In 2003 Dr. Suresh Reddy Traveled to:
India

Report

The International Association of Hospice & Palliative Care (IAHPC) sponsored me to deliver lectures in Annual meeting of The Indian Association of Palliative, WHO workshop in the MNJ Regional Cancer Center, as well as Foundation Course in Palliative Care at International Rotary Cancer Institute (Part of All India Institute of Medical Sciences), Delhi.

10^th International Conference of Indian Association of Palliative Care

Feb. 1-3, 2003, Hyderabad, India

This is the 10^th consecutive annual meeting by the association, but first in the city of Hyderabad. Hyderabad is a city in one of the southern states of Andhra Pradesh, recently was in limelight as a result of bustling information technology development and a recent visit by the last American president, Bill Clinton. Hyderabad has 8 cancer hospitals, but lacks an organized pain or palliative care program. It is certainly lagging behind the other major cities, like Kerala, where WHO model for palliative care exists, and has been spearheaded by Dr Rajagopal and team. It is a successful program and acting as a role model to develop palliative care in other major cities. However there are a number of hospice organizations throughout the country.

This conference was a 3 day event with delegates from both within India as well as from abroad. Some prominent international faculty included Robert Twycross, Jan Stjernswärd, David Jeffrey, Yashodara Sachidanand, and Ian Maddocks. Day one started off with plenary session by Dr Robert Twycross, who addressed the issue of oral morphine in advanced cancer, followed by Key note address by Dr Jan Stjernsward.

There were a number of symposia and "Special Issues" sessions. I chaired a session on Hospice home care/Team work in Palliative Care/Palliative Care –Calicut experience. Dr Sachidanand, from Buffalo, New York highlighted the definition of palliative care, addressed the difficulties of starting the services at her hospital, and revisited the importance of team work, as well as address issues of palliative care in non-cancer patient population. She addressed the futility of treatment options in terminal patients like TED hose and its doubtful indications in terminal situation. Dr McCaden, from Bangalore highlighted the importance of "Team Work" in palliative care settings. The Calicut group, from Kerala highlighted the clinical work, education and some research aspects. They apparently started the palliative care in the outpatient clinic and developed the network throughout the Kerala very successfully. Recently they started a program called neighbourwood network program in Palliative Care (NNPC), involving the local community volunteers. It is started in a small place called Mallapuram in Kerala. The program teaches and empowers the basics of palliative care management. The enrollment increased from 20 % to 40 % since the inception of the program. Calicut offers ongoing didactic and ongoing training programs to physicians, nurses and others. They are also offering diploma courses with Australian collaboration. Some research aspects in the pipeline include data collection of volume of cases they see and present to government, so that both awareness and funding will improve.

I delivered two lectures on 2/2/03, one on treatment of pain in gynecological cancer, and the other lecture was on the assessment and treatment of difficult pain syndromes. My lectures were received well. One of the participants asked me the question regarding morphine and its use in uremic patients in cervical cancer. My comment was "I don’t really like morphine. Methadone is the opioid of choice in renal failure setting. I also made a comment about introducing methadone in India, based on cost as well as its efficacy in intractable pain syndromes. Dr Rosalie Shaw made a comment on the difficulty using methadone. She said methadone caused lots of sedation, had problem with dose adjustments, and was in fact very expensive in Singapore. I made a comment that recent guidelines and conversion ratio should make it a safe drug to use. I also mentioned that one needs clinical experience with methadone before one starts using it. Other participants also approached me and were expressing displeasure about my comments on methadone. While I agreed that we all need to work on getting morphine available in all States, I defended my opinion on the efficacy and other aspects of methadone. In fact I later learnt that methadone will never be available in India, because no pharmaceutical company is willing to manufacture it based on the low cost. One of the questions raised was the use of Fentanyl patch in cancer pain. I made a comment that Fentanyl is probably not a good idea in India, cause of tremendous cost, and also the practicality of safety and its use in warm conditions. But I was told that Fentanyl patches work good in Head & Neck cancer patients. A speaker from Delhi delivered a lecture on "Intrathecal Pump-Delhi experience". They reported a good result with the pump. The cost of the pump in India is apparently $2000, dollars, substantially cheaper than US, where it costs approximately $22,000.00. Even $2000 for Indian standards is substantially expensive. I also chaired a session on "Itching", by Dr Robert Twycross, "Information Needs Of Palliative Care Patients, Canadian & Australian Perspectives" by Dr Peter Kirk, followed by a good discussion on these topics. I also participated in a group discussion on "Starting Palliative Care Service", in state of Andhra Pradesh. The local drug controller also participated in the session. He made it very clear that from his point of view one can order as much morphine as they want, provided a log was maintained. One of the fascinating facts that I noted was the reluctance on the part of one of the hospital superintendents to sign for the morphine log. After the discussion it was evident to me that some of the problem of obtaining morphine rests on the hospital staff. The staff is scared of the legal implications and the severe penalty that may result from either misuse or missing morphine.

MNJ Institute of Oncology & Regional Cancer Center: Feb 4-5

After the Palliative Care Conference I was invited to lecture at the WHO sponsored two day workshop on Pain & Palliative held at MNJ Cancer Hospital. MNJ Institute of Oncology & Regional Cancer Center is one of the 18 Regional Cancer Centers in India, which are federally designated hospitals with funding both by the state and federal government. Before the conference I was invited to participate in a press conference by the director of the hospital, DR B.N.Rao. We addressed all the questions raised by the press people, about the fundamental concept of palliative care in cancer patients. There was wide coverage of the conference in local newspapers. The conference was inaugurated by the health minister, followed by a couple of lectures. I lectured on "anesthetic procedures for cancer pain management" and "The management of difficult symptoms in advanced cancer". I briefly updated the audience about the new procedure called vertebroplasty for bone pain.. There were a number of questions about the new procedure. During discussions I learnt that some centers do it for osteoporosis for a very low cost. In fact they were telling me that they use dental cement, and do the procedure with the reusable epidural needles to cut the cost. At the end of the conference we had a brainstorming session on the development of Palliative Care Service at MNJ hospital. The participants included directors from other hospitals. They all seemed enthusiastic about starting the service at MNJ, and later network to their own centers. I offered to invite 1-2 observers per year to M.D.Anderson Cancer Center to learn about the principles of Palliative Care management. Dr B.N.Rao committed to increasing the faculty to staff the palliative care service. Dr Rao wanted to collaborate with M.D.Anderson Cancer Center on the education, research, and help to set up an In-Patient Palliative Care Unit at MNJ Cancer Hospital. The following day I had the opportunity to visit the hospital. Dr Rao was kind enough to allow me to go and see some of the patients on the floor. The majority of patients either had Head & Neck cancers or cervical cancers. The hospital had beautiful landscape, which I thought was an excellent environment for Palliative Care Unit.

That immediately raised my curiosity about doing some descriptive research in the above two cancers, as far as pain and other symptoms are concerned. Dr Rao also seemed very enthusiastic about the collaborative research with M.D.Anderson Cancer Center. The logistics are yet to be determined. I later presented Dr Rao with the M.D.Anderson Handbook on Palliative Care.

2^nd Foundation Course in Palliative Care, Delhi: Feb 7th

The following day I flew to New Delhi to lecture on the Pain & Symptom Management in cancer patients. The common questions about morphine addiction and morphine regulations have been raised. We had a good discussion on these issues. One of the speakers talked about the complex nature of getting approval for morphine in India. That lecture was followed by a heated discussion on the subject of morphine availability in India. I learnt that in addition to the administrative hurdles, some of the reservations from the physicians also contribute to this problem. I enjoyed the communications workshop conducted by Dr Rosalie Shah and Dr Rajagopal. I met with the director of the Cancer Center, Dr Kochupillai, and also with the Palliative Care Team staff and other members. Dr Sushma Bhatnagar, and Dr Harmala Gupta organized the course very successfully. Unfortunately I could not visit with patients in Delhi, as I had to catch the flight back.

My Impressions:

I was pleasantly surprised to see the advancement of palliative care in India. Thanks to the pioneers like Dr Rajagopal and his team. The international faculties like Robert Twycross, Ms Gilly Burn, David Jeffrey, Jan Stjernsward, and David Joranson, made huge contributions to advance palliative care in India. Change is slow to come by in India, but at least the movement has started. I wished to have spent some more time attending clinics and assess some of the patients. Going to developing countries as a visiting professor and lecturing is fun, but the real experience and local flavor of things is gained by spending some time with patients, visiting their homes, and talking with local health care givers will give more insight into the culture and local problems. I did opportunity to see some patients, but had limited time to explore issues in more depth. Perhaps one needs to visit the place many times and spend time locally to fully understand the health care system and intricacies. My advice to IAHPC is to educate the visiting fellow about the local practices as much as possible, and update on the current resources and drug availability and also about the palliative care and hospices in that geographic area. In fact the organization should make efforts to link their web page to local organizations, so that the visiting fellow will have good knowledge about the country, geography, culture etc. Based on the local knowledge the fellows can prepare the lectures somewhat to the local needs.

It was a very gratifying experience to my home country. I am very thankful to the organization for sponsoring this trip to India. Since my visit, I had the opportunity to visit India two more times. I learnt a lot more about local leaders, resources etc. Since I am born and raised in the city of Hyderabad, I have the natural tendency to concentrate and develop palliative care program in this city. I understand local culture better, speak the same language, and know the city well. During these visits I made some good contacts and friends in oncology and palliative care. They are looking forward to start palliative care program initially in Hyderabad, and later branch out to other districts. Will update on the development of palliative care program in Hyderabad in future issues.

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