Dr. V. Shanta, who was awarded the Padma Vibhushan this year, has won many awards for her work as an oncologist — Padma Shri in 1986, Padma Bhushan in 2006, and the Magsaysay Award in 2005 to name but a few — for public service and many more for academic distinction. Her name is synonymous with the Cancer Institute at Adyar, Chennai, a pioneering centre of oncology which, starting in 1954 from a thatched shed with 12 beds, has two campuses, 423 beds, and patients from all over the country. It is like a brand, earning instant recognition and smooth entry for its alumni in professional placements nationally and globally.
Much has been written on Shanta’s achievements and that of the Institute. This essay tries to delve deeper into the underlying processes that interconnect the individual and the institution.
The awards are a tribute to Shanta’s pursuit of excellence but equally about outreach to the poor and nurturing of a holistic ethic of service and care. Although Shanta credits her entire team, these achievements are indeed largely due to her leadership. But they are also part of the institute’s ethos which cannot be understood without exploring its history, the personalities who were founding members and their mutual relationships.
In this essay, I try to see how these three elements — of excellence, outreach and an ethic of care — came together in the making of Shanta, the doctor. I also look at the dynamics in the making of the Institute’s own signature approach. In doing so, I draw on feminist insights on the relationship between micro and macro domains of life and on debates on the ethic of care. Between 2009 and 2011, I had many long conversations with Shanta as part of my project to archive the Cancer Institute for the Dr. Avabai Wadia Archives for Women at the Research Centre for Women’s Studies, SNDT Women’s University. The narratives and documents I collected furnished a vantage point to grasp these intricacies.
I first visited the Cancer Institute as a patient in 2005. I could immediately sense its distinct character. There were many patients from ordinary backgrounds; the medical staff, although overworked, were competent in cutting-edge technology and had a sympathetic manner; the upkeep was about average and care facilities simple though adequate. Relatives accompanying patients from rural Tamil Nadu and Andhra would be squatting in groups in the spacious grounds, waiting to be called. There were long queues, but all patients got started on the investigation process the same day. The para-medical personnel were not quite on par with the medical staff, but still, things seemed to be working.
There was an income-based differential payment system. As I went through my own treatment, the Institute’s underlying approach slowly unfolded: priority to saving life at all costs, no frills; advanced technology for core treatment alone, no differentiation between different classes of patients in medical treatment. The overall feel was neither statist nor corporatist. It was a voluntary, charitable trust, but it did not have a ‘welfarist’ feel either.
The Cancer Institute was the first specialised hospital for cancer in South India at a time when there was no public awareness about it. It was a ‘karma vyadhi’ (ordained by fate), considered fatal – no cure, no escape. From the start, the Institute had to contend with political, governmental, bureaucratic and financial hurdles, and popular apathy. Yet, it established itself rapidly as a reputed institution combining quality and affordability. It pioneered the multidisciplinary approach, giving equal place to medical, surgical and radiation oncology.
There were many other firsts: The Institute started a department of nuclear medical oncology in 1957, introduced radioactive isotopes in diagnosis and treatment, acquired the Cobalt 60 unit in 1957 (the first in South and Southeast Asia), the first Indian-built X-ray Therapy Stimulator in 1969, and in 1976, the Linear Accelerator, a High Energy X-ray machine more advanced than Cobalt 60. It started specialised academic courses from 1960 through Madras University and later by establishing the Dr. Muthulakshmi College of Oncological Sciences, attached to MGR University, the first such in India.
That is not all. The Institute has contributed to mapping the course, spread and control of the disease through a Hospital Cancer Registry. From the start, protocols were developed for keeping detailed patient records, with a formidable follow-up system. On occasion, the Institute was known to send its personnel to track a recalcitrant patient to his village and escort him physically for follow-up! In a largely illiterate population, this reduced fatalities considerably.
Further, the repository of epidemiological data over 60 years has contributed to a rich institutional memory – an invaluable legacy for the younger doctors. The Indian Council of Medical Research initiated the network of Cancer Registries in 1981, locating the Madras Metropolitan Tumour Registry in the Institute. In 1974, the Government of India selected it as the Southern Regional Centre for Cancer Treatment and Research.
The Institute has devoted considerable effort to prevention through education, propaganda, field surveys and screenings. In 1956, it persuaded the Railway Ministry to grant concessional train travel for cancer patients. In 1971, it successfully petitioned the Union Finance Ministry to declare anti-cancer drugs as life-saving and allow import of chemotherapy drugs without licence and customs duty. It forged international scientific collaborations which helped with treatment protocols, provided laboratory support, funded training programmes for Institute doctors in the US and elsewhere. Distinguished oncologists would make it a point to stop over at the Institute when visiting India, and many international donors as well as grateful patients helped with funds.
Three key personalities
Shanta’s journey in oncology is intertwined with that of at least two other individuals: Dr. Muthulakshmi Reddi who established the Institute and her son, Dr. S. Krishnamurthi, who steered it into a powerful model for the newly independent nation. The Institute is also tied by an organisational umbilical cord to the Women’s Indian Association (WIA), which later became a branch of the All India Women’s Conference. WIA was set up in 1917 in Madras by three Irish suffragettes – who were also theosophists — Annie Besant, Margaret Cousins and Dorothy Jinarajadasa. It engaged with the major nationalist concerns of the time and played a leading role in pushing for women’s right to vote. Thus, the Institute’s origins are part of the legacy of the early Indian women’s movement. Shanta herself comes from an exceptional lineage of scientists. In her biography and that of the Institute, the histories of social reform and freedom, nation-building and institution-building, science and Nehruvian ideals, excellence and outreach are intermingled.
How is looking at Shanta’s work at the Cancer Institute through a feminist lens different from what any sensitive biographer would attempt? It is true that two of the three foundational figures of the Institute are women, and one of these was a campaigner for women’s rights. The Institute itself was established under the organisational rubric of a reputed women’s organisation, WIA, which was involved hands-on in the initial stages. But I would go further than this. The character and thrust of the Institute become comprehensible only through the personal lives and motivations of its three protagonists and their mutual relationships. It is this invocation of the political in the personal that helps us identify the source of its dynamism.
Dr. Muthulakshmi Reddi: Unstoppable zeal
The Cancer Institute’s unique profile is the outcome of the missionary zeal of its founder, Dr. Muthulakshmi Reddi. Her personality, social concerns and political engagements shaped its values and ethos. Her approach deeply influenced her son and successor Dr. Krishnamurthi and his colleague Dr. Shanta who steered its development.
Muthulakshmi was one of India’s early women doctors, graduating from Madras Medical College in 1912. A well-known gynaecologist and obstetrician, she was also an ardent social reformer and nationalist who crusaded for legislation to protect women and children. She was elected Deputy President of the Madras Legislative Council in 1927, globally the first woman to preside over a legislative body. She started the Avvai Home for orphaned girls in 1931. She was the force behind the Devadasi Abolition campaign in Madras Presidency from 1939 to 1948. Her mother was a devadasi and Muthulakshmi’s personal anger at the injustices and indignities of that identity gave an edge to her ferocious campaign.
When Congress leader Satyamurthi argued in the Legislative Council against abolition since it was an ancient religious custom with devadasis being the custodians of the traditional arts, she famously retorted that if such a caste was indeed necessary and since the devadasis had done it for so long, why did the brahmin women not take over? Muthulakshmi’s approach has been sometimes criticised as condescending towards devadasis, denying them subjecthood and agency. Yet her sincerity was never in doubt.
Muthulakshmi was the first Secretary of WIA and later became Life President. She edited its journal Stri Dharma. She had lost her sister to improperly diagnosed cancer in 1923. Nursing her through her last painful days, Muthulakshmi vowed to establish a specialised hospital for cancer treatment. Inspired by the emerging advances in the West, she spent a year at Royal Marsden Hospital, London, in 1925, specialising in cancer treatment. She got WIA involved in her mission. It was an unusual issue for a women’s organisation to take up but the sheer force of Muthulakshmi’s personality made this a major activity of WIA for many years, noted Sarojini Varadappan in an interview with me. Sarojini, who passed away in 2013, was a renowned social worker and one of the Secretaries of WIA at that time. She worked closely with Muthulakshmi.
Muthulakshmi wrote in academic journals and copiously in popular media, and spoke untiringly in various fora for her cause. In 1936, she mobilised several women’s associations in Madras and presented a joint memorandum to the King George Memorial Fund Committee urging that its funds be utilised for establishing a cancer hospital. Throughout the next decade, she continued to push the government on this. In 1949, WIA started a fund raising campaign – the Cancer Relief Fund. There were exhibitions, pamphlets, posters. Initially the male doctors were hostile or simply indifferent. They used to say, why are you wasting your time? They used to pass uncharitable remarks against Muthulakshmi, recounted Sarojini.
Eventually, Muthulakshmi managed to get the government to donate a piece of land at Adyar. Prime Minister Jawaharlal Nehru laid the foundation stone in 1952. Sarojini remembers how Nehru in his speech expressed pleasure that such a worthy activity was being initiated by women. The Institute is still officially known as Cancer Institute (WIA) as a permanent tribute to its lineage.
The son who supported his mother’s dreams
Muthulakshmi sent her son Krishnamurthi to the USA in 1947 for two years to specialise in cancer treatment. When she asked him to return to help her, Krishnamurthi was reluctant. He did not want to be a heroic pioneer, triumphing over ordeals. But eventually, she prevailed upon him as a son to support her dreams. As he recounted to me in an interview, “I was very attached to mother. Then and there we vowed that come what may, we would see the struggle through together.” Old timers remember their periodic stormy interactions, but he was devoted to her.
The Institute was inaugurated in 1954 by C.D.Deshmukh, then Union Finance Minister. Muthulakshmi was closely involved with it till her death in 1968. Krishnamurthi was associated right from the beginning. He was the Secretary of the first Governing Board and later held various positions. In 1980, he became Chairman. In 1997, he stepped down from direct involvement and became ‘Advisor’, remaining in the campus till his death in 2010.
The character of the Institute as a voluntary charitable organisation has been responsible for some of its difficulties in raising funds, tackling governmental bureaucracy, apathy and corruption. In recent decades, its ideals of simplicity and selfless service have been under attack as being impractical in a climate of corporatisation of health care. Of late, there have been internal rumblings from the doctors about low pay, long working hours, autocratic leadership and lack of autonomy in functioning. The Institute is grappling with serious questions of relevance, viability, survival and restructuring in the radically transformed health care scenario. Muthulakshmi was the quintessential activist. However, in the rapidly advancing field of oncology, it is Shanta with her training, efficiency and dedication, who can be seen as a woman pioneer in oncology in India.
But, it would be unfair to see the Institute as an exclusively women’s effort, for Krishnamurthi played a crucial role in shaping it. Shanta who has worked closely with Krishnamurthi acknowledges him as her inspiration and mentor. Right from the start, he gave Shanta positions of high responsibility. Indeed, the photographs and reportage of the early decades suggest that he encouraged her to take centre stage while he kept a low public profile. I interviewed Krishnamurthi when he was hospitalised, a month before his death. He expressed satisfaction that it was she and not he who won the Magsaysay award. In his functional hospital room was a picture of Ramakrishna Paramahamsa, a small statue of Jesus and a large framed photograph of a young Shanta. In the sweltering May heat, the air conditioner had been switched off. “We will only switch it on between noon and four o’clock,” he said.
In the male-dominated field of oncology of that time, it would have been impossible for a woman doctor to scale the heights of professional success without the platform and protection provided by a male mentor. That the two worked together as a team, with no major differences of approach, sharing a close personal relationship, has in fact been a crucial factor in building the character of the institution.
A calling and a quest
Dr. Shanta was born in 1927 in a family with strong educational values. Even so, in her generation a professional career in medicine for a woman was unknown in the family. Shanta passed the MBBS in 1949 from the Madras Medical College. She specialised in Gynaecology and Obstetrics with a diploma in 1952 and an MD in 1955. In 1950, she had interned briefly with the Cancer Unit of the Government General Hospital where Krishnamurthi was in charge. “The first time I met Dr. Krishnamurthi… there was no doubt that it had a significant impact on me… Much of what I have learnt in the early years came from him,” she said. In 1954 she joined the Institute as a voluntary doctor. In 1955, post-MD, she declined the offer of a permanent state job and joined the Cancer Institute as Resident Medical Office. Since then she has lived in an austere flat on the first floor of the Institute. In 1956-1957, she trained in oncology in Toronto and, in 1968, studied marrow transplantation in UK.
Serving in various positions, she eventually became Hon. Executive Chairman in 1997, a post she continues to hold. Despite a stroke in 2007, from which she has recovered, she is immersed in the Institute’s activities. Her personal and professional selves have merged seamlessly. When I asked her about her personal life and hobbies, she smiled slightly and drew a zero firmly several times in the air.
Oncology itself was recognised as a special field only in the mid-1960s, in some measure due to the work of the Institute. Even after that, women were rare in the field. Shanta had come into oncology not by design. “It was destiny, will of God, call it what you like,” she says.
What is special about Shanta is her single-minded nurturing of the institution with fidelity to all the goals set by Muthulakshmi and Krishnamurthi. Her personal concerns lay in enhancing access to the poor, prevention and early treatment, organisational innovations. She was also deeply concerned about the quality of patient care and developed protocols that went beyond treatment to holistic care. The science of oncology for her gets encompassed in an overarching ‘ethic of care’.
A family ethos
Shanta comes from a highly talented and accomplished family on her mother’s side, which was traditional in some ways and unconventional in others. Her mother’s brother, S. Chandrasekhar, and her maternal grandfather’s brother, C.V.Raman, were both Nobel Laureates in physics. Several family members have made a mark in science, engineering, literature, history, music and social science.
Shanta and her five siblings grew up in a large joint family with her authoritarian maternal grandfather, her parents and her mother’s siblings. Her grandfather, C.S. Iyer, had been a brilliant student and entered the British Railway Service as Deputy Accountant General. He was also a keen student of literature and Carnatic music and had published critically acclaimed books on the violin. His own father, R. Chandrasekhar, had already in 1888 entered St. Joseph’s College in Trichy, read philosophy, English literature, mathematics and physics and eventually became an eminent educationist. Thus, Shanta had three generations of high educational achievements available to her as a resource, albeit all-male. The family motto seems to have been pursuit of excellence for men, service and care for women, although this changed with Shanta and women after her. Shanta herself absorbed both these core values.
Iyer’s wife Seethalakshmi – that is, Shanta’s maternal grandmother — bore 10 children and died of tuberculosis when she was barely 40. Shanta’s mother Bala, who was the second oldest child, was already married. She and her husband stayed back with her father to take care of her six younger siblings along with her own six children. Shanta remembers: “She never made a difference between her children and others’ children… she was a personification of patience… As we grew up, we realised she was doing so much. She did not think she was doing anything special.”
Iyer also supported distant relatives in their times of need. His two widowed aunts lived with them. Needy or orphaned nieces and nephews would stay with them on and off; he educated many of them. It was this family ethos of care and service that Shanta brought in while implementing Dr. Muthulakshmi’s vision. Bala had been keen to study and become a nurse; but her education was stopped when her marriage was fixed. “At least you children should study,” she would say, recalled Shanta.
By age 11 or 12, Shanta had made up her mind to be a doctor. She was inspired by her mother’s life of care-giving. But there was a difference, she pointed out: “I wanted to be independent; my mother had spent too much time taking care with nothing to fall back upon.”
Everyone in the family knew about her desire to become a doctor. They were all a bit in awe of her and left her alone. No one suggested that Shanta should get married. It was not that marriage was ruled out, she says. “The circumstances were not right for me; that was all. But one thing I can say now, looking back. If you want to be a dedicated doctor, marriage is a hindrance. You cannot give everything to one, if you have another.”
Gender, science and care
Shanta is not very conscious of gender as an issue. In a way, Dr. Krishnamurthi’s support shielded her from potential gender bias and hostility from the medical world. Had there been occasions in her work when she was conscious of being a woman doctor? She smiled and said no: “There is no time. After work, you come back, watch some TV, read and then you are dead tired and you just want to sleep. Morning you wake up, get ready and go to work. Where is the time to think?”
Shanta’s emphasis on care manifests itself variously. What she enjoyed most in medical college was patient care: “No, not research at that time… somehow, I wanted to be with patients… professors do not talk to their students much about ethics… about personalised care.”
Krishnamurthi was moved when speaking about Shanta’s work: “Me, I can do surgery, I can give treatment, but I cannot give patient care the way she does. There was this young patient from Ooty. He was 22 or 23 and had cancer. I remember when he was seriously ill, he would say, ‘Mother, mother, hold my hand, I am afraid of darkness’. She sat with him that whole night and in the morning, he passed away. That’s the kind of woman she is.”
Shanta feels that her ideas on care are not to be found in practice these days. “I hesitate to talk because I am unhappy about it. There is no patient-doctor relationship any longer. No empathy. No compassion. They treat patients more like a consumer article… They say they need time for the family. Yes, family time is mandatory. But I say, in 24 hours, you can create time, you can always find time.”
For Shanta, the physician’s role goes beyond treatment: “Care is caring for the individual – like what you would do for your mother or father or son or child. It is a question of communication with the patient… The physician is not just a doctor but should become part of the family… Unfortunately, there is a stigma attached to cancer. Care means dealing with that as well.
Your vibration must go to them. You must be part of them… In the end, when they are dying, people don’t want anything. They only want someone there to take care of them. When they are not so ill, we have to prepare them gently. Here we need trained counsellors. Medical personnel are not enough. Here the regular problems are so enormous, we have no time to look into these things. Even when there is no hope, you have to give some message of hope to sustain them. It is a hard thing…”
My question was, whether at such times she saw herself as giving something else, not just a doctor’s care. She said, “I never thought of it like that, all that I gave was part and parcel of medical care.”
I asked Shanta about her understanding of science and rationalism. Did ‘faith’ enter the domain of care? Her reply: “I am not an atheist. But I am not devout, I don’t go to temples…”
Shanta has immense commitment to the scientific method. She implicitly conflates science with progress and scientific advancement with national pride and nation-building. Nehru was personally involved in the Institute on several occasions — laying its foundation stone in 1952, opening the Mc Connell Radiation block nine years later, sending a cheque for the paediatric wing in 1958, arranging to waive customs duty on the import of the Cobalt 60 unit in 1961. That both Shanta and Krishnamurthi were united in their admiration for him is symbolic of the Institute’s being embedded in the spirit of the Nehruvian era. Shanta is proud that the Institute has stood its ground with its home-grown approach. Visitors are surprised when they hear she has trained mainly in Chennai, she says: “They give value only if you have trained abroad. Yes, Dr. Krishnamurthi and I have taken a stand on this. They say we are mad people!”
Shanta is not opposed to alternate health and medical systems like ayurveda or siddha, but insists on rigorous scientific testing before they can be accepted. For her own patients, she leaves it to them, says she cannot take responsibility, but urges them not to discontinue the treatment at the Institute. But she agrees that hope and faith, and a positive attitude have some benefits for patients, as does family support, “compassion that they receive from medical professionals, confidence in the doctor, and significantly the attitude of the doctor.”
Shanta made her way in the male world of oncology becoming, in some ways an ‘honorary male’. It is intriguing that at the Institute she is referred to as ‘Chairman’, whereas Muthulakshmi Reddi many years ago had been designated as ‘Chairwoman’ of WIA. Through her competence and efficiency, Shanta ensured that her being a woman could not be cited negatively. In the larger canvas of the Institute’s struggles, gender is not her priority. Yet her own actions in the sphere of care giving do draw from traditional feminine resources – even though she has transmuted this from the narrow family arena onto a large setting with a universal vision. In this sense, we could see Shanta as bridging the two stages of caring, ‘caring-for’ and ‘caring-about’ identified by Nel Noddings in the book Caring: A Feminine Approach to Ethics and Moral Education. For Shanta, it is not actual hands-on application of caring services versus a state of being whereby one nurtures caring ideas or intentions. She does both.
The feminine care ethic is based on care as a woman’s duty with an emotional overlay of family and societal pressure, obscuring the labour that goes into it (which for instance facilitated the men in Shanta’s family to become world famous scientists). Shanta places the onus of action to rebel against such ascriptive roles on women rather than on structural change. When she finds women doctors not taking their work as seriously as they should, or when women complain about domestic violence without walking out, she sees it as their failure.
But we should not forget that Shanta’s maternal grandmother translated Henrik Ibsen’s A Doll’s House into Tamil. It must have had some reverberations among the women in the family. Superimposed on all this was the ‘scientificity’ Shanta acquired in childhood from her scientist relatives and her own medical training.
This raises a question, namely how all these influences have impacted on Shanta. Interestingly, her thinking, speaking and doing follow different modes. Shanta’s is a rather complex and shifting position interleaving masculine, feminine and feminist sensibilities. This is indeed a shadowy area of ambiguity for a person with such clarity in articulation. Muthulakshmi’s own outreach activity too was not just a ‘womanist’ concern but a result of her being a particular kind of woman embedded in a certain era and ethos.
A successful institution concerned with health and medicine can be analysed in many ways – in terms of deliverables, efficiency, coverage, outreach, affordability, economy of scale, technical capabilities, contribution to national development, adaptation to changing external environment and so on. But when one looks for the wellspring of motivation, one invariably finds it in the domain of individual lives and personal relationships. The sorrow of bereavement of a sister, unswerving love of a son and the fierce loyalty of a comrade ignited the passionate commitment of the three protagonists of this story. Their combined energies went into the making of a unique institution. As feminists, we are ever alert to the power of the intimate domain. Behind everything lies a personal story.
The writer is a sociologist based in Mumbai. This essay is based on her article ‘Healing Touch : Dr. V. Shanta’s Journeys in Cancer Treatment and Care ‘ in Feminists and Science: Critiques and Changing Perspectives in India vol. 2 edited by Sumi Krishna and Gita Chadha, due to be published by STREE, Kolkata.