Clare Roques presents research into pain management in India at two Indian conferences

Arriving in Mumbai, the city I am most familiar with in India, I reflected on how much had changed for me back home in the last year: a new home, a new job, and a husband. The noise, smells and sights of India felt reassuringly familiar. Less than 24 hours later I boarded a flight to Indore, and I was amazed to find that I knew several people on the plane making the same journey to a pain management conference. I even met a dear friend and colleague from the UK who had flown out specially to attend the conference to be presented with a lifetime achievement award.

For the last 3 years I’ve travelled to the national conferences of the Indian Society for the Study of Pain (ISSP) and the Indian Association of Palliative Care (IAPC) collecting interview and questionnaire data from local practitioners.

Now, in 2016, I’m in what I hope are the closing stages of my social science PhD at the University of Glasgow looking at the practice of pain management in India. In February I travelled to India again, this time to Indore and Pune with the satisfying task of presenting some preliminary research findings at the two conferences.

This trip, compared to the others I have made, was so much more relaxing without the pressure of having to collect data. I felt that I could finally start to do justice to the valuable data that so many participants had given to me.

Speaking at ISSPCON Indore

I arrived the next morning at the Brilliant Convention Centre which largely lived up to its ambitious title. Registration was very well organised and I was warmly greeted with many smiling faces and several hugs. I was particularly happy to see one of my fellow social scientists who is also researching pain management. We do not belong to a large tribe, and as on previous visits to the conference I was one of just a handful of European delegates.

Many of the talks at the previous conferences had a strong focus on the use of interventional techniques, as opposed to pharmacological or psychological treatment modalities, and this year was no different. However, the first plenary session had a specific focus on the idea of introducing some national guidelines into this practice.

In medicine, ‘interventional techniques’ essentially is used to mean the use of a treatment which typically involves an invasive process such as an injection to numb a nerve, an epidural injection, or even an operation to insert a pump or electrical device. These are grouped together as a set of treatments, separate from pharmacological or psychological modalities.

There were also some notable talks on work-life balance and on the philosophy and anthropology of the doctor patient relationship. Issues around ethical practice and the influence of pharmaceutical companies were also discussed.

A session dedicated to the effective marketing of one’s practice was quite a novelty to me as someone whose entire working life has been spent in the UK in the cushioned environment of the NHS. The tagline for the conference was ‘Pain Management – from Research to Result’ and there was a lot of dialogue focussing on the need to publish more research from India which, it was said, would start to redress the imbalance currently seen in academic publications, with the vast majority of clinical trials originating from Western countries. Especially when in India, I’m acutely aware of how difficult it is for those clinicians practising in the country to find the time and resources to carry out research that meets the high (as defined by the Western countries) standards required to meet the criteria for publication in reputable journals.

Chakrabarty’s theories

On the third and final day it was my turn to give a presentation, or to ‘exchange knowledge’ as I’m told it must now be called. I was nervous, not about facing a crowded room behind a lectern, but of sharing my research ideas and findings. In fact I think it was received very well.

I had thought twice about including some words describing the work of a post-colonial theorist Chakrabarty. He describes how countries being labelled as ‘developing’ implies they are on a fixed trajectory towards a Western defined standard. In fact, this was one of the aspects of my work that was particularly well received and provoked a lot of discussion. I felt reassured that I was on the right track or at least on one that was interesting to my audience. I was encouraged by many to formally publish the data. I hope that if nothing else my work will stimulate some dialogue about some of the often unspoken complexities of these issues.

I have always been treated to incredible hospitality India but I particularly enjoyed my time in Indore. Each day I savoured a peaceful 20 minutes walking back to my hotel from the conference venue through a pleasant residential area, with children playing and fruit and vegetable sellers pushing their carts along the quiet streets.

Pune, and a presentation at IAPCON 

After a few days back in Mumbai to gather my thoughts and meet my husband, we travelled on to Pune, the city hosting the IAPC conference. This time in a swish international hotel, but India was still there to be seen. The afternoon we arrived, we took a stroll from the hotel to a nearby shopping centre containing familiar retail outlets: MacDonalds, Pizza Hut and even Marks and Spencer.

We passed a homeless family sitting on the pavement and a small child ran up to me tugging at my dress asking for my plastic bottle of water. As many aspects of India become increasingly familiar to me, I am always, and indeed in many respects am reassured to still be horrified by the presentation of such brutal poverty and suffering.

We appeared in an article in the New Indian Express, reproduced here with kind permission of the newspaper, journalist Sruthi Paruthikad and photographer Rajeev Prasad.

The conference had a strong focus on patient care and contact rather than on interventional treatments. A campaign was launched with #LastWords, a very moving film of nurses recounting the last words of patients, ending with a plea to work towards improved palliative care so that in the future patients last words are heard by family and friends rather than healthcare professionals.

There was also a session devoted to the use of interventional techniques in palliative care and it was good to see this collaborative work. There was also a talk on how to introduce palliative care into the private and corporate sectors of healthcare.

There was a notable move towards discussing some of the negative aspects of opioid use – particularly with reference to the highly publicised and politicised debate in the US. Many talked of the need to learn from problems in other countries that have arisen partly from insufficiently regulated prescribing. The use of opioids to treat types of pain other than that of terminal disease was also discussed. This is a particular focus of my research so I was heartened to see these topics on the agenda.

A number of high profile international speakers attended and there were a lot of overseas delegates. Consequently a highlight was a discussion on the World Health Assembly resolution on palliative care. As always I was mesmerised by the words of MR Rajagopal – such an eloquent yet humble man.

As with the previous conference, my turn to present came on the last day. It was well attended, and indubitably benefitted from my practice run the previous weekend. I think it went well, ending with a very useful discussion on what I had previously thought of as potentially tricky concepts, and which are now entering the arena of debate. In particular, the potential problems of using opioids in areas outside of palliative care, and the role of non-opioid treatments within palliative care.

I left India satisfied, with a renewed enthusiasm for completing the often daunting PhD and, as always, I am humbled by my colleagues’ incredible dedication to their clinical work.

Dr Clare Roques

Clare is a consultant anaesthetist at Wexham Park Hospital, and a part-time PhD student at the University of Glasgow, studying the management of pain in India. She is a member of the Glasgow End of Life Studies Group.