Pappachan’s scar stretched from ear to ear and he could barely open his mouth, but he managed a smile as Dr. Thomas Cherian, his surgeon, recounted the operation 10 days prior. “I operated on him for 12 hours and removed the cancer from the jaw and cheek,” Dr. Cherian said. “And I reconstructed his face with skin from his leg. We must not only remove the cancer but also restore the patients so they can live their lives as humans.”

Dr. Cherian was making the rounds of the cancer ward at Green Gardens General Hospital, a no-frills three-story concrete structure in Cherthala, about 30 miles from Cochin, the largest city in the southern Indian state of Kerala. The hospital is just one of several buildings – including a school, convent and outpatient clinic – in the 16-acre compound. The compound was founded as a leprosarium in 1942 by Father Joseph W.K. Kavadathil. Father Joseph, who died in 1991, also founded the Assisi Sisters of Mary Immaculate, who staff the compound. Dr. Cherian joined the hospital in 2003.

The facility used to treat as many as 200 leprosy patients at a time, said Sister Michael Francis, who heads Green Gardens. But in recent years, leprosy, also called Hansen’s disease, has waned in India. Though it still accounts for 70 percent of the world’s new cases, the rate of infection in India has plummeted. Currently, the prevalence rate stands at about 2.5 per 10,000 people, with most new cases in northeast India – not in Kerala. In 1981, the prevalence rate was 57.6 per 10,000. The World Health Organization is committed to eliminating the disease – by which it means achieving a prevalence rate of less than 1 per 10,000 – by the end of this year. In Kerala, where the rate stands at 0.06 per 10,000, that goal has already been achieved.

“Now that leprosy is no longer much of a problem, especially here in Kerala, we decided to change our focus,” said Sister Michael Francis. “We decided to focus on cancer, because there’s a need here.”

A unique confluence of history, culture and enlightened government has allowed Kerala to stand apart from the rest of the country when it comes to health and other social indicators. Despite having a per capita income of $473 – only slightly more than India’s national average – life expectancy is 74 years, 10 years higher than the rest of the country and on a par with Western Europe. Infant mortality rates are much lower in Kerala. Literacy is nearly 100 percent. Experts credit a series of Marxist and progressive governments that have ruled the state since 1956 for enacting aggressive social policies – agrarian reform, health outreach, literacy campaigns, women’s education and empowerment – that have allowed Keralites to achieve a quality of life not to be found in any other Indian state. They also point to Kerala’s isolation – the state is bounded on the west by ocean, on the east by mountains – and a history of trade with the West. Another significant factor has been Christian social outreach, which introduced a network of schools and hospitals.

But as more and more people in Kerala live longer, they become increasingly likely to succumb to diseases, like cancer, that plague the elderly everywhere. “With aging, you get more occurrences of cancer,” said Dr. K. Somarajan, an oncologist who joined Green Gardens in 2000. Each year, between 40,000 to 50,000 cancer patients are treated in Kerala. Among males, about 50 percent of cancers are attributed to tobacco and alcohol, while breast cancer is the most common cancer among women, according to the state government’s Regional Cancer Center in Trivandrum.

By law, any citizen is entitled to free health care at Kerala’s state-funded hospitals. But the six government medical college hospitals that treat most cancer patients are underfunded. Only 3 percent of India’s gross domestic product goes to health care, and states are hampered by their responsibilities to meet payrolls. In Kerala, about 50 percent of state expenditures go toward salaries.

“The net result is that few patients get modern treatment,” Dr. Cherian said. “These hospitals are operating by the Western standards of the 1950’s.”

Moreover, given their hefty caseloads, doctors are reluctant to spend long hours performing surgery on patients whose survival prospects are dim, Dr. Cherian said. There is also the reality of corruption. “Some doctors at these hospitals will tell the patients they only have so much time to treat them, but if they see them outside their office hours they can provide better care, for a fee of course,” Dr. Cherian continued. Another problem is that many specialists tend to take it upon themselves to address a patient’s problem, even if he or she would be better off referred to someone else. “If you go to one of the state hospitals and see a surgeon for your cancer, then he is likely to operate, even if you might be better served by chemotherapy,” Dr. Somarajan said. “And if you see a radiologist, he’ll treat you even if you’re better off getting surgery.”

Those who can afford it seek treatment at one of Kerala’s two large private hospitals. Others go abroad. “Look at our MPs [members of Parliament]; whenever they need a major operation they go abroad,” Dr. Cherian said. “What kind of message does that send?”

For patients like Pappachan, a 65-year-old with few resources, Green Gardens is their final hope. Pappachan lives in Trivandrum – a four-hour train ride from Green Gardens. He received chemotherapy at the regional center in Trivandrum – the state’s best public hospital – but the treatment was unsuccessful. Then he made the trip to Green Gardens.

“We’re the place of last resort,” Dr. Cherian said. “Seventy percent of the patients come to us in a very advanced stage.” Consequently, the hospital cures less than half of the cancer patients it treats. “But if not for us, these people would go untreated,” he continued.

It is not uncommon for patients, like Pappachan, to come from many miles away. Theresa, a 62-year-old retired schoolteacher, made the 16-hour train ride from Goa. Dr. Cherian had treated her for throat cancer before he joined Green Gardens. Now, six years later, Theresa was concerned about a small growth on her tongue.

“It’s benign,” Dr. Cherian said. But Theresa was also concerned that the flesh around her reconstructed jaw was sagging. So Dr. Cherian operated and Theresa was recuperating from the surgery, her scar still fresh.

Currently, cancer patients make up less than 10 percent of the patients treated at Green Gardens, which includes not only the general hospital (where cancer patients occupy only one hall) but also an outpatient clinic. Each day hundreds of patients receive treatment at the clinic, another simple concrete structure without air conditioning (like the hospital), where sheets serve as office doors. Here, doctors set broken arms and attend to colds as well as more serious ailments.

But construction is under way on a far more ambitious, and expensive, facility, which will attract many cancer patients from throughout the state, said Sister Michael Francis. “With leprosy less of a problem now, we thought about what our role should be,” she said. “The leprosy patients we treated faced social stigmas and therefore there was a special role for the church to take care of them. Cancer doesn’t share the same stigmas. But it’s expensive to treat, and we feel that it’s an area where the state hospitals need help.”

Under a blazing March sun, workers were digging the foundation for the four-story cancer center. The $750,000 facility is being partly funded by the Assisi Sisters and the government. CNEWA has already committed $100,000 for the construction of the second floor. But the building’s cost is only a small part of the total bill for the facility. The CT scan the center requires also costs $750,000. All told, the facility will house $3 million worth of state-of-the-art cancer treatment equipment. (Currently, the cancer ward of the general hospital makes do with a conventional X-ray machine and an ultrasound unit.) The new facility will serve cancer patients throughout the state.

“Those who can afford treatment will pay for it, and those who can’t will get it for free,” said Sister Michael Francis. She said she expected the breakdown to be half-and-half and generate enough funds to staff the hospital. It seems a difficult arrangement to enforce. If free treatment is being handed out, who will pay voluntarily?

“Yes, that’s a problem,” Sister Michael Francis said. “That’s why we will send an accountant to investigate each case, to see if the patient’s family has the means to pay.”

And how would an accountant make that determination? Sister Michael Francis brushed the question aside. The arrangement would work, she said. The important thing was to get the cancer center built, to start treating sick patients, to heal.

Adjacent to the construction site, the old leprosarium dormitory still stands. A few women gathered on the porch. They were being treated for the disease, but they appeared to bear none of its accompanying physical ravages – the decaying skin that, for thousands of years, had led to stigmatization and quarantine. They would be treated and sent home, healed. And soon, if the World Health Organization pledge held true, the disease would all but disappear. At Green Gardens, it is time to focus on something else.

Paul Wachter is Assistant Editor of ONE magazine.