Dr. Vishnu Priya Bashyam
Specialist General Practitioner, Australia
Initially Hospice was referred to religious institution run by nuns, whose essential activity was to look after dying patients.1 They focused in providing refuge for travellers and provide care for poor, sick people.1 Some of these facilities were found in alpines1. In 1744, first hospital for incurable disease was opened in Ireland with help of Dublin Charitable Musical Society1. In 1842 in Lyon, France, Jeanne Garnier started an association to provide care for incurable and dying patients1. Following that another similar home was opened in Paris in 1874.1 In 1879 Our Lady Hospice was founded by new order of nuns created by Mary Aikenhead in Dublin to care for dying patients1. It was started with 12 beds, then gradually increased to 110 in 18881. It was built by charitable donation and is still functioning as Hospice1. Following that lot of homes were formed to look after the dying patients most of them where run by religious organisations1. C founded the first modern hospice, St Christopher’s Hospice in London in 19671. The growth of modern hospice movement led to the current style of palliative care.
In India palliative care concept was first introduced during mid 1980s.2 Initially palliative care services were established in cancer centre in major cities like Ahmedabad, Bangalore, Mumbai, Trivandrum and Delhi.2 The first palliative care service was established at Gujarat Caner and Research Institute under Anaesthesia department.2 Formation of Indian association of palliative care (IAPC) in 1994, paved way for further development of palliative care in India.2
In 1986 first hospice, Shanti Avedna Ashram in Mumbai was started by Professor D’ Souza and at the same time pain clinics were opened at Trivandrum and Bangalore.2 CanSupport, the first free home care in palliative service was started in 1997 at Delhi.2 Following that Cipla Cancer Palliative Care Centre was established in Pune.2
Shanti Avedna Ashram, Mumbai
In March 1994 IAPC was registered as Public Trust and Society in Ahmedabad.2 In January 1994, IAPC hosted first international conference in Varanasi.2 Kerala has wide spread palliative care services throughout its state and WHO uses the Calicut model as example for providing high quality, flexible and economical palliative care in developing world.2 Guwahati pain and palliative care services (GPPCS) provides palliative care services in Assam and few areas around it.2
Karunashraya Bangalore Hospice Trust is a 55-bedded hospice which provides both homecare and hospital service.2 They provide an entire circle of care to the patient.2
The Chandigarh palliative care which shares the same out patients with oncologist was started with view of integrating palliative care into comprehensive cancer care.2 Similarly, Kidwai Memorial Institute of Oncology has also been providing palliative care in Bangalore.2
McDermott et al. identified 138 organizations currently providing hospice and palliative care services in 16 states or union territories. Kerala state has wide spread coverage of palliative care services and first one to have palliative care policy.3
Opioid availability for clinical use in resource poor countries has been a problem for a while. In India this was mainly due to 1985 Narcotics Drugs and Psychotropic Substance (NDPS) Act.4 This legislation brought stiff penalties to minor clinical errors, following which pharmacist stopped stocking morphine and this lead to steep decrease in use of morphine.4 In 1998, Ravindra Ghooi’s approach to high court for morphine, lead to high court requesting swift action from government which initiated some changes into the legislation.4 Central government advised states to look into this matter but due the state autonomy and bureaucracy, rules varied considerably between states.4 In 2012, special provisions made for palliative care in 12th five year plan. Following that National Programme in Palliative Care (NPPC) was created but money did not materialise.4 So NPPC was not implemented but documents still available as guidance for implementation of NPPC.4
Opioids availability challenge: In 2012, Pain and Policy Group (PPG) at Madison-Wiscontin included three fellows in their fellowship programme and invited two officials Mr. Rajesh Nandan Srivastava and Dr. Sudir Gupta (Director of Narcotics in Depart of Revenue and Deputy Director General of Health Services respectively).4 This made positive impact on policy and Department of revenue along with palliative care and with input of Ms Tripti Tandon (a lawyer from The Lawyers Collective) NDPS amendment act was put forward to parliament in 2013 and was passed on February 2014.4 This act transfered state governments powers for legislation on essential narcotic drugs to central government and announced uniform simplified state rules.4
This process was completed in May 2015 with notification of rule change to state government. Now the responsibility lies on both, state government’s and palliative care activist to implement the rules in their state.4
Due to continued work of palliative care community, in 2010 Medical Council accepted palliative care as medical speciality and 2012 first Doctor of Medicine (MD) in palliative care was started at Tata Memorial Hospital in Mumbai.4
When discussing about evolution of palliative care, one also need to acknowledge the activists responsible for the evolution. The progress in Palliative care in India was achieved by relentless perseverance of numerous pioneers at different states. There are extensive number of people who have worked hard to improve the services in their respective areas and it is difficult to discuss about all of them individually.
One of pioneers who shaped palliative care in India, Dr MK Rajagopal is called father of palliative care. An anaesthetist by speciality, he founded the Pain and Palliative Care Society (PPCS) in Calicut.5 With community’s involvement PPCS expanded and evolved in to “Neighbourhood Networks in Palliative Care” (NNPC).4 He created Palliative care suited to Indian culture, which attracted international attention and by 1995, became a WHO demonstration project.5 In 1996, he also worked with PPG at Madison-Wiscontin to remove barriers in availability of morphine for pain relief.5 In 2003, he founded Pallium India a charitable trust and it has helped to establish two palliative care centres and palliative care services in 8 states who had no palliative care services.5
Since the introduction of Palliative Care in mid 1980s there has been steady expansion of palliative Care. However, the majority of the expansion happened only in cities and still less than 1% of the India’s population has access to Palliative care.4 Major barriers in accessing Palliative care has to be overcome. Significant achievements so far are simplification of narcotic rules, change in the perspective of healthcare professionals and policy makers’ view on palliative care in India, propaganda to implement palliative care in undergraduate curriculum and creation of NNPC.3+4
1.Textbook of Palliative Medicine and Supportive Care. Second Edition. Bruera E, Higginson I, Von Gunten CF, Morita T. USA. CRC Press Taylor and Francis Group. 2015. Part-1. The Development of Palliative Medicine. P.1-102.
- Divya Khosla, Firuza D Patel, and Suresh C Sharma. Palliative Care in India: Current Progress and Future Needs. Indian journal of palliative care. Sep-Dec 2012; 18(3): 149-154.
- McDermott E, Selman L, Wright M, Clark D. Hospice and palliative care development in India: A multimethod review of services and experiences. J Pain Symptom Manage. 2008; 35: 583–93.
- Rajagopal M. The Current Status of Palliative Care in India. Cancer Control. July 2015; 57-62. Available at http://www.cancercontrol.info/wp-content/uploads/2015/07/57-62-MR-Rajagopal-.pdf
- M.R.Rajagopal. International Association of Hospice and Palliative Care. IAHPC. USA. (Accessed on 7 Nov 2018) Available at: https://hospicecare.com/bio/mr-rajagopal/