Guest post by MOHAN RAO

This book, a brilliant book, received extraordinary attention in India.

You might disagree with me, but I believe we do not have a rich literary culture. This is of course fundamentally related to India’s caste structure, and that we haven’t changed that much since Independence. There is little public space for books, a space that has shrunk in the last 20 years, even as book sales have increased. But there lies another story – of the dumbing down of publishing, of the Chetan Bhagatisation of reading. All leading English language newspapers  – who have over the last 20 years dispensed with their book review editors, and indeed often book reviews unless they deal with fashion, food, fucking and the First World – discovered the book after Dr.Mukherjee had won the deserved Pulitzer Prize. They celebrated the book, highlighting the fact that it had been written by an Indian, with interviews of his family and school teachers in New Delhi and so on. Dr Mukherjee is also seriously good looking, and I heard, he is doing a role in a Bollywood film. I even know he has celebrity friends like Salman Rushdie.

Dr.Mukherjee is of course an American citizen, so these reviews suffused with jingoism were completely misplaced. We should celebrate the book – and not the Pultizer Prize – because it is a worthy book, an important book, a hugely well researched book, guilded by history, and occasionally poetry. I was dazzled by the book when I read it – it was gifted to me by my wife, and immediately wondered why neither The Book Review nor Biblio had asked me to review it. I did feel a bit hurt.  I did something unusual: I actually called up the editor of Biblio asking if I could review it, and she said, “Oh we sent it off to …, he’s a doctor who has written this book called …” Before she could finish the sentence she said “Oh I forget you are a doctor too”.

Which of course begs many questions but also highlights what I think is an important reason for the success of this book – it has a lovely simple linear view of history, of progress from darkness to light, which is terribly reassuring in the world we live in, especially when we face problems we have no answer to, like cancer, or indeed terrorism. This triumph of science and technology, battling evil disease, liberating mankind, is being led by doctors.  But the world is of course a terribly messy place, and a large place with a host of actors, not all of them dazzling doctors and scientists, as Mike Marqusee in a recent column in the Hindu, taking treatment for cancer in a London hospital, covered by the NHS shows us. Marqusee notes how lucky he is to be getting treatment, free of cost, because he is covered by the NHS. He pays tributes to the hundreds of scientists – who chipped away a little bit at understanding complex problems of cancer, and a range of war related subjects that contributed to understanding cancer – but above all to the faceless millions of people who changed politics, brought in the welfare state so that the NHS came into being and Marqusee could get treatment.

A public health person would emphasise both, the clinic approach emphasized by Mukherjee and a wider political economy approach that Marqusee highlights. A clinic can only be situated within a wider context.

Writing a biography of disease requires rare courage that usually intrepid historians have, exhibited after years of work in libraries. Another genre has been of case histories perfected by Oliver Sacks, and another American of Indian origin, Atul Gawande. A classic in the former genre remains the Dubos’s The White Plague[i] that studied the impact of tuberculosis on society in the West and the causes for its secular decline, commencing well before the identification of the tubercle bacillus in 1865, and the discovery of chemotherapy in the 1950s. Zinsser’s classic Rats, Lice and History,[ii] rich with epidemiological and historical nuggets, elaborated on the impact of typhus on medieval and modern society in Europe and indeed on the tides of history, tracing the decline of this disease to a broad range of social and economic factors.

In contrast to these masterpieces, bold themes on a large framework, McNeill’s Plagues and Peoples[iii] shrunk the epidemiological equation to a peculiarly germ-centric focus that characterizes much of the literature on the history of diseases. The history of health is of course largely the history of the remarkable decline in infectious diseases. It involves tracing secular trends in the consequences of exposure to changing, evolving, disease producing agents (the agent factors) and human resistance to infectious diseases (the host factors) equally changing and evolving, in a complex environment (the environmental factors). Together, these interacting, complex, systems constitute the epidemiological triad. That social, economic and political factors in the environment have relatively faded into the background in these studies is perhaps due to two factors. One is the shift in the concept of health itself, from one encompassing broadly social factors – availability of food, regularity and security of employment, hours and conditions of work, the structure of the family and of work for women, leisure time and care of infants, and a more nebulous sense of social solidarity and well being –to the absence of disease.[iv] Thus the Chadwickian revolution narrowed public health to water supply and sanitation while the Germ Theory sharpened this narrow focus further. Together with technological hubris and the behavioral approach to public health, these factors have profoundly shaped not just health, but how historians approach the subject.

Tracing the histories of cancer is not easy – there are cancers and cancers, their identification depends on technologies, their classifications change over time, as do their incidence and prevalence due to broad socio-economic changes and environmental changes. This is done magnificently in The Emperor. What is also does in one brilliant chapter tracing the smoking-lung cancer story is how the epidemic of smoking was introduced into the public by an industry that fought unethically – buying off individual scientists, sponsoring research that questioned the link, sponsoring medical conferences etc – to muddy the waters and continue to sell carcinogenic addictive substances as “individual choice”. The marketing of cancer is not something unique to the cigarette industry; examples could be multiplied. The question that is raised is: when an industry produces goods that also produce cancer, should profit-making be protected or the health of populations? Most countries have chosen the former, leaving the matter to “individual freedom”. This is of course bogus since I am not free to live in a cancer-free environment, nor do I know the carcinogenic substances that I am eating and breathing and drinking every day. This is a classical case of negative externalities where the state must act, but typically in capitalist states, cannot and does not. I wish this issue had been examined a bit more so that cancer is not seen as an individual “life-style” disease.

Similarly, what role does stress play in cancer causation? How do poverty, inequality and stress together contribute to increasing cancer prevalence?  How are adult cancers associated with childhood under-nutrition – and thus socio-economic factors – the so-called Barker’s Hypothesis?  Why is there a systematic relationship between most cancers and lower-socio-economic status? Unfortunately these questions are not adequately discussed.

Mukherjee’s book reveals a deep fascination with history – he traces the first mentions of cancer in Egyptian, Greek, Roman, Arab and early Indian histories. The terrible treatment methods, the pain and horror and terror are carefully detailed. And then details of the remarkable advances in cancer research and treatment in the mid-twentieth century in the West. He does record hubris – which is extraordinarily brave and unusual for a doctor – the completely misplaced faith in x rays for example – they were considered perfectly safe for pregnant women for example – or the terrible reliance on “total mastectomies” for the treatment of breast cancer, noting that epidemiological data showed this had been misplaced. And yet these were, as it were, “fashions” that had the imprimatur of the scientific establishment and the leading journals of the time. “Paradigm” shifts, he shows us, is terribly difficult given the financial power and the scientific might of the medical industrial complex, the third largest global industry.

What disappointed me in the book is that there is hardly a mention of cancers in the Third World. Indeed, the Third World does not exist. Why are there different patterns and trends? Given resource constraints, what are the best methods of prevention? And of course the ethical issues involves in global clinical research. I have a PhD student studying cancer research in India: most of the research is on cancers of significance in the West; none of the trial subjects or their relatives have a hope in hell of being able to access the treatment if the drug that is being tried on them is found to be beneficial. How unjust is the world? How can we tolerate this?

That cancer does not mean instant death is of course true. But let us look at one cancer in India. Among women, the largest proportion of cancers is cervical. Do we have a public health system that all people have access to, which includes screening for cervical cancer, or do we have immunization “trials” run by the INGO Path, funded by the Bill and Melinda Gates Foundation, that break every kind of ethical norm in their effort to open up the large and lucrative Indian market? It’s a different matter that health and women’s groups managed to stop these so-called HPV vaccine trials, but it again raises issues of power, of the First World governments and NGOs, and the complicity of Third World governments and NGOs. Is this not a story worth telling too in the history of cancer?  Why is primary prevention being neglected? Mukherjee’s vision of disease causation, I’m afraid, will lead to a further neglect of social causes of disease since it completely neglects the politics that governs disease distribution in the world.

I am curious about why some books get international recognition and awards and others don’t. What immediately comes to mind is the outrage I felt when Arvind Adiga’s novel The White Tiger got the Booker prize. I had gone and bought the novel thinking I could Bong myself – after all every Bong would rush after a novel written by a fellow Bong won a foreign prize. As a good Kannadiga, having read the book, I did not know how to say how terrible the novel was – although Sanjay Subramaniam, a Tamil did. Adiga was an Australian, for Christ’s sake, and worked with Time magazine. My outrage, I discovered, was shared among Indians who read or write about reading. None of friends accepted my gift of Adiga’s novel that I did not want. My outrage was magnified when I read the astonishing novel The Wasted Vigil by the British writer of Pakistani origin Nadeem Aslam, out around the same time. Clearly the politics of residence is not enough of an explanation: both Adiga and Aslam are foreigners, as indeed are Abraham Verghese and Mukherjee.

What distinguishes them is not the politics of ethnicity or residence but the politics of the world, and the ability to write. Aslam’s work, set in Afghanistan, exquisite and beautifully written, shows us how tragedy does not always derive from good versus bad, but often from good versus good. But imperialism hovers and shapes this work. Abraham Verghese’s work, on the other hand, is immature in that it starts with epic promises, but does not deliver. Perhaps his earlier non-fiction is better, but his novel is almost as bad as the film Slumdog Millionaire.

Why Verghese’s book or Adiga’s book is celebrated in India is not in question: the Indian elites and middle classes celebrate whatever the West acknowledges. Why the West acknowledges mainly Adigas and Vergheses says something about imperialism and the economics and politics of publishing. It also says something sad about the Indian elites and middle classes who believe these don’t exist.

Mukherjee’s book cannot be placed in the same bracket, but to say something about the celebrations around his book. I suspect it was not read. It is good, unlike Slumdog Millionaire! We should celebrate it for the right reasons.

References:

[i] . Rene Dubos and Jean  Dubos (1952), The White Plague, Little Brown & Co., Boston.

[ii]  Hans Zinsser (1935), Rats, Lice and History, Little Brown & Co., Boston.

[iii]  W.H.McNeill (1978), Plagues and Peoples, Penguin, Harmondsworth.

[iv] Christopher Hamlin (1992), “Predisposing Causes and Public Health in Early Nineteenth-Century Medical Thought”, Bulletin of the Social History of Medicine, Vol.5, No.1.

(Mohan Rao is Professor, Centre of Social Medicine and Community Health, Jawaharlal Nehru University. This review first appeared in The Book Review, Vol.XXXV. No.12, December 2011.)