No Relief

IN INDIA, A QUEST TO EASE THE PAIN OF THE DYING

TRIVANDRUM, India -- It was a neighbor screaming in pain 35 years ago
that set Dr. M. R. Rajagopal on the path to his nickname: India's
"father of palliative care."

"He was dying of cancer, with lots of tumors on his face and scalp,"
Dr. Rajagopal recalled. "His family asked if I could help, and I
couldn't -- I was just a medical student."

Today, the same neighbor with the same cancer would almost certainly
die the same way -- unless he lived in tiny Kerala State, where Dr.
Rajagopal runs his Pallium India clinic here in the capital. Although
opium was one of the chief exports of British India and the country
still produces more for the legal morphine industry than any other
country, few Indians benefit. They end up like millions of the
world's poor -- spending their last days writhing in agony, wishing
death would hurry.

About 1.6 million Indians endure cancer pain each year. Because of
tobacco and betel nut chewing, India leads the world in mouth and
head tumors, and has high rates of lung, breast and cervical cancer.
Tens of thousands also die in pain from AIDS, burns or accidents.

But only a tiny fraction -- Dr. Rajagopal estimates 0.4 percent -- get relief.

Clinics dispensing morphine are so scarce that some patients live 500
miles from the nearest. Calcutta, a city of 14 million, has only one.

"For a poor person here, that means just forget it," said Dr. Mhoira
Leng, a palliative care expert from Scotland. "It goes from dire to dreadful."

The exception is Kerala, where Dr. Rajagopal practices and about 80
percent of India's palliative care is delivered. A small slice of the
southwest coast, it is sort of India's Massachusetts: it has a mere 3
percent of the population, but high literacy rates, responsive local
leadership and a bent for bucking central government.

The state government allows any doctor with six weeks of training --
which Dr. Rajagopal provides -- to prescribe morphine.

Elsewhere, the state laws enforcing the Narcotic Drugs and
Psychotropic Substances Act, passed in 1985 to curb drug trafficking,
are complex and harsh. The book outlining them is 1,642 pages, and
even minor infractions can mean 10-year sentences. Legal morphine use
in India plummeted 97 percent after 1985, reaching a low of 40 pounds
in 1997. It has since crept up.

"India is a regulatory morass," said David E. Joranson, director of
the Pain & Policy Studies Group at the University of Wisconsin
medical school. "It is controlled by the Ministry of Finance, and the
rules are based on excise regulations that go back to the British Raj."

Each shipment requires five licenses. Pills must be locked in two-key
cabinets. When patients die, families must return unused pills --
sometimes a struggle in a country where the dead may be cremated with
their medicines.

Many pharmacists just cannot be bothered.

"It's a vicious circle," Dr. Rajagopal said. "If a doctor does get
interested, he runs into all these objections. And he eventually
loses interest."

And raising that interest is a struggle, because most were taught
notions long faded in the West -- that morphine inevitably addicts and kills.

Dr. Rajagopal lectures constantly at small hospitals. Morphine can be
tapered off, he teaches. And with pills, rather than injections,
accidental overdoses are almost impossible.

Dr. Rajagopal's manner is soothing -- he sits on beds, holds hands
and even strokes patients as he questions them. "For a senior doctor
in India, that's just unheard of," Dr. Leng said. "They usually keep
a formal distance."

Talking unravels fears. Chandraprabha, 40, who like many people here
uses only one name, avoided her hourly pills because she could not
bear to look at a clock -- it reminded her she was dying and her
children would go to a stepmother she detested.

Abdulaziz, 62, said that what upset him more than death was that he
felt too unclean to pray.

"My body is not pure," Abdulaziz mourned. "Also, because of the
bandage, it's difficult to bathe."

He had sung the call to prayer at his mosque for 20 years, but had to
stop in January when mouth cancer left him able only to mutter. Then
the aggressive tumor ate through his face, making a beefy crater as
if a firecracker tucked in his cheek had gone off. Then, worse: a fly
got under his bandage, and maggots began emerging, leading his imam
to "excuse" him from attendance.

That was something Dr. Rajagopal's team could help with -- cleaning
out the ghastly invaders. And the six morphine pills Abdulaziz takes
daily have taken away what he called "a catching pain, like a
fishhook in my face."

As the cancer advances, Abdulaziz will presumably need more -- some
patients take 15 times his dose without even getting drowsy.

As the cancer crushes his trachea and esophagus, the palliative care
team will give him, unless he refuses, a nasal tube to his stomach
for a rice and pill slurry. Then, if he wishes, a tracheotomy tube.
As his lymph glands swell, cutting off arteries to his brain, the
team may offer steroids. And finally, as he slips away, more morphine
to fight the panic of breathlessness.

Treating pain alone is not enough, Dr. Rajagopal explains.

As a young anesthesiologist, he helped a professor with a cheek tumor
by injecting alcohol to kill the nerve. It worked -- but the
professor hanged himself two nights later.

"I learned from his cousin that the fact that I had treated him for
his pain alone was what told him his condition was incurable," Dr.
Rajagopal said, still feeling guilty about it. "None of us had ever
asked him what he knew about his disease, or how he felt. If only we
had, maybe his children could have had their father for a couple of
years more."

Dr. Rajagopal has a mordant wit. He describes first-level Indian
medical education as "a license to kill," and when an interviewer
mentioned having had four hernia operations, he mused
sympathetically, "It's addictive, isn't it?"

But as he describes his struggle over morphine, only frustration registers.

"Since the 1980s, the government has paid lip service to palliative
care," he said. "But things change slowly here."

The 80-year-old Government Opium and Alkaloid Works in Neemuch smells
better than it looks. The turfy-chocolaty nosegay of raw opium wafts
from hundreds of milk cans. The sides of the bubbling steam dryer are
caked with it.

"If you breathe enough, as you are not used to it, you'll become
sleepy," said V. K. Harit, the plant's chief scientific officer,
while leading a tour.

The stone floors of the packaging room are slippery with brown ooze
as workers chop up huge blocks resembling mocha fudge, wrap them in
newspaper and stuff them into boxes -- in this case bound for the
Mallinckrodt Co. in St. Louis, which makes morphine.

Although many countries grow the poppies, Indian officials seem
deeply ambivalent about theirs.

Farmers in Australia and France for example, harvest dried pods by
machine. It's faster, but "straw extract" has fewer alkaloids than
opium bled by hand out of lanced bulbs.

Permission to visit the Neemuch plant -- its elder brother in
Ghazipur was described in 1889 by a young Rudyard Kipling -- took
many letters, and then, after the tour began, photographs were
banned, as was seeing the room where morphine is refined.

Jagjit Pavadia, the national narcotics commissioner, whose office is
decorated with a spray of dried poppies, defended the business,
saying she would make more morphine if only doctors would request it.

"We're growing poppy -- why would we not want to use it?" she asked.

In Neemuch, a midlevel plant official groused privately that he
thought India had been "stuck with the world's dirty work" -- growing
opium mostly for foreign producers.

About 62,000 farmers have opium licenses, which are powerful status
symbols. The government pays cash, "so if you have one, you can get a
bank loan easily," said Ramchandra Nagda, 66, a grower. "Or if you
want to get married, no one in the bride's family will question your worth."

And harvesting by hand employs poor peasants, who vote.

Nonetheless, the government is cutting back; it once had 150,000 licensees.

Although cancer is growing as a global killer, morphine demand has
grown little. In rich countries, morphine faces competition from
heavily marketed rivals like fentanyl patches. In poor countries, no
one lobbies for it.

Cipla, the largest pharmaceutical company in India, makes tablets
from government morphine to sell at 1.7 cents each or provide free at
its own hospice.

At those prices, said Yusuf Hamied, Cipla's chairman, and with the
licensing difficulties that narcotics face, "I'm happy to export, but
I'm not going to build a market in other countries."

Fear of diversions to the heroin trade adds to the government's ambivalence.

An opium farmer in Pratapgarh said the black market price was double
the government's, and local crop inspectors could be bribed for as
little as $25.

Mrs. Pavadia disputes estimates that a quarter of the crop is
diverted, but her bureau has seized 1,200 pounds of heroin recently
and raided 64 secret laboratories. .

"The more you grow, the more you have to control to make sure it
doesn't get into the wrong hands," she said.

Dr. Rajagopal argues that such crimes should not tar medical uses. A
clinic he founded in northern Kerala tracked all pills issued to
1,723 patients over two years and found none diverted.

Lobbying is also part of Dr. Rajagopal's mission, but India's chaotic
government complicates that. For example, while the national health
ministry endorses morphine, some of its own officers undermine its use.

Dr. Rajagopal showed a memo from another palliative care doctor
describing a meeting with a high-ranking political appointee in
health, a recent transfer from the department of industry.

The health official had insisted that morphine be dispensed only by
the nation's 28 regional cancer hospitals, even while acknowledging
that some refuse to stock it. None would be issued to independent groups.

That split in his own department was news even to the health
minister, Dr. Anbumani Ramadoss.

In an interview in New Delhi in June, he described his plans to give
more emphasis to pain relief in the national cancer plan then before
Parliament.

Then he was handed the memo. He read it over and smiled.

"It's good you gave me this," he said. "It may change the national strategy."

Told of this by e-mail message that evening, Dr. Rajagopal said he
was "dancing about" with happiness.

Last month, Dr. Ramadoss was reported to have intervened in
Parliament to increase the national cancer plan's budget for palliative care.

"Soon," Dr. Rajagopal said, "we may hear some good news after all."