The man sat doubled over on his bed,his hands extended in a sort of praying mantis position.
On the glazed screen of Dr M R Rajagopals laptop,its hard to guess what he was thinking,but if he were indeed praying,he was probably praying for death. The pain from his cancer had left him in that position for three weeks. The next frame has the same man sitting. The cancer had left him shriveled but from the depths of his sunken eyes,he looked relieved as he sat with a mug of tea. He sat up barely an hour after we gave him a dose of morphine. That was the first time he was drinking his tea in several weeks, says Dr Rajagopal,a palliative care expert whose Pallium India helps fill in a crucial vacuum in Indias medical practice that of dealing with pain.
More than 70 per cent of cancer sufferers in India have an incurable form of cancer,according to a new report by Human Rights Watch,and many of them are in severe pain. Also,India has more oral cancer patients than any other country. Then,there are people who die in pain from AIDS,burns and accidents. And more often than not,doctors in India dont do anything about the pain. In 2008,India used an amount of morphine,the easiest and cheapest way to relieve crippling pain,that was sufficient to treat only about 40,0000 people. Thats about 4 per cent of the people who need pain relief.
India is one of the largest exporters of legal opium in the world but the bulk of it is exported to developed countries and few Indians benefit. Unless of course,they are in Kerala,where Rajagopal and his colleagues pioneered the palliative care movement and where 80 per cent of palliative care in India is practiced. There are about 140 palliative care centres in the state and teams each with doctors,nurses and counsellors visit homes of cancer patients. In contrast,a state like Andhra Pradesh,which has a population of 73 million and a high prevalence of HIV/AIDS,has only two palliative care centres.
If a poppy farmer in UP,MP or Rajasthan,where bulk of the opium is produced,has cancer and is in pain,he goes to his doctor. And if the doctor is kind enough,he whispers to him to go find the right kind of opium in the black market the one that feels firm and use it to relieve his pain, says Rajagopal.
This is unthinkable in any developed nation. In the Netherlands,morphine is available as a prescription drug. There,morphine is a staple of cancer care, says Diederik Lohman,senior health and human rights researcher at Human Rights Watch.
But in India,the use of morphine is entangled in needless regulations and a stringent licensing policy that makes it impossible for doctors to ask for morphine. Narcotics regulations in states are based on the voluminous Narcotic Drugs and Psychotropic Substances Act,passed in 1985 to curb drug trafficking,and come with tough checks to prevent abuse. Any deviation from the law can land people with 10-year prison terms.
And so,doctors dont want to take a chance with prescribing morphine or with relieving pain. Doctors in India arent taught to treat pain. Now if you say that,they will show you a chapter in their pharmacology textbook that deals with pain relief. But thats hardly ever put into practice, says Rajagopal.
This is one of the practices that Rajagopal and others like him are lobbying to change. In July 2007,the Indian Association of Palliative Care moved a PIL in the Supreme Court,asking for,among other things,the Medical Council of India to include palliative care as part of the medical curriculum. But as Rajagopal knows,its a slow process.
Doctors are also scared of addicting their patients,a fear that is illogical,says the doctor. The most common use of morphine is as tablets and with that,addiction is rare. In Kerala,we followed up 1,723 patients who used morphine in home settings and there wasnt a single case of addiction or diversion, he says.
Its one of the messages Rajagopal has tried hard to get across with his lectures and training programmes for doctors. He also lectures them on the need to effectively communicate to terminally ill patients,help them with their unfinished business and say their goodbyes. As a doctor,you dont have to give all the answers,its ok to say I dont know when the patient asks if he will live long enough for,say,Christmas. But if you think he wont make it,you can say Christmas looks difficult and then,he can call his daughter from wherever she is and say his goodbyes.
Doctors in India rarely tell you that. And then,drawing his chair closer,Rajagopal says,If you were dying and you knew you were dying,would you want to do that in an intensive care unit,with all kinds of beeping gadgets around you or would you want to die holding the hands of your loved ones?