Interview by Madison J. Myers

International Affairs Forum: Please tell me about your research on “Kerala’s Cancer Crisis”. Why is cancer a “crisis” situation in the Indian state of Kerala in particular?

Abin Thomas: My interest in cancer began in childhood after I heard stories about other children dying from cancer. These stories have only increased over the years. Due to these experiences, I have developed an interest in studying cancer throughout BRICS countries. Others have developed interest as well. Kerala’s government has now proposed a new cancer speciality hospital in Kerala. This reflects Kerala’s cancer growth. In my article, "Kerala's Public Policy Crisis in Fighting Cancer”, I mention that cancer in Kerala has been on the rise for 30 years. One of my greatest concerns is the government’s role in guaranteeing welfare. No one is talking about philanthropic development or private parties playing a role in helping out the government and the government cannot fight cancer on its own. My concern is also that every discourse seems to include a focus on poor people’s access to cancer treatment. The problem with that approach is that the majority of people cannot afford cancer care, not only those who fall below the poverty line. Everyone is prone to cancer. Kerala also has a dwindling amount of poverty- down to 10% in Kerala, making this approach even less effective. Thus, policy based on granting only impoverished communities access to care does not help a great amount of the population. What we must also remember is that health is not only a medical matter, but it is a social matter as well.

International Affairs Forum: Why do you think Kerala’s cancer rates are higher in Kerala compared to other states in India? You have mentioned the role of tobacco in Kerala even with the ban on smoking, but is there another player to consider? Is Kerala’s diet, pollution level, demography or lifestyle contributing to this rise in cancer?

Abin Thomas: Yes there is a huge issue with tobacco. Because there is a ban on smoking, chewing tobacco is primarily used and it is widespread and culturally accepted so you even see children chewing tobacco. It ends up being lifetime use, but even so tobacco is only one contributing factor. Kerala also has the highest rate of alcohol consumption in India. We also must consider the growth of fast food chains in Kerala. Fast food is gaining in popularity and the population’s health reflects this.

International Affairs Forum: Are there preventative measures in place?

Abin Thomas: No, that is the problem. In 2007, the Regional Cancer Centre (RCC) conducted a study on oral cancer screening programme and suggested to integrate the screening mechanism to its care system.  Still, the access to screening facility is important for cancer care in the state. People do not have access to early screening and are not educated on how to prevent cancer and promote health. They are being told a number of things by doctors including to cut out sugar and maitha, or white flower, and pasteurized milk, but people do not know what to listen to because they hear something new from everyone. People are now also anxious about eating because these new suggestions challenge social habits. Currently in Kerala, there is a prevalent aura of fear for cancer so people start rumors on what causes cancer and what prevents it. There is so much fear that people listen to anything. One such rumor is the use of a certain brand of toothpaste. People started saying that it is a cancer prone product and blame cancerous developments on that toothpaste only. It is a dangerous situation where fact and fiction are not separated. So people have started trying to go back to nature, natural products and Ayurveda. But at the same time, people are still going out and buying burgers and pizza. Kerala is not an exception to these eating patterns in India, but Kerala’s consumption is still unique, especially differing social habits and the amount of fast food they are eating.

International Affairs Forum: You claim people do not have access to screening. Do you think the lack of access is a main contributing factor in the development of cancer in India? Is a portion of the greater issue that people are being diagnosed too late, when there is a lessened chance for recovery?

Abin Thomas: A lack of screening is a main issue, most definitely. The health of citizens must be the priority for all. We desperately need an elderly screening process in place. Although there is an efficient health sector in Kerala, no on cares about or seems to put any value on the screening process. Only when one feels very ill, they go to the hospital. They do not think about consistently checking for developments. This needs to change, most especially in the elderly community. That should be a focal point in Kerala’s new policies. Right now prevention is not discussed; policy right now is only focused on treatment, such as new cancer hospitals. No one is looking for the root cause. Prevention is being overlooked.

International Affairs Forum: You also mentioned a change in diet with the introduction to fast food and you mentioned doctors’ recommendations to cease the consumption of pasteurized milk and processed flour. In the context of recent findings that the majority of dairy milk in India found traces of cleaning and other products mixed within, and other several incidences of a lack of regulation in food, do you believe that food is also playing a large role in growing cancer rates?

Abin Thomas: Most definitely. [Farmers] also use pesticides indiscriminately. People are not considering safety in their practices. Cancer is not only a medical issue, it is connected to social practices, lifestyle behaviors and economic practices. Everything—the entire “ecosystem”— plays a part in the increase in cancer.

International Affairs Forum: You have also mentioned the issue of cost. Could you elaborate and put this into perspective for those who are not familiar with India?

Abin Thomas: There is no national health scheme like you have in the US. There is RSBY- the national health care run by the central government, but it is not a comprehensive insurance scheme. The central government cannot manage local health issues. There is a network for communication with NGO’s and non profits, but again these focus on impoverished communities when everyone is struggling to pay. Since there is not a welfare system like NHS in the UK, the approach to cancer will be very different. Kerala needs to strengthen the state medical colleges and research centers and have its own insurance mechanism that is affordable and accessible so that people will not be denied treatment. And insurance is only one main issue. Perhaps the development of schemes could help too. There needs to be a lot of research on what kind of insurance or scheme would penetrate the furthest- what would have the greatest impact.

International Affairs Forum: You mentioned that there is not a lot of support in academic research on this subject or an adequate amount of cancer research in India. Could you elaborate?

Abin Thomas: The demographic pattern has changed a lot over the last several decades in Kerala. The government promoted birth control measures, implementation and awareness to control the growing population and as a result of its success there has been a dwindling of Kerala’s birth rate and an increase of the older-aged population (11.2% vs national average of around 6%). By 2020/30 Kerala will have a higher level of senior citizens than other portions of the population. With this in mind, by the 1990s, with the liberalized economy, the Kerala government started thinking about geriatric centers and geriatric research in medical colleges. So the demographic change, and the issues that it presented, created a need for the government to start thinking about old age issues. That is the trend: the problem has to be visible or already out of hand to treat it. The trend in the health sector is to wait for an issue or see symptoms in order to make a new policy.

International Affairs Forum: So you are saying that policy development is reactive instead of proactive?

Abin Thomas: Yes, exactly. We did have a health policy that was drafted in 2013, but it doesn’t talk about many aspects of health, it talks about categories of medicine that are meant to alleviate pain. In Kerala he lack of a preventative vision prevents a great amount of research and an increase in medicinal study. People must begin to recognize the need for research and a change in public policy. There is also a pricey import duty to think about when it comes to pharmaceuticals and medical technology. So the government has to subsidize those expenses or produce the equipment and medicine domestically. That is part of the delay in the development of hospitals. Government hospitals are over crowded and there is no guarantee you will be treated. Government must reduce the cost of the production of these essential equipments or find a way to produce it indigenously so that cancer care access may increase.

International Affairs Forum: Explain the difference between private hospitals and government hospitals in India and please elaborate on your issues with these.

Abin Thomas: The access to private hospitals is important and we have so many private hospitals that specialize in cancer treatment, but the problem again is affordability. The debate is between private and public but the scope of treatment must be widened beyond just private and public hospitals. Government hospitals are overpopulated, understaffed and have issues with efficiency. Kerala’s are better comparably to other states, but it is still not a great place to get treatment. Private hospitals are unaffordable. The government must allow and encourage all players to participate. Political participation, community participation and others. Cochin Medical College is a great cooperation example.

International Affairs Forum: If you could give any advice for the best next steps, what would that be?

Abin Thomas: Awareness and screening. Community center screening processes would help stop the progression of cancer greatly so there should be a target based screening program in Kerala. But it is not only up to the government, people should also participate and build upon the existing strengths of the health system. We think of things at the macro level when we need to approach it from the micro level. We need to look at the local levels, not only the panchayat, but neighborhood associations, community centers, etc. By strengthening local institutions, you connect with people better and will see a greater success level. We have to find ordinary solutions and practical steps forward.

Abin Thomas is a PhD candidate at King’s College London and is currently working on a book project titled Beyond Welfare: What is next for Kerala? by the Centre for Public Policy Research (CPPR) in India.