APLI Newsletter, December 1999
Many of us are currently thinking of how we are going to commemorate the beginning of the new millennium. A particular marketing push is "Don't miss out" -on bargains, parties, the best seat in the house. Tuning in to the UN hunger site (website in this edition) provides a sobering contrast to the scramble for high times. The world maps shown dims every 3.6 seconds in one country, to signal another death from starvation. India, the focus country of this newsletter, dims most frequently. Watch it for a minute and try to imagine the reality behind the graphic. Our APLI mission statement states that we will also address the social and political issues integral to the ethical use of resources that are vital to the provision of effective palliative care to all. A brave cry but what have we done so far. One group that is doing something at this level is the Pain and Palliative Care Service in Calicut, Kerala. They have mobilised community support, lobbied at all levels of government and adapted their practice to help the disadvantaged in their communities. David Roy (Journal of Palliative Care) points to the need for poets in palliative care, who are "masters of saying the small things within which lurk the big things". This newsletter ends with Tagore's poem on Gift. Wishing you a very happy Christmas, full of "displaced moments" of "truest treasure to stop you in your tracks" .
Inside This Issue |
|
1 |
Opioid availability in India
Dr Suresh Kumar |
2 |
Cancer Pain Release |
3 |
CIPLA Centre, Pune, OPAL, Pain and Palliative Care Service, Calicut |
4 |
News Items, Tagore |
APLI NEWS acknowledges the support
of
MUNDIPHARMA
OPIOID AVAILABILITY IN INDIA:
AN UPDATE
Dr S. Kumar (Honorary Secretary)
Dr M.R.Rajagopal (Chairman)
INDIAN ASSOCIATION OF PALLIATIVE CARE.
The problem: Approximately one million people get cancer in India every year. The vast majority is incurable at the time of diagnosis. It is ironic that India produces much of the opium to make morphine for the world, yet consumes a very small amount despite its heavy burden of cancer pain. Although there have been many educational efforts to promote palliative care and the use of morphine for cancer pain relief, the national consumption of morphine has decreased since the 1986 publication of the Cancer pain Relief Analgesic Ladder. The reason appears to be that a 1985 anti-narcotics law established tough new penalties, adding to the burden of a nearly impossible licensing system for morphine. Misconception among professionals and general public about the use of morphine as an analgesic is another important factor.
What is being done: Thanks to the efforts of individual initiatives and activist groups, the concept of Palliative Care has now started taking roots in India. The public awareness campaigns and professional training programme has been showing a small but definite impact on the general awareness.
From 1992-1994, Government of India sponsored a number of workshops to discuss the problem of morphine availability. WHO even provided free morphine to some hospitals. Nevertheless, the problems in obtaining continuous access to morphine continued.
During the last several years, the Indian Association of Palliative Care (IAPC) has worked with the Government of
India to find a solution, with the assistance of Mr David Joranson of the Pain and Policy Studies Group (PPSG) / WHO Collaborating Center (WHOCC) for Policy and Communications at the University of Wisconsin at Madison, USA. 1995 saw the creation of a special IAPC committee on Morphine Availability and Control as suggested by WHOCC.
1996: in cooperation with the Committee, Mr Joranson prepared step by step guidelines that physicians and palliative care programs could follow to obtain morphine under existing requirements.
1997: also with the cooperation of the Committee, Mr. Joranson prepared a proposal to simplify the morphine regulatory system in India, and submitted it to the Narcotics Commissioner of India and to the Revenue Secretary. Shortly thereafter, the Government of India accepted this proposal, adapted it, and instructed all state governments to adopt a new regulation to simplify access to morphine and pain relief.
1998 : the Pain and Palliative Care Society of Calicut (PPCS), Kerala, collaborated with WHOCC and the Government of Kerala to conduct a series of meetings with the concerned state government officials. The result was a meeting at Trivandrum supported by WHOCC and the US Cancer Pain Relief Committee. Top government officials from the departments of Health, Excise and Drug Control attended the meeting along with doctors working in the field of cancer and palliative care. The meeting agreed to approve adoption of the modification proposal with minor changes. It also appointed a task force to prepare a draft proposal for submission to the Government of Kerala. The task force was comprised of the Drug Controller; Kerala, an official in the Excise Department and two palliative care doctors.
Following comments by the task force, a draft rule was prepared which reduced the number of licenses needed, simplified the licensing procedure, and increased the period of license validity. According to the Health Secretary, the draft rule is in its final form, and needs only approval of the committee of legislature, for notification.
Progress is also being made in Orissa, Maharashtra and Karnataka. In the meantime two states, Sikkim and Madhya Pradesh, have already amended their regulations. But it has become apparent that amendment of the rule alone is unlikely to succeed in achieving the objective of making morphine available to the needy, unless coupled with educational activities for the professionals and the public.
The process is rather slow. But there definitely is some progress! v
v
CANCER PAIN RELEASE: AN INTERNATIONAL
RESOURCE
Published consistently
since 1988 by the WHO Collaborating Center for Policy and Communication in Cancer Care,
Cancer Pain Release is the only WHO periodical on cancer pain and palliative care; it is
available in English, Spanish and French editions.
Each issue includes relevant abstracts from the international literature on hot topics in
pain and symptom control. Recent topics include a) Pain in children with cancer b) Fear of
addiction: confronting a barrier to cancer pain relief c) Physician education in
palliative medicine d) Medical needs for opioids and narcotic regulation e) Nursing
education: from international consensus to local practice.
Edited by Dr. Sophie Colleau. Subscription to the 8-page quarterly is US $17.00 p.a. Contact: Cancer Pain Release, 1900 University Ave, Madison, WI 53705, USA. Telefax: 1-608-263-0259.Abridged version of Cancer Pain Release is also available at: www.medsch.wisc.edu/WHOcancerpain.
v Cipla Centre, Warje Pune Pune is just 170 kms from Mumbai (Bombay) and is a busy industrial city with a major university. The Cipla Palliative Care and Training Centre was established in Pune in May1997. The facility is impressive with 4 wards in a courtyard arrangement, with achildren's playground in the centre,
accommodation for relatives, solar power and self-sufficient vegetable garden.
In addition to the clinical care provided,
the Dr. K.A. Hamied Institute for Education and Research in Palliative Care Science
(generally referred to as Hamied Institute) was established on 31st October 1998.
Courses run to date include seminars for local GPs and other medical practitioners and nursing training with allocation of certificates on completion of 15 months course on elementary nursing techniques.
v OPAL
Overseas Pharmaceutical Aid for Life - information provided by Dr Ruth Powys
2 main objectives: -Sourcing and collection of in-date pharmaceuticals from manufacturers, wholesalers and other producers in order to supply humanitarian pharmaceutical aid consignments for countries in need.
-The safe collection and destruction of unwanted or expired pharmaceuticals in an environmentally friendly manner.
All pharmacies act as collection points. Holds TGA license for exportation of controlled substances.
OPAL National Headquarters, Collex Industrial Park, 500 Churchill Rd, Kilburn, SA -Ph 08 8359 6055 fax 08 8359 6064 Email opal@camtech.net.au
Pain and Palliative Care Service(PPCS), Calicut, Kerala Dr Rajashree, visiting anaesthetist, PPCS
The Pain and Palliative Care Society, Calicut is a charitable organisation for people with incurable cancer and those in chronic pain. It has been a World Health Organisation Demonstration Project in palliative care for the developing world since 1996. Volunteers from the local community do much of the work. A management council supervises the activities. We support fifteen satellite centres in addition to the activities in the main centre.
We receive a total of sixty patients a day in our main centre at Calicut. After registration, these patients are interviewed by the volunteer who gives a special emphasis on the socio-economic status of the patient and his/her attitude towards the illness and the treatment. After that the patients is taken care of by the doctor who really LISTENS to his/ her problems. Most of these patients are burdened with the socio-economic problems due to isolation and poverty in addition to the illness. The treatment is free for the patients who fall into the poor category.
The family is given an active participation during the discussion for creating an awareness regarding the non-contagious nature of the disease, necessity of taking the medications regularly and wound toilette.
It is found that most of the time it is the lack of knowledge of palliative care treatment that prevents patients and families from using the service.
Home care services are meant for the needy people who cannot attend the clinic and who stay within 25 kms from the clinic. The distance involved, the state of the roads and poor communication systems are major difficulties for this venture. Despite these problems, the experience shows that a home care system is possible and essential for palliative care delivery in India.
Other difficulties are the lack of an inpatient care centre and the laws that govern the drug availability.
Opiods are not available outside the hospitals, hence the patients do suffer when they run out of medicines. The “high touch” and “low tech” nature of the service, the gentleness in the approach, the willingness to listen and help, the opportunity for an open communication and the effective team work without heireachy, giving the feeling of togetherness, make palliative care service different from other specialties.
We hope that with the amendment of the policy on drug availability and establishment of a teaching centre for the health care professionals in palliative care , we have a bright future.
About India:
Area: 3,287,000 km2 (1,281,900 m2) Population: 968 million (growth rate 2.1%)
Capital city: New Delhi (pop 10.1 million)
People: 72% Indo-Aryan, 25% Dravidian, 3%
Mongoloid. Languages: Hindi and English, plus
15 main languages and over 700 dialects Religion:
82% Hindu, 11% Muslim, 2% Christian, 2% Sikh, 0.7% Buddhist and 0.7% Jain
Gift
O my love, what gift of mine Shall I give you this dawn?
A morning song?
But morning does not last long -
The heat of the sun
Wilts it like a flower
And songs that tire `Are done
.
.
Whatever gifts are in my power to give you
Be they flowers Be they gems for your neck,
How can they please you?
If in time they must surely wither
Crack. Lose lustre?
All that my hands can place in yours
Will slip through your fingers
And fall forgotten to the dust To turn into dust
.
.
Rather When you have leisure,
Wander idly through my garden in spring
And let an unknown, hidden flower's scent startle you Into sudden wondering -
Let that displaced moment Be my gift
Or if, as you peer your way down a shady avenue,
Suddenly, spilled
From the thick gathered tresses of evening
A single shivering fleck of sunset-light stops you,
Turns your daydreams to gold,
Let that light be an innocent
Gift
v Rabindranath Tagore