English) Marie Faulkner, social media manager, Marie Curie

"We've had everything from my dad's delicious roast potatoes to people maybe highlighting a particular person that they've lost. I tweeted about my granny Molly and our notorious family home videos that she would appear in. We're getting all sorts really, but they're really happy and positive."

24. Mid of person tweeting memory

25. Close of screen reading: (English) "Made it down to the amazing @mariecurie tree. I'm remembering my nan and spending Christmas with her."

26. Mid of tweet being sent

27. Close of tree lights turning blue

28. Close pull focus of star on tree

29. SOUNDBITE: (English) Paul Sims, vox pop

"Yeah I'm remembering my mum. My mum died when I was 17 and actually Christmas hasn't been the same since then."

30. Wide of tree turning blue

31. SOUNDBITE: (English) Paul Sims, vox pop

"It is a very important time to remember who has come before us and especially for my mum, remembering what she came to do, what she did for us as a family and how much she loved us and cared about us."

32. SOUNDBITE: (English) Helen Swanton, vox pop

"I think you do, I think it's a time when families either get together or maybe they don't get together and it does make you think about people who should be there but aren't there with you. So yeah, it's a special time."

33. SOUNDBITE: (English) Jessica Gill, vox pop

"I would say the person I would remember is a really close family friend of ours who passed away a few years ago. Really healthy man, father, husband, and best friend to many. So I would be remembering him around this time of year and his family."

34. Wide of choir singing 'It's beginning to look a lot like Christmas'

35. Mid pan left of choir

36. Mid of choir's director

37. Wide low angle of tree and London Eye

On the rolling hills of Rwanda, a nurse is on an urgent mission, by foot, to bring relief to a patient suffering from severe pain. In her bag she carries liquid morphine.

For 15 years, Vestine Uwizeyimana had been in unrelenting agony, as disease caused her spine to disintegrate.

She could no longer walk and could barely turn over in bed without whimpering.

At times she could not eat, talk, even recognise loved ones.

Her life narrowed to a small, dark room in a dirt-floor home in rural Rwanda, a rosary hanging on the wall by her side.

Her cries could be heard by passers-by on the road down the hill from her home.

A year ago, relief came in the form of liquid morphine.

The drug, locally produced, is part of a groundbreaking effort by Rwanda to address the world's other opioid crisis, in which millions of people in developing countries are without strong painkillers to calm suffering so intense that some cannot help but scream.

The Associated Press followed the morphine solution from its creation in a modest one-room production plant, to its distribution to patients living on the green hills along Lake Kivu and in the capital, Kigali.

The region is of little interest to the for-profit drug manufacturers that are blamed for rampant opioid addiction in the United States.

Their neglect of sub-Saharan Africa, where most countries are still too poor to be attractive markets for expensive formulations like oxycodone, is now seen as a kind of blessing.

Born of desperation, in the drug makers' absence, a solution has been found that some health experts say could be a model for the world.

With little risk of addiction, and at low cost, the production of liquid morphine that began on a small scale in neighbouring Uganda years ago is now being taken significantly further in Rwanda.

It aims to be the first low or middle-income country to make palliative care, or the easing of pain from life-limiting disease, available to all citizens via universal health care, and for free.

The final steps toward that goal are made on footpaths between rolling bean fields and banana plants as community health workers with bottles of morphine visit homes across Rwanda, bringing relief that many in Africa once considered out of reach.

Uwizeyimana greeted the arrival of health worker Madeleine Mukantagara with a smile.

The 56-year-old nurse settled on the edge of the bed, and they began with prayer.

Then there were questions and checking of vital signs.

Uwizeyimana was feeling better.

They held hands and prayed again, in whispers.

Uwizeyimana closed her eyes.

"The hardest thing about my job is seeing someone who was normal before now approaching the end of their lives, step by step" Mukantagara said as a tear dropped from the corner of her eye.

Uwizeyimana is not the youngest among the 70 patients she sees.

Many have cancer, some have HIV and few have both.

As a palliative care worker, Mukantagara has long been a witness to death.

She watched her sister die of cancer decades ago, in agony, without relief.

Now she attends patients' funerals and thanks grieving families for their care and support.

To relax, she sings in her church choir, and in her office across from the hospital chapel she hums along with the hymns.

A psychologist colleague offers her counseling.

The work is never easy, she said. But with the morphine, at least, there is a chance for death with dignity.

Twenty-five years ago, Rwanda's genocide offered nothing of the sort.

The killing of some 800-thousand ethnic Tutsis and moderate ethnic Hutus over roughly 100 days left the small country with an intimate knowledge of pain.

Those who survived, sometimes hidden under bodies of the dead, struggled to recover from ghastly machete wounds and the cruellest of amputations.

With the health care system shattered, little or no pain medication was available.

As Rwanda rebuilt itself, resilience was essential.

Pain was to be borne, ideally without showing suffering. If you did, some said, you were not strong.

But the culture began to change.

As the country drew global attention for advances in health care people were living longer, into their 70s or 80s, and more were dying from diseases such as cancer, heart disease and diabetes.

Rwanda is quietly becoming the new model for Africa, putting liquid morphine production and distribution under strict government control, making it sustainable.

The country's health insurance system covers the drug's cost for patients.

At each hospital, teams are trained in palliative care.

The health workers who prescribe morphine, including nurses and midwives, are taught to differentiate between chronic life-limiting diseases, which can be treated with morphine, and chronic pain, which cannot, at least not without risk.

It is a key distinction.

Critics say for-profit drug makers have blurred that line in richer countries like the US, where untold numbers of people have become addicted to opioids after receiving prescriptions for chronic pain such as osteoarthritis.

Past assurances that addiction was no danger have been revealed as lies.

The resulting confusion over opioid use has caused dismay among health workers in Rwanda and elsewhere in Africa who now must work even harder to press for pain relief.

Even before the US crisis many local doctors were wary of morphine because of fears of abuse and hesitated to prescribe it, they said.

Now that "opiophobia" has deepened.

The situation worsened when the World Health Organization, under pressure from US lawmakers appalled by the addiction crisis, rescinded key guidelines on prescribing opioids amid accusations that they had been influenced by drug makers.

WHO now plans to revise them.

The misunderstandings frustrate Diane Mukasahaha, Rwanda's national coordinator of palliative care.

"Without pain management there is no human right. If people are dying and are in torture of pain that country or that community are not observing human rights regulations," she said, recalling patients without morphine who were near starvation because they couldn't bear to eat.

And yet while the global consumption of opioids has more than tripled since 1997 the increase has been in the use of expensive formulations such as oxycodone and fentanyl, mostly in rich countries where pharmaceutical companies market the drugs, according to a report this year by the International Narcotics Control Board (INCB) that tracked progress in morphine availability in the developing world.

There is enough morphine in the world to treat all who truly need it, the INCB report said, but more than 90 per cent is consumed by the wealthiest countries.

With morphine six times more expensive, on average, in many low and middle-income countries than in wealthy ones and with prices varying wildly, the INCB has told drug companies they should ensure low-cost pain medications as a social responsibility.

And so a growing number of African countries are stepping up to make and distribute morphine, usually in a non-profit and government collaboration.

Kenya is one, Malawi another, but many countries are far behind, without morphine on their essential medicines lists or even a policy on pain relief.

While 22 of Africa's 54 countries now have affordable liquid morphine, according to Hospice Africa Uganda, consumption is still badly limited by challenges such as poor logistics and lack of funding.

While acknowledging Rwanda's achievements, Mukasahaha said more work is needed.

The country's goal of reaching everyone who needs palliative care by 2020 is just weeks away but not everyone benefits from home visits by community health workers, she said. The training of those workers, thousands in all, goes on.

Later that day she visited one of Rwanda's youngest palliative care patients, a 6-year-old girl with bone cancer named Ange Mucyo Izere.

"She was not able to sleep, talk, pray. Now she even accepts chemotherapy," said her mother, Joselyne Mukanyabyenda.

The girl began sipping doses of the liquid morphine in October, and she has been transformed.

During Mukasahaha's visit to her Kigali home she took a visitor's smartphone and began snapping photos, then struck poses for a camera, suddenly emboldened.

Now Rwanda's liquid morphine is made three times a week, about 200 bottles at a time, in a room where a handful of workers in protective scrubs are checked before leaving to prevent the drug being smuggled out.

Health authorities in the capital request how much morphine is needed.

The bottles are sent to Kigali and distributed to hospitals and district pharmacies, where they are kept under lock and key.

The government tracks how much is used.

The oversight leaves little room for abuse or influence by for-profit drug companies, but few are around.

Just one drug maker had a presence at the African palliative care conference, attendees recalled.

Experts estimate it would cost only 145 million dollars a year to make enough morphine to ease end-of-life suffering for all, worldwide.

But there is limited interest in making sure poor people can access that cheaper, more reliable form of pain relief, according to the Opioid Price Watch, which tracks how accessible opioids are around the world.

Faina Nyirabaguiza is 52.

Each of her movements signaled pain.

She walked slowly.

She settled on a wooden bench and folded over herself, rubbing her wrist with her thumb.

The visiting nurse, Mukantagara, increased her morphine dosage on the spot.

She poured the liquid into the bottle cap.

Nyirabaguiza drank three, one after another.

"Now that the dose is up, maybe it will help me," she said, her eyes fixed on the floor.

"My wish is to die. Really, I'm suffering."

Her husband, Felicien Musemihari, was quiet.

"According to what we read, there is heaven. And heaven is better than earth," he said finally.

"Better to leave this world and we'll meet there."

They prayed.

Nyirabaguiza closed her eyes.

Mukantagara's hand was on her back, soothing.

Bushekeli, Rwanda - 5 November 2019

1. Various of nurse Madeleine Mukantagara on foot to meet patient in Bushekeli community

2. Various of patient Vestine Uwizeyimana in bed

3. Madeleine with liquid morphine bottle

4. Close of liquid morphine bottle

5. SOUNDBITE (Kinyarwanda) Vestine Uwizeyimana, 22, spinal degenerative disease patient:

"When I would cry in pain people could hear me up on the main road. It was difficult to talk and eat and often I couldn't recognise people. But since taking the medicine I can eat, talk and recognise people and sometimes I can turn in my bed. I am still sick but somehow, I am better because of the morphine."

6. Various of Madeleine and Vestine praying together

Ruesero (a village near the Kibogora District Hospital), Rwanda - 5 November 2019

7. SOUNDBITE (Kinyarwanda) Madeleine Mukantagara, 56, nurse from Kibogora District Hospital:

"The hardest thing about my job is seeing someone who was normal before now, approaching the end of their lives, step by step."

Kigali, Rwanda - 6 November 2019

8. Various general views of Kigali

Kibogora, Rwanda - 4 November 2019

9. People waiting outside pharmacy at Kibogora District Hospital

10. Young boy outside a pharmacy at the hospital

Kigali, Rwanda - 6 November 2019

11. Medical director Diane Mukasahaha of Rwanda Biomedical Center high fiving Ange Mucyo Izere, 6, bone marrow cancer patient at her home

12. Diane Mukasahaha hugging Ange

13. UPSOUND (English) Diane Mukasahaha, National Palliative Care Program Director, Rwanda Biomedical Center: "She has cancer. She has B-cell ALL (Acute lymphoblastic leukemia)"

14. Ange listening to music on her mother's phone.

15. UPSOUND (English) Diane Mukasahaha, National Palliative Care Program Director, Rwanda Biomedical Center: "Yes according to the mum, before getting morphine, the baby (Ange) was in severe pain and she was not even able to take her other medication because of the pain."

16. Ange taking pictures with her mother's mobile phone

17. Various of Ange

18. SOUNDBITE (English) Diane Mukasahaha, National Palliative Care Program Director, Rwanda Biomedical Center:

"Without pain management there is no human right. If people are dying in torture of pain, that country, that community is not observing human right regulations."

Butare, Rwanda - 7 November 2019

19. Richard Niwenshuti Gatera (in white coat), pharmacist and director of the medicine production unit in Butare, walking into laboratory where liquid morphine is made

20. Richard walking past plaque commemorating staff killed during the 1994 Rwandan genocide at laboratory

21. Close of plaque

22. Richard speaking with the staff that produce the liquid morphine

23. Various of liquid morphine being produced

Ruesero (a village near the Kibogora District Hospital), Rwanda - 5 November 2019

24. Madeleine Mukantagara, 56, nurse, from Kibogora District Hospital greeted by Felicien Musemihari whose wife Faina Nyirabaguiza, 52, has cervical cancer

25. Children of Felicien and Faina

26. Various of Madeleine giving Faina liquid morphine

27. UPSOUND (Kinyarwanda) Faina Nyirabaguiza, 52, cervical cancer sufferer

"I am taking the medicine now, but I am still suffering. Now when the dose is increased maybe it will help me, I don't know. But my wish will be to die. Even if this medicine helps ease my mind, I am really suffering, I just want to pass away."

28. UPSOUND (Kinyarwanda) Felicien Musemihari, Faina's husband: "My wish is for my wife to be able to pass on to go to heaven because I know one day when I too pass, we will be able to meet there again. So my wish is that it is better for her to leave this world."

29. Liquid morphine on the table

30. Various of Mukantagara and the family praying