The natural beauty of the land of course. But apart from that?

They share the pain and sorrow of man-made suffering in the face of disease.

Liliana DeLima, the executive director of IAHPC (www.hospicecare.com) writes about the “archaic restrictive laws” in Guatemala that prevented access to pain relief even in the face of a disease like advanced cancer. It almost reads like a horror story.

1. A representative of the National Competent Authority has to carry out visual inspections to ALL patients who are prescribed opioids. During this visit, the government representative verifies if the patients is really sick, verifies the amount prescribed, the amount dispensed and the amount taken by the patient to supposedly certify that no diversion has occured.
2. All physicians who prescribe need to submit monthly reports to the MOH with the names of the patients they prescribed opioids for, the diagnosis, the total amount in the month, the dates of prescription, the quantity and the formulation.
3. Patients who need opioids HAVE to travel to the capital to get their prescription stamped and approved by the NCA office – regardless of where in the country they are located. They have to travel each time with their prescription, get it stamped (confirmed as legal by the NCA) and then they can go to a pharmacy to buy it.

Fortunately, things have changed for the better in Guatemala very recently, and some of the restrictions have removed. But we have not done so well in Goa, the tiny beautiful coastal state in India.

In 1998, the Government of India asked all Indian states to simplify their narcotic regulations following a model structure. Goa is one of the 14 which did. But Goa effectively thwarted the purpose of the amendment by bringing in new barriers. The Goan with advanced cancer is forced to take every prescription to the Directorate and “apply” for a permit. He can buy the drug only when the permit is issued!

Good News from Vienna

The United Nations’ Commission on Narcotic Drugs (CND) met last week in Vienna.

Thanks to advocacy by several agencies, most noticeably Human Rights Watch, the commission has recognised that its role is not only to control narcotic drugs but also to ensure its availability for medical purposes.

Human Rights Watch conducted a side-event promoting the global need for opioids for pain relief which was attended by several organizations including PPSG and the Access to Control program of WHO and about 70 CND delegates from all over the world. HRW statements: Day 3: statement to the plenary & Day 4: supply reduction plenary

At the CND meeting, Mr Costa from UNODC highlighted [PDF] the need for improvement in opioid availability for pain relief.

The week long meeting passed a resolution “Promoting adequate availability of internationally controlled licit drugs for medical and scientific purposes while preventing their diversion and abuse.” [PDF]

We are sure it will be a powerful tool in our advocacy for pain relief.

News from the Opioid Availability Front

We have been blessed for a long time by strong support from the Department of Revenue and from the Narcotics Commissioner (and many other authorities) of the Government of India. The new desk calendar produced by the Narcotics Commissioner of India attracted international attention during the CND meeting at Vienna. It carries a slogan “Opium for Pain and Palliative Care”. Congratulations and thank you, Mrs Jagjit Pavadia!

So far in India, manufacturing of opiumand morphine from poppy has been the monopoly of the Government of India. In recent years, there has been a move to privatize this. We had a concern that this would steeply increase the cost of morphine. We now learn that the process of privatization has been delayed. The two firms which had initially come forward seem to have backed out. While the Government is still proceeding with the decision to privatize, it may take some considerable time to materialize.

Prestigious Award to Kathleen Foley

The Global Palliative care community rejoices the decision of the International Association for Study of Pain (IASP) that its John D. Loeser Distinguished Lecture Award goes to Dr Kathleen Foley. Dr Foley is an attending neurologist in the Pain and Palliative Care Service at Memorial Sloan-Kettering Cancer Center in New York City.

In IASP’s words,

the award recognizes work that gives new perspectives to understanding the experiences of pain and that opens the door to future reductions in suffering…

She is professor of Neurology, Neuroscience and Clinical Pharmacology at Weill Medical College of Cornell University, and holds the chair of the Society of the Memorial Sloan-Kettering Cancer Center in Pain Research. All that is how she is described in IASP’s newsletter. Let us provide our own six-word description of Kathy Foley:

She knows. She understands. She cares!

Congratulations, Kathy, and thank you for all that you are doing for this world.

Watch Dr Foley’s lecture “Pain and Palliative Care: What the Future Holds”

Annual Conference of IAPC at Lucknow

Mr Piyush Gupta of Cancer Aid Society, the organizing secretary of the next conference of the Indian Association of Palliative Care (IAPC) at Lucknow (U.P) on 11-13 February 2011 invites you to visit the conference website www.iapcon2011.com and to save money by availing the facility of early bird registration.

Last date Extended for Pallcare India Project

Pallium India has invited applications from cancer centers and Medical Colleges in North and North-East India for a project funded by Savitri Waney Trust, Farida &Yusuf Hamied Foundation and Bruce Davis Trust.

Please note that the last date for receipt of applications has been extended to 30 March 2010.

For details, see http://palliumindia.org/projects/pallcare

Leadership Development Initiative (LDI) at San Diego

San Diego Hospice and Open Society Institute together organized a Leadership Development Course for Palliative Care professionals from 15 different countries at San Diego, California.

Dr Priya Kulkarni from Cipla Hospice, one of the doctors who attended the course (the others from India were Dr Gayatri Palat and Dr Anil Paleri) writes about her experience.

We had the opportunity to learn from eminent teachers like Dr Frank Ferris, Dr Charles Von Gunten, Dr Kathy Foley, Dr Mary Callway, Dr Liliana De Lima and Dr Joe Harford.

A few of the things that I learnt from this course:

• Leadership may be by chance or by choice
• Identifying different personality types helps in dealing with team members as required.
• SWOT analysis (Strengths – Weaknesses-Opportunities – Threats) permits self analysis at depth.
• Developing a plan for individual development was thought provoking.
• Presentations related to Situation analysis from different countries and different individuals identified the similarities as well as country-specific problems.
• Presence of a Theatre and Drama person during the course helped us to make conscious efforts to learn presentation skills.

All the arrangements were excellent. It looked like a perfect team, all members performing in perfect synchronization with each other.

The Olbermann Videos

The ugly face of politics can distort any truth. In the recent American controversy which culminated at Blair House on the 25th of February 2010, palliative care services came to be called “death panels”!

You must watch Keith Olbermann’s “Countdown” at MSNBC where he describes his father’s experience in a hospital and proclaims that palliative care is indeed a “life panel”!

Please visit our blog and you will be able to watch the Keith Olbermann videos:

• An American Cry for Help
• Respecting Pain & Patient

Sadly, Mr Olbermann Sr passed away last weekend, read Keith’s tribute here…

Dignity and the Essence of Medicine

Olbermann’s description of his father’s experience brings to mind the following quote from Chochinov (BMJ.2007.335; 184-7):

“Treating a patient’s severe arthritis and not knowing their core identity as a musician; providing care to a woman with metastatic breast cancer and not knowing she is the sole carer for two young children; attempting to support a dying patient and not knowing he or she is devoutly religious — each of these scenarios is equivalent to attempting to operate in the dark.”

The United Nations’ Commission on Narcotic Drugs (CND) met last week in Vienna.

CND Delegates

Thanks to advocacy by several agencies, most noticeably Human Rights Watch, the commission has recognised that its role is not only to control narcotic drugs but also to ensure its availability for medical purposes.

Human Rights Watch conducted a side-event promoting the global need for opioids for pain relief which was attended by several organizations including PPSG and the Access to Control program of WHO and about 70 CND delegates from all over the world. HRW statements: Day 3: statement to the plenary & Day 4: supply reduction plenary

Antonio Maria Costa

At the CND meeting, Mr Costa from UNODC highlighted [PDF] the need for improvement in opioid availability for pain relief.

The week long meeting passed a resolution “Promoting adequate availability of internationally controlled licit drugs for medical and scientific purposes while preventing their diversion and abuse.” [PDF]

We are sure it will be a powerful tool in our advocacy for pain relief.

Kathleen M. Foley, MD

The Global Palliative care community rejoices the decision of the International Association for Study of Pain (IASP) that its John D. Loeser Distinguished Lecture Award goes to Dr Kathleen Foley.

Dr Kathleen Foley is an attending neurologist in the Pain and Palliative Care Service at Memorial Sloan-Kettering Cancer Center in New York City.

In IASP’s words,

the award recognizes work that gives new perspectives to understanding the experiences of pain and that opens the door to future reductions in suffering…

She is professor of Neurology, Neuroscience and Clinical Pharmacology at Weill Medical College of Cornell University, and holds the chair of the Society of the Memorial Sloan-Kettering Cancer Center in Pain Research. All that is how she is described in IASP’s newsletter. Let us provide our own six-word description of Kathy Foley:

She knows. She understands. She cares!

Congratulations, Kathy, and thank you for all that you are doing for this world.

Watch Dr Foley’s lecture “Pain and Palliative Care: What the Future Holds” given in 2008 at the UCSD Cancer Centre:

“Nationally recognized expert, Kathleen M. Foley, MD, talks about the assessment and treatment of pain in cancer patients, as well as developing policies for pain and palliative care worldwide.”

Conveying powerful messages about untreated pain and about end-of-life decisions. Very very powerful.

Of course it is all about USA.

So when you have finished watching it, please give yourself a minute to think about 80% of the world – the developing world.

What sort of torture goes on there?

Thank Heavens there are some clear headed people. Please see the touching video featuring Keith Olbermann on US TV, you cannot afford to miss it!

A Special Comment From My Father

I’m focusing on one thing in tonight’s Comment. The night my father asked me to stop his treatment. All Americans should be able to make medical decisions free of worry about cost…

This is not the central fact around which tomorrow’s health care summit at Blair House will, or should, revolve. But I’d like it on the record somewhere that I asked all those going there, including the President, to think more about people like my father – patients, in our hospitals, at this moment – and less about elections and political points and “crashing the party.” – Read the full transcript here…

Watch another Special Comment: “Respecting pain and patient”

“Four years ago, I lost my mother and my aunt in a road accident. My sisters aged 4, 2 and 1 though injured, survived. As they cried out in pain, I didn’t even know if they were getting the right medicines to reduce their pain. All of us suppressed the pain of losing our mother. What might have gone through the minds and hearts of my little sisters?- I have never enquired. Till today, I had never felt that those were things I should have found out. It never struck me that even my grief was something I should discuss with anyone else.

But, after coming here and experiencing the special interest and care all of you have given us, I can’t help but cry. The solace in sharing one’s grief and in crying- I have realised today. When I get back home, I will talk to my sisters; I will try to understand their fears and grief. I am grateful to you for having given me the awareness and the capability to do this…”

This was what Jeanette George – one of the seven students who came to Trivandrum from Iowa University in USA for a three week cultural immersion course on palliative care – shared with us. There were also participants from various parts of India – Assam, Andhra Pradesh, Tamilnadu, Uttar Pradesh and Kerala.

We are happy that the participants acquired not just professional training, but also gained valuable lessons in living life holistically.

Thank you participants, and thank you Professor Rajagopal Rangaswamy, Professor Joann Eland and Ms Donalda Carson.

Annual Conference of IAPC

Trichy, 11-14 February 2010

The Annual Conference of the Indian Association of Palliative Care concluded on 14 February 2010 at Trichy. All delegates were extremely appreciative of the arrangements and hospitality offered by the team lead by Dr Mohanasundaram Thyagarajan.

At this conference Dr Sukdev Nayak stepped down as president, and Dr Nagesh Simha was installed as the new president. Thank you for your performance as president, Dr Sukdev Nayak and congratulations Dr Nagesh Simha.

Tamil Nadu’s Gift to Palliative Care Offered at Trichy

At the inaugural function of the Trichy conference Dr Mayilvahanan Natarajan, the vice chancellor of the Dr M G R Medical University of Tamilnadu announced the decision of the University to start a Post-Graduate Fellowship in Palliative Medicine. Thank you Dr Mayilvahanan for this contribution to the palliative care movement in India.

Lucknow, 11-13 February 2011

We shall look forward to the next annual conference at Lucknow, Uttar Pradesh. Mr Piyush Gupta of Cancer Aid Society is the organizing secretary. For details please see the IAPCON website…

Bruce Davis Gold Medal

This year’s Bruce Davis Gold medal was won by Dr Bhaswant Dhanireddy from PGI, Chandigarh.

The medal was founded by Mr Wilfrid Bruce Davis from UK who has supported the palliative care movement in India for more than a decade now.

The medal is awarded following a competitive examination held by the Institute of Palliative Medicine at Calicut. We congratulate the winner and thank Mr Bruce Davis for his contribution to the palliative care movement in the country.

Hannah Gardner on Opioid Availability In India

Please read Hannah Gardner’s article at the problem of unrelieved pain in India:

Laws Leave Millions in Pain

Every day in his work at the regional cancer centre in Rohtak, in the north Indian state of Haryana, Dr Ashok Chauhan sees patients in the agonising pain that accompanies the final stages of cancer. Most of them are too sick to be cured, so Dr Chauhan and his colleagues try to do the only thing they can – provide relief from the intense suffering.

Read more at The National…

Thank you Hannah, for strengthening the cry for justice from people in pain!

Students’ Corner

Postgraduate Qualifications (MSc) in Palliative Medicine and Palliative Care

15 Commonwealth Scholarships available to cover Diploma/MSc course fees for students in developing Commonwealth countries. Two pathways are available:

1. The Postgraduate Diploma/MSc in Palliative Medicine (open to doctors)
2. The Postgraduate Diploma/MSc in Palliative Care (open to healthcare professionals)

Each qualification can be studied as an adult or paediatric option. These qualifications are designed to help busy professionals enhance their knowledge and inform and improve patient care. They are:

• modular and include symptom control, advanced communication skills, ethical issues & understanding the evidence
• immediately clinically applicable & Culturally sensitive
• delivered mostly by e-learning
• interprofessional & based on reflective learning

Courses start in September and will be conducted at Karunashraya Hospice, Bangalore followed by online learning.

Fees for 2010-2011 £1950 per year.

Closing date for scholarship applications: April 30th 2010

For further information:

• phone: 00 44 (0)2920 196111 (UK)
• visit: www,pallium.cardiff.ac.uk
• email: Dippallmed@velindre-tr.wales.nhs.uk for an application form.

Accolades

Pallium India is thankful to Lions Club District 324 E1 for the recognition it has given Pallium India and to palliative care.

On 13 January, Melvin Jones Day, the day of remembrance of the founder of Lions International, Dr Rajagopal received an Award of Excellence on behalf of Pallium India.

It was a particularly gratifying experience to receive it from the chief guest, Dr Sandhya IPS, Inspector General of Police, and a long-time friend of the Palliative Care movement. We thank Mrs Indira Ravindranath, the District Governor of Lions Club, Mrs Bhagawati Marthandan who got us in touch and all members of the Lions District.

And while mentioning this occasion, it would be relevant to quote the great man Melvin Jones himself, “You cannot get very far until you start doing something for somebody else.”

Human Rights Watch Report: “Unbearable Pain”

Over 7 million people in India suffer avoidable pain simply because they have no access to morphine, says a Human Rights Watch report on India’s obligation to ensure palliative care.

People in agony are often unseen and unheard because they drop off the social radar, unless they happen to be family or close friends. They are people battling life-threatening conditions including cancer, HIV/AIDS, tuberculosis and renal disease. Many paraplegics too suffer extreme pain.

People in agony are often unseen and unheard because they drop off the social radar, unless they happen to be family or close friends. They are people battling life-threatening conditions including cancer, HIV/AIDS, tuberculosis and renal disease. Many paraplegics too suffer extreme pain.

Read the summary from Info Change India…

Download the complete report from HRW (pdf links in right column) & a PDF with photos of Pallium India at work

MV Govindankutty Memorial Award For Social Work

This year’s M V Govindankutty Memorial Award for Social Work instituted by Pratheeksha Pain and Palliative Care Clinic, Koottanad, Palakkad, goes to Shri Y Philippose, Founder President, Health Care Charitable Society, (Karunya Pain and Palliative Care Clinic), Thiruvankulam, Ernakulam.

The award was given away at a function held in connection with the Community Based Palliative Care Day on 15th January 2010.

Staff Club

Featured website: PalliativeDrugs.com

The site provides essential independent information for health professionals worldwide about drugs used in palliative and hospice care. The content is based on the UK Palliative Care Formulary (PCF, 3rd edition) which was Highly Commended in the British Medical Association 2008 book competition. It includes details about unlicensed (unlabeled) indications and routes, and the administration of multiple drugs by continuous subcutaneous infusion.

The bi-monthly Newsletter has been replaced by the regularly updated ‘Latest additions’ and ‘News’ sections, and the Bulletin board expanded to cover non-drug issues. The search facility has also been improved. To access the site, it is necessary to register and create your own username and password. We will ask you to provide contact and other details, including your registration number with a professional body like the Medical, Nursing or Pharmacy Council of India.

Once registered, we recommend that you first read: Getting the most out of the PCF3

What You Should Know About NSAIDs

A review article published in the December 15 2009 issue of the American Family Physician offers recommendations for prescribing nonsteroidal anti-inflammatory drugs (NSAIDs) in the primary care setting.

• It should be avoided by those with significant upper intestinal tract bleeding,,particularly in older persons taking anticoagulants and with platelet dysfunction..
• Although low dose aspirin is cardioprotective, NSAIDs as a class can worsen congestive heart failure and increase blood pressure.
• They can lead to bleeding problems and renal failure in persons with cirrhotic liver disease.
• Asthma may be induced or aggravated.
• It is to be avoided in the last 6-8 months of pregnancy.
• There will always be patients with pain conditions relieved only by NSAIDs. There is need to focus on balance between risk and benefit before NSAID therapy As supplements to analgesic therapy, nonpharmacologic treatment such as physiotherapy and physical exercise may be considered.
  Read the full article at American Family Physician…

Anaesthesia During Cesarean Delivery

“Childbirth is an emotion-filled event and the mother needs to bond with her newborn baby as early as possible,” writes Anthony A. Bamigboye, from University of Witwatersrand in Nelspruit, South Africa, and G. Justus Hofmeyr, from University of Fort Hare, Eastern Cape Department of Health in East London, South Africa. “Any intervention that leads to improvement in pain relief is worthy of investigation. Local anaesthetics, either on their own or in combination with opioids or nonsteroidal antiinflammatory drugs, have been employed as an adjunct to other postoperative pain relief strategies.”

“A pharmacokinetic study of local anaesthetic absorption following wound and peritoneal infiltration is necessary,” the review authors conclude. “Ultrasound guided direct block of anterior abdominal wall nerves in caesarean section should be explored. An important research agenda will also be the effect of the intervention on chronic pelvic pain.”

Read the full review here…

Weighing Medical Costs of End-Of-Life Care: There is No End to the Debate.

If this is the reality for USA, how would such aggressive treatment add to suffering in resource-poor countries like India?:

How far should doctors go to try to save a patient’s life? “If you come into this hospital, we’re not going to let you die”, says Dr David T Feinberg, the chief executive of the Ronald Reagan UCLA Medical Center. According to data compiled at Dartmouth, Medicare pays about $50000 during a patient’s last 6 months of care at UCLA whereas Mayo Clinic in Rochester, Minn. incurs about $25000.The cost of treatment of a patient awaiting a heart transplant reached $300000 before he died after 5 weeks in the ICU. The moot point is, what is the cost-benefit ratio?

The current payment system encourages additional tests and procedures. As one doctor said,” The more tubes you put in, the more you get paid.” But, difficult family dynamics are also involved. Family members don’t want to let go. And, doctors too have trouble letting go. Doctors and nurses should talk to the patient and their families about their choices, educate them about the realistic chances of recovery; of the kind of life that awaits the patient even after the expensive treatment. A patient waiting for a liver transplant is seldom told about the severe repercussions of rejection; that he would have to live with a ventilator and dialysis for the rest of his life. If he was told, maybe he would opt for hospice care. Until recently, palliative care especially at end of life was an afterthought at such medical institutions.

Read more at the New York Times… & listen to the audio slideshow

Dark Humour?

Mr Innocent is a popular comedian of the silver screen in Kerala, India and a palliative care enthusiast.

He was to receive an award at a public ceremony and a tobacco company was one of the sponsors. They asked him to say a few good words about their brand of cigarette.

During his speech, Mr Innocent advised all the women in the crowd to persuade their husbands to smoke this particular brand more and more. He also advised them to get their children to start smoking as early as possible. And he had some innovative suggestions to them to make even snacks out of cigarettes.

The satire hit its target, bang on. The company withdrew from sponsorship of the award from the next year.

The anecdote though funny, is thought provoking, and the scenario lurking in the back drop very worrisome. Smoking among young people is increasing at an alarming rate. Recently,an Indian Health Minister bewailed that though his ministry was trying hard to ban smoking in public places, there were seven other ministries – Finance, Labor, Agriculture and several others – working in favor of tobacco.

As one palliative care worker wryly commented, smoking is good for the palliative care business too!

Finally, a Sweet Message for Valentine’s Day

On this Valentine’s Day,
I do sincerely pray
That all the tears YOU’ve wiped away
Will become guardian angels to protect YOU
And, help YOU in your mission, all your life through!

Read the whole poem on our Blog…

Thank you, Meera!

Please send us feedback about the newsletter here…

Editorial Board: K Govindan Kutty, A Salahuddin Kunju, C Mohanan, Rakesh Menon & M R Rajagopal.

PALLIUM INDIA (REGISTERED CHARITABLE TRUST)

Address: II Floor, S.U.T. Speciality Hospital. Plamood, Trivandrum 695004, Kerala, India

Phone: 91 471 244 0306 (office) & 91 938 729 6889 (mobile)

Fax: 91 471 244 0306

Email: info@palliumindia.org

Web: http://www.palliumindia.org

Pallcare India is a Pallium India project supported by:

• Savitri Waney Trust
• Farida and Yusuf Hamied Foundation
• Bruce Davis Trust

APPLICATION DEADLINE: 15 30 MARCH 2010

Read the proposal & apply online…

Living Is In Loving…

The sun rises brisk and bright,
Gilding the world with his light;
But,wait-
Its still a gloomy night
For those with not a hope in sight…

Eyes blinded by unshed tears,
Lips frozen by unspoken fears,
Hearts broken by unfulfilled dreams,
Life splitting apart at the seams…

Beaten, battered and broken,
By life betrayed and forsaken,
They know not what to do,
They know not whom to turn to…

When we strut along so tall and straight,
Do we ever think of those felled by fate?
As we celebrate and sing a merry song,
Do we see those who can’t even hum along?

Is life about living in an ivory mansion?
And being the epicentre of fickle attraction?
Or is it about riding in fancy cars?
And being decorated with spurious stars?

How long does it last:the music of empty applause?
Its time to leave the rat-race and for a moment pause…

But wait-
I do see a silver lining,
Behind those dark clouds gently shining,
Hearts that beat with love and care,
Hands that reach out to comfort and share,
A warm smile, a tender touch,
To those bereft, it means so much.

YOU who look at another as your own,
So, they no longer feel abandoned and alone;
YOU who with love ignite a spark
In lives gone cold and empty and stark;
YOU who so dauntlessly strive
To lessen the pain and help survive
Those floundering to reach the shore
Or those waiting at death’s door…

On this Valentine’s Day,
I do sincerely pray
That all the tears YOU’ve wiped away
Will become guardian angels to protect YOU
And, help YOU in your mission, all your life through!

Two of us at Pallium India had an opportunity to attend a refresher course in palliative care for doctors held at the institute and to see first-hand the tremendous progress made by the center.

The course demonstrated the great value of educational opportunities for professionals who go through short training programs and feel the need to update their knowledge.

We congratulate the Trissur team.