By Professor Eric Krakauer (USA)
Thanks to a supportive boss and team in Boston, I have the privilege of teaching palliative care and assisting with palliative care service implementation in developing countries. But this work teaches and assists me far more. I clearly felt this during a working trip to Nepal in my role as a member of the Expert Collaborative of the International Pain Policy Fellowship, based at the University of Wisconsin Cancer Center. During this visit I collaborated with Dr. Bishnu Dutta Paudel, a Nepali oncologist, friend, and tireless palliative care provider and advocate. On my first day in Katmandu, Dr. Bishnu mentioned that there was a hospice in a temple near my hotel. I asked to go there.
Pashupatinath Temple, Dr. Bishnu told me, is the most sacred Hindu Temple in Nepal. Its large campus is on the banks of the sacred Bagmati River, where many Hindus hope to be cremated on the Temple’s terraces beside the river. Adjacent to the cremation site of the royal family is Pashupatinath Hospice, a final refuge for the most lowly. In a space made available by the Temple, Mr. Padma Raj Bharati, a paramedic from a modest background, operates the hospice with his wife and one young helper. Supported entirely by donations, it has 40 beds and is equipped to provide oral and parenteral opioid therapy, intravenous fluids, oxygen therapy, pulse oximetry, EKG, and other services. The hospice turns no one away and provides all care free of charge. Virtually every day, people with advanced chronic illnesses, and too poor to obtain care elsewhere, arrive at the hospice, some brought there by family members, some arriving on their own. Although located at a Hindu temple, patients of any faith are welcomed.
On the day of my first visit, Mr. Padma took me to see a man he had found on the doorstep that morning. He was young, perhaps in his thirties, and had end stage renal disease, no access to renal dialysis, and was already cachectic, obtunded and short-of-breath. The hospice provided a bed, food, oxygen, morphine as needed, and accompaniment on the final leg of his journey. In the afternoon, singing, chanting, and banging of cymbals arose just outside the hospice on the terraces and gradually grew to a din over which I could barely hear Mr. Padma. I commented that this noise must be disturbing for the patients. He replied that, on the contrary, the music and the close proximity to the sacred river with its cremation sites is quite comforting for many Hindus.
When the hospice has many patients, the work-load must be overwhelming for Mr. Padma and his wife. They have no vacations, no days off, and funnel any donated income into the hospice. Why would anyone take on such a responsibility? Dr. Bishnu translated Mr. Padma’s answer: He and his wife did not choose this work. They were not only called, but claimed, by the distress of the indigent dying. While the voices of the most lowly and vulnerable usually are made inaudible by the cacophony of everyday life, here they were, for Mr. and Mrs. Padma, the highest calling. There was no choice for them to make. And they feel grateful for their vocation.
Eric Krakauer, MD, PhD, is Assistant Professor of Medicine and of Global Health and Social Medicine at Harvard Medical School, and palliative medicine specialist and co-chair the clinical ethics committee at Massachusetts General Hospital, Boston, USA.
Dr. Krakauer is a Member of the IAHPC Board. His bio may be found here.
By Professor Fraser Black (Canada)
The International Cancer Control Congress (ICCC) was established in 2005 and since that time aims to help establish national cancer control programs (including palliative care) in countries around the world. The 5th International Cancer Care Collaboration congress will be held in Lima, Peru this coming November 3rd - 6th, 2013.
The first ICCC Congress was held in Vancouver in 2005 and arose from the work undertaken in Canada to establish a national cancer control program (1996 - 2006 as the Canadian Strategy for Cancer Control, and from 2007- 2017 as the federally funded Canadian Partnership Against Cancer). In the absence of clear precedents for national cancer control programs, other than a few established high resource nations, the Congress was intended to bring together the "partners" whose engagement is necessary to understand, create and implement enhanced population-based cancer control activities which include palliative care.
ICCC-1 established the interest in cancer control and the expressed need to engage low, middle and high resource nations from the different regions of the world in these discussions. ICCC-2 (2007) was held in Rio de Janeiro, hosted by INCA (National Cancer Institute of Brazil), and fostered the development of a Latin American-Caribbean Alliance for Cancer Control and the continued planning of population-based control strategies by 14 countries within the Central and South American region. ICCC-3 (2009) was hosted by the Istituto Tumori in Cernobbio, Italy and assisted with the enhancement of national cancer control planning within the European Union. ICCC-4 (South Korea) was completed in November 2011 and the palliative care activities were led by Dr. Cynthia Goh, current chairperson of the Asia-Pacific Hospice and Palliative Care Network (APHN) and co-chair of the Worldwide Palliative Care Alliance (WPCA).
The visions of all of the congresses have been to create a forum to share knowledge, experiences, strategies, approaches, tactics and best practices that can enhance and accelerate the implementation of effective population-based national cancer control strategies and the evaluation of cancer control initiatives including palliative care.
The Congress in Lima, Peru is expected to attract more than 500 leaders and decision-makers from global and Latin American-Caribbean public health, clinical care and health research constituencies committed to defining, determining and implementing organized strategies to enhance population-based cancer control including palliative care.
Government and non-government cancer control practitioners, professionals, patients/advocates, researchers and volunteers will participate in order to learn and share experiences, tactics and best practices from diverse global jurisdictions. This global forum of health care experts, professionals and health system leaders will be sharing knowledge, experiences, strategies, approaches, tactics and best practices in clinical, hospital and community settings that can enhance and accelerate the implementation of effective population based national cancer control strategies including palliative care.
The congress in Peru will draw a number of palliative care leaders and presenters from the area and around the world including Dr. Claudia Naylor (INCA Brazil) and Dr. Gillian Fyles (TwoWorlds www.twoworldscancer.ca – INCTR Canada). For more information about the International Cancer Care Collaboration visit www.icccassociation.com and to hear more about the congress in Peru visit www.iccc5.com
Dr. Fraser Black, MD, CCFP, FCFP, is Associate Director of the Palliative Access Program (PAX) of the International Network for Cancer Treatment and Research (INCTR), Brussels, Belgium.
Dr. Black is a Member of the IAHPC Board. His bio may be found here.