1 Warren JR, Marshall B.
Unidentified curved bacilli on gastric ways of contributing the skills
epithelium in active chronic gastritis. Lancet 1983; i: 1273-75.
2 Dent JC, McNulty CAM, Uff JC, et al. Spiral organisms in the gastric
antrum. Lancet 1987; ii: 96.
3 Fox JG, Lee A. Gastric campylobacter-like organisms: their role in
gastric disease of laboratory animals. Lab Anim Sci 1989; 39: 543-53.
4 Lee A, ORourke J. Gastric bacteria other than Helicobacter pylori.
Gastroenterol Clin N Am 1993; 22: 21-42.
Mother Teresas care for the dying
SIR-I share Foxs distress over the lack of adequate
analgesics for patients with advanced cancer in Calcutta
(Sept 17, p 807). However, the problem is a much wider
one, and concerns the availability of morphine in India. The
government of India does not have a national policy on the
availability and distribution of morphine. Each state has its
own regulations, which are constricted by fears of addiction
and abuse. Consequently, prescription of morphine for
cancer pain is confined to large hospitals. Half a million
people in India are estimated to suffer with unrelieved
cancer pain. Doctors, nurses, and relatives caring for dying
patients in the community are thus deprived of a cheap, safe
analgesic to help patients in need. The difficulties are
compounded by the enormous social problems in India.
Only 5% of the total resources for cancer control world wide
are spent in less developed countries.
The suffering and isolation of these patients present us
with clinical, educational, and moral challenges.The World
Health Organization has produced clear guidelines on the
appropriate use of morphine.3 These guidelines dispel the
myths about the risks of addiction or abuse when morphine
is used for pain control. Unfortunately, these guidelines have
not been widely adopted. Doctors and nurses who wish to
deliver appropriate care are not to blame. Rather, the
complex bureaucracy is at fault. Educational initiatives,
based on multidisciplinary skills and perspectives, should
enable medical colleagues and government policy makers in
India to increase the availability of morphine.
David Jeffrey
Abbey Manor Farm, Evesham, Worcs WR11 4TA, UK
1 Stjernsward J. Palliative medicine: a global perspective. In: Doyle D,
Hanks G, MacDonald N, eds. Oxford textbook of palliative medicine.
Oxford: Oxford University Press, 1993: 803.
2 Jeffrey D. Palliative care in India: an educational challenge. Proc R Coll
Phys Ed 1994; 24: 462-65.
3 World Health Organization. Cancer pain relief and palliative care.
Geneva: WHO, 1990.
SiR-Fox believes that "Mother Teresas approach [is]
clearly separate from the hospice movement". I disagree.
Hospice care is characterised by a holistic approach to the
dying with attention to their physical, psychological, social,
and spiritual care. Despite few financial resources the
Missionaries of Charity have since the 1950s provided care
for thousands at their Home for the Dying in Calcutta. The
Sisters pick up the dying from the streets, and bring them to
a building given to Mother Teresa for the purpose, there, as
she puts it, to die within sight of a loving face.
It is vital to acknowledge the huge contribution Mother
Teresa has made to the care of two neglected groups-the
dying and the destitute. At the same time it is important to
apply the systematic approach to pain relief which Dame
Cicely Saunders has pioneered. With these two
complementary approaches in mind, British Aid for Hospice
Abroad was set up in 1993 with the aim of raising awareness
about hospice projects in the developing world and finding
1098
of British palliative-care
professionals appropriately.
We welcome news of any palliative-care programme
overseas to which we can contribute. We realise that contact
with the developing world is a two-way process: we in
western countries have financial resources and finely honed
symptom-control skills; our counterparts have much to teach
us about the real value of family and community, the reality
of a living spirituality of care, and the ability to provide
loving care in seemingly impossible circumstances.
Joseph ONeill
Trent Palliative Care Centre, Sykes House, Sheffield S11 9NE, UK
SIR-Although I accept that the hospice movement that Fox
knows from the UK was not evident in Mother Teresas
home, I believe she is using the word Hospice in its true
definition-ie, "a place of rest for the weary traveller". Fox
criticises Mother Teresas Order for not providing medical
assessment and care for which they are not trained. In
Indian hospitals there are countless cancer patients who
require strong analgesia and do not receive it. I have been
working in conjunction with the World Health Organization
.
in India for the past five years. Even in 1994 most cancer
patients who I saw did not have access to any analgesia,
because of lack of suitable drugs, of knowledge about the use
of the drugs by the doctors as well as in some instances no
understanding about pain management, and compounded
by a lack of resources. Mother Teresa is to be commended
for at least providing loving kindness. If Fox were to visit the
major institutions that are run by the medical profession in
India he may only rarely see cleanliness, the tending of
wounds and sores, or loving kindness. In addition, analgesia
might not be available.
There are three main difficulties with respect to pain
control in India: lack of education of doctors and nurses, few
drugs, and very strict state government legislation, which
prohibits the use of strong analgesics even to patients dying
of cancer. Most patients I have seen are diagnosed too late
to be cured and are dying in agony in hospital. At the other
end of the spectrum some patients are inappropriately over-
medicalised ; I have seen terminally ill cancer patients dying
on ventilators, without their family, without attention to
total pain, and not even receiving loving kindness.
I set up a registered charity in 1990, Cancer Relief India.
It has two main aims-education of doctors and nurses in
palliative care (including pain relief), and provision of pain-
relieving drugs and clinics for patients. We need to
remember that the philosophy of palliative care includes
partnership, team work, and learning from each other. The
traditional western-style hospice is not relevant in India.
The situation in India is so different from that in western
countries that it requires sensitive, practical, and dynamic
approaches to pain care that are relevant to the Indian
perspective.
Gilly Burn
2 Fairoak Mews, Fairoak Road, Cardiff CF2 4PL, UK
1 Burn GL. A personal initiative to improve palliative care in India.
Pall Med 1990; 4: 4.
2 Stjernsward J. Palliative medicine: a global perspective. In: Oxford
textbook of palliative medicine. Oxford: Oxford University Press,
1993.
CORRECTION
Cladnbine treatment of multiple sclerosis:-In this letter by Grieb and
colleagues (Aug 20, p 538), patients were evaluated at 7 (not 30) months
after initiation of treatment.