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On the Frontlines of Community-Based Palliative Care in Kerala

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In February this year, I rode with one of Pallium India’s seven Home Visit teams for a day, and observed as they visited patients and families to administer their unique brand of palliative care. I had accepted an invitation from Dr. M.R. Rajagopal to visit Pallium’s Trivandrum Institute of Palliative Sciences (TIPS) facility in India’s southwestern state of Kerala. “Mukund, you must come and visit us,” he had told me last year, “It will be an eye-opener for you.” It was certainly that, and so much more! Pallium’s Mission Pallium India is a charitable trust; a non-governmental organisation based in the coastal city of Trivandrum, about 100 km from the southern tip of India. It was founded in 2003 by Dr. M.R. Rajagopal and his colleagues, with the objective of alleviating the pain and suffering of millions of people across the state of Kerala (and eventually, all of India) – people dealing with serious, long-term health issues, as well as those suffering from acute illness and nearing the end of their lives. Pallium’s mission statement reads: “To catalyse the development of effective pain relief and quality palliative care services and their integration in health care across India through delivery of services, education, building capacities, policy, research, advocacy and information.” Dr. Rajagopal, widely known as the Father of Palliative Care in India, led Pallium India for the first 20 years.  He initially became involved with the development of palliative-care facilities and providing palliative care and pain relief in the 1980s, when he began to see the need for such services as a practicing anesthesiologist and professor at Calicut Medical College in northern Kerala. He started the first Pain and Palliative Care clinic in Calicut, and in 1993 he was one of the co-founders of the Pain and Palliative Care Society (PPCS).  The World Health Organization recognised PPCS as a model demonstration project for community-based palliative care in 1995. Dr. Rajagopal stepped away from actively running Pallium last year, and assumed the role of Chairman Emeritus so that he could focus on efforts to introduce palliative care across India, and drive the integration of palliative care and pain management into the delivery of medical care for seriously-ill patients. I met Mr. Raj Kalady, now the CEO of Pallium India, during my visit to the TIPS facility. “Everything we do at Pallium is based on what we call the D-E-F model,” he told me. “We demonstrate, educate and facilitate. Our experience has shown this to be the viable approach to promote the growth and spread of palliative care across the country.” TIPS Pallium’s TIPS Centre has been operating since 2007 with three major goals: Operate community-oriented clinical palliative-care services, including the service of local volunteers and home visits. Advocate at national, state and local levels for improved access to pain-relief medication. Conduct educational programmess in Pain and Palliative Medicine for South Asia. I spoke with Mr. Manoj Gopalakrishnan, the Executive Director of TIPS about their services. “We provide both in-patient and out-patient clinical palliative care on site,” he said, “but we go beyond that. We collaborate with half-a-dozen area hospitals. We work with volunteer-led pain and palliative societies in town and in the surrounding districts.”  TIPS operates a focused physical and medical rehabilitation programme on site, with dedicated physicians and physiotherapists.  They run a “Halfway Home” program, which trains wheel-chair-bound patients to navigate and use a simulated wheel-chair accessible home that includes a kitchen, bath and toilet, before being sent home.  TIPS also operates a free Telehealth service enabling people anywhere in India to talk to a palliative-care professional through a video or phone connection. This is a great asset for patients in remote locations and those unable to travel due to physical limitations or financial constraints. This work has received international recognition. TIPS was re-designated by the World Health Organization in 2024 as a WHO Collaborating Centre for training and policy on access to pain relief – a recognition it has maintained since 2007.  As their CEO Mr. Kalady had pointed out, Pallium India demonstrates palliative care delivery at TIPS, educates and trains professionals in palliative care nationally through in-person and virtual classrooms, and facilitates establishment of palliative care services across India, including access to opioids for pain management. Community-centered home visits Thousands of residents in rural and provincial Kerala are elderly, living alone, bed-bound, or have no means of transport to a healthcare facility. ‘Meet them where they are, when they need us’ is the underlying philosophy of the TIPS Home Visits programme, an important service component designed to address the needs of such individuals. Central to the programme is collaboration with trained community volunteers. TIPS has divided the region around Trivandrum into 20 zones, and created a “Link Centre” in each zone to serve as the vital conduit into that area. Each Link Centre is operated by trained volunteers who live in the area, and keep track of individuals and families in their community who need palliative care. These volunteers also assist TIPS by working with, and mobilising local government officials and other agencies to find solutions for the socio-economic needs of patients and families. Volunteers help identify the patients to be treated during each visit, and then coordinate visits by the TIPS team to see these patients either in individual homes or in a local school, library or community centre. Home Visit teams now operate daily, including special evening visits once weekly on Fridays. This schedule ensures that each zone or Link Centre receives a visit at least once a week. A home-visit team typically consists of the driver, a palliative-care physician, a nurse and a social worker. The list of patients to be seen during a visit is developed in collaboration with the Link Centre. A community volunteer meets the TIPS team when they arrive, and assists them through the day’s visits. On the road in Murukkumpuzha I set off with one of Pallium India’s Home Visit teams on a bright and warm Saturday morning to Murukkumpuzha, a provincial area about

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