*The Intellectual Legacy of Dr. Manu Kothari, Part III: Gabbar Singh and the Cardiologist

On an October evening in 1977, Manubhai received word of the unexpected demise of his younger brother Dipak, an orthopedic surgeon based in New Jersey.  Manubhai has described his brother in Living, Dying thus:  “Dipak was a tall, handsome person, athletically built and inclined.  He had neither diabetes nor high blood pressure, nor excess weight—none of the ‘risk’ factors.”  No one in the family had ever complained of anginal pain; and, yet, at 30 years of age, Dipak had suffered a massive heart attack and passed away in his sleep.  It was a “rude shock” for Manubhai, but then “the head consoled the grieving heart, persistently driving home the point that death’s mathematics does its task governed solely by Pascalian probabilities, irreverent in the face of medical attempts at prevention, diagnosis and treatment.”  On reading this, I was reminded of Ralph Waldo Emerson’s starkly beautiful essay on “Compensation”, where he described the loss of his small son as akin to the “loss of a beautiful estate, no more” (or words to that effect).  He wrote of his experience, “I cannot get it nearer to me”, words that have disturbed his detractors and some of his admirers who opine that Emerson was unable to feel anything.  Quite to the contrary, Manubhai, as Emerson much before him, had a deeper understanding of death as a soulmate, a profound awareness that the laws of compensation cannot be denied, and that what appears as a tragedy in one’s own personal life “is but a part of the impartial, fully just, greater order.”  It would be superfluous to add that, as with the case of cancer, Manubhai remained an unrelenting critic of coronary care, which he did not deign to redeem even as a form of dignified plumbing.  His conclusion to the article that he wrote on “Coronary Care” for the aforementioned The Future of Knowledge and Culture sums up his views:  “Our advice to the lay and the learned is to stay away from the well-conceived but useless and harmless procedures comprising invasive coronary care.  The cardiologists and coronary surgeons are riding a tiger they fear to dismount, lest the dollar Niagara come to a sudden end.  Angiography, by itself untrustworthy, inevitably spawns—plasty and/or bypass, the trio comprising costly iatrogeny on a global scale.  A wise person avoids any assault on the coronary tree, no matter how sophisticated the laser, reamer, rotor or what have you.”

Any tribute to Manubhai that does not acknowledge his wry sense of humor, erudition, love of literature, and cheerfulness would be woefully incomplete.  I last saw him, I believe, in or around March 2009.  He invited me to a leisurely breakfast at his home with him and Jyotibehn and two memories of that visit will persist with me to the end.  We had been discussing politics in Gujarat, and he was just as bothered as I was by the obscenity of some of the violence perpetrated in 2002.  Quite suddenly, Manubhai threw this question at me:  ‘What do you think is the holy book of the Gujaratis?’  I knew that he did not have the Bhagavad Gita in mind, nor the Tulsidas Ramacaritmanas, certainly not the Vedas; for a moment, I thought he might have had in mind the songs of Narsi Mehta, the great devotional poet.  But somehow I also sensed that Manubhai was laying a trap for me; and yet I could not bring myself to think of an answer beyond the ordinary.  I don’t now recall what I said; but whatever it was, it was not a patch on the brilliantly funny and incisive answer Manubhai had:  the cheque book!  We had a hearty laugh.  Later that morning, as we left his apartment, we made our way to the train station: for years, Manubhai had taken the local to KEM Hospital.  It was absolutely characteristic of him that he should travel in modesty:  however dreadful the cliché, “simple living, high thinking” seemed to furnish the motor to his life at every turn.

Manubhai died as he lived; moments before his death, I am told, he had been chatting and laughing away.  Not accidentally, one of the men he admired the most was J B S Haldane, a polymath who made significant contributions to physiology, genetics, evolutionary biology, statistics, biometry, and various other fields; more to the point, Haldane, an Englishman of considerable pedigree who was educated at Oxford and had published his first scientific paper at the age of 20, migrated to India in 1956 and eventually took up Indian citizenship.  Haldane, to Manubhai’s mind, stood for the other West—a West that was critical of its own past, tolerant of dissenting traditions, aware of the homology between colonial dominance and the suppression of women, religious minorities, and people of other ethnicities, a West with which, in other words, India could enter into partnership.  Haldane thought of India as a freer country than any other, and some of his thoughts may be surmised from his observation that “the people of Calcutta riot, upset trams, and refuse to obey police regulations, in a manner which would have delighted Jefferson. I don’t think their activities are very efficient, but that is not the question at issue.”  Percy Bysshe Shelley, be consoled:  it is not only poetry that makes nothing  happen.  Haldane passed away in 1964, but not before he had written a poem on his hospital bed, “Cancer’s a Funny Thing”, from which Manubhai quoted frequently:

I wish I had the voice of Homer

To sing of rectal carcinoma,

Which kills a lot more chaps, in fact,

Than were bumped off when Troy was sacked . . . .

Cancer could be “rather fun”, says Haldane,

Provided one confronts the tumour

With a sufficient sense of humour.

I know that cancer often kills,

But so do cars and sleeping pills;

And it can hurt one till one sweats,

So can bad teeth and unpaid debts.

A spot of laughter, I am sure,

Often accelerates one’s cure;

So let our patients do our bit

To help the surgeons make us fit.

Manubhai was far ahead of his times, and it may take a few generations or more for us to understand the manner in which he lived and how he helped us all to become “fit”.

Coda:  Shortly after I finished writing this, by sheer coincidence my friend Ajay Singh sent me the following joke:

कार्डियोलोजिस्ट और गब्बरसिंह में क्या समानता है?
दोनो यही सलाह देते है कि तूने नमक खाया है अब गोली खा ।
(What is common to the cardiologist and Gabbar Singh?  Both come forward with this advice, ‘You ate salt, now bite the bullet.)
To audiences familiar with the world of the commercial Hindi film, this joke will resonate strongly:  The outlaw Gabbar Singh, featured in the immensely poplular film Sholay (“Embers”, 1975), shoots dead one of his henchmen, one of those who ate his salt, when he finds him no longer competent in discharging his duties.
See also parts I and II

*An Intellectual Tribute to Dr. Manu Kothari, Part II: The War on “The War on Cancer”

In 1973, Dr. Manu Kothari and his associate, Dr. Lopa Mehta, published their voluminous tome, The Nature of Cancer, which I am tempted to describe as a war on the “war on cancer”.  The military metaphor has, of course, long been regnant in the US:  for well over a decade the American public and people overseas have been hearing about the “war on terror”, but this war was preceded by the “war on drugs”.  Neither war has been concluded; neither war is likely to be brought to a close; indeed, neither war has a foreseeable end, and the prosecutors of such wars, and their allies and friends in and out of government, have too much to lose if either war was brought to a decisive end.  All this is certainly true of the “war on cancer”, which has consumed hundreds of billions of dollars, perhaps trillions of dollars, thus far.

However, the war on cancer differs from the war on drugs the war on terror in some fundamental respects.   The war on drugs is increasingly being recognized, except by the Republican Party – not, it should be noted, by some outlandish or extreme members of the party, since such a view presumes that there are sane or even intelligent members of the Republican Party, which is very much to be doubted—as an egregious error which has needlessly committed hundreds of thousands of Americans to prison terms, and similarly the war on terror has had more than its share of detractors.  But the “war on cancer” is construed, by every sector of the American public, as a holy mission:  to be sure, there are those who think that there might have been some scams, and a few people have doubted whether all forms of cancer research have been productive, but there is an overwhelming consensus that cancer is a deadly disease that must be exterminated and that no effort must be spared to stamp it out.

Cancer research draws in more funding than any other medical endeavor; the war on cancer has its foot-soldiers and generals; and donors and philanthropists, whose wealth is often ill-begotten, easily become heroes and celebrities in a culture where donations in the name of cancer research earn one goodwill and, if the gift is substantial enough, cultural capital in the form of a building or institute named after the donor.  It is a telling fact that in his highly celebrated “biography” of cancer, The Emperor of All Maladies, the talented writer and doctor, Dr. Siddhartha Mukherjee, entirely succumbs to this dominant narrative.  On reading him, one inescapably reaches the conclusion that if we soldier on, achieve “early detection”, and eliminate the scourge of smoking—but apparently not bother with the monstrous-sized polluting SUVs and pick-up trucks with which America has an undying love affair—victory will be at hand.

Dr. Manu Kothari had an entirely different view of cancer and what passes for “cancer research”.  His views would be distilled in two much shorter works, both co-authored with Dr. Lopa Mehta:  Cancer:  Myths and Realities of Cause and Cure (1979) and Living, Dying:  A New Perspective on the Phenomena of Disease and Dying (1992).   He unflinchingly put forward the view, which certainly did not win him any friends from among those in the cancer(ous) industry, and even gained him the opprobrium of establishment doctors alarmed at his broader views about the nature of disease, that the billions of dollars expended on finding  a cure for cancer had not advanced our knowledge of the “disease” an iota.  Writing on cancer for The Future of Knowledge of Culture:  A Dictionary for the Twenty-first Century (Viking Penguin 2005), co-edited by Ashis Nandy and myself, Manubhai put the matter quite succinctly in expressing his agreement with the view of some patients that the “treatment [was] worse than the disease.  Macfarlane Burnett, the Australian immunologist of wide renown, summed up in the 1970s the outcome of all cancer research in just two words:  precisely nil.”  As Manubhai was to add towards his conclusion, “On the medical claims about the early diagnosis and treatment of cancer, one could invoke Churchillian rhetoric:  Never in the history of science has so much untruth been told by so few to so many for so long.”

How, then, was Dr. Kothari inclined to think of cancer?  His views may, at first, seem wholly unpalatable:  “Cancer—far more benign than malignant mankind—is what it is, and does what it does, because of unalterable, unabrogable biorealities that attend this fascinating phenomenon.” Manubhai took it as an imperative that we must first understand death and look at it not something that is to be feared, delayed, managed, ostracized, and repelled but rather as a friend, even as something that is to be revered.  He was critical of medical science for representing one disease or the other as the cause of death:  as he put it in Living, Dying, “Disease and death, in fact, are inherent components of man’s development, are governed by time and regulated by the herd, behave independently of each other and, in essence, are causally unrelated, death by itself being a programmed normal function performed by a living being.”

He argued that cancer occurs throughout the human lifespan; moreover, it is very democratic, and cancer’s “benevolence” could be inferred from the fact that it occurs everywhere “but in excess nowhere.”  He described cancer’s distribution as one in five:  one person bears the cancerous cross so that the other four might live.  Manubhai does not ask of us that we love cancer; but he does ask of us that we not hate it.  Once one understands that cancer is always with us, the very fibre of our being, we are no longer inclined to seek treatment:  he entirely rejected the idea of early screening, and deplored chemotherapy and radiotherapy as “despicable overkill by medicine.”  The fact that as a doctor, one remembered by his students as a very good one who did his profession proud, he was able to advance such views is a remarkable testament to his courage.  What is not less striking is that he had been articulating such a position for over four decades:  not surprisingly, one of his most ardent admirers was Ivan Illich, whose own Medical Nemesis, published one year after Manubhai’s The Nature of Cancer (1973), still remains the most trenchant critique of institutionalized forms of modern medicine.  Illich would go on to write the foreword to Manubhai’s smaller book on cancer.  Interestingly enough, the most recent exhaustive study on “early detection” all but confirms Dr. Kothari’s claims:  as reported by the New York Times on 20 August 2015, in an article headlined “Doubt Is Raised Over Value of Surgery for Breast Lesion at Earliest Stage”, “As many as 60,000 American women each year are told they have a very early stage of breast cancer — Stage 0, as it is commonly known — a possible precursor to what could be a deadly tumor. And almost every one of the women has either a lumpectomy or a mastectomy, and often a double mastectomy, removing a healthy breast as well.  Yet it now appears that treatment may make no difference in their outcomes. Patients with this condition had close to the same likelihood of dying of breast cancer as women in the general population, and the few who died did so despite treatment, not for lack of it, researchers reported Thursday in JAMA [Journal of the American Medical Association] Oncology.”

(to be continued)

See also Part I on this blog

*Dr. Manu Kothari and His Intellectual Legacy — Part I: Friend, Humanist, and Philosopher


I have a reasonably good recollection of the exact circumstances under which I first met Dr. Manu Kothari (1935-2014), or Manubhai as he was known to his friends and others accustomed to the mode of address common among Gujaratis.  I had heard of him many years before I had the pleasure of setting my eyes upon him:  as with many of the most interesting people I have met either in India or a dozen other countries, I was first introduced to the work of Manubhai by Ashis Nandy.  I had been advised by Professor Nandy that no visit to Bombay was complete without a stop at the home of Manubhai, described to me as a superb doctor who was nonetheless a radical dissenter from the medical establishment and as an intellectual maverick who was as much at home in the classics of English literature and Indian philosophy as he was in the technical literature on cancer, anatomy, and genetics.

Through a set of fortuitous circumstances in September 1999, I found myself staying with another common friend who lived across from Manubhai and Jyotibehn’s flat on Swami Vivekananda Road in Santacruz (West).  My wife and I were returning from Pune with our baby daughter and we were being hosted by the late Jayesh Shah, a kind soul and magnanimous man who had given up an extremely lucrative career as a stock-broker to found the fiercely independent journal Humanscape, to which Manubhai and I were both contributors.  Manubhai and I both served in later years on the journal’s editorial board.  When I expressed a desire to meet Manubhai, Jayesh just walked me over to his home!  That visit is etched in more than my memory:  Manubhai was being visited by his long-time associate and colleague, Dr. Lopa Mehta, and at the end of the day they gifted me a copy of their magnum opus, The Nature of Cancer, with the following inscription:  “To Dr. Vinay Lal, with warm regards for a kindred spirit.”  While being extraordinarily moved by their gesture, I was also greatly intimidated:  900 pages in length, the Nature of Cancer is fortified by some 6,000 references and dense discussions of carcinoma, immunotherapy, chemotherapy, and much else; more to the point, as a cultural historian, even (as at least I imagined) one with wide-ranging intellectual interests, I was entirely clueless about cancer beyond knowing how to spell the word.   However, with a twinkle in his eye, Manubhai gave me an assurance that I was none the poorer for being ignorant about the literature on the subject; as I was to find out in short order, Manubhai held to the opinion, one which he would defend to the end of his life with great vigor, that the tens of thousands of researchers who had dedicated their lives to cancer research had not contributed an iota to furthering our understanding of the nature of cancer.  As Manubhai might well have said, they were barking up the wrong tree.

The academic and intellectual career of Dr. Manu Kothari is better described by those who were fortunate to know him as a colleague or as a fellow traveler, even if a dissident one, in the medical fraternity.  Our friendship, which led me to a heighted awareness of the extraordinarily radical nature of his thinking, arose from very different considerations.  Though Manubhai was a doctor by training, he had an abiding interest in literature, philosophy, and a broad swathe of what one might describe as humanist writings.  He belonged to a small fraternity of people in India who were seriously questioning the received categories of thought and probing the politics of knowledge systems.  Though the conditions under which medicine is practiced in India are vastly different from those which obtain in the US or the affluent nations of western Europe, what has been true of the social sciences is also the case in medicine:  the concepts found in textbooks generated in the West have been adopted wholesale for use in Indian medical colleges, and with respect to medicine on the ostensibly more justifiable grounds that physiology is a universal science.  The neuroses and psychoses of the white man, if one may put forward such an example, were thus to furnish the models by which the neuroses and psychoses of colored people were to be diagnosed and treated.

To be sure, Manubhai was critical of the commercialization of what is called “modern medicine”, and he was fully aware of the nexus of interests that bound hospitals, pharmaceutical firms, manufacturers of medical equipment, philanthropists, and all too often medical practitioners, some more than others, together in an unholy alliance that compromised the health of those very patients in whose name “medical research” and expensive cures were carried out.  But had this been the extent of his grave misgivings about the modern medical establishment, Dr. Manu Kothari would scarcely have been alone.  He adopted unusual positions about the superflousness of most medical treatments and even what are called ‘investigations’, the imperative for the doctor to learn from the patient and indeed recognize the patient as oneself, and the necessity of understanding “disease” as something not alien and repulsive to oneself but rather as intrinsically a part of one’s own being.   Dr. Kothari’s views led him to some fundamental epistemic breaks with the models of modern medicine emanating from the West; indeed, he questioned whether there was anything intrinsically “modern”, apart from some obvious technological interventions, in modern medicine, and similarly he held such conceptions as “holistic medicine”, favored in the West by those who are critical of allopathic medicine and its vivisectionist tendencies, to be little better than tautologies.   Health is holistic; if it is not, one is speaking of something else.  In a word, Manubhai was sharply critical of modern or rather commercialized medicine’s deep grounding in violence.

By the late 1990s, when I met Manubhai, there was a growing if still distinctly minority indeed miniscule literature which questioned the wisdom of conventional thinking on such matters as treatments for cancer and heart disease.  In India, “five-star” and “super specialty” hospitals were just beginning to mark their presence on the scene, catering to the medical “needs” of not only the super-rich but growing numbers of middle-class and affluent Indians who had been the beneficiaries of the neo-liberalization policies of the preceding decade.  The Fortis Hospitals, now a vast enterprise with over fifteen hospitals in India’s metros, initiated its operations with a hospital in Mohali in 2001.  But nothing furnishes a better gauge of the tide against which Manubhai was swimming than the meteoric rise of Dr. Naresh Trehan, a cardiovascular surgeon who had returned from a career in the United States to establish the Escorts Heart Institute in Delhi in 1988.  By the mid-1990s, Dr. Trehan had become a celebrity, a cult figure on the Delhi party scene who hobnobbed with film stars, media moghuls, and powerful politicians when he was not performing surgeries or otherwise building his medical empire, and it became virtually a badge of honor among the monied class in the city to claim that Dr. Trehan had performed a triple or quadruple bypass on them.  To have had one’s arteries worked upon by Dr. Trehan, an aggressive proponent of surgical intervention for patients with cardiac problems, was rather like being admitted to an elite club.

(to be continued)