Beholden to the humble beginning of Palliative Care in India

Beholden to the humble beginning of Palliative Care in India

– Dr. Bidhu K. Mohanti, Bhubaneshwar

Oral morphine solution

Looking back to make a sense of the Palliative Care community and its activities, can give us all the essence of ownership and agency. At a professional level, to quote from an earlier published article, “In the 1980s, when I got into oncology, cancer therapies yielded only modest results, and comprehensive care in India was in its formative stage. In 1985, I became a faculty staff member at the Kidwai Memorial Institute of Oncology (KMIO), Bengaluru, after obtaining an MD in Radiotherapy (PGIMER, Chandigarh) and completing a residency program (AIIMS, Delhi). Radiation oncology, medical oncology, and surgical oncology specialists were still learning about their fields, and most cancer patients were being diagnosed at advanced stages of disease, when they were bordering on incurability. Long-term survival was possible for only a small proportion of treated patients. Therapy failure would become apparent soon after treatment, and second-line therapy was not often feasible. Available cancer treatments were of limited benefit. In fact, they would frequently result in toxicity.” [1]

During those initial years, I realized that it would be provident to combine the academic and research enthusiasms in oncology with adequate learning of the skills to manage cancer pain, physical symptoms and to make an open conversation with cancer patients in advanced and incurable stages. More importantly, the observation and communication had become the keys to shape the clinical services. My colleagues of Anesthesiology at KMIO had started a PC Clinic. I got curious to interact with them and learnt about the rudimentary ‘oral morphine solution’ prepared in-house to be dispensed in glass bottles for cancer pain relief as per the WHO’s 3-step cancer pain relief ladder, 1986. [2] Around the same time in 1989, Prof. Jan Stjernswärd, then the Chief of WHO’s Cancer Unit at Geneva, gave me a personal interview. He expressed deep concerns regarding the magnitude of cancer problem globally and the focus for cancer management in Third World (what we name now as low- and middle-income countries, LMICs). Nearly 33 years back, Prof. Stjernswärd had stated about 8 million cancer deaths worldwide by 2025 [snippet of the interview in photo]. How prophetic! and in 2020, the global cancer deaths were nearing 10 million.

Oxford to Varanasi

There was a perceptible inquisitiveness within the radiation oncology community, a small undemonstrative specialty in the 1980s and 1990s, that I would be drifting away. Whereas, the pursuit for improvements in cancer management and incremental benefits in cancer survival have remained equally a part of my medical romance. In 1992, I got selected as a faculty and returned to AIIMS, New Delhi. By this time, combining the technology of radiation therapy delivery with basics of cancer science, had given me the scope to understand the limitations of anti-cancer therapy for certain tumors and in advanced stages. To bolster my learning, the real turning point in this process came in 1993, when I and five other Indian doctors were given the opportunity to travel to the United Kingdom to take a 10-week course at the International School for Cancer Care Fellowship, St. Peter’s College, Oxford. Dr. Robert Twycross, Ms. Gillian Burn, and Dr. Michael Minton were our key mentors during the course. During this duration, Jan would travel from Geneva to interact with our group, and Gilly would drive us to the Macmillan Cancer Support Centre in London to understand the benefits of interacting with charity and voluntary organisations.

Soon after our return from training in the UK, in February 1994, a conference on palliative care was organized by Prof. Akram Lal and Prof. K Pandey of Anesthesiology department of Banaras Hindu University (BHU), with financial support from Govt. of India and WHO, Geneva. There at Varanasi, during this conference the IAPC was formed and around thirty odd of us became the first-time members of IAPC, which got registered later on at Ahmedabad by Prof.M Bhatia of Gujarat Cancer and Research Institute (GCRI). Such watershed moments of 1990s are integral components of the progress of palliative care in India. In it’s first ten years, the membership of the association became inclusive to have professionals from biomedicine, nursing, members of non-government and civil society organizations; and the annual conferences at different locations in India attracted attention on diverse topics ranging from opioid prescription to living will; from physiotherapy to body hygiene at end-of-life.

The pursuit

In 2006-07, the Central Council of the IAPC started a discussion to spread the knowledge and skill sets in palliative care to the medical community across the country. The IAPC’s Certificate Course in Essentials of Palliative Care (CCEPC) was launched in November 2007 in 12 centers across the country; and is currently being delivered in 47 centers across the country. This is a basic course in palliative care for doctors and nurses, which aimed to inculcate the principles of palliative care in every day practice for doctors and nurses to improve patient care through proper communication and effective management of difficult symptoms.[3] The CCEPC was a very appropriate initiative for the time, with preparations going into training the teachers, putting together the study materials, and presentation slides etc. for uniform conduct of the course. This emboldened the IAPC community in February 2011 to approach the Medical Council of India (MCI) for an approval process by the PG Board for starting MD in Palliative Medicine [Email content below].

“Curriculum for MD in Palliative Medicine”
From: Nagesh Simha <nagesh.simha@gmail.com> replied on Sun, 27 Feb 2011 To: You & 8 others | 
Dear Colleagues
At the recently concluded GBM, a task force was appointed to set in motion, the drafting of a curriculum.
You are one of the members of this important group by virtue of your experience and knowledge.
Dr Mohanti has graciously agreed to get us a structure of medical curricula from MCI by the middle of March.
This will be circulated to all of you and emails can be exchanged with your drafts. The deadline is June 1, 2011.

Dr. Anil Paleri will be the convener of this committee. As President, I am there to encourage you all!
May I have a line in reply, please?

Warmest regards.
Nagesh 

Dr. Nagesh Simha
Chairman and Medical Director Karunashraya
www.karunashraya.org
President, Indian Association of Palliative Care

During those years between 2006 and 2013, MR Rajagopal, Suresh Kumar, Anil Paleri, Lulu Mathews, Reena George, Rajashree K C, Firuza Patel, Nandini V, Mary Ann Muckaden, Sushma Bhatnagar, Nagesh Simha were the front runners leading the pack from IAPC to establish and implement the academic programs in India. On a lighter note, Ms. Nisha Krishnadas had joined IAPC as the National Information Officer to keep this pack of workhorses on their hooves!

I would like to conclude with an admission of guilt that from 2013 onward, the earlier regular association with IAPC has become patchy for me. The other professional tasks have taken more of my time. Yet, I remain beholden to all my colleagues in palliative care and to every reader of this piece. For all our patients and their caregivers, it is our obligation to undertake more than we have done so far in the last thirty years.

References:

1. Butola S, Mohanti BK. Learning palliative care in India: two personal perspectives. J Palliat Care. 2013 Summer;29(2):107-12. PMID: 23923474.
2. Vijayaram S, Bhargava K, Ramamani, et al. Experience with oral morphine for cancer pain relief. J Pain Symptom Manage 1989; 4(3): 130-134.
3. Bhatnagar S, Patel A. Effectiveness of the Certificate Course in Essentials of Palliative Care Program on the Knowledge in Palliative Care among the Participants: A Cross-sectional Interventional Study. Indian J Palliat Care. 2018 Jan-Mar;24(1):86-92. doi: 10.4103/IJPC.IJPC_116_17. PMID: 29440814; PMCID: PMC5801637.