Dr. Siddhartha Mukherjee – Author of Emperors

by katiclops

I got the book during a trip home to visit my parents, August 2010.

My mom had taken me to Costco.

I always find myself clinging to the books in Costco.

The whole experience is pretty overwhelming to a grad student. A decade of cramped apartments, small town and urban living has meant that I rarely have the means to visit a grocery store that is any larger than a few storefronts, let alone a city block, speak less of the equity or transportation necessary to purchase toilet paper for the year or tomato paste for a family of 50.

Even the idea of getting a shopping cart is still novel to me; what happens if I buy too many groceries to fit into my pack? How will I bike home? I remember my first trip to Red Barn Market on a Double Flyer Wednesday when I bought so many groceries I had to take the bus home. Struggling to strap my bike into the rack on the front of the bus, I stumbled in – head hung in shame – laden with not only my pack, but two massive bags filled with produce. The novelty of seeing household products on steroids, pre-packaged produce for a year, and Ikea-style warehouses of electronics quickly becomes dizzying. I am just as taken aback by the clientele – this particular location the majority fall into the the faction of the public I rarely see (the car-driving, suburban kind). Rapidly I find myself feeling foreign and lost; after a breezy pick-up of any palatable slightly-generic tasting samples, unfailingly I head to Books.

Set in the middle of the store, free from towering merchandise loaded scaffolding, the books are maleable, familiar, in reasonable, relatively low stacks. Archaic and humble compared to the massage chair twin seaters and “Party tents” for eight. Anyone who has previously visited cramped precarious used bookstores can attest to the relative relief the high ceilings and quiet nature of the Costco book section brings. After a quick perusal of redundant DVDs, it is here that I always find myself. And about fifteen minutes later, so does my mom.

“Why don’t you pick out a book?” she offers benevolently. My eyes undoubtably widened at such a suggestion. She urged once more before disappearing back into the metropolitan expanses of sunscreen and dog food: “You’re not home often, go ahead. Get yourself a nice summer book. My treat.” I get to work.

The limited selection at Costco always corners me into really considering books that may have otherwise fallen outside of my periphery. My best guess is that your average bookshop probably stocks no fewer than a thousand titles. In these instances I tend to regulate myself by clinging closely to familiar sections and authors, creating a map by which to navigate the sea of books. I also harangue my friends for recommendations via text message to further guide my perusal (sorry friends!). By contrast our Costco has one hundred titles at most, organized frenetically by relatively short stacks on card tables. Given the limited and un-intimidating nature of their display, I always find myself leafing through everything. Picking up titles indiscriminately, reading the backs absent-mindedly. Sometimes some are pretty good. Some are awful. Regardless, by the time she returned, I still hadn’t found anything that really jumped out at me. Sensing her urge to leave I grabbed the non-fiction, taupe-coloured volume bearing a Pulitzer sticker.

“This one I think.” She flipped it over. Then let out a breath and raised her eyebrows: “You sure? Sounds depressing. Not exactly a light summer read…” She popped into into the incredibly empty cart  and we headed out of the store.

I never started the book that summer. I did bring it with me to Victoria. I think. Silly new grad student, recreational reading is for regular people.

It’s sixteen months before I even crack the spine.

*              *              *

Even an ancient monster needs a name. To name an illness is to describe a certain condition of suffering-a literary act before it becomes a medical one. A patient, long before he becomes the subject of medical scrutiny is, at first, simply a storyteller, a narrator of suffering-a traveler who has visited the kingdom of the ill. To relieve an illness, one must begin by unburdening its story. ...Onkos…from which the discipline of oncology would take its modern name [is]the Greek term for a mass or load…cancer was imagined as a burden carried by the body.

-The Emperor of All Maladies (p. 47)

Dr. Siddhartha Mukherjee’s 600-page tome is certainly a physical burden. The novel includes 472-pages of books, and the balance in notes and appendices. The Emperor of All Maladies is intended to read as a biography of cancer. Charting the history and personality of the disease, it’s relationship with mankind. I envisioned it would start in Egypt (it does). It would be full of anguish, of dying. Of old, waif-like women, soberly reflecting on their lives: from Cleopatra through the middle ages, until now. Even the idea of the book didn’t seem right for summer, and it certainly didn’t strike me as good accompaniment to policy studies. However after finishing In the Realm of Hungry Ghosts (here and here), I was moved to read another account by a doctor. I started the book at the beginning of the summer, by lakes and on ferries. I finished yesterday, bundled in blankets on a blustery fall evening.

Reading the book was, I assure you, a bit of a massive undertaking – but it was also massively rewarding. I would not necessarily recommend this book to everyone, but would highly recommend it to those interested and committed to the subject. It is a huge, onkos. Lighter than other +500page novels I’ve read, Dr. Mukherjee walks you through cancer easily, gracefully, and humbly. He is able to meet readers where they are at, and writes so compassionately and eloquently the book can be read scientifically or for literare and history. Part of his success comes from his fantastic similes an metaphors that gently walk you through the tangle of oncology:

Cancer is that machine unable to quench its initial command (to grow) and thus transformed into an indestructible, self-propelled automaton.

Or later, he seamlessly develops another metaphor into a macabre explanation:

Halsted took this line of reasoning to its next inevitable step. Volkmann may have run into a wall; Halsted would excavate his way past it.

That being said, it is helpful to have some grounding in biology or even anatomy. The above passage continues  medically, but slips in explanation in a way that (while mildly horrific) is not patronizing.

Instead of stripping away the thin pectoralis minor, which had little function, Halsted decided to dig even deeper into the breast cavity, cutting through the pectoralis major, the large prominent muscle responsible fo moving the shoulder and hand.

Towards the end of book, as he gets into more modern molecular approaches to combatting the disease, I was transported back into a frigid cold Ottawa night, during my first year of biochemistry. Dr. Mukherjee explains that molecular chemists don’t tend to think of molecules as flat two-dimensional things, but as three dimensional objects. That chemists turn into architects and physicists  engineering new pieces to attack vulnerabilities within molecular structures. At a party of a friend of a friend’s, I had shyly injected myself into the corner of the conversation, lamenting over my understanding of my major. Upon over-hearing my struggles our host excused herself, and traipsed back into the room a few minutes later with a tiny grey plastic box. It contained a molecular chemistry modelling kit that she had been similarly gifted five years earlier.

The plastic atoms and little grey connectors nearly saved my life, becoming a staple in our late-night study sessions in the basement of monstrous Thompson Hall residence building. By enacting over and over again, mise-en-scènes of chemical reactions, suddenly the Morse code of pencilled orbits and valences became tactile magnified things.  Small vignettes that I would replay during exams and in our sterile, cavernous labs. It felt like seeing a globe for the first time as a child, and realizing that reality (we all live on a giant orbiting mobile of spheres) is paradoxical more far fetched and simpler than you had previously imagined.

Thompson Hall, (aka Home Sweet Home), Ottawa, November 2003

I have other, hazy memories of humanity in that cavernous year: trekking out the two kilometers in knee-deep snow beside a highway to one of my lab-mates apartments. It was a stone’s throw from my building, but the highway and canal meant an icy switchback over several bridges. Sri Lankan-Canadian, she radiated a warmth and colour that drenched her flat into humanity, transporting our study group from the stark monochrome of grey concrete, bleached labs and snow. On the longest nights she would make thick spicy dahl, plucking a few tiny hot chilis descendent from her one tiny plant of her family’s peppers that she and her sister miraculously kept alive in spite of the climate. She always had a giant pot of soup on, and rice in the cooker; we would eat heaping bowls of rice, drenched in the soup, with scrambled eggs and more chilis served on top.

These brief moments of people in the marching monotony of medicine are part of what makes this book so readable, so real. Dr. Mukherjee helps to cram all of this scientific detail into our heads by sandwiching it between punchy, colourful descriptions of characters and dialogue, turning passages into film and scientists into living breathing people with eye colour and character tic’s:…

…a pugnacious New Yorker who ha declared it her personally mission to transform the geography of American health through group-building, lobbying, and political action. Wealthy, politically savvy, and well connected, she lunched with the Rockefellers, danced with the Trumans, dined with the Kennedys, and called Lady Bird Johnson by her first name….Her disarming smile and frozen bouffant were as recognizable in the political circles in Washington as in the salons of New York. Just as recognizable was her name: Mary Woodard Lasker.

You can almost make out his subtle soft voicing, a trace of a British Indian accent. Despite innumerous quotes and literal references throughout the book, there are even more, sublter ones embedded in his descriptions, like the description of how each cancer is unhappy and infected in it’s own way, as to Tolstoy’s opening lines in Anna Karenina (“All happy families are alike; each unhappy family is unhappy in its own way”).

The Emperor is also filled with explanations and references to everyday things and trends. For example, for years I always assumed that a Pap-smear was named after the human PAPilloma virus…but in actuality it’s named after it’s creator (and his faithful, devoted wife): Papanicolaou,whose discovery and career is charted in The Emperor. The book fills in historical gaps not covered by popular narrative, like the science behind The Insider.

One does struggle with the layout of the book, but it adds to the experience. It is loopy and and cyclical. Loosely following a chronological format, but doubling back on itself so each strand fits together. You can not tell all the stories from all the perspectives at the same time. Breast cancer is chronologically followed in one section, which leads to genetic coding, which must be explained from the beginning. But even this overarching style, the see-saw back and forth builds the momentum of cancer’s story, highlighting it’s ruthlessness, and the frustration and futility in attempting to halt it’s progression.

It is partially the fatigue of this struggle that made me happy and relieved to have reached the end of the book. It is not entirely depressing. It is not a book about death. Major advances have been made in the past 15 years. But it was nonetheless a constant reminder that death is just around the corner. That genetically cancer is everyone’s end. Death in this book, as with in the Red Tent, is often referred to as an entity. Someone sitting in the corner. Someone that so many cancer patients know. Thom Wolfe is quoted in one of his last letters written during his battle with cancer: “I’ve made a long voyage and been to a strange country, and I’ve seen the dark man very close.” In this book however, death was not painted as defeat, but rather the lines that have created the picture. Without seeing people come close to death, often sacrificing themselves, oncology would not have advanced to where it is today. It is a biography of all the people cancer has stolen from us, and how science has tried to explain their absence, how it is trying to explain the white space. It is a manifesto of medicine, a reminder that science is storytelling.

(Continued tomorrow.)