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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 . 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.

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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.

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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.

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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.

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