The Emperor of All Maladies Read online

  Obviously, a more fundamental explanation lurked beneath all of this, an explanation that would connect cause and cure. So some researchers urged patience, diligence, and time. “The program directed by the National Cancer Institute has been derided as one that puts the cart before the horse by searching for a cure before knowing the cause,” Kenneth Endicott, the NCI director, acknowledged in 1963. “We have certainly not found a cure for cancer. We have a dozen chemicals which are somewhat better than those known before the program began but none are dramatically better. They prolong the patient’s life somewhat and make him more comfortable, but that is all.”

  But the Laskerites had little time for such nuanced descriptions of progress; this cart would have to drag the horse. “The iron is hot and this is the time to pound without cessation,” Farber wrote to Lasker. The groundwork for an all-out battle had already been laid. All that was necessary was to put pressure on Congress to release funds. “No large mission or goal-directed effort [against cancer], supported with adequate funds has ever been organized,” Mary Lasker announced in an open letter to Congress in 1969.

  Lasker’s thoughts were echoed by Solomon Garb, a little-known professor of pharmacology at the University of Missouri who shot to prominence by publishing the book Cure for Cancer: A National Goal in 1968. “The theme of this book,” Garb began, “is that the time has come for a closer look at cancer research and for a new consolidation of effort aimed at cure or control of cancer. . . . A major hindrance to cancer effort has been a chronic, severe shortage of funds—a situation that is not generally recognized. It is not enough, however, to point this out or to repeat it; it is also necessary to explain how additional funds would be used, what projects they would pay for, why such projects deserve support, and where the skilled scientists and technicians to do the work would come from.”

  Garb’s book was described as a “springboard to progress,” and the Laskerites certainly sprang. As with Farber, a doctor’s word was the ultimate prescription. That Garb had prescribed precisely the strategy advocated by the Laskerites instantly transformed him in their eyes into a messianic figure. His book became their bible.

  Religious movements and cults are often founded on a tetrad of elements: a prophet, a prophecy, a book, and a revelation. By the summer of 1969, the cancer crusade had acquired three of these four essential elements. Its prophet was Mary Lasker, the woman who had guided it out of the dark wilderness of the 1950s into national prominence just two decades later. Its prophecy was the cure for childhood leukemia, inaugurated by Farber’s experiments in Boston and ending with Pinkel’s astonishing successes in Memphis. Its book was Garb’s Cure for Cancer. The final missing element was a revelation—a sign that would auger the future and capture the imagination of the public. In the spirit of all great revelations, this one would also appear unexpectedly and mystically out of the blue. It would apparition, quite literally, from the heavens.

  At 4:17 p.m. EDT on July 20, 1969, a fifteen-ton spacecraft moved silently through the cold, thin atmosphere above the moon and landed on a rocky basalt crater on the lunar surface. A vast barren landscape—a “magnificent desolation”—stretched out around the spacecraft. “It suddenly struck me,” one of the two astronauts would recall, “that that tiny pea, pretty and blue, was the earth. I put up my thumb and shut one eye, and my thumb blotted out the planet.”

  On that pea-size blue planet glimmering on the horizon, this was a moment of reckoning. “It was a stunning scientific and intellectual accomplishment,” Time reported in July 1969, “for a creature who, in the space of a few million years—an instant in evolutionary chronology—emerged from primeval forests to hurl himself at the stars. . . . It was, in any event, a shining reaffirmation of the optimistic premise that whatever man imagines he can bring to pass.”

  The cancer crusaders could not have asked for a more exuberant vindication for their own project. Here was another “programmatic” effort—planned, targeted, goal-oriented, and intensely focused—that had delivered its results in record time. When Max Faget, the famously taciturn engineer of the Apollo program, was later asked to comment on the principal scientific challenge of the moon landing, he could only come up with a single word: “Propulsion.” The impression was that the moon walk had turned out to be a technological cakewalk—no more complicated than building a more powerful jet plane, magnifying it several dozenfold, and pointing it vertically at the moon.

  The Laskerites, transfixed in front of their flickering television sets in Boston, Washington, and New York on the evening of the moon landing, were primed to pick up on all these analogies. Like Faget, they believed that the missing element in the cancer crusade was some sort of propulsion, a simple, internal vertical thrust that would transform the scale and scope of their efforts and catapult them toward the cure.

  In fact, the missing propulsion, they believed, had finally been found. The success against childhood leukemia—and more recently, Hodgkin’s disease—stood out as proofs of principle, the first hesitant explorations of a vast unexplored space. Cancer, like the moon, was also a landscape of magnificent desolation—but a landscape on the verge of discovery. In her letters, Mary Lasker began to refer to a programmatic War on Cancer as the conquest of “inner space” (as opposed to “outer space”), instantly unifying the two projects.

  The moon landing thus marked a turning point in the life cycle of the cancer crusade. In the past, the Laskerites had concentrated much of their efforts on political lobbying in Washington. When advertisements or posters had been pitched directly to the public, they had been mainly educational. The Laskerites had preferred to maneuver backstage, preferring political advocacy to public advocacy.

  But by 1969, politics had changed. Lister Hill, the Alabama senator and one of Mary Lasker’s strongest supporters, was retiring after several decades in the Senate. Senator Edward Kennedy, Farber’s ally from Boston, was so deeply embroiled in the Chappaquiddick scandal (in July 1969, a car carrying Kennedy and a campaign worker veered off a Martha’s Vineyard bridge and sank underwater, drowning his passenger; Kennedy was tried for manslaughter, although eventually acquitted) that he had virtually disappeared into legislative oblivion. The Laskerites were now doubly orphaned. “We’re in the worst,” Lasker recalled. “We’re back to a phase that we were in the early fifties when . . . we had no friend in the Senate. We went on constantly—but no effective sympathy.”

  With their voices now muted in Washington, with little sympathy in the House and no friend in the Senate, the Laskerites were forced to revamp the strategy for their crusade—from backstage political maneuvering to front-stage public mobilization. In retrospect, that turn in their trajectory was well-timed. The success of Apollo 11 may have dramatically affected the Laskerites’ own view of their project, but, more important perhaps, it created an equally seismic shift in the public perception of science. That cancer could be conquered, just as the moon had been conquered, was scarcely a matter of doubt. The Laskerites coined a phrase to describe this analogy. They called it a “moon shot” for cancer.

  * The Jimmy Fund was launched in May 1948. September 1968 marked its twenty-first year. The date of Jimmy’s “birthday” was arbitrarily assigned by Farber.

  “A moon shot for cancer”

  The relationship of government to science in the post-war years is a case in point. Without very much visible deliberation, but with much solemnity, we have in little more than a decade elevated science to a level of extraordinary influence in national policy; and now that it is there, we are not very certain what to do with it.

  —William Carey, 1963

  What has Santa Nixon given us lately?

  —New York Times, 1971

  On December 9, 1969, on a chilly Sunday morning, a full-page advertisement appeared in the Washington Post:*

  Mr. Nixon: You can cure cancer.

  If prayers are heard in Heaven, this prayer is heard the most:

  “Dear God, please. Not cancer.”
r />   Still, more than 318,000 Americans died of cancer last year.

  This year, Mr. President, you have it in your power to begin to end this curse.

  As you agonize over the Budget, we beg you to remember the agony of those 318,000 Americans. And their families.

  . . . We ask a better perspective, a better way to allocate our money to save hundreds of thousands of lives each year.

  . . . Dr. Sidney Farber, Past President of the American Cancer Society, believes: “We are so close to a cure for cancer. We lack only the will and the kind of money and comprehensive planning that went into putting a man on the moon.”

  . . . If you fail us, Mr. President, this will happen:

  One in six Americans now alive, 34,000,000 people, will die of cancer unless new cures are found.

  One in four Americans now alive, 51,000,000 people, will have cancer in the future.

  We simply cannot afford this.

  A powerful image accompanied the text. Across the bottom of the page, a cluster of cancer cells was loosely grouped into a mass. Some of these cells were crumbling off that mass, sending a shower of metastatic fingerlings through the text. The letters e and r in cancer had been eaten through by these cells, like holes punched out in the bone by breast cancer.

  It is an unforgettable picture, a confrontation. The cells move across the page, almost tumbling over each other in their frenzy. They divide with hypnotic intensity; they metastasize in the imagination. This is cancer in its most elemental form—naked, ghoulish, and magnified.

  The Times ad marked a seminal intersection in the history of cancer. With it, cancer declared its final emergence from the shadowy interiors of medicine into the full glare of public scrutiny, morphing into an illness of national and international prominence. This was a generation that no longer whispered about cancer. There was cancer in newspapers and cancer in books, cancer in theater and in films: in 450 articles in the New York Times in 1971; in Aleksandr Solzhenitsyn’s Cancer Ward, a blistering account of a cancer hospital in the Soviet Union; in Love Story, a 1970 film about a twenty-four-year-old woman who dies of leukemia; in Bang the Drum Slowly, a 1973 release about a baseball catcher diagnosed with Hodgkin’s disease; in Brian’s Song, the story of the Chicago Bears star Brian Piccolo, who died of testicular cancer. A torrent of op-ed pieces and letters appeared in newspapers and magazines. One man wrote to the Wall Street Journal describing how his family had been “plunged into numb agony” when his son was diagnosed with cancer. “Cancer changes your life,” a patient wrote after her mastectomy. “It alters your habits. . . . Everything becomes magnified.”

  There is, in retrospect, something preformed in that magnification, a deeper resonance—as if cancer had struck the raw strings of anxiety already vibrating in the public psyche. When a disease insinuates itself so potently into the imagination of an era, it is often because it impinges on an anxiety latent within that imagination. AIDS loomed so large on the 1980s in part because this was a generation inherently haunted by its sexuality and freedom; SARS set off a panic about global spread and contagion at a time when globalism and social contagion were issues simmering nervously in the West. Every era casts illness in its own image. Society, like the ultimate psychosomatic patient, matches its medical afflictions to its psychological crises; when a disease touches such a visceral chord, it is often because that chord is already resonating.

  So it was with cancer. As the writer and philosopher Renata Salecl described it, “A radical change happened to the perception of the object of horror” in the 1970s, a progression from the external to the internal. In the 1950s, in the throes of the Cold War, Americans were preoccupied with the fear of annihilation from the outside: from bombs and warheads, from poisoned water reservoirs, communist armies, and invaders from outer space. The threat to society was perceived as external. Horror movies—the thermometers of anxiety in popular culture—featured alien invasions, parasitic occupations of the brain, and body snatching: It Came from Outer Space or The Man from Planet X.

  But by the early 1970s, the locus of anxiety—the “object of horror,” as Salecl describes it—had dramatically shifted from the outside to the inside. The rot, the horror—the biological decay and its concomitant spiritual decay—was now relocated within the corpus of society and, by extension, within the body of man. American society was still threatened, but this time, the threat came from inside. The names of horror films reflected the switch: The Exorcist; They Came from Within.

  Cancer epitomized this internal horror. It was the ultimate emergence of the enemy from within—a marauding cell that crawled out of one’s own body and occupied it from the inside, an internal alien. The “Big Bomb,” a columnist wrote, was replaced by “the Big C”:

  “When I was growing up in the 1950s, it was The Bomb. This thing, The Bomb, belonged to a generation of war babies. . . . But we are fickle even about fear. We seem to have dropped our bombphobia now without, in any way, reducing the reasons for it. Cancer now leads this macabre hit parade. The middle-sized children I know seem to think that death comes, not with a bang but with a tumor. . . . Cancer is the obsession of people who sense that disaster may not be a purposeful instrument of public policy but a matter of accidental, random carelessness.”

  These metaphorical shifts were more powerful, more pervasive, and more influential than the Laskerites could even have imagined. The Times ad represented a strategic realignment of power. By addressing their letter to the president on behalf of “millions of Americans,” the Laskerites performed a tactically brilliant about-face. In the past, they had pleaded to the nation for funds for cancer. Now, as they pleaded for the nation for a more coordinated attack on cancer, they found themselves colossally empowered in the public imagination. The cure for cancer became incorporated into the very fabric of the American dream. “To oppose big spending against cancer,” one observer told the historian James Patterson, was to “oppose Mom, apple pie, and the flag.” In America, this was a triumvirate too powerful for even the president to ignore.

  Impatient, aggressive, and goal-driven, the president, Richard Milhous Nixon, was inherently partial to impatient, aggressive, and goal-driven projects. The notion of science as an open-ended search for obscure truths bothered and befuddled him. Nixon often groused that scientists didn’t “know a goddamn thing” about the management of science. Nor was he particularly sympathetic to open-ended scientific funding. Corn-fed and fattened on increasingly generous federal grants, scientists (often called “nuts” or “bastards” by members of his administration) were thought to have become arrogant and insular. Nixon wanted them “to shape up.”

  For Nixon, this “shaping up” meant wresting the control of science out of the hands of academic “nutcases” and handing it over to a new cadre of scientific bureaucrats—science managers who would bring discipline and accountability to science. The replacement of Nixon’s science adviser, Lee DuBridge, a scholarly, old-school atomic physicist from Caltech, with Ed David, an impulsive, fast-paced engineer-turned-manager from the Bell research labs, was meant as a signal to the scientific community to get into shape. David was the first presidential science adviser to emerge out of an industrial lab and to have no direct connection with a university. His mandate was to get an effective science operation that would redirect its energies toward achieving defined national goals. What scientists needed—what the public demanded—was not an “endless frontier” (à la Vannevar Bush) but a discipline with pragmatic frontiers and well-defined ends.

  Lasker’s job, then, was to convert the already converted. In 1969, deploying her typical strategic genius, Mary Lasker proposed that a “neutral” committee of experts, called a Commission on the Conquest of Cancer, be created to advise the president on the most efficient strategy to mount a systematic response to cancer. The commission, she wrote, should “include space scientists, industrialists, administrators, planners, and cancer research specialists . . . entrusted to outline the possibilities for the conque
st of cancer for the Congress of the United States at whatever cost.”

  Of course, Lasker ensured that there was nothing neutral about the commission (eventually called the Panel of Consultants). Its members, chosen with exquisite deliberateness, were all Lasker’s friends, associates, and sympathizers—men and women already sold on the War on Cancer. Sidney Farber was selected as the cochairman, along with Senator Ralph Yarborough from Texas (Yarborough, like Lister Hill, was one of the Laskers’ oldest allies in Congress). Solomon Garb was appointed on account of his book. Joseph Burchenal was brought in from Memorial Hospital, James Holland from Roswell Park, Henry Kaplan from Stanford. Benno Schmidt, a partner in a prominent New York investment firm and a major donor to Memorial Hospital, joined the group. (An energetic organizer, Schmidt was eventually asked to replace Farber and Yarborough to head the panel; that Schmidt was a Republican and a close confidant of President Nixon’s was a marked plus.) Politics, science, medicine, and finance were thus melded together to craft a national response. To reinforce the facade of neutrality, Yarborough wrote to Mary Lasker in the summer of 1970, “asking” her to join (although he scribbled at the bottom, “Your letter should have been the first mailed. It was your genius, energy and will to help.”)

  The panel’s final report, entitled the National Program for the Conquest of Cancer, was issued in the winter of 1970, and its conclusions were predictable: “In the past, when the Federal Government has desired to give top priority to a major scientific project of the magnitude of that involved in the conquest of cancer, it has, on occasion, with considerable success, given the responsibility for the project to an independent agency.” While tiptoeing around the idea, the panel was proposing the creation of an independent cancer agency—a NASA for cancer.