I am glad to report that Pallium India has had its share in persuading the Government of India to support the move, particularly with advocacy by the Pallium India trustee Dr Shalini Vallabhan.

Within the WHO’s recently published consultation document, “A Comprehensive Global Monitoring Framework Including Indicators and a Set of Voluntary Global Targets for The Prevention and Control of Noncommunicabale Diseases,” the following statement appears on page 10 (PDF):

• Table 2: Core indicators for NCD surveillance
• National Health Systems Response
• Access to palliative care assessed by morphine-equivalent consumption of strong opioid analgesics (excluding methadone) per death from cancer

We all know that this statement is not perfect.

• For one thing, morphine consumption is an imperfect indicator of access to palliative care; but we also realize that there is no totally satisfactory indicator.
• We are particularly unhappy that the access to palliative care has been needlessly linked to cancer. We worry that with this sentence, the WHO may be unintentionally conveying to member countries that palliative care is meant only for cancer.

However, we also realize that it has been a huge achievement to have gone thus far and any change in that wording at this stage will be almost impossible.

WHO asks all member countries to respond to this with their comments by April 19:

Member States and UN agencies are invited to submit their comments on the second WHO Discussion Paper by sending an email to ncdmonitoring@who.int by 19 April 2012. Relevant NGOs and selected private sector are invited to submit their views to the same email address.

There will be a certain maximum number of indicators and it will need several countries’ support to ensure that the current recommendation will stay in the final form of the document.

This is the time when we must use all our contacts with the Department of Health to persuade them to strongly argue to keep the recommendation in.

We are honored and proud to announce that the Trivandrum Institute of Palliative Sciences (TIPS), the flagship program of Pallium India, has been named a World Health Organization Collaborating Center (WHOCC).

The Official Title: “WHO Collaborating Centre for Training and Policy on Access to Pain Relief”

This is a huge leap forward in the recognition of our model of palliative care for India and the rest of the world. The news was announced today in the March 2012 WHO Access and Control Newsletter.

Here is the news release:

TRIVANDRUM, Kerala, India – March 19, 2012 – Trivandrum Institute of Palliative Sciences (TIPS), the flagship program of Pallium India, a registered charitable trust headquartered in Trivandrum, Kerala, India has been declared a World Health Organization Collaborating Center (WHOCC). Dr Samlee Plianbangchang, Regional Director of World Health Organization, informed the organization in a message delivered on February 28, 2012 that the designation for a period of four years is for collaboration in the areas of “Training and Policy on Access to Pain Relief”.

“We are honored and pleased to receive this designation, which allows us to link up our work in the relief of pain and suffering in India to the national and international bodies that seek the same outcome,” said Dr. M.R. Rajagopal, chairman and founder of Pallium India and TIPS. “For too long, patients who needed pain relief and other palliative care services have been denied them due to outmoded bureaucratic red tape and other barriers. With the World Health Organization’s help, we envision a future in which all who need palliative care will receive it.”

Today in India, more than 99% of the needy — people with cancer, HIV/AIDS, and other diseases causing prolonged pain — have no access to pain relief. Twenty-five years after the World Health Organization (WHO) came out with a viable protocol for pain relief, oral morphine is still not available in the majority of hospitals in India. This is an essential medicine according to the WHO. Modern principles of pain management are not taught to medical students in all but a handful of the medical colleges in the country. Through this recent announcement, the WHO is showing its commitment to turning this situation around for India and the rest of the developing world.

In his message to Pallium India, Mr Willem Scholten who leads the “Access to Controlled Medicines” program in World Health Organizations headquarters at Geneva said, “Trivandrum Institute of Palliative Medicine is an example for other pain centres and policy makers around the world. Unfortunately, very restricted access to pain medicines is rather the rule than the exception, like it used to be all over India in the past, but Kerala shows that it is possible to improve.”

Pioneering work by the Indian palliative care community in association with the WHO Collaborating Center at Madison-Wisconsin has resulted in simplification of narcotic regulations in 14 Indian states. Kerala, where TIPS is headquartered, has particularly been far ahead of the rest of the country in this aspect. There, about 100 institutions stock and dispense oral morphine to the needy for use in the home setting. At least three medical colleges in the state impart education in pain management and palliative care. Kerala remains the only state in India to declare a palliative care policy. The result is at least 50% of the needy have access to palliative care.

Working towards improving access to pain relief in the rest of the country, Pallium India has successfully initiated development of palliative care centers in eight North and North-Eastern states over the last five years. Five of them are in Regional Cancer Centers. It continues to fund and train centers across India.

TIPS has its office in Pattom, Trivandrum, Kerala and its patient services based at the S.U.T Royal Hospital at Kochulloor, Trivandrum. It provides outpatient and home visit facilities from these bases of operation. The Institute works with volunteer-led community based organizations to provide weekly home visits to bed-bound patients. TIPS is also a training centre, conducting six weeks certificate courses for doctors, nurses and other professionals six times a year, as well as a ten-day foundation course for doctors. In addition, it conducts periodic volunteer training programs, as volunteers form an important part of the care team. The organization is also supported by volunteers around the world, and has a USA volunteer arm, Pallium India-USA, led by Dr. Jerina Kapoor.

“The newly designated WHO collaborating center at TIPS will work with organs of WHO, with Central and State Governments, with the Indian Association of Palliative Care and with other national and international agencies to improve access to pain relief for those in need in the country,” said Dr. Rajagopal. “Through these efforts, we will continue our goal of ensuring that all Indians are treated with respect, and that those with serious illness can live out their lives with the appropriate dignity they deserve.”

For more information, please visit http://palliumindia.org.

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Here is some of the news coverage it has received so far:

• Express Buzz: TIPS declared as WHO Collaborating Centre
• IBN Live: TIPS declared as a WHO Collaborating Centre

Help us spread the word by forwarding this to your email list, or by posting it on Facebook and Twitter.

Throw out opium, which the Creator himself seems to prescribe, for we often see the scarlet poppy growing in the cornfields, as if it were foreseen that wherever there is hunger to be fed there must also be a pain to be soothed; throw out a few specifics which our art did not discover, and it is hardly needed to apply; throw out wine, which is a food, and the vapors which produce the miracle of anaesthesia, and I firmly believe that if the whole materia medica [medical drugs], as now used, could be sunk to the bottom of the sea, it would be all the better for mankind,—and all the worse for the fishes. — Oliver Wendell Holmes, ‘Currents and Counter-Currents in Medical Science’, Address to Massachusetts Medical Society (30 May 1860).

Morphine is in the “Essential Medicine list” of the World Health Organization.  And, it’s importance is even understood in the art world, see this design by Dan Golden:

Each one of us is a potential patient; it is very likely that we shall need it some time in our lives. 

Is it not time we stood up and asked our hospitals,

“Does your pharmacy have oral morphine?  If not, what kind of a hospital are you running, without even essential medicines?”

In preparation for next month’s UN Summit on NCDs, the Indian Government’s Ministry of Health & Family Welfare and WHO India organized a 2-day National Summit on Noncommunicable Diseases, August 23-24, in New Delhi (press release). More than 200 delegates from various fields related to NCDs attended the meeting (programme).

During the inaugural function Mr RK Srivastava, Director General of Health Services, mentioned palliative care as one of the target areas of his department.

Minister for Health & Family Welfare, Mr Ghulam Nabi Azad, announced his ministry’s plans to launch home visit program for bed-bound patients in 100 districts in the country.

Our collective action is bearing fruit!

One of the most painful sights in many hospitals is that of children with cancer, HIV, burns or other accidents – all going through intolerable and needless pain.

WHO’s Research Agenda for the Treatment of Pain in Children

The World Health Organization aims to revise and publish an updated version of the 1998 guidelines Cancer Pain Relief and Palliative Care in Children (pdf) with an addition of other medical conditions with persisting pain: later this year, the WHO Guidelines on the Pharmacological Treatment of Persisting Pain in Children with Medical Illnesses will be published.

A part of this guideline entails WHO’s research agenda, which highlights critical research topics of paediatric pain treatment. The research agenda was recently published. The article calls on researchers to focus their studies on one of the proposed topics.

Download: WHO Calls for Targeted Research on the Pharmacological Treatment of Persisting Pain in Children with Medical Illnesses (pdf)

Research areas that need critical attention are: clinical studies on paracetamol, NSAIDs and opioid analgesics; clinical studies on adjuvant medicines (antidepressants, gabapentin, and ketamine) for neuropathic pain; safety and dosing of non-opioid and opioid analgesics in different age groups as well as dose conversion of opioids; and pain assessment tools for children.

In addition to the pharmacological research that is proposed in this WHO publication, we hope there will also be enough social research about getting the available science to reach the needy.

Is that not the major cause of unalleviated pain in the world – the failure of available knowledge to reach the needy?

Poonam and CanKids

Pallium India is proud to report that as part of its “We Can, We Should, We Will Conquer Cancer” campaign, the American Cancer Society (ACS) has selected Ms Poonam Bagai as one of two Indian Global Cancer Ambassadors.

Poonam, herself a cancer survivor, is President of CanKids and vice-chair of Pallium India. Her selection as a Global Cancer Ambassador is based on her dedicated work in these areas over the last few years.

During June, along with other select Global Cancer Ambassadors, she will travel to New York to be trained by ACS on meeting with UN mission representatives and decision makers, and on advocating to make cancer a health priority in India and globally.

UN High-level Meeting on NCDs

ACS’s training sessions are in preparation for the UN High-level Meeting on non-communicable diseases (NCD) prevention and control, which convenes in September 2011. She will also meet with the Indian Mission to the United Nations to put forward specific requests to be presented at the Meeting.

The UN High-level meeting will bring together heads of state and other high level political figures to discuss NCDs (cancer, diabetes, cardiovascular disease, chronic respiratory disease) and create international policy guidelines to address NCDs. The Global Cancer Ambassadors are integral to implementing these guidelines.

TOBACCO’S TOLL…

ONE death every SIX seconds
~ 6 million people die from tobacco use and exposure to tobacco smoke

63% of all deaths
are caused by noncommunicable diseases, for which tobacco use is the 2nd greatest risk factor

• Take the World No Tobacco Day quiz
• Visit the WHO’s World No Tobacco Day website
• Download the flyer
  
• Don’t forget about India’s own “Chew On This” campaign for a Tobacco Free India:

Dr Kathleen Holloway

Dr. Kathleen Holloway, Regional Adviser in Essential Medicines WHO South East Asia Regional Office, gave an illuminating talk during the National Initiative in Patient Safety workshop at India Habitat Center, New Delhi on 8 April 2011.

During her talk on Safety in Drug Use, she quotes from the World Health Organisation’s Rational use of medicines:

Rational use of medicines requires that patients receive medications appropriate to their clinical needs in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and the community.

That being the ideal, she points out the global estimated reality today:

• More than half of all prescriptions may be incorrect
• More than half of all patients fail to take them correctly
• In primary care, less than 40% of patients cared for by health professionals in the public sector and less than 30% in the private sector are treated in accordance with clinical guidelines.
  (Source: WHO 2009)

It is almost unbelievable!

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• You can find out more on this topic at the WHO’s Rational use of medicines website…

India: The principle of balance to make opioids accessible for palliative care

In the state of Kerala in South India, Dr M R Rajagopal has been working in the field of ‘Palliative Care’ for over twenty years. As the Chairman of Pallium India, he and his team have been working to increase the availability of such drugs for patients. UNODC South Asia interviewed him to understand the dimensions of the situation in India and also some of the effective solutions that have been tried to improve access to these drugs, while ensuring that they are not diverted for illicit purposes.

The questions asked by UNODC:

1. Please explain what is Palliative Care. How does it relate to drug control?
2. What is the scenario regarding the availability of these opioid drugs in India?
3. Can you explain what these regulatory procedures are?
4. You have been working in this area for over twenty years. Can you share some of your experiences and some good practices that are being followed?
5. What do you think needs to be done further to increase availability of opioids for palliative care?

Read the full interview & answers to these questions on the UNODC blog…

We have good news!

The Government of India Department of Revenue has always been proactive in the matter of opioid availability. Initiatives by David Joranson, his team and partnered by Indian palliative care workers (since 1994 and continuing now) were so well-received by the department that the 1998 recommendations for model rules  have now been accepted by 14 states in India.

Additional support came in the last few years from the WHO’s Access to Essential Medicines programme pioneered by Dr Willem Scholten, advocacy by Human Rights Watch, the positive approach from the International Narcotics Control Board (INCB) and from many other sources, not to mention the persistent and continued support from David Joranson and his team.

Recently, Mr Pavel Pachta, who heads INCB, visited India and had meaningful interactions with stakeholders in the field.

On the 1st and 2nd of February 2011, the Department of Revenue conducted a two day conference in Parliament House Annexe. There were about 100 participants – almost every state was represented by their Drug Control and Excise departments. One half day was spent on deliberations about availability of opioids for medical purposes.

The very fact that the meeting dedicated so much time to this subject shows the importance that the department is giving this issue. In general, the meeting agreed on the following matters:

Instead of only “morphine for cancer pain”, the model rules of the Department of Revenue hereafter would recommend the availability of “opioids for pain management”.

• This would mean that in future we should be able to access opioids other than morphine for treatment of severe pain conditions, when the patient does not tolerate morphine.

The Drug Controller General of India would initiate the process for making methadone available in the country.

• At the moment, it is manufactured in India for export, but not sold in the country.

The Department of Revenue will work with State Governments to simplify their narcotic regulations and to put in simple standard operating procedures.