Harvard Book Store; WGBH Forum Network; Siddhartha Mukherjee: A Biography of Cancer

Go ahead and get started now. Good evening. My name's Mike on behalf of our bookstore I want to thank you all for coming I want to welcome you to tonight's event with Dr. Siddhartha Mukherjee. Before we get started I want to mention just a few of the bookstore's upcoming events this Friday Jason Stevens will discuss God fearing and free a spiritual history of America's Cold War. That discussion is part of our Friday forum series will be here in the store at 3 o'clock in the afternoon. It is free. This weekend we're going to have our winter warehouse sale for those of you who haven't been for we have a warehouse over in Somerville. We keep thousands of used books and remainders and collectible books and bargain books so we only open it a couple times a year so if you're free it's going to be from tender for Saturday and Sunday you can get more information up at the information desk or online. And next Monday Harold McGee will discuss Keys to Good Cooking with reality show Chef Jody Adams that'll be here in the store at 7:00 o'clock and it is free. You can find more information on these and other upcoming Harvard bookstore events in our winter events flyer you can always go online to Harvard dot com for full listings. I'd ask everybody everybody to take a moment to

turn off your cell phones if you have those with you. Tonight I'm excited to welcome Dr. Siddhartha Mukherjee to Harvard bookstore to discuss his book The Emperor of All Maladies. Dr. Mukherjee is a cancer physician and researcher at Columbia University Medical Center as well as a professor of medicine at Columbia and a Rhodes scholar Dr. Mukherjee graduated from Stanford Oxford and Harvard Medical School. His writings appeared in nature the New England Journal of Medicine. The New York Times and The New Republic The Emperor of All Maladies is his first book. Dr. MUKHERJEE subtitled his book a biography of cancer. And he provides the reader the story of the disease from its earliest recorded history in ancient Egypt through the modern era in the thousands of years that humankind has been aware of the disease. Attitudes about cancer and approaches to its treatment have changed greatly. The prominence cancer holds in modern culture would have been unimaginable only a hundred years ago when the disease was considered shameful. Dr. Mukherjee also writes about his own experience treating cancer providing a need a unique insight into the ongoing fight against what he terms are desperate

malevolent contemporary doppelganger. Publisher's Weekly called the book a sweeping epic of obsession. Brilliant researchers dramatic new treatments euphoric success and tragic failure. It's time to welcome a new star into the constellation of great doctor writers wrote The Washington Post going on to call the Emperor of All Maladies enthralling juicy scholarly and wonderfully written. And just today the New York Times names the Emperor of All Maladies one of the 10 best books of the year so that's very exciting. We will follow Dr marker Geez talk with the question answer session will end with the book signing here the table will start clearing chairs as soon as they're free but alas they try to get the signing line form going to my left down this direction here and again will free up space as soon as we can. Copies of the book are available to purchase at the registers We do ask that you purchase your book before having it signed. And as always I thank those of you who do purchase the book tonight by doing so you're supporting a local independent bookstore and this author series and you make it possible for us to bring exciting new authors like

Dr. Siddhartha Mukherjee to you. So join me in welcoming him to the podium. Thank you so much for that lovely introduction. My introduction began at 5:00 in the morning and I got this phone call about the New York Times so a little bit groggy. But it was wonderful. This bookstore holds a very special place in my heart because much of this book was actually written just across from here at the Lamont library that was my chosen space of work. I used to sit in the windows and every evening that I would write or finish any work I would usually take a winding road back to my house which usually almost always involved a stop here and a slight unloading of my wallet. And and I was this I was in came I was living human for 13 years and I would say in one mild vicinity of Harvard Book Store. And I think some of that was conscious because I really am attached to this particular bookstore but the bookstores in general are

very happy to support it in any manner or form for tonight I thought I would do a couple of things. One is that I'd like to talk more about the book then read from it partly because that's a that's an experience that you can get from reading the book. And so I do a couple of small readings from the book but really I want to talk about how the book was written and why it was written and sort of what the what the overall global story is and I hope I'm obviously not going to give away any piece of it but I hope to convey the sense of what what the book is. To start I think one thing that struck me very early on Graham who was my editor in writing this book said to me that in the end the entire paraphernalia of the book world including bookstores and editors and publishers and designers etc. etc. are merely tools to get one author sitting alone in a room to communicate with one

reader sitting alone. And if you forget that for a second you are unable to write a book. And that struck me as very important because in some sense that is also the practice of medicine. In the end if you take the entire paraphernalia of a million dollar hospital and its CAT scans and MRI eyes and thousands of dollars of technology poured in every second. In the end the practice of medicine occurs between one person sitting in a room and the other person sitting hopefully in the same room. But nonetheless. And I think there's an important parallel there and that parallel is really what motivates this kind of book and that parallel is storytelling. That parallel is that much like the much like writing a book is a communication between As I said one person another person through the version through a story. Medicine at its best is begins with storytelling. And if you cannot tell a story the practice of medicine breaks down. And so in a very

very fundamental sense right at the beginning of writing this book I acknowledge that but also right in the beginning of writing this book I felt that this should be a story and if one could not construct a story of what has happened in our lives against cancer for you know the last 4000 years then there was something wrong because this had to be a story they could not. This could be nothing but a story because of course this is a story of many characters across many across a vast amount of time but nonetheless its narrative quality was very crucial. And so. I started one of the one of the very early devices that was used in this book is to find the stories of patients whenever whenever I felt the pulse of the book drop at any point of time the answer was always find the stories find the story of the patient forget for a moment about the advancement forget for a moment about the science because that comes secondary. That's a

secondary achievement. And what is really really central to all of this is of course the story. So I'm going to begin with let me tell you some of these stories I can tell you all of them. The book follows as McGrath pointed out in the Times the book doesn't follow a linear structure. It will bounce back it will move between characters and times moving back sometimes 4000 years. Switching back forward four thousand years. But the reason it's all connected of course is that. Medicine and science is also having a conversation with its past. So every time you perform I mean I see I see I want one point of the time in the book. I say science scientists are actually more obsessed with history than perhaps even historians because there is no discipline that I can think of which is so deeply dependent on history. We always think of science as a futuristic discipline but really it isn't. It is a discipline obsessed with immersed in its past. And it has to be because you're conversing always back you're conversing when I perform an experiment today. I'm actually conversing

back to someone who did it five years ago and that person was actually conversing back to Galileo or you know whoever else was sitting in some other point of time writing trying to explain or trying to create a journey through time. And so so so again much like that first analogy that I gave you between patients between patient and a doctor and a writer and as a storyteller. There's also of course a storytelling element in science except not in science story. It occurs to it's possible to tell the story not to a person in the physical present but a person in its physical in the temporal past. And I had that was also a very important piece of the book. So the first two I thought I would tell you is very early on one of the characters in the book and I want to follow the linear narrative but one of the characters in the book one of the central characters in the book is Sidney Farber. And early on had to make a decision to have a single narrative skeleton on whom a 4000 year old history could be hung. And that's obviously a difficult question how do you hang such an enormous history on a

single person or a single single story. And one thing that was particular important about Sidney Farber and it's the following. Sidney Farber was a pathologist. He was born in 1903. He was called the doctor of the dead because pathologists usually perform autopsies. They usually don't treat. They usually diagnose any part of the great ancillary services kind of invisible medicine that sits in every hospital and fire was a very prominent pathologist. He was a children's pathologist and he became very interested in a disease called acute lymphoblastic leukemia. It's a children's disease it's a form of leukemia a very aggressive form of leukemia for the following reason. In a word before CAT scans an MRI is quantifying the size of an internal tumor was impossible or nearly impossible. But leukemia could be measured because a tumor of the blood and you could drop a drop of blood you could look under a microscope and say well there are more cells or less cells.

Science always begins with measurement as soon as you perform a measuring activity of any kind that is already a scientific activity and so far been knew this he had inherited this idea from his predecessors. Others knew it too. So he knew that if if there was if something was to be done around cancer he might might as well start with its most one of its most measurable forms and therefore he gravitated towards acute lymphoblastic leukemia. The other reason was of course that this was a this was a surgically unknown disease that was surgically amenable. Surgeons couldn't operate on blood you can't take blood out obviously. So there was no it was it was as the book points out that the leukemia itself was like a pariah between disciplines the hematology assists the doctors of the blood. You passed it on to the oncologist and the oncologist passed it back to the mythologists and the children were sort of stuck in this in this in this betweens in-between space. And so it was that was another advantage it was a disease that had nothing you know was sort of a pariah between disciplines. Actually not unlike farmer himself he was also moving between mythology and medicine all

the time. And so Sidney Farber had a very key insight and that is that he imagined that there were chemicals in the world that could turn off or selectively kill cancer cells while sparing normal cells. This was a very important insight. The so-called penicillin for cancer this was a time when America was just emerging out of this in 1947 1948 just emerging out of the of the late tail of the war. And it was a moment actually very important in the history of cancer because cancer is a silent disease an invisible disease. There's an important anecdote in the book when Fanny Rosenow a breast cancer advocate calls up the New York Times. And she says I'm a breast cancer survivor. I would like to have a group of people who meet me to group of breast cancer survivors and there's a long hold. And The Times editor put her on hold and then the society editor comes on the

phone and she says to me Rosa I was puzzled and the society editor says well Mr. Rosenow you know we can't print the word breast cancer in the Times. What if we said that this was a meeting of women with diseases of the chest wall. So this is this is this is 1950 this is the atmosphere that Farber is working in. He's looking for a. He's looking for a chemical that will turn or turn on or turn off these malignant cells and he finds an important ally and that ally is a man named Yellow. Kind of interesting you forgotten in medical history and an Indian doctor who had come to Boston. He had actually applied for. He'd applied for a fellowship in the school of tropical health and medicine and not realizing that actually Boston was far from tropical. And so and this is where he came from address he came from on a boat landed up here in the middle of the winter almost really froze to death his first winter. He lived in a

kind of Garret underneath a house in Brooklyn I've been to his Brookline I've been to his his apartment and yellow was denied tenure at Harvard and then went off to a pharmaceutical company up north in New York and was synthesizing these chemicals which turned out to be the precisely the chemicals that fiber was looking for. So these were chemicals called anti Follett's fiber had figured out that folic acid was one of the chemicals that the blood that leukemia cells required for their growth. So look we're very dependent on the growth of folic acid and therefore an antagonist for the gas it would perhaps act as a chemotherapeutic drug. And he then contacted yella who is up north actually fiber was one of your last few friends while he was in Boston. You can have been sent to first vials of this new drug for it called AM an option

and far better without actually really knowing very much. Just roll up his sleeves and he began to inject these these tremendously ill kids with these anti-family and he saw these brief tantalizing remissions these kids who were these children two or three years old by the way this is a time when I had my my daughter was 3 had a very emotional connection to all of this and I had been in the wards and seen 3 year old children with lymphoblastic leukemia and now as I tell you later I'm going to I'm going to split the suspense a second this is a curable disease. This is a this is a disease that carries an 80 or 90 percent cure rate. But it was 100 percent lethal in five years time. And he began to inject these children with anti Phillips and he saw these tantalizing remissions the kids would go and have a remission five months six months 12 months and then they would relapse and die again. And so. So here comes a little personal story which is not in the book which is that now this I knew I had constructed these pieces of history from talking to farmer's

family from picking up records. There's a trail a paper trail. But now who was the first sarge to be treated and where with this did this child exist. So in the papers fabric refers to this child as a child called R S and then my quest became find R S because I felt as if I couldn't write this book if I couldn't find r s r s was going to be the central character in my book. But how does one find in this child lived for four months after Sidney Farber injected him with Auntie Phillips and then died afterwards. So so I began to put in advertisement on list serves around Boston I thought you know maybe the parents were alive. Maybe I knew the child had a twin who didn't have leukemia interestedly so I kept putting out ads saying that you know if you're Yes you have never brother who had leukemia in 1948 please contact me if you have if you have a parent if you had a father any connection. And there was nothing. There was no response so I got dejected

and I went actually to India or to my parents house. For a vacation and someone told me yella remember yellow chemist subtly yellers biographer and friend lived two or three blocks from my parents house in India. So I said fine since I'm not doing nothing except writing this book obsessively every day might as well go and visit the biographer's I went to your last biographer and yellow's biographer tells me that he had a long conversation at the end of the conversation he says well you know I was at a farmers Institute and I met Dr. Farber in one thousand 52 or 53 and while I was there I was taking notes and actually he gave me a roster of all the patients that he was treating for for leukemia. And in that roster if you look the last I heard he kept little cuttings was an article from The Boston Sunday Herald from 1948 containing the picture of Robert Sandler. And so that picture is reproduced in the book it's actually the first picture of the book. And in fact the book is dedicated to Robert Sander 1945 to 48 and to those who came before and after him.

And that's that's a great story but the story gets even crazier because last Friday when this event was announced. I get a phone call from my publicist from my publisher who says you won't believe it. Hang on the line and it's Robert Sanders mother and his brother and they contacted me last Friday and she was crying and because she had lost obviously the one of her twins the other twin had survived. And then she said something very interesting. I mean I spoke with her it was her with her son to her son she said something interesting. She said that when the child had died it was in there their fate was not to perform an autopsy. And Sidney Farber apparently begged them to perform an autopsy and she was really shaken by it and she had lived. She's eighty eight I think or 89. Eighty six years

after the death of her child she had lived with the guilt of having submitted her child's body to an autopsy. And she said to me that but of course that autopsy turns out to be very crucial because it was through autopsies like that that Farber finally figured out what the next step was how to how to use the next drug in the next mission. And so she said to me this book really brings that entire story that 87 year old open story to a close because finally at the end of 87 years she says I can now put that idea to rest that I had allowed my my dying child like my dead son to to be opened up for an autopsy so I thought it was a very moving testament to what books can do at times. So I'm going to now tell you and I'm going to read a little bit from a chapter called fibers gauntlet in which I describe that case I describe the case and remember the only thing and this is part of you know this is part of the part of learning to write for me was how do you take a paper which is about.

Two paragraphs two and a half paragraphs long a description in the paper. And how do you convert it into something that comes alive. That becomes a story and what tools do you use so that we now Sandra becomes a character not just a r s in a scientific paper but a real human being and his family becomes a real human when we really read a little bit and then then I'll do another section and then we'll stop and take questions. So here he is so it turned out that because I knew his name I could figure out his mother's name because it turned out that in the article his mother's name was listed from the Boston Sunday Herald. So Helen Sandra's name was listed in there you'll find her picture in the book. I have the book. It's in the picture section in the second page. Over here we just lift it up and show you. So that's that's Helen Sandler with the two twins.

And see. And so. So I knew and then but because Boston has very good records of death and because the Boston Public Library is a resource provides a resource and actually has a phone not a phone directory but a directory of addresses from 1948. I could very quickly figure out and I can figure out where the child had lived and then 15 minutes I could go back by the way there's a very important metaphorical quality in the story which is that the fact that I found this child a thousand miles away or 6000 miles away from Boston was very important to me actually in writing the book because it reminded me about the entire process of anything that happens in the book. You're looking in one direction you know inevitably find things 6000 miles away and they get connected up. So it was very For me it was very personally inspiring because I kept saying to myself if I could if I can do this if I can find someone 6000 miles away then I can unearth any piece of this history I mean you know there's been a little bit of luck. But. So I figured out

and then by doing this I figured out where the child had lived because I could find his address and by finding it as I could actually go to the house and again this was very important to writing the book. Every time I was struck I would often go so for instance in writing about the trials the Malmo trials the famous mammography trials in Sweden which were very important in the history of Margaret. I decided that I would go to MoMA because again I was stuck and there's no nothing else to do. You know there's no other way to move the book. And it was in Malmo that a woman told me began to tell me what it was like to undergo the first screening trials of mammography. And if you didn't go to Malmo you'd never discover this. Another example of this is you know there was a there's a there's a section in the book which talks about the link between smoking and lung cancer which was really invisible in the 1950s. People didn't know it no one suspected it had become invisible actually. And again to enliven that I decided that I would go to I would go to England

where the D-Link was first discovered really to the building where the link was being discovered in the 1950s in 1940s and 1950s and it was only by being in that building you realize what a short distance that building is physically from the ship building and the actuarial industry the insurance industry of England which is located in Threadneedle Street. And it turns out that's not a coincidence it turns out that the very equations that allow us to solve statistical. Relationships risks are in fact ball borrowed in epidemiology borrowed from the insurance industry because when a ship was up to see the actuaries had to make an estimate what the likelihood of of the ship coming back was and fortunes would be would be lost when the ship the ship didn't come back or half the cargo sank. And so there were all these assessments of risk being carried out along Threadneedle Street which were which were related to the fact is how does one manage how does one estimate risk was a function of risk and of course that allows us risk is what we measure when we measure. When we talk about cancer risk when we talk about. So another story in which you know unless

you physically travel to a space you never you would never figure out what what the geography is and what its interior landscape is. But back to back to Robert Sandler. So he lived in. He lived in Dorchester as it turned out. And so here is here is the description that comes out from a collection of going to the Going to the space looking up the weather report where they where it existed finding little bits and pieces and interviews all of which then get put in a big giant grinder and come out as a story as it were. So seven miles southwest off the Longwood hospitals in Boston the town of Dorchester is a typical sprawling New England suburb the Triangle where it's between the sooty industrial settlements to the west and the gray Green Bays of the Atlantic to its east in the late 1940s waves of Jewish and Irish immigrants it happened to be that Sandra's parents were Jewish immigrants ship builders iron casters his father was a ship builder rail engineers fishermen and factory workers settled in Dorchester occupying rows of broken clapboard houses that snake their way up Blue Hill

Ave. Dorchester reinvented itself as a quintessential suburban family town with parks and playgrounds along the river a golf course a church and a synagogue. On Sunday afternoons families converged at Franklin Park to walk through its leafy pathways or watch ostriches polar bears and tigers at it. And again this is drawn from little pieces of news from Dorchester from the 1930s and 1940s and newspaper clippings and so forth. On August 16th 1947 that day I knew because it was in the paper. In a house across from the just to the side of a ship work in the Boston yard still mysteriously ill with a low grade fever that waxed and waned over two weeks without pattern followed by an increasing lethargy and pallor. Robert Sandler was two years old. His twin Elliot was an active cherubic toddler in perfect health. So now we pick up from fibrous paper because he begins to describe this because every paper is a case history so there he is telling his story in scientific terms which I'm now translating into into nonscientific terms. Ten days after his first fever

Robert's condition worsened significantly his temperature climbed higher his complection turned from rosy to a spectral milky white and all of this is actually in forest paper he was brought to Children's Hospital in Boston. His spleen a fist sized organ that stores and makes blood usually barely palpable under the rib cage was visibly enlarged heaving down like an overflowed bag. A drop of blood on the fiber marks under fibers microscope revealed the identity of his illness. Thousands of immature lymphoid Lukey make blasts were dividing in a frenzy. Their chromosomes condensing in and condensing like tiny clenched and unclenched fists. Sanders arrived at Children's Hospital just a few weeks after fiber had received his first packets from literally we knew that because I had kept records of when he sent the packages across to Sydney fibrous hospital. On September 6th 1947 This is from the paper again. Farber began to inject Sandler with toroidal Spartak acid RPA the first of literally Zanti Follett's and the brackets he consent to a clinical trial for a drug even a toxic drug was not required. Parents are occasionally cursorily informed about

a trial. Children are almost never informed or consulted. The Nuremberg quote for human experimentation requiring explicit voluntary consent from patients was drafted. Interestingly on August 9th 1947 less than a month from the AP a trial survivor's trial so far were sitting here. The protocols for human voluntary consent are being drafted across the Atlantic. Farber in Boston it is doubtful that Farber in Boston had ever heard of such a required code. He would eventually hear about it of course everyone to hear about it. There was no such thing. The drug had little effect over the next month Sandler turned increasingly authoritarian he developed a limp. The result of leukemia pressing down a spinal cord joint X appeared and then violent migrating pains. Then the leukemia burst through one of his bones in his thigh causing a fracture and unleashing a blindingly intense indescribable pain. By December the case seemed hopeless. The tip of Sandra's spleen more dense than ever with leukemia cells dropped down to his pelvis. He was withdrawn listless swollen and pale on the verge of death.

When Elliot called me up he said How did you know about the bone fracture. Because he is his only memory from his childhood he said that I have only one memory. We shared a room in Dorchester with two adjacent cots and there were three years old two and a half years old he said much of that is a blur and maybe even this memory is mythical But he says one night it was one night when his brother starred was so ill and screaming so violently that in fact they had brought in EMT EMT as in that day and age do that to their to their home to take the brother to Farber hospital. In fact that was the night probably most like there was a night that he had the leukemia fracture this is a time when leukemia burst through your bones and actually causes what's called a pathological fracture. On December 28 However Farber received a new version of the anti for late from Subaru and Kilty. This one was called I Am An otter in a chemical with a small change from the structure of a fiber snatch the drug as soon as it arrived and began to inject the boy with it hoping at best for a minor

reprieve in his cancer. The response was market the white cell count which had been climbing astronomically 10000 in September 20000 November and nearly 70000 in December suddenly stopped rising and hovered at a plateau. And then even more remarkably the counts actually started to drop. You can make glass gradually flickering out in the blood and then all but disappearing by New Year's Eve the counter drop to nearly one sixth of its peak value bottoming out at nearly normal levels. The cancer had not vanished under the microscope they were still malignant white cells but it temporarily abated frozen into a humid logical stalemate in the frozen Boston winter. On January 13 1948 again we pick it up from farmers paper sand the returns return to the clinic. Walking on his own for the first time in two months his spleen and liver had shrunk so dramatically that his clothes Farber noted had become loose around the abdomen. His bleeding had stopped his appetite turned ravenous as if he were trying to catch up on six months of last meals. By February Farber noted the child's alertness nutrition and activity were equal to his twins

for a brief month or so. Robert Sandler and Elliot Sanders seemed identical again. So that's the story. And that's a little bit about sort of behind the scenes of what happens when you when you write a book like this. I'm going to skip forward and introduce you to one major other character and that is Mary Lasker and so far bers emergence from the farmer's emergence from the basement laboratory into the limelight of medicine is in some sense was his first experiment. But Farber performed actually what I call his second experiment a second experiment I think is actually just as crucial and just as important and this was an experiment in science but experiment in media. And so he realized having sent having invented essentially these chemotherapeutic drugs that he needed to launch a national platform or at least a local platform to begin with to attack cancer. And he began to then

look for collaborators who would allow him to do this and he found an incredible collaborator early on and that was the Variety Club of Boston this was a club of essentially movie makers. Again the post-war boom in moviemaking had begun to pour money into the coffers of the Variety Club these men were becoming very wealthy and in fact in their past they had adopted a child and made children's causes. A big part of their part of their general cause this is the Variety Club. And so far I thought this was an idealized because you could then hook up with a Variety Club and thereby launch a local a large local platform against cancer. And so he was he then again figuring out the past figuring out the idea that the writer had acquired this adopted child and thereby created an icon for we began to look for his own icon a child with cancer who would carry the message. And unfortunately when he went upstairs to his wards I mean these were children with leukemia being injected with anti folate and they were

desperately ill people who were throwing up lost their hair barely able to live let alone the vast mascot for or an icon for cancer. But there was one child who was not being treated for leukemia who he found and this child came from Maine and had you know was being treated for a different cancer. The only problem was his name was INR Gustafsson. And so so partly to conceal his name and partly to give him anonymity but also partly to create a name that was actually recognizable fiber rechristen him Jimmy. And so this was the birth of the Jimmy Fund and within by using the Variety Club and by using actually baseball which was a big Boston phenomenon remains a big Boston phenomenon by using again you see fibers mind at work here. He is he has a he has an he has a child that he's going to create anonymize and make the icon for cancer. But then he quickly leans in pulls in movies and then he quickly leans in and he pulls in actually

the baseball Ted Williams Most importantly there was a change in the baseball history of baseball in Boston which I won't go into but but Ted Williams eventually and then he incorporates all of this he puts it all into a big mixer and out comes the Jimmy Fund and has become a pops out. And within the first few the first few months it's generated enormous amount of money for what it was. And so this is this is Farber second experiment. And what is happening at this time of course is that fiber is emerging himself from the basement into public prominence and remember the story about Fanny Rosenow that I told you that mirrors the emergence of cancer from its basement as it were to public prominence this exact period of time. And that finally tells us why I chose fiber. I just fiber because of this metaphorical peril because his journey out from his basement to the invention of chemotherapy and subsequently to the Jimmy Fund and eventually to Mary Lasker into the into the public prominence into the war on

cancer is precisely the journey that cancer itself makes in a more metaphorical sense from it's hidden in the basement. A disease that couldn't be talked about to its vast public face today. And that again by using Sidney Farber story you could then tell the larger story of of what was happening to cancer at large. And at that point of time somewhere we don't know the exact date. Actually he meets this woman this magnetic character from from New York Mary Lasker Mary Lasker was described to me most recently as a woman who had never heard the word no. She was a very unusual for her time she had made a lot of money independently as an entrepreneur. She figured out actually just just after the war she figured out that actually in between the wars and after the war she figured out that women needed to go to work. And her genius was that she began to create what was prefab dresses

precut dresses so that you would have to go to your tailor and stick you with this Cash and Carry and that was an incredible piece of genius and of course you can understand how you know how the history of feminism is already working its way into the history of cancer. Truth. Mary Lasker but ultimately through many many other channels so nonetheless So Mary Lasker independently wealthy marries Albert LASKER who is an advertising executive also very wealthy and Mary Lasker turns begins to turn her attention onto the War on Cancer. And she she decides that she's going to use all her resources her philanthropic she's going to be going to take philanthropy to an enormous new scale and she's going to lobby Congress to unleash funds for the war on cancer. And she finds in Sidney Farber the ally that she's looking for. I describe it as really coming together of two halves of a map because fiber provides the scientific legitimacy. Mary Lasker provides the urgency and the the philanthropic

energy and these two things come together and they really launch and in the end they begin to really actively campaign for the war on cancer. And I reproduce for people of the book I reproduce this very famous advertisement that they launched in 1969 which says Mr. Nixon you can cure cancer. And at the bottom signed by Alaska and Farben various other people. And at the bottom it says why don't we cure cancer for it's for America's 200 birthday. What a wonderful gift that would be. And so right from that advertisement you understand what's going on there's a kind of optimism a kind of hubris This is America that's just put human beings on the moon. I solved the atomic bomb and therefore the idea that if you pour resources into a project into into a problem so-called goal directed or targeted research you will eventually crack the problem and cancer. Meanwhile childhood leukemia has been cured by a combination chemotherapy and so they get a real boost to this idea that cancer is basically a puzzle waiting to be solved and there's a

penicillin waiting somewhere and then from there on the rest of the book goes on to describe how that picture gets more and more complicated and advances are made but that that moment of hubris still haunts one quality over and over again we keep keep coming back to it to some extent. And one of the things of course we realize that there is never that there is no one solution. This idea of a penicillin for cancer breaks down and we begin to understand cancer as a much more complex entity not as one disease but as a family of diseases and we enter that new era finally in the last sort of last section of the book which I will not give away. I'm going to do one more reading and I'm going to stop and take questions and this is from the very last chapter in the book. And now my editor said to me you know it is a golden rule of writing that you never introduce a new character in the last chapter of your book. And she said Well OK but for you one time will make an exception.

So it turns out that there is a new character that is a patient and you know sometimes you write books and you break some rules and that's fine. So so this is a woman who I met actually at the Dana-Farber across the across town that was treating her. She had a very aggressive variant of stomach cancer and had an incredible response to a new drug molecular target a drug a striking response. And then she relapsed and then she came to Boston around the second relapse to try another experimental drug to see if she could get a third relapse. So this is a real fighter and a woman whose life had been extended by about six or five or six years during during this period by a novel experimental drug but now had relapsed the third time and was no longer treatable if you actually find she had finished her treatment. When I recalled that final conversation with Jermaine embarrassingly enough the objects seemed to stand out more vividly than the words the hospital room with its sharp smell in the city

of disinfectant and hand soap the steely overhead light. I wouldn't side table on wheels piled with pills books newspaper clippings jewelry and postcards. Room wallpapered with flowers whatever pictures of a beautiful house in Montgomery and of her daughter a standard issue plastic hospital which are filled with a bunch of sunflowers perched on a table by her side. Jermaine as I remember her was sitting by the bed one leg dangling casually down wearing her usual eccentric and arresting combination of clothes and some large and unusual pieces of jewelry. Her hair was carefully arranged. She looked formal frozen and perfect like a photograph of someone in the hospital waiting to die. She seemed content. She laughed and she joked she made an ace of gastric tube she made wearing is a gastric tube seem effortless and somehow dignified. Only years later in writing this book could I finally put into words why that meeting left me so uneasy. Why the gestures in that room seem larger than life. Why the objects seemed like symbols. Why Germain herself seemed like an

actor playing a part. Nothing. I realized was incidental. The characteristics of Jermaine's personality that had once seemed spontaneous and impulsive were in fact calculated and almost reflexive reflexive responses to illness. Her clothes were loose and vivid because they were decoys against the growing outline of the tumor in her abdomen. Her necklace was distractingly large so as to pull attention away from her cancer. Her room was topsy turvy with bubbles and pictures. The hospital which are filled with flowers the cards stacked to the wall. Because without them it would devolve into the anonymity of any other room in any other hospital. She had dangled her leg at that precise pose angle because the tumor had invaded her spine and begun to paralyze her other leg making it impossible for her to sit any other way. Her casualness was studied her jokes were rehearsed. Her illicit try to humiliate her. It made her anonymous and seemingly humorless. It sentenced her to die an unsightly death in a freezing hospital room thousands of miles away from home she came from the south. She responded with a

vengeance. Moving to be always one step ahead trying to outwit it. It was like watching someone locked in a chess game every time Jermaine's disease moved imposing yet another terrifying constraint on her. She made an equally assertive move in return. The illness acted she reacted. It was a morbid hypnotic game a game that had taken over her life. She dodged one blow only to be caught by the other and she too was like Carol's Red Queen stuck pedaling furiously just to keep still in one place. Jermain seen that evening to capture something essential about her struggle against cancer. That to keep pace with this malady you need to keep inventing and reinventing learning and undermining strategies. Do you mean for cancer obsessive Lee cannily desperately fiercely madly brilliantly zealously. As if channeling all the fierce inventive energy of generations of men and women who have fought cancer in their past and would fight it in the future. Her quest for a cure had taken her in a strange and limitless journey through Internet blogs and teaching hospitals chemotherapy and clinical trials. Halfway across the country to a

landscape more desolate desperate and disquieting than she had ever imagined she deployed every last morsel of energy to the quest mobilizing and re mobilizing the dregs of her courage summoning her will and wit and imagination until that final evening. She had stared into the vault of her resourcefulness and found it empty. In that last night hanging on to her life by no more than a tenuous thread summoning all her strength and dignity as she wheeled herself to the privacy of her bathroom. It was as if she had encapsulated the essence of a 4000 year old war. And that's the end of the book. Thank you. That led to questions. So today you know was an important person he was a he was a fund he was a fat he was a funder he was he was Charles Dana and very important in the history of Boston

it was hard to put every character in as you can imagine so that's why I didn't put him so that's the Dana part of the Dana-Farber but important character in the history the Dana-Farber. Yes. You know. Yeah I mean this is a very important question because of course it was Susan Sontag among others who first pointed out that there was a punitive quality of a battle metaphor if you if you if you visualize yourself as a battle in a battle against cancer and you lose that battle then you become a loser. And therefore all the punitive qualities of that then become burdens for you.

My general feeling is Susan is a very important mentor to this book an invisible mentor an important mentor. However my feeling is in some ways I wrote the book both as homage but also a challenge to Susan because I feel as if cancer and this is unusual in when you read her book to a few years of cancer is a disease replete in metaphors and getting away from metaphor and the word cancer comes from Crabb. It's a metaphorical word and it's because as we point out in the book it's because hypocrisy is thought that a tumor was a crab buried under the skin and the blood vessels around it were the legs of the crab. So right from every piece of language we use around this is a Met is a Met is it is metaphorical language and so there is a sense in which resisting that metaphor becomes itself a battle. And for and I'll tell you what my personal thoughts about this or my personal thoughts are for some patients a battle metaphor is crucial for other patients it's punitive. And I say if it works for you and if that's

what if that's what's needed for your resilience to be to come out then use it. And if it's not then don't use it. There is no archetype of battle. There is an archetype of metaphor and yet much like there is an archetype of cancer and there's an archetypal patient Everyones relationship to the disease is vastly different. And one way I think we can empower ourselves in our patients is to not tell them what metaphors to use but to allow them to invent their own. And there are plenty to be invented. So that's my long answer to this. Yes ma'am. So we are. We work in a team. I see patients half a day a week. I run a laboratory which focuses on to Kenya and my small story about that is so what happens is that for so I have a colleague we split our patients but just to give you a guess to give you a sense of what and what the book tour is like. I was on call to Thanksgiving

and I have always chosen Thanksgiving to be my call time because I was not born in this country. So it felt as if it felt as if number one everyone else had to do something so I might as well be in the hospital. And now it's become very different because I have a family. And you know I'm part of the fabric of this country and so but I kept it up as a sort of tradition myself because my own way of dealing with Thanksgiving. Happy to do it. So I landed on the plane from Toronto. And the reason it was in Canada was because they don't have tanks in the same time. And then on the plane I'm trying to I was immediately on call. So so so it I think it's what's nice about doing that is that it keeps your perspective. You think you've written a good book but there are people who have much deeper questions and issues in the hospital and so it was a very good reminder to be humble. Right.

I think I think as far as day to day work in patients you know I talk a little bit about this earlier referred to a little bit about this earlier. I think the understanding the narrative quality of medicine was very crucial. And if the one thing that this book reminded me over and over again was that if we lose the narrative quality of medicine that something terribly lost and we need to restore it. And there are dozens of ways to restore it one of them is by writing the other way. You know there are programs in narrative medicine that allow you to do this. I've heard the statistics of some of you might have heard this number. This is a great and important study when they recorded when when scientists researchers recorded patients giving their stories to doctors and estimated the amount of time when the doctor first interrupts

the patient. So how many how many seconds or minutes occurs between the time you start setting it what's happening what's your story. Why are you here. From that point of time for the first time that a patient is interrupted I then have a guess. So it's 18 seconds. So the number of seconds it has increased somewhat after that study was so embarrassing. So but I think I think the newest numbers are like 21 seconds and that's barely a sentence. So you know I'm not saying that anyone and I'm sure if you're if you're in medicine you know that no one is above it. We all interrupt that is that is part of you know what part of the profession involves cutting people short because of a variety of reasons but nonetheless. But it's a reminder for me to to do just to resist that force. And it's a reminder that again going back to the thought that I

had earlier the sheer manic aspects of medicine cannot be replaced. Even even if we invent the most incredible piece of technology we will we will be and I can guarantee you that we will be unable to replace the sheer manic aspects of medicine and they are so stitched into our anthropological consciousness that replacing them will really mean the death of human beings. So anyway other questions. Yes. Well I think it's both because in fact one of the things that we forget to remember one of the things that we forget is that patients also

expect a story back from you. And that's very crucial. So much as listening to a story is important reconstructing your own story. Often illness is as important in fact that is what that is what. That is what one of the practice of medicine is. So in this in a very abstracted sense you might imagine that the practice of medicine is a transaction of stories in which you tell me a story and say this and this happened to me. And then I tell you what my so here's my return story to you which explains some of this is story. And both of them are not only narrative but they're their series of hypotheses strung together. Right so there's I'm saying to you the way that I view what you just told me is the following You know you might come to me and say Well in fact I've had you know I've had a rash for 15 days and I don't know what happened etc. etc. I was traveling here or came back and did something. And I tell you back a story saying I think that in fact the rash is

because you've changed your detergent. Or I think you're having a rash because you travel to a foreign country and got exposed to this bacteria that you don't can't even see right now if you did the following blood test. We may be able to pick it up. So I think I think there's a transactional quality about the story the story tellings and they happen all the time in medicine. I think that's what's happening. People are constantly exchanging stories. You know one thing that I that's important in the book is that city for me Alaska complicated characters the idea of pushing money onto a problem throwing money into probably not necessarily didn't necessarily work. And yet without Sidney Farber Mary Lasker we wouldn't be where we are today. So that complexity is conveying the complexity itself. One of the one of the major efforts in the book.

I hope we do. I mean the question of money is often brought up I want to give you a couple of numbers that you might want to want to think about. The National Cancer should budget for this year is about five billion dollars. Let's multiply that by 10. Because you know about 10 because you know their clinical trials going on hospitals et cetera et cetera so you come to 50 billion dollars. We just spent a thousand billion dollars on this war. So by whatever account I did that's 20 fold or 200 fold. The number of men and women who die of cancer in America is 600000 this year so it will affect one in four of us one in three of us depending on how you cut the statistics. So I'm not going to belabor the point that people often say why aren't we pouring enough point money into cancer research. Let's keep that into perspective I agree we are. And I think there needs to be streamlining of resources absolutely every discipline needs streamlining of resources. But before we lose perspective those are the real numbers suggest to us.

To requests OK. All right sir. Right. That's a good question. I'm actually no longer at the Farber. So but in institutes around the nation particularly large conference of cancer centers there has been has been an of an attempt to create integrative medicine programs a strong attempt. But that said I would. The one thing I one thing I do feel very strongly about is it's very important that every time we integrate new forms of medicine talk about metaphors they can become punitive. So here's one that's very very queer common.

You want you want responding well to chemotherapy because you're stressed. Right. Or or or even more acutely in the 1940s and 1950s. You have cancer because you're overstressed this was actually the reason that people said you had people had gastric cancer. Right. So so I always thought I would make a plea to people who practice integrative medicine and other forms of medicine including the surgeons and chemo therapist. Let's not let's not invite another punitive metaphor for a disease that's already burdened with metaphors. I think it's a wonderful thing to have integrative medicine. But if the implication of integrative medicine is you know that we're going to now tell patients that unless you go to the acupuncturist you know you're not going to get relieved of the stress that is burdening you and you know you making your unable to get chemotherapy or get your surgery. I think that's a very complicated story. That's my plea to people who practice integrative medicine. Last question ma'am. Well I mean you know that's a question I think that's sort of beyond

the book. One thought that I have about it is that the one of the most chilling realizations of cancer biology which emerged in the 1970s was that the genes that allow embryos to grow in our hands to grow in our brains to grow. If you mutate and distort those genes if you activate them or inactivate them you get cancer. So in other words you take and you take the genes and this was a very very pivotal realisation of the 1970s in before that we had fantastically hoped or imagined that cancer would only be something exogamous something coming from outside like a virus for instance. The fact that it's not that in fact it emerges from you that stitched into the human chromosome and it merges only out of these very genes of course. I'm not saying that I mean carcinogens activate these genes so there is of course a relationship with the environment with the outside. But there's also the outside impinging on the

inside as it were. And so when you ask the question what purpose the only thing I can see is that these genes have very vital functions in normal biology and therefore are had to have a peculiar poise between performing these vital functions and when they get distorted becoming cancerous I don't know if that's a purpose or not but it certainly tells you why these genes even exist why cancer is part of our bodies part of our society's part of ourselves. Thank you. Thank you all so much for coming we will have a book signing here again I'll ask that we try to get the line form going this way will start pulling ceased as soon as there are free copies of Emperor of All Maladies are available to purchase right up at the registers.