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Project Hamrahi – Silchar, Assam

February, 2012

Participants

Cachar Cancer Centre
Iqbal Bahar – Palliative Care Specialist, Cachar Cancer Centre, India
Sarita Chetri – Nursing Team Leader in Palliative Care, Cachar Cancer Centre
Ravi Kannan – Director of Hospital, Cachar Cancer Centre, India
Nursing staff of Palliative Care Unit, Cachar Cancer Centre, India
Medical, Surgical, Radiation Oncologists, Cachar Cancer Centre, India

APLI
David Brumley – Palliative Care Physician, Ballarat, Australia
Oliver Haisken – Palliative Care Physician, Melbourne, Australia
Sarah Corfe – Palliative Care Nurse Specialist, Melbourne, Australia

Pallium India
Professor Rajagopal, Chairman and Founder

Summary
We visited at the invitation of the Cachar Cancer Hospital and Research Centre and with the support of APLI and Pallium India.. Our aim was to gain an understanding of the current service provision in the palliative care unit, to experience the hospital and ward environment, service activities and understand the social context of the experience of the cancer journey in Silchar. Our objectives were to support and mentor the clinical staff in the palliative care unit by exchanging knowledge and experiences of working within this speciality.

Background
The Cachar Cancer Hospital Society is a non-profit NGO located in the outskirts of Silchar town in the Barak Valley of Assam in India. The society consists of about 70 socially conscious citizens of the valley from different walks of life, and came into existence in 1992 as a result of a desperately felt need for a cancer hospital since the only cancer hospital in the entire north east was in far away Guwahati. At its inception, the society had three principal objectives viz. (i) to make people aware of cancer, adopt preventive measures and seek early detection, (2) to establish a full-fledged cancer hospital to provide meaningful services to all suffering people and (3) to set up a cancer research centre. Public philanthropy (from rickshaw pullers who contributed a day’s earnings to leading citizens) helped the Society establish the Cachar Cancer Hospital & Research Centre at Meherpur village, near Silchar town, on a plot of land (11 bigha) allotted by the Govt. of Assam, thus truly making it a people’s project. The hospital serves an extremely underserved and economically impoverished community of patients from the Barak valley districts of Assam state and from the states of Tripura, Manipur and Mizoram. The hospital sees about 4000 new and 10000 follow-up patients annually. The last few years have seen a steady rise in the workload of the hospital.

Palliative care patients come from a large geographical base throughout the region of Assam. According to the population-based cancer registry of Indian Council of Medical Research (ICMR), the incidence is higher with Assam alone adding roughly 26,000 new cancer patients every year. One of the primary reasons for the high incidence of cancer in Northeast India is high usage level of both smoking and non-smoking types of tobacco. Nearly 60% of the patients visiting the hospital earn an income of Rs. 2000 or less per month. They happen to be daily wage earners – labourers, tea garden and agricultural workers. The hospital makes efforts to offer the best treatment possible to all the patients irrespective of their socio-economic status. The palliative care service itself is predominantly funded by donations from the Indo American Cancer Association, but there is uncertainty about ongoing support.
Positive observations
Easy access to affordable services and they do not turn patients away
Effective multidisciplinary team – a happy work environment where all members were valued
Comprehensive services in all cancer treatment modalities
High level of administrative support to the palliative care team
High levels of commitment and motivation to care for this patient population
A good basic level of understanding of symptom assessment principles in the palliative c are nursing team
Rapid access to diagnostics and interventions relating to symptom management
Easy involvement of palliative care

Some recommendations: continue to work to ensure an uninterrupted supply of oral and parenteral morphine and improved documentation of morphine use within the ward. Universal precautions for nursing and medical staff could be strengthened. And discharge systems with documentation and education of family/attendants would help lessen re-presentations to hospital.

The plan is for a return visit in 2013 and for ongoing contact through skype and email in the meantime.

It was a very enjoyable visit for the mentor team and one in which there was mutual learning and exchange.

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