*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

*Ours But To Do and Die: The Culture and Politics of Death in India

Ours but to do and dieThe news that flashed across television screens a few days ago had a numbing familiarity about it:  ten people had been killed in a bomb blast outside the Delhi High Court, scores more were injured.  It was only some weeks ago that multiple bomb blasts, engineered by another terrorist outfit, caused havoc and panic in Mumbai, a city that, in the clichéd view, has learnt to rise above such atrocities and display a resilience that ought to put a dent in the armor of terror itself.  Since in this matter as in nearly all others the middle class Indians whose voices are heard in the media have embraced American idioms of expression and thought with a frightening fidelity, we have designated these dates as 26/11, 11/7, 7/9, and so on.  But, try as we might, our 26/11 or 11/7 or 7/9 can never have the resonance that 9/11 has come to acquire around the world, and that is not merely on account of the immense scale or gravity of what transpired when the Twin Towers were brought down and the Pentagon, the very seat of orchestrated terror masquerading as the guardian of world order, itself became susceptible to a sudden suicide attack.  The French have always displayed an admixture of admiration and disdain for things American; and, yet, when 9/11 occurred, Le Monde, the custodian of French intellectual republicanism, unequivocally declared that ‘Now we are all Americans’.  Are there people around the world who, after the attacks on the Indian Parliament in 2001, the 2007 terror strikes on Mumbai’s trains, or the Delhi High Court bomb blast, have been moved to say, ‘Now we are all Indians’?

Political commentators in India and its educated élites more generally have long complained that no one pays much attention to India’s claims that it is spectacularly vulnerable to terrorist attacks.  Indians like all others deplored the events of September 11, 2001, but some might have thought that the attacks would have the desirable effect of awakening the world to the threat of Muslim terrorists.  It cannot be doubted that the Hindu chauvinists who launched the pogrom against Muslims in Gujarat, barely six months after the attacks of September 11th, did so with the conviction that the world would barely take notice of atrocities that targeted Muslims –– among other things, September 11 succeeded remarkably well in rendering terrorism synonymous with Islamic terrorism.  The multi-pronged attacks on a number of Mumbai’s landmarks and buildings in 2008 were perhaps the first occasion when the world took notice of the problem of terrorism in India, but it is doubtful that the terrorist strikes this year, in Mumbai and Delhi, have created more than a fleeting impression.  No one outside India much cares, notwithstanding the customary messages of concern; in India itself, people have been inured to violence, and the threshold for what are considered acceptable levels of violence has been raised.

The most familiar part of the story, then, is very simply captured in the feeling that was often voiced in colonial times and is increasingly encountered in people’s anguished voices:  human life has little value in India.  There are variations on this argument, of greater or lesser subtlety.  For the middle class, one piece of evidence predominates over all others:  if America has thwarted all attempts at terrorist attacks since 9/11, why cannot India do the same?  How can we overlook the ignominy of repeatedly being made to look like fools? One school of thought takes refuge in the view that the Indian state is alarmingly inept when it is not corrupt, and that standards of security and safety have been seriously compromised ­­–– not only in the matter of counter-terrorism, but with respect to safety on our roads, railway tracks, and in our skies.  Another school of thought highlights the contrast with the US to different effect:  if in India human life appears to be cheap, the US has a singular obsession with accounting for every American life, particularly the lives of those who serve the country.  Consider, for example, that more than six decades after the conclusion of World War II, there is still an active mission along the borders of India and Burma to search for Americans ‘missing in action’.  The Indian state barely has time for its living subjects, many of whom have never remotely been accorded the dignity of being viewed as citizens:  indeed, a great many people, in the extant ideology of development, are so much waste that has to be shunned aside.  In the colonial anthropology of India, the individual as an atom did not exist; only collectivities –– masses of people shaped by their caste, religion, ethnicity, linguistic background –– were to be found in India.

The social Darwinism that began to mould India 150 years ago remains a vibrant part of our middle class sensibility.  The generation of colonial officials writing shortly before independence remained convinced that the ‘rising flood of human beings’ was the principal cause of Indian poverty and the reason why the British had been unable to raise standards of living. The grim Malthusian reading of India that, whether expressly or tacitly, still informs most middle class perceptions of the great unwashed has not departed very much at all from this view.  With 1.2 billion people, some might think of India as a country that has always registered significant population growth, but that is far from the truth.  For close to two hundred years, British rule in India was book-ended by famines –– ten million perished as hunger, anomie, loot, and confusion accompanied the British takeover of Bengal, and another three million were sacrificed to save the world from the peril of Nazism and Japanese militarism –– and in between epidemics, disease, war, and other famines took a massive toll of human life.  While life expectancy in Britain, most of Europe, and the United States increased significantly from the second half of the nineteenth century onwards, in India it declined from 24.6 in 1871-81 to 20.1 in 1911-21, and on the eve of independence life expectancy was still less than 30.

Death seems, then, to stalk this ancient land.  If famines, as these are ordinarily understood, no longer strike India, and life expectancy has increased to the mid-60s, malnutrition remains endemic, afflicting close to half of the population.  The advocates of ‘Shining India’ crow over India’s economic growth, but India also leads the world in infant mortality, fatalities from road and train accidents, HIV/Aids infections, and much else that the country would rather not advertise to the rest of the world.  The colossal loss of lives at construction sites, mines, hazardous waste sites, shipbuilding docks:  all this remains largely undocumented, on the rare occasion dignified by mention in a newspaper or a footnote in a human rights report.  Tens of millions of females are, in the euphemism made popular by Amartya Sen, ‘missing’.  Some degree of ‘concern’ for the poor has now become part of the sanctified middle class sensibility, but the conviction persists that the poor will always remain poor.  The middle class has even come to hold to the view that the poor do not experience death as it does, and that the loss of loved ones means comparatively little to those who are both accustomed to sudden death and have, by giving birth to a large number of children, taken out insurance to guard against Yamaraj’s unexpected moves.  We give little thought to the fact that the poor cannot afford the luxury of long mourning; tears are not theirs to shed, work lies ahead:  ‘Theirs not to reason why, / Theirs but to do and die.’

Whatever the merit of those views which dwell on India’s demographic excess, Social Darwinism, the great gulf between the rich and the poor, the callousness of the state and the grinding ineptness of government machinery, or the supposed absence of the individual in Indian culture, they do not take stock of how death is experienced and the changing contours of the culture of death.  The course of the long history of attitudes to death in the West was to culminate, Philippe Aries argued in a seminal book on the subject in 1976, in a concerted attempt to obscure the social reality of death.   Throughout the nineteenth century, improvements in sanitation, hygiene, and nutrition, besides the more celebrated innovations in medical care, led to enhanced life expectancy and it seemed as if the moment of death could be forestalled.  Yet this grand narrative of progress was to be rudely disrupted:  the trench warfare of the ‘Great War’ which saw millions of young men being sent to death like so many sheep being taken for slaughter, and the nearly countless dead of the World War II, deepened the resolve in the West to restore the pact which would render death, as Aries terms it, ‘forbidden’.  The entire care of death in the West has, over the course of the last few decades, been turned over to professionals and managers.   The loud mourning that characterized the 19th century has been replaced by quiet funerals; to the extent possible, death has become sanitized.  Responsibility for the patient is handed over to nursing homes and, of course, hospitals.  Ivan Illich, in a devastating critique of the modern culture of death in the West, called it ‘the medicalization of death’.

India presents the greatest possible contrast with the ‘death of death’, and not only because, however much we may attempt to banish the dead from our lives, there are people dying in our midst –– from malaria and dengue fever, untreated and undiagnosed illnesses, accidents at factories and industrial sites, and so on.   In every middle class family where there are cooks, drivers, maids, and washerwomen, there are such stories to be told.  Death is everywhere in more ways than we imagine.  The dead are taken through the streets to the cries of ‘Ram nam satya hai’.  The dead continue to exert a visceral presence through the living, through elaborate funerary rites as much as the fact that males and females of Hindu families might become walking signifiers of death.  If males shave their heads and facial hair, the upper caste Hindu woman who enters into a state of widowhood is recognized by her simple clothing and renunciation of the right to adorn herself.   Banaras is the City of Light, but it must also be unique among the world’s great cities in being devoted to death; one goes to Banaras to die.  Banaras is the great cremation ground; and in its midst, along the riverfront, is Manikarnika, the epicentre of the dead.  Where most other cultures bury their dead, Hindus burn their dead.  This must be one reason among many, as I have elsewhere written, for the supreme indifference of Hindus towards their own history.  The body –– the physical body, the body of history ­­­­–– is placed on the funeral pyre for all to see; and when it has been burnt to ashes, those who make their living off the cremation ground sift through them in search of valuables.

The dead and the living, as the Mahabharata instructs us, are knotted together:  in the words of the Shanti Parva (175.24), ‘Death is connected with life from the moment one is born’.  The Mahabharata is also clear that one may suffer a psychological death long before the biological fact of death stares one in the face:  death takes many forms, among them hatred and greed, anger, and the drunkenness of the mind (Udyoga Parva 42.7).  Beyond all this, as the Mahabharata recognizes only too well, there remains the one insuperable fact of life.  When it comes to death, the human instinct is always to think of the death of another, not the death of oneself.  In the justly famous passage of the Mahabharata that has come to be known as the ‘Yaksha Prasna’, Yudhisthira is asked what is the most wondrous thing in the world.  All around oneself, says Yudhisthira, one sees death and the fire of destruction, countless number of living beings taken to the beyond; and yet one persists in the belief that one alone is immortal.