Indian Journal of Medical Ethics


Cancer and caste inequality among rural women in South India

Sre Ratha

Published online first on February 24, 2024. DOI:10.20529/IJME.2024.014

Cecilia Coale Van Hollen, Cancer and the Kali Yuga: Gender, Inequality, and Health in South India, New Delhi: Orient Blackswan Private Limited; 2023. Rs. 1095, 302pgs, ISBN: 978 93 5442 336 9

Cecilia Coale Van Hollen’s book, Cancer and the Kali Yuga is a dense, “critical feminist ethnographic” study of Tamil Dalit women’s experiences with breast and cervical cancer, (which Van Hollen jointly refers to as “reproductive cancers”). Van Hollen’s work is mainly focused on the “nexus of gender, caste and class” that produce specific forms of vulnerabilities, especially to cancer, among the sample population. Employing a critical feminist lens, Van Hollen explores how caste-based occupations, economic marginalisation and gendered conceptions of women’s roles and their bodies, produce discourses around cancer and the paths adopted by women to navigate a cancer diagnosis. Through ethnographic data, this book demonstrates how a diagnosis of breast and cervical cancer acquires cultural significance, as this diagnosis has a direct impact on the reproductive function that women are culturally expected to perform in patriarchal societies. Though Van Hollen places importance on the causes of cancer and its medical implications, she is more keen to investigate the perceptions of these women diagnosed with cancer and the effects of a terminal illness on their lives. This detailed analysis of lived experiences and cancer among Dalit women in Tamil Nadu, is the most striking feature of the book and also what sets it apart from similar work on the same theme produced in the past. Borrowing heavily from Caduff et al [1], research conducted by the Cancer Institute, and Broom and Doron’s [2] work on structural inequalities and cancer rates in urban India, Van Hollen attempts to bring to the forefront the voices of those targeted by intervention campaigns and make their particular conditions known to larger local, national and global contexts. She argues further that while most campaigns assume that more awareness, information and earlier detection ie changes in individual behaviour would help women in lower class or lower caste communities, there needs to be a more critical look at the sociocultural factors that inhibit the efficacy of such programmes. This book, therefore, is her attempt to locate cancer firmly among the social and cultural factors that the women interviewed in this book deem important enough to highlight.

The evocative title ties cancer, a terminal illness, to the Kali Yuga which Van Hollen defines as “a period of darkness in which people have lost their way spiritually and are driven by avarice rather than dharma” (p 15). Cancer and the Kali Yuga shifts its focus away from clinical treatment of the disease and instead highlights how religious symbols and rituals acquire specific cultural meanings in the light of a cancer diagnosis.

The author begins by stating how women situate the causes of cancer in the vulnerabilities produced by demographic factors such as their caste, class and gender, rather than solely on physiological factors. Thus, the author builds her arguments towards advocating for a more nuanced look at the social factors behind healthcare issues. In the narratives, Van Hollen argues, Kali Yuga emerges as a critical motif signalling the many social, cultural and environmental factors that women see as the causes of cancer. Some of these include their exposure to agricultural chemicals by virtue of their work, water scarcity in their villages, lack of access to clean latrines and pesticide-laden food. The invocation of the Kali Yuga is therefore an important political critique and is emblematic of the marginalisation that women face and embody in their everyday lives. In this book, cancer emerges not only as a physiological health condition but also as a spectre that seems to haunt the social lives of the women it affects. From stigmatisation of those diagnosed, to misinformation produced by usage of colloquial terms such as “cancer germ”, “cancer bug” even by medical professionals (implicitly conveying the message that cancer is communicable and further stigmatising the women diagnosed with it), to the social effects of body parts undergoing inevitable and socio-culturally undesirable alterations due to radiation and chemotherapy, Van Hollen provides a microscopic look at how cancer disrupts the lives of rural Dalit Tamil women, and their strategies to negotiate through the diagnosis. In doing so, with a sharp focus on the cultural and religious symbols the women use as motifs of social and political critique, she sheds light on the inadequacies of public health interventions and highlights the need for policy that is sensitive to the material and social realities of those it is supposed to serve.

The introduction to the book begins with thick narratives of the women included in the sample. It also includes nuanced political and social context shaped by the intersections of caste, class and gender that affect the women’s lives. From the outset, the author argues that these women emerge as conscious agents trying to navigate the realities of their cancer diagnosis. They are aware of their position as women and how a cancer diagnosis, especially that of organs associated with reproduction expose them, and by extension, their families, to stigma. Furthermore, they display a nuanced understanding of the gendered milieu of moral values — especially vis-à-vis sexuality — that they have to navigate. It also sheds light on the gendered dimensions of care and the strain such a diagnosis can place on family relations as well as their finances. These women display significant concern regarding finances and a critical look at the medical systems they inhabit or families and are acutely conscious of the discrimination they face. Their narratives disrupt their stereotypical image as passive bystanders to their own diagnosis and show how they engage with not only their diagnosis but also with its causality.

In the second and third chapters, Van Hollen turns her attention to the women’s conceptions and their own understanding of cancer causality. In this regard, caste emerges as an important analytical category as it determines the nature of their occupations. In their case, it means daily wage work and/or agricultural labour in often suboptimal conditions. Van Hollen demonstrates how Dalit women, due to rising cancer rates, are motivated to follow a healthy lifestyle as prescribed by their doctors but often lack the means to do so. The women also attribute the causes of cancer to unclean latrines and public toilets due to water scarcity, pesticide and chemical fertiliser-laced food that they receive from the Tamil Nadu government, the agricultural chemicals they handle by virtue of their occupation, and other similar socioeconomic factors. Thus, to rural Tamil Dalit women, cancer is caused not by individual lifestyle choices but is a direct consequence of the marginalisations they face. Caste emerges as the cause of a certain kind of structural violence that is manifested in a susceptibility to cancer.

As a direct consequence of the caste-based, marginalised occupations that they perform, their families are often impoverished and can ill afford diagnostic tests, treatment and recovery. Indeed, in one instance, Van Hollen explicitly compares class differences in experiences of cancer stating that women from middle class families often came to see cancer as a blessing especially post-remission, in that cancer allows them to appreciate their life before the diagnosis and be grateful for their life after, some even finding purpose in social work. In stark contrast, Van Hollen points out how lower class and lower caste women often saw cancer as a curse that left their families even more impoverished and therefore emerged as an emblem of the “inhumanity and injustice” they associate with Kali Yuga. The book illustrates how Dalit, rural families in Tamil Nadu often have to sell assets such as cows to afford treatment and travel costs leaving them with even fewer streams of income and an inability to adhere to the standards of nutrition prescribed by their doctors. While this may be a phenomenon that may be observed in various other social and economic contexts in India, Van Hollen exemplifies the same through her detailed ethnographic work in Tamil Nadu touching upon the severe impact such measures would have on those already marginalised. The women directly critique the doctors’ advice stating that it is impossible for them to access “good” nutrition in their geographical as well as economic location.

In Chapter four, Van Hollen sheds light on how gendered notions of morality also hugely impact women’s experiences with cancer, by exploring concepts such as family honour, sexuality and their intersections with caste and gender. A particularly interesting argument the author makes across chapters five and six is with regard to body politics and gender concerning loss/transformation of bodies through the course of cancer treatments. Her ethnography reveals the various sartorial tricks that women have adopted in order to conceal a loss of breast due to mastectomies. Van Hollen argues that in Hindu culture, bald women are conflated with widowhood and consequently seen as bad omens. She clarifies that while the practice of tonsure to signify widowhood is a predominantly Brahmin ritual and indeed a practice that is no longer as prevalent, other caste communities also adapted the practice. In showcasing the visibility and scrutiny cancer brings in the form of baldness, Van Hollen also hints at the spectre of inauspiciousness (related to widowhood) that complicates women’s experience with cancer. She goes on to demonstrate how in such cases, religious rituals such as shaving off hair in donation to a deity has been used by these women to mask the stigma associated with hair loss during chemotherapy. This emerges as a particularly interesting mode of resistance and negotiation considering the various meanings ascribed to women’s hair in Hindu culture. The negative connotations that cancer might cast over women’s morality particularly the implication of illicit or immoral sexual relations given that the cancers in question affect the reproductive organs, in both cultural and embodied forms, might further the stigma of their diagnoses leading them to strategise their disease management in ways that legitimised their cancer diagnosis while also in some instances, concealing it from the larger public. In Chapter seven, she further looks at how women’s experiences with religion are affected, negotiated and mediated in light of a cancer diagnosis.

The culmination of Van Hollen’s nuanced study is in the critique of the underlying assumptions of public health interventions and awareness programmes. The findings provide important critical insights into the shortcomings of the public health interventions that have been attempted, and offer an alternative approach that can best be described as intersectional. In her analysis of public health campaign pamphlets and their implicit messaging, Van Hollen argues that public health interventions may themselves be propagating stigmas and misinformation around cancer and how it is understood. More specifically, she argues that the literature handed to Dalit women at these camps convey “normative middle-class ideas about gender, morality and modernity and about neoliberal assumptions regarding individual responsibility” (pp 110-111).

The culmination of Van Hollen’s ethnography lies in the scrutiny she brings to the public health interventions, awareness campaigns and policies, precisely in their inability to effectively communicate with their target audience as they do not take into account the socio-cultural and economic realities they contend with, and may, indeed, reproduce them as well.

Despite Van Hollen’s arguments being in some sense general, and applicable not only to Dalit women in Rural Tamil Nadu but to other sections in India as well, her ethnography has the potential to open up many potential threads of study and discourse. In fact, one of the biggest limitations of the book remains that Van Hollen does not delve much into the ravages of capitalism or indeed spend much time on the intersections of caste and class in India, often giving the impression that the two are conflated (which would be a reductive take). There seems to be potential that the women display in their narratives to tease critiques of capitalism. As Van Hollen herself writes, “They saw cancer as a modern disease resulting from business greed and government corruption: from drought and overwork; from agricultural chemicals and lack of nutrition; from unequal gender relations and irresponsible husbands; and even from uncaring gods and goddesses” (p 15). While this forms the crux of Van Hollen’s argument of the motif of Kali Yuga, invoking it as a powerful political critique, there is little reflection on structural economic issues brought on by capitalism and its effects on healthcare and access to the same. Caste, in Van Hollen’s argument and analysis is an important category insofar as it is a determinant of Dalit women’s occupation and the subsequent causality of cancer they attribute to it. In other instances, caste is invoked to signal the outright discrimination they face in medical spaces. However, there is little mention of the notions of purity and pollution that determine these interactions. Neither does Van Hollen examine the pervasiveness of caste in determining or indeed placing structural barriers that Dalit neighbourhoods often deal with vis-à-vis policy implementation, effective care, infrastructure or even representation in medical fields. In her repetitive allusions to Dalit women’s inability to follow doctors’ advice to consume “good nutrition”, she fails to recognise the Brahmanical undercurrents that such advice can often be charged with. Her argument might have been strengthened with more inquiry into the historical and present intersections of caste and food in India. One could therefore argue that Van Hollen’s repetitiveness regarding certain themes broadly and specifically, certain examples (notions of morality, “good” womanhood, access to nutrition, financial strain etc) try to signal the structural inequalities and violence that caste (in conjunction with structural economic inequalities) can be responsible for; but the inextricable ties it has to Indian social life (beyond outright discrimination) seem missing.

That being said, the book is set apart in its attempt to look at social, cultural and religious mores in relation to public health, using them to point out inequalities in the healthcare system and inadequacies of interventions. It offers a fresh perspective that could urge policy makers to consider new dimensions of public health. The narratives in the book especially open up possibilities for a nuanced critique of the inequalities pervasive within the Indian healthcare system and offer potential insights relevant to any public health practitioner, not just academics. The narratives in the book and the inferences that Van Hollen draws present inequalities and discrimination based on gender, caste and class as issues that exacerbate public health concerns.

The book provides several prescient insights and has the potential to inform nuanced and sensitive policies for public health interventions and awareness campaigns, while exposing the underlying assumptions and inadequacies of the ones that exist, and is honest in its call for inclusive policies that take these factors into account.


  1. Caduff C, Skelton M, Banerjee D, Djordjevic D, Mika M, Mueller L, et al. Analysis of Social Science Research into Cancer Care in Low- and Middle-Income Countries: Improving Global Cancer Control through Greater Interdisciplinary Research. J Glob Oncol. 2018 Jul;4 :1-9.
  2. Broom A, Doron A. The Rise of Cancer in Urban India: Cultural Understandings, Structural Inequalities, and the Emergence of the Clinic. Health (London). 2012 May;16(3): 250-66.