Doing More With Less

by Marcia C. Landskroener

Dr. M. Krishnan Nair is one of the most respected doctors in India. He was awarded the prestigious Padmasree Award in 2000.

Dr. M. Krishnan Nair takes a very pragmatic view of cancer treatment in India: catch it early when you can, and reach out to as many people as possible, and for those patients who have terminal cancer, provide them a pain-free and dignified end.

"We do not need to spend a lot of money to die," he says. "Every Indian knows he will die one day. He looks forward to death, and to rebirth. Indians don't welcome the western philosophy of fighting death. What they do welcome is a painless death."

Nair, director of the Regional Cancer Center (RCC) in Trivandrum, India, also believes Indians don't need to spend a lot of money - money they don't have - to treat cancer. That's why early detection is so important. That, and a standardized approach to treatment that is cost-effective.

"Early detection strategies should focus on cost-effectiveness," he insists, pointing to the Swedish model where regular screening programs and treatment facilities are readily available in a community setting. The young doctor who used to go into the villages to pick up cancer patients for treatment; the activist who started training health workers, dentists and volunteers to detect tell-tale lesions in the mouth; the idealist who convinced the Chief Minister of State to fund a modern cancer center in India, still dreams of doing more with less. The RCC, under Nair's direction since the doors first opened in 1981, was the first to start a community cancer center. Through public education and training of volunteers and doctors, they were able to reach more cancer patients earlier. Nair was also responsible for launching the first pediatric cancer center, and for developing the largest network of pain and palliative care centers in the entire country.

Nair's philosophy about drug therapies reflects his constant endeavor to stretch precious resources. He believes that there is too broad an application of the latest (and more expensive) drugs, and wants to standardize diagnostic tests and cost-effective treatment. He also wants to channel resources to those areas, such as pediatric cancers, where there is the greatest opportunity for cure. "The main objective should be to identify treatment that can be universally employed. We could reach more people and serve them much better," he says. The streamlined administration of morphine he engineered is a perfect example. A more rational scheme has been devised for the use of morphine in patients with terminal cancer, which has resulted in considerable saving of the drug. This means that those patients who might not have had access to morphine are now receiving it. And still, no cancer patients die in pain.

Nair is equally committed to advancing cancer research in his country. As chairman of the Board of Studies in Health Sciences at Kerala University, he is responsible for training a new generation of doctors. He also has led more than two decades of research, formulating and conducting more than 75 research projects investigating, for instance, the effects of natural background radiation, the relationship between cervical cancer and HPV infection, and low-cost strategies for early detection of cervical and oral cancers. In collaboration with major pharmaceutical companies such as Pfizer and Johnson & Johnson, RCC doctors are currently running 12 clinical trials in breast cancer, lymphoma, and other types of cancer.

"It is now known that over one-third of cancers are preventable, one third are potentially curable provided they are diagnosed early in their course and for the majority of incurable patients the quality of life can be improved by palliative care. However, control of cancer will not come about without an established mechanism."