Field of Science

The late Paul Kalanithi's book "When Breath Becomes Air" is devastating, edifying, eloquent and very real

I read this book in one sitting, long after the lights should have been turned off. I felt like not doing so would have been a disservice to Paul Kalanithi. After reading the book I felt stunned and hopeful in equal parts. Stunned because of the realization that someone as prodigiously talented and eloquent as Paul Kalanithi was taken from the world at such an early age. Hopeful because even in his brief life of thirty-six years he showcased what we as human beings are capable of in our best incarnations. His family can rest assured that he will live on through his book.

When Breath Becomes Air details Dr. Kalanithi's life as a neurosurgeon and his fight against advanced lung cancer. Even in his brief life he achieved noteworthy recognition as a scholar, a surgeon, a scientist and now - posthumously - as a writer. The book is a tale of tribulations and frank reflections. Ultimately there's not much triumph in it in the traditional sense of the word, but there is a dogged, quiet resilience and a frank earthiness that endures long after the last word appears. The tribulations occur in both Dr. Kalanithi's stellar career and his refusal to give in to the illness which ultimately consumed him.

The first part of the book could almost stand separately as an outstanding account of the coming of age of a neurosurgeon and writer. Dr. Kalanithi talks about his upbringing as the child of hardworking and inspiring Indian immigrant parents and his tenacious and passionate espousal of medicine and literature. He speaks lovingly of his relationship with his remarkable wife - also a doctor - who he met in medical school and who played an outsized role in supporting him through everything he went through. He had a stunning and multifaceted career, studying biology and literature at Stanford, then history and philosophy of medicine at Cambridge, and finally neurosurgery at Yale.

Along the way he became not just a neurosurgeon who worked grueling hours and tried to glimpse the very soul of his discipline, but also a persuasive writer. The mark of a man of letters is evident everywhere in the book, and quotes from Eliot, Beckett, Pope and Shakespeare make frequent appearances. Accounts of how Dr. Kalanithi wrested with walking the line between objective medicine and compassionate humanity when it came to treating his patients give us an inside view of medicine as practiced at its most intimate level. Metaphors abound and the prose often soars: When describing how important it is to develop good surgical technique, he tells us that "Technical excellence was a moral requirement"; meanwhile, the overwhelming stress of late night shifts, hundred hour weeks and patients with acute trauma made him occasionally feel like he was "trapped in an endless jungle summer, wet with sweat, the rain of tears of the dying pouring down". This is writing that comes not from the brain or from the heart, but from the gut. When we lost Dr. Kalanithi we lost not only a great doctor but a great writer spun from the same cloth as Oliver Sacks and Atul Gawande.

It is in the second part of the book that the devastating tide of disease and death creeps in, even as Dr. Kalanithi is suddenly transformed from a doctor into a patient (Eliot helps him find the right words here: "At my back in a cold blast I hear, The rattle of bones, and a chuckle spread from ear to ear")
. It must be slightly bizarre to be on the other side of the mirror and intimately know everything that is happening to your body and Dr. Kalanithi is brutally frank in communicating his disbelief, his hope and his understanding of his fatal disease. It's worth noting that this candid recognition permeates the entire account; almost nothing is sanitized. Science mingles with emotion as compassionate doctors, family and a battery of medications and tests become a mainstay of life. The doctor finds out that difficult past conversations with terminal patients can't really help him when he is one of them.

The painful uncertainty which Dr. Kalanithi documents - in particular the tyranny of statistics which makes it impossible to predict how a specific individual will react to cancer therapy - must sadly be familiar to anyone who has had experience with the disease. As he says, "One has a very different relationship with statistics when one becomes one". There are heartbreaking descriptions of how at one point the cancer seemed to have almost disappeared and how, after Dr. Kalanithi had again cautiously made plans for a hopeful future with his wife, it suddenly returned with a vengeance and became resistant to all drugs. There is no bravado in the story; as he says, the tumor was what it was and you simply experienced the feelings it brought to your mind and heart.

What makes the book so valuable is this ready admission of what terminal disease feels like, especially an admission that is nonetheless infused with wise acceptance, hope and a tenacious desire to live, work and love normally. In spite of the diagnosis Dr. Kalanithi tries very hard - and succeeds admirably - to live a normal life. He returns to his surgery, he spends time with his family and most importantly, he decides to have a child with his wife. In his everyday struggles is seen a chronicle of the struggles that we will all face in some regard, and which thousands of people face on a daily basis. His constant partner in this struggle is his exemplary wife Lucy, whose epilogue is almost as eloquent as his own writing; I really hope that she picks up the baton where he left off.

As Lucy tells us in the epilogue, this is not some simple tale of a man who somehow "beats" a disease by refusing to give up. It's certainly that, but it's much more because it's a very human tale of failure and fear, of uncertainty and despair, of cynicism and anger. And yes, it is also a tale of scientific understanding, of battling a disease even in the face of uncertainty, of poetry and philosophy, of love and family, and of bequeathing a legacy to a two year old daughter who will soon understand the kind of man her father was and the heritage he left behind. It's as good a testament to Dr. Kalanithi's favorite Beckett quote as anything I can think of: "I can't go on. I will go on".

Read this book; it's devastating and heartbreaking, inspiring and edifying. Most importantly, it's real.

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