When Breath Becomes Air

When Breath Becomes Air

By Paul Kalanithi

Published 2016

Read Oct 2020

This book was published posthumously after the author succumbed to cancer a mere twenty-two months after diagnosis with Stage IV Lung Cancer.  It has received several awards and spent over a year on the best seller lists.  The author had been struck down quickly and completely just as he was finishing his neurosurgery residency and just before he had originally hoped to launch a scientist/surgeon career and have a “normal” life with his wife, also a medical doctor.  The author wrote this book during the time between diagnosis and death.

These aspects this reader knew when she started reading the book. 

This reader posed some questions:   Was the hype surrounding this book associated mainly with the tragedy of the loss of a young medical superstar long before his time? Did the book itself have elements that could drive it to endure as a book of great substance after the early hype had faded? 

In Part 1:  In Perfect Health, the author gives us a sense of his journey leading to becoming a neurosurgery resident.   His father and uncles are doctors and he knew before graduating from high school that he didn’t want to become a doctor, especially as he saw little of his father while growing up He had decided “if that [little time with family] was the price of medicine, it was simply too high”.  He takes a BS in English and Biology at Stanford and then continues at Stanford for a MA in English.  After spending so much time with literature and words and his continuing interest in the biological aspect of identity, he decides to go to medical school.  He spends a year taking all the classes needed as prerequisites and during the year that his medical school applications are being considered, he completes a yearlong program at Cambridge in the History and Philosophy of Science.  That program confirms to him that words aren’t enough.  “I found myself increasingly often arguing that direct experience of life and death questions was essential [to him] to generalizing substantial moral opinions about them.”  “Moral speculation was puny compared to moral action.”

 So the author is off to Yale Medical School where he soon meets Lucy who will eventually become his wife (whom he discusses very little in the book).   When it is time to choose a path for residency, he chooses away from “lifestyle” specialties—those with more humane hours, higher salaries, and lower pressures.  So after choosing away from medicine before he entered college, he chooses neurosurgery because it “works in the crucible of identity” and it was the most demanding path.  Could he become a member of the ranks of the “polymaths”.  He now sought a career path that would be all consuming. 

While in his sixth year of residency, after he became chief resident, he begins experiencing a lot of pain in his back.  About six months later he finally submits to appropriate tests and scans and his feared diagnosis of lung cancer is made.

In Part II:  Cease Not Until Death, the author charts his progression through various treatments and through his evolution of the patient-doctor relationship.  Initially he is a clear partner with his oncologist in choosing his treatment course.   Although Paul initially doesn’t see the possibility of returning to surgery, his oncologist picks a treatment course that will be least damaging to his hands.  He does eventually return to residency, initially focused only on the surgery piece and later on the whole experiences of patient care as well after he learns his program may not find him worthy of graduation from residency if he doesn’t.    If ever there was a person motivated to be the best, Paul was certainly one, although he never actually says this.  He loses out on a Stanford surgeon/scientist position for which he was contending prior to his diagnosis but is later offered a similar position in Wisconsin which he decides he cannot accept.  His runway is no longer twenty years and the position required that in his view.  Through this period he understands that his oncologist has provided him the space to determine what’s most important to him so that the treatment course can be directed to support that. 

The patient-doctor relationship takes another turn just as he is about to graduate from residency abd just weeks before Lucy’s due date.  His disease begins to overpower him, preventing him from attending the graduation ceremony and shortly thereafter he releases himself from needing to be a doctor on his case.  He then fully devotes himself to writing this book. 

By considering the topics he spends significant time discussing, it’s possible to follow the author’s evolution on several paths:  what questions are important to him; what path should be pursued to answer those questions; what career path in medicine should be followed to allow driving as close to the asymptote of excellence he expects from himself.  A fundamental question he pursues throughout his life is what enables the essence of the identity?  Words can describe identity.  Biology must somehow define identity.  Neurosurgery can enable reclaiming the identity when the body is diseased.   But science is imperfect in answering some of these fundamental questions.   He comes to a wonderful conclusion:  Human knowledge is never contained in one person.  It grows from the relationships we create between each other and the world, and it is never complete.  And Truth comes somewhere above all of them…”

Lucy Kalanithi, Paul’s wife, provides a thirty page Epilogue that gives pictures from the last eight months of his Paul’s life:  his determination to write this book despite increasing pain including his fingers; the warm times they spend together with family and friends; the final days and hours of his life; the memorial service.  She attests she was a witness to his ability to face death with integrity. 

While the initial hype about this book was likely in part due to the tragedy of such a promising doctor being struck down at an early age, the book should remain recognized as a book of substance.  The author notes that dying of this type of cancer at such an early age is unlikely but dying at some point isn’t.  We all have to face death at some point.  His chosen vocation was to not only technically help his patients but also guide them in deciding paths of treatment—which might include no treatment.  He lived this situation from both sides of the patient/doctor relationship and it made him a stronger doctor.  In sharing his story the author the reader might choose to consider asking themselves a question he poised for himself—what gives a life meaning—which he learns is different than what gives a life purpose. 

The Girl with Seven Names—The Reality of Growing up in North Korea and Escaping from It

The Girl with Seven Names

By  Lee Hyeonseo

With David John

Published 2015

Read April 2018

This is one of several books published in 2015 by defectors from North Korea.  It is the only one read by this reader who can’t compare it with the other books.  However this reader can certainly recommend it for a look at life in North Korea and the daunting challenges facing those who wish to leave North Korea and live peacefully in South Korea or elsewhere.

The book has three sections:  “the Greatest Nation on Earth”, “To the Heart of the Dragon”, and “Journey into Darkness”.  The first section describes the author’s childhood including descriptions of the education children received to appropriately revere Kim Il-Sung “The Great Founder” and his son Kim Jong-il “The Great Leader” as well as “The Greatest Nation on Earth”.  All families had portraits of these men hung prominently in their homes and protected them carefully.  Her father focused on bringing the portraits to safety when their house was on fire, choosing this task above saving other household items.  The process of informing on other children for sins against the state was a regular part of the school week.   The second section describes her escape to China, her life there as an illegal alien (China pursues and expels North Koreans), journey to South Korea and her difficulties adjusting to life there.  In includes her amazement and initial disbelief in learning that many teachings of her childhood were blatant lies.  The last section describes her dramatic efforts to rescue her mother and brother from North Korea and get them to South Korea via Laos.  The difficulties she encountered and managed to overcome to accomplish this are simply astonishing.  While she remains grateful to be out of the harshness and constraints of North Korea, she also describes her longing to be able to return to her homeland, likely a universal feeling of many who have left their homeland.

The author gave a Ted Talk in February 2013 which has been viewed by millions on You Tube.  While this 13 minute talk is interesting, this reader recommends reading this book to get a more in-depth look at her extraordinary life and what she is teaching us regarding the realities of North Korea. 

Blue Nights

Blue Nights

By Joan Didion

Published 2011

Read June 2019

A wonderful aspect of being in a book discussion group is reading things you might not otherwise read.  One discussion group to which this reader belongs occasionally has its monthly meeting discussion books chosen by the reader based on some sort of assignment.  The assignment that brought me to this book was “A book with either “blue” or “blew” in the title.”  So this reader put “blue*” into the search engine for the library consortium, to which the sponsoring library is a member, to see what the search would reveal.  As expected—A LOT  of potential possibilities books.  As this reader worked through the descriptions of a variety of books, the title of this book first provided a source of pause.  Blue is this reader’s favorite color and is a delightful favorite as the sky provides a whole palette of blues to enjoy.  The period of twilight dissolving completely into night provides a specific blue palette that is especially remarkable.  The author’s name for this book was Joan Didion, an author this reader read years ago and enjoyed much for her remarkable language although not a single specific book title read could be recalled.  No worries.  The book was requested and delivered.

Upon opening the book, the first paragraph totally engaged this reader with her description of blue nights—apparent in New York (City) (where she now lives) but not in subtropical California (where she lived for much of the time described in the book).  “You pass a window, you walk to Central Park, you find yourself swimming in the color blue: the actual light is blue, and over the course of an hour or so this blue deepens, becomes more intense even as it darkens and fades, approximates finally the blue of the glass on a clear day at Chartres, or that of the Cerenkov radiation thrown off by the fuel rods in the pools of nuclear reactors.”  Although this reader has not been to Chartres nor seen radiation thrown off by the fuel rods in the pools of nuclear reactors, this reader knows that blue.  She continues “During the blue nights you think the end of day will never come.  As the blue nights draw to a close (and they will, and they do) you experience an actual chill, an apprehension of illness, at the moment you first notice:  the blue light is going, the days are already shortening, the summer is gone.”

Thus Didion sets the stage for this book.  Although some references and critics describe the book as an account of the death of her daughter, at age 39 and only twenty months after the abrupt death of her husband of a heart attack, there frankly isn’t really an account of her daughter’s death.  Rather there are short descriptions of aspects of her life with her daughter—getting a call for her adoption, the party celebrating her official adoption, taking her on various work trips, and others. She recounts several times hearing a group of doctors on rounds indicate the vent her daughter is on  is no longer able to provide the patient sufficient oxygen There are descriptions of fears she experienced during her daughter’s life (generally the ones all parents fear regarding injuries, losing them in a crowd, etc), fears she now experiences that are much more difficult (why didn’t she understand what her daughter might had been saying at various times, why didn’t she realize that her daughter would have the abandonment fears that adopted children often experience, etc), and the fear that she will lose her memories of her.   .  As well Didion discusses her concerns about aging which she now realizes is now occurring: the loss of physical capabilities, the increasing neuropathies that hamper her senses and impair her mobility, and especially her cognitive capabilities that are apparent in the act of writing: “What if the absence of style that I welcomed at one point—the directness that I encouraged, even cultivated—what if this absence of style has now taken on a pernicious life of its own? What if my new inability to summon the right word, the apt thought, the connection that enables the words to make sense, the rhythm, the music itself— What if this new inability is systemic? What if I can never again locate the words that work?”  “I encouraged the very difficulty I was having laying words on the page.  I saw it as evidence of a new directness.  I see it differently now.  I see it now as frailty.  I see it now as the very frailty Quintana feared.”

The book describes Didion’s raw thoughts and fears, some which are newly understood but had always there, some newly exposed and only evident when one reaches that certain point of the blue night.  Don’t read this book to learn about Quintana’s death.  Read this book to hear a wonderfully articulate author describe what she is experiencing as both a result of losing a daughter and as a result of realizing her summer is ending. 

Educated

Educated

By Tara Westover

Published 2018

Read Dec 2018

The author of Educated earned her PhD shortly after her 27th birthday and approximately ten years after she first left for Brigham Young University at age 17.  That she left for BYU seems extraordinary considering she had never attended any school previously. An older brother had a few years of public school (and earned a PhD as well) and had previously graduated from BYU.  He encouraged her to apply to BYU—study for the ACT exam to and attain an adequate score on the ACT exam and BYU would accept her as home-schooled.  . 

But Tara wasn’t home-schooled beyond learning to read.  Nor did she have a birth certificate until she was nine.  Tara’s world was defined by her father, a Mormon and separatist who is convinced that the family must prepare for both the End of Days (and was amazed the world survived Y2K), and the invasion of their property and their murder by the government.  He convinced Tara that the government would come after them, as they did the separatist Weavers, because they home-schooled.  Only when Tara was in college did she learn about what really happened between the government and Weavers, as well other historical events including the Holocaust and the assignation of Martin Luther King, Jr, to cite a few.

That Tara physically survived to turn 17 is remarkable as well.  Her father ran a salvage business and operated equipment with no thought to safety for himself or his “employees” (his children including very young Tara).  A near-fatal fall of brother Shawn while at work results in a severe head injury, which may have amplified his temper to the vicious and nearly deadly level he exhibits.  The leg of severely burned brother Luke is saved by Luke being placed in a barrel of cold water.  One car accident leaves Tara’s mother with a severe brain injury and brother Tyler with damaged teeth.  A second car accident puts Tara in bed with a neck injury.  Reading these sections almost feels voyeuristic. You know everyone survives but how? 

If that’s not enough, brother Shawn is clearly verbally, emotionally, and physically abusive towards Tara, her sister, and girls that, for some reason, are attracted to him, and to his wife.  Tara’s mother witnesses some of Shawn’s attacks on Tara but does nothing to stop them.  Brother Tyler likely saves Tara’s life in one instance when he arrives home after being away; Tyler prompts her to get away by going to BYU.  Tara’s father doesn’t believe her accusations about Tyler because there is no evidence beyond her recollections and what others have told her about their experiences.  Again this feels voyeuristic and believable only because it’s not a novel.

Tara does attain an acceptance level score on the ACT exam through self-study and with some tutoring from brother Tyler.  However getting to BYU doesn’t get her away from the brutality of her family as she returns home between semester breaks and for several summers.  During these times she both enjoys Shawn’s company and is attacked by him.  She slips back into her role in the family and accepts her surroundings and corresponding conditions. 

It takes Tara 10 years to complete her studies at BYU (BA), Cambridge (as a Gates Cambrige Scholar) (MPhil), Harvard, and again at Cambrige (PhD in History), which is actually a rather short period of time compared with most students.  Simultaneously, Tara is taking a tumultuous mental journey as she faces into the reality of her family and upbringing.  She details in the book some of the drama that accompanies visits home as well as the help she’s offered by her bishop at BYU and other friends and teachers (and refuses to accept).  She acknowledges that she suffered mental breakdowns (although she doesn’t use that name) and that years of counselling was required to help her progress this mental journey.   

The author’s preface includes these statements:  “This story is NOT about Mormonism nor any other form of religious belief.  In it there are many types of people, some believers, some not; some kind, some not.  The author disputes any correlation, positive or negative between the two.”  While I appreciate her statement, the Mormon religion certainly plays a role in Tara’s story.  The only reading material she was allowed was religious writings and texts of the Mormon Church. She acknowledges this provided her a very narrow take on the world including the one true acceptable path of women in the world.  She also credits this reading material limitation with teaching her how to deeply read material she couldn’t understand. Her bishop at BYU certainly places a significant role in helping her and without him it’s likely she wouldn’t have acquired funding required to complete her BYU degree or get to Cambridge.  In her attempts to talk with fellow Mormon students about her confusing feelings, their guidance reflected their own church upbringing and was often limited to what Tara already knew she should do:  pray for guidance. 

Certainly Tara’s parents are not average Mormons.  Tara suggests her father’s behavior is consistent with bipolar depression.  Certainly the sudden change from dark depression to extreme vitality leading him to require the family to travel in hazardous conditions back from trips to Arizona, resulting in major car crashes is consistent with manic episodes being triggered by a change in sunlight.  His ability to lecture for hours and his deep preoccupation that the End of Days was near and nothing in the “outside world” (healthcare, government, schools, etc) should be trusted greatly impacted the condition of the household and may have been fueled by manic episodes.  Tara’s mother’s interpretation of what it means to be a good wife helped further split the family from the rest of society and from protecting her children from her husband’s behavior and choices. 

Fortunately Tara does escape from this upbringing.  She tells us “I am not the child my father raised, but he is the father who raised her.”  Further she implies that while she now has several degrees granted by institutions of higher education, her “education” was learning to be the person she’s become which includes isolation from some of her family and coming to terms with that. 

All of us struggle to become our own person, to separate from our parents.  Some of us face the dilemma of weakened ties with our families while we’re going through that process.  Sometimes the ties stay weakened and sometimes the ties become even stronger eventually.  Tara’s story teaches us about the impact of living in a very isolated state, devoid of schoolmates, teachers, and other human contacts that provide us glimpses of realities that are different from our own and that ultimately help us on our maturation journey.   We don’t yet know how Tara’s story will fully turn out.  We can only hope that the connections she has with some of her brothers and with her mother’s family will be enough to provide the family warmth we all crave and need if the break with her parents can’t be healed.   It seems she anticipates that may be the case on both accounts.