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2015 Return to the Valley: Cachar Cancer Centre, Silchar, Assam, India

The visit made in December 2015 was the third visit to Cachar Cancer Centre undertaken by members of APLI in the last three years. The visits have been part of Project Hamrahi, a collaboration between APLI and Pallium India. In all seven members have visited now. Sarah Corfe, Ofra Fried and Oliver Haisken have visited in the past, and last December Lisa King, Joan Ryan, Niamh O’Connor and I spent ten days there. We enjoyed ourselves immensely, learned a great deal and as before came away full of admiration for the skills, energy and compassion shown by the staff of this cancer hospital in one of the poorest areas of India.

The hospital has grown before my eyes. Even in the four years since my first visit, bed numbers have grown from 60 to 100, with 200 staff now. Outpatient numbers have grown dramatically, so that there are now about 3000 new patients and 14000 reviews each year. The hospital has a new ICU, new accommodation for staff and many other improvements just in the last year.

Assam is a poor State of India. Tea production is a major employer in this part of Assam. The plantation workers are very poor and their reliance on piecework causes real fear of the costs of treatment, resulting in late disease presentation. More than half of the patients seen at the hospital earn less than R3000 per month ($A60). It is typical of Cachar Cancer Centre that they have actively engaged with these social problems with programs of community education, outreach clinics, financial assistance and other creative responses such as employment for patients and families at the hospital.

Much of the development of the hospital has been due to the efforts of Dr Ravi Kannan. A commentary on his work can be found at http://www.thebetterindia.com/48284/cachar-cancer-care-silchar-assam-doctor-kannan/ . An accomplished surgeon and oncologist, in addition his skill has been to cultivate an entire team of doctors, nurses and support staff who exhibit the same selfless energy in their work.

We were welcomed at the airport and driven through Silchar town to the hospital by Dr Iqbal Bahar, Nurse Sarita, the head nurse of the palliative care ward, and Mr Kalyan Chakravorty, the Chair of the Cachar Cancer Centre Society. We worked in several areas on this visit. We engaged at a direct clinical level with nurses and doctors, sharing ward rounds in the palliative care ward and occasionally elsewhere, discussing individual patient problems. These were commonly related to pain and physical symptom control but also included much discussion of the social problems of the patients and families. Niamh and I spent regular time in the outpatient department with Dr Bahar, the palliative care physician, gaining a great respect for his ability to work effectively in a hot, cramped and busy space. His workday is boggling by our standards. So too is his flexibility: no waiting for a pleural tap or an abdominal ultrasound – it’s done on the spot. This is a good teaching for those of us who are mired by protocol.

Cachar 1

David in outpatients

Joan and Lisa spent time with the nursing staff in the ward and also in formal teaching. They also examined the nurses for their hospital palliative care certificate, and presented certificates to the successful nurses at the end-of-visit party.

Cachar 2

Niamh handing out certificates

A recurrent theme in our past discussions had been the difficulty in providing follow-up to patients after discharge from the hospital. This is a result of the very slow roads and the cost for patients of being away from the workplace. Since the last visit two telemedicine centres have been established at a distance from Cachar Cancer Centre. Patients attend these centres after discharge and the staff at the centres communicate with the nurses and doctors at the hospital. Although not qualified as nurses, they provide a contact point for staff and arrange the sites for the regular fortnightly visits by the hospital team.

We were also given the chance to speak to large groups of interested local people, and to spread information about cancer prevention and palliative care in these areas. In particular, smoking and chewing tobacco cause many oro-pharyngeal cancers. One such speaking engagement was at Karimganj, a small city on the border with Bangladesh, and a difficult drive from Cachar along the Barak river. There Niamh spoke to a large group of local people, including nurses, in a tent erected for the purpose by the Rotary Club of Karimganj.

Cachar 3

Joan and Lisa at Karimganj community meeting

All of us had the chance to present tutorials and lectures on a very regular basis. Dr Iqbal enjoyed challenging us by asking all of us for yet another lecture at very short notice! An afternoon visit to a tea plantation and discovered a talk was required immediately on our return! We were all glad we brought our laptops with us.

We were constantly socialising over meals, both at the lunch cafeteria but also over the frequent dinners with staff members. This gave us the chance to talk about some social issues, and one such issue was that of truth telling. It is not usual practice for doctors in this part of India to tell patients bad news, but they usually tell a family member. It was interesting to find that this is beginning to change, and we were able to add our voices to the debate, and ask whether or not this represented a deeply held cultural belief. We hope to be able to discuss this matter further in planned ongoing Skype sessions.

We were given some relaxation time too. We had a delightful boating afternoon on the Barak river: on a small boat seeing the lives of the people in this riverine land. We had an evening celebration on leaving, at which dressups and singing were required!

We all hope that you might consider a similar venture to this. Many palliative care staff have expressed interest but at the same time wondered about their skills. The main requirement is a willingness to engage with and enjoy the experience of another culture. In the process of doing this, the differences fade and the learning is shared. The generosity of the people in places such as this reinforce my faith in human nature, and act as a powerful antidote to any ennui that might develop in the course of our normal lives. Go for it!

Rabindranath Tagore says it well in Poem 63 of Gitanjali.

Thou hast made me known to friends whom I knew not. Thou hast given me seats in homes not my own. Thou hast brought the distant near and made a brother of the stranger.

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

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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