When Breath Becomes Air
By Dr Syed Amir
Bethesda, MD

Once in a while one reads a book with a narrative so touching, and the narrator so expressive, so promethean, that it leaves behind a long-lasting impression. Dr Paul Kalanithi’s memoir, “When breath becomes air,” published a year after his death in March 2015, will eminently qualify for inclusion in that exclusive list. After publication, the book rapidly climbed the New York Times’ best-seller list and has stayed there for more than 11 weeks.

The author belongs to an elite class of second generation Indian physicians whose parents migrated to this country, and who have emerged as highly admired non-fiction writers, with millions of copies of their books sold worldwide. Kalanithi, an accomplished neurosurgeon, is distinct from others in one important respect: he died of metastatic lung cancer when he was only 38-years old.

US medical schools uniquely do not require a degree in biological sciences as a prerequisite for admission. In fact, some students obtain graduate degrees in English literature, pursuing studies in liberal and fine arts and only later deciding to go to medical school to become physicians or surgeons. Culturally, children of South Asian immigrants in the US feel some degree of pressure to study medicine, even when it may not be their own preference, since practice of medicine is a secure and highly lucrative profession.

Son of a Christian father and a Hindu mother from South India, who were repudiated by their respective families for marrying outside their religion and had to emigrate to the US, Kalanithi grew up in the state of Arizona, and developed an independent thought process. As a young man, he became fascinated by the question of “where did biology, morality, literature, and philosophy intersect.” In his book, he noted, “I studied literature and philosophy to understand what makes life meaningful, studied neuroscience and worked in a lab to understand how the brain could give rise to an organism capable of finding meanings in the world.”

Kalanithi obtained his undergraduate and Master’s degrees in English literature and then completed a BA in biology from Stanford University in California, the subjects reflective of his eclectic interests. He subsequently enrolled in the history and philosophy of science and medicine at Cambridge University and earned an MPhil. Having satiated his desire to explore literature, philosophy, and liberal sciences, Kalanithi finally sought admission to the Yale Medical School, one of the most prestigious in the country. He obtained his MD degree with high honors.

Dr Kalanithi and his newly wedded wife, Lucy, also a medical doctor, headed back to Stanford to complete their residency training in neurosurgery and research. The memoir described the joys and sorrows of a newly minted surgeon, drawn from both saving lives, and losing lives that perhaps might have been saved by a more experienced physician. He also learnt that although doctors were trained as healers, sometime, it was more humane to let a patient go, rather than condemning him to a vegetative existence. Meanwhile, he never lost his inherent curiosity, reminding himself that his “highest ideal was not saving lives—everyone dies eventually—but guiding a patient or family to an understanding of death or illness.” He exquisitely captured in words the emotions, the fears, the vulnerabilities of his cancer patients as he tended to their therapeutic needs. As the chief surgical resident, he was often powerfully moved, especially by his failure to save young patients, when his surgical skills and professional dexterity were not enough.

Finally, life seemed to be following an upward trajectory for the young doctor, who had invested many years in his training and development as a neurosurgeon. He had won many coveted academic awards and had been offered faculty positions in several prestigious universities, with job offers as well for his wife as an extra incentive. Even the research director at Stanford University, his own alma mater, held out prospects of a senior faculty job for him. Just when a rosy future seemed to be awaiting him, and when he and his wife were planning to have a baby, fate dealt a devastating blow. At age thirty-six, he was diagnosed with stage IV lung cancer.

The memoir traces in superb details the progression of the deadly disease, both from the perspective of a patient and a doctor. Kalanithi portrays his abrupt transformation from a physician who went on his routine of clinical rounds, training junior doctors in the hospital, issuing instructions for the treatment of his patients to becoming a patient himself, experiencing at first hand the tribulations of sickness. The problem started with severe chest pains and steady weight loss, progressing to ferocious back pains. A series of medical tests, confirmed the diagnoses of what he had suspected, he was suffering from terminal lung cancer.

On a long flight to the east coast to meet some old college friends in the hope finding some comfort and succor from all the stress and apprehension, he suffered terrible back spasms. On reaching Grand Central Railway Station to catch a train, the pain got so severe that he “curled up on the floor, screaming.” As he lay down on the hard floor in the waiting area, a security guard approached. “Sir, you can’t lie down here.” He muttered, “I am sorry,” gasping out the words, “Bad…back spasms.” The guard did not relent. “You still can’t lie down here.” The neurosurgeon on the floor wanted to plead, “I am sorry, but I am dying from cancer,” but he did not and moved. A temporary remission brought by chemotherapy permitted Kalanithi to briefly resume his surgical practice. The arrival of their baby daughter brought another joy in his life.

Paul Kalanithi started working on his memoirs when he was still in good health. When he got sick, he worked on it nonstop, virtually using the last ounce of his energy. Acutely conscious of the limited time available to him, he wrote furiously, even composing his thoughts while waiting to see his oncologist. His wife noted in the epilogue section, “Paul wrote, reclining in his arm chair, wrapped in a warm fleece blanket. In his final months, he was singularly focused on finishing this book.” Yet, he died before he could finish it, but a highly powerful and moving portrayal of his final days is provided by his wife in the epilogue.

The end came swiftly when the chemotherapy stopped working. His close family, mother, father, and siblings gathered around him, all emotionally distraught and unable to help. Various medical tests showed that his cancer had now invaded his brain; prospects of the loss of mental acuity would be most distressing to him. He was now struggling even to breathe and had to be moved to the hospital’s emergency room and connected to an oxygen reservoir. His doctors discussed the vanishingly few treatment options with him and the family. As a physician, Kalanithi knew there were none. The possibility of connecting him to a ventilator was raised, but it would mean prolongation of a meaningless life. He would not countenance that.

Kalanithi made the fateful decision. When his wife returned to his bedside, he was fully alert and said in a clear voice, “I’m ready.” He wanted all artificial means of life support removed and administration of morphine initiated to hasten the dying process. Surrounded by his loving family and his infant child, he passed away peacefully.

The book is only 225 pages long and has no chapters or subheadings. It is divided into two parts. Part one deals with the time when Kalanithi was healthy, his training and academic achievements. Part two deals with his devastating illness and ultimate demise. After reading the book it is hard to conclude whether Dr. Paul Kalanithi, if fate had dealt him a different hand, would have evolved into a great surgeon or a superior writer. At an early age, when asked by his uncle what he wanted to be in future, Kalanithi responded, “A writer.”