Book Review : "The Emperor of All Maladies" by Siddhartha Mukerjee

Sometimes, on a lazy, miserably rainy, Monday when my head is already spinning from too much frogtalk by lunchtime, I just recycle stuff I've already written up somewhere else. Désolé.
The Emperor of All Maladies by Siddhartha Mukherjee
My rating: 2 of 5 stars

Every year there's always one non-fiction book that the entire literate world raves about and that I hate. In 2009 it was Richard Holmes's "The Age of Wonder", the following year it was "The Emperor of All Maladies".

Universally admired, winner of a Pulitzer prize, this book annoyed me so profoundly when I first read it that I've had to wait almost a year to be able to write anything vaguely coherent about it. The flaws that I found so infuriating a year ago seem less important upon a second reading. Though I still think it is a poorly conceived book, executed in a manner that lacks all restraint, it's nowhere near as terrible as I remembered.

As I recall, the aspects of the book that most annoyed me were:

(a) the author's anthropomorphism of cancer -- a stupid, unhelpful, and ineffective metaphor. In general, I detest this practice of attributing personalities to diseases. Perhaps it's a necessary psychological strategy for oncologists. But it's particularly inappropriate in the case of cancer, as it perpetuates the incorrect belief that cancer is a single disease, as opposed to a "shape-shifting disease of colossal diversity". For the same reason, it makes little sense to speak of a "war on cancer", as if it were a sentient villain with plans for world domination, one that can somehow be vanquished if we just find the magic formula. Mukherjee correctly deplores this view as simplistic and reductive, but he then proceeds to adopt it hook, line, and sinker. It's a baffling and unfortunate choice, because its inherent deficiencies lead to a kind of narrative incoherence, as well as a damaging lack of clarity about the nature and scope of the book. It's a symptom of Mukherjee's vagueness of purpose that he often refers to the book as a "biography of cancer", as if that phrase had meaning.

(b) A complete, fatal, inability to leave anything out. There is a certain type of non-fiction writer who seems hellbent on inflicting everything he or she learned while researching the book on the misfortunate reader. No detail is spared. Everyone the author spoke to during the five years researching the book gets a mention, it would seem. As do a bunch of dead folks, some of them very dead, not all clearly particularly relevant.

If, by doing this, the author is trying to impress with the breadth of his research, then he fails. Leaving everything in is the simple, intellectually lazy, option. Where non-fiction is concerned, the reader has a right to expect the author to take the trouble to shape his material into some kind of coherent whole, recognizing that while some details are critical, others are not, and pruning accordingly. All too often, though, authors forget this. Their enthusiasm about the subject leads them to lose perspective: "the reader needs the whole story and will be thirsting for all the gory details; it would be criminal to leave anything out".

Well, actually, NO. We want you, the author, to point out to us what's important and what's not.

(c) The author includes stories of his own patients' experience with cancers of various types. I have nothing against this per se - it's entirely sensible to do so. However, it requires delicacy and finesse to report on his patients' stories without seeming exploitative or emotionally manipulative. Writers like Jerome Groopman and Oliver Sachs regularly navigate this terrain with grace and sensitivity. Mukherjee, a much less experienced writer, repeatedly crosses the line into bathos and melodrama. The language is overly dramatic; one senses also that Mukherjee succumbs to the oncologist's fallacy of believing that cancer is intrinsically "worse", or more serious, than all other ailments. Actually, I guess that's already evident from the book's title.

(d) He has a particularly unfortunate habit of prefacing each chapter with at least one "literary quote", and when the book reaches a new section (there are six in all), he tends to go hog wild and give us a whole page of quotes. These seem like a minor distraction at first, but their cumulative effect is to leave the reader with the impression that (i) it is very important to the author to let the world know that he is a well-read, Renaissance dude (ii) chances are the author is a bit of a poser. The bard, the bible, St Thomas Aquinas, Sophocles, Kafka, Hegel, Voltaire, Plato, Sun Tzu, and William Blake are all mined for a portentous snippet or two about mortality and the evils that the flesh is heir to. Not to mention Gertrude Stein, Jack London, Czeslaw Milosz, W.H. Auden, Hilaire Belloc, D.H. Lawrence, Lewis Carroll, Conan Doyle, Italo Calvino, Woody Allen, Solzhenitsyn, Akhmatova... . Using just the right quote to frame an argument, or introduce a topic, can be an extremely effective device, but its effectiveness diminishes rapidly with overuse. One gets the distinct impression that the author ransacked some quotation website in the mistaken idea that sprinkling them copiously throughout the manuscript would magically confer some kind of gravitas. I reached my eye-rolling moment on page 190, introducing part three, when Doctor Mukherjee felt impelled to quote T.S. Eliot:

"... I have seen the Eternal Footman hold my coat, and snicker.
And in short, I was afraid."

(e) As I mentioned, I think the structure and organization of the material leaves much to be desired. The writing is generally adequate, if a little verbose, though one tic of the author's drove me nuts. Each of the apparently infinite number of characters in the book is introduced in Mukherjee's characteristically breezy style, then immediately fixed in amber by means of a trio of adjectives. Accurate information about the personality and character of many of these historical characters being limited, one suspects that these adjective triplets may well have been chosen at random from a thesaurus. This kind of thing:

childless, socially awkward, and notoriously reclusive
wealthy, politically savvy, and well-connected
wealthy, gracious, and enterprising
ambitious, canny, and restless
self-composed, fiery, and energetic
proud, guarded, and secretive
flamboyant, hot-tempered, and adventurous
cool, composed, and cautious
intellectual, deliberate, and imposing
charming, soft-spoken and careful
outspoken, pugnacious, and bold
impatient, aggressive and goal-driven
brackish, ambitious, dogged, and feisty
suave, personable, and sophisticated (impeccably dressed in custom-cut Milanese suits)
brilliant, brash and single-minded
laconic and secretive, with a slippery quicksilver temper

Obviously, Dr Mukherjee is an adherent of the "Adjectives are Your Friends" school of writing. If this kind of tic bothers you, be warned that it really runs rampant in this book. In the general scheme of things, it's a minor detail.

Enough caviling. What has the author accomplished in this book? I think he has written an overly detailed*, partially complete**, suboptimally organized*** account of the evolution of our understanding of cancer and the development of treatment options to counteract it. The result is a very readable account, though I imagine some of the second half of the book may be hard for non-scientists to understand. In general, he seems to get things right, though there are a few lapses -- most notably in his discussion of the use of mustard gas in WWI. I can find no corroboration of his statement that "in a single year it left hundreds of thousands dead in its wake"; one wonders if he may have confused 'casualties' with 'fatalities'. His ability to explain biomedical ideas in terms a layperson can understand seems decent, though not exceptional. I don't think the writing is of a caliber that deserves the Pulitzer prize, but what do I know?

*: "overly detailed" - to give just one example, was it really necessary to devote a page and a half to reviewing Lister's introduction of antiseptics? And in a book which appeared to be focused on diagnostic and therapeutic options, why devote 40 pages to the link between smoking and cancer with the emphasis firmly on the legal and regulatory aspects?
**: eye-glazing detail about kinase inhibitors, but nothing about anti-angiogenesis agents (Avastin was approved around 2003, as I recall, so it's clearly well within the time horizon)
***: a person could get whiplash from all the zipping up and back down the historical timeline, for no obvious reason.


Thank you. Now that I've got that out of my system, I feel much better.

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