"Hippocratic: 18 Experiments in Gently Shaking the World" is a documentary movie that chronicles the journey of Dr M. R. Rajagopal, founder chairman of Pallium India and his initiation into the field of Palliative Care. A film synopsis and review by Dr. Shital Raval.
Released in 2017, the movie is based on 18 experiments or quotes by Mahatma Gandhi who happens to be his inspiration and guide. Founder chairman of Pallium India, Padma Shri award winner and lovingly called the “father of palliative care in India”, Dr Rajagopal has single handedly brought the spotlight to the scarcely discussed & practiced field of palliative care.
So what is Palliative care? According to WHO, “Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”
Sadly, Medical school and practice do not teach us much about palliation or how to help a dying person says Dr Rajagopal. Painkillers are taught in pharmacology but it’s vastly a dead subject. Approximately 250 million people live below the poverty line in India, with one doctor for every 1700 people. Doctors tend to needlessly write prescriptions for expensive medicines, even though cheaper generic versions are available.
Most doctors don’t understand that a prescription can deprive a family of their next meal. Such families who are under the poverty line often contemplate suicide under financial duress. One such case was that of a 60 year old vegetable vendor. She came to Dr Rajagopal with back pain, possibly due to a prolapsed disc. When further probed, it was found that she was the sole provider and care giver for her 85 year old father, 3 mentally challenged brothers and a deaf & mute nephew. She was started on epidural injections and painkillers for immediate relief. Any other doctor would have asked for diagnostic tests such as a MRI scan which is not a financially possible option for her. After inspecting her home, she was also provided with a sofa, free medications and foot care for her nephew. She recalls how her mother had contemplated mass suicide for all of them but one of the brothers had refused to comply.
Dr Rajagopal reminds us about what a Hippocratic Oath is and how it should be reviewed so that a person is treated as a whole and not just as a disease. Health care should be focused on building lives! Dr Rajagopal had his own revelation at the age of 39 when he was working as an Anesthetist. One day he had a 42 year old cancer patient who came in for a nerve block for his pain. After a successful block, he was told that he was rid of his pain and did not need to come back. The patient misunderstood that there was no more hope or treatment for him and committed suicide the following day. This came as a great shock and realization that the emotional and psychological state of every patient must be assessed.
After attending a talk on Palliative care, Dr Rajagopal went on to attend a workshop in Oxford University with Dr Twycross and started the Pain & Palliative Care Society in Calicut, Kerala. By 1995, this society had over 60 centers in Kerala with WHO recognizing it as a model project which fitted best with the sociocultural background of the Indian people. However, the shortage in morphine supplies due to the Narcotic Drugs and Psychotropic Substances Act (NDPS) of 1985 hampered pain management efforts. To increase morphine access for all patients, Dr Rajagopal revised the stringent Act and advocated for an amendment that was passed in 2014 by the Parliament of India.
In 2003, Pallium India, a charitable trust was started with the aim to spread the access of palliative care throughout India. It now spans across 15 states, providing free of cost palliative care for 82% of the patients. The Pallium India head office in Kerala houses an OPD, training center, pharmacy and a halfway home for paralyzed patients amongst other facilities. Care and treatment is provided for all patients who need it. Type of disease or proximity to death is not a criteria for patient enrollment!
The film reverts back to the Hippocratic oath which reiterates that medicine should be practiced with warmth, understanding and empathy. Only by practicing it, do we bring the oath alive. Because as Dr Rajagopal puts it, “when I become a patient, I would want the same of my physician”.
Although, it starts off as a promotional film, it does come around to brilliantly encapsulate the poverty burden and dire need of palliation in India. Keeping aside the negative scrutiny of the existing practices of the medical fraternity, it does present the various challenges faced by the medical community. The film could do more by presenting their current clinical, structural and operational practices, so that other organizations, hospitals and clinics can follow, share or adopt the same. Featuring more patient cases that benefitted from palliation & pain management efforts would have been given the audience better insight into their working model system. The focal point of the movie could do with a more distinct narrative on the sole subject of advancement and future of Palliative care in India.
