course change

India moves towards treating disease by targeting not just causes but also symptoms

New programmes are being set up based on evidence that early palliative care improves patients’ survival and quality of life.

Tata Memorial Centre, India’s premiere hospital for cancer treatment, is in the process of setting up five centres for palliative care to treat children with non-cancerous diseases. The programme indicates a significant departure from how palliative care is perceived and provided in India, where it is mostly associated with alleviating pain and symptoms for people who are dying.

“It is incorrect to think that palliative care is end-of-life care,” said Dr Pradnya Talawadekar, project coordinator of children’s palliative care at Tata Memorial Centre. “Children with chronic conditions, like cerebral palsy and mental retardation, may see a significant improvement in the quality of life if they receive palliative care.”

Palliative care is the branch of medicine that deals with relieving pain alleviating symptoms without addressing the cause of a disease. The goal here is to make a person more comfortable and improve his or quality of life.

Many doctors in India are now advocating a shift from providing palliative care when all other treatments for recovery have been exhausted to providing palliative care as soon as a disease is diagnosed.

“The problem is that doctors think that palliative care practitioners are there to pour Ganga jal in the mouth of the patient,” said Dr Vineeta Sharma, head of palliative care department at Bhaktivedanta Hospital in Mira road, referring to the Hindu ritual of giving a dying person water from the Ganga river to ensure his salvation. “Doctors would only refer the patients to me when they would have a few hours to live.”

Pheroza Bilimoria who runs Palcare, a palliative care facility in Mumbai, said that most of her patients are admitted when their disease at already at advanced stages. “Affluent patients try every possible treatment before considering palliative care,” said Bilimoria. “About 49% of patients die within the first two months of enrolling as they are already in a very advanced stage of the disease.”

A patient receiving palliative care at home. (Photo: The Jimmy S Bilimoria Foundation)
A patient receiving palliative care at home. (Photo: The Jimmy S Bilimoria Foundation)

But this is what Tata Memorial Centre has set out to change.

“We want to introduce palliative care early so that patients can receive holistic care,” said Dr Jayita Deodhar, who is currently in charge of the palliative care department at the hospital. “Patients as well as doctors have to understand that palliative care has benefits in non-cancerous conditions such as thalassemia and HIV.”

Early palliative care

Dr Geeta Joshi, chief executive officer of the Community Oncology Institute attached to the Gujarat Cancer Research Institute, remembers treating a 62-year-old man from Ahmedabad with recurring buccal mucosa – lining of the mouth – cancer. “He survived for almost two years on palliative care and was almost pain-free,” she said. “Palliative care helps in symptom control, which helps improve adherence [to therapeutic treatment] and reduces dropout rate which will improve the overall prognosis of the patient.”

Joshi’s observations are backed by plenty of recent research on the benefits of starting palliative treatments. For example, a study published in the New England Journal of Medicine in 2010 showed that integrating palliative care early with standard oncological care in patients with metastatic non–small-cell lung cancer resulted in increased survival by two months and improvements in quality of life and mood.

A team of doctors at Tata Memorial Centre are now looking at the benefits of introducing early palliative care for patients with head and neck cancer.

Early palliative treatment is especially important for cancer patients, pointed out Dr Shrikant Atreya, a palliative care consultant at Tata Memorial Centre in Kolkata. “Chemotherapy leads to side effects which need to be addressed,” he said. “Oncologists have enough on their plate. We need a separate specialty for the management of the pain and psychological impact of the treatments.”

Joshi and her colleagues from the gynaecological department of the Gujarat Cancer Research Institute are devising a project to understand the benefits of early palliative care in women with cervical and ovarian cancers.

A beginning

There are problems with starting palliative treatment early, especially in India. Most cancer patients are diagnosed only when their diseases are in an advanced stage and introducing palliative care early is a challenge. At the same time, there is a rise in the demand for palliative care, said Joshi. She once used to get five patients a day. “Now, I see more than 100 patients a day. But, more people need it and we have to reach them.”

India has a national programme for palliative care which is a state sponsored scheme with funding under the National Health Mission. For example, Gujarat has been sanctioned Rs 35 lakh to develop infrastructure and train staff for palliative care in six districts of the state, Joshi said. Dr Gayatri Palat from MJN Cancer Hospital in Hyderabad said that the Telangana health insurance scheme covers palliative care. “Patients get free medicines and other support related to hospitalisations through the insurance,” she said.

But, implementation is not uniform across the country. In Maharashtra, many trained palliative care staff have left these jobs as they had not been paid for almost eight months. A Maharashtra’s health department official said, “There was no funding and we could not pay them. Now, we are planning to revive the program by training and recruiting new staff.”

Deodhar estimates that less than 1% of patients who need of palliative care actually get it. “There is only one palliative care physician for every one million patients,” said Deodhar.

The biggest challenge comes from within the medical community as doctors fear losing patients, if they refer them to palliative care. Another challenge is acceptance of providing palliative for children. “Palliative care improves quality of life of both the patient and the family,” said Talawadekar. “Teaching parents to dress wounds can help the child physically, mentally and emotionally.”

We welcome your comments at
Sponsored Content BY 

Relying on the power of habits to solve India’s mammoth sanitation problem

Adopting three simple habits can help maximise the benefits of existing sanitation infrastructure.

India’s sanitation problem is well documented – the country was recently declared as having the highest number of people living without basic sanitation facilities. Sanitation encompasses all conditions relating to public health - especially sewage disposal and access to clean drinking water. Due to associated losses in productivity caused by sickness, increased healthcare costs and increased mortality, India recorded a loss of 5.2% of its GDP to poor sanitation in 2015. As tremendous as the economic losses are, the on-ground, human consequences of poor sanitation are grim - about one in 10 deaths, according to the World Bank.

Poor sanitation contributes to about 10% of the world’s disease burden and is linked to even those diseases that may not present any correlation at first. For example, while lack of nutrition is a direct cause of anaemia, poor sanitation can contribute to the problem by causing intestinal diseases which prevent people from absorbing nutrition from their food. In fact, a study found a correlation between improved sanitation and reduced prevalence of anaemia in 14 Indian states. Diarrhoeal diseases, the most well-known consequence of poor sanitation, are the third largest cause of child mortality in India. They are also linked to undernutrition and stunting in children - 38% of Indian children exhibit stunted growth. Improved sanitation can also help reduce prevalence of neglected tropical diseases (NTDs). Though not a cause of high mortality rate, NTDs impair physical and cognitive development, contribute to mother and child illness and death and affect overall productivity. NTDs caused by parasitic worms - such as hookworms, whipworms etc. - infect millions every year and spread through open defecation. Improving toilet access and access to clean drinking water can significantly boost disease control programmes for diarrhoea, NTDs and other correlated conditions.

Unfortunately, with about 732 million people who have no access to toilets, India currently accounts for more than half of the world population that defecates in the open. India also accounts for the largest rural population living without access to clean water. Only 16% of India’s rural population is currently served by piped water.

However, there is cause for optimism. In the three years of Swachh Bharat Abhiyan, the country’s sanitation coverage has risen from 39% to 65% and eight states and Union Territories have been declared open defecation free. But lasting change cannot be ensured by the proliferation of sanitation infrastructure alone. Ensuring the usage of toilets is as important as building them, more so due to the cultural preference for open defecation in rural India.

According to the World Bank, hygiene promotion is essential to realise the potential of infrastructure investments in sanitation. Behavioural intervention is most successful when it targets few behaviours with the most potential for impact. An area of public health where behavioural training has made an impact is WASH - water, sanitation and hygiene - a key issue of UN Sustainable Development Goal 6. Compliance to WASH practices has the potential to reduce illness and death, poverty and improve overall socio-economic development. The UN has even marked observance days for each - World Water Day for water (22 March), World Toilet Day for sanitation (19 November) and Global Handwashing Day for hygiene (15 October).

At its simplest, the benefits of WASH can be availed through three simple habits that safeguard against disease - washing hands before eating, drinking clean water and using a clean toilet. Handwashing and use of toilets are some of the most important behavioural interventions that keep diarrhoeal diseases from spreading, while clean drinking water is essential to prevent water-borne diseases and adverse health effects of toxic contaminants. In India, Hindustan Unilever Limited launched the Swachh Aadat Swachh Bharat initiative, a WASH behaviour change programme, to complement the Swachh Bharat Abhiyan. Through its on-ground behaviour change model, SASB seeks to promote the three basic WASH habits to create long-lasting personal hygiene compliance among the populations it serves.

This touching film made as a part of SASB’s awareness campaign shows how lack of knowledge of basic hygiene practices means children miss out on developmental milestones due to preventable diseases.


SASB created the Swachhata curriculum, a textbook to encourage adoption of personal hygiene among school going children. It makes use of conceptual learning to teach primary school students about cleanliness, germs and clean habits in an engaging manner. Swachh Basti is an extensive urban outreach programme for sensitising urban slum residents about WASH habits through demos, skits and etc. in partnership with key local stakeholders such as doctors, anganwadi workers and support groups. In Ghatkopar, Mumbai, HUL built the first-of-its-kind Suvidha Centre - an urban water, hygiene and sanitation community centre. It provides toilets, handwashing and shower facilities, safe drinking water and state-of-the-art laundry operations at an affordable cost to about 1,500 residents of the area.

HUL’s factory workers also act as Swachhata Doots, or messengers of change who teach the three habits of WASH in their own villages. This mobile-led rural behaviour change communication model also provides a volunteering opportunity to those who are busy but wish to make a difference. A toolkit especially designed for this purpose helps volunteers approach, explain and teach people in their immediate vicinity - their drivers, cooks, domestic helps etc. - about the three simple habits for better hygiene. This helps cast the net of awareness wider as regular interaction is conducive to habit formation. To learn more about their volunteering programme, click here. To learn more about the Swachh Aadat Swachh Bharat initiative, click here.

This article was produced by the Scroll marketing team on behalf of Hindustan Unilever and not by the Scroll editorial team.