Project Hamrahi in Ambala, Haryana February 2017

It was a dark and stormy night. It wasn’t really, it was a dark and foggy morning and we were at the wrong gate of New Delhi railway station. The gate also happened to be locked although this proved to be only a minor inconvenience as our porters scrambled down on to the tracks with our suitcases on their heads as we scurried along behind them. We were back in India and on our way to Ambala.

Ambala, is a city in the state of Haryana about three hours by train to the north of Delhi tucked in beside Punjab to which Haryana was once joined and with which it shares a capital Chandigarh – a planned city with a lake; a bit like Canberra with mango trees. We had visited Ambala the previous year when we spent just 8 hours there; a stopover en route to Jalandhar and Amritsar, having been there to visit the Ambala Rotary Cancer and General Hospital.

The story of Ambala Rotary Cancer and General Hospital is an interesting, possibly remarkable, one. Ambala Rotary Club, instead of donating a park bench to the city council, with the help of a local benefactor decided to build a cancer hospital. They have since gone on and, among other things, established a palliative care Home Care team with a nurse, a nursing assistant, a driver and, sometimes, a medical officer serving the needs of the more disadvantaged members of the community without charge.

Our contact in Ambala is Rotarian Mr Subhash Bhansal, a retired businessman who is the driving force behind the developing palliative care service. He does not work alone, however, and is supported by a group of Rotarians who are both organised and committed; the absence of a trained health professional does not appear to have been an impediment although they have been mentored and supported at a distance by the redoubtable Dr Savita Butola.

Mr Subhash Bhansal (second from the left) with his family. His daughter in law, standing next to him, taught us how to make chapatis.

Mr Subhash Bhansal (second from the left) with his family. His daughter in law, standing next to him, taught us how to make chapatis.

This time we were back for a week to spend time with the Home Care team and give a series of talks raising awareness of palliative care in and around Ambala. Our programme was full and mixed and had been advertised in the local newspaper so that everywhere we went patients came for consultations. It was a little odd to have patients and their families sit in on our presentations and then queue to be seen by the Australian doctor.

  • 30/1/2017: Arrived in Ambala. Seminar at Nanyola village.
  • 31/1/2017: Visits with Home Care Team. Tutorial with medical and nursing staff at Rotary Hospital.
  • 1/2/2017: Lecture to nursing students at Philadelphia Hospital, Ambala City. Patient consultations.
  • 2/2/2017: Lecture to nursing students Mahabir University. Patient consultations.
  • 3/2/2017: Visits with Home Care Team. Presentation to Ambala Rotary Club.
  • 4/2/2017: Lecture to University students at Sanatan Dharma Lahore College. Patient consultations.
  • 5/2/2017: Visits with Home Care Team. Return to Delhi.

In our two previous visits to India we had struggled with the language as we endeavoured to talk to patients or teach. The Rotarians of Ambala fixed that. They provided us with two “translators”. Delightful young men, non-medical university students, with excellent English, who accompanied us everywhere and… translated. It was a bit of a struggle at first but as we got to know each other we developed a good rapport. They were also able politely to keep us culturally appropriate. It is difficult to overstate the helpfulness of these young people.

Our translators were, however, only one facet of the excellent organisation we enjoyed. Every morning we were collected from our hotel and taken to where we needed to be, driven around and taken back to our hotel at the end of the day. Every evening we were entertained by Rotarians, either in their homes or once in a restaurant in Chandigarh. The hospitality was warm and generous and we valued the opportunity to connect with these new friends who support palliative care in Ambala.

The home care team while small is certainly hard working. Attending to wound dressings is a large part of their work and we were able to work with the team to demonstrate an alternative non-stick dressing using petroleum jelly (Vaseline) to replace the Betadine soaked dressings previously used. This is an inexpensive dressing and petroleum jelly is readily available. Services offered by the home care team are limited by the lack of training in palliative care and support from other health professionals, particularly medical support. Access to medical advice seems to be limited and inconsistent, at least during the period of our visit.

The home care team is on the right. The two young men on the left are our translators. The grey haired gentleman was our Rotary driver for that day.

The home care team is on the right. The two young men on the left are our translators. The grey haired gentleman was our Rotary driver for that day.

Shortly after returning home we prepared a formal report for the Palliative Care Committee in Ambala which made a number recommendations based on the Indian Standards for Palliative Care and which we believe are achievable given the Team’s current circumstances. At a meeting on 10/3/2017, the Committee resolved to address the following:

  1. Establish a system of clinical documentation which was lacking.
  2. The Home Care team does not have access to a medical officer on a daily basis. The Committee has identified an interested doctor in the hospital who will be available to the home care team on a daily basis.
  3. A nurse from the home care team and a doctor from the hospital (the interested doctor) will enrol in the IAPC Certificate Course in Essentials of Palliative Care. The next course starts in June 2017.
  4. The intention is that the doctor will proceed with whatever they have to do to be able to prescribe morphine or other opioids.

We have developed a soft spot for Ambala and the people we met there for their warmth and enthusiasm and look forward to returning in February or March next year (2018).

David and Jane MacKintosh

Project Focus

As some of you may be aware, in early 2016 the Asia Pacific Hospice Palliative Care Network (APHN) held four ‘APHN Dialogs’, in which clinicians across the Asia Pacific region could link in through Skype to attend a webinar. The following webinars took place:

- A discussion of palliative care service development in the Asia Pacific region, presented by Odette Spruyt
- Pain control in palliative care by Yoshiyuki Kizawa from Kobe, Japan
- Management of the cancer wound by Edward Poon from Singapore
- Bereavement care by Jun-Hua Lee from Taiwan

These sessions were well received and provided a valuable opportunity for clinicians in different countries to learn from an expert in that field and also to share their own professional experiences. Unfortunately, not all countries in the region have reliable internet coverage or sufficient bandwidth so some attendees were unable to join the meetings. In response to this, in recent months APLI has been looking at a new educational initiative in partnership with APHN.

Project Focus aims to set up online discussion groups between palliative care clinicians in specific countries in the Asia Pacific region and APLI mentors. Some nascent palliative care centres struggle with isolation, limited practitioner experience and variable institutional support. In effect, Project Focus would work towards similar objectives to Project Hamrahi: to improve the capacity for best practice patient care in the local setting and to reduce the isolation of palliative care providers in emergent services.

APLI is therefore calling for expressions of interest for mentors to volunteer their services to help support our regional partners. Project Focus would particularly suit clinicians who might otherwise find it difficult to travel overseas for mentoring work, as the contact will be online using a small group discussion format on the ‘Slack’ communication platform. APHN has already identified local clinicians in two separate services in remote and regional Indonesia who would like to be partnered with APLI mentors. In addition to this, there has also been some interest from doctors in Vietnam, Brunei and Nepal whose learning needs were unable to be supported by the APHN Dialogs.

Although the exact process will be flexible, it is proposed that education would begin with case presentations from the local APHN clinicians. These would then serve as a springboard for the APLI mentors to explain current evidence based practice recommendations. The subsequent discussion would then take into account local factors such as medication availability, local resources, staffing and other factors such that a viable and culturally appropriate management plan can be formulated.

I hope that you will share our excitement for this initiative. Project Hamrahi has demonstrated the value of teams of mentors made up of both doctors and nurses working together with local Indian clinicians over a sustained period of time. Project Focus has the potential to broaden the scope of such partnerships to other countries and so I invite you to contact me via chairman@apli.net.au with a short biography and reflection on why you would wish to work as a mentor.

- Anil Tandon


Your donations to APLI help in the following ways:

assist with training of doctors and nurses in palliative care practice in developing nations

support nurses to travel and teach as part of Project Hamrahi

help with purchase of critical site resources such as essential equipment and supplies,  medicines and educational materials