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CANCER CONTROL 2015 59
service existed. Whether they followed the complicated old
"narcotic" rules or the simpler new ones in some states,
access to morphine became a reality in all these centres soon
after the initiative.
In 2005, Pallium India submitted a representation to the
Government of Kerala and to the Government of India for
the creation of palliative care policy. The Kerala state
government acted on it and created a task force to formulate
a draft policy. Many meetings and discussions later, in 2008,
the Government of Kerala declared a palliative care policy
integrating it into health care (11). This has since then been a
huge success so that today each of about 900 local selfgovernment
institutions called panchayats employ one nurse
trained in palliative care. The funds for this came through the
National Rural Health Mission which, by the very function of
its being, had to serve rural areas and therefore had to
restrict their activities to community health centres and
primary health centres. No budget allocation, unfortunately,
was made for much of the activities envisaged in the
palliative care policy, namely, the creation of palliative care
centres in district hospitals and in tertiary referral centres.
This has resulted in the anomalous situation in which the
patient has to go through intolerable pain and other distress
for weeks, months or years of treatment in major hospitals,
to get palliative care only in the last few weeks at home
through the primary health centre. The monitoring
committees planned in the state policy were also not
established and hence there was no forum for review and
modification of strategy.
The Government of India formed a committee in 2006
involving experts from various parts of the country to create
a national policy for palliative care. The committee worked
together to create a draft policy document. However,
following a change in one official, this did not see the light of
the day. Representations to the Medical Council of India and
Indian Nursing Council for the incorporation of palliative
care into the undergraduate curriculum also were
unsuccessful during that decade.
Following the initial growth in the 1990s, there appeared
to be a plateauing of improvements in palliative care access
at the national level in India. In 2007, palliative care activists
took the matter to the Supreme Court of India. The
petitioners were the Indian Association of Palliative Care
(represented by the Chairman of its Opioid Availability
Committee), Dr Ravindra Ghooi who had earlier taken the
matter to Delhi High Court and Ms Poonam Bagai, a cancer
survivor and founder of Cankids, a child cancer organization
and Vice Chair of Pallium India. Two Supreme Court lawyers,
Mr Ashok Chitale (one of the trustees of Pallium India) and
Niraj Sharma, gave their services gratis for this purpose. The
Supreme Court accepted the case in file which in itself was a
success because only about 7% of all submitted petitions are
usually accepted by the Supreme Court. The petitioners
argued that lack of access to palliative care violated an
individual's fundamental right to life with dignity that was
guaranteed by the constitution of India and asked essentially
for three things:
‰ the central and state governments should develop
palliative care policies;
‰ the NDPS Act of India must be simplified ensuring access
to opioids for those who need them; and
‰ palliative care must be made a part of undergraduate
medical and nursing curricula. During periodic hearings
of the case which is yet to be settled, the court's
questions to the central and state governments have
been a significant factor in catalyzing action.
A further development occurred in Kerala between 2005
and 2008. Acting on a request from Pallium India, the
Government of Kerala appointed a committee to draft the
Palliative Care Policy for the state. The policy came into
being in April 2008. It accepted palliative care as an
essential part of health care in the state. However, the
Government made no budget allocation for palliative care
and the implementation of palliative care was left to the
National Rural Health Mission (NRHM). This has been
largely successful.
Kerala, though it covers only 1% of India's land mass and
cotains 3% of India's population, has now more palliative
care services than the rest of the country put together. In a
study published in 2008 (12), McDermott E et al found
Kerala to have 83 palliative care services as against 139 in
the whole of the country. As of 2014 in Kerala, more than
170 institutions stock and dispense oral morphine.
International advocacy has always had a major role in
supporting palliative care efforts in India. In 2009, the
Human Rights Watch published the results of their research,
namely "Unbearable pain: India's obligation to ensure
palliative care" (13). One of its recommendations was to
International Narcotics Control Board (INCB) to plan a factfinding
mission to India, with the availability of controlled
substances for medical and scientific purposes as one area of
focus. INCB did take up the suggestion and a delegation
came to India and interacted with Government officials and
representatives of palliative care associations. Its
recommendations had a major role in persuading further
government action. India, till around this time, did not have a
proper system in place for assessing opioid consumption and