The Emperor of All Maladies: a Biography of Cancer

The terrible omnipresence of cancer.

"I feel it in my fingers/I feel it in my toes/Love is all around me/And so the feeling grows . . ." So have crooned a succession of pop stars, from the Troggs, who first coined the expression, to Bill Nighy and Wet Wet Wet. But from where I'm sitting a more plausible candidate for omni­presence would be cancer. Let's make the substitution and see how it sounds: "I feel it in my fingers/I feel it in my toes/Cancer is all around me/And so the feeling grows . . ." Ye-es, much better, I'm sure you'll agree.

Both of my parents died of cancer; my wife is receiving radiotherapy for breast cancer; the sister of one of my closest friends is in a hospice dying of lung cancer; I was on the phone recently to another friend whose breast cancer - treated a decade ago with a mastectomy and chemotherapy - has recurred and metastasised into her bones; another good friend is suffering from throat cancer; indeed, cancer is so much all around me that two people I know well are being treated for leukaemia in the same ward of the same hospital.

I don't imagine that I'm exceptional in this regard - cancer really is all around. Whether it's a function of an increasingly carcinogenic environment - and lifestyle - or merely our ageing population, the incidence of cancer has now reached one in five of the population. Some epidemiologists believe that in years to come half of us may well die from the disease that the oncologist author Siddhartha Mukherjee hails as the "emperor of maladies". Yet, despite this ubiquity, the available cancer literature has been notable for its specificity. From Crazy Sexy Cancer Tips to Because . . . Someone I Love Has Cancer: Kids' Activity Book and from Prostate Cancer for Dummies to Cancer Etiquette, this is a subject that readers seem to encounter only on a need-to-know basis - until now, because Mukherjee's book lifts cancer bodily from the self-help section of the bookshop, dissects it and then apportions it to several other genres.

The Emperor of All Maladies styles itself as “a biography" of cancer, but while Mukherjee does indeed survey the historical and even archaeological evidence, this is remarkably sparse. Yes, there are mummified remains dating from the 10th century that were found in the Atacama Desert, where aridity has preserved tumour as well as bone, and there is inferential proof of the existence of cancer in human populations going back to the Neolithic age. As for treating "bulging tumours of the breast", we have a papyrus, dated to 2625BC, in which the Egyptian polymath Imhotep describes them with unsurpassed forensic accuracy, while offering, under the heading "Therapy", the bleak prognosis: "There is none." Herodotus begs to differ; in his Histories, he retails a characteristic anecdote concerning the Persian queen Atossa (550-475BC), whose Greek slave Democedes performs on her the first recorded mastectomy.

It was Hippocrates in the 5th century BC who named the cancerous tumour, with its defining network of blood vessels, karkinos, or "the crab". By the time we reach the physician Galen in the 2nd century AD, the malady has become incorporated into his system of humours and resides in the most gloopily malevolent and systemically prevalent of them all, the dreaded "black bile".

All of this background Mukherjee dutifully records, but it is the era of modern medicine that thrills him most (he, too, is a physician). He dates the genesis of the modern search for cancer therapies to 1845, when the German researcher Rudolf Virchow renamed what was previously adjudged a "suppuration of the blood" as weißes blut, or the more academic-sounding "leukaemia". It is here that the pur­view of The Emperor of All Maladies becomes sufficiently magnified to encounter the cellular ontogeny of cancer, and here also that the narrative starts to feel like a thriller more than
anything else.

In fact, Mukherjee has already primed us for this genre-bending by introducing two other strands to his story: first, the tale of one of his own cancer patients, Carla Reed, a young mother struck down by the sudden onset of leukaemia; and second, the equally dramatic story of Sidney Farber, who first administered cytogenic (cell-killing) drugs to leukaemia patients in the 1940s at Children's Hospital Boston, becoming the founding father of modern chemotherapy. In the rest of the book, Mukherjee moves back and forth between timelines, ramping up the tension as the reader riffles through 400-odd pages of detailed explanations of advances in cancer therapeutics, molecular biochemistry and genetics, desperate to find out whether a cure is discovered in time to save Carla.

This isn't altogether fair, but although in the United States The Emperor of All Maladies received a National Book Award and fulsome encomiums for its literary merit, I suspect British readers may, like me, find the introduction of scores of American lab rats with notable characteristics - "Rous was bulldoggish, persuasive and inflexible", "restless and imaginative Tamer" - more than a little wearing. Then there is the author's dogged insistence that America's "war on cancer", inaugurated by Sidney Farber, is, was and always will be where the action is. It's strange, because Mukherjee studied in the UK, and he writes particularly well about the pioneering 1950 study on smoking and cancer conducted by Richard Doll and Austin Bradford Hill, which not only established a link between the two factors, but also inaugurated a wholly new approach to epidemiological statistics.

Another feather in British - or at least, Scottish - medicine's cap was the launch of the hospice movement, which Mukherjee rightly identifies as a timely corrective to the "heroic" excesses of chemotherapy in the 1980s and early 1990s, when patients were callously sliced, diced, pickled and irradiated until they toppled into the grave. Overall, though, he is a peerless guide to the depredations of and battles with the demon crab, and seems to have retained a healthy scepticism about the effects of professional closure within the medical industry.

In his acknowledgements, the author cites Richard Rhodes's book The Making of the Atomic Bomb, and The Emperor of All Maladies is an equally accomplished example of popular science writing. Mukherjee never condescends, yet he manages to write lucidly and tellingly about complex experimental, technological and theoretical matters. This is very much a narrative of hard science, but Mukherjee has the grace to admit that, despite all the advances, "much about this battle [with cancer] will remain the same: the relentlessness, the inventiveness, the resilience, the queasy pivoting between defeat­ism and hope, the hypnotic drive for universal solutions, the disappointment of defeat, the arrogance and the hubris".

I feel it in my fingers, I feel it in my toes - that I've been waiting a while to read a large-scale book about cancer - and this one, though it hasn't cured my desire, has managed quite effectively to palliate it. That's probably just as well, because, given my life expectancy as a smoker of 35 years' standing, I am unlikely to live long enough for the next one to come along. l

The Emperor of All Maladies: a Biography of Cancer
Siddhartha Mukherjee
Fourth Estate, 592pp, £25

Will Self is an author and journalist. His books include Umbrella, Shark, The Book of Dave and The Butt. He writes the Madness of Crowds and Real Meals columns for the New Statesman.

This article first appeared in the 14 February 2011 issue of the New Statesman, The Middle East

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Sunjeev Sahota’s The Year of the Runaways: a subtle study of “economic migration”

Sahota’s Man Booker-shortlisted novel goes to places we would all rather not think about.

This summer’s crisis has reinforced the ­distinction that is often made between refugees, who deserve sanctuary because they are fleeing from conflict, and “economic migrants”, those coming to Europe in pursuit of “the good life”, who must be repelled at any cost. The entire bureaucratic and punitive capacity of our immigration system is pitted against these ne’er-do-wells and their impudent aspirations.

Sunjeev Sahota’s fine second novel, The Year of the Runaways, now shortlisted for the Man Booker Prize, takes a closer look at “economic migration”. Why do people – many of them educated, from loving families in peaceful communities – leave their old lives behind and come to Britain? Are they fleeing desperate circumstances or are they on the make? When they arrive here, do they find what they were looking for? Should we welcome them, or try to persuade them to stay at home? The book illuminates all of these questions while, much to its credit, offering no simple answers.

Sahota interweaves the stories of three people whose reasons for emigrating are as individual as they are. Both Avtar and Randeep are from Indian Sikh families that might be characterised as lower-middle-class. Avtar’s father has his own small business – a shawl shop – and Randeep’s father works for the government. Both boys are educated and Avtar, in particular, is smart and motivated. But with employment hard to come by and no social security net to fall back on, it doesn’t take much to make leaving the country seem like the only option. Avtar loses his job, his father’s business is failing and he has high hopes of earning enough to marry Lakhpreet, his girlfriend-on-the-sly. Randeep’s family’s finances fall apart after his father has a psychological breakdown; their only hope of maintaining a respectable lifestyle is for their eldest son to take his chances abroad.

For Tochi, the situation is very different. He is what used to be called an “untouchable” and, although people now use euphemisms (“scheduled”, or chamaar), the taboo remains as strong as ever. He comes to Britain not so much for financial reasons – although he is the poorest of the lot – but to escape the prejudice that killed his father, mother and pregnant sister.

Tying these disparate stories together is the book’s most intriguing character, Narinder, a British Sikh woman who comes to believe that it is her spiritual calling to rescue a desperate Indian by “visa marriage”. Narinder’s progress, from the very limited horizons for an obedient young woman to a greater sense of herself as an active participant in her destiny, reminded me of Nazneen, the protagonist in Monica Ali’s Brick Lane. But Narinder is a more thoughtful character and here the Hollywood-style journey of personal liberation is tempered by a recognition of the powerful bonds of tradition and family.

Once in Britain, Avtar, Randeep and Tochi enter a world of gangmasters, slum accommodation and zero job security, with an ever-present fear of “raids” by immigration officers. They work in fried chicken shops, down sewers, on building sites and cleaning nightclubs. Health care is off-limits for fear of immigration checks. Food is basic and the only charity comes from the gurdwara, or Sikh temple, which provides help in emergencies.

Avtar and Randeep struggle to send money back home while living in poverty and squalor that their families could barely imagine (at one point, Randeep notes with understandable bitterness that his mother has used his hard-earned contributions to buy herself a string of pearls). In the meantime, their desperation leads them to increasingly morally repellent behaviour, from selfishness to stealing and worse. Even if they do eventually find a measure of economic stability in Britain, they have done so at the cost of their better selves.

It has been pointed out that the novels on the Man Booker shortlist this year are even more depressing than usual and The Year of the Runaways certainly won’t have raised the laugh count. At times I had to put it down for a while, overwhelmed by tragedy after tragedy. It was the quality of Sahota’s prose and perceptions that brought me back. He is a wonderfully subtle writer who makes what he leaves unsaid as important as the words on the page. A wise and compassionate observer of humanity, he has gone to some dark places – places we would all rather not think about – to bring us this book. Whether we are prepared to extend a measure of his wisdom and compassion to real immigrants, in the real world, is another question.

“The Year of the Runaways” by Sunjeev Sahota is published by Picador (480pp, £14.99)

Alice O'Keeffe is an award-winning journalist and former arts editor of the New Statesman. She now works as a freelance writer and looks after two young children. You can find her on Twitter as @AliceOKeeffe.

This article first appeared in the 08 October 2015 issue of the New Statesman, Putin vs Isis