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 Queen’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, 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 the negress in her village, I could see the heart pulsating. That was just before her death.”