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 anesthetist’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 anesthetists. 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 realized 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.”

* * *

We all wish for a pain-free, dignified death. Too few of us achieve it. Worldwide, the last year of life is marked by widespread unnecessary suffering. At least 40 million people need palliative care each year, but only around half that number receive it, according to the Worldwide Hospice Palliative Care Alliance.

India comes near the bottom of the global league in access to end-of-life care—ranked 67 out of 80 countries in 2015—but Kerala is an exception. This small green and fertile state in the south-west has just 3 percent of India’s population but provides two-thirds of the country’s palliative-care services. These have developed over the last 20 years, driven by the local community and supported by a unique system of volunteers. Some claim it is Kerala’s strong ethos of community involvement that is the secret behind its palliative care provision, which would be difficult to replicate elsewhere.