A birth to remember
Faceless and nameless, rural migrants to India’s urban centres deserve far better than being pushed to the margins and into poverty
Dr Mammen Chandy is a former director of the Tata Medical Center, Kolkata, and an alumnus of Christian Medical College, Vellore
Back in 1979, very few physicians in India were treating acute myeloid leukaemia (AML). I was then a junior lecturer at the Christian Medical College (CMC) in Vellore under Dr Benjamin Pulimood, the only physician there willing to treat these AML patients. One patient with AML, named Anthony, was surviving after basic chemotherapy and immunotherapy with a monthly BCG vaccination. This treatment was tried by Georges Mathé, the French physician, in 1969 and subsequently published in The Lancet in 1974 (BCG is now used only for bladder cancer since we have much better drugs to treat leukaemia).
I got to know Anthony well and managed him at the time of a relapse, when it was a nightmare to find a vein since we were not using central lines at that time. In 1984, we were not ready for bone marrow transplants, but Anthony convinced us to go ahead (with his brother as the donor). This was our first transplant — and it was not successful.
Going forward, after finishing my master's in medicine at CMC in 1978 and working under Dr Pulimood, I realised that I needed more training in blood diseases. There was no super specialty course in haematology in India then. I was able to secure a registrar position at Westmead Hospital in Sydney, Australia, and completed my studies. I returned to Vellore in 1982 and started the department of haematology (DoH) with one intern and a small procedure room. Today CMC’s DoH has the largest ‘hematopoietic stem cell transplant’ programme in the country.
We started the first doctorate of medicine course in haematology in India. Patients with three haematological malignancies — leukaemia, lymphoma and myeloma — can now get state-of-the-art treatment at Vellore, as also treatment for numerous benign blood disorders. Other cancers are treated by the medical oncologist.
CMC requires faculty to retire when they have completed 60, which for me was in August 2009. I was contemplating what I would do when Dr Ketayun Dinshaw, former director of the Tata Memorial Hospital (TMH), Mumbai, after her retirement, was commissioned by Ratan Tata to be the project director and develop a world-class cancer centre in Kolkata. This was at a time when the Tata group was setting up the Nano project in West Bengal.
The TMH story
TMH Mumbai, was established in 1941 in memory of Lady Meherbai Tata, who died of chronic myeloid leukaemia, and in 1952 the Indian Cancer Research Institute was set up for cancer research. Both of these were handed over to the Indian government in 1957 and administrative control of the two passed in 1962 to the Department of Atomic Energy. By virtue of TMH being founded by the Tata Trusts, two trustees from the Trusts are always on the hospital’s governing council.
During his visits to TMH, Rata Tata noticed that there were many patients from eastern India being treated there. TMC in Kolkata was conceived as a cancer hospital to meet the needs of such patients, and those from the Northeastern states, who would not have to travel far away from home for treatment.
Dr Dinshaw, a CMC alumnus, kept calling me in the early months of 2009, requesting me to join the project. I kept refusing since I could not imagine working in Kolkata for the Tatas when I had spent most of my working life in a mission hospital in South India. However, in late 2009 she convinced me to meet Mr RK Krishna Kumar at Bombay House, the Tata headquarters in Mumbai.
It was a memorable meeting in an office with an entire wall filled with Ganeshas of varying styles and sizes. We discussed religion, philosophy and more before I finally told him that I would join but only as a haematologist, not as director. “Then we do not want you,” he replied. I was amazed when he qualified the reply by saying that he did not want the tail to wag the dog, that unless I was the director I would not be able to bring “something of the ethos of Vellore” to this Tata project.
For a corporate honcho to feel that this was important was remarkable. I was then asked to make a presentation of my vision of what TMC should be. I did this one rainy evening at the site office in Kolkata when Mr Ratan Tata and Mr Krishna Kumar were on a visit.
I moved to Kolkata in April 2010 and for the next 12 months I wore a construction helmet at work, being at the site for most of the day before returning to the hotel in the evening completely soaked (that is when you realise air-conditioning is not a luxury). It was a fantastic time, interacting with architects and engineers and seeing something wonderful coming up.
It was also great to go to Mr Krishna Kumar with my requests — another 
100 million over budget for laboratory equipment, a lily pond with a waterfall as part of the landscape and such — and being told to go ahead without any committee approval. The project was something new to me in terms of what the Tata group would do for aesthetics and functionality.
Building an institution
The external cladding of the building was made from a Rajasthan soft stone called Yellow Teak, dry clad on stainless steel pins in an intricate design approved by Mr Tata at a cost of more than 100 million (the surface protection cost in excess of 20 million). A team of doctors was recruited months before the hospital opened and they spent a whole lot of time at Tata Consultancy Services developing a clinical and hospital information software program.
Many of the recruited faculty helped in other ways to set up the different clinical departments and develop the clinical pathways for the hospital to function. It was a fantastic experience working with landscape architects from Delhi and a 75-year-old horticulture expert.
We bought 10-foot-tall trees grown in large tubs and they grew fast once they were put in the ground. We soon had a beautiful campus. Artists were requested to donate their renderings for the hospital and these were spread all over the buildings (all of this art was collectively valued at $350,000 by a gallery in Mumbai).
On May 16, 2011, TMC was inaugurated by Mr Ratan Tata. It was a stunning piece of architecture with a blend of glass, steel and stone, making the hospital look more like a research building in Scandinavia than a cancer facility.
However, a stunning building and good infrastructure do not by themselves make a great hospital. Rather, it is the people staffing the institution at different levels who make that happen, people who believe in the hospital’s purpose and mission and are willing to contribute to that mission in terms of competence, compassion and care for patients with cancer, the 'emperor of all maladies'.
TMC has been able to recruit such individuals to implement its mission of patient care, education and research. Precision in diagnosis is the first step in cancer care and TMC has all that is necessary for this, with an excellent histopathology lab, flowcytometry, cytogenetics and next-generation sequencing to document and track mutation-causing malignancies, and imaging techniques to gauge the extent of the disease.
Compassion is the key
Treatment with surgery, radiation or chemotherapy, or combinations of the three, is discussed and decided upon by tumour boards with access to international protocols and capable of evaluating treatment outcomes. But all of this must be undergirded by compassion. One could get a Christmas card from grateful parents whose child has been treated and cured at TMC, but the real credit comes when parents who have lost a child with cancer choose to continue to remember the treating team years later.
In February 2020, just before the Covid pandemic hit, I was diagnosed with colon cancer. A laparoscopic left hemicolectomy was done, and I had a difficult time in intensive care for many days. This was followed by six months of chemotherapy and I returned to work by the end of 2020.
What I tell my patients is that life is uncertain even when we are well. The secret is to take one day at a time, like children with cancer who only want to know when they can go back to school.
Cancer treatment has advanced in leaps and bounds over the last decade, with new therapies being added to the armamentarium almost every year. Most of these new drugs are expensive and beyond the reach of the poor, but government schemes are making it possible for many patients to have good cancer treatment.
For those with aggressive cancers that have spread and for which new therapies have become available, the physician is faced with a difficult choice when he advises patients and their families on how to proceed. The cancer care team must remember that patients and their families need support even when all curative medical options have been exhausted. We have to minimise pain and discomfort and help patients die with dignity when there is no other option left.
My personal journey as a physician who treats patients with leukaemia, lymphoma and myeloma has been rewarding and the progress that has been made in these three malignancies over the last decade is tremendous (there is the possibility of cure in over 90% of children with acute lymphatic leukaemia).
New drugs for chronic myeloid leukaemia have converted a cancer to a disease where one can carry on with normal life on the back of a pill a day. For me, it was great to be part of the team, backed by the Tata Trusts, that established a high-quality cancer facility and recruited an outstanding team of healthcare individuals.
