This month’s Grants in Action reports describe a pair of projects at their halfway point. The first is a year-long program in India; the second is a two-part Traveling Scholarship to Haiti. Information on applying for — or donating to — the IAHPC grants & fellowships program appears at the end of this section.
In May 2017, Dr. M.R. Rajagopal, the Chairman of Pallium India, embarked on a year-long project to embed tenets of an amended Narcotic Drugs and Psychotropic Substances Act within India’s 29 States and 7 Union Territories. The IAHPC supplied a Program Support Grant of $7,500 to help implement the project. This is Dr. Rajagopal’s interim report.
India is a leading producer of opium, but patients have had virtually no access to opioids or morphine since 1985, when the Narcotic Drugs and Psychotropic Substances (NDPS) Act was passed. Its controls were so strict that government statistics show medicinal use tumbled by 97% after the Act came into force.
After 19 years of advocacy both in India and abroad, an amendment to the Act that allows ‘essential narcotic drugs’ for medicinal use was passed by Parliament in 2014. The State Rules by which local legislation was to be governed followed in May 2015. But medicinal morphine will continue to elude patients until each of India’s 36 States and Union Territories implement the new rules. Most have yet to do so.
One large impediment, says Dr. M.R. Rajagopal, is the fact that ‘when we visit the concerned state officials, most are not even aware that the state government no longer has any legal right to legislate’ on essential narcotic drugs for medicinal use.
With momentum thus stalled, Rajagopal and colleagues designed a four-point program to help induce local legislation:
He successfully applied to the IAHPC for a grant to embark on the program. ‘The aims of the project are to break barriers and ensure that the NDPS amendment Act is implemented by state governments,’ write Rajagopal in his IAHPC proposal. ‘It is hoped that the widening of scope’ that the amended Act initiates, he says, ‘will pave the way for more research on the beneficial use of narcotics, which, up until now, remained out of bounds for the medical and scientific community due to the overtly prohibitive nature of the law.’
At the halfway mark of the program, Rajagopal and his team have achieved the following:
Experiences on the ground have added two new strategies to the last half of the project: gather written proof of the amended Act, and submit a written application to the Principal Secretary of each State and Territory for implementation of the amended NDPS Act.
More than unlocking the potential for significant patient pain relief, the amended Act authorizes the government to recognize and approve addiction treatment centers, which currently operate without license or accreditation, and ‘inflict violence and torture on drug users,’ says Rajagopal.
But his primary concern is alleviating patient suffering, which he knows is far too pervasive.
‘The road ahead is not smooth and the task is not easy,’ says Rajagopal. ‘Working with governments and persistently knocking on many doors is not the most enjoyable of tasks, but there is no other way. It is simply not acceptable to see all that suffering and do nothing.’
September 1985 The Narcotic Drugs and Psychotropic Substances Act is passed by Parliament. It issues stringent provisions for the control and regulation of operations relating to narcotic drugs and psychotropic substances, including cannabis, all coca derivatives, opium derivatives, and poppy straw concentrate.
It initiates extremely complicated licensing processes that vary from state to state. Typically, a hospital needs 4 to 5 different licenses, all of which must be valid at the same time. Furthermore, multiple government departments must concur for each license to be issued.
The Act also levies stiff penalties for violation of the law, essentially meaning that even clerical errors could lead to imprisonment. A first offence is punishable by 10 to 20 years in prison, plus fines.
March 2014: After 19 years of advocacy, the Indian Parliament passes an amendment that creates a new category — essential narcotic drugs — and gives itself the power to legislate the drugs for medical use, ensuring uniformity throughout the states and territories.
‘Importantly,’ writes Rajagopal, ‘medical use has been specified and could include a variety of medical conditions besides drug dependence and pain relief.’
The Rules and procedures applicable to all states and union territories are passed by the central government. Now, only one official (the drugs controller of the state) is required to approve the use of essential drugs by recognized medical institutions. The institutions have simplified procedures to procure opioids, and provide proper documentation and monitoring to prevent diversion for non-medical use.
On December 19, Michael Gosey, MD, of Johnson City, Tennessee, USA, embarked on a four-day trip to Saint-Marc, Haiti. A $1,720 Traveling Scholarship grant is funding two trips; this is his interim report. ‘IAHPC made my journey easy,’ he said. ‘My accommodations were comfortable, the transportation convenient, and I had a wonderful, caring host.’
In some ways, Dr. Michael Gosey felt completely prepared for his mission to help further palliative care in Haiti. He knew that it is the Western Hemisphere’s poorest country, that palliative care is woefully sparse, and had learned about conditions on the ground from his daughter, who spent a summer volunteering at an orphanage there while in university. He followed Haiti’s progress while supporting the orphanage throughout the intervening years.
In other ways, Gosey was totally unprepared.
For instance, he quickly realized that he should have brushed up on basic Creole before coming — his three years of high school French were useful, but inadequate. The doctors he met were fairly fluent in English, and residents had a smattering, but ‘a lot of hospice care has to do with nurses,’ he said, ‘who didn’t speak English.’ Lectures were translated on the spot, but Gosey suspects that a lack of a single communication since — despite offering to provide clinical consultation by email or Skype — may be due to a language barrier.
He revamped PowerPoint presentations on the fly when he discovered that Haiti has access to only 10 or 12 of the 50 medicines that US hospice and palliative care workers rely upon. ‘I wanted to make sure I drove home what would help them in their next step... They don’t have hydromorphone, but do have fentanyl and morphine, so I hit those hard.’
Then there’s the matter of Gosey’s to-do list. ‘As Westerners, we’re so task-driven,’ he said. ‘We want to get things done. I only accomplished two of the 10 things on my list.’
Dr. Gosey’s goals were to help develop palliative care models, train health care providers, begin the process of establishing hospice care, and enact an ongoing Telemedicine link. Gosey felt certain that six years of bedside experience in end-of-life care could be put to good use in a country with such tremendous need. His three full days, crammed with lectures, was an incredibly educational journey; unexpectedly, he often felt like the student.
‘I learned a lot about the hospital formulary and how important it is to work with the government or hospital to negotiate for other medicines, or forms of medications,’ said Gosey, noting that while Haiti has access to morphine, it isn’t available in liquid form.
Another important lesson? ‘I went with my own plan, but I learned that to be effective and have a long-term impact, local people have to come up with the plan. Then I need to see how I can fit in.’
Gosey was surprised and honored to learn that an annual spring palliative care seminar at the local Hôpital Universitaire de Mirebalais was shifted to overlap his lectures, allowing him to meet the region’s two doctors with palliative care training: Gueilledana Paul and Ornella Sainterant. Sainterant’s mentor is IAHPC board member Dr. Eric Krakauer, who specializes in delivering palliative care to low-income countries. Gosey hopes to connect with Krakauer to ‘learn the ins and outs of how to get things done’ in creating sustainable, scalable palliative care that delivers optimal outcomes.
‘I learned a lot,’ Gosey mused, ‘and it wasn’t answers to the questions I had, but to questions I hadn’t even thought of. I laid the groundwork, found out where I need to be, and learned to back off and ask them to be involved in moving forward.’
Despite feeling a bit deflated on his return, he is learning to celebrate any and all successes, no matter how seemingly small. He is already gearing up for a second trip, in March. His original strategy was a five-year commitment to Haiti, propelled by working trips four times a year. The man’s tactics may have changed, but his commitment hasn’t.
And Creole lessons? Yo te kòmanse!*
* They have begun!
To find out more about IAHPC’s Program Support Grants, and our Traveling Scholarships and Traveling Fellowships, please visit our website. Through these programs we support projects and individuals around the world, especially in developing countries in Africa, Eastern Europe, Asia, and Latin America.
You can contribute to this program and help palliative care workers attend and participate in congresses and courses by donating to the Traveling Scholarships Campaign in the Global Giving website.