`An uphill task all along'

Print edition : August 26, 2005

V. GANESAN

Interview with Dr. V. Shanta, winner of the Ramon Magsaysay Award.

From across the country they come - men, women and children - with fear and uncertainty. Often unlettered, all that they know is that they are ill. For over half a century, thousands of them have thronged the huge reception hall of the nine-acre Cancer Institute (WIA) in Chennai; for the place inspires hope of a cure.

Better known as the Adyar Cancer Institute, it was set up by Dr. Muthulakshmi Reddy in 1954 - the realisation of a 27-year-old dream. (Muthulakshmi Reddy was the world's first woman Vice-President of a Legislature.) Her son Dr. S. Krishnamurthi, director of the institute since 1959 took his mother's project forward. Dr.V. Shanta has stood by him in this effort. She has dedicated her life to build the Institute into one of India's finest centres for oncology treatment and research.

The 428-bed state-of-the-art facility has grown from a 12-bed hospice owing largely to the untiring and selfless work of Dr. Shanta for over half a century.

So much has happened in cancer care over the past 50 years - in diagnostic methods, treatment options, preventive care, early detection and patterns of cancers - but what has remained unchanged, almost as if caught in a time warp, is Dr. Shanta's spartan office, the small functional dwelling unit within the Institute that has been her home for the past 50 years, and most important, her warm, affectionate and infectious smile.

Various awards have recognised her illustrious life, the latest is the Ramon Magsaysay Award for Public Service. Dr. Shanta has dedicated the award to the institute, saying that there "is a long way to go". The Cancer Institute, which she has nurtured, lives up to its motto: "With humanity and in wisdom." Says Dr. Shanta: "When the sick approach the gates of the Institute, weak in body and spirit, and full of fear, there is only one response, you have to become part of them" (Frontline, July 7, 2001). This spirit is amply reflected in the dedicated team of doctors and paramedical staff, for whom each patient is a commitment for life.

The award citation is worth quoting to describe aptly Shanta's service. It reads:

"In an era when specialised medical care in India has become highly commercialised, Dr. Shanta strives to ensure that the Institute remains true to its ethos, `Service to all.' Its services are free or subsidised for some 60 per cent of its 100,000 annual patients; travel allowances make regular treatments accessible to the poor. And through a volunteer programme called Sanctuary, the Institute provides hope-giving emotional support and counselling to patients and their families and to cancer-afflicted children. There are thousands who might say, as leukaemia victim Delli Rao, a wageworker, has said, `I owe my life to Dr. Shanta.' Seventy-eight-year-old Shanta still sees patients, still performs surgery, and is still on call twenty-four hours a day."

Awarded the Padma Shri in 1986, Dr. Shanta has published nearly a 100 research papers in national and international journals. She is a member of the World Health Organisation's Advisory Committee on Health and has been on several national and international committees on health and medicine. But for her the real reward is the joy of those who return home cured.

In an interview to Asha Krishnakumar, Dr. Shanta gives a glimpse of her inspirations, aspirations and future plans. Excerpts:

What or who was your inspiration? When professionals these days are so bothered about career and making money, why did you dedicate yourself to public service?

I come from a fairly illustrious family. C.V. Raman (my grandfather) and Dr. S. Chandrasekhar (my paternal uncle) were on whom we youngsters modelled ourselves. My grandfather was a voracious reader and we were in awe of him and he was a constant source of inspiration. We wanted to emulate him. Naturally, we all aspired to do something unique and make some contribution in our own fields. I am the eldest and no one in my family has taken to this profession.

We had an excellent library in our home - almost as in schools. That got me very interested in reading. I am talking about the 1940s, when there were very few professionals, particularly among women in India. They were mostly in teaching or nursing. Doctors were few. I came across a few people like Lady Duffrin, a medical professional, who went about in uniform, smart, independent and extremely professional. This had a lasting impression on me.

By the time I completed school - National Girls High School (now P.S. Sivaswamy Higher Secondary School) - I was determined to get into the medical profession. Miss Wheel, from Ireland, was our Principal. She instilled tremendous discipline in us. Every day, she would speak to us on the need for honesty, to be caring for others, and so on. This again made a deep impression on me.

I completed intermediate in 1943, when I was 17, and waited a year (as I was under-aged) to join medical college - my dream. That year, when I stayed at home was an important period as I read a lot of literature, which I could not do after I joined the Madras Medical College in 1944.

Were your parents and other elders at home supportive of your decision?

They supported me but thought it would be very difficult for me to complete the course as I was very small and thin. But I did fairly well and completed the course in 1949. At that time, even within the profession, women generally took obstetrics and gynaecology. But I thought I should be different.

How did you get interested in oncology?

I was first posted to the General Hospital's cancer unit, which had just then been started by Dr. S. Krishnamurthi, who had returned after training in the United States. I was impressed by his attitude and the way he handled patients and conducted the OP [out-patient] unit. May be that influenced me.

I learnt a great deal about proper conduct and behaviour [in the medical profession]. This is particularly so as corruption was rampant at that time in the hospital. None of the cancer patients could get admitted easily. Patients went to the surgeons there, paid them `something' and only then could they get admitted. This Dr. Krishnamurthi could not tolerate. So he started maintaining a waiting list. But the surgeons got around it by asking the patients to come to the casualty department complaining of stomachache or bleeding and got them admitted out-of-turn.

I was there for only a short while but that had made a deep impression on me. I also knew about cancer and that the facility for treating the disease was very meagre both within the country and the world over primarily because there were very few treatment methods, only surgery and radiation. This was in the early 1950s. But, by then Dr. Muthulakshmi Reddy had started a campaign for a separate cancer hospital. The then Minister for Health, T.S.S. Rajan, opposed it saying there was no need for a separate cancer hospital; cancer affects only the old and in any case they die. But she would not bow down to these oppositions. Having lost a sister to cancer, she was determined to take up the cause of the cancer patients.

She then opened the cancer relief fund. I was part of the campaign in a very small way right from the start. When she set up the Cancer Institute in 1954 I had just finished my Doctor of Medicine (M.D.). I had also got through the Public Service Commission examination and was posted to the Women and Children Hospital. I had to make a crucial decision. I decided to join the Cancer Institute instead, upsetting many people.

The outpatient hall at the Cancer Institute, Adyar.-V. GANESAN

How were your initial years at the Institute?

Dr. Krishnamurthi made it very clear that he could offer me nothing. There was no money in the Institute. But that hardly mattered to me. For three years we worked as honorary staff. There were only two doctors - Dr. Krishnamurthi and me. We alternated being in the hospital during the day and operating together - we need two doctors to conduct operation - after 6 p.m. every day as the anaesthetist, whose fee we could not pay, could come only at that time, after working elsewhere. We would start surgery at 7 p.m. and complete by midnight. I would stay with the patient, as there was no other doctor, and would be relieved the next morning by Dr. Krishnamurthi. But this could not continue for long.

The Institute decided to pay me Rs.200 every month and also offered me residence within the campus. So I moved into this campus on April 13, 1955, and have remained here ever since.

From then on it is a long story.

Can you trace the development of the Institute?

Dr. Krishnamurthi and I always looked at ways to further the Institute. We started with 12 beds, and now we have 428. We had facilities only for surgery and radiotherapy. Even the radiotherapy we had was a high-voltage radiation and not sophisticated.

But, then, most of the times we were the first in the country to install cancer treatment facilities though we were an unknown voluntary organisation. In 1957, we installed Asia's first Cobalt Teletherapy Unit. We call it the tryst with destiny. On December 25, that year, we got a call from the Atomic Energy Commission telling us that it would give us a cobalt unit. Like the Magsaysay Award now, it woke up the Central and State governments, to take notice of this relatively unknown Institute. They began to extend support in small ways.

The Institute has many firsts to its credit: The nuclear medical oncology department in 1956; a paediatric oncology department in 1960; mammography to diagnose occult breast tumours in 1965; and a linear accelerator in 1976. We pioneered combination therapies of oral cancer with radiation, surgery, chemical sensitisers and cytotoxic drugs, raising the cure rate from 19 per cent to 60 per cent. It is the only place in the country offering hyperbaric oxygen therapy (started in 1978), hyperthermia (1984) and intra-operative electron therapy (1992). The institute designed and fabricated a fully indigenous Brachy therapy unit for the treatment of cancer in 1995.

We have become a comprehensive cancer centre today by begging for funds, both nationally and internationally. We were declared the first regional cancer centre in 1976.

What is a comprehensive cancer centre?

It means you have a hospital, a research centre, a division for preventive oncology, and teaching. We also have a College on Oncology Sciences, also the first in the country that takes care of super-speciality training.

What is the high point in your life?

I can say that when the Cobalt 60 unit came we had a high point; when the linear accelerator was installed, we had a high point... . Like that, it goes on. There is no one thing I can say as the high point. Now, we believe, Magsaysay is a very good recognition. We are happy. But we just have to continue, and go on.

Can you think of a low-point?

So many, not just one or two. We have come through innumerable obstacles, trials and tribulations. For instance, it took us 10 years to meet people at the Medical Council of India to ask them to recognise oncology as a super-speciality. That was not easy. We struggled at every step. When we applied to the Rockefeller Foundation for funds to buy books for the library, the DME [Directorate of Medical Education] asked us to explain the need for a library.

The Government of India has communicated to us that it has set apart Rs.3 crores for equipment. But, for some reason, committee after committee has been set up to clear the funds, which are yet to be disbursed. Apart from funds - always a problem - we have faced at every step unnecessary obstacles. There are any number of such low-points.

When I met Chief Minister Jayalalithaa [after winning the Magasaysay award], she promised to look into some minor things we need at the Institute. But now, fortunately, there is some recognition because we have come up to a certain level. But it has been an uphill task all along.

What are the common types of cancers among men and women? Has there been a change in the profile of cancers in India?

The incidence of cancer in the country has remained almost constant in the past 20 years. It is about 81 per 100,000 for men and 95 for women. But the burden of cancer - the total numbers - is very high and that is essentially a demographic effect because the population is growing. According to reliable projections, India has more than 800,000 new cancer patients every year. In the next couple of years, this is projected to rise to 900,000. This is particularly worrisome as the number of patients is large and rising even as the cost of treatment is soaring.

The incidence is more among women as they have two more organs than men - breasts and cervix. In India, the common cancers among women are of the cervix, the breasts and the mouth - in that order. With lifestyle changes, breast cancer has overtaken cervix. But, in Chennai, cervical cancer is still the number one type of cancer. Mouth cancers are essentially tobacco-related.

Among men, the type of cancer varies across States. The common cancer in Chennai is of the stomach, then of the mouth, the throat and the oesophagus. In the north, more common is lung cancer, which is gradually increasing primarily because of the rise in smoking. That is why we have a major tobacco control programme. We have established tobacco cessation clinics, where people are counselled and given drugs to kick the habit. In addition, we go to schools and talk to children, who are at an impressionable age, about the dangers of smoking. According to the latest Tobacco Report, 80 per cent of men use tobacco in some form in North India. In South India, it is much better, but we cannot afford to be complacent. Nearly 40 per cent of cancers in men are tobacco-related.

How important are genetic and environmental factors in the rising incidence of cancers in India?

Certain cancers such as those of the breast and prostrate have a genetic background and hereditary tendency. Nearly 10 per cent of breast cancers have a hereditary basis. We have a hereditary cancer clinic. As the gene that produces breast cancer has been identified globally, we can find out the risk of breast cancer among family members prone to such cancer.

With changing lifestyles are the patterns of cancer also changing?

Certainly, there is a change in cancer patterns due to lifestyle changes. Breast cancer, for instance, has been on the rise due to lifestyle changes. The increase in the age of marriage, fewer children and change in dietary habits with emphasis on high-fat fast-foods, have led to increased incidence of breast cancer.

What are the treatment options?

Now treatment options for all cancers are satisfactory. We have good methods of surgery and radiation. Developments in medical oncology or drug treatment have changed the horizon of cancer cure. Cancers that were beyond cure have now been brought into the ambit of cure. For example, 80 per cent of Hodgkins disease and 60 per cent of leukaemia are now curable. Organ conservation is now possible in bone tumours. Limbs can be restored and amputation avoided in several cases. These are the major advances. Concepts of treatment and care have now undergone a change. Today, cancer is preventable and curable. The fear should not be of cancer, but only of delay [in detection].

How do you plan to steer the Institute forward?

Three things are important for the future:

Most important for the control of cancer is early detection. For, more than half of the patients come to us only in an advanced stage. So our concentration should be on early detection. There must be a network of early detection centres rather than a few here and there.

Two, we must ensure that all the benefits of research reach everyone in need of it, irrespective of class. Treatment and care are very expensive now. But probably a system of insurance can help the poor access the fruits of cancer research.

Three, we have to enhance our research capabilities. We cannot afford to be complacent. Today's research is tomorrow's treatment.

But research is expensive. Where will the money come from?

From governments, corporations, or collaborations. There is enough money. But research does not appeal to those who have the money.

The Magsaysay Award is another milestone in your career. Where do you think it will take you in your `tryst with destiny'?

The award has come at a good time. It has given us international exposure and appreciation. We hope it will also enhance our local appreciation. But how much support it is going to actually get us I have to wait and see. It may improve things slightly. But lots more need to be done. We have to work harder to show that we can do things.

But you have already showed that through your sustained efforts over the last 50 years.

But we have to do more and more....

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