Paul Kalanithi, When Breath Becomes Air

How does one review a book like this? How is it possible to even judge a book written by someone with such deep insight into life and living and living while dying? I don’t think it is. In fact, it’s impossible to be anything but moved by Kalanithi’s gracious manifesto which is on so many levels a love song to his young daughter, to his life, his wife, and all that he will never experience.

So do not consider this a review. Consider this instead a series of reflections about this profound and beautiful memoir.

There is no doubt that Kalanithi was an exceptionally gifted human being. Born in 1977 he graduated from high school as valedictorian, from Stanford with a BA in Literature and MA in History and the Philosophy of Science and Medicine and then – despite the fact that he had the option to pursue a PhD in English literature, he switched to the Yale School of Medicine where he graduated in 2007 cum laude winning a prize for his research on Tourette’s Syndrome. He went on to become a neurosurgeon. All of the depth of this intellectual experience is clearly reflected in Kalanithi’s book which blends art and science into a magnificent reflective tapestry.

In many ways, the book’s title reflects this tapestry – when does breath become air? Does it actually become air? What is air? Breathing is a scientific concern, the result of a biological process that involves the exchange of gasses. You can watch someone breathe. But can you watch breath? What does breath look like? It’s easy to see when it’s cold outside and breath takes on a form … but otherwise, how do we know breath? I wonder about a person’s last breath … the final inhalation and exhalation. I am reminded of my Bobba – my grandmother – whose last breath I watched. She was surrounded by family and my Oupa (grandfather). It was quite beautiful to know that we could all say goodbye. There was a ceremony to it and a sense of release that I think we all – her children and grandchildren – felt. I certainly felt comforted to know that my grandfather wasn’t alone in this moment. He took his last breath alone in a hospital room and I always felt that there was an injustice in that … but it’s another story altogether. Kalanithi takes his last breath before the publication of his memoir and the epilogue is in fact written by his wife Lucy. She commences with a poem by Emily Dickinson which sums up Paul’s attempt to reconcile his reflections about life with his knowledge of science and medicine.

You left me, sweet, two legacies –

A legacy of love

A Heavenly Father would content,

Had he the offer of;

You left me boundaries of pain

Capacious as the sea,

Between eternity and time,

Your consciousness and me.

– Emily Dickinson

Lucy tells us that Paul died surrounded by his family … his daughter, Cady, wasn’t yet one year old. A life lived … but not enough.

Yet, despite the sadness that tints these pages, this is a love story on so many levels. It’s Paul’s love for learning – for literature and words and ideas and thought. It’s his love for the human brain, for science in general, for patients and the impact that his work can have on them. It’s his love for Lucy and her love for him which she describes in an interview after his death as a kind of “forever” love. There is so much to learn here about the value of human connections and the importance of knowledge and passion and commitment to challenging oneself on all levels. Paul teaches us to never be satisfied. To always strive to improve because that is part of what makes life worth living.

Most of all, this is a book about the worth of a life. And here it is impossible to improve upon Paul’s own words:

Everyone succumbs to finitude. I suspect I am not the only one who reaches this pluperfect state. Most ambitions are either achieved or abandoned; either way, they belong to the past. The future, instead of the ladder toward the goals of life, flattens out into a perpetual present. Money, status, all the vanities the preacher of Ecclesiastes described, hold so little interest: a chasing after wind, indeed.

Yet one thing cannot be robbed of her futurity: my daughter, Cady. I hope I’ll live long enough that she has some memory of me. Words have a longevity I do not. I had thought I could leave her a series of letters — but what would they really say? I don’t know what this girl will be like when she is 15; I don’t even know if she’ll take to the nickname we’ve given her. There is perhaps only one thing to say to this infant, who is all future, overlapping briefly with me, whose life, barring the improbable, is all but past.

That message is simple: When you come to one of the many moments in life when you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more, but rests, satisfied. In this time, right now, that is an enormous thing.

It is easy to see why When Breath Becomes Air was a finalist for the Pullitzer in 2017. It traverses the human experience with such soft empathy that it is impossible not to appreciate both its literary and thematic value. But is also reminds us that we should take nothing for granted. Dr Paul Kalanithi, for all his commitment to learning and medicine and to understanding what makes a life worth living, never actually practised as a neurosurgeon. His diagnosis came toward the end of his 10 years of training for the specialty. What a profound irony that a man so gifted with so much to live for could die just as his life was about to truly begin.

This is a book abounding in wisdom, beautifully crafted and magnificently profound. Dr Abraham Verghese, author of Cutting for Stone, writes the prologue to When Breath Becomes Air. He ends it with the following words:

Be ready. Be seated. See what courage sounds like. See how brave it is to reveal yourself in this way. But above all, see what it is to live, to profoundly influence the lives of others after you are gone, by your words… experience this dialogue with my young departed colleague now ageless and extant in memory. Listen to Paul. In the silences between his words, listen to what you have to say back. Therein lies his message. I got it. I hope you experience it, too. It is a gift.

Simply put: Everyone should read this book. Don’t just read it and move on. Instead, read it and carry it in your heart, allow it to remind you to live not just any life, but a life worth living. Work and grow and learn and strive, but don’t do it at the cost of living.

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