In India, a Quest to Ease the Pain of the Dying
By Donald G. McNeil, Jr.
The New York Times
TRIVANDRUM, India — It was a neighbor screaming in pain
35 years ago that set Dr. M. R. Rajagopal on the path to his
nickname: India’s “father of palliative care.”
“He was dying of cancer, with lots of tumors on his
face and scalp,” Dr. Rajagopal recalled. “His family
asked if I could help, and I couldn’t — I was just
a medical student.”
Today, the same neighbor with the same cancer would almost
certainly die the same way — unless he lived in tiny
Kerala State, where Dr. Rajagopal runs his Pallium India clinic
here in the capital. Although opium was one of the chief exports
of British India and the country still produces more for the
legal morphine industry than any other country, few Indians
benefit. They end up like millions of the world’s poor
— spending their last days writhing in agony, wishing
death would hurry.
About 1.6 million Indians endure cancer pain each year. Because
of tobacco and betel nut chewing, India leads the world in
mouth and head tumors, and has high rates of lung, breast
and cervical cancer. Tens of thousands also die in pain from
AIDS, burns or accidents.
But only a tiny fraction — Dr. Rajagopal estimates 0.4
percent — get relief.
Clinics dispensing morphine are so scarce that some patients
live 500 miles from the nearest. Calcutta, a city of 14 million,
has only one.
“For a poor person here, that means just forget it,”
said Dr. Mhoira Leng, a palliative care expert from Scotland.
“It goes from dire to dreadful.”
The exception is Kerala, where Dr. Rajagopal practices and
about 80 percent of India’s palliative care is delivered.
A small slice of the southwest coast, it is sort of India’s
Massachusetts: it has a mere 3 percent of the population,
but high literacy rates, responsive local leadership and a
bent for bucking central government.
The state government allows any doctor with six weeks of
training — which Dr. Rajagopal provides — to prescribe
morphine.
Elsewhere, the state laws enforcing the Narcotic Drugs and
Psychotropic Substances Act, passed in 1985 to curb drug trafficking,
are complex and harsh. The book outlining them is 1,642 pages,
and even minor infractions can mean 10-year sentences. Legal
morphine use in India plummeted 97 percent after 1985, reaching
a low of 40 pounds in 1997. It has since crept up.
“India is a regulatory morass,” said David E. Joranson,
director of the Pain & Policy Studies Group at the University
of Wisconsin medical school. “It is controlled by the
Ministry of Finance, and the rules are based on excise regulations
that go back to the British Raj.”
Each shipment requires five licenses. Pills must be locked
in two-key cabinets. When patients die, families must return
unused pills — sometimes a struggle in a country where
the dead may be cremated with their medicines.
Many pharmacists just cannot be bothered.
“It’s a vicious circle,” Dr. Rajagopal said.
“If a doctor does get interested, he runs into all these
objections. And he eventually loses interest.”
And raising that interest is a struggle, because most were
taught notions long faded in the West — that morphine
inevitably addicts and kills.
Dr. Rajagopal lectures constantly at small hospitals. Morphine
can be tapered off, he teaches. And with pills, rather than
injections, accidental overdoses are almost impossible.
Dr. Rajagopal’s manner is soothing — he sits on
beds, holds hands and even strokes patients as he questions
them. “For a senior doctor in India, that’s just
unheard of,” Dr. Leng said. “They usually keep a
formal distance.”
Talking unravels fears. Chandraprabha, 40, who like many
people here uses only one name, avoided her hourly pills because
she could not bear to look at a clock — it reminded her
she was dying and her children would go to a stepmother she
detested.
Abdulaziz, 62, said that what upset him more than death was
that he felt too unclean to pray.
“My body is not pure,” Abdulaziz mourned. “Also,
because of the bandage, it’s difficult to bathe.”
He had sung the call to prayer at his mosque for 20 years,
but had to stop in January when mouth cancer left him able
only to mutter. Then the aggressive tumor ate through his
face, making a beefy crater as if a firecracker tucked in
his cheek had gone off. Then, worse: a fly got under his bandage,
and maggots began emerging, leading his imam to “excuse”
him from attendance.
That was something Dr. Rajagopal’s team could help with
— cleaning out the ghastly invaders. And the six morphine
pills Abdulaziz takes daily have taken away what he called
“a catching pain, like a fishhook in my face.”
As the cancer advances, Abdulaziz will presumably need more
— some patients take 15 times his dose without even getting
drowsy.
As the cancer crushes his trachea and esophagus, the palliative
care team will give him, unless he refuses, a nasal tube to
his stomach for a rice and pill slurry. Then, if he wishes,
a tracheotomy tube. As his lymph glands swell, cutting off
arteries to his brain, the team may offer steroids. And finally,
as he slips away, more morphine to fight the panic of breathlessness.
Treating pain alone is not enough, Dr. Rajagopal explains.
As a young anesthesiologist, he helped a professor with a
cheek tumor by injecting alcohol to kill the nerve. It worked
— but the professor hanged himself two nights later.
“I learned from his cousin that the fact that I had
treated him for his pain alone was what told him his condition
was incurable,” Dr. Rajagopal said, still feeling guilty
about it. “None of us had ever asked him what he knew
about his disease, or how he felt. If only we had, maybe his
children could have had their father for a couple of years
more.”
Dr. Rajagopal has a mordant wit. He describes first-level
Indian medical education as “a license to kill,”
and when an interviewer mentioned having had four hernia operations,
he mused sympathetically, “It’s addictive, isn’t
it?”
But as he describes his struggle over morphine, only frustration
registers.
“Since the 1980s, the government has paid lip service
to palliative care,” he said. “But things change
slowly here.”
The 80-year-old Government Opium and Alkaloid Works in Neemuch
smells better than it looks. The turfy-chocolaty nosegay of
raw opium wafts from hundreds of milk cans. The sides of the
bubbling steam dryer are caked with it.
“If you breathe enough, as you are not used to it, you’ll
become sleepy,” said V. K. Harit, the plant’s chief
scientific officer, while leading a tour.
The stone floors of the packaging room are slippery with
brown ooze as workers chop up huge blocks resembling mocha
fudge, wrap them in newspaper and stuff them into boxes —
in this case bound for the Mallinckrodt Co. in St. Louis,
which makes morphine.
Although many countries grow the poppies, Indian officials
seem deeply ambivalent about theirs.
Farmers in Australia and France for example, harvest dried
pods by machine. It’s faster, but “straw extract”
has fewer alkaloids than opium bled by hand out of lanced
bulbs.
Permission to visit the Neemuch plant — its elder brother
in Ghazipur was described in 1889 by a young Rudyard Kipling
— took many letters, and then, after the tour began,
photographs were banned, as was seeing the room where morphine
is refined.
Jagjit Pavadia, the national narcotics commissioner, whose
office is decorated with a spray of dried poppies, defended
the business, saying she would make more morphine if only
doctors would request it.
“We’re growing poppy — why would we not want
to use it?” she asked.
In Neemuch, a midlevel plant official groused privately that
he thought India had been “stuck with the world’s
dirty work” — growing opium mostly for foreign producers.
About 62,000 farmers have opium licenses, which are powerful
status symbols. The government pays cash, “so if you
have one, you can get a bank loan easily,” said Ramchandra
Nagda, 66, a grower. “Or if you want to get married,
no one in the bride’s family will question your worth.”
And harvesting by hand employs poor peasants, who vote.
Nonetheless, the government is cutting back; it once had
150,000 licensees.
Although cancer is growing as a global killer, morphine demand
has grown little. In rich countries, morphine faces competition
from heavily marketed rivals like fentanyl patches. In poor
countries, no one lobbies for it.
Cipla, the largest pharmaceutical company in India, makes
tablets from government morphine to sell at 1.7 cents each
or provide free at its own hospice.
At those prices, said Yusuf Hamied, Cipla’s chairman,
and with the licensing difficulties that narcotics face, “I’m
happy to export, but I’m not going to build a market
in other countries.”
Fear of diversions to the heroin trade adds to the government’s
ambivalence.
An opium farmer in Pratapgarh said the black market price
was double the government’s, and local crop inspectors
could be bribed for as little as $25.
Mrs. Pavadia disputes estimates that a quarter of the crop
is diverted, but her bureau has seized 1,200 pounds of heroin
recently and raided 64 secret laboratories. .
“The more you grow, the more you have to control to
make sure it doesn’t get into the wrong hands,”
she said.
Dr. Rajagopal argues that such crimes should not tar medical
uses. A clinic he founded in northern Kerala tracked all pills
issued to 1,723 patients over two years and found none diverted.
Lobbying is also part of Dr. Rajagopal’s mission, but
India’s chaotic government complicates that. For example,
while the national health ministry endorses morphine, some
of its own officers undermine its use.
Dr. Rajagopal showed a memo from another palliative care
doctor describing a meeting with a high-ranking political
appointee in health, a recent transfer from the department
of industry.
The health official had insisted that morphine be dispensed
only by the nation’s 28 regional cancer hospitals, even
while acknowledging that some refuse to stock it. None would
be issued to independent groups.
That split in his own department was news even to the health
minister, Dr. Anbumani Ramadoss.
In an interview in New Delhi in June, he described his plans
to give more emphasis to pain relief in the national cancer
plan then before Parliament.
Then he was handed the memo. He read it over and smiled.
“It’s good you gave me this,” he said. “It
may change the national strategy.”
Told of this by e-mail message that evening, Dr. Rajagopal
said he was “dancing about” with happiness.
Last month, Dr. Ramadoss was reported to have intervened
in Parliament to increase the national cancer plan’s
budget for palliative care.
“Soon,” Dr. Rajagopal said, “we may hear some
good news after all.”
September 11, 2007 |
