The Emperor of All Maladies, by Siddhartha Mukherjee

My previous book review talked about medical ethics in a fictional case. It introduced me to the question of whether orthodoxy is something that can be adhered to when it seems to be on the sure path to failure. This book brought up some more of those issues, and while it solidified some of my convictions, it cast others into doubt…

The novel I read was The Emperor of All Maladies, by Siddhartha Mukherjee, and it essentially is boiled down to a brief history of cancer. Cancer has always occupied a very strange place in my life. I never knew my grandfather because of it (more on this later), I lost a cherished great-uncle because of it, and have seen it affect people all around me. Because of the ubiquitous nature of cancer, I relegated it to the status quo, and never paused to think about what happened in the background, or what the history was.

Admittedly, I was skeptical of cancer research prior to reading this book. I knew millions went into research, I volunteered at the James Cancer Hospital, and I never saw a decline in the number of patients, or any definitive proof that this was working. If you’ve seen Interstellar, you can relate to this notion of a false hope. The thought of seeing so many people be so cheerful for Buckeyethon, only to realize that money may sink into ordinary pipet tips, salaries, and nothing of guaranteed significance was a disgusting thought for me.

This book gave me a new perspective on cancer research. I realized that we while we aren’t churning out immediate cures, we are still relatively infantile in this combat. In that way, our progress has been astounding. However, even these basic concepts are double-edged swords. The fact that there is so much yet to learn means that claims that the cure for cancer is near are not only false, but morally wrong. In addition, the progress that I claimed as astounding has come at the cost of thousands of human and animal lives. The book told me how many failed trials occurred, how many people died or had their lives compromised from poor treatments. Galen’s theory of black bile set progress back hundreds of years, while Halsted’s radical mastectomy left women left devoid of breasts and other critical body parts. The concept of multidrug chemotherapy that pushed the body to its limits is especially daunting, as that’s what I realized killed my grandfather.

When I was very young, I never understood what it meant to go to my grandparent’s house. This was because my grandmother refused to leave India, and my grandfather had passed away. I asked my mother what happened, why he wasn’t with us. She told me a lot of dubious information that I may have been able to reconcile with this book.

Essentially, my grandfather was a civil engineer, working on structures and dams. He was exposed to the burning Indian sun for long periods of time, along with poor working conditions at the sites that he had to visit. He also had enemies because of the wealth he acquired, and was once poisoned by a competitor with some unknown substance. Eventually, he was diagnosed with a “blood cancer” that claimed his life quickly. He was administered to one of the best hospitals in India (one of the most Western), yet died because “he was given the wrong drug”.

This concept was the birth of a hatred for India. I was Indian, but throughout my life, had never felt the source of pride that one does with nationality. After all, how could someone claim that India is advanced when it “administers the wrong drug”? This permeated into every aspect of my life, from my interactions with native people (initially with a spiteful tone) along with a rejection of my own culture. I hated every aspect of it. Relatively recently, I forgave the hospital and forgave those who I had wrongfully blamed, but I didn’t realize that they had just committed the crime that was already present in “idealized” Western culture: multidrug chemotherapy, the agents that pushed my once stern grandfather to the limit. The agents that were used at this Westernized hospital as the pinnacle of cancer therapy. The untested multidrug chemotherapy that was proven to be only occasionally helpful, and often hastily administered. This book let me recognize one of the biggest mysteries of my life by informing me of the history, and letting me probe into and realize what actually had happened.

Medical ethics are again brought up, but this time in a more deeply personal manner. It seems to always whittle down to “orthodoxy” vs “unorthodoxy”, but now it gets deeper. It deals with large institutions vs small institutions, and, if I am to reference my previous review, big business vs the morally sound few. The novel brings up a few prominent cases where my beliefs were called into question. I had believed that big institutions and regulations were necessary, especially after incidents of fraud, along with horribly conducted and unauthorized trials. But eventually, the Herceptin fiasco with Genentech, and the FDA’s refusal to approve Herceptin for general use because of its “experimental” label, told me that sometimes too much institutional involvement can stall some really important treatment options.

In addition, the focus was brought up by Dr. Mukherjee that the extension of life needs to be considered, as opposed to the elimination of death. The focus on humanity and not numbers was referenced in my first review by Dr. Kubler-Ross, and she mentioned that when people died, they often died unhappily. In the olden days, hospice and comfort were emphasized, and now numbers and artificial measures are more important. This could be because of our innate inability to face the concept of death. This is an important concept, because failing to keep humanity in medicine means that frenzied doctors with supposed cures run rampant, and the fate of my grandfather befalls other people.

I would like to close off with some thoughts about the James again. Dr. Mukherjee mentioned that it’s unlikely that cancer will ever be cured. This is something I had believed as well. When thinking on this concept, and reflecting upon the James, one cannot help but believe that the James and everything it stands for is a massive monument of failure. A monument of humanity’s futile attempt to stave off death, and the countless resources poured in vain. This is quite the depressing thought, and brings to mind the history of cancer research, where false hope was circulated only for everything to come crashing down. Why is the James different?

Dr. Mukherjee explains that we can redefine victory as extending lifetimes to the norm. A cancer patient living as long as a healthy individual would be a way to define victory. In that sense, all that needs to be changed is the rhetoric. Instead of claiming to cure cancer, we must focus on outliving it, tending to it, and using the James to increase length of life. If we do that, I do believe things will turn out all right.


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