Book title: When Breath Becomes Air
ISBN: 978-1-9848-0182-1
Author: Paul Kalanithi
Publisher: Random House LLC New York
When Dr Paul Kalanithi sent his best friend an email in May 2013 revealing that he had terminal cancer, he wrote:
“The good news is that I’ve already outlived two Brontës, Keats, and Stephen Crane. The bad news is that I haven’t written anything.”
It was a jokey way of dealing with the unthinkable but also an indication of Dr Kalanithi’s tremendous ambition. He had led a fascinating life and was not about to leave it unchronicled.
The bittersweet news is that in the 22 months left to him, Dr Kalanithi, who died at 37, went on to write a great, indelible book, “When Breath Becomes Air”, that requires a different kind of mindset for reading.
You need to give yourself over to the narrative and be prepared to jump on an emotional rollercoaster. At the very least, you need to respect it by giving it your full attention. So, I decided to read it on our recent flight to Qatar. I figured the eight-hour journey from Singapore would be perfect for this compact hardcover book with a pale blue feather that epitomised the title.
I was prepared for tears. I was prepared to be moved. What I was not prepared for was the beauty of his prose. How can a neurosurgeon wield both the scalpel and words with such exquisite precision? It turns out Dr Kalanithi was a student of literature and philosophy long before he turned his focus to medicine. And he was a master of both these tools.
To paraphrase my wife, reading this book is to feel that Dr Kalanithi still lives, with enormous power to influence the lives of others even though he is gone.
She suggested not only reading “When Breath Becomes Air” but also listening to the overwhelming response it prompts in you.
I guarantee that finishing this book and then forgetting about it is simply not an option.
There is so much here that lingers, and not just about matters of life and death. One of the most poignant aspects of Dr Kalanithi’s story is that he had postponed learning how to live while pursuing his career in neurosurgery.
By the time he was ready to enjoy a life outside the operating room, what he needed to learn was how to die.
Dr Kalanithi’s abiding and eclectic interest in serious literature serves him well throughout the book. Its hauntingly beautiful title is a paraphrase from the poem “Caelica 83”, part of a 17th-century sonnet series by Fulke Greville. It’s obscure but could not be more apt. Thomas Browne’s “Religio Medici” was the book he loved most.
He wrote his own book with great determination but also encountered great difficulty. At one point, he even wore silver-lined gloves to use the trackpad, as his fingertips began to crack during chemotherapy.
(In the epilogue and afterword by his wife, Dr Lucy Kalanithi, also a doctor, she mentions that the manuscript had to be completed posthumously.) But the difficulty doesn’t show: Dr Kalanithi knows how to make a paragraph fly. The book opens with a beauty, quoted here to demonstrate its swift economy and precision:
“I flipped through the CT scan images, the diagnosis obvious: the lungs were matted with innumerable tumours, the spine deformed, a full lobe of the liver obliterated. Cancer, widely disseminated. I was a neurosurgical resident entering my final year of training. Over the last six years, I had examined scores of such scans, on the off chance that some procedure might benefit the patient. But this scan was different: it was my own.”
With those facts established, he is free to flash back through the lifetime of experiences that brought him to this point: an unusual love-hate relationship with medicine, as the thing that kept his father, a cardiologist, away from home at night, but also struck him as a calling rather than a profession.
After his family moved from Westchester, NY, to Arizona, he and his brothers were essentially home-schooled by a strict mother who had no idea what truly excited Paul, the neurosurgeon-in-waiting.
She worried about her sons and drugs, “never suspecting that the most intoxicating thing I’d experienced, by far, was the volume of romantic poetry she’d handed me the previous week.”
With a seeker’s restlessness that seemed to persist until his last breath, he went on to earn two B.A.s and an M.A. in literature at Stanford, followed by a Master of Philosophy at Cambridge, before graduating cum laude from the Yale School of Medicine. He returned to Stanford for a residency in neurological surgery and a postdoctoral fellowship in neuroscience. His training was almost complete when the bad diagnosis hit.
In the first half of the book, Dr Kalanithi provides a collection of anecdotes about his journey from medical resident to seasoned doctor: his first cadaver (formaldehyde stimulated his appetite), his first experiences with births and deaths on the same day (which reminded him of “Waiting for Godot” and its line about “birth astride of a grave”).
From the start, workaholic though he is, he understands patients’ needs better than most young doctors do.
Then everything changes. In a single moment of recognition, everything Dr Kalanithi has imagined for himself and his wife evaporates, and a new future must be imagined. Should they have a child, or would that make it harder for him to die? (They do. The book is dedicated to their daughter, Cady.)
A job at Stanford for which he was the prime candidate? Not happening. Another good job that would require the Kalanithis to move to Wisconsin? Too far from his oncologist. Long-term plans of any kind? Well, what does long-term mean now? Does he have a day, a month, a year, six years, what? He’s heard the advice about living one day at a time, but what’s he supposed to do with that day when he doesn’t know how many others remain?
“When Breath Becomes Air” grips readers from the start, but it becomes even more compelling as Dr Kalanithi tries to reinvent himself in various ways with no idea what will happen next. He can’t gauge how much strength his body still has until he tests it, and sometimes the consequences are horrific.
He no longer knows who he is or what he wants; his whole sense of identity is shaken. During a terrible period when his oncologist is away, he is treated as a problem rather than a patient by an inept medical resident, who nearly hastens his death by denying him one of the drugs he desperately needs.
Part of the book’s tremendous impact stems from the fact that its author was such a brilliant polymath, and part comes from the way he conveys his experiences — passionately working and striving, deferring gratification, waiting to live, and learning to die — so effectively. None of it is maudlin; nothing is exaggerated.
As he wrote to a friend: “It’s just tragic enough and just imaginable enough.” And just important enough to be unmissable.
