The original concept of diseases of civilization dates to the mid-nineteenth century, primarily to
Stanislas Tanchou, a French physician who served
with Napoleon before entering private practice and studying the statistical
distribution of cancer. Tanchou's analysis of death registries led him to
conclude that cancer was more common in cities than in rural areas, and
that the incidence of cancer was increasing throughout Europe. “Cancer, like insanity,” he said, “seems to
increase with the progress of civilization.”
He supported this hypothesis with communications from physicians
working in North Africa, who reported that the diesease had once been rare or nonexistent in their
regions, but that the number of cacer cases was
“increasing from year to year and that this increase stands in connection
with the advance of civilization.”
By the early twentieth century, such reports had become the norm among physicians
working throughout Africa. they would typically report a few
cancers in towns where the “natives mingled with Europeans” and had copied
their “dietetic and other domestic practices,” but not in those
areas where lifestyles and diets remained traditional. These reports, often
published in the British Medical Journal, The Lancet, or local journals like the
East African Medical Journal, would typically include the length of service
that the author had undergone among the natives, the size of the
native population served by the hospital in question, the size of the local European
population, and the number of cancers diagnosed in both. F.P. Fouché, for instance, district surgeon of the Orange Free State in South Africa,
reported to the BMJ in 1923 that he had spent six years at a hospital
that served fourteen thousand natives. “I never saw a single case of gastric
or duodenal ulcer, colitis, appendicitis, or cancer in any form in a native,
although these diseases were frequently seen among the white or European population.”
In 1908, the Smithsonian Institution's Bureau of American Ethnology
published the first significant report on the health status of Native Americans.
The author was the physician-turned-anthropologist Aleš Hrdlička,
who served for three decades as curator of the Division of Physical Anthropology at the National Museum in Washington
(now the Smithsonian's National Museum of Natural History). In a 460-page report entitled
Physiological and Medical Observations Among the Indians of Southwestern United States and Northern Mexico,
Hrdlička described his observations from six
expeditions he had undertaken. “Malignant diseases,” he said, “if they
exist at all - that they do would be difficult to doubt - must be extremely
rare.” He had not encountered “unequivocal signs of a malignant growth
on an Indian bone.” Hrdlička also noted that he saw only three cases of
“organic heart trouble” among more than two thousand Native Americans
he examined, and “not one pronounced instance of advanced arterial
sclerosis.” Varicose veins were rare, and hemorrhoid's infrequent.
“No case of appendicitis, peritonitis, ulcer of the stomach, or of any grave diseases
of the liver was observed,” he wrote.
Hrdlička considered the possibility, which Keys would raise fifty years
later, that these Native Americans were unaffected by chronic diseases
because their life expectancy was relatively short; he rejected it because the
evidence suggested that they lived as long as or longer than the local whites.
In 1910, Hrdlička's field observations on cancer were confirmed by
Isaac Levin, Columbia University pathologist, who surveyed physicians
working for the Indian Affairs Bureau on reservations throughout the
Midwestern and Western states. Levin's report, entitled “Cancer Among the North American Indians and Its Bearing
upon the Ethnological Distribution of the Disease,” discussed the observations of 107 physicians who
had responded to his survey, with their names, locations, size of practice,
duration of practice, and number of Cancers diagnosed: Chas. M. Buchannan, for instance, practiced fifteen years among two thousand
Indians with an average life expectancy of fifty-five to sixty years and saw only one case of cancer, Henry E. Goodrich,
practicing for thirteen years among
thirty-five hundred Indians, saw not a single case. Levin's survey covered over 115,000 Native Americans treated by agency doctors for anywhere
from a few months to two decades and produced a total of twenty-nine documented cases of malignant tumors.
The two most comprehensive attempts to deal with the question of
cancer in isolated populations were in The Natural History of Cancer, with Special Reference to Its Causation and Prevention,
published in 1908 by
W. Roger Williams, a fellow of the British Royal College of Surgeons, and
The Mortality from Cancer Throughout the World, published in 1915 by the
American statistician Fredrick Hoffman. In the Natural History of Cancer, Williams marched from continent to continent, region to region.
In Fiji, for instance, in 1909, among 120,000 aborigines, Melanesians, Polynesians, and “Indian coolies,” there were only two recorded deaths
from malignant tumors. in Borneo, a Dr. Pagel wrote that he had been in practice for ten years and had never seen a case.
Williams also documented the
rising mortality from cancer that Tanchou had reported in the developed nations. In the United States, the proportional number of cancer deaths
rose dramatically in the latter part of the nineteenth century: in New York,
from thirty-two per thousand deaths in 1864 to sixty-seven in 1900; in
Philadelphia, from thirty-one in 1861 to seventy in 1904.
Hoffman dedicated the better part of his career to making sense of
these observations. He began his cancer studies as chief statistician of the
Prudential Insurance Company and continued them as part of an investigation
of the Committee on Statistics of the American Society for the Control of Cancer (a predecessor of the American Cancer Society, of which
Hoffman was a founder). In The Mortality from Cancer Throughout the World
and then again in Cancer and Diet, his 1937,
seven-hundred-plus-page update of the evidence, Hoffman concluded that cancer mortality was
increasing “at a more or less alarming rate throughout the entire world,”
and this could only partially be explained by new diagnostic practices and
the aging of the population.
Hoffman could not explain away the observations that physicians like
Schweitzer and Hutton had made around the world and that both he and
Williams had documented so comprehensively. In 1914, Hoffman himself had
surveyed physicians working for the Bureau of Indian Affairs.
“Among some 63,000 Indians of all tribes,” he reported, “there occurred
only 2 deaths from cancer as medically observed during the year 1914.”
“There are no known reasons why cancer should not occasionally occur
among any race or people, even though it be of the lowest degree of savagery or barbarism,” Hoffman wrote.
Granting the practical difficulties of determining with accuracy the causes of
death among non-civilized races, it is nevertheless a safe assumption that
the large number of medical missionaries and other trained medical
observers, living for years among native races throughout the world, would
long ago have provided a more substantial basis of fact regarding the frequency
of occurrence of malignant disease among the so-called “uncivilized” races,
if cancer were met with among them to anything like the degree
common to practically all civilized countries. Quite to the contrary, the negative
evidence is convincing that in the opinion of qualified medical
observers cancer is exceptionally rare among primitive peoples.
Through the 1930s, this evidence continued to accumulate, virtually
without counterargument. By the 1950s, malignancies among the Inuit
were still considered sufficiently uncommon that local physicians, as in
Africa earlier in the century, would publish single-case reports when they
did appear. One 1952 article, written by three physicians from Queens's University in Ontario, begins with the comment
“It is commonly stated that
cancer does not occur in the Eskimos, and to our knowledge no case
has so far been reported.” In 1975, a team of Canadian physicians published
an analysis of a quarter-century of cancer incidence among Inuit in
the western and central Arctic. Though lung and cervical cancer had
“dramatically increased” since 1949, they reported, the incidence of breast cancer was still
“surprisingly low.” They could not find a single case in
an Inuit patient before 1966; they could find only two cases between 1967
and 1974.
These missionary and colonial physicians did often diagnose tumors
and other diseases of civilization in local whites, and among natives who
were working for European households and industries. In August 1923,
for instance, A.J. Orenstein reported in the British Medical Journal
on his experience as a superintendent of sanitation for the Rand mines in South
Africa: “in a series of one hundred consecutive necropsies on native
mine laborers conducted by myself in the latter part of 1922 and the first two
months of 1923, two cases of carcinoma were observed - one was carcinoma of the pancreas and glands of the neck
in a native male of the
Shangaan race, age about 40, the other was a case of carcinoma involving
practically the whole of the liver, in a native male of the same race, age
about 25.” The reports from these physicians were a reminder of how
dramatic the course of the disease could be could be, and evidence against the argument
that sophisticated diagnostic technology, unavailable in these outposts, was
required to diagnose cancer. In 1923, George Prentice, who
worked in Nyasaland, in southern central Africa, described one native
patient with an inoperable breast tumor in the British Medical Journal. “It
ran an uninterrupted course,” Prentice wrote, “completely destroyed the
breast, then the soft structure of the chest wall, and then ate through the
ribs; when I last saw that negress in her village, I could see the heart pulsating. That was
just before her death.”