Excellence Has No Borders

Dr B.S. Ajaikumar et al.

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First published in Portfolio by Penguin Random House India 2019

Copyright Dr B.S. Ajaikumar 2019

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Chapter One

I stepped out of the patio overlooking the beach and trudged across the warm sands. It was a typical Boston summer night—warm and breezey. I neared the lapping waves and stopped.

The North Atlantic stretched in front of me, like some great, swirling, dark abyss waiting to swallow me whole. I stepped into the waters. The cold current bit. I looked back at my palatial house and thought of the family inside. I wondered whether I would ever see them again.

I turned my gaze back to the ocean. Mysteriously, it had changed. It seemed friendlier now. Almost welcoming me into its waiting arms.

For a moment, the events of the preceding months flashed through my mind like a movie. The loss of twenty million dollars in the dot-com bust, the ripple effect it had had on the people who depended on me, and its impact on my dreams. Twenty million dollars! What all I could have done with that money!

It had been an exhilarating time for dot-com investors. Riding on the stupendous growth of the Internet as a business enabler, many investors had ploughed fortunes into Internet companies and almost anything that ended with a '.com'. Speculation had driven valuations through the roof and fundamentals had been thrown to the wind. It had been a perfect bubble that everyone had bought into.

Everyone, including me and my advisers.'

I had invested hard-earned money. All in the hope of windfall gains and capital appreciation. Somehow, I had been carried away by the euphoria and professional advice.

Pretty soon, I was sitting on a war chest of Internet stocks, all registering unprecedented price gains. Perhaps I had been too immersed in my work and too dependent on the professionals to take note of the red flags and the imminent fall.

But fall the stock market did.

Perhaps 'fall' is not the word to describe it. It plummeted. It was a free fall. Which then turned into a free-for-all. Retail investors began pulling up their agents. Analysts were disagreeing with the actions of the Federal Reserve in the run-up to the crash. Venture capitalists were at loggerheads with reckless entrepreneurs, who had burnt through piles of cash.

As the world exploded around me, my stockbroker reassured me that all was well. Expectedly, his reassurances proved to be as worthless as the paper stock I was sitting on. Horror-struck, I realized that my dreams were shattered and I had let my people down. I felt miserable.

I had just remodelled my house in Boston. We had been recently graced with the birth of twins, Aagnika and Asmitha. I had also opened a not-for-profit hospital in Mysuru, a private hospital in Bengaluru, and an N.G.O for women's empowerment. The employees' families were dependent on me and I had a definite moral obligation. With my investments wiped out, these commitments started to look like millstones round my neck. It was then that the sleepless nights and burning sensations in my stomach started. Paranoia gripped me.

As I stood there in freezing cold water, the North Atlantic lapping at my feet, the burning sensation in my stomach returned with a vengeance. My financial losses seemed mind-numbing. Wild thoughts lashed my feverish mind.

How would I answer to myself about the moral obligation to the people who had trusted me? In all my life I had never worried about what society would say, but my conscience was my keeper. I was answerable to my conscience.

What would I tell my wife, Bhagya? She would be devastated.

What would I tell my people back home in India? Had I lost confidence in myself? How could I face my young children? They were too naive to realize what a gamble their father had taken to fulfil his dreams.

The reality finally hit me.

There was no way back.

I looked ahead at the North Atlantic as it mocked me. I stared right back.

I'm coming!

I started wading forward, unmindful of who or what I was leaving behind.

I would not return. I would keep walking into the ocean until it consumed me, until it erased my existence from the face of this world.

As I ploughed into the inky black waters, fighting to keep my balance, a strange thing happened. As I stood knee-deep in water, an incoming wave hit my legs and pushed me back. I staggered.

Now, I'm normally not someone who believes in mumbo jumbo about signs, but that push by a harmless wave somehow halted my train of self-destructive thoughts.

A singularly assertive thought hit me like a freight train.

I am a fighter. I love challenges.

I looked down at myself. I was half drenched. Defeated. All at sea. But here I was, alive! I had lost money, tons of it. But I still had myself. I had my family. I looked up and stared at the ocean again.

Today's not your day!

I turned back.

It was a stare-off that had not ended well for the ocean.

I needed to get my confidence back. I knew that if I worked with all sincerity and determination, I would be able to salvage the situation. I glanced behind me for one final look at the ocean—my co-conspirator in crime not too long ago.

What was I thinking?

As my pace quickened over the sands back towards my house, my thoughts raced faster.

I could sell my house, get some liquidity. I would make sure that none of my hospitals closed. No employee would be laid off. I would rebuild everything!

And then, suddenly, it struck me.

My stockbrokers from the investment bank! I could sue them!

I clenched my teeth, recalling all the rosy outlook and reckless investment advice given to me.

The shrill ring continued. *****

I stirred in my bed. It was the bedside telephone. In the darkness, I peered at my watch. It was 2 a.m. This couldn't be good. I had just landed in Chicago a few hours earlier and had been looking forward to a full night's rest.

I snatched the receiver off the hook. It was Raghavendra, my domestic help in Mysuru.

'Sir, Adarsh ...'

I bolted upright in bed, a sickening knot forming somewhere deep in my gut. 'What happened to Adarsh?'

'Sir, he ... he fell down.'

'He . . . what?'

'He fell, sir. We've called the doctors.'

I was already out of bed, nudging Bhagya awake with one hand while I juggled my glasses and phone with the other. 'Where is he now?'

'Still on the floor where he fell. We couldn't lift him. What should we do now?'

Barking instructions over the phone, I pulled out my overnighter and started packing essentials. Three hours later, I was at the O'Hare International Airport, on board a Lufthansa non-stop flight to Bengaluru. Bhagya was beside me, distraught yet strangely emotionless.

As I looked out the window, waiting for departure, I sunk back into my seat. This couldn't be happening, I thought. My dear son Adarsh. Bound to a wheelchair. All of twenty-seven years and born with a rare genetic muscle-wasting disorder called Duchenne muscular dystrophy (D.M.D). This left him weak, brittle and injury-prone. And now he had fallen—a catastrophe with his condition.

While on my way to the airport, I had had a discussion with the doctors and it had been decided to shift him to Bengaluru for further investigation and treatment/surgery.

The head of anaesthesia at our Bengaluru hospital, who was also a good intensivist, Dr Rajesh, had taken our fully equipped ambulance to Mysuru and brought him to Bengaluru. During my layover in Frankfurt I checked on the progress. Once I landed, I immediately headed to the hospital and had a discussion with the team. The doctor had diagnosed bone fractures in three places, on his hips and his shoulder.

We took Adarsh to HealthCare Global (H.C.G) Oncology, the cancer-focused hospital I had started in India. He was breathless and in great pain. It was clear that Adarsh needed surgery, pronto. But there was a hitch. General anaesthesia was not advisable because of his condition, D.M.D. So we decided to go for a nerve-block approach, where the nerves related to the trauma sites are blocked to induce numbness. This blocks out the pain of the surgical procedure.

After the necessary pre-operation preparation, the surgery was successfully done by a team led by Dr Pramod. Adarsh was moved to the post-operative I.C.U. Then trouble started. He was on various medications, including antibiotics and steroids. During the night his blood pressure started falling and his heart rate spiked.

He was given medication to keep his blood pressure up. His oxygen saturation level was also dropping. He was put on bi-pap, a type of breathing machine. It became a crisis situation. As a family, we were dismayed and losing hope.

I had to take the tough decision of intubating (inserting a tube into the windpipe) Adarsh, knowing it might be very difficult to extubate him (to remove the tube). His kidneys were also beginning to shut down.

When my friend, Dr Ajith, from Manipal hospital, learnt about Adarsh's condition, he rushed to our hospital in an ambulance, ready to transfer him to the Manipal I.C.U, where multi-organ failure could be better managed. Intubation was done successfully, and then he was shifted to Manipal.

Adarsh started showing signs of improvement; his kidney functions got back to normal.

Five days later, we decided to take him home and manage everything from there. Adarsh came home with a ventilator and was monitored by an electronic I.C.U. The mood at home lifted. Bhagya's pensiveness erupted into motherly relief.

My daughters were beside themselves with joy. Little did I know that there was more in store for us.

A few days later, Adarsh had another near-death experience.

That fateful night, around 1 a.m., I jerked up in bed. I had a queasy feeling in my gut. On a screen in my bedroom I could see Adarsh's monitor; the blood pressure was dropping to 60/0, with his heart racing above 180. I bolted downstairs to where Adarsh slept. The duty doctor was drowsy, and I woke him up and leapt into action.

Here was my boy fighting for his very life, his blood pressure plumbing to abysmal depths. His heart rate had now hit an astounding 200 pulses per minute. It was going like a trip hammer.

At that point, I felt this was not going to end well. Adarsh was going into septic shock. His whole life flashed before me, like some cruel time-lapse video created by a demented force from the dark side.

I rarely cry. That night, I cried.

I just couldn't imagine life without him. Hell, I couldn't imagine even having dinner without him.

But I also realized one thing. If I had to help him, I could not think like a father. There would be too much emotion attached. No, I had to be detached. I had to treat him like a patient. The doctor in me had to treat him, not the father.

And that's exactly what I did. I treated him as a doctor would. I still believe that's what saved him.

*****

These two incidents in my life sparked and nurtured in me two very essential philosophies that I still practise to this day. They give me a sense of direction whenever I am at a crossroads. They give me a sense of orientation when confronted with crises or situations that demand trade-offs between principles and practicality.

The first incident was cathartic. Never had I felt so deeply introspective. I found great inner reservoirs of strength, which I'd never suspected in myself. I learnt to take the painful path and test the limits of my mental endurance. I learnt to rebuild. Importantly, once I had rebuilt my life from scratch, I realized something that I continue to believe to this day—anything is possible. This is a recurring theme in my life story, as will be evident in the rest of this book.

The second incident was emotionally draining, but equally rich in revelation. It taught me the fine art of detachment during times of crises. The problems in life that emotionally affect us the most are the ones that are best solved by isolating emotion completely from the decision-making process. This incident touches upon the principle of 'oncophilosophy' in my life. I will share more on that later in the book.

At its simple best, it helped me ask a very fundamental question: What did I learn from this?

Chapter Two

Life, as we know it, is replete with conflicts. My journey as an entrepreneur is motivated by challenges—and indeed as a person of conscience, began with a conflict. It was a conflict that was to define my approach to life itself, which is to fight for the underdog. The incident occurred when I was in seventh grade.

My classmate, who was not very bright, was walloped hard by a teacher till his hand became red and swollen. He had committed a small indiscretion.

I still don't know what came over me, but I was livid. My reaction was not so much to the corporal indignity of the act as it was to my sense of injustice and lack of fairness in the intensity of the punishment meted out. I took it upon myself to form a delegation of students and report the incident to the head of the institution.

I was oblivious to the fact that this could lead to undesirable consequences for me. Yet, there I was, marching off a group of excitable youngsters into the lion's den to complain about what I felt was a barbaric act. Providentially, and unbelievably, the said lion saw merit in my indignation. The teacher was dismissed from service.

When I think about this now, for a twelve-year-old to audaciously take on a teacher at his school is not only inconceivable but also possibly tantamount to academic suicide. But it is this very same sense of justice that spawned in me the seed of what would later become a core element of my personality: the need to welcome challenges. This is crucial for an entrepreneur to succeed in business. For an entrepreneur, life is nothing but a continuous series of challenges.

The growing pains of childhood

The Fifties were a time of transformation and renewal in myriad ways. India had declared itself a sovereign democratic republic and set itself on the path of re-emergence as a newly assertive people. The first Five Year Plan was tabled in Parliament. Individuals who would go on to redefine the fields of politics, business and philanthropy—like Vinod Khosla, Indra Nooyi and Lakshmi Mittal—were born.

Globally, too, seminal events peppered the untainted pages of time. The United States (U.S) commenced development of the first hydrogen bomb, close on the heels of the Soviet Union's atomic bomb. The Kuomintang troops of Burma (now Myanmar) surrendered in China. Jordan annexed the West Bank. Thailand anointed a new king. The Korean War began. The first Volkswagen Type 2 rolled out in Germany. The first Formula One championship race was held at Silverstone in England. Uruguay beat mighty Brazil to win the 1950 fifa World Cup.

Of course, I was blissfully unaware of all this. I had my own wars and anointments to contend with. All of five years old, I was studying at Bishop Cotton School. There is no greater nightmare for a hapless five-year-old than an elder sibling who is a superachiever. And my older brother Amar Kumar was exactly that.

A student of Sacred Heart School in Bengaluru, Amar was every parent's dream come true. He was supremely talented, a phenomenal debater, fluent in English and, of course, an academic achiever.

They say that the birth order of siblings dictates everything from their personalities to parental affection to the world's perception of the siblings in question. More specifically, first-borns hog the lion's share of parental love, not to mention the shadow they cast on their younger siblings. It was no different in my case. So, while my brother continued to enjoy quality schooling at Sacred Heart, I was shifted to a 'regular' school called Bala Mandira. My father could not afford to put both his sons through elite schooling.

My brother's debating achievements were storied affairs at home, while the prizes I won at school were relegated to oblivion.

During my time in Bishop Cotton, I, too, had won several prizes both in academics and sports. One day when I won a book as a prize and shared it with my family, there was hardly any reaction or appreciation. Hence when I won a prize of sweets for sport, I decided to walk home eating the sweets rather than sharing them. These were my first pangs as someone with a successful older sibling.

As a natural corollary to this dichotomy, even planning for the future took on different hues for the two of us. My high school years were at Gandhinagar High School. My brother was studying at Bengaluru Military School. The futures envisaged by my parents for the two of us could not have been more different. Amar was destined for great things. I recollect the intense passion with which my father planned a career in medicine for him.

Later, Amar was shifted to my school, where, again, he was an instant hit.

Amar became the general secretary of Gandhinagar High School. I was proud of him, but the older brother's shadow had lengthened. My identity soon morphed into 'Amar's brother'. In one particular incident, during a school debate, when I went on to the podium, I was referred to as 'Amar's brother', rather than called by my own name. I repeatedly faced this ordeal with teachers as well. All this was tremendously stressful for me.

The older brother's shadow was also evident in my parents' plan for my future. I remember one day I overheard my parents discussing our future. My father was commenting that while Amar's was secure, 'I don't know what will become of Ajai'. My mom replied, 'He loves cricket. Who knows, he may become a famous cricketer, or there will always be a job for him in my father's grain store.' At the time, cricket did not enjoy the cult following it does today. It was an afterthought of a 'career'—if you could call it that—for students who were deemed to deserve no more.

But, in spite of everything, I still loved my family. Why did I care so much for my father? While I knew he loved me, his way of showing that love and care was not conventional. He expressed his love and affection in unique ways. He showed his deep affection for me with his obsession with my academic performance. This was especially so during my pre-medical-college years. He went about with an anxious look day and night, worried about my performance. He could not let go until he was sure I would do well. Anything that his mind became obsessed with was a problem to be solved.

I was close to my three younger sisters—Manjula, Komala and Pushpa. I was particularly attached to Manjula and Pushpa. Manjula used to study in Central College in Bengaluru, which was one of the oldest colleges in India. Stalwarts like Bharat Ratna recipients Sir M. Vishweshwaraiah, C.N.R. Rao and Chakravarthi Rajagopalachari were alumni of this vintage college, so there was always a sense of pride when it came to Manjula. Every now and then, I picked her up from college in the evenings. On days when she did not return home on time, I would panic and go off immediately to check. Komala was a little weak in studies. So I used to spend hours with her, coaching her to make sure she got through her exams. Pushpa and I played a lot of games growing up, and I was very particular about the subjects she picked, because we were grooming her to become a doctor.

I was closest to my mother. She was opinionated. There was also something tragic about her. She had puerperal psychosis—a kind of mental stress brought about by postnatal depression.

After she delivered Pushpa, she lapsed into psychosis and depression due to the stress and the shock. However, to me, she was everything a mother should be. She was an ideal mother, teaching us compassion, love, affection and care for the poor. She also taught us the Mahabharata and the Ramayana and the implications of everyday living.

The most important value my mother taught us was to respect everyone, irrespective of their economic status or caste.

Shadows that create hunger

I did not realize it at the time, but years of living under my elder brother's shadow seeded a sense of healthy deprivation in me. As paradoxical as that sounds, it was a truth that was to become a reality of unimaginable proportions later in my life. Somewhere along the way, I started to sense an internal volcano of grit and tenacity that urged me to strike out on my own, to grab and create my own destiny if one were not written for me. I began to sense a hunger for greater things—a hunger that emerged not only from the early years of deprivation lived in my brother's shadow but also from my developing tendency to take challenges head-on.

This burgeoning hunger was crystallized by an incident that is still firmly etched in my mind. The incident involved one of my brother's mercurial teachers, Mr Shama Rao. At that time, I was studying for the Secondary School Leaving Certificate (S.S.L.C), or tenth-grade exams.

That particular day, I was studying in the attic. Amar returned home from school. He charged up the stairs and strode in. He looked angry.

'I met Shama Rao.' His tone was flat.

My eyes met his. 'Okay. What happened?'

'I asked him how you were doing. He said that you were nowhere near me and that you wouldn't even get first class.'

'Oh yeah?' I shot back.

'I'm ashamed of you!'

I was outraged. Not only by what Mr Rao had said, but also by the way my brother was behaving with me. I was working very hard. I was determined to do well and emerge from the shadow of my older brother.

To give him due credit, Amar used to help me every now and then with my studies. He also made sure I was studying hard. But here he was, demonstrating his sense of superiority, which I had come to abhor—that he had just used to dismiss me without a second thought, blind to the effort I was putting in. The shadow had just thrown me a challenge, rather unwittingly.

I studied like the devil, day and night. I would often lock myself in and not come out for hours. My parents were amazed.

They confessed that they had never seen me study like this. They even asked me to slow down. They were worried about my health.

I knew they felt I could not do better than Amar. To them, I was a mediocre student, trying to better myself. They didn't realize I was intelligent. The only person in the extended family who believed in my intellectual ability was my paternal uncle.

I was further provoked by another incident. There was a family gathering at my maternal grandfather's place. My uncles, one of whom was particularly close to Amar, were present.

During the get-together, they commented that Amar would easily get into medical school but they doubted if I would be able to secure a good seat in any mainstream academic field. I felt humiliated and found them condescending.

Then, the unthinkable happened. The S.S.L.C results came out—and the tables had turned. Amar had scored 75 per cent, while I had bested him by achieving 82 per cent.

I had missed the state rank by a mere 30 marks. The volcano within me had done its job. Spurred on by the low image my parents had of me and taking it as a personal challenge, I had hunkered down, leaving no stone unturned in my exam preparations.

These episodes left in me a lasting hunger to gun for greater things. The Rubicon had been crossed. I became accustomed to taking on challenges with gusto: If something wasn't a challenge, it wasn't worth the time or the effort.

When I now relate these incidents to my entrepreneurial life, they were a godsend. If not for them, my success as an entrepreneur, and indeed my decision to go the entrepreneurial way, seems unlikely. So, I have my brother, his teacher, and my extended family's lack of faith in me to thank for sparking this hunger born out of the shadows.

Fighting to get into St John's

Raising children in their formative years is one thing, putting them through college is quite another. For parents with limited means, if the former is like bearing Atlas' burden, the latter is similar to parting the Red Sea. To their credit, my parents did the best they could with what they had.

As far as Amar was concerned, his career had already been planned meticulously down to the last stitch. Passing out from Government Arts and Science College, Bengaluru, with a score of over 70 per cent in his pre-university course (P.U.C) examinations, he had gained admission to the prestigious Bangalore Medical College. Established in 1955, it was the only government medical college in the city, so getting admission to the college was notoriously tough.

My own entry into graduate college was less straightforward and decidedly less smooth. After my S.S.L.C results, my stock at home had seen an uptick. Horoscopes had come waltzing out of the closet. Predictions about my destined future had flown thick and fast.

My father anointed me the new star of the family. He quoted the prediction of one of the professors at his law college at the time of my birth—that I would become a star doctor. I joined St Joseph's for my P.U.C undergraduate degree. During this one year, riding my newfound swell of self-confidence, I had given my all for good grades. Course books had become my oxygen for achievements, with the flames of academic ambition fanned by my hunger for greater things.

Ironically, despite my prowess in P.U.C, my admission into graduate college hit a few air pockets. While I got admission in another medical college, my eyes were on St John's Medical College, one of the premier institutes in the city. For a teenager fuelled by an insatiable hunger for challenges, nothing less would do, so I took their entrance examination. However, a battle of ethics got in the way of my admission.

One of my father's hallmark characteristics was honesty. His ethics were impeccable and he was always very particular about this. One of his friends, who was the registrar at the Bangalore University and a professor of chemistry, was not that ethical in his dealings.

This had caught my father's eye, who was a university syndicate member. The syndicate is a powerful university body, like a council, so my father was seen as a powerful figure.

My father questioned this professor at the syndicate, even though he knew him very well. This fractured the friendship and this, in turn, affected me, in a very strange way. My father's friend took it personally. He knew I wanted to get into medicine.

During my P.U.C studies, I'd taken P.C.B—physics, chemistry and biology—as my combination of electives. In the final exams, I knew I'd done very well in all three subjects. However, when the marks came out, there was a shock in store for me.

I got 90 in physics and 70 in biology, but in chemistry I got a mere 60. I was outraged because I knew I'd performed very well in the exam. The total came to around 69.5 per cent, which meant I could not get into the prestigious Bangalore Medical College. Their cut-off was 71 per cent at that time. I got a letter that my interview appointment would be at Belgaum Medical College. At that time, I also applied to St Johns by sitting for the entrance exam. At St John's, they had only fifty seats at that time and most of the students admitted were Catholic, but they also allocated a small number of seats for non-Catholics. I was put on the wait list at St John's.

Then my father suggested that we get my chemistry paper revaluated. That required a special fee. At that time, a former student of my father's was the controller of examination. He looked at my chemistry paper and said something was wrong.

In his view, I had done very well, but someone had scribbled comments like 'This is not the right answer', which is not usually done. We were shocked.

My father went straight to Dr Gokak, the vice chancellor of the university. I still remember the day we met him in his office. My father came to the point straightaway. 'This is my son's chemistry paper.

We know he's done very well, but the marks are very low. Can you please take a look?'

The vice chancellor looked at my paper and nodded. 'There is something wrong here.'

My father straightened. 'I'm not going to keep quiet. I'm going to raise this as an issue. I think the registrar has meddled in this.'

'Wait. Your son is also shortlisted at St John's. There is a way to solve this problem.'

'Yes?'

'St John's has applied for ten extra seats, so the number of seats there will increase from fifty to sixty. I will agree to give them the ten extra seats, and show them your credentials and talk to them about you. Because your son is already on their wait list, they should accommodate you.'

'In that case, the problem is solved.'

So, after what seemed like a lifetime on their wait list, I was admitted to St John's. It was the start of a new phase in my life.

Chapter Three

While the fight to get into St John's was won, another personal battle started. Schoolmates used to look at me and make fun of my chubbiness. I often shot back that it wasn't fat but muscles. Amar's friends used to laugh and comment sarcastically that I was polishing off masala dosas and putting on muscle.

It was the beginning of a sense of oppression that I wouldn't be able to shake off for some time.

Leaning left at St John's

It was the Seventies. Many parts of the world were besieged by leftist movements. In the West, the New Left movement was making its presence felt. Class hierarchies were being demolished.

Civil rights, gender justice and gay rights bludgeoned their way into the public narrative. India was no exception. The zamindari system was being challenged. The Naxal movement was gaining steam, with the Naxalbari uprising and Charu Majumdar's writings. influencing thousands of young, fertile minds with the ideologies of Mao Zedong.

As a young adult, I was not immune to these social upheavals. With my tendency to stand up for the underdog, my internal volcano seemed to bubble up at the slightest hint of injustice. At St John's, I was known to be an unapologetic leftist who stood for values.

I was just over sixteen years old, the youngest in my class. I do understand that sixteen years was very young to get into medical college. Fortunately, I was able to get several double promotions in my primary and middle school due to new educational rules. I used to sit in the second bench and was very nervous, since it was my first year at university. All the other students in my class were adults, street-smart and hostel boarders. One incident that transpired among the hallowed portals of St John's changed things considerably.

The physics teacher had a bit of an accent and used to pronounce 'cc' (cubic centimetres) as 'sheeshee'. One day, unable to control myself, I ended up covering my mouth and laughing.

Face contorted with anger, the lecturer strode up to me. 'Take your books and get out!'

I sat there in silence, without moving.

'I said take your books and get out,' he repeated.

Finally I found my voice. 'I've done nothing wrong. When I'm not guilty, I won't go out.'

Anger turning to mortification, the lecturer blurted, 'I will report you to the Father, who is the head of the department of physics!'

'Please do.' I felt strangely calm.

I was reported to the head of the department and summoned by the Father. This was a matter of principle for me. I was ready to stand up for it.

I told the principal, 'Father, I will not leave the classroom when I've done nothing wrong.'

I was able to hold my ground, and no action was taken against me.

My older classmates began to treat me with respect after this incident. It crystallized for me the importance of standing like a rock by one's principles.

Coupled with my internal volcano of tenacity and my hunger for challenges, this gave my emerging personality multiple dimensions.

I would no longer stand with my head bowed when injustice slapped me in the face. I would not take indignities lying down. I would not shy away from taking someone on when they threw down the gauntlet to me. In the coming years, it would be one or more of this triad of personality traits that would come to the fore when it came to life decisions or whenever I found myself at a crossroads.

A battle between principle, principal and debt

During my years at medical school, the debts my father had accumulated changed the course of my life. He had taken a loan to buy a car when he became the principal of the Government Law College; he believed owning a car would befit his status. He also took a loan to build a house in Kumara Park, Bengaluru. The debt, with accumulated interest, ballooned to thirty thousand rupees, which was a lot of money in the early Seventies.

As a family, we knew he was borrowing a lot. My father used to say he couldn't afford basic amenities, so he used to borrow money from anyone possible. Private lenders were giving loans at a monthly interest rate of 4 to 5 per cent, yet that did not deter him from borrowing time and again. The idea was to pay off the bank loans at the earliest. Even though he was the principal of the college, his salary was only 800 to 900 rupees a month. When it became difficult for him to service the bank loans, the banks put pressure on him. He then borrowed from individuals.

I remember he tried to borrow from his own sister and her husband. They made a big issue of that, and charged him interest. My father also borrowed from a lawyer who was known for lending money at phenomenally high interest rates.

That lawyer would demand repayment from time to time. My father also borrowed money from my maternal grandfather. Here a battle simmered between my father and him—a battle of male ego, between the rich father-in-law and the middle-class son-in-law, and each made a case about the moderately educated rich businesspeople and the highly educated academic people who were paid poorly. My maternal grandfather was on the Basava Samiti, a society involved in the propagation of the humanitarian teachings of the twelfth-century reformer Basavanna. He was a renowned mandi merchant at that time.

His wholesale shop, Vishwanathappa & Sons, was well known in the mandi area near Minto Hospital in Bengaluru, which housed all the popular shops at that time.

We were reeling under debt and my father was desperate. At that time, a professor brought home a businessman to meet my father. My father was then also an examiner for the Indian Administrative Service (I.A.S). The businessman tried to bribe my father to help his son pass the exam. He tried to give my father twenty thousand rupees in cash. The money would have solved our debt issue.

But my father was livid. He threw both the professor and the businessman out of the house. I ran to my father and hugged him.

With tears in my eyes, I told him how proud I was of him. My father was a straight shooter, someone who would not do anything against his principles, no matter what. This rubbed off on me.

Making foreign exchange work for us

After completing my bachelor's degree in medicine at St John's, I joined St Martha's Hospital in Bengaluru as a senior house officer (S.H.O). Meanwhile, Amar was getting tired of our mounting debts and a life of obligations. He saw going abroad and sending money back home as the only way of helping the family out of this mess. Back then, the rupee-to-dollar exchange rate was around seven rupees per U.S dollar.

So, Amar emigrated to Chicago to do his residency at Cook County Hospital. There, he worked very hard so he could send money back to India to help our father pay off his debt. He used to moonlight while working as a resident surgeon in Illinois. He would go to different hospitals on weekends to earn extra money. Gradually, with the money sent by Amar, we cleared all the loans and even went on to build one floor above our house. That helped us considerably.

By this time, my father was on the verge of retiring. He wanted to make sure I, too, went abroad. Much to my father's consternation, I had other ideas. One day, he accosted me as I was going up the newly constructed stairs to the top floor of our house.

'Ajai, you should go abroad.'

Curious, I asked him, 'Why?'

'It's very important. You should join your brother there.'

'I will take a job here, and do some rural work.'

'I am very clear about this. I want you to take that exam.'

I was adamant. 'Anyway Amar's there. Why should I go? I don't see any need to go.'

This was one of the turning points in my life. I was idealistic in my twenties. I wanted to look beyond money and explore how I could contribute to my country. As I was about to become a doctor soon, I strongly felt I should go to the villages and work there. And I always wanted to be in India. On the other hand, my parents needed help with the financial situation at home. I could understand my father's anxiety. Amar was working very hard to earn and help my father. I could not be apathetic. So, there was an internal conflict in me.

I decided to go and join Amar. At the time, I also felt enormous pressure from my father. I had to discard my idealism and dreams of working in rural India. I was twenty-two years old at the time. I did not want to disobey my father, and he was clear that I had to leave for the U.S.

My father was a calculative, intelligent man. He wanted me to be financially secure and not see the kind of financial turmoil he had had to face in his life. He also wanted to live a comfortable life, and two sons earning in dollars would mean more security for him and the rest of the family.

There was another unexpected outcome of all this. Before Amar had gone abroad, he was in Bangalore Medical College, while I was in St John's. He had his own friends with whom he used to hang out. So, even apart from the sibling rivalry/shadow business that had affected my younger years so much, we weren't really that close. When his medical college exams got over, he immediately did his E.C.F.M.G (Educational Commission for Foreign Medical Graduates) exam and relocated to the U.S, so I didn't really get to spend time with him. Ironically, we became close after moving to Chicago, far away from home.

We remained close for several decades there. Then started a dramatic deterioration in our ties, leading to an intriguing phase in my life. But more on that later.

My journey to the U.S started with the passing of my E.C.F.M.G exam in Kuala Lumpur. Even during my exam I was firm in my mind that I would come back to India and give back to society. And after being in the U.S for close to thirty years, I did come back to India. That was my calling, even though sometimes life takes its own course and you have to flow with it to see where it takes you.

Chapter Four

It was the summer of 1975. The world was in upheaval. In India, political unrest had seized the country for the past two years. After the splitting up of the Congress, Indira Gandhi had emerged as the undisputed leader of her faction, Congress (O). With radically left-leaning moves like the nationalization of banks and the abolition of the privy purse, she had established herself firmly as a socialist leader, much to the annoyance of her opponents. Under her reign, there was a constant tug of war between the judiciary and the executive, with brazen attempts by Mrs Gandhi to control the judiciary.

During this period, the country was rife with student agitations, labour union unrest and farmers' agitations. Law and order across the country was spiralling out of control. Mrs Gandhi's staunch rival and Gandhian socialist J.P. Narayan called for a countrywide non-violent revolution to protest against the state of affairs. Despite this, Mrs Gandhi ruled with an iron hand, ruthlessly quashing the nationwide railway strike and arresting hordes of its employees.

There were also allegations of election fraud and misuse of government machinery against her. The Emergency was well and truly on.

The country I wanted to emigrate to was also in turmoil. The twenty-year Vietnam War was coming to an end, with the U.S pulling out its forces from Vietnam. Over 58,000 U.S soldiers had been killed there, with many missing in action. In the U.S, the anti-war movement had been gaining steam, fuelled by excesses committed by the U.S Army. Desertion rates were shooting though the roof. U.S morale, overall, was down; resentment was growing.

Martin Luther King Junior, an icon of the American civil rights movement in the Fifties and Sixties, had been assassinated a few years earlier. America was just beginning to emerge from the throes of violence that had erupted after King's assassination. There were still signs that equality was an afterthought in many pockets of the country. Many signboards still proclaimed 'Whites Only' and 'For Negroes'. To comply with court rulings on equality, black children were being bussed to higher-quality schools in more affluent white neighbourhoods. This led to discontent amongst the white population.

From the boiling cauldron into the frying pan

India and the U.S. Two societies in chaos. I was jumping from a boiling cauldron into a frying pan. There was also the psychology of the U.S society that needed to be considered. Despite being a global superpower, they had been given a bloody nose by Vietnam, an Asian minnow. Perhaps undercurrents of racism emerged in pockets of the U.S society at that time as a result. Years later, I would experience this very same racism and resentment to a degree that would prove to be decisive in my life.

In the summer of 1975 after my E.C.F.M.G exam, I applied to New York State for immigration, and got it. At that time, one didn't need to get a job at a hospital in the U.S for immigration status. So, while I was waiting for my immigration papers, I began to have second thoughts about uprooting myself from my home and moving to a distant land. Life was good in India. I had become popular at St Martha's, and I was very attached to my parents and sisters.

I also kept thinking about my vision to be of service here. I had also heard many stories of people who had gone abroad but hadn't come back for good. So, moving to the U.S didn't really make sense.

The day I finally got my immigration papers, I was in tears. With so many things preying on my mind, I had another of those conversations with my father.

Seeing me in that confused state, my father firmly stated, 'You have to go join your brother.'

I decided to try one last time. 'Why should I go? He's taking care of himself there.'

'No, you have to go. You have to be there with him—you'll be the only family,' he shot back.

I turned to my mother. 'What do you think?'

My mother, obviously in a dilemma because she was also very attached to Amar, was non-committal. 'Consider what your father says. It may be good for you to go.' Amar had promised that he would come back to India for good (but he didn't).

So, the decision was made. I reached Chicago on 3 May 1975. It was a sunny Saturday and my brother came to pick me up. Amar lived in a dorm—a single-room studio apartment with a kitchen—in Cook County. It was a university neighbourhood, with hospitals and quarters everywhere, bustling with hospital staff, nurses and medical students. It also had a big library.

My initial days in the Land of Opportunity

At my brother's studio apartment, my routine was simple. While Amar was at work, I used to sit and watch a great deal of television. But my brother's shadow continued to make itself felt even on American soil, although in a very different way. He expected me to prepare lunch for him.

So every day, by noon, I would have piping-hot Indian food ready. Lunchtime used to pass quickly, with Amar and I engaging in good-natured banter.

Evenings were spent in front of my new friend—the television. That is how I got to see the American life, watching shows like All in the Family (which I think of as the Archie Bunker show), The Jeffersons and the like. At that time, disparity between whites and blacks was the raging theme.

All in the Family was about the racial discrimination shown by a white family towards African Americans, while The Jeffersons was an all-black show. It was interesting to observe this, and the discrimination meted out to socially backward classes in India echoed loud and clear in my mind.

Politically, at that time in the U.S, scandals were rocking the nation, leading to the fall of mighty personalities. U.S President Richard Nixon had resigned by that time, after the Watergate scandal, and in his place Republican Gerald Ford had assumed presidency. Ford's presidential pardon of Nixon was perhaps as controversial as the Watergate scandal itself, where political opponents and detractors had been bugged, activists detained routinely, and other abuses of power carried out by the Nixon administration. Americans were just coming to terms with all of this.

I used to watch the news avidly. While sitcoms such as All in the Family and The Jeffersons were a window into American life, news was a window into the world outside. Walter Cronkite on C.B.S News was a favourite. At that time, there was simmering tension between Iraq and Iran over the Kurdish rebellion and control of the oil-rich Kurdish region. The two countries had just signed an uneasy treaty to settle their bloody border dispute. This was the precursor to what would go on to become the infamous Iran-Iraq War of the Eighties. Sitting in that small studio apartment, I absorbed all the prominent global news even as I worried about my residency.

As the days passed, there was no news on any of the applications I had submitted for my residency programme. I was looking at a lot of places and Amar was helping me, but I was not getting a positive response from anywhere. Amar then suggested I study for my board exam.

While most hospitals required residency experience, there was one state at that time—Nebraska—that allowed you to take your board exam without doing a residency. So, I started studying for it. I used to study all the time, whether it was day or night. It was a crazy time—I was looking to cover a year's study in about a month's time. I wanted to make sure I did that right.

This was between May and June. Residency offers closed on 30 June every year. With no residency offers in sight, I was obviously concerned about the future. Meanwhile, Amar wanted to make sure I did some work and made myself useful. The apple did not fall far from the tree: Amar was so much like our father.

An opportunity to make some money came up. One of Amar's friends, Manohar, had come to the U.S a year after him, like me. He, too, didn't have a residency offer, but he had a job at a nursing home in Worcester near Boston. His sister was a doctor, and she and her husband were working in Worcester. The position of medical assistant was available at the same hospital. Amar urged me to take the assistant's job. I decided to go with an open mind and find out more about it. To earn some money was extremely important for me.

I took a Greyhound bus to Worcester. Little did I know what awaited me. The bus ride was a great experience. I was the only passenger for 300 miles, but they still ran the bus! So, I reached Worcester and stayed in Manohar's house.

When I started working at the nursing home, I couldn't stop wondering why the bloody hell I had come to this country! In India, I was a doctor from a prestigious college. Here I was, in the U.S, doing a job for which I was supremely overqualified. At that moment, earning a few extra dollars didn't look so attractive any more.

Somehow, I managed to put in a few hours at that nursing home for two days. On the third day, I called Amar.

'Amar, if you can't take care of me, fine,' I blurted out. 'But I'm not going to work here. I'll take a return ticket and go back to India. Or I'll find a job elsewhere. But I don't want to be a slave here in this country. I'm quitting.'

Amar was shocked. 'Why? What happened?'

'My conscience doesn't permit me to do this work. This is not what I was meant to do.'

Realizing I was dead serious, Amar backtracked. 'Okay, okay, come back here. You can study for your Flex exam.'

The Greyhound ticket I had was for a round trip, so I used the same ticket to return to Chicago. In less than seventy-two hours, I was in and out of Worcester. I had gone to the U.S to do a lot more than just medical assistance at some nursing home. I could have taken up the job, since it was only temporary, and it would have helped pay for some of the daily expenses, which would have really helped in that situation, but it was not about the money, it was not about the temporary nature of the job—it was about my sense of purpose, which was not being served.

The dollar dream begins

June was a nerve-wracking time. I spent the entire month waiting for a phone call, a residency job offer. None came. All seemed lost.

Just when I'd given up hope, the unthinkable happened. I got a phone call on 30 June. It was the last day of invitations for residency programmes in the U.S and very few aspiring doctors would be available for enrolment. The call was from Dr Constable, the head of radiation oncology at the University of Virginia in Charlottesville, one of the hospitals where I'd applied.

'Hey, are you still available?' Dr Constable's clipped British accent was unmistakable.

I was bursting with anticipation. 'Yes, Dr Constable. I am.'

'Why don't you come and meet me? I want to interview you.'

My jaw dropped. That was it! I dropped whatever I was doing, immediately called Amar and told him I was going to Virginia. Amar was already thinking ahead. He suggested I go bag and baggage, so that if I got the job I could stay back in Charlottesville instead of shutting up and down from Chicago. He felt I was better off staying back. in Charlottesville, and we could meet every now and then. Maybe he wanted me to become independent. Maybe he was looking at the cost angle. I'll never know.

So, I took the next available flight to Charlottesville—my first domestic flight in the U.S. I landed at the Charlottesville Albemarle Airport at 7 p.m. that day. It was a busy Monday. I took a room in a Harvard Johnson motel right next to the hospital. Charlottesville was a small city in the heart of Albemarle County, and had got its name from the British Queen Charlotte of Mecklenburg-Strelitz. Although located in Virginia, the city had been spared the violence of the Civil War. The place and the population had an easy-going nature.

The next day, I arrived at the university at 9 a.m. My whole life was about to change in the next few minutes, but I didn't know it at that time. A huge beige building with red foundational blocks—laid by the founding father and third president of the U.S, Thomas Jefferson—greeted me. It had a very typical hospital appearance. I walked in, introduced myself and asked to meet Dr Constable. I was asked to wait. So, I waited, wondering if this was all a big practical joke on a desperate Asian, thousands of miles away from home, trying to land a residency job offer.

Dr Constable walked in and wasted no time. 'Ah! Aiy-Jay! How are you?'

Somehow reassured by the now-familiar British accent, I dove straight into the conversation. We talked for just under half an hour. Another doctor, Dr El Mahdi, an Egyptian, also joined us.

Suddenly, Dr Constable declared, 'You're in!'

Speechless, I simply looked at him, stunned by his words. I couldn't believe I had gotten the residency job so quickly, without much of an interview.

'You're in!' Dr Constable repeated, enjoying himself now.

I finally found my voice. 'Then why did you make me come all the way for an interview?'

Dr Constable's eyes were twinkling. 'I wanted to make sure your English was good. So, when do you want to come back?'

'Dr Constable, I'm ready to join tomorrow. I came with everything I had.'

It was his turn to be amazed now. 'What?' He called out to his staff. 'Look at this guy, he's come completely prepared!'

I could tell that he already liked me. 'I need a place to stay.'

'Don't worry, we have university dorms. You can stay there.'

The university dormitories were next to the hospital. Each dorm had a single room with a bed. That was it—just a bed! I was allocated one such dorm. Meals were available in the canteen, and there was the Recreation (Rec) Room in the basement. So, I moved into my dorm and called Amar to let him know.

The best part of my residency offer was my salary, which was eight thousand dollars a year. I remember telling myself at that time: Wow, this is crazy! Eight thousand dollars a year was almost like seven hundred dollars a month. At about eight rupees per dollar at that time, I was going to get around six thousand rupees a month. I was going out of my mind with this turnaround in my fortunes. Wow! How many people make that much in India? Also, there were no rent expenses for me, since the dorm was rent-free. I could spend all the money I wanted. This was it! I was all set to start living the American life. With one caveat—my father's expectations!

Chapter Five

Charlottesville is a typical American university town. I landed there in summer, when most students were away for the holidays. The town was deserted.

Students would only come back in late August. I was used to the hustle and bustle of Indian life, with the teeming multitudes of people all around. At home, too, we were a big family, so I was pretty used to having people around. Charlottesville, Virginia, during summer was a far cry from what I'd left behind.

I had a couple of months to kill in solitude. I decided to sit and work. I knew nothing about radiation, so I started studying that. Luckily, I did find some company: Dr Xavier from Kerala, who was in the psychiatry department. We became friends and used to go to places together.

The other thing about Charlottesville was the transport. There was no local transport. It felt strange.

Here I was, in the 'advanced' Western world with automatic doors and so many advanced electronic appliances, but the city of Charlottesville had no visible public transport! Even the remotest village or town in India had some form of public transport, even if it was a bullock cart. I couldn't believe it.

I started to walk around. I walked for grocery purchases, I walked for other kinds of shopping, and I walked for my haircut. Soon I got used to walking about in an empty town. I still can't decide if that experience was strangely relaxing or downright creepy.

I hit upon a novel idea—it seemed novel at that time—to kill time and solitude simultaneously. I took up tae kwon do. Tae kwon do, or T.K.D, as it's sometimes called now, is a Korean martial art characterized by face kicks, spinning kicks, and fast-kick sequences. The emphasis is on agility and speed.

I got heavily into T.K.D, practising up to five times a week. As soon as work was over in the evening, I used to run to the T.K.D centre. I remember the exhilaration I felt when I discovered I could break tiles with parts of my body. As a bonus it also helped me lose weight. I loved it.

The addiction sets in

Do you remember the feeling when you got your first pay cheque? You feel right up there, a responsible adult earning your way through life, ready to take on whatever life throws at you. I was two months into my residency at the University of Virginia when I got my first pay cheque—in U.S dollars. All eight hundred and forty dollars of it. At the prevailing forex rates, that converted to easily around seven thousand in rupees. Wow, I told myself, that was ten times what Father was earning back in India despite his experience and position.

The first thought I had after getting that bumper pay was my father's plight back home. I ran to call him and told him I was transferring the whole amount to him. Then I called Amar and told him what I had done. Curiously, Amar was taken aback.

'What about you, Ajai?' Amar couldn't believe I hadn't kept a single dollar for myself.

'I'll manage, Amar.'

'I wanted you to buy a new car.'

'A new car?' I was incredulous.

'Yes. A Duster.'

'I'm not sure ...'

'You'll need it, Ajai. Winter's coming.'

So that was his angle—he had wanted me to save up to buy a new car costing two thousand dollars. He explained to me that a car was necessary to move around in this part of the U.S. Funny thing was, he himself had a beat-up second-hand car. So that was how caring he was during those days. He didn't mind roughing it out in a foreign land but he wanted me to have the better things in life. Maybe he felt protective of me. Maybe he felt responsible for me there, as the older sibling. (Later, of course, things changed.)

Having gone to the U.S a year earlier than me, Amar was doing better than me financially. He continued to moonlight, drive to different hospitals, make money, earn in dollars and send it to India, where it exploded into rupees. Now I was sending money back home as well. We were very proud to be doing so. At long last, we were starting to repay our father's grit and hard work, which had brought us this far but affected the family's fortunes.

That sense of repayment and that spirit of giving back sometimes got the better of us. We went to great lengths to save money. Once, Amar came to visit me in Virginia towards the end of the year. We went to Washington D.C.

It was a two-hour drive on Interstate 66. Over a hundred miles of nothing but pure driving pleasure on a smooth road.

For six months, I hadn't eaten Indian food. I got this craving to eat dosa. However, the price was one dollar for a dosa. Immediately, our minds did the maths and converted dollars to rupees. We were so used to doing that by then. Our minds immediately went to India and what could be done with that money if it wasn't being spent here but sent back home. Amar decided against spending.

So, we ended up not having a dosa. Coffee was ten cents at that time. Everything was counted in dollars and converted into rupees before spending. That was our agenda then—not to spend, but to conserve money and bring our family to a decent financial position.

It was something that made me think of our value system. It wasn't not that we would not spend, but we were thoughtful of our expenses.

Meanwhile, back home, things were changing. All along, my father had been used to getting just 800 to 900 rupees as salary every month. With Amar and me sending home all those dollars, there was suddenly thousands of rupees coming to him every month.

In the Seventies, this was really good money, especially for a man who had always had it tough and had made ends meet by continuously borrowing at high interest rates. Also, my father was about to retire by then. All the dollars we sent made a huge difference. So, from a middle-class person, he had suddenly transformed into a wealthy man.

Coincidentally, my maternal grandfather's wholesale business was on a decline at that time. My grandfather had become old by then and wanted to retire from the business. As the area near Minto Hospital in Bengaluru had become very congested, every merchant had to move their shop to an area near Yeshwantpur in Bengaluru. But one of my grandfather's sons—my mother's brother—who had been involved in the business, decided he didn't want to do it any more. He took some money from my grandfather and left, only to plough it all into the leather business, where he lost a lot of money. So the whole thing fell apart.

This was maybe when my father started getting too used to receiving dollars from the U.S every month. On the one hand, he was able to repay his debts. On the other, he could finally stand tall in society, in the eyes of those who had looked down upon him earlier.

I don't blame him. His attitude was perhaps natural. But his continued need for this money later created complications and divided us as a family. It also brought out a unique difference in Amar's personality and mine.

A haunting enigma called cancer

At the University of Virginia, I continued to learn, with dreams of taking my learning back to India one day. I continued to absorb what I could. I was put on different rotations in the one year I spent there as a resident surgeon. Once I was posted in the E.N.T (Ear, Nose and Throat) department. As I did the rounds of the wards, what I saw made me change my choice of speciality in medical studies.

For long, I had set my heart on cardiology, because it had been my favourite subject in medical school. I had been very good at it. I was dead certain I would be specializing in cardiology in the U.S.

At the university hospital, I saw something that changed my mind. Here, I observed cancer patients in wards. They looked like they had no hope. Patients were called 'victims', or spoken of as 'terminal' cases. Treatments discussed were palliative—which treated only the symptoms and the pain—and never definitive—which treated the root cause of the disease. No one talked of conquering the disease.

This reminded me of a similar mindset that used to prevail at St Martha's Hospital in India, where I had done my senior housemanship in 1973 to 74. There, too, cancer had become a terror of mythical proportions. I was struck by how people were treating cancer patients. I remember a young girl in St Martha's hospital, who had a type of leukaemia. It almost seemed like she was fobbed off in the ward with some treatment, and eventually died.

She was the only daughter in her family. An interaction with her father made me realize they didn't understand or internalize the severity of her disease. No one knew what to do and everyone felt nothing could be done.

I asked myself: Why not? Why can't we do anything about cancer? The more I thought about it, the more these questions started haunting me. Cancer is an internal problem, so why can't it be solved? Why does it cause so much pain? What is this enigma?

So, I decided to go deep into it. It was a challenge. A tough challenge. And I was not about to back down. I loved such challenges.

I was always a 'why' and 'why not' kind of person. This came in handy throughout my medical career and other future ventures.

For me, it was settled: I would study oncology and not cardiology. The next question was: Where? When I did my radiation stint in Virginia, I felt it was incomplete. The university hospital was a multispeciality one with an oncology wing, and the University of Virginia was a good school. But I wanted to go to the Mecca of oncology, as one would say.

Unsure of how to go about it, I asked one of my professors, Dr El Madhi. I told him frankly that I was not happy at Virginia, since I wanted to acquire in-depth knowledge of oncology. He told me of the two centres in the U.S with deep expertise in this area—Sloan Kettering in New York City and M.D Anderson Cancer Center in Houston, Texas. He said I could try for M.D Anderson. And, holding his coffee, a cigar clenched between his teeth, he sauntered off to his room. This is 1975 we are talking about—there was no Internet to research my options. So I did my research work manually to find out about M.D Anderson, and applied there. I was determined to go to this place, come what may.

But there was bad news in store. I got a call from M.D Anderson saying they were full for the next three years, that 1978 was when the next opening would come up. I was told I could still come for an interview, for which I would have to stay there for three days. Until then, no Indian had joined the radiation department at M.D Anderson. If I got in, I'd be the first.

I took a Greyhound again. Only, this time, it was 1300 miles through six states of southern U.S and a daylong journey to reach Houston, Texas. I went through North and South Carolina, Georgia, Alabama, Mississippi and Louisiana, all the while navigating border patrols and stern faces at checkposts. At one such checkpost, I had got out to get some coffee. As I was sipping it, I heard a guttural voice behind me. I turned.

'I'm going to need to see some form of I.D, sir.' It was the one of the two border patrol officers who had come up behind me.

'What's the matter, officer?'

'Sir, I'm going to repeat. I will need to see some of government-issued I.D from you.'

At this point, the second officer, standing behind the first, had spread his stance wide, blocking off any chance of attempted escape.

I reached for my wallet to fish out my green card. There was a slight stiffening of their postures. 'This is my green card.' I kept my voice calm, extending my I.D to the first officer.

The moment he saw my green card, the officer's body language changed. 'Sorry, doctor, this is because of lots of illegal immigrants around and all that. You can carry on.' His tone had softened markedly.

En route to Houston, there were places like Texarkana where life seemed straight out of the movies. There were people with guns walking into restaurants, cowboys brandishing their double-barrelled shotguns, sheriffs with their shiny badges keeping an eye on things, raucous laughter all around peppered by the trademark Texan drawl. It was just like the Wild West they showed in films.

Houston was more cosmopolitan. I stayed there with an Indian family. The big day arrived. I went to the M.D Anderson campus, not knowing what to expect. They put me through a grilling interview.

I wanted to do radiobiology as well, so they sent me to the academy wing, which included the P.H.D department. Luckily, I was interested in everything. On the third day, they came back and said they were so impressed with me that they wanted to take me right away for June next year as a cohort. I was thrilled. There was more good news in store. They also said they would give me a better salary. So, from eight thousand dollars, I went straight to fifteen thousand dollars in pay. It was beyond anything I had hoped for. After my successful interview at M.D Anderson, I took the Greyhound bus back in January.

I'd been living in a dorm until then, for about six months. That changed. President of India V.V. Giri's grandson, Shankar Giri, who was my classmate from St Johns, also came to Charlottesville. He wanted to stay with me because he had no job and was looking for something to do. Since he couldn't stay in the dorm, I moved to a camper, or R.V, as it is called, which is like a mobile home. It was, of course, my first time in a camper. We lived there for the first six months of 1976. The experience was quite unlike anything I ever had. The outdoor-indoor experience was unusual, going to campsites and meeting new people.

The Multidisciplinary Approach at M.D Anderson

It was July 1976 when I joined the M.D Anderson Cancer Center at the University of Texas—a full year after I had taken up my residency at the University of Virginia. M.D Anderson was considered the Mecca of radiation oncology. Its founder was, surprisingly, not a physician but a banker from Jackson, Tennessee. Born in 1873, Monroe Dunaway Anderson established the M.D Anderson Foundation in 1936, which helped establish a cancer research and treatment hospital under the aegis of the University of Texas. This hospital went on to become the M.D Anderson Cancer Center and began its operations during the Second World War in the 1940s.

At the centre, Dr Fletcher was an iconic figure, and was considered the father of radiation. On entering the centre, one of the things I immediately noticed was how no one talked of palliative care. No one labelled cancer patients as 'victims' or 'terminal'. There was no categorization of patients into stages such as 'advanced' or the like. I also noticed how a multidisciplinary approach was employed. Practitioners were devoted to a speciality. For example, Dr Montague did only breast radiation, while Dr Delcos focused only on gynaecology and Dr Fuller treated only lymphoma.

On my second day at the centre, a curious ritual played itself out. We were all required to report to the auditorium. Dr Fletcher was there at the front of the auditorium, seated in his mobile examination chair.

Next to him was a case documenter. A new patient was brought in on a wheelchair, accompanied by the examining physician. The physician came to the podium and presented his preliminary findings and symptoms.

Dr Fletcher examined the case briefly. He then turned to the other professors and asked how the case should be treated. They gave their opinions from the perspective of their specialities. Dr Fletcher asked the patient to go and then he announced the decision, calling it a team decision.

I was amazed. I later learnt that what I had just seen was called the 'planning clinic', which happened without fail every day at 7 a.m. Everyone from all departments had to be there. And all of them had to give their opinion if the case or the symptoms were relevant to their speciality. The best part about the planning clinic was that the final decision was a team one.

I was really impressed. I mean, here was Dr Fletcher, the father of radiation, listening to a room full of doctors, most of whom were junior to him. How easy it would have been for someone in his position to assert his authority and experience to decide on cases.

Instead, Dr Fletcher made sure all doctors at the centre weighed in on different cases. Thereby they also got wider exposure to the eccentricities of the disease called cancer and how best to treat it. The patient also benefited from the expertise of an entire auditorium of doctors! It was a brilliant approach. This later influenced me to a large extent to think of cancer as a whole-body disease, not just a localized one. I wanted to make sure I learnt about every aspect of cancer, not just one or two. When I later built H.C.G, a multidisciplinary clinic in India, I replicated this approach.

Chapter Six

As a family we had grown up close. I was quite close to my sisters, since I used to play with them a lot more than my brother. In 1977, my father was trying to find a match for Manjula.

At that time, it was all arranged marriages and mostly through intermediaries. A friend of my father told my parents about a boy, Basavaraj, who was an electrical engineer with a government job. My father sent us all the information.

We all agreed that he was a good match and that Manjula would be very happy with him. I became emotional and was very eager to attend the wedding, as was my brother. But reality struck.

Weddings were expensive and my father wanted us to fund it. The money required was so much that there was nothing left for our travel expenses. It was a shock. For years I felt cheated that I couldn't attend my sister's wedding. At times, I was angry and bitter.

Manjula often questioned me as to why I had not come for her wedding. I didn't tell her the real reason then because I didn't want to hurt her.

The one-week chess game

Houston, Texas, is one of the largest cities in the U.S. It is also one of the most populated. Founded in 1836, it is located in southeast Texas near the beautiful Galveston Bay and Gulf of Mexico. I took a flat in Ravenwood Apartments in Harris County, along with Prakash, a dentist from India. The apartment complex had tennis courts, among other facilities. When I first saw the courts, I didn't dream that I would be playing in them at the oddest hour possible.

Life at M.D Anderson Cancer Center was hectic, to say the least. Work started early in the morning and continued until long after the city had gone to sleep. I remember going home at 2 a.m. many times, drained. Sometimes, on the way home, I would drive on the median, I used to be so sleepy. It was a hectic life, but fun.

Due to the crazy hours we kept at work, play and leisure used to happen at odd hours. Prakash was a very good chess player, so we played a lot of chess but with a twist. Since our timings seldom overlapped at home or at the centre, we used to play chess games without ever seeing each other. When he came home, he used to make a move and go. When I came home, he wouldn't be there, so I would make my move and go. This would go on until we could sit across each other on a Sunday and wrap up the game. Each chess game lasted a week.

Tennis, similarly, used to happen at midnight, since that was the only time we got if our timings ever overlapped. When I was still in India, if someone had told me that I would be playing midnight tennis and week-long chess games in the U.S, I would have laughed them off.

I found out something else about myself—I was a good dancer. At that time, disco dancing was popular. I remember my colleagues and I used to hit this particular club that had four floors.

We used to go there very often. The thing with me was, I had to hit all four floors before leaving. So, I used to dance on one floor, go to the next floor and dance away there, and go on all the way to the top floor, and only then stop.

It used to be three to four hours of crazy, continuous dancing. But I never drank. I was a dancer, not a drinker.

By the second year at the centre, I became friends with another Prakash, who had just arrived at Houston. A P.H.D, he was doing postdoctoral studies at Baylor College and would later go on to become the head of the Central Food Technological Research Institute in Mysuru, India. Prakash didn't know how to drive. So I decided to teach him. He got a learner's licence and I taught him to drive on the Rice University campus.

I remember once at a traffic light, he turned on to the opposite lane like in India. I shouted at him for driving erratically. The traffic came to a halt, with many drivers honking. Fortunately, nothing happened, and nobody was hurt.

Prakash and his friend Gopal used to come to our apartment frequently and stay with us over the weekend. They used to hate the mess at our place and tidy it up for us.

Prakash and Gopal lived in an apartment complex called Favorite Hall, which was in the Baylor College campus. It was a short walk from M.D Anderson. I was very fond of onion sambar, which Gopal and Prakash used to make. Since I had a key, I would get in uninvited, have lunch, take a nap and go back before they arrived for their lunch. They always wondered why the quantity of the onion sambar looked much less than what they expected. Finally one day I had to break the news, and had a hearty laugh over it. Those were very good times spent in the company of fellow Indians far away from home. Probably these experiences worked to dissipate some of the tension of the phenomenally stressful lives we were leading as budding oncologists at the Mecca of radiation oncology.

From rock star to traitor

M.D Anderson was good for me in a unique way. It helped me build a mindset that I carry to this day as an oncologist. At M.D Anderson, palliative treatment was never the default approach. The thinking was: What can we do for this patient?

Can we offer something effective? Is it in the early stage, and can we control it? How can we manage the side effects, what are the research angles and the trial angles? Should there be more research on this kind of cancer?

These are some of the things that stayed with me. At M.D Anderson, we learnt to never give up on cancer patients and look for ways to give them a better life, instead of letting them be resigned to their 'fate'.

During this two-year period at M.D Anderson, I was posted in different rotations to different divisions in the radiation department. Each division was designated based on a linear accelerator unit or a Cobalt unit, which was treating a particular disease—for example, breast cancer had a different machine with a different expert, or lymphoma had a different machine with a different expert. At that time, Cobalt was the most commonly used treatment option for cancer patients.

A linac is an external beam radiation unit that delivers high-energy X-rays or electrons to the region where the tumour is located in the patient's body. In my rotations, I was posted at the breast machine, electron beam therapy, palliative care, lung machine and so on. I also did radiobiology. It was a phenomenal learning curve.

The other huge takeaway from M.D Anderson during this two-year period was the planning clinic. When I saw doctors from different specialities and disciplines weigh in on each cancer patient and suggest treatment approaches, it set me thinking. I began to think of cancer as a whole-body disease. And I wanted to make sure I learnt every aspect of it. I was seeing advanced cases coming there, which also got me more interested in them. Being a 'why' person at heart, the questions formed in my mind. Why do some treatments fail? Why do they succeed?

Ironically, this very same takeaway also got me thinking in a contrarian way. When I saw, over this two-year period, how oncology was being done, I was not satisfied doing only radiation. I wanted to help cancer patients in every way I could, not just through radiation oncology.

Oncology has mainly three sub-specialities: radiation oncology, surgical oncology and medical oncology. In one of my discussions with a fine doctor at the centre, called Dr R. Whithers, my internal dilemma became apparent. While on the one hand, I wanted to pursue a P.H.D in radiobiology, on the other I was also beginning to feel that I needed to learn more about oncology overall. This led me to choose medical oncology as my field for fellowship studies.

I remember an explosive conversation with Dr Fletcher. Nothing moved in that department until it had the blessings of Dr Fletcher, who was an iconic physician. Also, not many went from a radiation background to do medical oncology, as, at that time, divisions were very clear between the three sub-specialities. But I went to him anyway.

'Dr Fletcher, I need to talk to you about my further plans. I want to do medical oncology.'

Dr Fletcher's eyes flashed. 'How can you go from radiation to medical?'

I measured my next words very carefully. 'See, Dr Fletcher, I'd like to know more about oncology and other fields of oncology apart from radiation.'

'You are a traitor! You can't change your branch!' The father of radiation was radiating pure, unadulterated rage.

'No, I don't think I have learnt all I can.'

'How can you say that?' Dr Fletcher was now shaking, berating me at the top of his voice. His pain at losing a promising radiation oncologist and his sense of betrayal were tangible and understandable.

Fortunately, another oncologist, Dr N. Taply, was also present. She was understanding and reasoned with Dr Fletcher. 'Doctor, let him do what he likes. Why are you pressurizing him? Leave him alone, let him pursue something he loves. Why should we interfere?'

So that was that. I applied for the fellowship in medical oncology in June 1978, just a month before the start of the fellowship programme. But that was not the end of my dilemma. In M.D Anderson, there were two departments within that sub-speciality: medical oncology and developmental therapeutics, which was more research-oriented.

I thought: Why should I restrict myself to regular medical oncology? I wanted to do developmental therapeutics, dealing with trials and complicated cases. The department was led by Dr E. Friarach, who had written authoritative books on the subject.

He was previously a renowned cancer specialist at the National Cancer Institute in Bethesda, Maryland.

A momentous decision

Developmental therapeutics is a research-oriented field, so it suited my skills closely. But there was one hitch. You have to do three years of internal medicine to get into medical oncology, under which developmental therapeutics generally falls. So, usually only those who had done internal medicine applied for developmental therapeutics, whereas I had a radiation background.

The fellowship programme in developmental therapeutics would start on 1 July, which was drawing near. Initially, I applied to the head of the training programme, an Australian by the name of Dr J. McCredie. My application was not looked upon favourably, although I had tried to emphasize my passion and interest in the field. I still remember his retort in his Australian accent: 'You want to join here from radiation? I'd be nuts to take you!'

Dr McCredie said they didn't have seats. I was disappointed. It was almost the end of June. I had given up hope and was considering signing up for a radiation fellowship programme. I began to check out how to pursue a radiation fellowship in Wisconsin and Delaware. I had to make a quick decision, as most programmes would be starting on 1 July. As Lady Luck would have it, I got a call from an unexpected source.

It was Dr McCredie, with his Australian accent. 'Are you still available?'

I leapt to my feet. 'Yes!'

'Get over here. Come and meet me now.'

I rushed to his office.

Dr McCredie then said the sweetest thing I could have heard. 'Someone was supposed to join but hasn't turned up.

And I need people. Do you want to join?

Do birds fly? Is the Earth spherical? Yes, of course, I wanted to join!

I signed up for the developmental therapeutics fellowship programme under Dr McCredie. It was to be one of the best decisions of my life. This marked a turning point in my career, as challenges quickly overran me but also caused a decisive change in my personality—I became more confident and fearless in my entrepreneurial journey, something neither my father nor Amar could have expected.

Chapter Seven

The months leading up to my developmental therapeutics fellowship programme, slated to start in July, were very eventful. It was as though the events that unfolded in those six months were a precursor of things to come in my third year at M.D Anderson.

The year 1978 had gotten off to a devastating start. In January that year, the Great Blizzard hit six of the states surrounding the Great Lakes in northeast U.S. Illinois, Indiana, Ohio, Kentucky, Michigan and Wisconsin were pounded by severely cold weather generated by a low-pressure system, with 100-mile-per-hour winds lashing the entire region. Homes and counties were buried under 40 inches of snow in places. The temperature plummeted to -50 degrees Celsius. Over seventy people died, unable to bear the withering cold. Coming from a tropical country, and sitting in sunny Texas, this was unimaginable for me. Amar was still in Chicago and smack in the middle of things. The Great Blizzard of 1978 is still cited as one of the worst natural calamities to have hit the U.S.

In June, something more relevant to my medical career happened. The Supreme Court of California ruled as illegal the racial quotas set up by the University of California Davis School of Medicine for minority students, although the same judgement also upheld the affirmative action programme (reservation for minorities) followed by various institutions.

Coming from a country often in turmoil over caste quotas, I remember instinctively flinching at the Supreme Court's ban on racial quotas. What if Indians were no longer welcome at medical schools? What if M.D Anderson suddenly withdrew my admission for a fellowship? I needn't have worried.

Nothing of the sort happened. Still, the development made me skip a heartbeat or two.

Incubating pressure-soaking skills

Doctors and healthcare professionals are known to handle stress and pressure phenomenally well. But this skill doesn't come automatically. It's built over time. However, there comes one incident or phase in every doctor's career where they learn for the first time how to soak in the mind-numbing, minute-to-minute, hour-to-hour pressure and yet not go crazy. This is usually the first time they are stretched to seemingly inhuman limits as far as the demands of the profession go. It is the first time they wonder why they took up medicine as a career. For me, this was during my third year at M.D Anderson, when I started my developmental therapeutics stint.

I didn't have to wait too long for things to go crazy. The first incident was very dramatic—on the very first day of my fellowship programme, when I was the 'doctor on duty' to oversee all in-patients and attend to all emergencies. I had a beeper for attending to calls. I was told I was the only doctor for the 100 patients who had come in for various issues. I went to my room and lay down. Confident that my beeper would alert me to any case requiring my attention, I began blissfully watching T.V. Three hours went by and no calls came.

Suddenly, I got a phone call. It was from the head of the department, Dr McCredie.

'Where the hell are you?!' The Australian accent exploded in my ear.

'I'm in the duty room.' That was all I could muster.

'Everybody's looking for you! There are many emergencies!'

Shocked, I looked at my beeper. My beeper was off! I don't know how that had happened, but it was off. I turned on my beeper and rushed to the hospital wards on the eleventh and twelfth floors of the adjoining building.

The nurses there said there were three places where I was needed: one case was in the I.C.U, and two others in other rooms on the twelfth floor. It could not have been more challenging for a young resident doctor who was handling his first day of duty all on his own. All three cases had to be resuscitated at the same time.

I took a decision. I identified the most critical case, and went to that room first. We had to ventilate the patient, so I put a tube inside his nose and started resuscitating him.

Simultaneously, I was on the speakerphone, telling the nurses in the other two rooms what to do. The second patient was also having difficulty breathing, so I told the nurses in that room to put him on the monitor and shift him to the I.C.U. The third patient was similar to the one I was personally handling and needed resuscitation. There was a respiratory therapist with him, so I asked him to intubate the patient and put him on a respirator. Meanwhile, the patient I was handling was having a cardiac arrest, so I started pumping his heart and applying cardiopulmonary resuscitation. Thankfully, he started breathing again.

All this decision-making was on the fly—I was thinking even as I was doing the resuscitation. I was amazed at the speed at which I was taking critical calls and managing three cases simultaneously. So that gave me a lot of confidence, when I look back at it. Even though it was a bad situation, I learnt a lot. The first patient eventually didn't make it, as the complications were too many, but the other two did.

From this one incident, much to my surprise, I earned the reputation of a star doctor. The nurses in the I.C.U began to consider me one of the best emergency doctors there because I had calmly handled so many cases at once.

And as the months went by, whenever there was an emergency or a critical case, they used to say, 'Call Dr Ajai'. There was one respiratory therapist in the I.C.U. I remember working extensively with him in reviving critical cases. I used to intubate people. Even though I was not highly trained at that time, I was good at what I was doing.

Still, in that one year, I did make some mistakes. I remember an African American girl in her twenties who had leukaemia. She was in a lot of distress. We couldn't find her veins to give her medication.

She had sepsis (severe full-body infection), and I had to put a sub-clavian catheter to access the vein under her collarbone. It was a delicate procedure: Since the top of the lungs is very close to the collarbone, I had to be very accurate while inserting the catheter. And I had to do it blind (without any visual imagery).

As luck would have it, the girl gave a sudden jerk just as I inserted the catheter. I punctured her lung! As a result, she developed pneumothorax, from which her lungs were in danger of collapsing. I immediately realized what had happened, as I could see the girl suddenly becoming breathless.

We had to suck out the air that was present between her chest wall and her lungs; otherwise there was a real danger of her lungs collapsing. I immediately called a surgeon, put a tube inside her lungs, and relieved them. I felt terrible about the incident, as it was an induced complication and a mistake on my part.

But such a beginning—under so much dramatic pressure, then managing I.C.U cases and acute cases—was honestly a great confidence builder. That's why I call it a turning point in my life. Also, after joining developmental therapeutics, I started meeting all kinds of people and making many friends. I also started partying a lot. This added to the gradual surge in my confidence level, even if I didn't realize it at that time.

My routine continued to be crazy. My day used to start at 7.30 a.m., when I would make my rounds. I would then go to the cafeteria to have lunch. After that I would work till around 7 p.m. and finish with all my outpatient cases. Then it was time to party and dance away the night.

I used to go home not earlier than 2 a.m., get some sleep, get up at 6 a.m. again and come to work, where I would be put on 'duty', which meant I'd be there till 6 a.m. the next day. So, then I'd work for thirty-six hours straight, with no sleep in between. Effectively, I was sleeping just once in two days.

Come weekends, I used to sleep on the floor. It was my way of de-stressing. Apart from partying with my friends at M.D Anderson, I used to go kayaking too. This was my first water adventure sport. I used the closed-deck kayak, although nowadays the open-deck ones are becoming popular. The kayak was originally built by the Inuit for hunting, and literally translates to 'hunter's boat'.

So, I took to kayaking to doing some hunting of my own—hunting for greater confidence. Meanwhile, my T.K.D training continued and I was making rapid strides, earning double-belt promotions from time to time. So, while I was gaining in confidence, I was also becoming leaner.

Lasting impressions of a hell that defied imagination

Working in the developmental therapeutics department, I was meeting patients from all over the country. I was like the gatekeeper, as they would have to meet me first. I had to prepare the full programme for them, analyse the case and make calls accordingly. This gave me a huge opportunity to learn. I was initially posted in the clinic, where I met people in research and worked with new miracle drugs at that time like interferon, which was an early form of immunotherapy drug.

While posted on the leukaemia floor, I came across cases so gripping that they left a lasting impression on my mind. One such case was that of a young farm owner from Orlando, Florida. A self-made man, he and his wife had a big, beautiful farm in Orlando and were dog lovers. The man was suffering from acute myeloid leukaemia (A.M.L). A.M.L is a type of cancer that affects the white blood cells.

I was his doctor at M.D Anderson. There's always a protocol for treatment, so I put him on a protocol. He went into remission, with the disease subsiding, and did well for a while. The couple used to come regularly for check-ups. They often invited me to dinner, and treated me like a good friend.

Around eight months after he went into remission, tragedy struck. His disease reappeared. We tried everything—multiple approaches, various dosages, protocols—but nothing worked.

The young man told me something that still haunts me to this day. 'Dr Ajai, I'll give my farm and my everything if only I can get back my life.'

And he died after that, with those words on his lips. I desperately wished I could do something for him, but I felt so helpless. I even wished I could give my blood—anything to make him live—but that was not to be. When I think about this incident today, it touches me deeply. Even after so many decades, it's still so fresh in my mind.

There was another case that was even more graphic. It shook me to my bones. I was on the bone marrow transplant team, which is one of the most difficult rotations. I saw so much disease and complications here.

I remember a well-built, muscular football player who had leukaemia. He developed a significant infection that involved fungus growing out of his bones. The fungus was oozing out of his face, breaking through the bones and skin. It was a sight I can't forget.

There was one more case. This was a man who came for treatment with a phase 1 drug for colon cancer. I still remember that conversation.

I told the patient, 'This is a very toxic drug for colon cancer. Do you want to take it?'

He said, 'My body is an experiment; give it to me, Doc!'

'Are you sure?'

'Hell, yes!'

After administering the clinical trial formalities, I gave him the drug. For twenty-four hours, he was okay, oblivious to the hell he was about to go through. Then he developed mucositis, getting blisters in his mouth. We started medications to the drug.

Then, on the fourth day, he started having a burning sensation in the chest and abdomen. We put him on antacids. I also got an opinion from a gastroenterologist, who said the patient was developing acute gastritis and inflammation. On the fifth or the sixth day, the duty nurse called me and said the patient was vomiting.

I rushed to his room. The patient looked at me with blood-red eyes. Alarmed, I noticed that his body was also a disturbing shade of red. What happened next was unbelievable.

The man coughed, and threw up his intestines, which came out in bits and pieces. The experimental drug given was so strong that it had caused acute ulceration and perforation of the entire intestine, and had stimulated his stomach to throw it all up. He just vomited out his guts! His bowels came out as if they were being pumped out of his body, the drug was so toxic.

At the crossroads of destiny and learning

I saw many such cases, which had a psychological effect on me. It was a hard reminder to me that life could be as cruel as it was precious. After this case, I started rethinking my plans to continue at M.D Anderson and conduct advanced research there. Do I really want to handle clinical trials and research for the rest of my life? Also, if I do, I probably won't return to India. Can I do this in a different way, by learning how to set up cancer centres and treat patients on a larger scale?

So, at the end of my third year at M.D Anderson, I was torn between two equally strong forces. On the one hand were destiny and opportunity calling out to me. On the other hand were my socialist mindset and long-term plans of doing something for the greater good in India.

Whenever I think about whether I should have stayed on at M.D Anderson, one thought in particular strikes me: I had amassed a phenomenal amount of learning at the place. Working thirty-six hours at a stretch, handling multiple cases simultaneously, pushing myself beyond human limits, I had gained tremendous confidence in those three years at M.D Anderson. I had developed very good in-patient-assessment skills. And because I had come from radiation oncology, I had that knowledge as well. Also, I had gotten used to Houston, the big-city life, and all the friends I had made there. I felt I would miss something big by not staying on at M.D Anderson. If I stayed there, I'd go places.

One afternoon, Dr Hickley, the medical director of M.D Anderson, called me and said, 'Dr Ajai, I want to talk to you.'

'Yes, sure.'

That afternoon, I went to meet him in his chamber. He asked me to sit down and said he had a proposal for me.

I was bewildered. He offered an assistant professor post and gave me two options.

In the first option, I could go to the King Faisal Hospital in Saudi Arabia and head the oncology centre that they were building there.

This, I rejected. If I had to go to Saudi Arabia, I might as well move to India.

In the second option, I could head the lung programme at M.D Anderson, an opportunity offered to me because of my dual training. This was a once-in-a-lifetime opportunity. Today, the lung programme is so exciting. I'd have been at the cutting edge of research, and would have published many papers. I'd have been an authority in the field of cancer. People would have called me to present papers, and so on. Essentially, it would have been a great academic career.

However, I'd never have come back to India. I could never have accomplished what I eventually did, which was my entrepreneurial career. My end goal was to serve society at large, not just a few thousand patients that I personally treated. And that was possible only through an entrepreneurial route.

Chapter Eight

As my third year at M.D Anderson drew to a close, so did the deadline for a decision: Should I continue at M.D Anderson or go into private practice and learn the ropes of establishing a cancer centre, with the India dream in the background? I discussed my dilemma with Amar. Amar was looking at the financial angle. He felt that if I stayed at M.D Anderson, I would never make it big financially, but would become a prominent oncologist. On the other hand, if I went into private practice, I would financially be in a better position to go back to India someday and fulfil my dream.

Eventually, I did exit M.D Anderson after my third year there, albeit for reasons I had not considered before. And this paved the way for me to realize my dream of coming back to India twenty-one years later. But I don't call this destiny.

Destiny doesn't do anything for you if you don't do something for yourself. I left M.D Anderson, and after that, I still stayed on in the U.S. I did not return to India immediately, even though that was my final destination. This was by design. I had something in mind. I needed to move some crucial chess pieces in place before I could embark on the path to my final goal: do something in India, for the country. I believed in something, and I would fight for it.

Three incidents during my third year at M.D Anderson helped me resolve my dilemma of whether to go back to India or stay on in the U.S; and if staying on in the U.S, whether to stay on at M.D Anderson or strike out on my own. While I was almost decided on not continuing at M.D Anderson, I was still divided between the other two options. These three incidents helped break the deadlock in my mind.

The genesis of my Burlington move

The first incident occurred in October 1978, when I had just begun my fellowship during my third year at M.D Anderson. I happened to attend that year's annual edition of the American Society for Therapeutic Radiology and Oncology (astro) conference. Founded in 1958, astro had started as an annual gathering of the country's radiotherapists in November or December of every year, and had gone on to become a premier radiation oncology society worldwide.

At the conference, a short, stout man with a moon-like face approached me. Not knowing what to expect, I waited. When he introduced himself as Dr John Gates, I realized he was the radiologist from Burlington, Iowa, who had heard of me through a mutual connection and called me a couple of months earlier. He wanted to meet me at the astro conference to discuss something he did not want to reveal over the phone.

Dr Gates cut straight to the chase, something that I liked. 'Dr Ajai, I'm looking for someone to start a cancer centre. I've heard about you. I thought I should speak with you.'

Immediately, my curiosity was aroused. 'Where do you plan to start it?'

'In Burlington. It's a small town, right on the Mississippi river. It'll be good if you can come visit us.'

I could feel my heart thumping a bit faster in my chest, but tried to react normally. 'Dr Gates, I would be interested. But you're saying it's in a small town, in the middle of nowhere.'

'Think about it. It's a good opportunity to show what you can do. If you go to already established centres, you can't do that.'

'I'll think about it and let you know.' I didn't let on, but I was quite excited.

I went home and called Amar. After some discussion, I concluded it was a good opportunity but that I wouldn't decide immediately. Three months later, in January 1979, I visited Burlington for an interview and met Dr Robert Bell at the Burlington Medical Center (B.M.C). A senior radiologist, Dr Bell was a father figure and an amazing person. I cannot forget the warmth and hospitality he showed to a complete stranger, and a foreigner on top of that.

Dr Bell showed me around. Burlington was, and still is, a very small town perched on the banks of the Mississippi river. It is the county seat of Des Moines County, Iowa, and the local Indians call it Shoquoquon, or 'Flint Hill'. Merely 15 square miles across, it was home to a sparse population of around 30,000 at that time. It is an old Dutch town—and it looked like a mini San Francisco. The local economy consisted mainly of manufacturing and transportation, which had started to peak at the time.

The community was predominantly white and there were hardly any foreigners around. There were some people of Austrian and German origin, though. I remember a few with very interesting backgrounds. Dr George Gandram, an Austrian, had fought for Germany in the Second World War. He had been captured by the Americans in the war and brought to Oklahoma. When he was released after the war, he decided to make America home. Then there was Dr C. Hahns, an E.N.T specialist, who eventually became my patient. He had been a fighter pilot for Germany, and after the war, had come to the U.S and become an E.N.T surgeon. Dr Hahns was also a war veteran. It was a good group.

My feelings at that time were mixed. Burlington looked like the right place to start something from the ground up. It needed a cancer centre and I'd be at the right place at the right time. The people were welcoming, which was something that touched me deeply. Most importantly, it was the perfect launch pad for my India plan, since I could learn here how to set up a centre from scratch, and apply those learnings later when I went back to India. However, I wasn't fully convinced about moving to Burlington just yet. I was very used to a big city like Houston and all the social activities with friends, which had become almost routine.

Resolving an excruciating dilemma

A second incident shaped my thinking about the dilemma I was facing in 1979. During my third year at M.D Anderson, I went back to India to deliver a talk at Kidwai Memorial Institute of Oncology, or K.M.I.O, in Bengaluru. K.M.I.O had been established six years earlier, in 1973, and was in the process of being converted into an autonomous institution by the government of Karnataka. It had been set up with the objective of growing into a tertiary care centre complemented by its academic and research wings. After my session, I caught up with Dr Krishna Bhargava, who was heading K.M.I.O.

As we got talking, I put forward a proposal. 'Dr Bhargava, I have something on my mind. I'd like to discuss it with you.'

'What is it?'

'As you may know, I've trained at M.D Anderson in both radiation and medical oncology.'

'Yes.'

'I'm thinking of relocating to India now. I could join Kidwai, if you're interested.' I leaned forward, fully expecting him to jump at my offer.

'Hmm . . .' Dr Bhargava's face remained expressionless.

'So, what do you say?'

'You can apply through the normal process like everyone else.'

I was stunned. What's going on here, I remember thinking. Here I am, an oncologist trained at a premier centre in the U.S, offering to come back to serve at a government institution in India, and they're not even interested.

It was disheartening, to put it mildly. The talent on the table was not being appreciated. This put a really big dent in my motivation to come back to India and serve patients here.

After the Kidwai incident, another similar incident occurred after I went back to the U.S to complete my fellowship at M.D Anderson. I was about to be appointed on the staff of M.D Anderson. One day, Dr Hickley called me about a specific case.

'Dr Ajai, I want you to manage pain for this patient. Give him narcotics.'

'Okay. But Dr Hickley, I've measured his pain. I don't think large doses of the drug are required,' I said.

'Whatever it is, you're fired!'

'What?' I was taken aback.

I went straight to my head of the department and asked him how I could be fired when I hadn't even signed on for a staff position. Although the departmental head took up the issue with Dr Hickley and the matter was resolved, I was disheartened again. That was when I started feeling that I should be my own boss, that I should become an entrepreneur and chart my own course. I wanted to do certain things and take up certain challenges in the field of cancer. And I wanted to do it my way and go all the way, not be restricted by other people's opinions and diktats.

Since India wasn't ready at that time for all I could offer and the environment there wasn't welcoming of entrepreneurial activity in cancer healthcare, I decided to stay back in the U.S and wait for the right time to go back to my country. Suddenly, things became clear. M.D Anderson was out of question: I didn't want to be a small fish in a big pond. India wasn't ready for me yet. At the same time, since I wanted to go the entrepreneurial way, working for somebody else or at some other hospital in the U.S was out of question. So only one option remained: Strike out on my own in the U.S.

Burlington, here I come!

This is when I decided to give Burlington a chance, try it out for a few years perhaps, and see how it goes. I had already informed M.D Anderson that I wouldn't be continuing in their programme, even though I had a verbal agreement with them to that effect. I signed up with the B.M.C to become a partner in their radiology department. My initial position would be that of a consultant radiation oncologist and I would run their oncology department.

My term at M.D Anderson ended in June 1979. In early July, I packed up everything in my apartment. There wasn't much to pack, in any case—whatever I had fitted into a couple of suitcases. I took the suitcases and dumped them in my Duster. I had a small T.V set then, which I stashed in the back of my car, and first set out for Chicago to meet my brother. The drive to Chicago was around 1000 miles via the Interstate 57. I stopped only at gas stations and highway eateries to save time. I stayed with Amar for a couple of days and then drove to West Burlington.

The doctors at the B.M.C had found an apartment for me on Agency Road. It was a basement unit. I signed a rental lease for a hundred dollars a month and moved in. The next day, I drove over to the centre and reported for duty. It was a community hospital. There was Dr D. Clarke, the head of the oncology department, who was the acting head of the oncology centre and had taken the initiative of setting it up. I worked with him closely during the transition period.

When I arrived at the centre and was shown to my office in a corner of the hospital, for a moment I was flummoxed. There was nothing there—just a table and a chair. Although Dr Gates and Dr Bell had prepared me mentally for my move to a small town by the river, nothing had prepared me for this. Having spent three years at M.D Anderson, where everything was high-end and cutting-edge, seeing just a table and a chair in a congested space that was to function as my 'office', was a momentary let-down.

I quickly recalibrated my thoughts. This was my decision. I had chosen the entrepreneurial path. This was the 'scratch' in the 'starting a centre from scratch' I had set out to accomplish. I couldn't expect all the bells and whistles and the trappings of a high-flying medical research career that would be available at a top institution like M.D Anderson. Moreover, the pay was good. I had been appointed at a yearly salary of sixty thousand dollars. At the prevailing exchange rate of ten rupees per dollar, my monthly pay would come to around fifty thousand rupees—a phenomenal amount of money for us in those days. The only thing was, my social life would not be what it had been in Houston.

When it came to kick-starting the oncology practice at Burlington, I had a huge challenge on my hands. The centre had just installed a linac, which could be used to treat patients, but the oncology department was virtually non-existent at that time. It was a small hospital, and the doctors around used to refer most cancer cases in Burlington and surrounding counties to the University of Iowa hospital. There was also Mayo Clinic in Rochester, Minnesota, which was a six-hour drive. All the doctors practising in Burlington were trained at these two centres, and naturally had an preference for these two hospitals. So, all cancer patients were automatically referred to either of the two.

I was trained at M.D Anderson and people outside the B.M.C were perhaps wary of me because of that. But I was what I was. I was concerned with how patients were treated. And I was confident about my own abilities and treatment approach. There were no treating doctors in my department. So the older doctors at the centre were all excited about me, an oncologist trained at M.D Anderson, joining their medical centre.

I remember Dr Gates admitting to me that they really didn't know how they got a doctor from such a high-end centre to join them. It was uplifting, yet very humbling.

Equally, the healthcare personnel at the B.M.C were intrigued by me, perhaps also because they'd met so few people from India. The staff meetings used to be loaded with questions about me. What was my background? How had I landed up in Burlington? What did I have for dinner? Dr Gates, the director of radiology at the B.M.C, was conscious of this and used to talk a lot about me. He introduced me to everyone and made sure I was acquainted with everything around.

Now my real work started—building the oncology department at the B.M.C practically from scratch. It was an interesting start. One of my first patients was Annett, a forty-four-year-old woman with breast cancer.

I reviewed her medical records and saw that she had been categorized as 'terminal'. I immediately decided to meet her. I went to her room, 474, and began to talk to her about her treatment plan and recovery.

The expression on her face changed. She was staring at me. 'You mean I'm not terminal?'

I felt a twinge of sadness and fury as I realized what this woman had been made to believe all along. 'No, you're not. Tell me more about yourself. What do you want to do in life?'

As if someone had suddenly released a chokehold on her, Annett burst forth into happy banter. 'My ancestors are from Ireland. I work at General Electric. I had planned to work until I was sixty-two and then retire. I wanted to do some fun things like visiting my ancestors' home in Ireland, and cross-country bicycling and skiing across Colorado.'

I heard her patiently, and with a broad smile I said, 'Look, Annett, you're not terminal. There's a good chance you'll go into remission. We can lay out a plan where you can go back to work, and still do all the fun things, including your trip to Ireland. What you had planned to do at the age of sixty-two, you can do now.'

We created a personal profile for her, which included 'chemo holidays'. During these 'holidays', which lasted two to three weeks, she would go on her trips, and we kept in touch with her. She felt reassured because she knew we were monitoring her condition. She went into remission and fulfilled all her wishes over the next seven years.

Something she had said struck home and stayed with me—the word 'homeland'. That word must have meant so much to her. She expressed her dream to return to her homeland after retirement. If she had really been terminally ill, all her hopes of her life's dream being fulfilled would have been dashed.

As her treating doctor, I felt exultant. If I hadn't understood the value of that dream for her, I wouldn't have done my best for her. This thought stayed with me as I went about building my practice in Burlington. There were many more intriguing and touching stories of cancer patients that came my way.

Chapter Nine

Burlington wasn't a ghost town like Charlottesville, where I had done my residency programme. But, even then, the social life there was no great shakes. It was only in summer that the social life came alive when there were fests like the Steamboat Days on the Mississippi river. Thankfully, I made friends in Burlington very quickly.

Harry Shah, a fellow tennis enthusiast, lived on a street close to my house. Harry, who had married an Iowa girl named Joy, became my official chartered accountant. We played tennis on Sundays at Crapo Park nearby. Crapo Park is an 85-acre city park located on Parkway Drive along the Mississippi river. It is apparently where the American flag was first raised in Iowa. That is where I met Ray Kress, who was an athlete and a great tennis player. Ray was married to Laurie and was a businessman selling light bulbs on a wholesale basis.

He was the same age and height as me, so there was some natural bonding. I began playing tennis with him on Wednesday afternoons, which became our thing. I also started waterskiing with him on the Mississippi and became quite good at it, despite some accidents that could easily have taken out an arm or a leg.

Among the other people I got to know in Burlington were older doctors like Dr R. Allan and Dr J. Sarr, who were surgeons and really old-school. They were liberals, very accommodating and saw me as a novelty as there were no other Indians around, except for Harry. There were also Dr Kathy and Dr Michael Wilson, who were orthopaedic and gastrointestinal doctors. They were the liberal, bohemian type. All in all, I developed a network of diverse individuals and professionals.

At work, something interesting was starting to happen. Patients from surrounding counties who were earlier going to the University of Iowa hospital began to come to the B.M.C for oncology treatment. The B.M.C did not have any idea how to set up oncology operations. So, I created a small office in the space I was given.

No one expected many patients. Still, I hired a secretary. But she had no experience in billing. So, I just started treating patients who came to us and started off in a small way, even though the finances were not being handled well. I worked on Saturdays and sometimes even on Sundays. And I came across some pretty intriguing cases. One of them has stayed with me.

The case of Alaina

Alaina was a teacher in Burlington and a mother of two kids. At the age of thirty-two, she was diagnosed with an aggressive cancer of the breast. She was operated on by Dr Allan and referred to me.

During the consultation, she asked me, 'Doctor, what do I have?'

I told her, 'It's inflammatory carcinoma of the breast and you require aggressive chemotherapy for a long time.'

Disheartened, she said, 'I'll take some time to think and come back.'

Within a few days, she was back, ready to undergo treatment. I heard that she went to the university hospital and several other places for a second opinion. So began the long journey of her treatment. She and her husband, who was working at the University of Iowa, became more like friends to me.

She had one wish, very similar to Annett's: She wanted to see her two little kids grow up and one day be a grandmother to their kids. A tall order, but with a positive approach and focused therapy, we were able to achieve it. Alaina went on to live to the age of sixty-four and died of cardiac disease. She wrote a beautiful note to me when I eventually left Burlington, which I still cherish.

Alaina lived not only for the next thirty years but also saw her children get married and even played with her grandchildren. Her case again shows that if you can understand what your patient wants to do in life, have a positive approach and treat aggressively without compromising, you can get good outcomes.

Another case I cannot forget is that of Helen from Keokuk. Originally from Oklahoma, she was the secretary of a big-time politician in Iowa. She was referred from Loyola University, Chicago. They wrote a letter to me, saying, 'Dear Dr Ajai, this patient has extensive disease in the bone and requires some palliative radiation to the painful areas, so kindly do the needful.'

When I saw her in the consultation room, she was in a wheelchair and accompanied by her husband. I reviewed her scans and asked her how she was feeling. She replied that she was in pain, unable to walk and had been told she was terminal. I felt that familiar fury return.

This was Annett all over again. So, I had a lengthy discussion with her and her husband. I gave her various options and added more nuance to her notion of being terminally ill.

I asked her, 'Do you really want this palliative treatment or do you want to go for more definitive treatment? Can I offer you chemotherapy and try to get you into remission?'

She asked, 'Doctor, are you sure? Because the university hospital said they can't do it.'

I replied, 'We can give you a more definitive treatment.'

After much discussion, they agreed. Her husband was very supportive. For two years, I gave her chemotherapy.

She went into remission. She went back to her old job. When I left Burlington, she was still working.

In 1980, I got another intriguing case—that of Quinn, who was a farmer's wife. Quinn had extensive breast cancer. I treated her, took good care of her, and she went into remission. Quinn went on to live for seven more years.

But finally, in the late Eighties, the disease caught up with her and metastasized to her liver. She became terminally ill. I got to know of this and visited her on a Sunday afternoon. She had low blood pressure of 60/0 and knew she was dying. As I held her hand, the entire seven years I had known her and helped her with the disease flashed through my mind and I became emotional—it was too much for me.

Quinn squeezed my hand and consoled me, saying, 'Dr Ajai, you've given me seven years of life. You've done more than enough. Don't cry.'

Instead of the doctor reassuring the patient, here was the patient consoling the doctor!

Philosophy is about seeking knowledge about the fundamental aspects of life. I learnt it from patients like Annett and Quinn. There is a lot you can learn about life from someone who is facing imminent death. This led to my leanings towards what I call 'oncophilosophy'. Oncophilosophy is where you learn from a cancer patient's fight with his or her condition.

You learn the value of life when death is near or imminent. You learn how precious each moment becomes when the concept of mortality becomes real. You understand the value of human aspiration and what it means for the person holding that aspiration. All this can have a phenomenal effect on your understanding of your own life and what it should mean to you. It can also have a marked difference in your approach as a healthcare giver towards patients.

The University of Iowa feels the pinch

As I continued to treat patients coming to the B.M.C, the other doctors at the B.M.C started hearing good things about me from patients I'd treated. I remember Dr Allan once telling me, 'Doctor, I get such good feedback about you.' Very quickly, the doctors' fraternity at the B.M.C developed a lot of confidence in me due to my quality of healthcare, my way of talking to patients, and my style of personal care. One off-heard feedback about me from patients was: 'It's as though I'm the only patient he treats.'

Before I took over the oncology department at the B.M.C, people in the local community were used to the University of Iowa's conservative approach. The hospital was not used to advanced cases and gave up very easily. They used to tell patients they had three or maybe six months to live, categorizing them as cancer 'victims'. So, when I started treating patients in the region and getting better results due to my more radical approach, it was a game changer for the public and the doctors. The older generation loved it, and they started distancing themselves from the University of Iowa.

I got patients from Fort Madison, Mount Pleasant and other small towns within a 100-mile radius. Fort Madison, the county seat of adjoining Lee County, is a half-hour drive southwest of Burlington. Mount Pleasant, the county seat of adjoining Henry County, is also a half-hour drive from Burlington, to the northwest. Both towns were more sparsely populated than Burlington then, but we kept getting more and more patients from these regions. The B.M.C couldn't understand how a town like Burlington could have so many oncology patients.

My reputation in the region grew at a phenomenal pace. People who were told by the university hospital that they wouldn't live beyond a few months went on to live for years after my treatment. I succeeded in my approach because I didn't believe in giving up and also because I had a deeper knowledge from M.D Anderson. I would take advanced cases head-on with an intent to treat patients rather than be content only with palliative treatment.

With cancer patients diverting from the university to the B.M.C, our oncology department became terrifically busy. I became one of the busiest doctors at the B.M.C in a very short time—perhaps within a year of starting operations. I would begin work at 6.30 a.m. and come back at 9.30 p.m. There were days when I would have seventy patients on the floor and another sixty or seventy patients in the clinic, or the O.P.D. Until then, there was no Cat scan facility. Soon a Cat scan machine was set up. Also, the B.M.C decided to go for a mobile M.R.I machine that used to come in on a truck for two days in a week. All this assisted in diagnosing patients and improving the efficacy of treatment.

However, there was a dark side to all this too. The University of Iowa, which had a big hospital, was becoming concerned about losing patients. Dominant until then, the university began to feel threatened about this guy from M.D Anderson who was weaning away patients.

Also, professional jealousy at an individual level was setting in slowly but surely. I heard one of the new doctors in Burlington asking patients: 'Why do you keep talking about Dr Ajai? What's so great about him?' He received the by-now-standard feedback, much to his amazement: 'He treats me as though I'm his only patient.'

Professional jealousy soon inflamed into discrimination with racial undertones. While I had the good fortune of working with some exceptional colleagues like Dr Jones, Dr Sarr and Dr Allen, there was another side to this as well. Plus, with more Indians coming into town and into the U.S, racism inevitably reared its head. And when the local populace feels threatened, insecurity and racism come out of the woodwork.

There was another fallout. Before I started reviving the oncology department's operations at the B.M.C, cancer patients in the region used to pay up at the university hospital and claim reimbursements from Medicare. Once these patients began to shift to the B.M.C for their treatment, Medicare suddenly started receiving a huge number of insurance claims from the B.M.C, which was a red flag for them. They started questioning us aggressively. However, it soon became evident to them that I was doing things the right way and that there was nothing amiss with the ballooning claims from the B.M.C.

Indian cowboy with a ranch

In 1980, I started looking for a house in Burlington. As my search for a house continued, I met many more people. There was a banker called Dick Wright and another called Barry Corson, whom I started meeting over tennis sessions. These sessions inevitably ended up in beer guzzling, but somehow I didn't touch beer.

Meanwhile, by now, Saturday and Sunday mornings were devoted entirely to tennis with Ray, with three to four hours each day being the norm. Ray and I became very good friends, and started inviting each other home.

My real estate agent was also showing me properties that were up for sale. At some point, I had started fancying the idea of living in a ranch, which is usually a one-storey house. I decided to buy a 5-acre plot, and planned to keep a horse. I finally found one to my liking. It was located on Walker Road, on Rural Route 2 (R.R.2) outside Burlington on the outskirts of the city, about 6 miles from the B.M.C. The asking price of the house was two hundred thousand dollars.

I was making sixty thousand dollars a year at that time, a big jump from the seventeen thousand dollars at M.D Anderson when I left it in 1979. At that time, the interest rates were actually high, hovering around 12 to 13 per cent. Yet I took a bank loan and bought the house in early 1981.

One of the things in a small community is that if you buy a house, it means you're going to settle down there. So, when I bought the ranch, my frequency of interaction with the people in the neighbourhood increased. In particular, Dr Bell showered a lot of love and affection on me. Meanwhile, Ray and his wife Laurie had their second child.

Unfortunately, theirs was a rough marriage. Whenever they fought, Ray would come and stay over at my house. I would then call Laurie and help patch things up.

It was a good life. I had become more comfortable in the city. I remember coming to India just after buying the house.

It may sound strange, but I did not lock the house. When I returned after a whole month away, everything in the house was as I had left them. It was an absolutely safe neighbourhood, with no crime.

Chapter Ten

In early 1980, following the recession that was fuelled by the 1979 oil crisis, the U.S domestic economy was in turmoil. The U.S government had to bail out Chrysler Corporation with loan guarantees of 1.5 billion dollars. The commodity stock markets were reeling under the panic caused by the Hunt brothers, who tried to corner the silver market but had to finally file for bankruptcy, unable to meet their margin calls.

Elsewhere, Miami, Florida, had been roiled by violent race riots, while Nebraska was hammered by deadly tornadoes causing over three hundred million dollars in damages. Unemployment rates reached a four-year high. The U.S imposed economic sanctions on Iran in response to the Iranian hostage crisis, in which fifty-two American diplomats at the U.S consulate in Tehran were taken hostage.

It was against the backdrop of this turbulence that Ronald Reagan romped home as the fortieth president of the U.S in November 1980 and assumed office in January the next year. One of the first measures he announced was the drilling for oil in the beautiful Grand Teton mountains. I decided to backpack in the Grand Teton and the Yellowstone National Park in July 1981. My uncle, Neelakantappa, a timber merchant, had come to visit his daughter. When he learnt that Amar and I were going on this trek, he said he wanted to come along. Amar, my maternal uncle, and Robert Hage, a friend from M.D Anderson, left for the trek.

The landscapes were breathtaking, with huge geysers erupting all over the place. We saw the famous ones: Old Faithful, Riverside Geyser, Castle and Steamboat.

When you are far away from human conflict, in the midst of nature, you get time to think. It was an exhilarating, and at the same time calming, experience. That was one of my first adventures in backpacking. I thoroughly enjoyed this first experience and made up my mind to do it more often. Being amidst those heights, scaling seemingly insurmountable peaks, my confidence skyrocketed as though with a dopamine shot. Coupled with the confidence I had gained from my M.D Anderson stint and my T.K.D training, I was now brimming with self-assurance to take on life—something that had been sorely lacking in my childhood.

A life-changing moment during Amar's wedding

Amar was happy with his work in Chicago. Amar being Amar, he didn't want to go to India and get married. I wasn't having any of it, and convinced him to go to India. He went in early 1981 and met his future wife, Mangala. The daughter of a doctor, she had just become a doctor herself after graduating from K.L.E Medical College in Belgaum. The wedding was fixed.

I came to India in November 1981 for Amar's wedding. They had a very simple wedding. My brother was always like that: He didn't like inviting too many people and wanted just a small reception. My sisters were all there for his wedding, as none of them had moved to the U.S yet.

I was in India for three weeks. Before I returned to the U.S, my parents said we should go and meet the family of a girl they had chosen for me. They lived in Jayanagar. It all happened very quickly during that time. I said okay, more out of curiosity than anything else. That is when I saw Bhagya for the first time.

My brother also came to 'see the girl'. He had always wanted me to marry a professional. Now that he was hitched, he probably felt the need for me to do so as well. After we came back, Amar was not sure if Bhagya was the one for me.

However, I wanted to know more about Bhagya and talk to her. So the next day or so, she and I went out. Sapna Hotel on Residency Road, where we went, was famous for its rava idli. It was my first conversation with a girl in the context of marriage, so it's safe to say there was more than a tinge of apprehension in the air.

I was older than her by nine years. She was only twenty years old at the time and was a graduate of R.V College, Jayanagar. I could see she was quite intimidated by this oncologist from the U.S sitting in front of her.

Bhagya was painfully shy. It was far from what they show in the movies, with sparks flying on the very first meeting. Instead, it was a stoic, studied meeting, more like an appraisal process between teacher and student!

That 'date' made me feel we had a similar nature. We mainly talked about what we liked. We both liked the outdoors and, coincidentally, she liked many of my favourite outdoor activities as well—such as horse riding and backpacking. She was a science student, but was into art—ikebana and painting, in her case—which I had an interest in. Moreover, my mother did not want me to marry a doctor, and I was fine with that notion. In our family, there were already three doctors: Amar, my sister Pushpa, and I. Amar then married a doctor, whose father was also a doctor. You could say our family was overflowing with doctors!

So in my mind, Bhagya was ticking all the right boxes for what I was looking for in my life partner. When I look at our relationship now, I am very happy it's so strong and binding.

A few days after the first meeting, we met a second time, this time in Bengaluru's famed garden, Lal Bagh. Before I left for the U.S, we had more or less decided to get married, but we didn't have any formal engagement. We just decided to write to each other.

We started exchanging letters. For almost eight months, we wrote to each other, once every few weeks. One incident that I described to her really scared her.

I was returning home one night in my 4.W.D Trusty Rusty after seeing a patient. It was winter so the road was covered in snow and treacherous. It was also very dark near my house.

As I began to drive up the incline leading to my ranch, the truck simply refused to climb, its tyres getting no traction on the slippery road. It then skidded backwards and to the right, where there was a huge ditch. The truck came to a halt, hanging partly off the road, teetering over the edge. Below me I could see the bottom of the ditch—it was a nasty 20-foot fall. Somehow, I crawled out of the truck without upsetting its balance and crept up the icy road to the safety of my ranch. Bhagya was very upset on reading this letter.

In those days, we used inland letters for overseas communication. Delivery by postal service would take around a week. It was an experience in itself: posting your letter, knowing it would reach your love interest only after a few days, then counting those days as they went by, then getting to know it had reached only when you got a reply by another inland letter about two weeks later, and then trying to remember what you had written so you could make the right connections.

A season of partnerships

While I had decided on my life partner, it was time to identify a different kind of partner—a partner for my practice. Back in Burlington, the number of cancer patients was increasing. The cancer scenario in the U.S had changed drastically in the late Seventies and early Eighties. More and more Americans were getting afflicted with cancer of one type or the other.

One type of cancer that was proliferating was lung cancer. While the initiation age into smoking for men was continuously dropping, women had started smoking more like men—starting earlier in life and smoking heavily. The daily consumption of cigarettes by men, which had peaked during the Seventies, had continued into the Eighties. With women also smoking more, their daily consumption started to peak in the Eighties. In male smokers, especially, there was an increase in the incidence of adenocarcinomas, which is a type of non-small-cell lung cancer (N.S.C.L.C).

A similar story was unfolding in the skin cancer area. Incidence of the basal cell carcinoma (B.C.C) type of skin cancer, which appears as painless skin nodules or ulcerations, had begun to increase in the late Seventies and early Eighties.

In the same period, there was increasingly higher incidence of the squamous cell carcinoma (S.C.C) type of skin cancer, which presents itself as hard lumps on the skin. Breast cancer was another type of cancer that was seeing a jump in the number of incidences and detections, although the spike was not that high as for lung or skin cancer.

To deal with this influx of patients, I decided I needed a partner. In early 1982, I put out an advertisement and left word everywhere that I was looking for someone to join me in my oncology practice. A husband and wife, both doctors practising in New York, applied to join me. Dr Shiva Reddy and Dr Rohini Reddy were originally from Andhra Pradesh. While the husband was a radiation oncologist, the wife was a medical oncologist.

I thought it would be ideal if I got the two of them in, so I could do my own practice. I invited them for a discussion. They met me in Burlington, where I introduced them to the doctors and we went out for dinner. My first impression of the couple was good, especially of Rohini, who I thought was more accommodative and interested in collaborating. The only question I had in mind was whether I should bring in a husband-wife pair, but then I decided to go ahead with it. So, I brought them in as partners.

Two more Indians, therefore, joined our community. They would be consultants at the B.M.C, just like me. They had to have a contract with the B.M.C, plus an agreement with me. Instead of immediately becoming partners, for the first one and half years, they would be employees and I would pay them a salary. By the end of that period, if we felt we suited each other, they would sign up to become equal partners, wherein they would get an equal share of the practice's profits. I still joke with Bhagya that this kind of 'testing the waters' was possible only while looking for business partners, and not while finding a life partner.

Whatever professional services we provided directly to patients, we would bill separately for them, without the B.M.C coming into the picture. That would be our income, which would be shared with all partners of the oncology practice. No share of this income would go to the B.M.C, which would only provide technology and technical services, such as radiation treatment, for which they would bill the patients separately.

Around this time, I was in touch with Professor A.K. Ramanujan, who taught South Asian studies at the University of Chicago. Amar knew him well and I began to visit him by driving down to Chicago over the weekends. Professor Ramanujan and I discovered a lot of common ground when it came to our pet topics—capitalism, socialism and where India was headed. He became fond of me and we enjoyed each other's company.

I was doing well by this time. To enjoy the fruits of my hard work, I bought my first Mercedes. It was a gorgeous two-seater 3.2.0.C.X.L with a canopy. I thoroughly enjoyed this phase of my life.

Grand Teton, we meet again

That summer, seven years after I had first arrived in the U.S, our parents came to visit us for the first time. It was important to spend time with them. They first came to Chicago and stayed with my brother for a few days, before joining me in Burlington.

It had been exactly a year since I'd explored the beauty of Grand Teton. Now the mountains beckoned again.

I described the Grand Teton's haunting allure and my father was hooked. We decided to go on a long road trip to Grand Teton. I couldn't wait to be there again. But first, I had to make some arrangements at work, so I could take two weeks off.

We hired a camper. It was exhilarating, driving on the open road, zipping past gas stations and Western-style towns. My father loved it. I still remember his first words on that trip: 'What a wonderful drive!' In between, we camped out in the middle of nowhere. We would make ourselves tea and coffee in the camper itself.

We drove 600 miles in one day and reached Casper, Wyoming, where we camped out. The next day we reached Grand Teton, passing this 'Western' town called Cody. My father was intrigued by the town, with all its cowboys swaggering about and the unique signboards reminiscent of the Wild West of the yesteryears. We didn't know at that time that Cody was the hub of a form of tourism in western U.S where tourists from eastern U.S—called 'dudes' by the locals—would be hosted at 'dude ranches' to live the rough 'cowboy life'.

We drove up hilly roads and camped out at a place called Colter Bay for a few days. This was soon to become a family thing for the next forty years.

Colter Bay was miles and miles of pure visual pleasure. With the snow-capped peaks of the Teton range appearing as rugged patches of grey and moss green in the distance, tall evergreen conifers in the foreground, and the crystal-clear waters of the bay, the vistas were nirvana for the soul. It was a postcard picture come alive. Colter Bay was located to the northeast of Jackson Lake and was part of the 'Mission 66' programme of the National Park Service to rejuvenate park facilities for visitors. There were hundreds of campsites and some log cabins there.

My father thoroughly enjoyed the experience. My mother also enjoyed the trip, but didn't express it. In the mountains, my father was so enamoured by the surroundings that he wanted to stay there forever. It was a memorable family trip. From Grand Teton, we proceeded to San Francisco, the famed Bay Area.

To most people, travel opens up new horizons and perspectives. For me, travel is also a way of bonding with family. It helps me learn more about the people I love, understand them better. Treating cancer patients had helped me realize how fragile and mortal human life is. Travelling with loved ones helped me savour this mortal life even more through the memories that we created.

Chapter Eleven

After we returned to Burlington, there was a rather scary incident, in which my father had a close shave. That day, Ray had come home. We were all relaxing by the lake behind my ranch, which was popular for fishing and boating.

My father and I decided to go for a swim. Somehow, he swam farther than he should have and got into difficulties. Unable to breathe, he began to shout for help. In a trice, Ray, an excellent swimmer, jumped in and made straight for my father. He quickly reached my father and pulled him out to safety.

It was time for me to enter a different phase of life. In November 1982, I flew to Bengaluru for my wedding with Bhagya. Bhagya had two older sisters, Veena and Sandhya. Her brother-in-law, Shivaprasad, was also an important member of the family. I got along well with Bhagya's parents and family, as she did with mine. Bhagya was very comfortable with my father, as he used to put people at ease by talking and cracking jokes.

It was decided that the wedding venue would be the Kuchalamba Kalyana Mantapa in Jayanagar, Bengaluru. The wedding itself was a one-day affair, with muhurtham in the morning and a reception in the evening.

The memorable thing is that, along with all the usual stuff that happens at weddings, in the evening, after the reception, you are supposed to go to the bride's house and stay there. So Bhagya's family had prepared a lot of dishes and savouries. But there was also something I wasn't prepared for.

The bed had been filled with things that made various sounds when you sat on it. It was a custom. Of course, we 'sat' on that bed, and, of course, it made a lot of noise. There were people standing outside, listening and giggling away. Bhagya and I had our share of laughs that night.

After marriage, things went fine for some time. Then my father and mother started showing some signs of insecurity. I was very close to them. By that time, my eldest sister, Manjula, had already gone to the U.S. Amar and I had anyway gone long back and settled there. So my parents started going through what is often called the 'empty nest syndrome'. Whenever I went to Bhagya's house, they would ask me when I was coming home that day.

My parents were feeling that I was drifting away from them. They were very attached to me and even if I spent a day at my wife's place when I was visiting from the U.S for a few days, my parents would feel that I was not spending enough time with them. That way, we were a very dysfunctional family.

Bhagya applied for immigration to the U.S immediately after our wedding. In May 1983, she arrived in the U.S and joined me at my ranch. My work kept me away from her from 6.30 in the morning until around 8 in the evening. Bhagya would often tease me about this. But we were already beginning to bond as a couple during this phase. Summer and winter were heavy. There were days when I never saw sunlight. So the whole idea was that, during weekends, I would play a lot of tennis.

I had good friends like Harry and Ray, as well as Dr Shiva Reddy, and a small Indian community to socialize with. At this time, Anthony Lazar, a former St John's classmate and a cardiologist, was practising in Chicago and looking for a change. Fortuitously, we needed a cardiologist at the B.M.C. So, I encouraged Anthony to come to the B.M.C. He relocated to Burlington and joined us.

Bhagya mingled easily with everyone, losing her shyness and getting accustomed to life in the U.S. Dr Bell taught her gardening. As with me when I'd first come to Burlington, he became a father figure to her. I still had my open-top Mercedes sports car. I used to take Bhagya out in that open car, and she loved the experience. Things were really flying on the personal front.

Third time unlucky at Grand Teton

Bhagya and I engaged in plenty of outdoor activities in and around Burlington, and she had also taken up running. So, it did not take much for me to convince her to do her first backpacking trip with me in the summer of 1983. It was the end of June, barely a couple of months after she had come to the U.S, yet she was raring to go. I had already planned to go to Grand Teton with Harry and his wife Joy. They'd never done any backpacking either. So, among the four of us, I was the expert, as I had done it twice before!

I advised the Shah's on their gear, and got Bhagya boots, trekking shoes and other gear she would need. She was skinny and petite, so I was a little worried about her surviving the ordeal. I needn't have.

As we set out for Grand Teton, I felt a familiar surge of excitement. The Shama Rao incident in my childhood had triggered in me a lifelong hunger for challenges. To me, Grand Teton was as good a challenge as any. It was akin to what entrepreneurs face in their struggle against uncertainty and risks as they go about building their business and scaling the heights of success. My previous two backpacking trips there had been uneventful. But this time around, I couldn't have guessed what was in store.

As usual, we had tents, food and other supplies with us. We'd even packed chapati (roti) makers this time. At the trailhead we readied our backpacks, put on our hiking boots and locked the car. We told the ranger where we were heading and set off into the 'back country', as it's called.

It was undulating, mountainous terrain. Snow season had ended but the snow had not yet melted, as the temperature was still not hot enough.

In the U.S, while on a trek, you can't set up camp just anywhere by the trail. There are designated campsites, some of them equipped with toilets, showers and a store or two. So it's important to plan your walk for the day such that you land up at a campsite at the end of the day.

On the first night, we chose a camping site in the middle of nowhere. There were no other humans in sight. It was a designated area but it was all open country and there were absolutely no facilities. It was phenomenally cold at night. There were no storage bins (usually campers were given sealed bins to store food), at that time, so we had to store the food on top of a tree by tying the food bag to a rope, slinging it over the highest branch, and pulling it up. This was to prevent bears from getting hold of the food.

We retired for the night in our respective tents. Bhagya and I talked for some time before she fell asleep. I closed my eyes, imagining the open skies outside the tent and the hypnotic landscape around us. It must have been around 1 a.m. that I heard a sound. A scraping sound.

I opened my eyes to complete darkness. The sound was coming from outside. I slowly crept to the front of our tent and raised the flap just enough for a peek outside.

As my eyes adjusted to the dim light outside, I froze. There, in front of me, about 20 yards away, a gigantic figure hulked near the tree where our food was tied. It was a grizzly! The North American brown bear! All seven hundred pounds of it! Standing tall on its hind legs, it was looking up at the food bag tied high up in the branches. Perhaps sensing a presence, the grizzly turned in my direction and locked eyes with me. The next ten seconds or so were perhaps the longest—and the scariest—ten seconds of my life. Finally, the bear decided that this little staredown was enough and ambled away, leaving me to catch my breath and sink to the floor in relief.

The next morning, the story of my night's ordeal thrilled the Shahs and petrified Bhagya. The rest of the day, we were imagining grizzlies everywhere. That night, we reached the Alaska Basin, on the western slopes of the Teton range, near the border of the Grand Teton National Park. We camped there for two days. I remember taking photos at one spot where there was a dangerous precipice, not realizing I had gone so close to the edge. I was pulled back by a ranger who was around.

We decided to hit Buckpeak lake on the fourth night. This is a beautiful lake at the highest point of the Teton range, at 7000 feet. From there, we planned to descend.

That morning, looking to get a head start on the day, we set off early. We had a 10-mile walk ahead of us. But luck was not with us. We ran into heavy snow. It was end-of-season snow but it was piled on pretty thick.

I told Bhagya that maybe we should go back. To my surprise, Bhagya put her foot down and insisted on going forward as planned. So, we ploughed on, with me in the lead. With great difficulty, I put one foot forward and then the next, and the others literally followed in my footsteps because we didn't know where the trail was. To our right, the mountain fell away into the valley below.

The slope was not vertical but very steep. We were making the trail as we went along, and we were all holding on to each other.

We were on the peak. Suddenly, disaster struck. Hearing a cry behind me that struck a chill in my heart, I swung around.

Even as I watched in horror, Harry tumbled down the slope, his backpack dragging him down. Joy was frozen in position, mouth open. Harry continued hurtling down the slope, towards what looked like a plunge vertically into the valley below.

Before anyone could react, suddenly the backpack shifted to one side and changed the trajectory of Harry's slide. If he had continued to roll straight down, he'd have been a goner! Fortunately, he rolled sideways and stopped.

Shocked and helpless, we waited as Harry slowly made his way back up. We were almost halfway to the next camping area now. We had to get there before dark. One thing on our side was the sun: There would be sunlight until 10 p.m. All we had to do was not lose our way, which could have easily happened in that snow-covered landscape.

Fortunately, we discovered horse tracks in the snow, so I created a trail on the horse tracks. Harry was shaken by his near-death experience and kept asking if it was fine ahead and if we could walk safely. Everybody was now holding on even more tightly to each other. We didn't have any rope to strap around us. Finally, we made it to the camping area by 5 o'clock. That night, we talked about our adventure.

We had had two close shaves, yet it was exciting and rewarding. The challenge of the mighty Grand Teton had been answered. Yet again.

Chapter Twelve

Between 1983 and 1984, my oncology practice grew significantly. People who earlier used to go through university hospitals started coming to Burlington because of our patient-centric approach. We invested both quality of healthcare service and time in our patients.

Also, word began to spread in the small community about some of the treatment outcomes of people with advanced disease. My partners, the Reddys and Anthony, were happy with this development and we were able to run the practice smoothly, resolving whatever minor issues we had from time to time.

With significant revenue coming from oncology, particularly in pharma, the hospital was also looking at expanding their oncology chain. Sensing an opportunity to expand my practice, I went to the B.M.C management and asked for a bigger place, which unfortunately they didn't have. So, we took a radical decision: to move out of the B.M.C.

I was still in touch with Dr J. Beckner and Dr G. Gandam, whom I had met when I had moved to Burlington in 1979. They were practising in the B.M.C as primary doctors.

Dr Gandram owned a big building on Central Avenue in Burlington, half of which was empty. These two doctors had a clinic in that building. So, we took their building on rent and remodelled it for medical oncology. Since radiation oncology needed plenty of equipment, technology and other infrastructure, we couldn't move our radiation practice from the B.M.C. So, we shifted only our medical oncology practice to this new building, while we continued our radiation practice at the B.M.C.

While we got along very well with the small Indian community around us, I also worked with American doctors like Dr Marshall and Dr Shaw. I used to visit the latter's homes and also invite them over for dinner. However, as my oncology practice became more successful, I felt that invitations to white American community events and houses were decreasing. At the time, I couldn't really understand why this was happening, although I had an inkling it was somewhat racial in nature.

This became evident as the years went by. When we had functions, we always invited white Americans, who used to come home, party and generally enjoy themselves. But they hardly ever invited us back. Indians had parties and invited local Americans, but this wasn't reciprocated to the extent you would expect in India.

The beginnings of an unwelcome war of personalities?

In September 1984, there was a shock in store. My father complained of shortness of breath. Amar and I decided to contact Dr Prabhudevan, who was Amar's former classmate. We got our father admitted to Jayadeva Institute of Cardiology in Bengaluru. Dr Prabhudevan confirmed that my father had suffered a silent heart attack (no pain). As he was a diabetic, he suffered from diabetic neuropathy: a condition where the nerves are damaged due to diabetes and the patient is unable to sense any pain.

My father was admitted to the I.C.U. Amar travelled to India to see him, but I couldn't at the time. My father was monitored closely for a week in the I.C.U before being shifted to the general ward.

This is where Amar perhaps started to seed certain thoughts about me in my parents' minds. Amar had been close to me in the U.S, so he probably couldn't bear the thought of my becoming close to Bhagya after our marriage the previous year. I felt that Amar's need to control people and relations around him began, at this point, to actively affect the relationship between him and me.

During one of my visits to India, my father related to me the following narrative:

One day, Amar brought up the topic with my father. 'There's something about Ajai that I have to tell you.'

'What?'

'I think we have lost him. He's no longer that close to us.'

My father was taken aback. 'What do you mean?'

'He is focusing more on his wife than you.'

'Why? Why do you say that?'

'He's become like a puppet in the hands of his wife. He has a room full of her photos and is totally in her control. He's neglecting you and the family.'

'But they took such good care of us when we were in the U.S. Why are you talking so negatively when I'm in the hospital?'

My father couldn't believe Amar was talking like this. On the other hand, Amar was unhappy that my father was speaking positively about me and Bhagya, instead of believing his words. This marked the start of a new phase in the relationship between Amar and me.

Reconnecting with my roots

In November 1984, I went to Kathmandu to meet the king of Nepal and his sister, who headed the country's Cancer Society. Over dinner, we got talking and they requested me to fund the society, but I declined, saying that I could only run it.

A lot of my affinity for trekking is because of the parallels between how you successfully complete a difficult trek and how you grow your business as an entrepreneur, including your ability to adapt to changing terrain and circumstances as well as having a never-give-up attitude. Since I was anyway in Nepal, which is known for its challenging trekking circuits, I made use of the opportunity to meet a Sherpa group in Kathmandu that organized trekking in the Himalayas. I was planning to do the trek from the Kanchenjunga base camp to the Mount Everest base camp. The Englishman running the Sherpa group asked me to write in whenever I wanted to do it.

In early 1985, I began to feel a particularly strong urge to do the trek. It had been ten years since I had left India, building a career and a practice in faraway U.S. Of course, I had been to India on short visits a few times, but those had been leisure or personal trips. I used to spend time with my family or stay in hotels while I visited touristy spots like the Taj Mahal and Udaipur. Now I wanted to see the real India, the teeming masses, the everyday lives of common people, the daily struggles and challenges, and how the medical community was dealing with cancer. So, this would be no ordinary visit to India. I wanted to stay in India for six months, starting with a trek in the Himalayas. This would mean travelling to both India and Nepal.

Bhagya and I packed our bags. I made arrangements at work and wrote to the British guy who was heading the Sherpa group in Kathmandu, informing him of my visit. I also sold my Mercedes sports car because it was not practical to maintain it and I had gotten over that phase. We landed in Bengaluru in early March, 1985, and stayed there for a few weeks before flying to Kolkata the next month to start our pre-trek journey. In Bengaluru I managed to meet my grandfather for the last time.

From Kolkata, we needed to take a train to Siliguri, and from there, a car to Darjeeling. Siliguri was notorious for harbouring Naxalites. In Kolkata, when we went to book a train to Siliguri, we were told to catch a particular train that would depart at 8 p.m. On the day of our departure, we were waiting on the platform, when somebody asked us why we were waiting for this particular train. We said we wanted to go to Siliguri. To our shock, we were told that this was a passenger train and would take two days to reach Siliguri. We had no option but to board the train. We had booked first-class tickets, so we had our own cabin.

We settled down and had dinner in our cabin. The train started moving.

There was a big police contingent on the train. I stopped one of them and asked, 'Can you let us know what's going on?'

The policeman looked at me. 'Please lock your cabin at night.'

'Why?'

'This is a Naxalite stronghold. People raid this train.'

Hearing this, Bhagya got very scared. We didn't want to open the door at all. During the night, every time there were footsteps outside, we would freeze and wait in the darkness, afraid to even breathe. The scariest part was, the train stopped in the middle of nowhere for hours.

Outside it was pitch-dark and uncharacteristically silent. It was all very unnerving.

Finally, we reached Siliguri after a day and a half of travelling through Naxalite-infested jungles and terrain. From there, we took a car to Darjeeling, where we stayed at a very good hotel called Windamere. I called up the Sherpa assigned to me, Aan Pasang, and asked him to meet me. We also enlisted the services of a helper.

After staying in Darjeeling for a day, we took a bus to Gangtok in Sikkim. The trailhead of the route to the Sikkim-Nepal border was on the outskirts of Gangtok. There were several international trekking groups starting out that day. Walking from Sikkim, we crossed over to Nepal. Although the distance was less than 14 miles, it was a difficult climb. So one person had to help Bhagya with her backpack throughout the stretch.

That night, we stayed in an outhouse on the trail just after crossing the border. We had scaled a vertical distance of around 3000 feet from Gangtok, reaching an altitude of around 9000 feet, and had been walking all day, so it's safe to say that we were dead tired. We resumed the next day, crossed the Aruna river and pitched tents for two nights on its banks.

Those two days were fun and relaxed. We enjoyed the views and bathing in the Aruna river.

On the second night on the banks of the Aruna, there was terror in store. Bhagya and I were fast asleep, when suddenly we were awakened by hideous howling right outside our tent. We sat bolt upright and switched on a torch. There, just outside our tent, we could see glowing pairs of eyes, staring at us right through the tent. Himalayan wolves! A whole pack of them!

Himalayan wolves are closely related to Tibetan black wolves and close cousins of the African golden wolf. Apart from the Himalayan regions of Nepal, they are also found in Ladakh, Himachal Pradesh and Uttarakhand in India. With long, pointed snouts, broad foreheads and thick, pale fur, they are not as aggressive as the Tibetan black wolf but can be quite dangerous.

The wolves started pawing and sniping at our tent. As we sat stunned inside, frozen in fear, Aan Pasang swung into action. He was sleeping outside our tent.

Ignoring the wolves' low-throated growls, he quickly fashioned a flaming torch from a branch and swung it around in sweeping arcs, shouting at our canine visitors to chase them away. I still wonder how he was not mauled by the pack despite sleeping out in the open, without a tent, unlike us.

On the subsequent days, we stayed with local families and made use of Nepali huts. The only food we had every day was rice and dal. There wasn't much else available for vegetarians. The locals thought we were holy people and therefore did not eat meat!

One morning, to our surprise, we saw three women in colourful saris, carrying pots on their heads. When we found that they had yoghurt in their pots, we couldn't control ourselves. In a trice, we pounced on the curd and finished off all of it! I still remember how heavenly it tasted, after seven full days of just rice and dal.

Disaster on the expedition

At Taplejung, bad news trickled in. Taplejung was the village near the Tibetan border from where we were to proceed to the Kanchenjunga base camp. Here, Aan Pasang went to a local function. Soon we got word that he was down with stomach ache.

We had a helper with us and Aan Pasang sent him with us for the base camp stretch. The next day, we left early in the morning, telling Aan Pasang we would be back by the evening.

We started up the mountain and made good progress, hitting an altitude of 18,000 feet under the cloudy skies. There was no water, so we boiled ice and drank the water. Due to the cloudy skies we were unable to see the Himalayan peaks, so the assistant advised us to wait till morning.

We pitched a tent. The assistant Sherpa woke us up early, at 4 a.m. the next day, and we started out again to complete the rest of the trek up to the base camp. We could see Mount Everest and Kanchenjunga in the distance. It was a phenomenal sight.

At that time, technology was not advanced, and of course there was no Instagramming or Facebooking of the experience, or selfies. We had gone with a good old S.L.R camera, so we took some pictures. But we mostly savoured the breathtaking scenery with just our eyes. Then we decided to climb down. Just as we reached halfway down, we bumped into a Nepalese guy in a tent. He offered us coffee—and disastrous news.

The Nepalese looked at me. 'You must be the couple who went to Kanchenjunga.'

I nodded. 'Yeah. It was phenomenal.'

'Your Sherpa is not well.'

It sounded serious. 'What happened?'

'He's vomiting blood!'

We rushed down to Taplejung. Sure enough, Aan Pasang was vomiting blood. His tunic was drenched. We tried to call for a helicopter, but the weather did not permit a chopper. We were stuck, since there were no roads. We were four to five days away from the nearest bus stop, and there was no big town in the vicinity.

So, we were in the middle of nowhere, really. It was just a village on the mountainside on the Tibetan border.

I talked to the district collector, and he managed to arrange for some intravenous (4) fluids. A local paramedic helped us and we put a tube into Aan Pasang's nose and tried to suck out the blood. While I was doing this, his blood pressure dropped. He kept saying, 'Doctor sahib, sorry I couldn't take you to the top.' I took out a lot of blood from his stomach.

Just as I was thinking of a blood transfusion and how to do it, Aan Pasang had a second bout of vomiting. It was shocking to see him in that condition. Due to sheer bad luck, there was no proper facility for me to give my blood, which we were contemplating.

Before our very eyes, Aan Pasang's life ebbed away and he breethd his last. According to Nepalese custom, the dead are not cremated with their valuables, so Bhagya made sure Aan Pasang's team member retrieved his valuables—in particular a tea cup gifted by a foreigner—from his person so that they could be handed over to his family. Before we knew it, the body was cremated as if he never existed.

Aan Pasang was alive one moment, and the next it was as though he had never existed. Somehow, in spite of encountering death regularly in my work, I found this very difficult to digest.

I tried to send a message to the Sherpa group in Kathmandu, but it was impossible. Even to return to Kathmandu, we had to wait two days for the helicopter as transport services had been severely hit due to a storm. We had to leave all our baggage. I couldn't believe it: Whatever could go wrong was going wrong. Bhagya was so distraught that it took her a long time to shake off this experience.

We reached Biratnagar and from there caught a flight to Kathmandu. When we reached Kathmandu that night, I went to the Sherpa group office and met the Englishman in charge. On his recommendation, I sent Aan Pasang's family ten thousand rupees and a note expressing appreciation for everything he had done for us. We both felt devastated, as though we'd lost a great friend. Still in a state of shock, Bhagya was not keen on trekking any more, and wanted to return to India.

We flew to Delhi and found a hotel on Janpath Road. For the first time in a month, I had a proper look at myself in a full-length mirror. It looked like half my body had magically disappeared. Not having shaved for several weeks, I looked like a caveman. Both Bhagya and I had lost a lot of weight during our Himalayan expedition.

Chapter Thirteen

It was around November 1985, after returning from our Himalayan trip, that I decided to travel across India to check out the cancer situation in the country. I asked around, and some doctors I knew suggested places and hospitals to visit. One of the places I visited was the government hospital in Bhopal. At that time, there was no direct flight to Bhopal. I'd have to embark on a circuitous journey of first flying to Mumbai and then taking a train to Bhopal. But I was not deterred. I'm a crazy guy that way: Once I've decided on something, I'll do it at any cost.

In a way, my journeys to trek to far-off places in the world were led by this trait as well as reinforced by it. The exploration of cancer in India was one such journey. Just like the treks, this journey of exploration would be fraught with hardships and unforeseen challenges—all of which I loved—but also came with new insights. More importantly, just like trekking, this exploration would teach me more about myself.

So I set off on my exploration. It was 10 p.m. when I arrived at the government hospital. I had come alone to Bhopal and met with a local doctor at the government hospital. We took a round of the oncology department. There, I saw an old, broken-down Cobalt unit being used to treat patients.

Outside the treatment room, I saw a woman sitting on the ground, fanning her three-year-old baby. When we enquired, I was shocked to know she had been waiting the whole day for her baby to be treated.

I was touched by the whole incident. I had seen the highest levels of treatment and technology at M.D Anderson. And here people were waiting in line for over twelve hours just to get some basic treatment, that, too, with dilapidated equipment. I saw similar scenes unfold at other centres, like Kidwai in Bengaluru and K.R. Hospital in Mysuru, where frustrated patients were made to wait in line for very rudimentary treatment.

At that moment, all my suppressed memories—of cancer patients at M.D Anderson, my dilemma at the end of my third year there, my rejection by Kidwai in India, and the reason for choosing to set up my own practice at Burlington instead of continuing at M.D Anderson—came flooding back. I resolved right there and then that I'd come back to India to address this disturbing state of affairs in oncology treatment, no matter what. I needed to start putting together a concrete plan, convince my family and make arrangements. It might take me five, ten or even fifteen years, but I would do it.

Bhagya and I visited different cities and towns. We went to rural and semi-rural areas, walked a lot, talked to people on the streets, and reflected a lot. It was an unforgettable six months of travelling across India and studying the cancer situation there. This India trip was truly a turning point in my life.

The whole trip for me was a philosophical lesson in understanding life. Especially the incident with Aan Pasang had taught me the life lesson about how suddenly things could change and how one needed to be prepared. One day you were here and the next you were gone! This had been brought home to me in a very profound way.

I often think of the 'Yaksha Prashne' story in the Mahabharata. The eldest Pandava, Yudhisthira, is asked by a yaksha, 'What is the most amazing thing in the world?'

Yudhisthira replies, 'The behaviour of humans acting as though they are immortal.'

Human life has a shelf life. It derives meaning from the accomplishments achieved during one's lifetime. For this, good health is crucial. For, anything can be bought or repaired with money, but there's only so much money can do when it comes to health. As an oncologist, I realized how important it was for me to come back to India to make a difference in the lives of my own people here, helping them live their lives to the fullest.

For life was too precious to be doing anything else. I began to question myself. What am I doing in the U.S? What is my purpose? What is stopping me from helping millions of cancer patients in India regain their lives through advanced treatment and care?

Finding a resting place for these questions took me the next fifteen years.

Anjali walks into our lives, into my heart

When we returned from our India trip, we realized Bhagya was expecting. I teased her that she must have conceived in the heights of the Himalayas. I was very excited as it was our first baby, but at the same time I was busy working too.

We went for Lamaze classes, where I helped Bhagya do her exercises. In the evenings, after I came home from work, we went for walks. The pregnancy period was thankfully uneventful and Bhagya handled it very well.

During the time of delivery, in India and for Indians living abroad, normally a set of parents come over to help out. But we decided to handle it ourselves.

D-day arrived: 7 May 1986. Bhagya started complaining of pain. It was time! I rushed her to the B.M.C, where her water broke. Dr Maggie and Dr Kent were on call. Bhagya delivered the baby early in the morning.

It was a girl. Looking at our baby girl, that fragile human life I was cradling in my arms, I was thrilled and overcome by emotion. The entire hospital erupted in joy at the good news. Thereafter, we had a steady stream of visitors—doctors of the B.M.C, nursing staff, friends and colleagues—all bringing gifts for the new parents and the little one, whom we decided to name Anjali. It was as if the whole hospital was celebrating the event.

Anjali's birth brought about one very remarkable change in me. Although my family had traditionally been vegetarian, I had started eating meat during my medical-school years. Amar had become a non-vegetarian at that time and my father also used to eat fish, so I had followed suit. Once Anjali was born, it struck me that my baby girl may also follow in my footsteps. I didn't want that to happen. Then and there, I decided to give up meat forever.

I became a strict vegetarian. However, this was purely a philosophical decision, and nothing to do with religion.

Once Bhagya and the baby came home, we decided to adopt the American way of bringing up a baby. I wanted to try out different ways of bringing up Anjali. We put Anjali in an independent room, although Bhagya was not entirely in favour of this. We would check on the baby every hour. Whenever she cried, I would tell Bhagya that our daughter should learn to console herself and become independent. Bhagya would immediately get upset. Now I joke with Bhagya that Anjali has turned out to be ultra-independent—more than what we perhaps bargained for.

A few months later, Bhagya's parents visited us and stayed with us for some time. My sister Pushpa had just moved to the U.S; she also stayed with us at the same time.

Obstacles on the way

In early 1987, I started thinking seriously about starting a cancer centre in India. I had two locations in mind: Bengaluru and Mysuru. I always liked Mysuru, as my father hailed from there. I thought the city deserved a not-for-profit hospital. We all have these idealistic dreams, where we aim to give back to society. This was my dream and aspiration.

However, I had overestimated the goodness in people. I thought people would come forward and support me in setting up a cancer centre in Mysuru, as it was a noble cause. My father had a government contact and when I applied for some land, the official said he would try to help. I, too, had some contacts in the government. Everyone spoke of supporting this venture, but did nothing to help.

In the U.S, my weekend talks with Professor A.K. Ramanujan of the University of Chicago continued and he realized I harboured a deep desire to do something in India. He told me that the Karnataka chief minister was coming to the U.S and urged me to meet him. I still remember that day when I took the afternoon off and drove 300 miles to reach the Indian consulate in Chicago, where I was supposed to meet the chief minister.

At the consulate, he was accompanied by a senior bureaucrat and another minister, who would later go on to become the chief minister himself. Professor Ramanujan introduced me to the delegation and told them about my desire to make a difference to the oncology situation in Karnataka. My suggestion was laughed off. I was told they already had Kidwai for that and that there was no need for anything else.

We came out of the meeting, and Professor Ramanujan was upset and furious. He apologized profusely about the fact that I'd come all the way only to get this kind of treatment. He lamented that entrepreneurs and professionals were not encouraged in India. I consoled him, saying I would do it my own way and that my goal of doing something in India remained steadfast as ever.

Bharath Hospital breathes life into a twenty-one-year-old dream

In 1988, I identified a 15-acre plot on Nanjangud Road in Mysuru. I got the land allotted by the Mysore Urban Development Authority (muda). However, trouble was just around the corner. As I began work on setting up the centre, all of a sudden, the Mysore City Corporation took a stance against it and the local newspapers, too, started writing negatively about it. Whenever I was in Mysuru, I used to stay in Siddhartha Hotel, whose owner was my friend. To my amazement, the papers started plastering stories all over that this cancer centre was bogus and my real intention was to construct hotels.

As the saying goes, 'No good deed goes unpunished.' So a good deed was punished heavily by the city of Mysuru.

I was shocked that the press was spreading these rumours. I was trying to do some good for the city—why was there so much resistance to it? I found the overall mindset to be very negative. Far from supporting a good venture, here were people trying to actively sabotage it.

Surprisingly, I found a similar kind of tepid response from the doctors' community too. Nobody saw any value in what I was doing. My father was frustrated and disappointed when he saw how things were panning out. He started to talk negatively about my dream of coming back to India.

Shockingly, the Mysore City Corporation occupied the Nanjangud land, and even today, twenty years later, it is under dispute. Also, I wasn't the type to pay a bribe to get my work done. So, the manufactured dispute persisted and I got more and more frustrated.

At this point, I also remembered the negative feedback I had received in Chicago from the Karnataka chief minister. The situation looked bleak.

In desperation I called K.K. Murthy, who was additional chief secretary to the government of Karnataka—a very admirable man. I had met him in Chicago. He asked me to meet him in the Karnataka legislature building, Vidhana Soudha. When he heard my story of being repeatedly promised that the land would be handed over and the runaround I was getting, he laughed and said, 'Dr Ajaikumar, it is quite obvious that people are giving you a hard time because you don't cut corners. Take it from me, it's going to take a long time for you to take control of the land.'

I asked, 'Mr Murthy, what should I do? Should I go back to the U.S or keep fighting?'

As I made this statement and sat back in my chair, I realized how hopeless the situation was. I was running from the proverbial pillar to post to take control of the allotted land. This runaround just to get the land back would continue for two or three months in a year.

I used to travel to Mysuru at unholy hours to get a head start to the next day's work. During one such trip, I remember I had a burning fever and was really sick, but had to reach Mysuru. More than my fever, there was something else burning strongly within me. I have to get this land. I have to do something. I had taken the Bengaluru–Mysuru Shatabdi Express. Seated in my berth, suddenly the world went black.

The next thing I knew was the train conductor shaking me awake at Mysuru station and informing me that I had not yet paid for my ticket. I had passed out for the entire three-hour journey! I got up in a state of shock, clueless about where I was and what I was doing in a train, of all places. Finally, when I realized I was in Mysuru, I called my friend V. Prakash. He arrived at the station with his wife and picked me up. It took me three days to recoup from the ordeal, but on the fourth day I was raring to go again. That was the determination I had.

But, over time, I had started to feel that the system was getting the better of me. People were a great disappointment. Since I was ethical and refused to bribe anyone, I wasn't getting anywhere. On the other hand, all the newspapers were writing about me as though I had stolen some land.

Even my friends had become suspicious. It was so paradoxical.

I snapped back to the present when Mr Murthy got up and touched my shoulder. He said, 'Dr Ajai, I know you are leaving in a few days and you've had a hard time with this land. I know your level of frustration. Let me help you by allotting some land in an industrial area of the city. I'll call the concerned authorities now.

Please go meet them. About your Nanjangud Road land, keep fighting, and who knows, one day you may get it.'

Finally, there was some light at the end of the tunnel. I thanked him profusely and left. This shot in the arm came just in time: I was planning to leave for the U.S that very night, because I finally felt I'd had it with this project. Suddenly, with this meeting, a direction for the future emerged, and I grabbed it with both hands.

But as they say, the devil lies in the details. The plot that was given to me was in no man's land. Several experts advised me against setting up a cancer centre there.

But my mind was set. I made it clear to everyone that I was going to set it up there, and got fully involved in the project. I found an excellent architect, who planned and built the hospital. This was the birth of Bharath Hospital in Mysuru.

However, my troubles didn't end there. The doctors of the city were not cooperative. They were dismissive of my initiative and ideas, and wanted me to coax them into joining Bharath Hospital. Again, I didn't yield.

I believe in being a thorough professional, and my focus was on doing the right thing for the patients and for society at large. I didn't believe in dancing to somebody's tunes just to get my work done. All this put my father through considerable stress. Finally, he roundly chided me for taking up such a stressful venture and washed his hands off the project.

The hospital became operational in 1989. While I still did not get the type of publicity I wanted then, today people recognize it. After so many years, it is now a landmark establishment.

The birth of the Bangalore Institute of Oncology

In a year, Bharath Hospital was up and running. My attention then turned to Bengaluru. I wanted to see what I could achieve as an entrepreneur. This was not a philanthropic project but a venture, an attempt to start a company of my own. I wanted to see what I could do in a private setting.

I had been thinking along those lines even before the establishment of the Mysuru hospital. In 1988, in a conference in Los Angeles, I had happened to meet Dr. Kilara, who is also an oncologist and was then a junior in college. We sat up till very late and deliberated on plans for starting something in India. We discussed the model to be adopted for a cancer centre. I was keen on two models: one would be a non-for-profit hospital in Mysuru; the other would be a for-profit hospital in Bengaluru, partnering with a group of doctors. While it would have been good to start a not-for-profit centre in Bengaluru too, it would have required a constant flow of grants. So a for-profit hospital would be more sustainable, particularly if you had a large vision (which I did). I opined to Dr. Kilara that this model would have a larger social impact and would be sustainable.

When he learnt that I wanted to start a hospital in Bengaluru, he indicated that he was also planning something on the same lines with three other partners: Dr Ramesh, who was my classmate in pre-university; Dr Gopinath, a surgical oncologist; and Dr Vishweshwaraiah, a radiologist. I joined them, and the five of us became equal partners. The company started in 1989 with the name Bangalore Institute of Oncology (Bio).

There was a backlash from my family, which I had not anticipated. Amar was dead against this. He was furious.

My father was concerned that I would end up wasting my money on such ventures. One day, he locked me inside the bathroom and tried to get me to promise I wouldn't get into such hare-brained things and fritter away my hard-earned money. Of course, I was not deterred by all this.

During this period, I was shuttling between India and the U.S. Back in the U.S, I remember being very affectionate to Anjali, who was now a toddler. I used to carry her in my arms whenever I could and stayed close to her. In August 1989, Bhagya became pregnant again. A new member of the family was on the way.

Our brood was growing! I decided that I wanted my children to live inside the city rather than on the outskirts, where our ranch was located. That way, everything would be closer. Also, winters were especially severe when you lived in a ranch due to its structure and location.

So we decided to sell the ranch and move closer to downtown Burlington. There was one small problem, though. Anjali had grown very attached to the ranch. So when we wanted to sell it, she was very much against it. Though only around four years old at the time, she had grown to be quite feisty. When a prospective buyer came to take a look at the ranch, Anjali scared them away by showing them a section of the house where 'the ghosts lived'.

There was another incident around this time that could have actually proved fatal to Anjali. One day, she was playing outside the ranch. By then, we had a dog—an Alaskan husky named Shogun. Like all huskies, which are primarily sled dogs, Shogun had phenomenal strength and was very ferocious. Out of nowhere, a snake slithered out near Anjali, who was oblivious to the danger.

Shogun, who was chained, immediately started barking furiously and pulling at his chain. Straining at his leash, he created such a racket that the scared reptile scurried away. That was one dog not to be messed with!

Finally, in 1990, we moved to a house with tall ceilings and a quite historical character, which I loved. Located on 421 Central Avenue in Burlington, this house was just two blocks away from my new medical oncology clinic. It was uphill from the B.M.C and very close to a park and art gallery. The house was close to downtown Burlington and the Mississippi river as well. I used to come home for lunch and take short walks.

Life was peaceful. But it was just the lull before the storm.

Chapter Fourteen

Our Indian venture, Bio, did not go according to plan. By 1991, it was floundering. While all the partners took their salaries, the company itself was sinking. Bio had borrowed at a 20 per cent interest rate and had not even made enough to keep servicing its debt.

It was borrowing more than it was making and heading into the classic debt trap. At that time, Dr Vishweshwaraiah was the chairman and Dr Ramesh the managing director of Bio. That year, we had a board meeting and I was critical of both the chairman and the managing director. I made it clear that I thought this was a very grave situation.

Dr Vishweshwaraiah offered to resign as chairman and board member. This was accepted by the board. I was nominated as the chairman.

I brought in more funds and became a major shareholder, and reorganized the company. Dr Ramesh was a good man and had put in a lot of hard work from the beginning. But, with all the goodness in his heart, he had not recognized the dire situation we were in.

So, the board decided to replace him as well, and brought in Dr B. Srinath as managing director and a shareholder.

These were all good people at heart, but we had to make hard choices from a business perspective, and I didn't see any other alternative. We had multiple meetings burning the midnight oil, but we knew these were the right decisions, as time would tell. There was a tremendous need for quality cancer care and we focused on that. We became popular and more patients started coming in. Dr Srinath and Dr Gopinath were prominent surgeons, who gave the organization a good name.

So did Dr Ramesh, Dr Kilara, the new medical oncologist Dr Shaker Patel and radiation oncologist Dr Nalini Rao, to name a few. Gradually, our income began to rise and we were able to service our debt. Things changed. Bio started to grow. It was a team effort. We even started thinking about expansion and acquiring new technology.

Back in the U.S, things were moving well with my family and work. Globally, it was a period of extraordinary growth in technology and communication. Cell phones were starting to become more common.

In 1987, I became friends with a technology-savvy person called Gary Huelett. He introduced me to the Internet in early 1991 and I became a member of the A.O.L electronic mail community by creating my first ever email id, which I use even today. Used to snail mail and inland letters, it was remarkable to be able to write an email to someone anywhere in the world and get a response within seconds. It was a true breakthrough in communication, something that transformed people's lives, and an era I will always cherish.

Gary was also an exceptional human being and a great friend to do things with. I have fond memories of our backpacking trip to Grand Teton in the summer of 1989, along with Amar. It was packed with snow and we were advised not to go on certain trails. Amar got scared, and the first night itself, he decided not to trek further. So we had to leave him behind.

Gary and I had a great time trekking on the snow. Gary was an epidemiologist who was working for the state's cancer registry, working on the analyses in cancer cases, trends and outcomes. This helped me a lot in understanding cancer incidences in India and thereby carry out my planning for cancer care in India. In recent years, I have lost touch with Gary, but I understand he is doing well.

A house on the river that swept us away

Although I thought our new house was very pretty and had its own character, Bhagya didn't like it. She thought it was scary, especially the basement. The funeral home next door added to her discontent with the place. She always used to ask me why I'd bought a house next to a funeral home. I can't say she didn't have a point. So we decided to switch houses again, just two years after we had bought this one.

So I was in house-hunting mode again. Pretty soon, I found the perfect alternative. It was a house right on the bank of the Mississippi river at 414 North Street. It was in a premium location and the neighbourhood was expensive in terms of real estate.

Situated next to Mosquito Park, this house was between the river and Highway 34, on the other side of which was my new medical oncology clinic. There were railway tracks nearby for goods trains passing through Burlington, so you could hear the occasional freight locomotive whistle its way through the neighbourhood.

Built in classic Tudor style, this house on the river had many trademark features, such as low arches and bay windows. There were other houses all around us, but our house was right on the edge of the river, so we had an amazing and expansive view of the mighty Mississippi. We bought it in April 1992. The house on the river is my favourite, of all the houses we lived in, with a majestic river view and the occasional rumble of trains for company. We lived there for nearly eight years. In 1993, Anjali was around seven years old, while Adarsh, my second child, was still a toddler. Anjali would go bicycling with her friends on North Hill Street, close to our house and her school. They would then get tired and the mother of one of her friends would go pick them up. It had become a routine. Anjali's independent streak began to develop and increase.

Although the house on the river was a bit expensive, I didn't feel the price was out of place. Compared to India, everything in the U.S was priced higher, with frequent upward revisions. So the nation increased its affluence through higher and upwardly mobile prices. For example, we pay higher for a driver, a secretary and nurses.

We pay higher for everybody. Once everybody gets higher pay, their buying power increases, and they become more affluent and spend more on others, creating a virtuous cycle. That is how the nation advances.

Here, in India, prices only get lower and lower. There is a bargaining mindset in every transaction. That is why I felt we should turn the whole concept on its head and create an environment where you can earn more and spend more.

When you are working more and earning more, your buying power increases. That should be the rationale for making the country advance. This is not to say that savings are to be neglected completely.

India is primarily a savings economy and will remain so, more or less. But a tilt towards paying more and spending more could be encouraged in order to create that virtuous cycle of affluence.

In 1992, tragedy struck Bhagya's family. Bhagya's sister Veena and her husband Shivaprasad were a happy and loving couple. As an elder sister, Veena had played a central role in Bhagya's education. Shivaprasad and Veena had visited us in the U.S when we moved to Iowa, and we had travelled across the U.S. In 1992, Veena had a respiratory episode, and the technology was then not advanced enough in India to take care of her. She passed away soon thereafter. Once more, this highlighted the need for me to bring proper technology to India. Even today, it is these experiences that motivate me to focus on proper intensive care for patients.

Over the years, Shivaprasad has helped us a lot by staying with us in both Burlington, Iowa and Boston, especially in times of need, even driving my children to school. He is an exemplar of the value of family ties and support. Even today, he is involved in managing the non-profit hospital in Mysuru, along with pursuing his passion for organic farming. These experiences with people I'm close to have, to an extent, influenced the way I think in business as well, where I have learnt that many things are resolved not by money or status but by trust and goodwill. In some ways, this has led to the 'handshake culture' of H.C.G—I will talk about this later in the book—which has greatly increased the speed of doing business in many cases.

A double whammy that hit us hard

In 1994, I took a call that both our children should spend some time in India to get a feel of the country, the systems there and the culture. So, in May 1994, we moved to India. The idea was for the children to spend that academic year, until March 1995, in India and in the Indian educational system. So, we enrolled both Anjali and Adarsh at a school called Puskerni in Mysuru; Bhagya would be staying with them. I helped the family settle and returned to my practice in the U.S.

In August that year, I again came to India for a few weeks. Calamity struck. My father-in-law fell extremely ill and the symptoms seemed to confirm the worst. I took him to Bio for a scan. The scan showed extensive disease in his pancreas: He had pancreatic carcinoma.

I was there during the surgery. Unfortunately, we couldn't remove the tumour, since it had spread all over. There was no treatment possible.

It was an open-and-close operation. We just administered some symptomatic treatment and brought him back to his home in Jayanagar.

This development underlined for me once again that life was not fair by any standards. While my mother-in-law came from a very prominent family—her grandfather was the chairman and founder of Mysore Bank (one of the first banks of Karnataka)—my father-in-law came from a very humble background. He had studied in the Lingayat hostel near Race Course. He was almost Buddha-like, a saintly person who never wished anyone any harm, even someone who had done him an injury. So, it seemed very cruel that he had been afflicted with such an extensive, painful disease.

Even as my father-in-law was recuperating after that open-and-close operation, there was another calamity lurking. One day, in December 1994, when I was in Mysuru with Bhagya and the children, a friend, Nagabhushan, who was an orthopaedic specialist, visited us. Adarsh was doing his usual toe-walking. I asked my friend why my son walked only on his toes ever since his birth.

My friend suggested we get it examined at the earliest. I became quite worried. I recollected that whenever Adarsh would come home from school, he would have someone carrying him.

I really didn't know why he was walking on his toes since childhood, and it hadn't struck me as odd until then. He had consistently had difficulty in walking normally. Suddenly I felt a twinge of panic. What is going on with him?

After checking with one of the orthopaedic surgeons at our Mysuru hospital, I brought him to Bengaluru. There we went to hosmat (an orthopaedic hospital), to Dr Thomas Chandy, who was a college mate. He conducted the Gowers' sign test and concluded that Adarsh had Duchenne muscular dystrophy, or D.M.D. It is a debilitating condition that causes progressive muscle degeneration and weakness. D.M.D is caused by the absence of a protein called dystrophin, which helps keep muscle cells healthy. It rarely affects girls.

I was devastated. Children with D.M.D at that time did not live beyond fourteen or fifteen years of age. There was no treatment for the disease. My mind was in turmoil, grappling with feverish thoughts.

Looks like Adarsh will not live for long. How do I break this news to my family? I remember coming home and breaking the news to my parents. That's one of the few times in my life I had tears in my eyes. When my parents heard the news, they were initially too shocked to even react.

Bhagya took it hard. We had to take Adarsh to the U.S for further investigation and do a muscle biopsy, as those facilities were not available in India then. Bhagya immediately said she'd come too. I asked her to stay back and take care of her father, who was himself sick. But her mother insisted that Bhagya go to the U.S if Adarsh was not well. That was the last time Bhagya saw her father.

It was one of the toughest periods of our lives: my father-in-law was on his deathbed in India, whereas my son was suffering from a rare disease and had to be taken to the U.S. Whom do we prioritize or stay with? It was a decision you didn't want to take, a situation you didn't want to be in. But such situations also made you realize how strong people really were, and reinforced that strength. Although Bhagya was initially deeply affected by these two blows, she became very strong over time in Adarsh's case—the way she was strong when her sister died. What we often don't realize as men is that women have immense internal strength, as history has often shown.

We returned to the U.S in January 1995. When I met Amar and his wife Mangala, they were shocked at the news. More than that, they were perplexed by my behaviour. I was laughing and being light-hearted while discussing Adarsh's condition. They wondered why I was being so jovial when I should have been more concerned. I told Amar, 'I will accept that my son may not live long, but I will work hard to see how he can live longer. Through detachment, love and affection, I can achieve it.'

The battle for Adarsh's life begins

I took up the challenge of battling for Adarsh's life. This was a seminal moment in my life. I remember I promised myself I would never give up fighting for Adarsh. Life had thrown me a challenge, and a daunting one at that. But I would not back down. I would answer it with resolve and persistence. I would find whatever opportunity there was to increase my son's life by a year, or even by a day.

I took him to the University of Iowa, where we met Dr V. Romonov. He was supposed to be an authority on D.M.D and was not very optimistic about the prognosis. I asked him a lot of questions about the use of steroids, stem cells and related matters. His advice was: 'Dr Ajaikumar, there is no treatment for D.M.D. Do not go fishing for something when there is no treatment. Your son will stop walking at eight-nine years, and maybe then you can start him on steroids. But most children do not live beyond fifteen years.'

I looked at him in a state of shock. I said, 'Thank you, Doctor, I hear you, but I will not give up.'

That was when my true journey started. I took Adarsh to various medical institutes in Chicago, and Rochester, in New York. I was doing a lot of research. I came to know about Dr George Karpati at Montreal Neurological Hospital, and took Adarsh there.

For a young boy of four years, Adarsh displayed remarkable courage in facing the tests and the needles that were poking him all over his body. The next step was to get a muscle biopsy done. When Adarsh knew he had to undergo a procedure involving more needles, he was understandably reluctant.

We hit upon a strategy to get him to agree. Children's desires are so simple yet of such great importance to them. That year, The Lion King had been released and Adarsh was very eager to watch it. The nurses, who were very kind to him, told him they would play The Lion King for him if he underwent the biopsy. Adarsh readily agreed.

Dr Karpati was very supportive throughout and was like a grandfather to Adarsh. Finally, we got the report confirming the diagnosis: It was D.M.D indeed. This showed that he had gene duplication, which was the cause of D.M.D.

This mutation duplicates exons 45 through 50 of the gene. This test finds the exact gene for proper treatment; future treatments were based on this. It can also help in disease prognosis. We returned from Montreal, dejected.

Anjali had stayed back in India to finish her year of schooling in Mysuru. She was in my friend Prakash's house there. She used to periodically visit her maternal grandfather in Bengaluru, who continued to deteriorate. Since there was no definitive treatment for advanced pancreatic cancer at that time, he was put on supportive care. Today, there are definitive treatments available.

He developed jaundice. Bhagya, of course, was constantly in touch with her family members. He passed away on 1 March 1995. As customary in our Lingayat community, he was buried.

Unfortunately, Bhagya couldn't make it to her father's last rites, but her family understood.

Chapter Fifteen

Desperate times can turn your belief system on its head. As there was no allopathic treatment for Adarsh's disease, some people around us suggested Ayurvedic therapy. We were clutching at straws at this point. I wanted to conquer this disease somehow and so was willing to give anything a shot. It's funny how you sometimes end up investing hope in something you never believed in.

In the summer of 1995, we found this town called Kottakkal in Kerala, which was famous for its Ayurvedic institute called Arya Vaidya Sala. So Adarsh and Bhagya went to Kottakkal and spent a few months there. Every day, Adarsh underwent massage therapy, with us hoping against hope for a miracle. Apart from the therapy experience, Adarsh met some interesting people: one child who had a stroke, another with a severe back-pain problem, another child with D.M.D. It was a unique experience for him.

As much as the Kottakkal experience gave us hope, paradoxically it also brought us face to face with the bleak prospects of those who suffered from D.M.D. Accessibility was very poor all over India, yet people would come to Kottakkal with hope, knowing that very few diagnosed with the condition would live long. We met two children with the same problem. Their mother would be seen lifting both her children and carrying them everywhere.

There was another family where several sons had died and they had brought their last son who had D.M.D to Kottakkal. Many women, whose husbands had deserted them, were battling the situation all on their own. It was shocking to see what was happening to people with the disease. It reinforced my determination, infusing me with even more strength and the will to do the best for Adarsh.

While Adarsh was in Kottakkal, I came in contact with an association called Parent Project for D.M.D through Dr Karpati. Attending their meetings brought me in touch with two remarkable women: an American, Pat Furlong, who had lost both of her sons to D.M.D, and a Dutch woman, Elizabeth Vroom, with a son, Justus, with D.M.D. Adarsh and Justus were the same age. Elizabeth, to this day, is a very good friend.

I was now more than an interested party in this fight. I decided to financially support the Parent Project as well as fund Dr Karpati for stem cell research. Compared to the billions of dollars spent on such research, it was a drop in the ocean but I wanted to help in any way I could. Unfortunately, no definitive treatment emerged at the end.

After returning to the U.S, Adarsh resumed school. He continued to be brave. Whenever we did blood tests in our lab, he sat on my lap to get blood drawn, but did not cry. We put him on a drug called deflazacort, after which he stabilized and his walking began to improve. At the same time, we continued the daily massage learnt at Kottakkal.

We constructed a special table for him to lie down on, where the oil could drain out, and put on music during his massage. Anjali also participated many times. This brought our family even closer.

The controversial start of Curie Care

During one of my India visits in 1995, when I was at the Bengaluru airport to catch my flight back to the U.S, I got a disturbing call from our managing director. Apparently, one of our prominent doctors was secretly helping build a rival cancer centre for General Electric (G.E) at St John's Hospital. I was stunned. I couldn't believe one of our own people was helping a potential competitor in such a clandestine manner.

As Dr Srinath filled me in on the details, the backstory of this explosive development became clear. American conglomerate G.E had been doing some work in the cancer area with Cobalt and linac units. At that time, the president of G.E India wanted to start a cancer centre in St John's in Bengaluru, with St John's outsourcing it. So, they had approached S. Soni, who was running diagnostic centres and a couple of cancer centres in the New York area. The effort was being front-ended by a former G.E officer.

They had approached one of our doctors for help. He had been unhappy ever since I had become the chairman of Bio. Being one of the original directors of Bio, he had been resentful ever since, as his powers had been curtailed. So, he had jumped at the St John's offer. Soni had approached him because he knew he had played an important role in setting up Bio. In return, he had promised him the post of director at the new centre—a sweet quid pro quo. The new centre would be run under the brand name of Curie Care.

This director was officially bound to protect our company's interests. Instead, here he was, hobnobbing with the competition and potentially undermining Bio's position in the healthcare market.

After speaking to Dr Srinath, I immediately called the doctor who had gone behind our back.

He picked up on the third ring. 'Dr Ajai?'

'You're fired from Bio!'

'What?'

'I've just come to know about your involvement with Curie Care. You're fired!'

'There's no need for that. I'm resigning!'

Disgruntled, the doctor put in his papers at Bio and joined the Curie team. They gave him the directorship as promised. G.E bankrolled Soni, who became the owner of Curie Care. The transaction was structured as a debt, with G.E as the creditors. Curie was set up as a separate legal entity on land that belonged to St John's Hospital. As part of an agreement on the financial arrangements, St John's would refer to Curie Care all the oncology cases that came to it and in turn would receive periodic rent for the land.

Meanwhile, the doctor who left us was all pumped up about his baby and keen to set things in motion. He joined hands with Dr Brindha Sitaram, a psycho-oncologist, and built a posh oncology centre on the St John's campus. Dr Sitaram managed the visual aspect of the centre in terms of creativity, aesthetics and interiors. She also created the department of psycho-oncology within Curie Care. They planned to make it an upscale centre, but with a Cobalt unit.

Compared to Bio, this doctor could do a better job at Curie Care, as he was only an employee on the rolls of the company and hence not burdened by fiduciary responsibilities. He was not a founder director, as was the case at Bio, where there had been questionable financial management. His responsibilities were relatively more limited and specific at Curie.

An eventful year

The year 1996 marked the start of my expansion plans in India. At that point, I had only Bio operational in Bengaluru, so the situation was ripe for me to start other centres in India. Coincidentally, in August that year, I was approached by Dr H. Mallesh and Dr Narendra Bhat, who were obstetrician-gynaecologists based in Shimoga. They wanted to set up a cancer centre in Shimoga, and wanted my help.

Known as the 'Gateway of Malnad', Shimoga is a beautiful place in central Karnataka, peppered with paddy fields and coconut groves, with the Tunga river cutting through the district. Shimoga district had formed the southernmost tip of Emperor Ashoka's Mauryan empire, and more recently, had been part of the kingdom of Mysore before Independence. It is known for its higher secondary and pre-university education, and is home to foundries manufacturing quality castings and areca nut industries.

Although the location was tempting, I was hesitant at first, since buying land and infrastructure to set up a cancer centre from scratch was such a nightmare: I had burnt my fingers once with the Mysuru land fiasco. My friend Dr Ganesh Nayak had a pivotal role in convincing me to go for the joint venture. He used to visit Shimoga often and our conversations often veered around to whether I should get involved in the Shimoga centre.

Finally, I surprised myself and accepted, although I had other reservations. I thought the centre would be too small to be beneficial to society or in line with our vision. What drove me forward here was my intent to help other doctors along the entrepreneurial path. Perhaps if I had thought about this from a purely business angle, I may not have gone ahead with it. Eventually, three more doctors joined us in this project: Dr H. Manjunath, Dr Y.V. Shashidhar and Dr Venkat Rao.

The first step was to buy land. This time I did not go for government land. In 1997, we identified a 7-acre land belonging to an oxygen company that was going bankrupt and wanted to sell it. It was located on the 9th Milestone in a very nice spot on the highway between Bhadravati and Shimoga. After obtaining the necessary clearances, we started construction of the centre. With this, somewhere I felt my entrepreneurial dream take wing.

Mysuru comes to a boil

Meanwhile, unknown to me, trouble was brewing in another part of the state: Mysuru. Bharath Hospital had been run by Ranganath, its C.E.O, from the early Nineties as a non-profit organization (N.P.O). A very professional manager, he was trying to inject corporate culture into the organization, although he was a little bureaucratic in his way of working. There had been no major issues on the operational front until then.

However, in June 1998, things exploded. For some time, there had been some labour unrest due to stagnant salaries. Perhaps emboldened by my absence in India for large periods of time, the workers formed a group under the leadership of a loutish man called Devaraj. They wanted to take things a notch higher and form a union. They ran a smear campaign that somebody from the U.S was pumping funds into the hospital, thereby casting aspersions on the good work we were doing there.

At this point, they approached the Labour Department. The next thing I knew, I was on a call with the Labour Department. The person who called me was Lucas Velluthore, the Labour Department secretary and a college classmate.

'Dr Ajai, how are you? This is Lucas. From St Joseph's. Remember me?'

I was pleasantly surprised. 'Lucas! How are you? It's been a really long time.'

'I've been reading about you in the papers.'

'Oh, really?'

'Yes, about some hospital in Mysuru that you're funding.'

I frowned. I didn't like where this was going. 'Well, we're trying to do our bit for society there.'

'Seems like you have a bit of a labour problem there.'

I leaned back. 'Nothing that we can't sort out.'

Lucas's voice hardened, but very imperceptibly. 'Your hospital workers had come here. You know ...'

'Who? Devaraj?'

'Yes, he and some others. You know, you should allow them to form the union. Sort it out with a soft touch.'

I got up. 'No way! Absolutely not!'

'You know, under the law, you are required to recognize a union if they decide to form one.'

'No! We are an N.P.O. I don't need to recognize any union. Whatever happens, I won't encourage any of this. You can do whatever you want to do.'

While Lucas was my batchmate, during this call, he was also the representative of the Labour Department.

As it turned out, the department did not take kindly to being rebuffed like this. Things started sliding pretty fast from here. Word of this conversation got around and the workers decided to go on a strike. They even went to the extent of threatening Ranganath. Most of the staff got involved in the agitation, with the exception of a handful of employees.

Sensing big trouble, I decided to take matters into my own hands. Many people—including friends and advisors—suggested that I give up the hospital. Amar, for example, suggested that I hand over the hospital to an N.G.O. There was tremendous pressure to walk away from it all.

But walk away I did not! This hospital represented my passion and my sweat. There was no way I was giving it up because of mere posturing and hooliganism by fringe elements. I decided to target the root of the issue: the troublemaker Devaraj. I showed him the carrot first.

I tried to reason with him that we were a small hospital trying to do good work for cancer patients. I even told him he had good leadership qualities, and would be supported and groomed for bigger roles. The man didn't budge.

That's when I took up the stick. I set a date by which I'd arrive in India. The day I landed in India, I headed straight to Mysuru and asked P. Pratap, who headed the Bharath Diagnostic Centre (B.D.C), to list out all of Devaraj's activities. B.D.C was an outpatient unit we had started at the same time as Bharath Hospital and Institute of Oncology (B.H.I.O). The same day, Devaraj received his marching orders. He was no longer an employee of Bharath Hospital. The word spread like wildfire, and soon the entire workforce boycotted their duties. I was equally swift in my response: I had the gates of the hospital locked and asked all the boycotting employees to stay away from the premises. Their salaries were stopped with immediate effect.

Taking the bull by the horns, I began running hospital operations myself. I started with driving the ambulance myself. Not to be outdone, the expelled workers protested by lying down in large numbers outside the hospital gate and shouting, 'Dikkaara, dikkaara, chairman ge dikkaara'—'Down, down, down with the chairman.' These poor fellows thought their salaries would be resumed and they'd soon be reinstated, as they couldn't imagine we would be able to manage the hospital's work without them.

Days passed. Soon, days turned into weeks but we showed no signs of flagging. My spirit kept me going. Without their salaries to sustain their livelihoods, the workers became frustrated. That's when they committed a cardinal mistake. They stopped our driver, who was ferrying patients in an ambulance, and beat him black and blue, leaving him with severe head injuries. This attracted the provisions of the Essential Services Maintenance Act, which prohibits the obstruction of essential services like medical or healthcare services.

After getting our driver admitted at K.R. Hospital, I immediately filed an F.I.R with the local police station. The workers involved in the attack were taken into custody. This broke their back.

Severely jolted, their bravado crumbled and all the workers started filing back into the hospital, ready to work. I could have fired them, but I didn't. I had them sign a declaration that they would never join a union again. We eventually took back all the workers. All except the prime instigator.

Even though I started as a self-professed socialist, and the socialist ideology gives prominence to the labour union movement, paradoxically I'm against labour unions as the way forward for socialism. In a labour union, since power gets centralized and concentrated in the hands of one or a few persons who are typically trade union leaders, there is a high chance of misuse of that power, which may lead to inefficiency, business disruption and prevention of social good. Instead, the management and employees should understand each other and work with a collaborative mindset.

The management should have a balanced viewpoint and should not short-change employees. Equally, employees should not undermine the management, but instead work to achieve the common goal of the enterprise.

Chapter Sixteen

By 1998, within a few years of starting operations, Curie Care ran into trouble. As creditors, G.E was perhaps tougher than any bank in terms of repayment obligations and debt retirement. On the other hand, Curie Care was not profitable and started sinking, its revenues unable to keep pace with mounting expenses and liabilities. It fell into a classic debt trap.

Surprisingly, Ravi Narsimhan, the C.E.O of Curie Centre, contacted me to see whether I wanted to take over. Ravi had known me since I had become the Bio chairman, and everyone in Bengaluru knew I was running Bio. Plus, I was in the U.S, and Soni, Curie's promoter, was also in the U.S, so word got around. Ravi confided in me that there was a problem at Curie and it'd be good if I took over. I said I'd think it over.

I discussed the proposal at Bio. I wanted Bio to take over Curie Care so that we could expand and grow our services across India: one of my long-standing plans, brewing since I started my independent practice in Burlington.

Unsurprisingly, Dr Srinath was sceptical and not in favour of it. The board also rejected the proposal, saying it didn't want to get into takeovers and other business complications. They didn't have that long-term vision. I couldn't wait.

And I didn't want to lose the opportunity. So I decided to do it myself: I would take over Curie Care myself and make it grow it as part of my expansion plans. That is when Dr Srinath got angry with me and our relationship soured.

Around this time, I also wanted to get the latest equipment into Bio. The Bhopal experience was weighing heavily on my mind. I did not want the poor of India to wait in line endlessly for treatment with some very basic equipment. So I decided to get a linac into Bio, since the prevailing Cobalt technology was more harmful for patients. It was time India had the best of infrastructure when it came to oncology.

The board at Bio, however, had a different take. They were looking at the cost. While a Cobalt unit then cost just around sixty to seventy lakh rupees, a linac cost around six crore.

Treatment with a linac would cost the patient around forty thousand rupees. Dr Ramesh and Dr Gopinath were against such a risky investment, since they felt people would not be able to afford such 'expensive' services.

The surgical takeover of Curie Care

I signalled to the Curie team my interest in an in-person discussion. A meeting with Soni was arranged in New York at the Cassa Hotel Times Square. On the day of the meeting, Soni put up quite a show, arriving in a sparkling Mercedes-Benz sports car, immaculately dressed. A clean-shaven Punjabi, he had all the swagger Punjabis are known for. After some small talk over spring rolls and lime juice, Soni started talking shop.

'Doctor, Ravi would have briefed you on the issue. Have you thought about our proposal?'

'Yes, he has. And yes, I have, but I want to know why exactly you want to exit.'

'I'll be frank. G.E has created this problem for me. Their debt is structured at a 20 per cent interest rate. I can't pay these high interest rates. I want to get out of it.'

'Well, that may be a problem for me as well.'

Soni leaned forward. 'G.E is ready to compromise if I give up my shareholding.'

'Compromise?'

'If you take over, we'll settle it. You pay me a discounted rate on the book value of the equity. G.E will agree and give you 100 per cent ownership.'

'We can't become 100 per cent. At least, not immediately.'

Soni nodded. 'So, you'll do it then?'

I nodded. Somehow, things were falling in place for me, even though not quite in the way I had planned. I had been looking to expand Bio but that had met some roadblocks. Still, a takeover of Curie would lend muscle to my overall plans of expansion, albeit not under Bio. Four months later, we met again in Connecticut. This time Ravi was also there.

By this time, I had briefly discussed the potential Curie acquisition with Amar. As my brother he was interested in my welfare, even though we had a difference of opinion about Bio and Curie. He had tried to help me by meeting the directors at times. He had also put me in touch with a few financial folk, which was helpful. Possibly because he was a first-born son, he was conservative and felt he should hold me back from what he saw as wild ideas. This was something I didn't need. But his intentions were good, and for that I respect him.

During my next visit to India we had to finalize the final terms. I met Ravi and the chief financial officer (C.F.O) Vasudevan. As Ravi and I discussed how to structure the deal and related things, Vasudevan started to intervene. Aggressively. He was talking very tough with me. This was the phase of finalization and closure of the financial terms. Vasudevan was trying to renegotiate each term of the transaction as if it were his own company, and refused to budge when it came to the valuation and discounting.

Finally, at one point, I decided I had had enough.

I looked him straight in the eye and asked, 'Why are you talking like this with me? Who do you think you are?'

Ravi butted in. 'He's Vasudevan, our chief financial officer.'

Vasudevan rejoined the conversation. 'I'm protecting the interests of my client.'

I stared at him. 'There's a way to do that.'

I was angry but not angry enough to walk away.

In early 1999, we were ready to close the Curie deal. All of us—Soni, Ravi, Vasudevan and I—met in Bengaluru, finalized the financial nitty-gritty, and signed off on the deal. Then they set an effective date for the takeover the same year.

They arranged a get-together for the announcement at Nethralaya in Hesarghatta near Bengaluru. Ranganath, who was the C.E.O of our Mysuru hospital, helped me in taking over operations at Curie Care. Soni flew over to India for the get-together, where he announced my takeover.

Dr Kilara wasn't in the know of the negotiations and the takeover decision. He was upset when he found out. 'Why are you after me, Dr Ajai?' He thought I had intentionally targeted the acquisition of a venture he had helped launch.

I felt sorry for him. 'Look, guru, I don't have any animosity towards you. The opportunity came, with the centre sinking, and I took it. You become the director, be one of us. We'll all be fine.'

After that, we became good friends. Somehow my gesture turned his ill will into camaraderie. He was happy and became very supportive.

Then, another strange thing happened. Vasudevan, the erstwhile C.F.O of Curie Care under Soni and Ravi, approached me. He wanted to join me. Surprised, I asked him why, especially after he'd acted so tough with me. He admitted he liked my ethics and transparency during the whole deal-structuring phase. I brought him on board as well, and he became my C.F.O.

A redwood tree in my life crashes, never to rise again

The relationship between father and son cannot be easily expressed in words. From the moment a son learns to walk and run, holding his father's supporting hand, to the day when the father leans on his son's shoulders for support during his sunset years, a father is like an anchor in his son's life. He stands tall, strong and immovable—like a redwood tree—ever ready to help his son achieve his goals and aspirations in life.

I found this to be true of my own father in many ways that were not evident in my earlier years. Even though my father's outlook had changed over the years and he had become increasingly obsessive about specific things, I respected him. I recognized his immense contribution to my life and whatever I had achieved. That simply cannot be measured. Also, I don't believe in judging a person based on day-to-day disagreements or dissatisfactions—these come and go. What matters is the heart and soul of the person. In this, my father was pure gold. He was my redwood tree.

On my frequent visits to India, my father would voice his desire to visit the U.S again and again. It was no different when I came to India in May 1999 for a Bio board meeting. It was just another ordinary visit. My father and I used to go for walks in a park on Serpentine Road in Kumara Park, which was opposite our house.

On 9 May, we went for our usual walk. He always wore a suit. That day, too, he was wearing a suit. He said he wanted to go to America again. He had visited five or six times by then. I advised him to get his health back, after which he could come and stay with me. For some strange reason, he kept repeating that he wanted to make one more visit to the U.S. It was as if he was in his own world and my words were falling on deaf ears.

That midnight, I left for the U.S. That was the last time I ever saw my father. I went to Chicago and then landed in Burlington around 2 a.m. I was about to go to work around 7 a.m. when I got the heart-stopping news—my father had passed away. After I had left India, he had gone for his late-afternoon walk the next day. He was familiar with people there and everybody knew him.

He had completed his round in the park and come up the hill to our house. On the way back, right in front of the bus stand nearby, he had collapsed on the road. My driver had come running and exclaimed loudly to passers-by to help bring him back home.

Sitting in the sunroom overlooking the river, for a few minutes, my mind went blank. I could hear the Mississippi gurgling outside. Stunned, I tried to digest the news.

My redwood tree had fallen! I staggered to my feet, informed my partners at work, then told Amar, and drove to Chicago. I picked up my brother, who was equally devastated by the news, and we took the 3 p.m. flight to India. By the time we arrived, my father's body was in the freezer. My sisters had also reached. Then we took our father's body to Mysuru.

The family met in grief to decide on the site of burial. I expressed my father's desire to be buried in the Bharath Hospital land. My father was born in Mysuru and had helped me in my efforts to set up the hospital there. He had expressed his wish to be buried there, even though he had not put it in writing. Everybody agreed and we decided to bury him there.

Differences now arose between my brother and me, even though we were quite close at this point. I would have done anything for him, even after we both got married. We had been clear that our relationship shouldn't change and money or status shouldn't come in the way, as we were both doing really well.

In this case, maybe because of the emotionally charged situation, Amar perhaps felt he was not in control of family affairs despite being the elder son, and that I was taking over. I remember in the Kumara Park house, he accused me of not respecting him as the first son of the family and other things.

I was shocked and dismayed. That is when I exercised my first philosophical approach successfully. As he was accusing me, I introspected. If what he was telling me was true, then I should correct myself. I came to the conclusion that he was falsely accusing me. In that situation, instead of shouting back at him and arguing, I told him that I refused to accept his gifts. He got angrier and angrier. By then I almost felt like laughing and thought: What more can this person do short of hitting me? This philosophy has been a great boon for me in the last few decades. I have used it in many business situations, and it has helped me become a successful entrepreneur by not letting me get affected by others' accusations if they are not true, based on my introspection. This is one of the essentials of Buddhist philosophy too.

Twin additions to our family

We had newer worries now. Given his condition, we wondered if Adarsh would ever have friends. In society, you have to forge some sort of an identity with what you do—become a football player, or a rock musician, or a good swimmer—in order to make friends. Adarsh could not do any of that, so it became very personal for us. We decided that maybe we should have one more child so Adarsh could have company while growing up. At that time, I was forty-eight and Bhagya thirty-seven.

Finally, Bhagya did become pregnant and we found out it would be twins. We were so happy. Meanwhile, Bhagya had applied to the Fine Arts College. Because of her pregnancy, she requested them to allow her to join a year later, to which they agreed. So Bhagya would join her baccalaureate programme in 2001.

Meanwhile, I decided to shuttle between India and the U.S. I had spent nearly twenty-one years in Burlington, and our children Anjali and Adarsh had grown up there. My partners, when I started the separate clinic in Burlington, Dr Reddy and Dr Reganti, were very good people, and I'd made many friends in Burlington. It was not easy to say goodbye to them. But in life, sometimes you have to take a decision without looking back.

Eventually, my plan was to move back to India and this was the path for it. We waited until the twins were born in October 2000, and in December 2000 we said goodbye to the quaint little town in Iowa, to move to Boston. It was a stormy and snowy 1000-mile drive. Helping us with this big move was Bhagya's sister Sandhya and her brother-in-law Shivaprasad from India. I was looking forward to a new beginning in Boston, particularly after becoming a father for the third time. I would often gaze at the adorable faces of my two little angels Aagnika and Asmitha. Life was beautiful.

But disaster was hurtling towards me.

The dot-com crash

Planning to stay only for a few months every year in Boston, I had started frequenting India. I was planning my next move and trying to chalk out a game plan for Bio's expansion. Meanwhile, the dot-com crash of 2000 had crippled the stock markets like a silent heart attack. With stocks plummeting in value and newly listed companies sinking without a trace, the crash wiped out almost 75 per cent of the market capitalization of technology stocks by the end of the year. And it obliterated twenty million dollars.

I had had my stare-off with the North Atlantic, returning with renewed will and purpose. I needed to rebuild. I had my hospital staff who were dependent on me. I had to make sure the hospitals didn't close down. I had my family that I needed to look after. The fighter in me came to the fore.

I decided to become practical. I needed to make up for some of the losses. As a first step, I decided to sell our villa in Boston. to make up for the loss, even if partially. We had to move to a rented apartment. Bhagya was very understanding, and agreed. Any other wife would have probably berated her husband for the terrible inconvenience he was putting their family through.

But Bhagya was made of different mettle. She stood shoulder to shoulder with me during this crisis, not once complaining about the hardships we were beginning to go through.

I identified a real estate agent, who listed our property. We had bought it for one and a half million dollars. Now, the listing price was three million.

One day, the agent informed me that there was an interested buyer. Things work in a strange way when you least expect them to. The buyer turned out to be none other than the son of a patient I had treated for prostate cancer years earlier. This man had visited us on occasion and had always liked our villa.

He had just sold his biotech company for twenty-five million dollars, so he was flush with cash. The next thing I knew, he had bought the villa. All cash. Zero negotiation.

My next step was to take my stockbrokers and investment advisers to task. While I was driving Anjali to college, I got hold of the legal help hotline of Massachusetts. They put me in touch with a lawyer called Angela Hayden. While I was still driving, I gave her the particulars of my situation. She was interested and sounded positive. By the time I reached Anjali's college, I felt my situation had already improved a bit and was more positive than when I had started my drive.

The next day, I went to meet Angela in her downtown Boston office. I also met her senior colleague, Robert J. Apparently, the lawyers would charge me a success fee: a percentage of the amount awarded by the court. Angela made a list of all the documents needed. I had my work cut out. Angela needed documentary evidence of the investment banking firm's wrongdoing. Now, this was the early Noughties, when cloud storage was nowhere what it is now. It would have been a Herculean task to dig out all my email correspondences with the investing banking firm and my stockbrokers over twenty years. Even if we did collate all that, finding incriminating evidence in it would be like trying to find the proverbial needle in a haystack.

It was here that Bhagya came to my rescue, like a guardian angel. She had painstakingly kept a record of all my communication with my advisers and brokers over twenty years. I had boxes of letters to take to the lawyer.

I could have kissed her for joy (and I did!). I submitted all the evidence I had to Angela, who ploughed right into the case. We filed a suit against the investment banking firm that had advised us. After trading a few blows in mediation, the firm was forced to settle. However, I did not recover my entire investment. I was awarded damages of three million dollars. After paying the lawyer firm, I took home two million dollars.

I had lost my entire wealth during the dot-com crash, I could have become a pauper. While I had a moment of weakness, I could have walked straight into the ocean. And after that I did not wallow in self-pity. I decided to fight. That is the only way I know to react when my back is against the wall. That is the only way I know to live. I clawed my way back to where I am now. I survived. My approach to life solidified: If you have the grit and the courage to face your failures, anything is possible. My entrepreneurial story has been fuelled by precisely this unwavering belief, that anything is possible as long as we will it to happen and leave no stone unturned to make sure it does.

Chapter Seventeen

The year 2001 saw Bengaluru's I.T sector recovering from the Y.2.K scare, only to be battered by the dot-com crash. The year also marked the start of the real estate boom in the city that would carry on for the next seven years or so. With a population of around five million then, it had become one of the fastest-growing metropolises in the country in the previous decade. The city's demographics also began to change, with a steady trickle of non-Kannadigas making Bengaluru their home. The city was then also bang in the middle of what some call the golden rule of the S.M. Krishna government, which gave a fillip to the I.T sector.

Meanwhile, for me, Bio and Curie became the focus. At Bio, people began to warm up to my proposal of bringing in advanced technology like linac. Dr Srinath, Dr Nalini Rao and others on our team extended their support for investing in this. At the same time, Dr Srinath wasn't happy with my taking over Curie, since Bio hadn't wanted to do it. This went against my plans of expansion and consolidation. of resources. That's when I thought we should look at the bigger picture.

At Curie, I had similar plans for upgradation of infrastructure. I was one of the first in India to bring radio surgery into mainstream oncology healthcare. With my experience at M.D Anderson and the Burlington practice, I understood the technology deeply. Dr Kilara was keen on installing a linac too. So, we replaced the Cobalt therapy unit with linac with a radio surgery head, a specific radiation oncology therapy.

The radio surgery unit was inaugurated by none other than President A.P.J. Abdul Kalam in 2002. With this, we ushered in radio surgery services in India, making Curie a very advanced centre. I was pleased as punch. Things were beginning to happen.

Perhaps in keeping with the spirit of my grandiose expansion plans in India, I started thinking like a true entrepreneur and made some atypical moves to market my cause. Around mid-year, I produced a movie called Neela, in which I played the role of an oncologist and which went on to win an award from the central government. The idea was to show positivity but the director, Nagabharana, made it like a historical story and brought in cancer. The movie got a medal too, but it was not successful commercially. While I loved the overall experience, there was one hitch—my own voice was not used for my character in the movie and someone else dubbed for me. This voiceover was something my family really didn't like.

A chance meeting that changed my life's direction

There comes a time in everyone's life when they meet an extraordinary person, someone who makes it worth having waited for them, although you didn't even know you were waiting. It is the kind of a special relationship where you gain a rare confidence to go beyond 'normal' achievements and feel like you can conquer the world. When you finally meet that person for the first time, you wonder where they were your whole life.

A multifaceted whiz kid, Gangadhar Ganapati, or 'Gans', as we call him, was forged in the intellectual crucibles of I.I.T Chennai and I.I.M Ahmedabad. Also an alumnus of the Wharton School at the University of Pennsylvania, Gans had started Triesta Sciences in the U.S in 2003. The company was into molecular diagnostics, a field of study where the biological markers of an individual's genetic code are analysed by applying molecular biology to medical testing. By using molecular diagnostics, the specifics of a patient's disease and potential approach for therapy can be determined, opening up opportunities for personalized therapy and medicine.

Gans had taken an office space in St John's Hospital in Bengaluru and employed a few P.H.Dees for biorepository work, where they collected, processed and stored biological specimens and material for distribution and scientific investigation. He used to come from California often to work with his team here.

I knew that Gans was trying to collaborate with Bio to set up biorepository labs, where live tissue would be stored. His vision was to set them up everywhere. He was way ahead of his time. In 2003, he met me for the first time at Bio with his scientists. I still remember the day vividly. I was working on some legal matter when Gans walked into my office.

'Doctor, you know we're working on this biorepository project to set up labs.' Gans parked himself near my desk.

'Yeah.'

Why don't we come together?

'What do you mean?'

'I want Bio to participate in our vision. We can do this jointly.'

'Sure, why not? We're also interested in that!' I didn't hesitate for even a moment.

Triesta's biorepository work aligned perfectly with my vision of advancing research in molecular diagnostics work and applying that in the Indian oncology landscape. More than that, I had observed Gans as a person and liked what I saw. I knew I wanted to work with him. Apart from his Ivy League pedigree, he had phenomenal business analytical skills and a rare vision that gelled nicely with what I was trying to do for the cancer scenario in India.

By April 2003, the construction of our oncology centre, Malnad Institute of Oncology, on the Shimoga-Bhadravati highway had been completed under the stewardship of our architect Namit Verma. It had come up beautifully. Namit was a visionary architect who had a reflective personality. Interaction with him helped me on the entrepreneurial journey, with the concept of detachment often being the topic of our discussions. The same month, we launched it officially. We had put a linac unit in Curie, so we moved the Cobalt unit from there to our Shimoga centre in June. It took time to mature, but today it is a landmark centre doing very well.

This is something that needs to be understood by investors and partners alike—no cancer centre can establish itself very quickly. It takes years, because people have to develop confidence, the quality has to get internalized and institutionalized, and outcomes have to be managed. With my team's support, the Shimoga centre has today become an excellent one, but I don't look at any returns there. The Shimoga centre is a low-profit centre with a high social impact.

Kick-Starting H.C.G's Global Expansion Plans

To quench her own thirst in the creative disciplines, Bhagya moved to Chicago in August 2002 for further studies in arts. I still remember the dilemma we faced when she was planning to do her master's, and the choice was between Chicago and Boston. The Fine Arts College of Boston had offered Bhagya a scholarship and even a place to stay. On the other hand, the University of Chicago Art Institute was a top-rated institute with a low acceptance rate. They had invited Bhagya to come and study further based on just her work. The only hitch was that they did not offer a scholarship.

Bhagya had been undecided, and had wondered whether to take up the Boston offer, since there were no fees. But I would have none of it. I wanted her to go study at the best place possible, because she deserved it. She had quite never understood how good she was at what she did: painting and art in general. So finally, she agreed to take up the Chicago offer. With that settled, I found her an apartment in Chicago.

Next came the issue of taking care of the kids. While Adarsh wanted to study one more year in Boston, Anjali had finished her tenth grade. We also had two toddlers demanding all our attention.

Our hands were full. While Bhagya studied in Chicago, I managed to hold the fort, oftentimes getting some much-needed help from Bhagya's brother-in-law, Shivaprasad. Whenever I visited India for my ongoing work, Bhagya would put the kids in a day-care centre in Chicago. We took each day as it came and somehow managed.

I remember an incident that occurred during one visit to India in 2004. It demonstrated to me the subjugated mentality of government officers in India. I had gone for a Sunday-morning jog up the Chamundi hills, a main tourist draw near Mysuru. Standing a majestic 3000 feet tall, it houses the Chamundeshwari temple atop the main hill. The temple has a standing statue of the demon king Mahishasura and one of Goddess Chamundeshwari—who killed Mahishasura in battle, according to mythology—in a cross-legged yogic posture.

That day, I saw people standing around in the hot sun. The police had restricted their movements. I approached a deputy commissioner of police (D.C.P) stationed nearby.

'Officer, why are all these people standing like this?'

'Sir, we have orders.'

'To prevent them from moving around? Why?'

The D.C.P squirmed, a sheepish grin crossing his face. 'What to do, sir? The chief minister and some politicians are coming here. They're the ones who pay our salaries, so we have to do what they say.'

I was dumbstruck. 'Who told you they pay your salary?'

'That's what I thought.'

'Officer, they don't pay your salary. We do. The taxpayer public pays your salary.'

The hapless police officer didn't know his salary was paid from public taxpayer money. I couldn't believe it. Here I was, thinking that the nation had a long way to go in the healthcare area—especially oncology—but people's mindsets had a long way to go as well. So, somewhere as I was seeding my entrepreneurial dreams of global expansion and setting up of centres of excellence in cancer care nationwide, I strongly felt the need to do something to mend these prehistoric and colonial mentalities of public servants.

I was looking at creating a single global entity under which my expansion plans for Bio and Curie would take shape and which would house other top-drawer oncology centres. It struck me that the name of this entity should necessarily include 'global' and 'healthcare' since those keywords reflected my vision of what I was trying to create. Thus was born the brand name 'HealthCare Global', or 'H.C.G'.

H.C.G needed to expand operations. Expansion needed resources, and resources needed capital. So, my first task was to solve the funding problem. We were past the seed capital phase, since I had myself brought in enough seed capital, aided by contributions from my partners. Therefore, we had to look for external sources of funds. This could be either equity or debt.

I.D.F.C Becomes the First P.E Investor to Show Interest in H.C.G

In early 2005, Gans and Vasudevan started to put together a plan for raising funds. Vasudevan suggested we meet investment bankers. That was a game changer.

In those days, meeting investment bankers for raising funds was not the norm. Vasudevan introduced me to Satish Shenoy, an investment banker who was also Gans's senior at I.I.M, Ahmedabad. I met him in Mumbai. Subsequently, he also met me in Bengaluru, and I shared my vision and expectations.

Satish recommended approaching private equity (P.E) investors, as they were more likely to fund our growth. Satish got me and Gans to meet several investors as part of our fundraising exercise, which quickly became the proverbial wild goose chase. Naysayers were many, and their predictions dire. The whole thing seemed to follow one script, where we'd knock on the door of the investors and say we had an idea, and each time the door would be shut in our faces.

A lot of people expressed their reservations about linac technology and the traction it would get in India. People at that time thought we were doomed to fail. Vivek Paul, then vice chairman of Wipro, told us categorically that we would never succeed in our vision, since India wouldn't change from the prevailing Cobalt technology.

More surprisingly, many among our own doctors' fraternity were sceptical. A majority of them, including our own H.C.G doctors as well as those from multispeciality hospitals, didn't buy into my idea. It was only me and a few other doctors, along with Satish, Gans and Vasudevan, who were convinced about this vision. In the midst of all this, we got an unexpected query from the Adag Reliance group. It wanted a stake, but the offer it made was poor: It was trying to squeeze me, and hence we did not take it up.

By mid-year, I had met about fifteen P.E investors. I remember Satish telling me categorically that if the P.E funding game plan didn't work out, we'd go public. I told Satish I had a revenue of just ten crores, so there was no question of going public. Even as I told him that, I knew that H.C.G was desperately in need of fund infusion. By then, I'd planned a centre of excellence in Bengaluru. Also, we were staring at a huge debt, as I had set up things to bring in a cyclotron, which would be a big cash drain.

A cyclotron produces the ingredient needed for a P.E.T scan. I had already ordered the cyclotron equipment from G.E and told them I'd be ready to receive it by mid-2005. The cyclotron needed a bunker. I had identified a building on J.C. Road for this, planning to take it on rent. My idea was simple: I had a building, so I could build a bunker.

But the owners of the building objected to this. I was taken aback. Yet, I didn't want to be entangled in legal issues. I was about to search for another building when I had a stroke of luck. In Tower 1 of our building, Khivraj Motors was about to build a showroom. I rushed to them and requested them to sell that space to me. Initially, they thought I was joking.

But they soon realized I was dead serious and badly wanted that space. We discussed financials.

Strangely, there was no written or formal agreement between us, unlike most other real estate deals. The whole deal went through purely based on our word. I paid only a token advance of one rupee and shook hands with the grandfather.

We had to borrow a great deal of money from the State Bank of India (S.B.I) and other banks for the bunker construction. In essence, I took a sizeable risk and built the bunker. I could have lost my investment, had Khivraj Motors refused to hand over the building space after its construction.

But true to its word, it handed over the space, which we took over after direct registration.

By mid-2005, we had completed the cyclotron transaction, and the huge loan we had taken from S.B.I would have drained us if we didn't secure funding immediately. Coincidentally, at that time, Satish set up a meeting with some people he knew at Infrastructure Development Finance Corporation (I.D.F.C). I was introduced to Prakash Karnik and Nimesh I., who were really nice folk, extremely humble and approachable. They liked our story and vision, and agreed to introduce me to Louis Miranda, who was president of I.D.F.C Private Equity.

Louis was based in Mumbai, so a meeting was set up to connect with him there and pitch our company. I flew to their Mumbai office, remembering not to expect much, based on my experiences with P.E investors so far. I didn't expect to get a red carpet welcome, but didn't expect to get blown off in a few minutes either. But that's exactly what happened.

The meeting was very short: Louis had just wanted to say hello to me. My first impression of him, thus, wasn't very positive. Apparently, Louis was a very busy man. But the tide was going to turn, and in an unexpected way.

Chapter Eighteen

I.D.F.C had been founded in 1997 with the express mandate of building the nation. It had registered with the Securities and Exchange Board of India (sebi) in 2000 as a merchant banker. In 2002, I.D.F.C Private Equity had been set up as an investment manager for P.E funds and had raised two hundred million dollars the following year for its first infrastructure-focused P.E fund. It had successfully launched its initial public offering (I.P.O) in 2005, following it up the next year by mopping up almost two thousand crore rupees for its second P.E fund.

So, by the time they started talking to us, I.D.F.C P.E was flush with money. Until then, they had been investing only in roads and turbines. When they saw our concept and story, they liked it and seemed interested, as they had never been in healthcare before. At that time, they were also looking at Manipal. Finally, after a lot of back and forth, they visited Bio in Bengaluru. Their interest began to rise.

Bengaluru Becomes the Battleground for Bio

Meanwhile, in the second half of 2005, I was also in the thick of action at Bio. Vasudevan recommended that I take up more shares in Bio and consolidate my majority shareholding. I owned around 60 per cent of Bio at the time. I then passed a resolution in the board that we needed more equity since we needed more funds. Everyone was asked to infuse more capital into the company, and I increased my own shareholding to 86 per cent.

As my next move, I called for a board meeting and proposed to change the company name to HealthCare Global in order to reflect its wider vision and bigger growth plans, of expanding across India. Immediately, Dr Srinath, Dr Gopinath and a whole posse of them opposed my plan. They all wanted to continue as the Bangalore Institute of Oncology. I felt they wanted it to remain a mom-and-pop cancer centre. They were happy with whatever we were doing at that time and didn't want to risk any changes. Dr Gopinath, in particular, was very categorical in rejecting the proposal and asked to be left alone.

This was a rehash of the Curie takeover proposal, which had met with similar resistance. Again, I was having none of it. I still remember my terse reply to them that said it all: 'If you're not interested, I'll do it on my own.' Perhaps they were right in their own way in worrying about losing money in such a risky expansion plan—after all, they were doctors, not entrepreneurs. While I recognized their right to not participate in H.C.G's growth story—I had felt then that it was going to be their loss—I was equally convinced about the direction I was about to take in making cancer care across India accessible and affordable.

Of my colleagues at Bio, Dr Gunasheela was an exception. I knew her well, but she didn't know what was going on; her son-in-law was dealing with these developments. Unknown to me, a secret board meeting was convened. While Dr Gunasheela supported my proposal to rename Bio as H.C.G, others wanted to know how they could remove me from the chairmanship. They even consulted lawyers, who advised them that I couldn't be touched since I had over 86 per cent shareholding.

Once they found out I couldn't be removed, things sobered down a bit. One more board meeting was called, where I was also invited. The developments after the previous board meeting came to the fore. I realized the time had come for me to make my next move. My next words to my Bio colleagues proved to be telling: 'You want Bio? No problem. I'll go and create H.C.G, and 86 per cent of Bio will be owned by H.C.G.' I went ahead and renamed Curie as H.C.G.

En route to expansion

Meanwhile, my association with Gans was growing in strength and spirit. In December 2005, we completed the legal formalities for the acquisition of Triesta Sciences. I had known Gans for some time by then, and found him to be an extraordinary human being and extremely multifaceted. More than acquiring Triesta, I was happy about working with Gans. That was perhaps why we had given quite a bit of valuation to Triesta: I believed in the strength of human relationships and did not want to put a price on that.

So now I had my chess pieces in place and my opening game was shaping up quite well. I already had Curie, which was now H.C.G, and now I had Triesta as well. With this, I had the basic foundation on which to build my expansion. After this, I transferred my 86 per cent shareholding in Bio to H.C.G, which became the majority shareholder of Bio. This had been my original objective all along. Just that the route to achieving it had been different. When one door closes, another opens.

I continued my parleys with I.D.F.C and Louis, an alumni of Chicago Booth School of Business. Bhagya was still doing her master's in Chicago, and my kids were also there. In June 2006, Louis came to our Chicago home and interacted with my family over dinner. The conversation was anything but business talk.

I remember being a wee bit disappointed that we could not progress on the funding discussion. Somewhere, I was beginning to think that I.D.F.C had done due diligence of H.C.G only to benchmark against the likes of Manipal, which was another potential investment opportunity for them. Or maybe they had done it to get a first-hand insight into the healthcare industry, which they wished to enter.

Finally, when I had almost given up hope of I.D.F.C investing in us, Louis made an offer. Surprisingly, he made a funding offer of ten million dollars, with no conditions whatsoever. I had been used to getting offers buried under layers and layers of conditions. The typical legalese in such offers would be on the lines of: 'If you achieve X, you'll get Y, but if you don't achieve this, you will lose Z.' It was all based on performance.

For the first time, with I.D.F.C, I had received an offer without any preconditions, so I was floored. Even today, I am really appreciative of I.D.F.C's gesture. The fact that they gave me the letter without conditions gave me the freedom to do the right thing for oncology patients and the community without worrying about the financial implications all the time.

At a personal level, too, over the months leading to I.D.F.C's offer, my impression of Louis underwent a sea change. Initially, I felt that he was a very busy investor and had no time to spare for personal interactions. It was only after that dinner in Chicago that I started to understand and appreciate him as a genuine person. As we went through the due diligence process, he and his team encouraged us even as they assessed us. As a team, we were able to solve whatever issues came up.

The idea to get P.E funding was a game changer for us. We pivoted into a new orbit after this episode. When I think of the contributions of Vasudevan and several other people to H.C.G and to my life, I recall an important lesson: 'Never forget what others have done for you, but forget what you have done for others.' I believe this helps tremendously to simplify things and make human relationships easier to navigate.

When you do something for others and they don't do something in return, you feel miserable. Whereas when you don't expect anything in return, you're fine. If people come and ask you to give them one lakh rupees, and you give them the money, you'll be worried about when they will pay you back.

Instead, give them 20 per cent of that with no expectation of return, and automatically the worry goes away. In simple words, do what you can for others, then forget about it. This is the way forward for me, and today this is part of H.C.G culture.

While Bengaluru was feeling all the heat, things in Mysuru had cooled down after that devastating labour strike in 1998. Since then, Bharath Hospital had grown. I wanted to replace the Cobalt unit there with a linac but that would have cost us crores, which I knew we couldn't afford at that point.

So, I approached the reputed J.S.S Medical College in Mysuru, where I knew the swamiji. J.S.S Math runs multiple educational institutions and hospitals. Whoever is appointed as the swamiji is head of the math. Started in 1984, their campus is situated in a 43-acre plot in Sri Shivarathreeshwara Nagara, Mysuru.

Coincidentally, J.S.S also wanted to install a linac in their hospital so I proposed a 50/50 partnership in the investment. It was the best of both worlds for J.S.S and Bharath Hospital, since the investment requirement halved and both hospitals got very advanced equipment with which the quality of healthcare could be ramped up. We borrowed money and finally replaced our Cobalt unit with linac in May 2006.

The action shifted back to Bio in Bengaluru. When people heard that H.C.G had received an offer of ten million dollars, there was pandemonium among the naysayers and fence-sitters. Everyone from Dr Srinath and Dr Gopinath to Dr Ramesh and Dr Shekhar Patil came around, reversing their earlier stand. Gone was the reluctance, resistance and risk-averseness. They all wanted to back me now.

I could have refused to take them on board due to their earlier resistance, but I took them at the same value without charging them any share value premium. That's why they—including the likes of Dr Gopinath and Dr Kilara—are all now dedicated. With this, H.C.G acquired a majority shareholding of 98 per cent of Bio and the merger was practically complete.

We were unable to tie up the remaining 2 per cent shareholding as the shareholders' addresses had gone missing. In July 2006, finally, I.D.F.C awarded us the funding, completing the financial and legal formalities. We had achieved our first goal of P.E infusion: ten million dollars in the bank.

Using partnerships and risk-taking to achieve one's vision

Most entrepreneurs these days come from middle-class families. So, some amount of financial insecurity may always be there and may limit the entrepreneur's risk-taking ability. In my case, by nature I am confident. And perhaps my U.S experience has given me added confidence.

I choose a path and stick with it. My thinking is: What's the worst that can happen? When you want to do something, risk is part and parcel of the journey. You should be prepared to lose everything.

I remember an incident in which I was chatting with Namit, my architect friend.

With a twinkle in my eye, I casually told him, 'What if we become coolies?'

Namit stared at me. 'Well, you're known for radical thoughts, but this is really outlandish, even for you!'

'Why all this ado about money, success and a cushy life? We'll become coolies at a bus stand, get that coolie experience. What's stopping us?'

Namit laughed. 'Then you can't come back to this life. Only then will it be a true coolie experience. If you know you can return to this comfortable life, it won't be an authentic coolie experience.'

While this was a casual discussion and the idea does sound zany, that is indeed how I think in real life. I tend to think through things with a sense of detachment, especially if it's an adverse situation. While I have no intention of becoming a coolie, I am always prepared to confront the worst life has to offer if ever such a calamity were to befall me. Bhagya and my entire family know what the 'coolie experience' means.

Life will hit you. You should be prepared to take it on the chin and not buckle. Instead, you should brace yourself to take a few more on the chin.

Fight for what you want, by all means. Do not become bitter. Instead, learn from your failures and the experience, and reapply yourself.

The day I lost all my money in the dot-com bust, I could've thought I had become a pauper—which I had—and let myself be devastated by the emotion of the moment. But you have to think what you can do. Instead of becoming angry, I decided to become detached and challenge myself to take on the difficult task ahead.

With I.D.F.C investing in us, next came the reality check of how to use the funds when they became available. When the ten million dollars came into our hands, the challenge was how to use that money effectively and make sure it was deployed properly as per the agreement with the P.E investor. People are always taught in business schools that equity is more expensive than debt. Why is that so? It's because higher returns are expected from equity than from debt. I have always felt that equity money is more precious that my own money.

Also, in debt there is no dilution—you repay your debt, and keep your shareholding percentage. Whereas with equity, you can reverse the initial dilution by buying back the new investor's shareholding and offer more returns through capital gains if the company performs well. However, since the risk for the new equity investor is higher than that of the new debt investor in terms of getting their money back, the equity investor will expect higher returns to compensate for the higher risk. So, in the case of equity, if all goes well, you can achieve a net dilution of zero and pay the new investor handsome returns when they exit.

In our case, the expectation of return for equity infusion was a minimum of 18 per cent. Typically, equity investors expect upwards of 20 per cent. Yet, why I liked the equity route was that it had one great advantage: There was no sword hanging over your neck every day, as in the case of debt. As a doctor, I felt this was an important differentiator.

As a healthcare giver, I should not be burdened every month with debt servicing and repayment stress. My primary role was to restore the health of my patients and add years to their lives. If I could find an equity investor who shared that vision and had confidence in me, I could get the funding I required for expanding my services at the cost of some dilution of stake, while the investor would also get the returns they expected: a win-win and a no-brainer.

More than dilution of my stake, I was more worried about the dilution of my vision. The question I was often asked then was: 'Why did you decide to take up this challenge of setting up centres all across the country? Why did you go to P.E? Why not be satisfied with one centre?' A lot of people advised, and even warned, me that I was trying something outrageous for a doctor.

Prominent doctors and oncologists told me that in one's lifetime, to do one social good was in itself an achievement. Their typical question was, 'Why are you out to set up not only a number of outpatient clinics, but also comprehensive cancer care clinics?' My answer was usually, 'It's time to do what others have not done.'

I felt that this was a great opportunity of executing a big vision. We understood oncology and we could do a lot to bring the country up to speed. I was clear that this should be done across India and not just in the big cities. That approach—of merely focusing on profitable hubs like cities—would just create further disparity.

It was also not practical to focus only on the big cities. When you create only one centre, people have no option but to come from smaller cities to larger cities. But oncology therapy is a drawn-out affair.

It doesn't end in days, but takes months, if not years, of treatment and patient follow-ups. So, to get a good outcome, provide top-quality medical care and to make it all accessible and affordable—which has become our mantra—it was clear that we should establish comprehensive cancer care across the country.

That would work only if we could work passionately for our patients without being constantly worried about paying the interest or repaying the principle, which is the norm when it comes to debt funding. Debt servicing then takes centre stage, eclipsing our vision.

So it was obvious that P.E was the best route to achieving my vision. Even though there was dilution, I did not mind because the cause was more important than the financial implications for me. I didn't become one of those control freaks, holding on to the majority stake and saying I wanted to be the key decision-maker. This is probably why many P.E investors saw this outlook of mine as a pleasant and refreshing change in a promoter's approach to funding.

Another important tool in an entrepreneur's arsenal is business partnerships. I have always believed in taking along right-minded and like-minded individuals and business entities to further my vision. In this context, Gans introduced me to Anula, who was an adviser in Triesta Sciences, which we had taken over. Originally from Sri Lanka, Anula was an M.D P.H.D and an M.B.A from Harvard. She was an amazing person with a very interesting history.

After the Triesta merger with H.C.G in late 2005, Anula started getting in touch with me—she was keen to invest in H.C.G. In 2006, she had become a partner of a business group called Evolvence, which was founded in 2001. She was keen on the H.C.G investment because of our vision of molecular diagnostics at that time, and because she wanted to come on the board of H.C.G.

At Evolvence, Anula had two other partners, Hari B. and Vishy K. She got her partners on board with her idea and approached me sometime in 2006 with her proposal to invest. We were not very sure of what to do, but kept her proposal in mind. Being approached by investors is music to the ears of any entrepreneur. But, somehow my gut said otherwise. I decided to sit on the issue.

Chapter Nineteen

The linac unit set up in Curie years earlier was proving to be worth its weight in gold. Now part of H.C.G, the equipment helped us bring quality oncology treatment to the masses and we began to acquire a name for high-end cancer therapy. We realized that this model was working and could be replicated across other centres to be launched as part of the expansion efforts. The opportunity for replication came sooner than expected.

In July 2006, I was in discussion with Guru Nath Kilira. The next thing we knew, we were in a discussion with the M.S. Ramaiah Group for a partnership. We approached Dr M.R. Jayaram, who was the chairman of M.S. Ramaiah Medical College and also M.S. Ramaiah's son, and proposed to set up an oncology care centre at this hospital and medical college campus. Dr Jayaram responded with unbridled enthusiasm to the proposal. He left it entirely to me to set up a quality cancer care unit and agreed to give me a piece of land on their sprawling campus.

Dr Kilara and I worked out the modalities and set up a model similar to Curie's all those years ago. Today, the M.S. Ramaiah Centre has become a premier oncology care hub, delivering advanced therapy to thousands of patients from Karnataka and other parts of India.

H.C.G's Partnership Model Takes Off

You know your partnership strategy and branding approach are working when potential partners come in search of you. It's as simple as that. By now, H.C.G was having no trouble attracting partners. One such partner was Dr Raj Nagarker from Nasik, who approached me in late 2006. We got talking about working jointly and I remember one conversation in the initial stages that demonstrated the power of our H.C.G partnership model.

'You know, Dr Ajai, about that cancer centre in Nasik,' said Dr Nagarker, 'I've been thinking …'

'Tell me.'

'Why don't I do it myself? My friend in Belgaum is building one, you know?'

I leaned back in my chair. 'See, it all depends. If you want to be a small fish, struggle and build, go ahead. By all means.'

Dr Nagarker fell silent.

I continued in a softer tone. 'But if you want us to come in, use our H.C.G brand and leverage that, your time to market will be quicker. As it is, cancer centres and equipment take a long time to break even. You know this.'

I could almost feel Dr Nagarker do some mental back-of-sheet calculations. Fifteen minutes later, we shook hands. The deal was done. In December 2006, we got into an in-principle agreement to build a cancer centre in Nasik under the H.C.G Manavatha brand.

In a very unorthodox move, we didn't get into any legal bindings or elaborate corporate transactions to make this happen. That partnership has lasted for almost thirteen years now. That's the magic of trust-based partnerships and hard-nosed thinking.

This strategy of trust-based partnerships and business dealings would eventually form H.C.G's 'handshake culture'. This 'handshake culture' is one I have strived hard to preserve in today's world of legalities and agreements, where a battery of lawyers and accountants are involved. I question the very basis of this kind of elaborate and time-consuming work.

Essentially, it shows, in a way, a lack of trust between the two parties concerned.

I strongly believe we should go back to the olden days of handshake culture. A handshake or word of mouth should be enough. I hope to leave this 'handshake culture' of trust behind as a hallmark of H.C.G's culture. It is very disturbing for me, whether it be in family, management, board or public meetings, that the trust factor is questioned. Today's political system and the media, with their associations with money, greed and fame, have led to negativism and mistrust in society. All this has interfered with doctor-patient relationships. In my experience, I have noticed that the trust factor in India is very low. One of the challenges H.C.G has taken up is to build this trust factor in the coming years.

It's not that there were no issues between Dr Nagarkar and us. Sporadically, there were some wrinkles in understanding. For instance, he was unhappy with several aspects of the administration. There were midnight calls between us to sort out various burning issues. On several occasions, he even threatened to quit, saying he didn't need me. But my response was always consistent in this regard: patience. Despite all misgivings and disagreements, I separated the issues from the person. This is something I've always practised, and will continue to. I've always told him, 'Raj, as a person, I like you. I respect you as a person, and I have affection for you.'

Entrepreneurs should always have that personal respect for their partners or whoever they are dealing with. Differences in the way they look at things can always be discussed and thrashed out. But never should the person and the issue be mixed. Personal love and respect can be segregated from the issue, much as one would when one needed to move a paperweight. The issue is akin to moving a paperweight: the focus should remain on how to go about doing that, rather than devising ways of changing its shape or physical weight to make it easier to move. The weight is like the person, and moving it is the issue, which has got nothing to do with changing its shape or physical weight. Don't put the issue inside the person; if you can take care of that, most conflicts can be resolved.

Another example of how we successfully implemented our partnership model was the Astha Group's multispeciality hospital MediSurge, being run by a group of surgical oncologists in Ahmedabad. In 2007, I got the word through an intermediary that they wanted to sell off MediSurge and were interested in a cancer centre. I thought we could convert MediSurge itself into a cancer centre. It was in the heart of the city, so the location was convenient as well.

We got the agreements and the deal done through our intermediary. Then came the tough part. The problem with MediSurge was that it was being run as a true nursing home, a mom-and-pop clinic. A doctor would bring his family, and they would help run the place. All family members available would be employed. The funniest part was, people would take cash. There was absolutely no order and the hospital was doing very badly.

When we bought the hospital in July 2007, the condition was that some of the doctors and oncologists would stay with us, but some of the others would leave. Entrepreneurship presents us with opportunities, but it also requires us to take some tough decisions. You can't let emotion overrule rationale. I could've taken a sympathetic view and let all family members of doctors stay on as employees. But then the quality of healthcare offered to our patients wouldn't have been top-notch.

Then the City Corporation threw us a curveball: They refused to give us the approval for a bunker and I could not convert it into an oncology centre. So, we just kept it as a multispeciality clinic. We moved on to our next project and worked with the Astha Group to create a separate cancer centre, which has been very successful. The Astha Group wanted it to be called 'H.C.G Astha' but somehow Dinesh Madhavan, H.C.G head of branding, convinced them otherwise and it remained just 'H.C.G'.

Subsequently, H.C.G, with Asthma Group holding 26 per cent shareholding, was successfully built as a separate oncology centre known as the H.C.G Cancer Care Centre, which is growing rapidly today. It has become one of Gujarat's premier centres with cutting-edge technology and excellent clinical talent.

We have an excellent working relationship with the Astha Group and all issues are addressed at regular board meetings and management community meetings. I am proud of this partnership, which I feel is truly a model to be emulated. It is a classic example of a national brand and locally well-known doctors coming together. The whole idea of our partnership model is to collaborate with an increasing number of complementary partners in the ecosystem and build something that is greater than the sum of the parts. In any such model, conflict resolution becomes key.

It is here that separating the issue from the person, and being completely issue-based becomes paramount, because you still need to work with that person the next day. Entrepreneurs can never afford to lose that friendship and human relationship.

Premji Invests in H.C.G

With the I.D.F.C funding in place, we injected life into H.C.G's growth trajectory. Fund infusion tends to do that. It's probably the reason why I began to look at Anula's investment proposal with a new lens. After some deliberation, we decided to go for it. With the H.C.G board vetting the proposal and green-lighting it, Evolvence came in as our second investor in March 2007 with a cash infusion of twenty-five crore rupees.

Later that year, there was an interesting development. We were dealing with a lot of equipment, mostly from Siemens and G.E, and working with G.E on our cyclotron project. So, this centre in Bengaluru was quickly becoming a centre of excellence and we were looking at high-end equipment such as the CyberKnife. While this was going on, in September I got a call from one Mr Raja, who was the president of G.E, India, and Anant Kittur (formally in G.E, but now H.C.G director of projects). They said Azim Premji wanted to meet me, so we drove over. Since he was the chairman of Wipro G.E, I thought it was something related to that company, which sounded natural, since I was also in the life sciences field and he would be interested in that.

Mr Premji is obviously a figure of great repute, and known for transparency and major business achievements. I was looking forward to an interesting meeting. We got there, and were ushered into his simple yet tastefully decorated office.

True to his style, Mr Premji quickly got down to business. His talk lasted about half an hour, and in about fifteen minutes, I believe he had asked me everything, from my background to my current situation, and given my C.V a once-over, saying it was very interesting. He complimented me on my 'commendable achievements'.

Then he did the most unexpected thing. He said he wanted to invest in H.C.G. I simply didn't know what to say. Here was a business tycoon who had shaped entire industries at the global level and was at the top of his game—and he was interested in me. He wanted to invest in me! In the interest of transparency, he did tell me he had looked at some other hospitals for investment. However, there were some issues with transparency and family involvement, because of which he withdrew. He was extremely interested in healthcare and because of our transparency and ethics, he was keen to invest in us.

I was pleasantly surprised. At that point, I was not looking at raising more money. Yet, I felt maybe we could expand more and use the offered funding, although there would be stake dilution. Still, for me, the opportunity was more important than the dilution issue, so we decided to go for the funding.

Then Wipro's business due diligence team, led by their director, Prakash Parthasarthy, began to visit us. For nearly eight months, Prakash and his team came and studied us from top to bottom, leaving nothing unchecked. Finally, in April 2008, their diligence process completed, Mr Premji green-lighted the deal, and they invested forty crore rupees in H.C.G. Our third, and perhaps most prominent, investor was on board! Prakash Parthasarthy and Bobby Mustafa from the Premji Group joined the board. Prakash Karnik and Shivani B. represented I.D.F.C, and Anula Evolvence. We used the money effectively, and promptly executed seven to eight projects successfully.

We were excited about our growth, but unbeknownst to many, including us, economic disaster was slowly creeping upon the U.S at this point. Housing speculation in the U.S had risen substantially with mortgage originations to non-residential investors almost doubling between 2000 and 2007. Sub-prime lending—lending to borrowers with poor or suspect repayment capacity—had risen from the historical 8 per cent of all lending in a given year to almost 20 per cent by 2006.

This housing bubble had been exacerbated by dubious financial products like mortgage-based securities (M.B.S's), which had been sold to investors with promises of higher interest rates than government-backed securities, except that the underlying collateral was of poor quality, owing to a high percentage of sub-prime mortgaged properties being collateralized. With U.S home prices plummeting in 2007 and adjustable-rate mortgages (A.R.M's) resetting at higher interest rates, monthly mortgage repayment requirements soared and mortgage defaults shot through the roof.

Consequently, market prices of M.B.S's began to fall. Many financial institutions that had held most of their portfolios in M.B.S's and collateralized debt obligations (C.D.O's), which were financial vehicles to refinance M.B.S's, started to fold up in 2007. This led to a vicious downward spiral as global investors pared down their holdings in M.B.S and C.D.O products, further bringing down the asset values of portfolios held by financial institutions. Panic gripped the markets, with central banks the world over tightening their credit policies, resulting in higher interest rates and stagnation of economic growth.

In 2008, just as we were tying up with Premji Investments, the U.S entered a deep recession, with a job loss of nearly nine million. U.S housing prices fell by almost 30 per cent on average, while the U.S stock markets fell by around 50 per cent by 2009, devastating the economy. Europe, similarly, was dealing with its own financial crisis, with raging unemployment and impaired financial assets clogging up national economies. The entire investment atmosphere turned into one of gloom and doom, with all investors holding on tightly to their purse strings.

According to the agreement we had had with Premji Investments, the second round of funding of forty crore rupees was due, with the board also having given its approval. Accordingly, I had made a lot of commitments to buy equipment, certain things had been shipped, bank loans were waiting to be paid, and some big purchase orders had been sent out. Just when we thought we had some breathing space, the earth below our feet caved in. The Subhiksha scam hit the country.

Started in 1997, Subhiksha was a retail chain that began operations with a single outlet in Chennai but quickly grew to fifty stores in the city by 2000, and to over 1600 stores across six states, including Tamil Nadu, by 2008. This gravity-defying growth had come at the cost of zero or wafer-thin margins. Soon, the company's debt became insurmountable and it ran out of funds in October 2008. Unable to pay its suppliers, its operations suffered and the company was unable to even pay staff salaries. In February 2009, Subhiksha announced closure of all its stores, only to be hit by a winding-up petition filed by Kotak Mahindra, one of its investors.

All this would probably not have hit us directly had it not been for one small niggle: Mr Premji had also invested in Subhiksha, to the tune of three hundred crore rupees. Somebody wrote him a nasty letter, insinuating that I could also be a similar risk for him. I was in Kolkata when a director of Premji Investments urgently asked to meet me. Pulling me aside, this director informed me that Mr Premji had received such a the letter. Also, I had the reputation of being an 'aggressive oncologist', plus somebody in the U.S had sued me. All put together, I was probably looking like a risky bet for Mr Premji, who instructed Prakash to put a hold on the forty-crore investment, and backed off.

This was one of the few times I really lost it. I said I knew my reputation was impeccable but if they had no confidence in me, they should withdraw completely from H.C.G. The Premji Group neither withdrew nor gave additional funding, so, I began to look for other investors by the end of 2008 and early 2009. Internally, we resorted to innovative ways to ease the cash-crunch situation. We talked to the board and proposed to ask investors, our present shareholders, and doctors to invest, offering them 14 to 15 per cent interest. Only, we would not pay them interest—that interest would get converted into shares at the end of three to four years.

So, we got the transitional money where a lot of doctors, happy with the prospect of getting interest and shares, participated. I also put in about five crore rupees myself, and that helped. We again innovated in certain ways to make sure we could service the debt. I didn't take a salary for close to a year. People like Dr Gopinath helped fund about thirty to forty lakh rupees.

Essentially, we took funds from credible people who were interested in H.C.G's growth and ran H.C.G like a mom-and-pop store at that point. We put all expansion plans on hold, reorganized everything and continued to service loans. To put it mildly, it was a major spanner in our works.

Chapter Twenty

Even today, it is an enigma to me why investors were not willing to help during our time of crisis. Somehow, I always felt they would, but they didn't. Perhaps they got spooked by that letter somebody wrote about me, which was in bad taste anyway and purely speculative. Perhaps it was the general gloom and doom in the financial ecosystem.

Or, perhaps I was thinking purely from a relationship perspective and expected investors to reciprocate, but for investors at that point, it may have been purely about numbers and money. A case in point was Evolvence.

Evolvence had the funds, so it could have given us money if it wanted to. Instead, it offered to give me five to ten crore rupees, but only if 25 per cent interest was guaranteed.

I pulled Gans aside. 'No way, Gans!'

Gans was more circumspect. 'That's the way investors think, Doctor. Nothing to fret about.'

'Whatever it is, Gans, I will work hard. I will sell my property, but I won't budge to these strong-arm tactics just because we're desperate for money.'

'No, no, Doctor, don't do that.'

'No, whatever money our existing investors have already invested I regard as mine, and I need to safeguard it. The profits generated belong to the whole company and the people working for us. It is their money. I cannot pay 25 per cent interest because that'll eat into those profits. It is immoral and unethical!'

I was very unhappy with Evolvence because of their insensitive stand during a crisis. When they didn't help during this period of need, I began to think I didn't need them any more in H.C.G.

Investors Play Musical Chairs, H.C.G Consolidates

As we slowly consolidated our financial position in the aftermath of the sub-prime crisis, I made my next move. I was interested in launching mega branding activities. I had got board approval at that time to buy a five-million-dollar CyberKnife. We started working with the Times of India Group on a branding exercise, and they gave us a brand capital proposal. I wanted to portray H.C.G as the pioneering oncology care provider with the latest that technology had to offer. But first I needed to understand the equipment.

I went to Stanford and spent time with Dr Adler, who is still a good friend of mine, to get a grasp of this new equipment. This was a radiation oncologist's wish list at that time. Oncologists at that time were grappling with the issue of treating a tumour without affecting normal tissue.

I follow a simple principle. I like to take complex situations and simplify them. If you can do that, you've understood the issue well.

If you make complex situations more complex, you've not understood the situation.

So I reasoned: As a radiation oncologist, what did I really want? I wanted to ensure I treated only the tumour without damaging the normal tissue. The CyberKnife was geared for that, did radio surgery where it had intra-fractional correction and minimized normal tissue exposure. I studied the patient profiles treated by Dr Adler and was convinced this was the right technology for H.C.G.

However, very few doctors in India appreciated it. Even radiation oncologists had very little knowledge of it. Bringing the CyberKnife into H.C.G's scheme of operations helped us implement treatment protocols better, and H.C.G's name became branded as an oncology destination. The step also reinforced our reputation as a world-class cancer hospital chain. Every radiation oncologist sat up and took notice of us.

Simultaneously, we didn't give up on fundraising. Mr Premji had backtracked. Evolvence did not help. Still, we were hopeful.

We hired Equarius, a firm of investment bankers, to scout for friendly investors. Equarius searched hard and brought several investors to the negotiation table, but all of them offered a low valuation for H.C.G. Only Religare Milestone was straightforward in its negotiations. Unfortunately, it, too, gave a low valuation because of the despondency in the prevailing economic scene.

Eventually, it invested in H.C.G in February 2010. We got back to building the company.

While it was a period of consolidation and opportunistic growth, it was also a period of selective pairing. We became choosier about our partners and exited agreements where we felt our partners were not as committed as us about providing world-class healthcare service.

Just as the general gloom and doom was getting over, there came a profound moment. Our very first investor was planning to exit. Louis at I.D.F.C wanted to quit his company and get into N.G.O activities. I.D.F.C quietly informed me it wanted to exit H.C.G because of the 'key man' clause provisions—this is the limited partners' condition for exit.

For us, it was rinse-and-repeat. We next had to find a buyer, for which we hired an investment banker, and the whole process started again. There was no break for us from these fundraising cycles, although we just wanted to focus on building the company.

The fundraising effort came in the way, valuations came in the way. There were also board considerations. We didn't want too many outsiders to come in either, so I finally convinced Religare and Mr Premji to meet with I.D.F.C. They worked on their own, came up with a formula. The valuation unfortunately was low again.

They also put March 2011 as the exit month. While this was going on, a 100 per cent merger of Bio and H.C.G took place, with the remaining 2 per cent shareholders submitting their shares.

Meanwhile, we had to upgrade the equipment for Bharath Hospital. I wanted to be financially conservative. The cost of replacing and upgrading ran into crores. I knew I could not personally borrow a large amount, so we decided to focus on financial innovation.

What if there was a model where someone put in the required funds for investing in equipment, and hospitals like Bharath Hospital just leased the service? As always, my focus was clear: What was the best thing for our patients? The machines had to be upgraded, and with no money, financial innovation was the only route.

I proposed to H.C.G that we 'invest' in the specialized radiation therapy called intensity-modulated radiation therapy (I.M.R.T) and do telephysics, for which Bharath Hospital would pay H.C.G around one to two lakh rupees per month. In July, we implemented this model. This was the birth of H.C.G's 'hub-and-spoke' model, where the hub invests in and houses expensive equipment needed for treatment, and centres at other locations that cannot afford to buy the equipment outright—the spokes—access the treatment services through telephysics and videoconferencing on a 'pay as you go' principle. Thus the hubs invest and get a return on investment, whereas the spokes don't need to make heavy investments (by borrowing and getting into a debt trap) but still get the high-end technology and treatment services they want.

The challenge with Evolvence

This model has worked out really well for us. Centres like the ones in Mysuru, Shimoga and Nasik, which cannot afford the huge expenses of planning, personnel and high-quality equipment, just need to pay H.C.G for the services only when they need them. This model has been a total win-win.

Come 2012, I faced one of the most challenging situations in my life. Evolvence wanted to exit and started to pressurize us. At times it seemed they felt I did not know how to run the company, yet I refrained from reacting and kept going. Apparently, for some reason, Evolvence had lost faith in H.C.G's ability to fulfil its growth potential. They said they needed to exit. I couldn't have agreed more.

I left the formalities to Gans, who was brilliant at this. We looked hard for a buyer. To put it in a nutshell, they wanted a certain valuation. Two term sheets we got were lower than expected, and so we couldn't go for it. I still remember the torrid conversation I had with Anula at that time.

'Anula,' I tried to reason, 'you are getting a buyer. You should go for it.'

Anula was adamant. 'We have conveyed the returns we want. This valuation is too low.'

'Anula, you don't want to wait. How can I do magic?'

'But we have a right to demand more from you!'

So, it was sleepless nights at that point. Also, there were some taxation issues. Evolvence engaged a law firm and started driving Gans nuts. I have no idea how Gans handled them.

At one point, I said that the deal was dead—I was done. I was so frustrated at that point.

Finally, Gans closed it. He knew Rohit Pilani at Temasek, which was keen to enter healthcare. We were one of their first investments in healthcare. They were very accommodative and understanding. The only hitch was they were headquartered in Singapore and the government of Singapore had stipulated tons of rules and regulations for institutional investment transaction. Everything had to be airtight, and the due diligence took a lot of time.

Finally, in 2013, the process was completed, and Temasek came in as our fifth investor. I was relieved to see Evolvence leave. This whole episode taught me one thing about P.E: When the going is good, your investors will be your best friends, but when things go south, or when your investors are in exit mode, they can be your worst nightmare. I don't hold this against them—it's their money, after all—but I just wish they had reposed more faith in me.

Partnerships, diversification and a customs scare

The partnership model continued to work for us. The idea was simple: Merge a local entity with a national brand to leverage the strengths of both and cover shortfalls, creating a powerful entity. It is the ideal healthcare provider system: The local doctor has the contacts and the goodwill of the local community, so he's looked upon as the local community person, while the national brand, with its expertise in training and domain knowledge in oncology, helps the local partner raise the bar. Also, the local partner would have typically struggled for a long time to even sustain operations, let alone grow. And our vision of penetrating the tier 2 and tier 3 cities and making cancer accessible and affordable would also be met.

Take the case of Rajiv Bhat, who was an onco-surgeon practising in Africa. In the mid-Nineties, he came to his hometown Vadodara to look into building a cancer centre. Intending it as a non-profit trust hospital, he put together a plan and went to a local trust with it. Unfortunately, the plan didn't work. After that, he went to other hospitals asking them to either invest or take over his trust hospital, but no one would buy it because it needed investment and everybody wanted a proposal where he would stay on as a partner.

Finally, he approached us through Dr Bharat Gadvi, who was our business head for Gujarat. Dr Gadvi is a close friend with remarkable administrative capabilities. His vision and his execution abilities are well aligned with H.C.G culture. His contribution to cancer care in Gujarat by creating an H.C.G model is commendable. So, when Dr Gadvi asked me to launch a centre with Dr Bhat in Vadodara, I was all for it. This again fit into our vision of penetration into the tier 2 and tier 3 cities.

So we put together a plan—and today it is one of the best centres in the country. Of course, Dr Bhat is also a 26 per cent partner, and while there are always issues in any partnership, he's happy he could realize his vision: a comprehensive cancer care centre that he's involved in. Our vision of entering a smaller city like Vadodara was also met. Here, the trust placed by Dr Bhat on us to make the Vadodara centre a profitable and quality centre worked well to keep the model sustainable in the long run.

You can build your strategy on spreadsheets and PowerPoint presentations. Or you can build it on the ground, by keeping your nose and ears close to the ground. I belong to the latter category. Over the years, we had been looking for entrepreneurs who were interested in some neesh areas.

But I never thought we'd get into in vitro fertilization (I.V.F) as a strategic foray. Yet, that is exactly what happened. And it's a decision I don't regret.

Dr Kamini Rao was my junior in college. Her brother Aravind was my classmate. Their father, Dr P.R. Desai, was a famous gynaecologist and we were good family friends. I used to meet them at home, have dosas made by their mother, and Aravind would come home to study with me. When Vasudevan informed us in early 2013 of one Dr Kamini from the Middle East who was running an I.V.F centre and wanted to discuss working together, I had no idea it would be my college mate. When I came to know, I was pleasantly surprised. It's a small world indeed.

Dr Rao had started the Bangalore Assisted Conception Centre (B.A.C.C) Healthcare in 1989 with a vision to offer couples access to advanced medical diagnosis and treatment options in the field of assisted reproduction (I.V.F treatment and intrauterine insemination, or I.U.I, treatment). A Padma Shri awardee, she brought several firsts with her: south India's first semen bank, facilitating India's first Semen Intra-Fallopian Transfer (sift) baby and south India's first babies born through I.C.S.I (intracytoplasmic sperm injection) and through laser-assisted hatching. She was looking for someone who could lead from the front and execute her vision of I.V.F. She wanted to work with H.C.G since she knew me very well, following the hub-and-spoke model.

This found favour with us and I convinced the H.C.G board as well. Gans put together the terms of the engagement. All this worked out in a matter of days: We prepared a term sheet and it was executed as planned. In March 2013, we invested in B.A.C.C Healthcare and got a 50.1 per cent stake. B.A.C.C Healthcare was rebranded as Milann.

Today, when we look back, it was a good decision, since Milann has been at the forefront of high-tech fertility care ever since we entered into a strategic alliance with B.A.C.C, and has been redefining it. It houses medical professionals with postdoctoral fellowships extensively trained in assisted reproduction, including reproductive endocrinology, ovarian biology, reproductive immunology and the genetics of fertility. Serving as a beacon of hope to thousands of childless couples, Milann has been recognized by Frost & Sullivan (a business consulting firm) for its fertility treatment expertise and has received an award for being India's best fertility and I.V.F centre in 2016. Financially, too, it was a brilliant move, because I.V.F is in high demand now and valuations are really high.

By mid-2013, we were sailing smoothly with a strong board in place. Temasek had Dr Jennifer Lee, a renowned doctor, on the board, and Religare was represented by Dr Amit Verma, an intensivist-turned-investor who had moved from the U.S. He now runs a famous healthcare investment fund called Quadria. Bobby Mustafa from the Premji Group retired, and Satish Mandana from I.D.F.C left with the exit of that company. Anula had also left the board with the exit of Evolvence. In several board meetings, there were discussions about the future of H.C.G, including possibly going public. It was decided that when there was to be a visibility of hundred crore ebitduh, we should consider going public.

As they say, life happens when you are busy making other plans. As we were keeping the drawing board busy with our plans of going public and kick-starting a hockey-stick growth curve, an incident worth narrating happened. In January 2014 we received a letter from the Directorate of Revenue Intelligence (D.R.I). It carried a demand for customs duty for the linac equipment that had arrived in two shipments: one in Chennai and one in Ahmedabad.

People advised me that D.R.I was to be dreaded, given their power in India. One could go to jail for even the smallest discrepancy, or so I heard. I was even advised to pay them off. Meanwhile, D.R.I opened up our case, identified all the parties involved, and slapped us with a notice asking us to pay eighty lakh rupees. Our ordeal began.

I put my foot down and decided that no matter what, we were not going to pay them. Then our Ahmedabad team was called and grilled by the D.R.I officers, who asked them who their chairman was. They googled the company to find my name and head office address, and sent me a show-cause notice.

I went to meet the D.R.I officer who was working our case. He was originally from Bihar and a decorated officer, being the recipient of an award.

As soon as he saw me, he barked, 'Sit down!'

I took a chair, not saying anything.

'Your equipment has been caught without customs duty being paid. It is not right. You have to pay this.'

I retorted, 'I've not done anything wrong.'

His eyes flashed. 'How can you argue with me? Don't sit on the chair, sit on the floor!'

They called the magistrate and threatened to arrest me. The whole drama was played out to intimidate me.

I asked the officer, 'What can you do? Arrest me? Beat me, torture me? Do it. I've done nothing wrong.'

The officer was livid by now. 'You're from Karnataka and you're talking to me, a Bihari, like that?'

'I don't care about all that!'

That evening they let me go. I immediately reported this harsh and shoddy treatment to the Human Rights Commission, marking a copy to their head office in Delhi. I shared my ordeal with whoever I knew, so some people wrote to the D.R.I officer in question, asking him to explain the alleged abuse.

I got a call from the officer. 'What, Doctor? You wrote a letter about me?'

I was unperturbed. 'Yes, you abused me.'

The officer was stunned. 'You don't know what you are doing. This time come with your lawyer.'

'Whatever you want to do, do it.'

The stage had been set for a showdown of epic proportions.

Chapter Twenty-One

I went to see the D.R.I officer with my lawyer. I was met with a cold reception, but there was no question of abuse this time, since the lawyer was with me. Once again, the officer warned me that what I was doing was wrong and that I would face consequences. I did not change my response. I said, 'When I am in the right, I will face any consequences.' He made me write my version of the software issue as well as the customs issue, and we were asked to leave after that. It has now been several years since the incident and I have not heard from them again.

While investigating the matter, I heard rumours that once the D.R.I broke people mentally with threats and forced them to pay the duty, the customs officers got a commission on the recovered money. Recently, too, we had an incident where one of our employees was slapped on the face. Again, we reported it to the Human Rights Commission. The letters to the human rights department and to the D.R.I headquarters have still not been replied to. Is the government not responsible for replying? And what action can we take? as ordinary citizens? I leave the answers to the reader's imagination.

It is not easy to start any venture in India in a transparent way. In fact, sometimes it's pure torture. If you want to do something underhand, you can easily do it. We're in an era of darkness—it all revolves around bribery.

Probably, things may change or are changing now. The fact is that if you're an honest entrepreneur, the system tries to intimidate you. Many people are in it for the money.

Straightforward business transactions are unnecessarily subjected to scrutiny and harassment.

Normally, people may succumb easily, as these are all powerful people. They use various tactics to intimidate people, such as calling up the magistrate in front of you and telling you 'they' are coming. When I see young entrepreneurs today, I can imagine what many of them must be going through.

All I can say is, don't get cowed down if you are in the right. Stand up for what you believe in, and prepare yourself for the worst. It's the only way you'll be able to look at yourself in the mirror the next day.

Going public: our first tango with retail investors

In 2015, while planning for our I.P.O, we were looking at a number of investment bankers. One of them was the New York-based Goldman Sachs, a leading American multinational investment bank. The Premji Group in New York had introduced me to Robert King, the head of Goldman Sachs for healthcare, who had said he wanted to engage with us. So, we started working with them. In July, we filed our draft red herring prospectus (D.R.H.P), putting up company shares of more than three crore rupees for sale.

As we were gunning for the I.P.O, some multispeciality hospitals, which were going for their I.P.O at the same time, played smart. I heard through some investors who later invested with us that these brands posed as institutes with grand plans for oncology and were dismissive of the notion that H.C.G was one of the pioneering players in the oncology space. So, they began to gain traction among the investor fraternity, although we already had fifteen dedicated cancer care centres by then.

One particular incident comes to mind. In October 2015, I was in Singapore to attend an investor meeting. I was standing outside the building when I heard a comment from one of the investors. Apparently, the investor had asked a prominent promoter of a multispeciality hospital, which was going public, what he thought of H.C.G. The promoter had dismissed H.C.G by remarking that he was in multispeciality care and he could also do oncology, so what was so great about H.C.G?

On the contrary, oncology was our sole focus and we were devoting all our energy to it, so we were in a better position to serve cancer patients. Unfortunately, that promoter's words carried more weight—he was a celebrity of sorts—whereas I was not known yet. That damaged our prospects.

In November, sebi cleared our initial proposal of share sale. We were going to list our shares on the Bombay Stock Exchange (B.S.E) and the National Stock Exchange (N.S.E). The year 2015 had been a bumper year for I.P.O's, with eighteen I.P.O's already floated by then, mopping up over Rs 11,000 crore in fundraising. In contrast, the previous year had seen only six I.P.O's and fund collections of just around Rs 1200 crore. So, we were very excited and looking forward to going public.

In December, suddenly there was a deluge of I.P.O's in the healthcare sector. Among them was Dr Lal PathLabs, listing at an amazing Rs 720 per share. Next came Narayana Hrudayalaya's I.P.O in January 2016, opening at Rs 291 per share on its listing day, and closing at the same level. This was scary and encouraging at the same time.

So, we did a roadshow to understand the market pulse. The response, unfortunately, was lukewarm. The valuation asked was very low, with some quoting Rs 1300 to 1400 crore. No one was willing to invest at Rs 2000 crore, which was our debt issue.

People never understood the whole model of H.C.G. We got a lot of questions that showed they hadn't understood our model and our vision. Why should a partner come to you? How can a cancer centre do it alone? Why did you get into I.V.F? Gans and I were devastated. But we had come that far and couldn't stop.

Sometime in January, I was in San Francisco for a healthcare meeting. It was at the back of my mind that Gans and I had to take a decision on finalizing our investment banker. Robert King from Goldman Sachs was also in the city, but he was staying in another hotel.

I called Robert. 'Bob, I have to decide between you and J.P Morgan. I have to meet you.'

'Oh, okay. Come on over.'

'I'll meet you in five minutes.'

He was in a hotel up the hill. I went up to his room. He was relaxing with a pina colada, documents and sheaths of papers strewn across the table.

I settled down on a plush couch opposite him. 'Look here, Bob. We can only afford to pay you a certain amount. You have to agree.'

Robert didn't flinch. 'You know our standard fee for this.'

'We can't afford to pay in millions, Bob. I can only do about Rs 700,000 to 800,000 right now.'

Robert didn't react.

'Let us shake on this now and sign the documents later.'

That conversation ended inconclusively, and I returned to my hotel. I thought it was a no-go. This was Goldman Sachs—they were not going to bend to a nobody like me. We were almost back to the drawing board. Surprisingly, Robert called me after ten minutes and said the handshake was done. I didn't even have a written agreement with him.

With that, the deal went through. We went public through Goldman Sachs. Of course, eventually some agreement was inked, because Goldman, being Goldman, things had to be in black and white. But what I want to reiterate is once a handshake is done, it is done; once a word is given, it is given. That is the culture of H.C.G. That is something I've followed all my life.

I knew we had a great thing going in molecular diagnostics, and we were doing well in ongoing research. We also had I.V.F with us, so it was a strong portfolio. Given this, while going public, even today I'm surprised that no one saw value in all this.

Getting a valuation became a nightmare. We were literally working day and night, trying to get a fair valuation. By March, the Premji Group assured us that if no one came forward, they would take us at a certain level. I agreed and proposed to do the valuation at Rs 1800 crore.

I also wanted them to take majority for a short term, which was rejected since that had been offered to us months earlier and the same could not be offered now. Then I called Gans and told him I wanted to go public, whatever happens. We were planning to raise around Rs 650 crore. Analysts and trade media had tagged our impending I.P.O as 'attractive' due to the inherent potential, so we were all charged up. This made it even harder to understand why we had not gotten a higher valuation.

The surprises were not over, by any yardstick. By the time we wanted to go public, sebi had a question for us. We were ebitduh-positive but not profit after tax (Pat)-positive because of huge depreciation. So, sebi felt that the public should know this.

I couldn't believe it. We were not asking people to gamble. They should see the market, take investment advice, and yes, not go for fly-by-night operators, but we were clean. Our track record spoke for itself. Our ebitduh was positive and that should have been enough.

Pat could be negative because of depreciation, and anyone who understood business would know this. There was no need to proclaim publicly that we were a loss-making company as per sebi requirements. I was very upset.

Anyway, we all had a meeting, and decided that we should put in bold letters: 'We are a loss-making company.' So, when we put out our ads, we said in black and white that we were a loss-making company. Fortunately, because of our ebitduh and size of the company, we didn't need to have 40 to 50 per cent retail investors. Instead, we had only 30 per cent retail and the majority were institutional investors, who understood our position. That's how, later, International Finance Corporation, and Harvard, which had an endowment, invested in our I.P.O.

The issue was priced in the Rs 205 to 218 price band. At this point, some reports in the media pegged us as 'expensive'. Still, we were oversubscribed by 1.6 times, even though that was unsatisfactory for us. The day of listing arrived. I still remember the day as clearly as daylight. It was 30 March 2016. We got a lot of media coverage for this event. So, it was building up very well. Finally, I rang the bell. H.C.G had gone public!

Then the inconceivable happened. The stock opened at Rs 210, which was at the lower end of our issue price band. The stock market head came over, and even as I was talking to him, the stock started sinking.

It tanked all the way to Rs 171—a drop of around 20 per cent—and closed the day at that level. Gans was in a state of shock. I was speechless. Healthcare I.P.O's that had come before us had registered gains between 13 and 69 per cent on the opening day. And here we were, registering a drop. Something didn't add up.

Gans and I wanted to buy back the stock to shore up the price, but we were prohibited from buying. Eventually, we got to know why the stock had tanked on the opening day. Apparently, one of the major investment banks that had invested in our I.P.O had put a 'sell' instruction on it when the stock did not rise by 20 to 30 per cent like other healthcare I.P.O's at the time. It went down another 10 per cent, and some investors then automatically put a 'sell' on it—and the stock went down further.

I gathered myself. I told Gans that my job was to build a company, not be obsessed with stock prices. Gans, still in shock, was mumbling, 'How can it be? How could this have happened?' I told Gans that he might not sleep well, but I would.

Nothing had actually changed for me, except that there was a new system of reporting and some questions to be answered every quarter, for which we would have to prepare. Otherwise, it was back to running the company the only way I knew—by doing the right things, not by being swayed by money or share prices.

Speaking of doing the right thing, the industry we were in presented a number of opportunities where I could have gone more commercial. For example, we were doing business with Zydus Corporation, as with any pharmaceutical company, for many years. In 2017, we learnt that they had gone into hospital-building.

That was not right. I remember feeling distinctly uncomfortable. A pharma company going into building hospitals was not ethical, so I strongly felt we, as doctors and hospital owners, should not support this.

So, we put an embargo on Zydus and stopped doing business with them. Their vice president sought to know why we were doing this. My reply was simple yet direct: 'Your company has crossed the line and I want to protest. You're a billion-dollar company, so I know my protest may not move your needle back by much. But by protesting, my views are expressed. It sends a message to the ecosystem at large.' It was a matter of principle. Although we resumed business with them for a brief period during 2018, we turned off the tap by February 2019.

This is where I admire the likes of Azim Premji, who invested in H.C.G. Now, Mr Premji himself is a billionaire, so he could have easily started a hospital on his own. There was no need for him to call me and invest in my company. But look at what he did. He said he wanted to be in healthcare, so he wanted to support a healthcare entrepreneur with a vision. His focus was software and he did not want to dilute it. But he wanted to play a role in healthcare and hence decided to back us. Eventually, his vision was fulfilled and ours achieved.

This is what we expect from any pharma company, or any other company, for that matter. Just because a pharma company has a lot of money, it doesn't mean it will go into hospital-building. It's just not right. What if doctors join hands and say they will build a pharma company too?

Is that okay? Obviously not. So, I think lines have to be drawn. Interestingly, we don't see this happening globally. We don't see Roche or GlaxoSmithKline opening hospitals, so is this an Indian trait? Why is it that Indians think anything is okay in this respect?

This really bothers me. I strongly feel that entrepreneurs who have the domain knowledge should be supported and that is the best way to contribute to society.

In the same year, 2017, that we stopped transacting with Zydus, we also started receiving a lot of African patients. Now, I don't believe in the concept of medical tourism. While it is important for patients to come where high-end technology and treatment is available, a lot of routine work can be done locally. Again, it's about social impact, affordability and accessibility. So, with this in mind, we were looking at doing something in Africa itself. The question that used to haunt me until recently was: Why not set up a cancer care centre in Africa?

In 2017, an opportunity to do so came along through the Commonwealth Development Corporation (C.D.C). They were interested in improving overall healthcare in Africa. After meeting us, they saw oncology as one of their focus areas. The demand for oncology care was definitely on the rise in Africa and very few centres existed. People used to ask me why we didn't start centres in the U.S or Europe, but my answer was very clear—I didn't want to open centres in a mature market.

I always want to focus on where there is a need so we can make some impact. I don't care if that leads to financial gain or a short-term loss. At that time, I strongly felt that we should have a centre in Africa and that the hub-and-spoke model was the way to go.

Dr Adamali is a doctorpreneur, radiologist and visionary. Moreover, he is an admirable personality. When he went to Kenya to work as a radiologist, he saw the need for cancer care, worked with Kenyan doctors and the M.P Shah Hospital, and developed a modern facility called Cancer Care Kenya. He had a great vision, but as he aged, it was difficult for him to continue. He did not want his vision to dissipate or give it up. So when he found out about H.C.G, he met Dinesh Madhavan and me. Dinesh was playing an active role in international division and branding.

Dinesh also met him several times in Nairobi. Dr Adamali was an idealistic doctor. His intent was very clear—to see how he could work with us, and how we could take over his centre. We worked out the finances over the centre and took over the C.D.C centre in late 2017. Still a partner with a share of 10 per cent or so even though his centre was taken over, Dr Adamali continues to contribute to the centre.

I had one very significant takeaway from this episode: It is important to work with doctors and their vision. A doctorpreneur's vision brought to life by another doctor—and not by an M.B.A or a non-healthcare professional—is the most successful model. Proof of that is right in front of us. I can say with pride that H.C.G, with its unique hub-and-spoke model, succeeded beyond anyone's wildest imaginations. This can be replicated in parts of Africa as we move forward with the idea to give people access to high-quality and affordable cancer care.

Chapter Twenty-Two

India has a value-based healthcare system and is one of the top leaders when it comes to quality in such a system. Now, what does this mean? India has multiple social structures or, as some people term it, multiple countries within a country. We have a large population of around 250 to 300 million moving up the economic ladder, who are demanding quality healthcare. We also have another 800 million who are in the lower socioeconomic group, who are trying to move up the economic ladder.

What do they look for? Education and healthcare.

This staggered social structure across the large population has major implications for healthcare and education. Obviously, the more educated you are, the more confident and secure you are, and you seek better healthcare. Whereas, if you're not well educated and in the lower socioeconomic strata, you only have access to cheap healthcare.

But cheap healthcare is not quality healthcare. What I'd like to see in the health sector, whether you are rich or poor, is value-based healthcare. Sometimes our country is given two names— 'India', which is the middle and upper middle class, and 'Bharath', which is the lower socioeconomic strata comprising nearly a billion of the population.

Now, what is value-based healthcare? For a particular type of condition, with the same technology and expertise, we can deliver in India for one dollar what costs ten dollars in advanced countries like the U.S—or the equivalent of seven dollars in Europe, or four dollars in Africa—and get the same or maybe even a better outcome. That is value-based healthcare.

I think in India today, as a doctor and healthcare provider, I'm very proud to say we have mastered value-based innovation. In the example of our own H.C.G cancer care, we have done that successfully in tier 2 and tier 3 cities. When you make cancer care accessible by expanding operations geographically, it also becomes affordable because the cost comes down significantly. This is especially true with innovations like our hub-and-spoke model, which lends itself very well to a value-based healthcare system.

Value-based healthcare through innovation—a case study

Bringing in value-based healthcare while reducing the cost and increasing accessibility is one thing, but helping doctors themselves in distress is quite another. You need to do the latter in a systemic way to achieve the former. Otherwise, you will not have as many healthcare providers as you need to bring in value-based healthcare at scale.

Suchirayu is a case study of how H.C.G tries to help doctors in distress. My firm belief is that when doctors start an institution or healthcare facility, they have a vision.

Some people tend to be dismissive, saying that doctors are self-centred, money-minded and poor administrators. But I like to cut through all that and just focus on their vision. Suchirayu, in the north Karnataka city of Hubli, had been built as a sophisticated centre, complete with a helipad and meeting all global standards. It had been commissioned in 2015. The group of doctors behind it had this great vision of building a very modern hospital.

But they had made one big mistake. While planning, they had been carried away. To fund their grand plans, they had not only put in their own money, but had also gone overboard in borrowing around one hundred and twenty crore rupees.

The monthly interest payment itself was coming close to a crore. Soon, their bottom line failed to keep pace with their debt liabilities, and their pile of debt began to grow. Unable to service the growing debt, they had fallen into a classic debt trap. These were all leading doctors in Hubli, well respected by the community.

This may be a good time to take a step back and look at what it takes to be a specialist doctor. He or she has to do their bachelor's degree (M.B.B.S) over five years, followed by a postgraduate degree over three years, and then a specialized degree over another three years. So, you are looking at a minimum of ten to eleven years of education and hard work.

Medical practice becomes part of your everyday life. Night calls, rounds, emotions, unpredictability, disruptions in your personal life, and dealing with sickness and mortality—all this is bound to have an impact on the individual and his or her family, which society may not realize. So, when a group of doctors with a passion start a hospital and appear to fail for the wrong reasons, I feel it is important to give them a helping hand.

When the hospital first got into trouble, the Hubli doctors had asked a major corporate hospital to come in and manage their operations. For this they agreed to pay the hospital around fifteen lakh a month. All the corporate hospital did was use their bed sheets and charge them for that, which became an issue. This turned out to be a mistake in the long run. Eventually, the debt crisis worsened, with banks hounding them for repayment.

Almost bankrupt, Suchirayu approached several corporates and institutions, but no one wanted to fund them. It became very difficult to restructure the loan because of banking rules and regulations.

In August 2017, when they approached us for restructuring on operations and management (O&M) contract, my team literally wrote them off, warning me against taking them on. I knew it would be very difficult. I could have easily ignored the doctors' request. The problem was, these doctors had pledged their properties as collateral for the bank loans, so they were in real danger of losing their hard-earned personal wealth. They were obviously stressed and had a lot of disagreements.

We first looked at the quality of the doctors. We assured them that we had faith in them and that they could get this hospital going again. On the other hand, for us or anyone else to build a hospital like that from scratch would take years.

Not just that, there was a great vision in this project, as I have mentioned. To allow it all to be wrecked would be criminal. The money had to come in right away. With my gut feeling that these were good doctors who were trying to make an impact, I decided to take it up as a challenge. I told my team that even if we didn't succeed, it would still be a great learning.

It was not easy to convince the board of our plan, but I told them we could get into it in a structured way, and they could take their time to figure it out. Anant Kittur, our director of projects at H.C.G, studied the case and came up with some ideas. He talked to the Suchirayu doctors, discussed the case with Yes Bank, and brought all stakeholders together. Then we started talking about the issue-based revival of Suchirayu.

We confided to the banks that Suchirayu was in some difficulty but that we would certainly repay every last dime. We negotiated with S.B.I to bring down the dues owed and asked Yes Bank to fund the hospital over the long term in what was called a 'camel back' repayment. Anant restructured the deal in a brilliant way and without any significant debt on H.C.G books. We restructured it in ten months, took a stake and now have the entire funding redone, with H.C.G itself funding it partially.

We paid doctors what they were due, and all the top doctors returned to practice at Suchirayu. The H.C.G brand name gave them confidence and they restarted work with great dedication, while we managed the working capital and debt repayments, resulting in improved revenues and debt position. Today, Suchirayu is healthy and doing better than ever before. We're not out of the woods yet but I am confident that this centre will shine. More than the financial recovery of Suchirayu, I feel happy that we were able to help some deserving doctors avert financial ruin.

Another interesting way you can lower costs while still ensuring value-based healthcare is by exploring alternative ways of spreading awareness and sourcing inputs. We did this in the joint venture we had with J.S.S in Mysuru, which was called J.S.S Bharat. Here, I introduced the concept of medico social workers, and brought it to Bengaluru as well. Lots of people have expressed appreciation for this idea. I used it as infrastructure to develop many rural programmes. and camps. (At the time I used to do a thousand camps, one after the other like a crazy man. I went to every nook and corner of the district, despite tremendous back pain at the time because of a disc problem.)

Our persistent efforts paid off and J.S.S Bharat became a landmark in Mysuru. Then we put a linac at J.S.S, which helped improve our treatment services. Fortunately, I also had 10 acres of land, which we utilized for organic farming. Today, we serve all patients organic food and they stay there for a nominal cost.

Unlike in the case of other multispeciality hospitals or hospital chains, no one here complains of the cost. It has become a low-cost quality centre, where we have built private wards, and expanded that to surgical wards. Today, it is a state-of-the-art cancer care centre with high-end equipment such as linac and P.E.T scan, which even more 'reputed' older cancer care institutions do not have.

Private healthcare in India today

Somehow people seem to have a hard time recognizing what we have built at centres like J.S.S Bharat. In smaller cities like Mysuru, the attitude and culture tend to be oriented towards cost-consciousness. Keeping this mind, we have innovatively built a very cost-conscious cancer centre.

We set this up as a not-for-profit centre. You go to someone who can afford to put high-end technology in a centre, and you manage all the services while managing the costs, which results in value-based healthcare; at the same time you are not burdened by debt servicing. This is the model that has worked out for us.

Here, one aspect I'd like to call attention to is that when I set up the Mysuru centre, people asked me if I was from Mysuru.

Similarly, when I set up the Shimoga and Hubli centres, people asked if I was from Shimoga or Hubli, respectively. Why do I need to be from any of these places to set up cancer care centres there? If you want to do something, it need not be in your own backyard. This mindset in people has to change. They need to recognize good work for what it is, without attributing banal reasons to it. Cancer is the same everywhere and everyone deserves the same kind of treatment, rich or poor, urban or rural.

Interestingly, when it comes to private healthcare, the role of the government is key. I find their policies short-sighted and lacking in vision. Part of the reason for this is that government advisers are all government doctors or bureaucrats. How can a bureaucrat who is today in charge of, say, Metro construction, become the healthcare in-charge tomorrow? How can he or she say they have domain knowledge and teach the doctors what to do? It is high time we looked at domain experts to handle issues. They should be part of expert committees and come up with recommendations and policies that can be executed by the bureaucrats.

When healthcare professionals and doctorpreneurs set up models (such as for-profit and not-for-profit) and devise policies for their organizations around retained profits and dividends, bureaucrats may not always understand the business rationale behind them. In September 2018, I remember speaking to the director general of employees' state insurance (E.S.I). He was a former I.A.S officer who became our consultant. In that particular conversation, the talk veered to corporate profits, and I asked him casually whether he knew that private institutions like ours did not give dividends; instead, at H.C.G, the money was ploughed back into the system to bring in higher technology and also make it accessible and affordable in tier 2 and tier 3 cities. He was shocked because he was under the impression that private healthcare institutions made tons of money.

Similarly, when we opened a centre in Nagpur recently, I talked about the enormous impact made by private healthcare. I informed the audience that it was a private institution that was opening this cancer care centre in Nagpur, where there is much need for it. When I revealed that without any government help (or taxpayers' money), we are able to plough the money back into the system and create value-based healthcare by facilitating high-end technology in tier 2 and tier 3 cities, there was surprise all around; the chief minister who had graced the occasion was astonished too.

I feel N.G.O's and the media have a role to play in sustaining certain misconceptions surrounding innovations in our sector, which are promptly dubbed 'capitalist' and 'elite'. N.G.O's are fond of saying they are fighting for the public, but have not understood how much private institutions have contributed to advancing this country. Most of the media, obsessed with sensationalism, are quick to label as capitalist any initiative we take or look at only one aspect of the entire thing.

Let me list a few examples here. If you study how media interactions take place in this country, typically we have a press meet, where we invite the media to talk about a new technology that we have brought in. For instance, the CyberKnife technology, which costs six million dollars and is not available anywhere else in India, except one other centre, was procured by us after an exhausting struggle. Now, when we explain to the media that it is a precision medicine, that there are only a few centres globally that have this kind of advanced technology, and that India is at the forefront of advanced care because of this, the first question the media comes up with is: What is the cost? What about poor people?

Here is a technology that has never been available to thousands of Indians who need it, but look at the kind of questions being asked. Were people happier when such technology was not there, and they were getting treated by outdated technology like Cobalt units? So, when you bring in linac or CyberKnife, suddenly people start focusing on the cost instead of trying to understand how this technology has come to the country or how value medicine is being practised here. I think the media and N.G.O's in this country need to change their mindsets; the chatter should instead be about value-based medicine.

To be fair, I think some of these misconceptions and doubts have been born out of instances of unethical practices carried out by some private healthcare providers. Then again, when there are unethical practices in government hospitals, or when a patient dies in a government hospital, no questions are asked. There is a gross lack of ventilators, lack of support for pregnant women, no wheelchairs for patients and no basic processes. Quality in government healthcare institutions has a ceiling, and these institutions don't produce outcomes, but somehow it is not important because it is the government.

Examples of this abound in every state, district and city. Today, anaemia levels in rural women of reproductive age are below that of the sub-Saharan African region. In some states in India, maternal and infant mortality are the highest in the world. The healthcare index in India is abysmal, and is comparable to African countries. So, when we have such enormous demand for primary care, why are we not demanding that the government focus on primary care rather than intervening in affairs of tertiary care? Why is there no public demand for this accountability?

On the other hand, if there is ever an issue in the private sector, it gets blown out of proportion. Say a patient dies in a government hospital or there is an issue of government negligence, does the responsible person in the health ministry resign? Or does one see bureaucrats stepping down? Do they resign if there is a fire in a government hospital? No. But if this happens in a private enterprise, there is a big hue and cry, and people are put in jail. That will be the right thing to do if there has actually been negligence on the part of the caregiver, but there should be consistency in the applicability of this accountability.

To call a spade a spade, certainly there are cases in the private healthcare sector where the question of ethics is being raised, and there is a small section of the private healthcare sector that does resort to unethical practices or negligence in patient care. What can the government do in such cases? It should identify these practices, close down the hospitals following unethical practices, and cancel licences for doctors who are running such questionable operations.

Viewed from another angle, this kind of huge disconnect between the ways we look at the government and the private sector is because the government is the monitoring agency and, at the same time, also part of execution and performance. For example, while it runs hospitals and medical colleges, it also monitors the healthcare sector on the whole. So, certainly there is an inbuilt bias. This bias has to be addressed in a systemic way and removed for the greater good of society. The government should redefine its role, be involved only in monitoring and empower private enterprise to give value-based healthcare for all sections of society, especially those in the lower socioeconomic strata.

For the welfare of society and better health of all individuals, the government and private enterprises should work together. When 75 per cent of healthcare is provided by private enterprise, the government has to create bodies where there are joint working relationships. The government should become a monitoring agency looking at the ethics and quality of care. It should focus more on primary healthcare.

Cashless universal healthcare to all can lead to equality of care. There should be no difference in treatment for the rich and the poor. Outcomes should be measured, reimbursement should be proper, and institutions should invest in technology, research and development, and proper talent. With such a system in place, we in India today will have a huge opportunity to reverse-innovate, create value-based models, challenge the world and truly become a leader in healthcare services.

Epilogue

My journey has been an adventure in two worlds: India, where I was born, and the U.S, where I emigrated at the age of twenty-two. In the U.S, I was able to experience an advanced society.

My happiest moment has been returning to India for good and making a difference in healthcare by building the H.C.G chain of oncology care centres, but at this juncture my story is not complete. As I reflect and look to the future, I am amazed at how much more one can do in a country like India—a country where 1 per cent of the population controls 85 per cent of the wealth. The political system is rife with populist ideas, where we seem to celebrate poverty rather than prosperity.

When I went to the U.S in 1975, a well-dressed cleaning lady came in a nice car and cleaned my apartment. Even after nearly forty-five years, we don't have that in our country and don't harbour any hope of seeing that in the near future either. We are informed of various subsidies and waiver schemes through prominent advertisements by the government; they tell us how the government is helping the poor by giving them free cooking gas and other free or subsidized commodities. When will we see ads that say the government helped the poor earn so that they could access these commodities at the right price? Isn't this what would bring pride to our nation and make us an advanced country?

Once, at a talk, His Holiness the Dalai Lama said we should develop a generation of children that has confidence. I asked him a simple question: 'How can children become confident when we tell them to take pride in being a member of the backward class and take benefits rather than work towards becoming a forward class and refuse benefits?' Today, there is a great urban–rural divide in this country, a divide between the haves and the have-nots. There is considerable polarization.

The religious card has been used heavily by the political system. There is a fundamental question about whether we are a secular country. People with dubious backgrounds are our elected representatives in many cases.

For centuries, we have been a tolerant society, maybe because of the theory of karma, where we are told to live with the consequences of our actions. When it comes to adverse consequences, it can instil a defeatist attitude in us. The concept of karma is being misused and misinterpreted, and hope dangled in front of the poor to exploit the lot of the have-nots. Corruption, nepotism and misuse of religion are eroding the very foundation of our democracy. Our laws, bureaucracy and systems are leftovers from the British rule. Even though the British left India seventy-two years ago, we still suffer from their legacy.

Today, in India, we need leaders with vision and boldness, not leaders with merely populist ideas. We should take pride in ourselves, our own capabilities as much as our rich heritage, instead of looking towards the West to lead us. The goal is to become an advanced country—and we certainly have rich resources, the most important being human talent. An ecosystem has to be created where we nurture these values and talents, and celebrate failures as well. There is a golden opportunity in health, education and skill development for us to leapfrog and become an advanced country.

Our work in healthcare, particularly in rural India, has led us on other paths as well. In 1988 I started an organization called International Human Development and Upliftment Academy (I.H.D.U.A) to see how we could improve the economic condition of women. The genesis of this idea was a project we did on downstaging cervical cancer. We conducted a house-to-house survey of 150,000 women, where we found that most of them were working an unbelievable eighteen hours a day. More poignantly, they were living a hand-to-mouth existence and eating only leftovers. Most of those in the reproductive age were anaemic. It was clear that we needed to improve their economic condition before they could focus on health.

As a pilot project under I.H.D.U.A, we started a women's empowerment programme. It was based on the self-help group (S.H.G) model. Over the last decade, this initiative of ours has helped the S.H.G members to not only take large loans at low interest rates to develop businesses, but has also eliminated local lending at high interest rates. The per capita income of this segment has increased manifold. This has helped the local population considerably by increasing prosperity levels, and I.H.D.U.A can become a model for the development of Indian villages.

We have ventured into education. In 1994, we started a school in a remote rural area called Mullur near Mysuru, where I have been holding health camps for the past twenty-five years. The school had its genesis in the lack of basic amenities for the local population.

Prominent locals told me that such health camps were fine but what they really wanted was education for their children. We immediately swung into action and I started a school in Mullur, an area that did not even have electricity at the time. The school, Vinayaka Gyanashaala, where we have now brought in computers, is thriving. The pass percentage for the school-leaving exam (S.S.L.C) is almost 100. Students have gone on to become scientists, software engineers and other professionals. Thus the families can now afford quality healthcare.

Both these experiments, in livelihoods and education, have shown that proper investment in improving the prosperity and education of underprivileged sections can bring about more focus on health, both at the individual and the society levels. These aspects—economic condition, basic education and primary healthcare—are thus interrelated. They are the nub of the matter, the factors to focus on in order to bring prosperity to rural India and make India an advanced nation.

Looking ahead, I would like to concentrate on education and economic well-being, along with healthcare, expanding our think tank 'Antardhwani' to becoming a public-policy-inclusive institute. I look at this as the next phase of my life, after my achievements as an entrepreneur in healthcare and guiding H.C.G to serve society. Today, India needs activism and accountability. We have a rich heritage and are capable Epilogue of being an advanced country, if we hold governments accountable and become responsible citizens of society. I intend to actively grow into this new disruptive avatar of entrepreneurship. It's a new chapter in my life—one that promises much in terms of what can be achieved for society at large.