INTENSIVE

YET

SUSTAINABLE

Irrigated rice fields are found to be fertile after continuous cropping for decades using chemical fertilizers, which debunks the notion that intensive rice farming is unsustainable.

Limited scope for expanding rice production area
necessitates intensive rice farming to meet growing
demand. However, some people contend that modern,
intensive farming is unsustainable. It is said to degrade
soil, eventually causing it to lose its ability to support
crops. In the case of rice, this is untrue.

Most rice, unlike other major food crops, is grown
on submerged soil, which supports fundamentally
different biological and chemical processes and
requires different management practices. Conclusions
on the sustainability of intensive rice farming must
therefore consider the unique features of rice production
compared with other major food crops.

Scientists at the International Rice Research Institute
(IRRI) established experiments in the 1960s that
subsequently served as “living laboratories” for
strategic research quantifying the sustainability of
intensive rice farming. One of these experiments, the
Long-Term Continuous Cropping Experiment, had by
the end of 2009 produced 137 crops of irrigated rice
with fallows of only 3 weeks between harvesting one
crop and planting the next.

A report published in the Soil Science Society of
America Journal by Roland Buresh, Mirasol Pampolino
and Eufrocino Laureles of IRRI and Hermenegildo
Gines of the Philippine Rice Research Institute used
findings from four long-running experiments to show
that, with proper fertilizer management, continuous
rice cultivation on submerged soils can sustain soil
organic matter and the capacity of soil to supply
nitrogen that is available to plants. In fact, in all four
experiments, total organic carbon and total nitrogen in
the topsoil — which serve as measures of soil organic
matter — were not only consistently maintained but
even increased slightly during 15 years.

“The floodwater overlying soil during rice cultivation
is a favorable environment for the growth of aquatic
biomass such as algae, which, upon death, settle onto
the soil and add carbon to soil,” explains Buresh. In
addition, organic matter in submerged soil decomposes
more slowly than in aerated soil. Thus, under intensive
rice cultivation, soil organic matter is maintained.
Furthermore, the unique properties of the flooded rice
system help sustain soil fertility because of biological
nitrogen fixation, in which soil and floodwater organisms
convert atmospheric nitrogen into a nutrient usable by
plants. The nitrogen produced through biological
fixation per hectare per crop is equivalent to all the
nitrogen in a 50-kilogram bag of urea fertilizer.
The findings reveal that farmers need not apply
crop residues to fi elds to maintain soil organic
matter as long as the nutrients that have been
removed are replaced by appropriate applications
of chemical fertilizers. Contrary to widely held belief,
the long-term application of manufactured fertilizer
does not damage soil health.
The unique features of flooded soils help sustain
intensive irrigated rice systems that now occupy 24
million hectares in tropical and subtropical Asia, on
which 1.5 billion rice farmers and consumers depend.
But more research is needed.

“Scientists must increasingly develop management
practices to ensure continued sustainability as
irrigation water becomes limited,” Buresh concludes.

Palliative Care in India

The concept of palliative care is relatively new to India, having been introduced only since the mid 1980s. Hospice and palliative care services in India have been developed through the enormous effort of committed individuals who include Indian health professionals and volunteers, in collaboration with international organisations and individuals from other countries.
This section highlights some of the formative events in the development of hospice and palliative care in India as well as some of the lived experiences of the people involved.
In the beginning: 1975 to 1990
In 1975, the Government of India initiated a National Cancer Control Programme.By 1984, this plan was modified to make pain relief one of the basic services to be delivered at primary health care level. Unfortunately this policy was not translated into extensive service provision. The hospice and palliative care movement in India started tentatively in the early 1980s and slowly increased in the latter part of the decade. Dr Mohan Bhatia describes his experiences of early palliative care development in India:
In 1973 when I came back from one year’s stay in the UK, there was no concept about palliative care, a terminal patient was given perhaps aspirin tablets and let go, the concept was OK this patient isn’t curable, give him radiotherapy or let him go, in ’73 perhaps first we started thinking that we required something better than the aspirin for these patients so we went to the real opium, we were giving pure opium dissolved in tea to the patients and that was working but then the problem was that every time they had to come back and collect their opium and that was proving to be difficult but that’s the system we ran on for quite a number of years, until the Indian Society for the Study of Pain was formed in ’84. It started at Amadabad, Varanasi and Delhi, three places simultaneously and in ’86 we had the first meetings and then the concept came in of the oral morphine.
In 1986, Professor D’Souza opened the first hospice, Shanti Avedna Ashram, in Mumbai, Maharashtra, central India. At a similar time, pain clinics were established at the Regional Cancer Centre, Trivandrum, Kerala with the assistance of a WHO subsidy,and at Kidwai Memorial Institute of Oncology, Bangalore, Karnataka. Oral morphine was made available, free of charge for the first time. Dr Saraswati Devi recalls the early development of the Kidwai pain clinic:
When we started we saw many numbers of patients suffering from very, very severe pain, so our Professor here, started this clinic as a pain relief clinic in 1986 and for two years it was running just to relieve the pain, we used to give some blocks or some anaesthetic. This is a regional cancer centre and at that time we were seeing around 7-8,000 in a year, and we used to get lots of patients with very, very severe pain. So we started the clinic like that, and later on he went abroad and he worked at the Royal Marsden and got the Royal Marsden formulary, how to manufacture and dispense morphine. With this I joined him, then we started, we bought morphine in India in an institution for the first time in our country in 1987, December. Since 1988, January 1st, we started dispensing morphine to the patients. So we used to import crude morphine sulphate powder from government factory, then get the crude morphine sulphate powder to dispense here with that Royal Marsden formulary.
Jeevodaya Hospice opened in the city of Chennai, in the southern state of Tamil Nadu in 1990. Dr Manjula Kishnaswamy describes how the hospice was established:
Well basically I am a general surgeon and in the late 80’s I was working in the cancer unit of a hospital, and more than 90% of the patients that we were getting were in the advanced stage of cancer and we didn’t have anything special to offer them because they were beyond cure but then we didn’t have any special medicines or anything to relieve their pain and it was terrible to see them coming back to us with unrelieved pain and very advanced tumours, fungating tumours which needed a dressing very frequently and being a hospital with limited resources we were not actually able to cope with the entire population that came in. We realised that these people needed a special service, maybe in a special institution where they could be looked after until the end to relieve them. That was how it started and then we were on the look out for places where and people help us and it was at that time that we met the Sisters and right from day one, the project took off, it was in late ‘89, so the hospice got registered in ’90. At that time there were no others in palliative care, we hadn’t even heard of the word hospice at that time so this was the first hospice of South India and maybe it’s the second in the whole of India the first one we realised started in Bombay Shanti Avedna in 1986.
A key factor in generating awareness of the concept of hospice and palliative care at this time was the input of palliative care expertise provided by international colleagues, especially through WHO. Gilly Burn made her first visits to palliative care services in Ahmedabad, Mumbai and Goa. As a consequence of these visits, she delivered, in collaboration with Dr Bhatia, a six-day course on palliative care and pain relief with 40 nurses. This was followed by a three month palliative care diploma course for doctors and nurses at Gujarat Cancer & Research Institute in Ahmedabad.
Further development: 1990- 2005
From the 1990s onwards there was a significant increase in the momentum of development of hospice and palliative care provision. This was demonstrated through both an expansion in the number of services as well as other key events and initiatives. The few services established were able to act as examples of the ways in which care could be offered to people at the end of their lives. Mr Kishore Rao, the managing director of Bangalore Hospice Trust which was founded in 1994 describes the importance of being able to visit other hospices and how it influenced the development of his own ideas about hospice and palliative care:
And it was those visits I used to make to the hospital periodically that really opened my eyes to, not cancer care so much, as what happens after the care, after the curative part is over, and with illiteracy, you know, with poverty and things being so much in this part of India, it was really tragic that people were not being counselled properly when the treatment ended; they were not being taught what to do or told how they can manage the rest of their lives. That’s when I thought of doing something for palliative care: to me that word was not known at that time, I didn’t even know what palliative care was, but in my periodical visits on business to Bombay I started visiting Shanti Avedna Ashram, India’s first hospice, and that really was an inspiration to me. Throughout the rest of my working career from 1986 onwards I used to visit this organisation every time I went to Bombay. That’s how in 1992 I thought of taking early retirement from the job I was doing to devote the rest of my time to this work, to palliative care.
An important event in the development of palliative care was the proposal to establish the Indian Association of Palliative Care (IAPC) in January 1993, during a workshop arranged with the guidance of WHO and the Government of India. Dr Mohan Bhatia recalls the early aims of the IAPC:
The IAPC was started in Amadabad, I was the first honorary secretary for nearly 3 or 4 years to get it started. In my own mind the aim of the IAPC was to get people interested in palliative care. I’m not talking only of nurses, I’m talking of doctors who are interested and primary health centres, primary health workers whom they call in China barefooted doctors, those types of people interested in palliative care and I think the message was very clear.
IAPC held its first international conference at Varanasi in January 1994 (with WHO and Government of India assistance) and adopted a constitution.The following year, the IAPC set up a Palliative Care Drugs Committee and Educational Task Force and held its Second International Conference in Ahmedabad, where 180 delegates attended. At this time the importance of international support and expertise to Indian hospice and palliative care is demonstrated by the IAPC list of overseas & WHO representatives on the Advisory Faculty; these included:
Dr Jan Stjernsward (WHO, Switzerland)Dr Vittorio Ventafrida (Italy)Dr Robert Twycross (UK)Ms Gilly Burn (UK)Mr Helmut Sell (WHO Delhi)Ms Sally Wimbles (UK)
Dr Sukhdev Nayak, the IAPC Hon. Secretary at that time, states in his 1997-98 report, ‘The help and co-operation from our friends abroad can’t be emphasised more. The role of Dr. Twycross, Dr Stjernsward, Dr Joranson and Ms Gillian Burn in several ways to improve palliative care activities in India has been a great help to our association. The association is extremely thankful to them and our other friends from abroad’(p.49).
Dr Robert Twycross, who has been involved in providing training to colleagues in India since the mid 1980s, writes in his report on visiting India in 1994:
Having met on this visit most of those who have come to the UK over the last 5 years, I am convinced of the value of this form of training for selected potential palliative care leaders. Given the size of India, I anticipate the need will continue until the end of the century. It is necessary to establish indigenous enthusiasts not only in all the Regional Cancer Centres but also in the medical colleges.
The mid to late 1990s saw a range of developmental activities. The embryonic Pain and Palliative Care Clinic was established at Medical College Hospital, Calicut, Kerala, south India. Over the next few years this organisation went on to form the Pain and Palliative Care Society and the Neighbourhood Network in Palliative Care, a community-based palliative care service which became a WHO demonstration project. CanSupport was founded by Harmala Gupta in Delhi which provided the first free palliative care home care support service in north India. In Pune, Maharasthra, central India, the Cipla Cancer Palliative Care Centre was established. In consultation with Cancer Relief India, it developed a new concept of a ‘living’ palliative care centre which has 50 beds arranged in a quadrangle with a children’s playground in the middle.
Morphine availability was a considerable problem to the provision of hospice and palliative care at this time. In 1998, the first collaborative workshops organised by The Pain and Palliative Care Society and the WHO Collaborating Center for Policy and Communications in Cancer Care were held in Kerala. This was one of a series of workshops held across India which were a co-ordinated attempt to persuade state officials of the benefits of adopting the simplified narcotics regulations and thus improve accessibility of morphine. Dr Rajagoapal describes these early efforts:
And David Joranson has I think a very, very pragmatic approach, he would go about talking to people and keep picking people’s brains. He made so many contacts with the government, because he recognised that whatever we do with non-government organisations, morphine availability cannot improve without government’s involvement, because narcotic regulations were preventing access to opioids. Then our association started and we started working together with the Indian Association of Palliative Care, which was also founded in ’93, became a partner to it, but I’m sure David’s role in it was the biggest factor which improved things. What we did together at that time was he raised the money, he found the money, and wherever we could identify a champion, in that state, we would try to get the administrators and palliative care doctors together round the same table with him. We did that first in Kerala; we could get the government official, senior bureaucrat to support us, so there was this bureaucrat and then the doctors and drug regulators, and the drug regulators could bring out their fears about addiction; other doctors could talk about their fears and things could be clarified over the table, across the table, and the decision was taken then to improve things.
The Future
The growth and development of palliative care in India over the last twenty years is reflected in an analysis of journal articles which have been written about palliative care in India. Figure 1 demonstrates the rise in internationally available published articles.
Figure 1. Published journal articles 1989- 2005
However, Dr Rajagopal, writing in 2005, presents a more detailed assessment of palliative care development in India:
Look back at the development of palliative care in India: from its birth as a hospice in Mumbai in 1986, to its acceptance as an essential part of National Cancer Control Program in 1991, to its establishment in many of the regional cancer centres, to its spread as a community oriented network in Kerala, and to a reversal of the downward trend in opioid consumption in the country. Some of us palliative care workers tend to pat ourselves on our backs – till we are taken aback by someone like Dr Jan Stjernswärd who points out that all considered, the progress is “disappointing”. When the blinders fall from our eyes, we see the disappointing bits. The policy exists, but only on paper. Oral morphine reaches less than 1% of the needy, even now. The vast majority of institutions treating cancer patients have no palliative care services. There are many states in India which even now have not even a single palliative care facility. It is easy to blame the red tape and the Government, but the fact remains that the medical and nursing professions at large, have not accepted palliative care as an essential part of health care.