Vasant Ramji Khanolkar shared Joseph Gillman’s preoccupations regarding non-Western populations and their susceptibilities to cancers. Like Gillman, Khanolkar, who was president of the Cancer Research Commission of the UICC from 1950 to 1954, had led national-level cancer surveys for over a decade in India, focusing on an industrial population of millworkers in Bombay and its hinterland. He also led the geographic pathology of cancer studies in India. His networks in the Indian political establishment were deep and wide, ranging from close ties with Indian industrialists such as Naval Tata, whose family had set up a trust fund for cancer research in Bombay, to contacts in Delhi with leading figures in the Indian Planning Commission and the national leadership.
Early in his cancer research, Khanolkar focused on challenging the persistent claims made about cancer and its geographical specificity. Even at the Cancer Research Commission meeting in Bombay in 1952, he stated in the press that although cancer was now recognized as a world problem, it still lacked a distinct, scientific name in India and was known only by its Sanskrit name. Khanolkar’s mission was to make the disease and its related scientific evidence visible, as well as to demonstrate that countries such as India could suffer from diseases and conditions of industrialized nations. No longer should these countries be associated only with the pathologies of tropical diseases also linked to India’s colonial past.
His public health colleagues in India echoed Khanolkar’s concerns. Writing in 1954, a senior public health functionary speaking at the Indian Science Congress observed that challenges like cancer were becoming increasingly prominent simply because “old problems are solved and new ones (have) arisen.” He added that “tropical disease” was a concept that lacked wider purchase, since no diseases were peculiar to tropical climates. That category referred only to diseases of poverty, and “if taken in the sense of latitudes labels like tropical disease and tropical medicine were misnomers, since these diseases were not typical of tropical climates but of backward countries that had been banished from the west only because it had banished food deficiencies, industrialized and acquired colonies, improved sewerage, and introduced sanitary reforms.”
Khanolkar’s research, presented at multiple meetings such as the CIBA colloquium, at the Oxford meeting on the geographical pathology of cancer and at other international meetings, was significant in challenging a persistent debate regarding the differential incidence of cancers in India. He argued that there was a “sameness” in diseases such as cancers across the world and noted that arguments that the cancer rate was “eight times as high among the 500 millions of civilized races as among the 1,200 millions of backward races including the 300 millions in India” were misplaced.
However, establishing the incidence of cancer was by itself not a badge of modernity, since Khanolkar was aware that many developing countries were reporting an increasing incidence of cancer cases.
Khanolkar also explored cancer’s characteristics and social gradient in India, implying that vulnerabilities to different types of cancers varied greatly among the population. He therefore argued that cancer differed greatly in India based on “habits and customs and usages” among its social groups, depending on the impact of historical events over time that changed the environment of the people. He identified two factors – environmental determinants and inbreeding or “endogamy” – as critical determinants for the occurrence and types of cancers in India.In a widely quoted statement cited by Cowdry, Khanolkar argued that the more common types of cancers in India tended to occur above the chest, rather than below it, in contrast to Western populations in industrialized societies. By terming certain bodily sites or organs as more susceptible to cancers in environments such as in India, and some cancers as common in the industrialized West and rare in the Indian setting, Khanolkar was trying to align the differential development and modernization between countries.
According to him, cancers associated with specific customs and chewing habits were also distinctive of certain classes of people, such as the Deccani Hindus who worked mainly as gardeners, mill hands, stevedores, and policemen. These habits were in turn compounded by “ancillary factors” such as poor oral hygiene, malnutrition, and lack of adequate vitamins. Tobacco chewing was common among lower classes and migrant workers in cities, who retained their traditional tobacco consumption habits; this implied these behaviors and cancer risks were typical of those who had still not adapted to modern habits and an industrialized life.
Khanolkar’s research identified some social groups in India who suffered from chronic diseases in their older years and manifested the same susceptibilities as Western white populations. Parsi women, or those of the Zoroastrian faith who formed part of an urbanized, educated elite in Bombay, were an exceptional group among Indian women who had similar rates of breast cancer to those in London county hospitals and in New York, at the Memorial Hospital. The Parsis, he noted, were a tight-knit community with close inbreeding; they were prosperous business people. Their women were often unmarried or had late marriages and fewer children – very different from Hindu women “amongst whom the opposite conditions prevailed” – which caused Parsi women to suffer from higher rates of breast cancer.
Even as Khanolkar wrote up these last conclusions in the early 1950s, he was aware that his own professional support for cancer research had originated from the Parsi community and from the interest of its leading business family, the Tatas.
After Lady Meherbai Tata died from leukemia, her husband had endowed in her name a trust for cancer research in Bombay. Both Cowdry’s visit and recommendations on planning cancer research in India and Khanolkar’s own career at this point were supported by this largesse. Leukemia and breast cancer in this case were feminized diseases in the West, associated with white women. Their occurrence among Parsis, who were associated with Westernized, liberal, modern lifestyles and endogamy, reinforced ideas about their being modern and mimicking white populations in their disease susceptibilities.
In these years, cancer research was beginning to generate interest in other Indian cities, such as Madras, among an urban middle-class public that was founding cancer societies due to growing concerns for the number of lives lost among their young professional colleagues. In this case, chronic, degenerative diseases such as cancers were affecting a productive and socially significant population – and felling them in their middle rather than later years as in Europe or the United States. Khanolkar was aware of these trends, and he used the association between an earlier age of cancer onset and the implications for development and productivity in India to good effect. The ominous challenge posed by cancer in Indian life, he noted, lay within the “age composition of the Indian population”. He observed that too much attention had been focused on one age group and its premature deaths in India, such as the deaths of infant children, of whom “roughly a quarter die during the first year.” Their plight had drawn public attention “mainly due to the excellent propaganda by infant welfare organizations on the matter of deaths in infanthood. However, the mortality of older age groups had been overlooked.”
In India, Khanolkar wrote, unlike in the West (where higher mortality occurred later in life due to longevity and child mortality rates had fallen), high mortality occurred during infancy and continued to be four to eight times higher until the age of fifty-five. “Considering the short life expectancy in the country relative to the west, this had serious implications because it implies a forfeiture of nearly half of its population during the most productive period of life or the period of their greatest effectiveness,” he wrote. “These are the people for whom the family, the community and the state make the biggest sacrifices and who in other countries live long enough to prove of inestimable value by attaining the full span of their usefulness. It is the age group which supplies in other countries men who rule over the destinies of institutions, armies and empires”. This did not preclude attention to older groups in the long run, he wrote, since cancer “occurs most often in people more or less advanced in years and that mortality from it rises as the number of elderly people in a community increases.” This would happen eventually in India through the elimination of “avoidable disease” and a reduction in mortality, but the immediate challenge was different from that in the West.
Excerpted with permission from As The World Ages:Rethinking a Demographic Crisis, Kavita Sivaramakrishnan, Harvard University Press.