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CC-BY: Ben Gilbert/Wellcome Images

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CC-BY: Ben Gilbert/Wellcome Images

Shah Ebrahim was born in England, his father South Africa and his grandfather India. Now, back in India himself, he studies the impact of migration on health.

Professor Shah Ebrahim steps out of his office for nearly the last time. In the meeting room, ten of his 25-strong staff have gathered to discuss their application for another five years of funding for research into chronic health conditions, including the impact of factors like migration and urbanisation. He will not be part of the work that the money, if they get it, will fund: he is handing over to a new generation.

Outside, the Delhi traffic brays its incessant tune. It is distinctive enough that when Ebrahim talks to people on the phone, they can tell where he is by the background noise. The car horn is not as much of an indication of objection as it is in some other countries. In India, it is a more neutral, if noisy and continual, expression of existence: “I am here, I am moving, I am not going to stop.”

He remarks to the team, only half-joking, that auditory environment is often overlooked as a factor influencing people’s state of mind and health. But the offices of the South Asia Network for Chronic Disease (SANCD) are far from the busiest parts of the city. Two decades ago, this part of Delhi was a sleepy green suburb where children would ride their bikes in the street and stare up at the aeroplanes dreaming that they might one day get a chance to fly away somewhere. The planes multiplied and the roads got busier as the city grew; there is no safe passage for children’s bikes any more, although patches of greenery remain.

SANCD is based in a partly converted residential building on the corner of a garden square – it is spring, and the staff often eat lunch on the grass or walk around its perimeter. Their offices are on the ground floor, while the basement houses laboratories. Also in the basement are two rooms with rows of freezers: they store blood and urine samples from the Indian Migration Study, which assessed the health of 6,500 rural, migrant and urban people to understand the biological effects of moving from a village to a city.

The Indian Migration Study was led by Ebrahim, then based in the UK, and its success led him to set up SANCD in 2009. Its aims were to support the development of scientific research in India and neighbouring countries, as well as to continue investigating people’s long-term health in ever more urban environments.

It was also a chance for him to move to India, to explore the prospect of living there permanently and closing a loop of his family history. But the loop will not close. India – Delhi, in particular – has proved too bad for his health.

Shah Ebrahim's family

The Ebrahim family.

© Shah Ebrahim

Shah Ebrahim’s grandfather was Mohammed Kassim Ebrahim. His name was on a list telegraphed from a steamship anchored in Table Bay, South Africa, in 1899. A list of “prohibited immigrants” on board – of passengers unwelcome in Cape Town.

Kassim’s descendants agree that he was born in a village near Ratnagiri, the Indian port at which he boarded the ship to South Africa. No one knows exactly why he went, what problems he was trying to solve, what hopes he took with him. They’re not sure if he was a legal migrant or planned to jump ship. They know only that he never set foot in India again – though being on that list meant his immediate problem was setting foot in Africa.

At the end of the 19th century, nations had begun to discriminate more than ever about who to let in and how to treat them when they were there. Health concerns were a particularly convenient mask behind which racial discrimination could cower. In his letters to the Times of India, Mohandas Gandhi (who was living in Durban in 1899) reported a speech by a medical officer in Maritzburg, Natal. A (false) rumour of an outbreak of bubonic plague was spreading through the colony, and Indians were again being blamed. The medical officer supported drastic measures, including a complete ban on the import of rice and other food from India: “If it is an Indian ship it must have a secret manifest,” he railed. “Infection, unlike everywhere else, is in South Africa personal to the Indian. He and his goods only can bring the infection.”

Kassim Ebrahim got off the boat eventually. Relatives who had migrated to Cape Town in more amenable times helped him acquire a permit and legal status. He joined the family’s trading business, settled down, found love with an African woman and started a family. Life was far from easy – they were still dependent on the support of his relatives – but it paid off in 1946 when his son Donald enrolled at the University of Cape Town to read medicine. Their plan was that Donald would qualify as one of the first ever ‘Cape Coloured’ doctors and then support his family by running a small medical practice in the city.

In a single generation, the Ebrahims had risen from “prohibited immigrant” to pioneering medical student. But it was far from the end of the journey.

In 1948, when Donald Ebrahim was two years into his medical studies, the South African National Party came to power and instituted a regime of apartheid. Pernicious limits were set on interactions between people of different races. The University of Cape Town became an almost all-white institution, and Donald was sent to England to complete his training at the University of Sheffield instead. Still, the hope was that he would come home to repay the family’s investment in his education.

A combination of love and politics scuppered the plan. Donald married Marjorie Evans, a nurse at Sheffield Children’s Hospital. Marjorie was half-English, half-Welsh; wholly white. As ‘mixed’ marriage was by then outlawed in South Africa, Donald and Marjorie couldn’t live there. He did end up running a general practice but it was in Coventry, not Cape Town. Unable to fulfil his familial obligations, Donald disguised his guilt with a clipped English accent and cut his cultural ties to South Africa. But another heritage remained strong: for his first-born son, he chose a name with Indian and Muslim resonance.

Shah Ebrahim followed his father into the medical profession. A geriatrician, he also developed interests in epidemiology, public health and research, and he spent at least a month every year working in a developing country, supporting local scientists and sharing ideas. Perhaps it was inevitable, given his family history, that he would decide to investigate the effects of migration.

Now in his 60s, Ebrahim describes his career as a “wonderful meander” between the UK and Thailand, the jungles of Malaysia, the mountains of Laos. More recently, it brought him to India to find out how moving from villages to cities affects people’s long-term health. 

The staff meeting draws to a close. Professor Ebrahim has offered his advice on each of the research themes being developed in the grant application in an open, questioning discussion in which everyone was encouraged to have their say. It is in keeping with his style: soft-spoken, good-humoured, but not willing to let ideas pass if he thinks they are “bonkers”. He apologises for being blunt (an “un-Indian” characteristic) but the others are familiar with his sense of humour by now.

However, five years in Delhi has proved enough for Ebrahim and his wife, Fiona Taylor. When he describes his time in India as potentially closing the circle traced by his grandfather and father in their international migrations, she quickly jumps in to say that the circle will have to remain open because they are not staying.

Ebrahim had lived in developing countries before, and worked in India, too, but Delhi was much harder than he had expected. “Every day there was a minor crisis, and every week a major one,” he says. “For the first year and a half, there was never a day when you could say, ‘Good day’.”

The crises encompassed their home, their finances, work, everything, especially their health. Lactose-intolerant and wary of eating meat in India, Ebrahim developed a deficiency in vitamin B12 because of the restrictions in his new diet. He got bronchitis every winter, presumably from the pollution and smoke that often hangs in the Delhi air. They both got constant gut infections, no matter how careful with food and water and hygiene. These niggles might have been manageable except that they came on top of a litany of underlying anxieties of Delhi life: hassles, minor and major, chipping away at their mental health and their relationship. Taylor says it took her six months to overcome the culture shock, and she can see distinct stages of adjustment in other Westerners who move here. Even crossing the road in Delhi requires a strategy – Ebrahim has been known to hire an auto rickshaw just to get from one side of a six-lane road to the other.

So they are putting their affairs in order ready to leave. Ebrahim is proud of what has been achieved with SANCD but, he says, “I’ve exhausted my capacity.” He is making one last migration, retiring to rural Spain. He’s looking forward to doing some fishing.

Reflecting on his experiences and research, Ebrahim is confident we will one day be able to connect migration behaviour to biology. As a result, we might be able to broaden our understanding of human behaviour more generally. If migrants are, as he puts it, “in the vanguard of social change”, if they are physiologically primed to leap into the unknown, whether the leap is a few kilometres or a few thousand, then perhaps they can help the rest of us to adapt as the world changes around us.

The Indian Migration Study was funded by the Wellcome Trust, the publisher of Mosaic; the South Asia Network for Chronic Diseases was a collaborative venture between the Public Health Foundation of India and constituent colleges of the Wellcome Trust Bloomsbury Centre for Clinical Tropical Medicine.

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