Thirty years ago a young anaesthetist, newly appointed as head of department at Calicut Medical College Hospital in the Indian state of Kerala, encountered a case that would change his life.

A college professor aged 42 with cancer of the tongue had been referred to him by an oncologist. The man was in severe pain and the anaesthetist, Dr M R Rajagopal, was asked if he could help. He injected the mandibular nerve in the jaw in a procedure known as a nerve block, and told the patient to return in 24 hours. Next day, the pain had almost completely gone and Dr Raj, as he is known, was pleased with his work.

“He asked me when he should come back. I told him there was no need to come back, unless the pain returned. I thought he would be happy I had cured the pain. Instead, he went home and killed himself that night.”

It turned out that the oncologist had avoided explaining to the college professor that his cancer was terminal. Instead he had said he was referring him for further treatment.

“It was only when I told him there was no need to come back that he realised his cancer was incurable. He went home and told his family it was all over.”

Dr Raj reaches for a glass of water. We are sitting in his simple home in Trivandrum, the leafy state capital, where he now lives with his wife, Chandrika, a pathologist. In front of us, a plate of yellow jackfruit gleams in the low afternoon light. A fan whirrs above.

That experience caused Dr Raj to examine his own practice. In addition to putting people to sleep for surgery, an anaesthetist’s job is to tackle pain. So what was he missing, he wondered.

“In those days pain was all over the hospital. It was everywhere. We pretended not to see it, but it was there. Injections of morphine were used sparingly, after surgery and for patients injured in accidents. It was never used in cancer pain.”

Medical staff coped with the suffering the same way they cope everywhere. “No one teaches you, but you learn to see only the disease, not the human being who has it. Maybe if there is nothing you can do it is easier to turn your back.”

Dr Raj had had two earlier traumatic experiences involving the dying. Aged 18, in his first year in medical school, he had lived close to a man who had terminal cancer of the sweat glands. “I would hear him screaming in the night. He had nodules all over his scalp. The family knew I was a medical student and asked if I could do anything. I didn’t know how – I was helpless. I am ashamed that I never visited him after that. I did not want to go there and feel helpless again.”

Later, he was looking after a patient with a gangrenous toe who was in excruciating pain. “I asked my head of department if I could try a nerve block. He refused – it was not part of routine care and there was a shortage of anaesthetists. I had to tell the man there was nothing I could do. I still remember the look of hopelessness on his face.”

When he became head of department at Calicut, there was no one to tell him what he could and couldn’t do. That is how he came to treat the college professor. But his patient’s suicide showed him that treating the pain was not enough.

“I realised that thinking about nerve blocks was too narrow. Pain is just the visible part of the iceberg of suffering. What is ignored is the part below the surface – feelings of hopelessness and despair, worries about money, about children. That is what palliative care is about. That man gave up his life to help me understand it.”