RAISE A TOAST TO COFFEE

India’s love affair with the brew has come a long way, as cofffee is increasingly becoming a lifestyle statement. GEETHA PADMANABHAN with Deepa Kurup in Bangalore


Mr. Ram, 70, wakes up at 5.00 a.m. and heads groggily for the kitchen. He puts water to boil, and begins a ritual common to millions of homes. He sets up a mini coffee-maker and, with immeasurable care, spoons in coffee grounds. He taps it just so an d pours boiling (not boiled) water gently in a circular motion to fill the filter. He places the lid leaving a small slat. He waits for the drip.

Mr. Ram cannot tell whether he wakes up for the coffee or goes for it because he’s awake. The distinction is perhaps irrelevant for people like him who were initiated to the habit early. What he does remember is learning what “degree” coffee meant as a kid. And never settling for anything even a degree less. In his impoverished Mandaveli home of nine members, the standard of this one item was never compromised.

Except for one detail. His mother bought raw beans, rolled them on a spit for an even brown roast and stored them in a glass bottle. Powder was ground every day, fresh for the day’s brew. The kids took turns to feed and crank the grinder, inhaling the rich fumes in anticipation of the afternoon cup.

To Mr. Ram andhis retired friends, childhood memories are enveloped in this “divine” aroma. His mom, however, gave up the routine when roasted beans began to be sold, and eventually coffee came home as powder in paper packets. The instant avatar invaded the stores, but she wouldn’t let this abhorrence defile her davarah-tumbler.

“Being allowed to drink coffee in the morning is a coming-of-age rite,” said Srinath Narayan, who promotes Dragon software.He remembers walking, robot-like, to a pottikadai half a km away for that glass of life-giving liquid during his hostel days.

Arabica, Robusta, Peaberry — someone smitten by coffee’s sensuous aroma must have suggested those names. Micky Kalappa, a coffee grower in Coorg, traces the royal lineage: “Kaffa in Ethiopia and Central Africa are reckoned to be the home of Arabica and Robusta respectively. Arabica is believed to have been introduced in India sometime in 1600 AD by Baba Budan, a pilgrim from Yemen — at Baba Budan Hills near Chickmagalur in Karnataka. Robusta came from the Indo-China at the close of 19th century. Malabar Muslims brought coffee seeds to Coorg around the 1820s. The British commercialised the plantations in the 19th century.” Coffee is grown in south India with a few parts of north-east under its acreage.

Credit for popularising Indian filter coffee must go to India Coffee House, which began an active promotion in mid- 1940s. A “coffee house culture” was launched in which grew a cast of celebrities. Coffee became the reason for get-togethers and brain food for conversation. Strong filter coffee was the star of “messes” and hotels. Coffee House regulars grew up, left to make their mark and money in the world, but came back for that shared sense of connection.

The destiny of India’s coffee has been controlled by the India Coffee Board, an autonomous body, functioning under the Ministry of Commerce and Industry. Set up under an Act in 1942, the Board focuses on research, development, extension, quality upgradation, market information, and promotion of Indian coffee. According to its website, the Board relinquished marketing in 1995, but runs 14 India Coffee Houses in the country. The India Coffee House brand of coffee powder was the preferred brew for many years.

In the 1950s the Board downsized the Coffee Houses due to a policy change. Under A.K. Gopalan, the workers took over the branches, and renamed the network Indian Coffee House. The Indian Coffee Workers Co-Operative Society was registered in Bangalore on August 19, 1957. The first ICH outlet opened in Delhi in October that year. Gradually, the Indian Coffee House chain expanded across the country.

On February 12, 1958, the Society started an Indian Coffee House in the Mangalodayam buildings, Thrissur. The ICH claims to be the biggest restaurant chain in Kerala, with over 51 outlets and associate canteens operating in all major towns from Thrissur to Thiruvananthapuram, and in government establishments like the Secretariat, Legislative Assembly, MLA-Hostel, medical colleges and universities. The Society also sells pure coffee powder at reasonable prices.

Pub culture


Then came competition. In the last decade, coffee houses have yielded their place to trendy “coffee pubs” run on post-millennium business practices. Ujjwal Grover writes a moving farewell to one in Jabalpur. “At this very same place, there used to be an old India Coffee House, renovated to make way for an ultra cool chill-out place for youngsters like myself. It would be a lie to say that I don’t miss that coffee house — a dingy place with ceiling like a dome; the cheap wooden tables coloured to give an impression of mahogany; waiters in long pagadis; the always-present group of oldies who looked like communist poets or war veterans or editors of forgotten newspapers; the glasses and the occasional plates of egg pakodas. I thought the oldies owned the place, but I realise they were there because that was the only place that had not grown younger as they grew older. The India Coffee House had grown old with them... Now a cafe stands in its place. I hang out there, but it reminds me of the coffee house and its surprisingly affordable delicacies… Not that this change isn’t good, but I want to know what happened to that group of oldies, those waiters, that manager and those tables...”

Today, the cash-rich young drive to the mushrooming (more than 500 and counting) coffee bars not really because of the coffee that comes in many flavours and temperatures, but because they offer more than just coffee. It is to “meet up” rather than “meet for coffee”. “The hip, laid-back ambience is the draw,” said Unnamalai Thyagarajan, award-winning organic coffee grower. “It’s a healthy trend to hang out openly to make friends, exchange views. I hear they are planning similar outlets for the elderly.”

As Café Coffee Days, Baristas and Café Mochas go on to open joints in petrol stations and in smaller towns, coffee will not be the sole ingredient of their campaign. Yes, there will be imported brands, but with merchandise like filters, mugs and T-shirts jostling for space. Menus already include teas, smoothies and non-local “health” foods.

One outlet in south Chennai has a shop-in-shop selling a Khadi line of clothes. Some others could let out space for book launches, film clubs and birthday parties.

Narayan is appalled. “Why make coffee an excuse for this outlandishness?” he asks. “You come to be seen here, drinking that Rs.50+ pretentious apology for coffee!” He is grateful that Chennai hasn’t become too urban to lose its old coffee places. “We meet once a month in places like Woodlands for coffee, cricket and Carnatic music. What is a coffeehouse where you can’t shout in Tamil, pack in steaming idli-vadai-pongal and sip filter coffee? The bill for about seven persons is never more than Rs. 300!”

Divided house


The coffee culture in Bangalore has also seen similar changes. Like a city divided, there is the café culture and the kaapi culture. The latter ensures that there is a minimum level of caffeine and chicory in Bangalore’s arteries. From the unique “by-twos” stretched out in minuscule steel tumblers — the average Bangalorean’s idea of a high-chicory shot — to its trendy, multi-flavoured, Italian counterpart, the fundamental purpose of coffee joints has hardly changed. While old-timers recall debates and conversations over their kaapi tumblers, young 20-somethings explain the concept of “chilling out” in their “happening hangouts”.

India Coffee House on M.G. Road may not offer different flavours or change the décor with the season — loyalists find solace in the dank walls and matter-of-fact tables — but it is packed. “Most of these old joints have been demolished and the new ones are too expensive. People are clinging to the remaining joints with a deep sense of nostalgia,” says Lakshmi Raman, a Coffee House loyalist.

Rapid expansion






Coffee giants like the Bangalore-based Café Coffee Day (popularly dubbed CCD) and Barista say that Bangalore is one of their most rapidly expanding markets. The first CCD at Brigade Road pioneered café culture with an Internet centre-cum-café as early as 1996. From wi-fi zones to periodically changing menu and décor, these cafes target a young audience that has the power to purchase and will pay to “hang out”.

“The market in Bangalore is very young and very cosmopolitan. Our studies reveal that the ‘out of home’ factor is what has driven this growth,” says Rini Dutta, spokesperson for Barista, which has 21 centres across the city. On the other hand, CCD (with 98 cafés in Bangalore) is in every nook and corner. “We record over 80 million walk-ins across the country in a year. Roughly 88 percent of them are between 15 and 29 years of age, either older students or young working professionals,” says Shyamala Deshpande, Sr. General Manager, Café Coffee Day.

Problems


But all is not well in the coffee realm. “Coffee cultivation in India is at the crossroads,” said Kalappa. “Just as prices were looking up came the severe labour crunch. Plantations are becoming unviable, due to fragmentation of holdings.” Instead of getting into the hot water of global demand/supply, freight rates and the rising rupee, the spigot should turn inward, he feels. We down 80,000 tonnes of coffee annually, shouldn’t we tap the local markets? The crop has no future in India unless the government can support it. Plantations are “neither industry, nor agriculture, and don’t get the benefit of either.”

Coffee estates, he says, now see a flight of eco-sensitive planters to cities, the properties taken over by people keen on converting hilly areas into resorts and hotels. To a committed grower like him it is loss of topsoil, local livelihood, mature trees and a fragile bio-diversity.

Coffee creates a community, uniting us in celebration and tragedy. It is a warm drink in more ways than one.

Coffee in literature
Rev. Edward Terry, chaplain to Sir Thomas Roe, wrote in 1616: Many of the people there (in India), who are strict in their religion, drink no Wine at all; but they use a Liquor more wholesome than pleasant, they call Coffee;

David Burton, a food historian, writes in The Raj at Table (1993): India’s first coffee house opened in Calcutta after the battle of Plassey in 1780. Soon after, John Jackson and Cottrell Barrett opened the original Madras Coffee House, ... [They recovered] their costs with the high price of one rupee for a single dish of coffee.


170208

I DON'T BELIEVE IN DYNASTY

Legacy of a name: Fatima Bhutto has lost much due to politics.
In an exclusive interview, Fatima Bhutto, granddaughter of the late Zulfiqar Ali Bhutto, talks about her writing and why she stays away from the political furnace.
“My father wanted me to be a writer. He sent my poems to the publisher with his signature the night before he was killed. After he was killed, I kept writing in his memory.”
In a perfect world, Fatima Bhutto would have been behind a desk or with her laptop, putting together her next poem. Her father, the late Murtaza Bhutto, would have been around, lending a helping hand in drafting letters to publishers, just as he did when she was a teenager.

However, life is no fairytale, and hours after he put his signature of approval to her first book, he breathed his last.

Today, Fatima, from the illustrious clan of the late Zulfiqar Ali Bhutto, who would rather not use her surname to enter politics, writes books. Never mind, life has not been a bright book for her.

At 25, that age when you are neither too young nor too old, she still maintains good cheer. Moral cretins abound in her universe. But hers is a peculiar world, as one found out in the course of a discussion at the Jaipur Literature Week recently.

Ernest Hemingway, Sartre, Asma Jehangir and Mukhtar Mai occupy the same mindscape. And young Fatima, smart enough to be a politician, and wise enough to stay away from the crucible that took the lives of three of her family members — grandfather Zulfiqar, father Murtaza, and most recently aunt Benazir — would rather talk about her work, how she has been saved from great tragedies by a divine hand — she was in the U.S. on 9/11, in London on 7/7 — and the like. Yet her life has followed a tragic trajectory.
Sorrow and creativity

Angst and sorrow have stirred her creative juices: her poetry and the book on the Kashmir earthquake have both stemmed from sad events. Is it essential for a writer to experience the adversities of life rather than having only good things happening to her?

“I think what is essential for a writer is a strong and sensitive imagination. Certainly tragedies can enhance a writer’s creativity and ability to empathise, but it’s not essential. I think imagination and that ability to empathise are keys for creativity.”

Simply put. Just like her writing that has a simplicity, which makes it more identifiable to the common reader. Did her father specifically groom her to write simply in an age when children tend to flaunt their vocabulary? “I was raised to speak openly and honestly. I think that moved into my writing. When you write what is true to you and what is earnest, you write in a manner that people can identify with, whether they agree with you or not. I do have to thank my parents for instilling this in me, but as I started writing I found that when I wrote that way I loved the process of creating. It felt most natural.”

This “natural” writer started early, real early. She was just 15 when her first collection of poems was published. “I started writing for a school project. I have always enjoyed writing and my father wanted me to be a writer. After reading my poems, he made me write a covering letter and send it to publishers. He had sent the poems to the publisher with his signature the night before he was killed. He had even named the book, Whispers of the Desert. I asked him, why ‘desert’? He said, ‘Well, because you hail from a desert, Sindh’. After he was killed, I kept writing in his memory.”

Ask her to describe the poems in her book brought out by OUP in 1997, she simply says, “They reflect my relationship with my father. They are about loss, emptiness….”

Her speech still retains the memories of her father’s death. “He returned from Damascus in 1993. He won an election in exile. We campaigned for him. In 1996 Dad was killed, he was shot at point blank range. He was hit on the jaw, bled on the street for 45 minutes. The cops responsible for the investigation, and later trial, got double/triple promotions. One went on to head the commission on women.”

Her second book was about the earthquake victims, particularly children orphaned by the earthquake in Kashmir. “We had never had anything of that magnitude in our country. There were 80,000 deaths and an entire generation of children was lost because they were in school. I wanted to do something. People were living in tents even months after the tragedy. I did not want to send blankets and the like, as relief was pouring in from all quarters. We gave blood, medicines but I wanted to do something more lasting.

“I went to Balakot and other places. I went to hospitals where the affected were being treated. I met girls who wanted to be doctors. My mom went to a girl called Afira Zara Naaz. She had been amputated. She wanted to be a doctor too. She was a survivor. I said if kids want to write their stories, I will help them publish. I had almost forgotten about that when two weeks later, to my surprise I got an envelope with their stories. We published a book, 8.50 am, 8 October, 2005. The proceeds went to a charity.”

Natural too, that being a young woman with a mind of her own, she would write about women as well. As she has about Iran, where her work has been a bit of an eye-opener. Incidentally, Iranian women, according to her, have found their own niche, taken strides in the field of education. All in their hijab during the Islamic Revolution.
Women in Pakistan


But the situation in her own country, despite a brave unlettered woman like Mukhtar Mai, and even more intrepid Asma Jehangir, is far less impressive. They are not quite symbols of liberation yet. She agrees, “We are not yet in the same position that Iran is in regard to women — and I’m sure people will find that strange if they’ve never been to Iran and seen first hand the courage and strength that is the Iranian woman. But we have strong women role models. Fatima Jinnah was a political and public woman decades before her time. Asma Jehangir is another role model in terms of activism, and Mukhtar Mai is a brave symbol of dignity and struggle.”

Talking of struggle, her life has been one too. “I was brought up in Damascus. There was a military coup in 1977 by Gen. Zia ul Haq unseating my grandfather’s democratically elected Government. My father moved to Syria, raised me as a single parent. I got my own space to grow up there. I had a modest upbringing, doing my own laundry and the like. I had to learn, work, earn. Back in Pakistan I was like an outsider looking in. Pakistan was a dream, nostalgia, folk songs, ice-creams. I went to Karachi, Larkana… These were mythical things that only existed in my mind until then. I went to my grandfather’s grave too. I felt tall.”

So much for a girl looking for her roots! Soon the writer in her takes over as she describes her ancestral place. “Larkana is very close to Mohenjo Daro. A city of four million people, it is located in Sindh. Here rickshaws and cars compete for the same space. My house is an old haveli-like structure with a zenana and mardana — sections for ladies and men. Initially, it was frightening. There were people everywhere in the city. But once there I realised people were interested in my last name. In Damascus I was an individual. Here I was a Bhutto.”

Back in Pakistan, she discovered “feudalism is an attitude, not a lifestyle”. It is an attitude that does not suit her. “I don’t believe in birthright politics. I have lost too much in politics. My dad was 42 when he went away, my uncle 26, my grandfather 50… Benazir lived the longest at 54.

“I don’t have to be in dynasty politics to make a mark… my name does not prevent me or take me forward. Certain things I can say as a writer that I cannot as a politician. For instance, I can say that Mukhtar Mai changed the culture of silence. She is an illiterate woman who was punished for raising her voice after a gang-rape. But she stood up, and has now built a school for girls from the money that poured in for her… By writing we chronicle the injustices of our times."

Fair enough. But isn’t it a tool she has used with adeptness in her regular writing when talking of her father’s political adversary, her aunt, Benazir Bhutto, whom she calls “Wadi Bua”?
Memories of Benazir

“I don’t believe in dynasty. I don’t regret what I wrote about Benazir. It was never personal. It was political. People wrote to me in response to my articles, saying ‘Shame on you…your grandfather won’t have approved of it.’ I write what I believe in. My earliest memories of Benazir are very beautiful. I had great affection for her when I was very young. I loved her. A little later, I respected her for the fight she showed in the mid-1980s. She was struggling, fighting the State, the system, the dictatorship. But, with her, there was always that element of looking back to look forward.

“I regret she is not there anymore. If she were, she would have given me more ammunition. However, the manner of her violent death has to be stopped. If we have to foster democracy, violence has to be stopped. Politics in many places is like family business. Power does not change hands in my country. For instance, I have been told in Pakistan, 20 political families monopolise politics, 20 families monopolise the economy.”

So, what is the way out? “Spread power, make those in power accountable. And I am a great believer in people. They have to build bridges. Governments will do what they do. As citizens of India and Pakistan, we are like twins. We are like siblings who occasionally fight but still remain siblings. People want buses, trains, peace. It does not pay to wonder what would have been the condition of the subcontinent if there were no Partition. I would say, there would have been no Faiz without Pakistan!”

But isn’t she limiting the prospects of peace by writing in English alone? “I write in English but I am published in Urdu as well,” she says, adding, “I speak Arabic fluently. My Urdu is good, I know a bit of French, even a smattering of Sindhi.”

Is the purity of English being compromised in Pakistan too? “To a lesser extent I think it happens here. But rather, it’s the purity of Urdu and other vernacular languages that is most compromised here as everything has become Anglicised and made ‘foreign’. We don’t use our language as a primary one, it’s become secondary to English. That’s a great tragedy for such a beautiful language.”

Having lived in Syria, the U.S., the U.K. and, of course, in Pakistan, does she feel like a citizen of the world? “I am a proud Pakistani. I would like to remain in Pakistan,” is all she offers. Politician? Maybe. A young writer at ease with words? Certainly.

A family in politics
Zulfiqar Ali Bhutto (born on January 5, 1928) was the founder of Pakistan’s People’s Party and the President of Pakistan from 1971 to 1973. Deposed by a military coup he was executed on April 4, 1979 after a controversial trial for authorising the murder of a political opponent.

Benazir Bhutto (born on June 21, 1953) was the first woman to head a Muslim-majority state. She was elected as Prime Minister twice in 1988 and in 1993 but removed from office on corruption charges. She was killed at a rally in Rawalpindi on December 27, 2007.

Mir Murtaza Bhutto (born on September 18, 1954) won a seat as an independent in the 1993 elections. In 1995, he led a breakway faction of the ruling Pakistan People’ Party. He was killed in an encounter with the police on September 20, 1996.

Shahnawaz Bhutto (born in 1958) was in Switzerland when his father was executed. He was believed to have links with Al-Zulfikar, a group dedicated to overthrowing Gen. Zia’s regime. He was found dead on July 18, 1985 at his home in Nice, France.

ZIYA US SALAM(170208)

HOW CONFIDENT ARE WE?

Media claims that the Indian woman has arrived look only at partial realities. The full picture, with numbers to back it up, tells a different story.
Different realities: Not everyone has arrived.


When the media claims that the Indian woman has finally “arrived”, that there is a noticeable change in her status, and that she displays a new confidence, how should one react? Believe? Disbelieve? Applaud? Be cynical? Or conduct a reality check?

It is virtually impossible to generalise on the status of women in India. For every plus point showing an improvement, there are a dozen minus points indicating the reverse. Therefore, arriving at a mean between these two extremes becomes difficult.

Last month, the Centre for Study of Developing Societies (CSDS) with two media houses, Indian Express and CNN-IBN, released the results of an interesting survey on the status of Indian women. The sample was small — 4,000 women in 20 states and across 160 locations — and the survey acknowledge that it had a decided urban skew. Yet, the results indicated some notable trends.

One of the interesting findings was that the majority of Indian women wanted to “work” outside the house in paid labour. Those not engaged in such work at the moment, wanted the chance to do so. They felt they got more respect if they worked outside the house. Yet, the majority also admitted that they were not paid equal wages to the men nor did they get the position they felt they deserved at their place of work. And a large number complained of harassment at work.
Work without pay

As many as 67 per cent of the women surveyed said they ought to be paid for the “work” they do inside the house. And that is not surprising given that both rural women, who are engaged in agricultural labour, and urban women, who work outside their homes, put in an average of a 10-hour day that includes the work inside and outside the house. In other words, the fact that they brought in an income did not absolve them of the primary responsibility for the unpaid work that they still had to do at home. Despite this, most women said they wanted to work for wages even if they did not need the money.

But how many of them could decide how to use that income? Only half the women surveyed said they could. Although most women said they were included in the decision making process, only a third said they had they could independently decide, for instance, whether to purchase a household item. In fact, most of the women said they could not make independent decisions on whether to pursue further education or to work. Even highly educated women said they did not have the right to decide independently on such issues.

Only one in five of the single women surveyed said that they could decide on their own on the question of marriage. The one area where they could decide was when it came to voting. Over half said that they were free to decide but clearly the other half still did not have that freedom.

So the picture that emerges is a mixed one. Women want to earn, want respect, want autonomy but still don’t really get it, not even on questions of further education and certainly not on the crucial issue of marriage. So the confidence in a few is not reflected in the absence of autonomy amongst the majority of women even in the context of this small survey.

While such surveys are interesting because they provoke discussion on this subject, the data from the National Family Health Survey III (NFHS III) is probably a far more reliable way to judge the progress made by Indian women as it has surveyed 1.25 lakh women across 29 States. Some of the facts that emerge from it are disturbing, particularly those relating to violence against women. The health data, such as the incidence of anaemia amongst married and pregnant women is another disturbing measure that reveals that all is not so well after all.
Disturbing trend

For example, 57.8 per cent or more than one in every two pregnant women in this country is anaemic. This is the consequence of lack of adequate nutrition and neglect of health problems. The worst State is Haryana, where an astounding 70 per cent of the pregnant women are anaemic. Amongst married women in the age group 15-49 years, the incidence of anaemia has increased from 51.89 per cent in 1998-99 to 56.1 per cent in 2005-06. That is an unacceptably high figure for a country claiming it is on the verge of becoming a global economic giant.

Take another measure, that of crimes against women. The National Crimes Record Bureau (NCRB) has figures for 2006 on its website. We find that the incidence of reported rapes has increased by 5.4 per cent while that of dowry deaths has gone up by 12.2 per cent. In fact, it is the figures on dowry-related crimes that are most disturbing. Apart from dowry deaths, the incidence of complaints filed under the Dowry Prohibition Act 1961 has increased by an astounding 40.6 per cent. Add to this the increase in the number of cases registered under Section 498 A of the Criminal Procedure Code that relate to violent acts by husband or another relative, and you get a very disturbing picture of what women face within their homes.

In fact, the NCRB site is interesting for a number of other reasons. For instance, Andhra Pradesh leads in the States with the highest number of crimes against women followed by Uttar Pradesh, Maharashtra, Madhya Pradesh and Rajasthan. And the first five cities in terms of number of crimes against women are Delhi — no surprises there — followed by Hyderabad, Mumbai, Bangalore and Ahmedabad.

It is comforting to look at a partial reality, be content at what we see around us and believe that this represents the full picture. But a closer look exposes uncomfortable details, unsavoury realities that suggest that the struggle to really improve the status of women in this country cannot be cosmetic, cannot be fought only at one level, but must continue on many different fronts.

KALPANA SHARMA

IMPORTANCE OF BEING BILKIS

It took exceptional courage for Bilkis Bano to walk up to the police station and file a complaint, and persist with it.
Rare courage: Bilkis Bano at a press meet after the verdict.



It is one of those horror stories from the Gujarat carnage of 2002 that few can forget. A young Muslim woman, six months pregnant, runs for her life from her village when rampaging mobs attack it on February 28. She has with her a three-year-old daughter, her mother and other relatives. They move out of their village under cover of darkness and hide in a field hoping to escape. Instead, the next morning they are confronted with a mob of 20 to 30 men carrying swords and sickles who assault and gang rape the four women, including Bilkis and her mother, kill many of the others, and kill her three-year-old daughter by “smashing” her on the ground. Of the 17 who left the village, only three survived, the bodies of eight were found and six are still missing.

The horror does not end there. Bilkis pretends she is dead and waits till the mob leaves. Then with the help of a home guard, and with her six-year-old nephew and a three-year-old boy who have survived, she trudges to a police station to register a complaint. On the way she borrows some clothes from an Adivasi woman to cover herself.

At the police station she receives little sympathy. Instead the policeman on duty pretends to listen to what she is saying but writes something completely different in the First Information Report on which he gets the illiterate Bilkis’ thumb impression.

Two days later, local photographers find eight bodies of the massacred family. This forces the police to act and post-mortems are conducted. Again, instead of recording the truth, they conduct what has now been termed a “shoddy” post-mortem and bury the bodies. Some years later, when the bodies are exhumed as part of a fresh investigation, none of them have skulls. It appears that they were decapitated after the post-mortem to prevent identification. In addition, salt was sprinkled on the bodies so that they would disintegrate.
Need to intervene

The case of Bilkis Bano has all the elements of the worst kind of horror including the indifference and complicity of the State in covering up the truth. But it also illustrates the kind of intervention that is needed in such situations to ensure that some justice is done. For, it is now evident that the case would not have moved if it had been tried in Gujarat where it was first filed. In August 2004, the Supreme Court ordered that the case be tried in Mumbai. At this stage the CBI took over the investigation and ordered that the bodies of the eight people from Bilkis’ village be exhumed.

In just over a year after taking over the investigation, the CBI gathered enough evidence to arrest 20 people including six policemen. On February 21, 2006, the trial began in Mumbai. On January 18, 2007, the trial court held 12 of the 20 guilty including one policeman, sub-inspector Somabhai Gori, who “suppressed material facts and wrote a distorted and truncated version” of Bilkis’ complaint, according to the CBI. While Gori was given only two years imprisonment, the other 11 were given life sentences.

Apart from hearing the case in Mumbai, the decision to hold the trial in camera has also made a difference as it encouraged witnesses to testify without fear, something they would not have done in an open court. The policeman’s conviction, for instance, was made possible because three witnesses heard Bilkis give her report and what they said they heard differed substantially from what the policeman noted down.

Even today, fear dominates Radhikpur village. In anticipation of the judgment, the 60 Muslim families who still live there apparently quietly left the village as they feared a backlash from the families of those convicted, most of whom are from the same village.

But above all, it is Bilkis’ courage in going to the police station in the condition in which she was after a gang rape and after seeing her infant daughter being brutally murdered that clinched the case. Most women hesitate to go to the police. If you are poor, a Muslim, and living in a situation like the one that prevailed in Gujarat in 2002, the chances of turning to the police are even more remote. This is what makes Bilkis’ action so exceptional.
Uncertain future

Even after filing the complaint, she could have given up, been intimidated, allowed herself to be bought off, decided it would be simpler to forget about it. Yet, she persisted even though the personal price she has paid is hard to imagine. Nor can we fully comprehend what is her future, whether she will ever be able to live in peace in her village, or whether she will forever be a refugee hiding from those waiting to teach her another lesson. But amazingly, she has gone on record to say that she will not give up and continue to pursue the case until the five policemen who were let off for lack of evidence are also convicted.

Seeing photographs of this diminutive woman, one wonders from where she got the courage at that terrible moment to make the journey to the police station. If she had not done so, the story would never have been told. This ordinary woman has to be saluted for her extraordinary courage

KALPANA SHARMA

THE NOBLEST CALLING

S. C. Bhargava: Professor of physics and integrity.
The best teacher furthers the life chances of his students without necessarily doing anything beneficial to his own.




I come from a family of teachers. My mother taught in a school through much of her adult life. My sister, a highly qualified doctor, chose to teach in a medical college rather than go into private practice. My father was a research scientist through whose hands passed numerous doctoral candidates. And the tradition goes back further. Three of my granduncles were teachers, as were two of my great grandfathers.

In this respect I am the black sheep of the family. Although I had the necessary qualifications, and opportunities, I chose a career that is in many respects diametrically opposed to that of teaching. To be a writer is to privilege your individual self, and (especially) signature. Your name is carried alongside all you say; the credit (and, it must be added, discredit) that the work brings is yours alone. Writing is a profoundly egoistical enterprise; and writers are indeed the most self-centred and self-absorbed of men (and, of course, women). On the other hand, to be a teacher is to subordinate your self and your ego, your needs and your ambitions, to the self and ego of others. The best teacher furthers the life chances of his students without necessarily doing anything beneficial to his own.
Vital difference

Writing is all about “me, mine, myself”; teaching about “his, hers, theirs”. It may be because of this conceptual (and moral) distance between my profession and theirs that I have always had a profound respect for caring and conscientious teachers. The teacher I most admired died in the last weeks of the year that has just ended. His name was Subhas Chandra Bhargava, and for more than three decades he taught physics and integrity at St. Stephen’s College, Delhi.

I first got to know Bhargava Saab in the mid 1970s, while I was a student at Delhi University. I was registered for a degree in economics, so I was never in fact formally taught by him. But we had a common interest in the game of bridge (which he played brilliantly, and I no more than adequately); and a common physical affliction, bronchial asthma. Through exchanging bidding conventions and bronchodilators we forged a friendship that endured for 30 years.

Bhargava Saab was a tall, thin man with a shock of thick, dark hair. He was upright in his bearing, and even more so in his character. The physics students, naturally, adored him because he was an exemplary lecturer and because, unlike most other teachers, he did serious scientific research himself. But beyond his discipline and his college, he was known throughout Delhi University for his generosity and his integrity. Students who could not find a hostel room stayed with him for months on end; students in trouble with the (instinctively authoritarian) authorities found him an able interlocutor on their behalf. Ex-students visiting Delhi could always count on free board and lodging. I was one of those who extravagantly abused this privilege; over the years, I must have spent at least 300 days at his home, working in the archives in the day and discussing bridge and other matters with him at night. (His democratic instincts extended to his politics; he was an early critic of the Emergency, and also active in the civil liberties movement.)

I have spoken of the veneration we students had for Bhargava Saab; if anything, his fellow teachers admired him even more. As the physicist lay dying, one old colleague wrote to me of how “For 30 years he has been a kind of fixture in my moral universe. On all the ‘small’ things which constitute personal integrity and friendship, he was always a guide, and at important moments it has often been ‘What would Bhargava Sahib say?’”.
Just another Rahul

One day, in the mid 1980s, Bhargava Saab received a call from a high school student named Rahul, who wished to consult him as to which subject to study in college. An appointment was fixed for 9. 30 a.m. the next day. At 8. 30 Bhargava Saab went to the lab to set up some experiments. When he next looked at his watch it was 9. 20. He put down his instruments and rushed back to his apartment. The route from lab to home was normally leafy and quiet. But on this day it was swarming with policemen. About 50 yards from his house he was stopped and not allowed to proceed further. “Mujhe jaane do, ghar mein ek ladka mera intezar kar raha hai,” pleaded Bhargava Saab (“Let me go, there is a student waiting to meet me at home”). The cops would not relent; policemen and Professor argued, back and forth, until it finally dawned on the former that this was the man their boss’s son had come to meet.

Some credit in this story accrues to Rahul Gandhi’s advisers. They had done their homework, thus to find that the Delhi University teacher most likely to give the best, or most fair-minded, career advice was a man who did not carry an elevated title such as Dean or Vice Chancellor. But most of the credit must remain with Bhargava Saab. All Rahuls were akin to him, be one the son of the college chaprassi or another the son of the serving Prime Minister of India. (It is characteristic that he did not bother to ask the caller his surname.) We can be sure that for any other Rahul he would still have arrived on the dot.

RAMACHANDRA GUHA

RENAISSANCE MAN

Nobody has excelled in so many fields or dominated his culture to the extent that Tagore has.



It is genuinely difficult to explain to foreigners the scale of Rabindranath Tagore’s accomplishments. Some have made glib comparisons to Shakespeare and Goethe, but neither man, despite his undoubted greatness, excelled in as many fields as the Bengali Thakur, nor dominated his culture to the extent that Rabindranath has. Think of it: he was not merely an extraordinary poet, the only Indian to win the Nobel Prize for Literature (in 1913, for his Gitanjali). He was also a prose-writer and essayist of the first rank, whose articles, books and monographs commanded a wide readership around the world. As a philosopher and mystic, he was perhaps the first to develop a synthesis of Eastern and Western approaches, and he developed political ideas of great depth and humanity (of which more later). He was a great, if uneven, novelist and short-story writer who produced several masterpieces that continue to be read a century and a half after his birth. He was also a playwright of rare distinction: “The Post Office”, for instance, was one of the most popular plays in the world before the Second World War.

Enormous range

But, added to all that, were other talents: he was a painter of high quality and perceptiveness, an artist with a poet’s eye. He was a composer of over 2,000 immortal songs, of which he authored both the lyrics and the tunes, and through which he essentially founded his own branch of Indian music, known as “Rabindra Sangeet”. He is the only person to have created the national anthems of two different countries (India’s “Jana Gana Mana” and Bangladesh’s “Amar Sonar Bangla”), though both nations were born after his own death. (Even greater than both official anthems is his “Where the mind is without fear and the head is held high,” an inspirational poem that could serve as the anthem for any nation seeking freedom.) And he was an educator of great vision and courage, founding Vishwa Bharati at Santiniketan to offer an authentically Indian experience of higher education, following systems and approaches of his own devising. It educated the likes of Satyajit Ray and Indira Gandhi (not to mention offering a cradle to Amartya Sen, whose first name was given by Rabindranath — probably the only instance of a Nobel laureate baptising another!)

If all this were not more than enough — representing a level of achievement so towering that it is difficult to imagine an individual in any other culture who comes close — there is also the remarkable fact of Tagore’s huge worldwide impact, which even today’s Indians may have difficulty imagining. Tagore was a global giant before the era of globalisation. When he was to speak at New York’s 4,000-seat Carnegie Hall in 1930 (itself a rare enough honour, since the hall is usually reserved for concerts, not orations), more than 20,000 people were turned away from the sold-out event, creating a mass of humanity on the streets outside that blocked traffic for miles. No living writer on the planet had ever had something comparable happen, and what’s more, Tagore was handsomely paid for his speeches. One American critic, not without a tinge of jealousy, wrote acerbically that the Indian “scolds Americans at $700 per scold”. (By today’s standards that would be more like $7,00,000 in purchasing power terms.)

But the chauvinist glee with which I, as an Indian writer, am celebrating Rabindranath Tagore, would not particularly have appealed to him. Though his decision to return his British knighthood after the Jallianwallah Bagh massacre led Indians to regard him as a great hero of the nationalist struggle, Tagore did not really believe in nationalism but in the values of the human spirit, transcending all national boundaries. At the same time, he was not exactly an internationalist in the classic sense beloved of U.N. types like myself. He died before the United Nations was created, but he did not think highly of its forerunner organisation, the League of Nations. Tagore wrote of the League that it was well conceived in theory but not in practice, because it was an institution in which the world was represented by national Governments and nationalist political leaders. “It is,” he wrote, “like organising a band of robbers into a police department.” There is no reason to believe he would have felt any differently about today’s U.N., which is also an organisation of States rather than peoples.
The archetypal sage

With his long beard and his flowing white robe, Rabindranath Tagore epitomised for many the archetype of the Indian sage, the precursor of so many godmen and gurus who have followed his footsteps to the West. There is little doubt that his magisterial mind and his authoritative presence did a great deal to inspire admiration across the world, and to spark a revival of interest in Hinduism and in the teachings of Hindu spirituality. Tagore’s Hinduism had little to do with the Hindu-ness sought to be promoted by today’s Hindutva brigades; it was a faith free of the restrictive dogma of holy writ, untrammelled in its yearning for the divine, and universalist in its conception and its appeal. This is what made his ideas so attractive to non-Indians. When the great British poet Wilfred Owen (author of the greatest anti-war poem in the English language, “Dulce et Decorum Est”) was to return to the front to give his life in the futile First World War, he recited Tagore’s “When I Go From Hence” to his mother as his last goodbye. When he was so tragically and pointlessly killed, Owen’s mother found Tagore’s poem copied out in her son’s hand in his diary.

With his typical generosity, Tagore said of the artist William Rothenstein, “He had the vision to see truth and the heart to love it.” The same was true of himself. It is reason enough, today, to pay tribute to the greatest Indian who ever picked up a pen.


THE SHASHI THAROOR

TOWARDS A MONOLITHIC MODERNITY

In our quest for modernity, narrow streets and tiled houses with character in India’s smaller towns are losing out to a faceless mass of glass and concrete.
Meandering streets that organically weave their way into the natural topography. Row houses with tiled roofs and colonnaded verandahs. Waves gently lapping against fishing boats anchored alongside a towering lighthouse. What may seem like a nostalgic conjecture is in fact Bimilipatnam, a historic Dutch port settlement, 25 km from Visakhapatnam in Andhra Pradesh. Apart from being steeped in history and an extremely scenic locale, Bimilipatnam also harbours a sense of place with a social fabric where everyone seemingly knows everyone else and your neighbour is not someone you glance at on your way to work, but is almost extended family. Evolving lifestyles and new-age economics have, however, begun to affect irreversible changes in this quaint town. The tiled-roof and brick walls that once kept the house cool, today is seen as an element that cannot accommodate vertical expansion. The narrow winding street that once gave enclosure and character to the townscape today cannot accommodate a car. The first step towards overcoming these apparent shortcomings is to bring down the vernacular house and erect an apartment that can accommodate five times as many families or build a concrete independent house. Acquisition of a car demonstrates the unsuitability of the winding street and the family is driven to move to Visakhapatnam. This is not a dilemma that is specific to Bimilipatnam. It is a representation of hundreds of vernacular towns all over India.

Different destinations

The quasi ideal India of the picturesque postcard fame still lives in her villages. The real India has packed her bags and is making a beeline for the allure of modernity. With every passing day, more of our country is transforming into the faceless mass of glass and concrete we seem to have taken a fancy for. And the back-breaking brunt is borne by the generic Indian vernacular town. These towns are tangible seats of history, of experiences and images across time. They are a record of the evolutionary indigenous skills we have possessed and probably still do. While shifting to new technology does carry its share of convenience and makes practical sense, our ties with our roots are in danger of being severed with this shift. There are two categories of Indian historic towns that are threatening to become obsolete. The first, abandoned settlements stripped of continuity in time, hauntingly devoid of everyday life. The second, like Bimilipatnam, are palimpsests of sorts, trampled upon by the climb towards progress.

Examples of the former are the Chettinad villages in Tamil Nadu. Aesthetically resplendent and a contemporary exhibition of the lavish lifestyle of the Chettiyars, these villages are no doubt extraordinary examples of Indian architecture. But without the buzz of human activity, they are reduced to mere artifacts; visual treats with vivid imagery that lack soul. However, despite their quiescence, one can draw solace from the survival of these antiquities in the face of time. The settlements slotted in this category unfortunately belong to a disappointing minority. The reality of a larger percentage of small towns in India is harsher. Where once stood buildings firmly rooted to their context, that integrated climatic viability, social dictates, cultural content and aesthetic richness, today stand testimonies of our allegiance to an architecture, which albeit alien is now the norm. Humanity stacked one upon the other in apartments with their pretentious trimmings seemingly mocks at the 100-year-old, tile-roofed courtyard row house, valiantly fighting its losing battle. A parody is enacted through yet another set of buildings that masquerade as vernacular by merely sporting a pastiche tiled roof on a reinforced concrete slab.

What leads to the death of small towns? On the one hand are the economic and commercial angles like increasing land value, newer materials and techniques of construction available and new typologies of buildings that supersede traditional usage of space. When land is a scarce and highly valued commodity, it is not economically viable for a nuclear family of four to inhabit a house socially conceived for the joint family of 20. More efficient transport and communication no longer requires us to group ourselves into small, self-sustaining communities.
Cultural issues

On the other hand there is a more philosophical angle. One that calls for an examination of our value systems as a people, our changing definitions of status and progress, our changing patterns of social interaction (or the lack of it), our aspirations for ourselves and our vision for our future. Thiruvaiyaru, a historic town 13 km from Thanjavur in Tamil Nadu demonstrates one such change in ascribed values. The hometown of Saint Thyagaraja, an exponent and one of the Trinity of Carnatic music, is best known for the Thyagaraja Aradhana held in memory of the saint each year. The musical procession begins from the house that the saint was born in and lived and died. About a year ago, the simple original brick vaulted structure was brought down and a three-storey building erected in its place that neither conveyed the feel of the original house nor was representative of the Saint in anyway. The sanctity attached to the very space where hundreds of the Saint’s immortal compositions were born was negated by a desire to indulge in a show of status and wealth. Where is the room for even a debate on value when sanctity can be measured in rupees?

After having generalised up to this juncture, the decline and subsequent need for conservation of these towns personally affects me through different sensibilities. That of a student of architecture in terms of their architectural content, that of a humanist in terms of respect for the history embedded in them and that of a citizen in terms of the collective national identity. However, there also occurs a dichotomy of sorts in my personal conviction. A guilt that is not completely unfounded makes its way into my voracious lobbying for the cause of the small town. A guilt that stems from my being a part of the very city that is swallowing up these towns. A guilt that cautions me against being prescriptive of solutions to preserve the small town, but rather accept the reality as inevitable. The guilt of an urban dweller looking wistfully at the small town and hailing its virtues from afar, while revelling in the luxuries that the city affords. But I quell this guilt by reasoning that absence indeed makes the heart grow fonder. Value is often emphasized by void.

“To know where we are going, we need to understand where we come from”.

Our roots are an inseparable component of our identity. With the erasure of our heritage towns, we are losing far more than just heritage buildings. We are letting go of a way of life, one that maintains the harmony with nature and fellow beings, which we started out with.

Our native identity is degenerating as fast as our traditional settlements. It is time we bolstered nostalgia with a little more retrospection.
SANGEETA KAMATH

CARE BEYOND CURE

When relieving pain is the priority…

For millions of patients with terminal illnesses, pain is an everyday reality. But with only two per cent of India’s population under the palliative care cover, we need to put a professional health service system and a well-defined policy in place.

It is imperative to use a multidisciplinary approach involving doctors, nurses, clinical social workers, psychologists, physiotherapists, dieticians and allied health personnel…

To die proudly when it is no longer possible to live proudly. Death of one’s own free choice, death at the proper time, with a clear head and joyfulness, consummated in the midst of children and witnesses: so that an actual leaving is possible while he who is leaving is still there.

Friedrich Nietzsche


The word “palliative” is derived from the Latin word “palliare” meaning to cloak or to cover. According to the International Association for Hospice and Palliative Care, palliative care is the care of patients with active, pro gressive, advanced disease, for whom the focus of care is the relief and prevention of suffering and maintenance of quality of life rather than striving to halt, delay or reverse progression of the disease itself or provide a cure. Originally, the term “palliative care” was synonymous with care for cancer in its various manifestations. Today, it is increasingly used with regard to diseases other than cancer such as chronic, progressive pulmonary disorders, renal disease, chronic heart failure, progressive neurological conditions and progressive infections such as advanced stages of Acquired Immune Deficiency Syndrome. In addition, there is growing awareness of the need for services geared specifically for children with serious illness, paediatric palliative care.

According to the World Health Organisation, the aim of palliative care is to improve the quality of life of patients with life-threatening illness, and that of their families. This encompasses all interventions that prevent and relieve suffering, physical, psychosocial and spiritual. Thus, with regard to pain, a common symptom of many progressive and debilitating disorders, a number of interventions in combination are useful. Drugs, both oral and intravenous for pain management; physical therapy to reduce pain, especially that relating to the joints, nerves or secondary muscle spasm; psychological approaches to help address grief, anger and guilt; emotions associated with terminal illness; and a spiritual approach that provides solace, helping the person cope better with the pain, thereby reducing the nature and quantum of human suffering. There is, therefore, a definite need for care providers to go beyond the conventional in providing care and solace to the dying person, addressing the varied dimensions of the human condition in the setting of chronic illness. Indeed, caring for the family in this setting is as important as caring for the ill person.

Hospice movement


Palliative care began in the hospice movement although it is now widely used outside the realm of traditional hospice care. Hospices were originally places of rest for travellers in the fourth century. In the 19th century, a religious order established hospices for the dying in Ireland and London. The modern hospice movement, credited to Dame Cicely Saunders, gained momentum in the United Kingdom after her founding of St. Christopher’s Hospice in 1967, and has grown dramatically in recent years. In India, Dr. D’Souza, a cancer surgeon from Tata Memorial Hospital, Mumbai, is thought to have started the first hospice, “Shanti-Avedna Ashram”, in the year 1986. Over the years, although there has been a mushrooming of such centres around the world, there remains a challenge of proportional provision of required services, especially in developing countries. There is also the challenge of meeting quality standards in palliative care. Key institutions like the Palliative Care Network; Asia Pacific Hospice Palliative Care Network (APHN); International Association for Hospice and Palliative Care (IAHPC) and the Indian Association of Palliative Care (IAPC) are involved in developing these resources, setting standards and influencing policy.

Significant burden

The World Health Organisation (1990) and the Barcelona (1996) declarations have called for palliative care to be included in every country’s health services. It is estimated that 52 million people die each year and a good proportion of them die with unrelieved suffering. About five million people die of cancer each year, to which can be added the numbers of patients dying with AIDS and other chronic infections who will benefit from palliative care. Add to this the number who suffer in terminal stages of non-communicable disease; afflictions of the brain, heart, lungs, kidneys, bowels, bones, joints and nerves; many consequent to lifestyle diseases. In developed and developing countries alike, people are thus living and dying slowly in unrelieved pain, with uncontrolled physical symptoms, with unresolved psychosocial and spiritual problems and in fear and loneliness. While this phenomenon has been widely reported and published, both in the scientific and the lay press, affirmative action in public health terms, to develop and provide services for people with terminal illness seems grossly inadequate.

Burden on the family


In India for example, the care of such individuals falls on the family, and the assumption appears to be that the family alone should take responsibility. Given our ethos and culture, while we would perhaps continue to make the family the focus of palliative care provision, it is critical that we understand and appreciate their need to be supported by health service providers and to ensure that such support is available, accessible, affordable and acceptable. At present, the efforts to support families of individuals needing palliative care are few and far between, many being cancer-led and NGO-based. All this places an enormous burden of care giving on families, and affects both their quality of life and their productivity. One comes across many young professionals who are forced to put their lives and careers on hold and care for their loved ones. With rapid urbanisation and changing family structures, there is an urgent need for the policy maker to focus his attention on developing adequate and appropriate resources that will support families of people with chronic and progressive illness. The relief of suffering is after all an ethical imperative for the healthcare provider and every patient with an active, progressive, far-advanced illness has a right to palliative care.

There is no one right or wrong model for the provision of palliative care. The best model is determined by local needs and resources. IAHPC believes that each developing country should be encouraged and enabled to develop its own model of palliative care, appropriate to the needs of the local patients and the available resources, taking advantage of the experience and expertise accumulated in developed countries, and not be expected to copy models more appropriate to affluent countries. The in-patient palliative care unit may be part of a hospital or an independent free-standing unit, community based, day hospice and/or day palliative care unit. A combination of these services may be ideal as it will give the patient and his family the opportunity to choose from a buffet, depending on their individual needs, rather than make do with what is available. In the Indian context, the development of community-based resources, including the training of primary care physicians, community health workers and relevant others in palliative care provision are urgently required. With the family being the focal point of care in India, training family members and developing supportive community resources may well be the ideal for us to aspire for.

It is also imperative to use a multidisciplinary approach involving doctors, nurses, clinical social workers, psychologists, physiotherapists, dieticians, and allied health personnel to cover all aspects of care. Such a holistic approach to care, encompassing all aspects of a patient’s suffering, is generally not regarded as modern medicine’s strength. Integration of the allopathic system with traditional indigenous medical streams that have innate palliative care based strengths; Ayurveda for example, may offer the person with terminal illness in India, a better quality of life. What is necessary, however, apart from developing awareness of this emerging need, is to develop health policy that will effectively address the gamut of palliative care needs in the years that come.


Dr. E.S. Krishnamoorthy is Director,

TS Srinivasan Chair and Senior Consultant

and Thadeus Alphons is a Clinical Social Worker

and Senior Research Associate at The Institute of

Neurological Sciences, VHS Hospital, Chennai. E-mail: esk@nsig.org


Guidelines to care-givers

Care-giving is a difficult and stressful process, one that can drain our energy and resources and test our resilience. Your ill relative may be battling with several emotions surrounding the illness and transmit these to you. You would do well to:


Try to accept the situation your loved one is in; focus on keeping her/him comfortable and stop constantly battling the cause once palliation has been chosen as the way forward.


Find an obliging local doctor who will support you in your intermittent needs; Once palliation begins, the relevance of the specialist diminishes considerably. Find a nursing service that can help you at least for half the time each day or through daily visits during which the more difficult tasks bathing; toileting; management of feeding and draining tubes etc. are taken care of.


Conserve your energy and draw upon all available resources to share the burden of care; no one can shoulder the burden of care giving alone, nor should they try to.


Find your own reference points - people you can share your emotions with; a shoulder to lean on. Your loved one can no longer do this for you, and yet you will have to be there always to support her/him.


Do not feel guilty about needing some respite or taking a break. It's important to take regular breaks in order to sustain effective care-giving. Continue to engage in your hobbies, meet up with friends, watch movies, read; in short doing things that give you pleasure.


Do not feel guilty about becoming angry (inside your head) with your loved one; or frustrated; or even feeling hostile at times. These are normal emotions that are brought on by the stress of care-giving. They are transient and will pass.


Do not panic each time there is a blip in your loved one's condition; remember palliation is about keeping a person comfortable and helping to maintain their quality of life.


One family member usually takes the lead in care provision; others play a supporting role. It's important that care-givers playing a supporting role learn to trust the judgement of the primary care-giver who is best placed to make decisions about situations as they evolve.


Remember, the effective care-giver is brave but not foolhardy. Do not hesitate to ask for help from loved ones and professional agencies.

--DR. ENNAPADAM S. KRISHNAMOORTHY AND THADEUS ALPHONS

BREEZE IN THE VALLEY OF PAIN

The comfort of assurance…

The palliative care movement is a silent social revolution that is sweeping across the villages of Kerala.


The rain, like a battered street dog, whined all night. Listening to the patter of raindrops on the banana leaves outside the window, Sameer wondered if the rain’s whine rhymed with the ups and downs of his pain. As the rain tapered off and the first rays of dawn filtered in through the broken window, Sameer’s face paled into a soft smile. “I’m alive to see one more dawn,” he sighed. After a huge effort, he managed to turn his fragile, cancer-eaten body to face the window. Then the pain erupted again. It pierced through every nerve and cell of his body, every finger and toe. The beast mauled him with a thousand claws. Sameer cursed God for the millionth time; and, then prayed to Him to take his life.

Sameer’s wife rushed out to ask the neighbour to call Haseena. Within an hour, Haseena arrived with her two colleagues from the Palliative Care Society. She put the doctor-prescribed morphine tablets in Sameer’s mouth. “The pain will go soon,” she assured him. The team turned Sameer to face the window and started attending to his bedsore. They kept on chatting with him even as they dressed his wounds, changed the “condom catheter” to help him pass urine, and told his wife to give the morphine tablets to him every four hours without fail. They handed the next week’s supply of medicines to the wife along with five kg of rice they had brought with them. “We’ll be back next week,” Haseena told Sameer as the team prepared to leave. “We will find someone to sponsor a water bed for you so that there will be no more bedsores.”

As he watched the three trek back the hillside and disappear, Sameer wondered how his poor family would have coped without the support of the Palliative Care Society. After three years of fight with cancer — several rounds of radiation and chemotherapy and months of hospital stay — his family was broke.


Silent service

Haseena and her friends are part of a silent social revolution taking place in Kerala’s villages, mainly in the northern districts of Malappuram, Kozhikode and Wayanad. The palliative care movement, born in the late1990s, has attracted thousands of ordinary people to the care of the terminally ill and bedridden people. And, tens of thousands of other common people make small donations to help the movement going. Trained volunteers like Haseena go to the homes of end-of-life patients and attend to their medical and psychological needs. “Since most of our patients are very poor, we have to provide not just drugs, wheelchairs and commodes for them, but often rice for the family, books and school fees for the kids and sometimes even clothes too,” says Haseena.

Sharafudheen Padath, a videographer who volunteers for a day every week for the Valanchery Pain and Palliative Care Society in Malappuram district, recalls how his unit once bought a pair of silver anklets for a five-year-old leukemia patient. A few days after she got her wish fulfilled, the girl died. The volunteers sit with the patients listening to their sorrows and fears. They also listen to the concerns of the family members and train them in simple nursing tasks. “Sharing of problems with the patient and the family is very important in palliative care,” points out Mohammed Saif, a pharmacist-turned-palliative care volunteer, who is now the State manager of the palliative care component of the National Rural Health Mission (NRHM).

The volunteers, coming from different backgrounds, serve at least two hours a week going on homecare visits, helping at the outpatient clinics and organising family help and raising funds. Most of the funding comes from the local people. For instance, in Nilambur, the crews of all the buses entering the local bus stand donate Rs. 2 a day, at the rate of 50 paise by each of the four crew members, to the Nilambur Pain and Palliative Care Society. Shopkeepers, autorickshaw drivers and schoolchildren all chip in.

Community participation in the management of pain and suffering of the chronically ill, called Neighbourhood Network in Palliative Care since 2001, is often referred to as the “Kerala model” (also, “Malappuram model”) internationally. “NNPC is a volunteer-driven people’s movement in which doctors and other healthcare professionals have only a secondary role,” says Dr. E. Diwakaran, director of the Institute of Palliative Care, Thrissur.


Global recognition

The movement has won global recognition and the WHO is now promoting it as a model for developing countries. “NNPC, with its focus on homecare, involvement of the community and the extension of coverage to many chronic diseases besides cancer, evolved in response to patients’ needs,” Dr. K. Sureshkumar, who heads the Kozhikode-based Institute of Palliative Medicine, recognised as a centre of excellence by the WHO, says. “It was a spontaneous evolution and was not planned by any single individual.” Volunteers, whom he calls the soul of the movement, had a big role in developing the concept, Dr. Surehskumar, who is one of the pioneers of the movement, adds.


Inadequate coverage


Thanks to NNPC, about 70 per cent of patients needing palliative care in the three districts are covered. Palliative care coverage in Kerala as a whole is 20 per cent and in the rest of the country it is just two per cent, notes Dr. Anil Kumar Paleri, honorary secretary of the Indian Association of Palliative Care. In Malappuram district alone, there are 29 palliative care units, and 25 of them have their own clinics with paid part-time doctors and auxiliary nurses and own homecare vehicles. Each unit serves several Panchayats.

It was the astounding success of the Nilambur Pain and Palliative Care Society, set up in 1998, that became a turning point in the NNPC experiment, says Dr. Mathews Numpeli, the programme executive of NNPC. K.M. Basheer, a farmer who has only studied till Class X, who had worked with the homecare unit at Manjeri, founded the Nilambur unit. Basheer was perhaps the first non-medical person to have headed a pain and palliative care unit in the world. In just one year, he had 60 trained volunteers and the ranks swelled in the following years. “A kind and caring heart and willingness to serve without any financial return were the only qualifications required,” Basheer says.

Following the Nilambur success, many such units opened in Malappuram, Kozhikode and Wayanad and, later on, in many other districts too. Panchayats and municipalities support the movement with money and buildings to locate palliative care clinics. Lately, the police also have joined in the movement and there is an ongoing project to train at least two policemen in each station as palliative care volunteers.

Recognising the importance of palliative care, the Kerala government has, for the first time by a government in Asia, come out with a palliative care policy. The policy emphasises the community-based approach to palliative care and considers home-based care as the corner-stone of the palliative care services. It also highlights the need for integrating palliative care with primary health care.

The challenge now for NNPC is to carry it forward to a people’s “total health care” movement.
-- N P K BASHEER

INDOMITABLE SPIRIT

She did not allow the diagnosis of MS to intimidate her …Instead, she seemed to get on with life, as if MS were an incidental inconvenience.


A s a physician I come across several people every working day, each representing a certain aspect of the human condition. Few of these meetings leave in me a lasting impression and it is one such experience that I recount here. I was called to see M rs. Santha Narasimhan for the first time a few months ago. Diagnosed in the mid-1970s as having Multiple Sclerosis (MS), an inflammatory disorder of the nervous system, she experienced progressive disability from the mid-80s, resulting eventually in her becoming largely house bound. Wife of a captain of the publishing industry and a tennis player of some repute, she had in her hey day donned many an impressive avatar, with a wide circle of friends and relatives. This wide circle remained closely aligned with her, judging by the number of visitors anxiously hovering around, each time I visited. That she was widely loved and revered was clearly apparent in the devotion she inspired in her family and friends. What amazed me most about this lovely lady of over 80 summers, however, was the indomitable nature of her spirit.

She did not allow the diagnosis of MS to intimidate her. Instead, she seemed to get on with life, as if MS were an incidental inconvenience. She did not view herself as a patient; more as a host receiving graciously a stream of visitors, including medical professionals like myself. She did not take on the sick role. Instead, she remained, until the very end, independent in her choices — her home, her devoted staff, her furniture, its arrangement and her daily activities. She did not wither with the travails of her illness: pain, disability, dependence and incapacity, all of which can reduce greatly the dignity of the human condition. Instead, she seemed to accept her declining health with all the cheer she could muster, dignifying it and everything around her, in the process. Other patients would wait for me to ask “how are you”? With Mrs. Narasimhan it was always her asking me, first, how I was, and enquiring about my family. From insisting that her family was present for doctor visits, as a courtesy to the doctor; to ensuring that those who visited her were received and well cared for, no detail missed her unwavering attention. Indeed, when I last met her on Deepavali day, she insisted on giving me sweets to take home, despite having suffered a painful injury to her foot, which had just been dressed by my surgical colleague. Sadly, that was the last time we met.

We medical men are fortunate to learn many lessons every day, from the patients we have the privilege to care for. Mrs. Narasimhan taught me the most important lesson, by far, that I have learnt to date; the indomitable nature of the human spirit and its inherent capacity to triumph over disease and disability.





DR. ENNAPADAM S. KRISHNAMOORTHY

LEADING THE WAY

In trusted hands…

Shanti Avedna Sadan, India’s first, and probably largest, hospice is an inspiring community effort.

Every bed overlooks the sea in Shanti Avedna Sadan, India’s first hospice to take care of the advanced and terminally ill cancer patients, set up in 1986. Run by a trust of the same name, it is entirely free for patients. Earlier called Shanti Avedna Ashram, the name was changed in 2003, as “ashram” gave out wrong signals to people that this was a place to dump patients, explains Sister Siena, hospital administrator.

Located opposite the Mount Mary church in Bandra, the hospice has recently expanded to 100 beds from the 50 earlier. It is a palliative care centre and provides medicines, food, clothes and occupational therapy for those inclined. Two doctors form a part of the 50 members of the staff, 30 of whom are voluntary. Dr. L.J. De Souza, a cancer surgeon at Tata memorial hospital, founded the hospice to ease the misery of patients who were either sent home or left on the street to die.

Keeping them comfortable

Run entirely on donations, the hospice could well be the largest one in India now, says Sister Siena. With the expansion, there will be some focus on research and alternative medicine. Patients come from all over the country and here the emphasis is on keeping them comfortable and giving them love. “We get people from all classes and communities and it is both a hospital and a home for them,” she says. There are facilities for indoor games, occupational therapy, handicrafts and music but many are too sick to do anything. In the women’s ward, beautifully lit by the evening sun, women sit and knit or do cross stitch. Each bed can be cordoned off by curtains for privacy. Some of the women have been here for a year or so. Sister Siena says, “When it is not possible to cure people, this is the best thing we can do for them. We also help the families reconcile with the person’s condition. When patients come here, they are still in a state of rebellion, especially if they are young. It is not easy for them to accept their situation.”

Special care

While most patients are in the ward, the more serious ones are given separate rooms so that their family member can also stay and care for them. There are 40 such rooms. Most people are visited by their families and rarely do they dump them. Some of the patients have to be tube fed or have frequent nausea spells. “In the hospice we focus on tender loving care,” smiles Sister Siena. There is only one thing she had to get used to, the frequent deaths — at least two or three people die every day. “In a hospital you get the joy of seeing people recover, here the staff has to contend with the opposite. The joy lies in giving the people happiness in their dying moments,” she smiles.

The hospice, though run by a trust, is a community effort. As you walk around, you can see that even school children have contributed to it. In fact, on the day it was inaugurated, “The School’s Ward” was opened by a young girl from Canossa high school which had made the highest contribution to the hospice.
--MENON MEENA

VITAL SOCIAL NEED

It takes skill and compassion…


Palliative care’s viability cannot be judged by commercial models, say experts who look at the current scenario in Chennai.



There is an increasing number of advanced diseases, beyond curative stage, that need care. About 80 per cent of cancer patients come for treatment in the advanced stage. This is a burden to hospitals, as there is a shortage of beds for such patients. These patients also need a multidisciplinary team and constant care. Modern palliative care centres are not homes for the dying. They take care of patients with the complete medical team, psychosocial workers, physiotherapists and counsellors, to improve all-round quality of the patient until the end comes.

Not enough

In India, there are around 72 Hospices with the south accounting for over 67 per cent. Considering the incidence and the demand, there is a long way to go.


Apart from this, there are problems palliative care specialists like us have to contend with every day: Non-availability of morphine and other relevant palliative drugs; lack of professional education and therefore, professionals in the field; lack of adequate training in syndromic management of chronic diseases, particularly for medical officers; lack of resources to train health workers in needed numbers; lack of public awareness on the subject; lack of proper understanding of policy issues relating to care of terminally ill or cancer pain relief and the general fear that use of opiod drugs may encourage drug abuse.

The government has to have a more rational policy on morphine usage and its availability for palliative care providers. The current regulations make it extremely difficult for patients to get access to medication for the management of pain.

Indian health insurance companies too need to recognise palliative care since it has significant cost savings without compromising on the care provided to patients.

There is a huge demand-supply gap in healthcare infrastructure which makes it very difficult for hospitals to cope with the demand for beds. The cost of care delivery is also on the increase. Healthcare service providers need to recognise that palliative care is one way of ensuring that the terminally ill patients get better quality care with significant reduction in costs.

Most importantly, palliative care is a social need and cannot be evaluated based on the conventional, commercially viable models. There is a need for subsidies by way of free land and financial support to establish more palliative care centres. The benefits of establishing more palliative centres is that we will be able to provide focused care for the chronically and terminally ill patients at the hospitals, and there would be more beds available for patients who need curative care.

Dr. Republica Sridhar, RMD, Pain and Palliative Care Centre, Chennai.


It began in 1991, when we took in an old man who was lying in the gutter and started our home for the destitute elderly. Since then, 64 people have died here and six of them, of cancer. More recently, we took in a Nepali woman with cancer and in grea t pain. Her cries of pain disturbed others in the senior citizens’ home and we found we could not provide her medical care.

A couple of my students are oncologists at the Adyar Cancer Institute (WIA), so they helped out initially, but looking at our numbers, they suggested that we set up our own palliative care centre, providing the range of facilities for people who are terminally ill.

The facilities for palliative care are better in Kerala. We were looking for nurses and finally, chose two people and sent them to Jeevodaya for training.

Fr.V.V. Paulose, managing trustee, St.Thomas Charitable Trust.

(Fr. Paulose is currently involved in raising funds to set up “Abhayam”, a palliative care centre.)


As far as palliative care in India goes, there are serious issues in the areas of awareness, education and training.

Firstly, no doctor wants to work in a palliative care set up — not only because there is no money involved in it, but also there is nothing much the doctor can do, curatively. So palliative care is the last of the specialities one chooses. There are a few correspondence courses and certificate courses that are being offered, but we are looking for an inclusion in the medical curriculum.

Strangely, India is the third largest producer of opium and we have problems getting our hands on the drugs. While availability of oral morphine has been made simple with the amendment of the Narcotic Rules, there are still problems with procuring injectible morphine.

It is key in the management of the terminally ill, whose pain, on a scale of 0-10, will be at 8, 9 or 10. Relieving pain is paramount and only morphine can do it. With morphine and palliative care, patients can live a fairly long while with a tolerable quality of life. Again, morphine is not available at the Primary health centres and at district-level government hospitals, leaving the rural areas nearly bereft of any palliative care facilities. We are struggling to raise funds to set up institutions in rural areas.

There is also the issue of the “point of crossover” — when does one move from curative to palliative care? It is a point of debate with doctors. When people come in at end stage when no treatment can help them, it would be better if doctors and family members realise that the patient has entered the palliative care stage and provide that kind of care.

Social stigma

Stigma continues to be huge. There was a case where a husband thought his wife’s cancer was contagious and isolated her at home. We have also known of a family where the girl’s marriage was called off when the groom’s parents found the father of the bride had cancer.

We get very little support from the government, raising our funds largely through public donations. Our expenses are huge — salaries, fuel for transportation (home care), morphine, blood and blood products and other medical consumables. The service we provide our patients is totally free, though some people pay for buying consumables.

Deepa Muthiah, Dean Foundation


The biggest need of the hour is to recognise palliative care as a specialisation — an MD Course. It has to be incorporated into the medical syllabus and we are meeting with the Indian Medical Council to incorporate the basics of pain management and general psychiatric counselling in the medical curriculum. It is also important to bring it into the nursing curriculum.

Through the Chennai-based Lakshmi Pain and Palliative Care Trust, we are conducting courses in palliative care, for batches of 20-25 at a time. In Tamil Nadu, we have already met the Health Secretary and he has given us the go-ahead to start a training course at the government hospital. We are soon going to begin an eight-week course, with 10 days clinical training at Government Royapettah Hospital, for MBBS graduates.

--RAMYA KANNAN

SMALL BEGININGS

Hard-won peace: A patient at a hospice.
In Andhra Pradesh, palliative care, with a few pioneering exceptions, still depends on the support structure of the family.


The absence of hospices or such services leads terminally ill patients to be tended at home as they simply cannot afford hospital expenses.


“Thanks to them, I could get tremendous psychological boost. They are doing remarkable service,” remarks a retired septuagenarian, who is among the 100-odd terminally ill cancer patients receiving home-care support in Hyderabad, from Dr. Reddy ’s Foundation for Health Education.

Launched as a pilot project as part of Dr. Reddy ’s Corporate Social Responsibility, “Life at your door-step” aims to provide “holistic” support to such patients — both physical and emotional — during a very stressful and difficult period, says an official in the Foundation, who did not wish to be identified.

Providing relief

The innovative project provides palliative care through symptom and pain management and seeks to re-assure patients that life is not burdensome despite devouring illnesses. It is a kind of mobile hospice designed to provide relief to patients who are unable to travel to the hospital due to financial, social or medical reasons. Only a fortunate few receive palliative home care support in Hyderabad. However, the virtual absence of hospices or such services elsewhere in the State leads terminally ill patients, particularly from poor families, to be tended at home as they simply cannot afford hospital expenses.

Take for example the case of Subbulu, a casual labourer from Ongole town, whose 37-year-old son, a municipal councillor, is battling leukaemia at an advanced stage at the Indo-American Cancer Institute and Research Centre in Hyderabad. Thanks to a grant of Rs. 1.37 lakhs from the Chief Minister’s Relief Fund, the family was able to cope with the resultant expenditure. “We will keep him here if there is a cure or take him home”, he says dejectedly. Subbulu lamented that most hospitals in smaller towns turned away such terminally ill patients without “giving even a tablet to ease the pain”.

With practically no hospices, there is a crying need for setting up palliative care centres all over the country, says Dr. G. Durga Prasad, a specialist in cancer pain management and palliative care. Dr. Prasad, an Assistant Professor of Radiotherapy at the Government-run Mehdi Nawaz Jung Institute of Oncology & Regional Cancer Centre, said that a separate department for palliative care was started at the institute with the help of International Network on Cancer Treatment and Research, American Cancer Society and Pallium India.

Pointing out that palliative care starts right from the time the patient is diagnosed with cancer, he observes that, “Difficult as it indeed is, we try to give the bad news as comfortably as possible”. Initially, the focus is on curative treatment, but as the disease progresses, palliative care becomes very important and continues beyond the patient’s death. The members of the bereaved family are provided emotional and psychological support.

Dr. Prasad points out that the Kerala Government had made palliative care a part of its healthcare system and sought a similar policy to be implemented on a countrywide basis. The concept of hospices has not quite taken off in India, he feels, essentially because palliative care is more of an unknown territory in our healthcare system. Another reason for the absence of hospices is because of the fact that it is primarily a Western concept. In the West, the family system has broken down as a support structure. But, this is not true of India where the patient receives a lot of family support right from the moment the disease becomes known. In hospices, the patients feel lonely and homesick.

Dr. Prasad said that plans were afoot to develop community-driven palliative care centres in rural areas in Andhra Pradesh on the lines of Kerala.

Providing service

Disagreeing with this line of argument, Dr. M. Subramanyam, an anaesthesiologist, says hospitals are not interested in establishing hospices not because the idea is Western in nature, but because “there is no money in it. Hospices are more like service centres. That’s why nobody is keen to start them.” Dr. Subramanyam, who runs Axon Anaesthesia Associates Private Ltd., says that his company was planning to set up a hospice in Hyderabad with the help of philanthropists. “Having a hospice will help people save money to a large extent. Typically, in end-stage cases, there is no point in keeping a patient in the hospital as it will be a drain on his resources,” he comments.

Describing palliative care as “adding life to months and not months to life,” Dr.Ch. Mohana Vamsy, Director, Indo-American Cancer Institute and Research Centre, says the first priority should be to take care of patients who are curable, particularly children. The next area of attention should be to create exclusive facilities for the terminally ill.

Dr. Durga Prasad says guidelines conforming to WHO norms would be framed in three months to help hospitals and other organisations establish palliative care centres.

--Y.MALLIKARJUN