The article was published in the British Pain Society’s Spring 2013 Newsletter
The years leading up to and immediately following India’s Independence were decidedly tumultuous. A remarkable man, however, was going about his work with serenity. His pioneering work was to benefit millions around the world in years to come, and inspire many generations of clinicians. His cherished goal was to rehabilitate and restore self-respect among people living in what he called the ‘land of painlessness.’ India was then home to millions of leprosy sufferers and thousands of leper colonies. The problem with leprosy was painlessness, which left patients unprotected from injuries, often with disastrous consequences. His Pain: The Gift Nobody Wants (1993) was an account which was in equal parts fascinating and powerful, and a treasure trove in its entirety. His revolutionary idea was that leprosy attacked the sensory nervous system resulting in patients losing warnings of pain. The resultant tissue abuse and loss of body parts, therefore, was not because of inherent decay brought about by the disease, but entirely due to infection and thereby preventable. The man with the radical idea was Dr. Paul Brand. Born to English missionary parents in 1914 at the remote Kolli Hills – the ancient kingdom of the much celebrated philanthropist King Valvil Ori in Southern India – Brand was sent to England for further studies. On his return, following medical training, he joined Christian Medical College & Hospital in Vellore, India, to herald a new chapter in the science of rehabilitation.
As is Brand’s story, so is pain medicine: rarely taught in our medical schools. There is, however, much inspiration to be drawn from the former to address the latter. But, ours is a nation of idiosyncrasies. While Brand’s groundbreaking rehabilitation methods were creating ripples across the world, we were busy legislating against leprosy patients from contesting elections (repealed as recently as 2012), obtaining driving licenses, or travelling in trains. Similarly, pain clinics figure prominently in the assessment form for accreditation of post-graduate courses by the Medical Council of India (equivalent of GMC), but pain management is not part of the curriculum in either under-graduate or post-graduate courses. A damning Human Rights Watch report in 2009 said, ‘Official curricula for undergraduate and postgraduate medical studies do not provide for any specific education on palliative care and pain management. As a result, the vast majority of medical doctors in India are unfamiliar with even the most basic tenets of palliative care or pain management.’ Since then there have been certain cosmetic changes, but nothing to stop one wondering – particularly when in a nihilistic mood – whether we are a nation of flower and fresh air lovers without the sense of smell, á la Wordsworth.
With initiative from the top not forthcoming, the choice of training opportunities in pain medicine in India is limited to private enterprises and a handful of government-run hospitals. Typically run as 2 to 4 week programme of observership, the private enterprises tout injections/interventions with alacrity, at the expense of multi-disciplinary pain management. Like Kipling who wrote Mandalay, without ever setting foot in the Burmese city, the observers too (without any hands-on training & with their wallets much lighter) go away to set up pain practices. The entrepreneurial ones, who have within them the pomposity of Kipling, thrive well. The majority, however, fall along the wayside, never to practice pain medicine again. This provokes a strange situation in professional meetings where psycho-social aspects of pain often draw the short straw, while the finer points between hydro-discectomy and ozone-discectomy for low back pain are discussed in detail. Eerily similar to Kipling’s offer to women in Mandalay, ‘I will teach her not to defile her pretty mouth with chopped tobacco in a cabbage leaf, but to inhale good cigarettes of Egypt’s best brand.’
The concept of Traveling Pain School was born out of a compelling need to educate health care professionals on the basic science and clinical aspects of pain management; to create awareness of the benefits of effective multi-disciplinary management of pain; and to increase the number of health professionals in our state with special interest in the science and treatment of pain. Andhra Pradesh, our state, is perched proudly atop the Deccan plateau, and is home to 85 million people. Hyderabad, the capital, is a melting pot of cultures. The Indian Society for Study of Pain (equivalent of British Pain Society), had been quite proactive with its educational programmes in our state. The mandate, when I was elected as its Secretary, was to come up with innovative ideas in pain education and to promote it across the state. There was only a slight hitch – the logistics of reaching out to clinicians (mainly anaesthetists) practising within 106,000 square miles. Distances could be managed, but the anxiety inducing challenge was to find faculty who were willing to share the ordeal. It eventually turned out to be the easy bit. Hands went up, and it seemed as if people knew these things instinctively – a sharp-elbowed levity to nudge me out of my morbid anxiety. IASP’s curriculum for pain education among doctors would suit our purpose very well. We just had to ‘Indianise’ it. We worked on incorporating India-centred anecdotes in the delivery of lectures to drive home the point effectively. Appropriating others idea and tinkering it to suit the local palate has a bit of a history in India. We have done it to the Chinese in the form of Chicken Manchurian (equivalent of Chicken Balti).
With an estimated cost of £1500/programme and with plans to hold a dozen of them, wherein only multi-disciplinary aspects of pain would be emphasised, educational sponsors were hard to come by. A couple of industry sponsors, who placed social responsibility over profit, were agreeable to a restricted grant. It had to be done on a shoestring. We did not expect it to be otherwise. We struggled. We still do. If the financial support towards our objectives is a trickle, the professional support continues to be a deluge. The Indian Society of Anaesthesiologists (equivalent of AAGBI) has endured as our buttress. They have encouraged us to examine what is desirable over exploring what is possible. The selection process of a name for the programme, in comparison, was effortless. Since it involved travelling to the towns and cities in our state to conduct a day long programme in pain management, it would be eponymous – Traveling Pain School.
Frederick Law Olmsted famously recalled in Walks and Talks of an American Farmer in England his chance encounter with a Birkenhead baker which directed him to the enchanting Birkenhead Park, designed by the ever inventive Joseph Paxton. Six years later, in 1857, it served as his inspiration to design the Central Park in New York. As a trainee in pain medicine, I have moved around Merseyside. There were no helpful bakers, only senior colleagues to guide me along. There were no enchanting parks, only exalted places of learning. The Traveling Pain School came exactly six years after my time at Merseyside; but it is no Central Park, not on a shoestring anyway. To create a new concept that is meaningful and purposeful – and that which could reach out widely – requires many things to fall in place. Chief among this is formation of a core group, which could amalgamate with uncompromising wisdom the different forms of knowledge and skills. Olmsted himself could not have worked on his masterpiece without the draughting skills of the British architect Calvert Vaux. The audience would be primarily anaesthetists, for whom interventions could be of interest. We would have to impart learning of the effectiveness of multi-disciplinary treatments, without interventions being too obtrusive. Olmsted’s radical design, which won him the contest to landscape Central Park, was to place the cross streets in trenches, below the line of sight, so that park visitors could pass safely above on bridges. Our curriculum was built similarly, where evidence-based interventions would be taught, without obstructing the bigger picture that is multi-disciplinary management.
‘The secret of all victory lies in the organisation of the non-obvious,’ said the stoic philosopher and Roman emperor Marcus Aurelius. As a team, we have focused on doing the little things right, without being drearily over-systematic. At the outset, each episode of the pain school would be an informal gathering. There would be eight lectures of 45 minutes each, weaving together the different strands of managing persistent pain into a lucid narrative. The motive was never to place commercial profit over societal profit; the registration fee was fixed as £2.50. A multiple choice question test was conducted before the start to assess pre-CME knowledge. To avoid being entrenched in habitual patterns, we actively sought candid appraisal of the programme through standardised feedback forms. We have conducted two schools so far and have met 150 clinicians, with plans for a dozen more over the year. The feedback has been overwhelmingly positive. We have tried to restrain ourselves from the temptation of looking at ‘what would be?’ But, by the end of the project – thousands of hours would be spent by the faculty in preparing the talks; tens of thousands of miles would be travelled to meet potential pain physicians; more than a hundred thousand pages would be given out as printed hand-outs; and more than a thousand clinicians would be addressed. Even if we could inspire a small percentage of them to take up managing pain with confidence, it would be a triumphant homecoming. Put simply, a project this size has never been attempted before in our country.
When we started off, our stated goals were to act as a catalyst for bringing together healthcare professionals; to create a supportive network; and to accomplish regional centres for pain service and research. The pilot programme has provided us with much optimism and heart. We still have a considerable distance to go, but the goals no longer seem distant. At a personal level, it made me realise that the notion of travel is a metaphor for living a life, and without confidence travel is misery.