When Breath Becomes Air Read online

  “What?” she said. “I didn’t realize you were actually worried about this.”

  I didn’t respond. I didn’t know what to say.

  “Do you want to tell me about it?” she asked.

  She was upset because she had been worried about it, too. She was upset because I wasn’t talking to her about it. She was upset because I’d promised her one life, and given her another.

  “Can you please tell me why you aren’t confiding in me?” she asked.

  I turned off my phone. “Let’s get some ice cream,” I said.

  —

  We were scheduled for a vacation the following week to visit some old college friends in New York. Maybe a good night’s sleep and a few cocktails would help us reconnect a bit and decompress the pressure cooker of our marriage.

  But Lucy had another plan. “I’m not coming to New York with you,” she announced a few days before the trip. She was going to move out for a week; she wanted time to consider the state of our marriage. She spoke in even tones, which only heightened the vertigo I felt.

  “What?” I said. “No.”

  “I love you so much, which is why this is so confusing,” she said. “But I’m worried we want different things from our relationship. I feel like we’re connected halfway. I don’t want to learn about your worries by accident. When I talk to you about feeling isolated, you don't seem to think it’s a problem. I need to do something different.”

  “Things are going to be okay,” I said. “It’s just residency.”

  Were things really so bad? Neurosurgical training, among the most rigorous and demanding of all medical specialties, had surely put a strain on our marriage. There were so many nights when I came home late from work, after Lucy had gone to bed, and collapsed on the living room floor, exhausted, and so many mornings when I left for work in the early dark, before she’d awoken. But our careers were peaking now—most universities wanted both of us: me in neurosurgery, Lucy in internal medicine. We’d survived the most difficult part of our journey. Hadn’t we discussed this a dozen times? Didn’t she realize this was the worst possible time for her to blow things up? Didn’t she see that I had only one year left in residency, that I loved her, that we were so close to the life together we’d always wanted?

  “If it were just residency, I could make it,” she said. “We’ve made it this far. But the problem is, what if it’s not just residency? Do you really think things will be better when you’re an academic neurosurgery attending?”

  I offered to skip the trip, to be more open, to see the couples therapist Lucy had suggested a few months ago, but she insisted that she needed time—alone. At that point, the fuzziness of the confusion dissipated, leaving only a hard edge. Fine, I said. If she decided to leave, then I would assume the relationship was over. If it turned out that I had cancer, I wouldn’t tell her—she’d be free to live whatever life she chose.

  Before leaving for New York, I snuck in a few medical appointments to rule out some common cancers in the young. (Testicular? No. Melanoma? No. Leukemia? No.) The neurosurgical service was busy, as always. Thursday night slipped into Friday morning as I was caught in the operating room for thirty-six hours straight, in a series of deeply complex cases: giant aneurysms, intracerebral arterial bypasses, arteriovenous malformations. I breathed a silent thanks when the attending came in, allowing me a few minutes to ease my back against a wall. The only time to get a chest X-ray was as I was leaving the hospital, on the way home before heading to the airport. I figured either I had cancer, in which case this might be the last time I would see my friends, or I didn’t, in which case there was no reason to cancel the trip.

  I rushed home to grab my bags. Lucy drove me to the airport and told me she had scheduled us into couples therapy.

  From the gate, I sent her a text message: “I wish you were here.”

  A few minutes later, the response came back: “I love you. I will be here when you get back.”

  My back stiffened terribly during the flight, and by the time I made it to Grand Central to catch a train to my friends’ place upstate, my body was rippling with pain. Over the past few months, I’d had back spasms of varying ferocity, from simple ignorable pain, to pain that made me forsake speech to grind my teeth, to pain so severe I curled up on the floor, screaming. This pain was toward the more severe end of the spectrum. I lay down on a hard bench in the waiting area, feeling my back muscles contort, breathing to control the pain—the ibuprofen wasn’t touching this—and naming each muscle as it spasmed to stave off tears: erector spinae, rhomboid, latissimus, piriformis…

  A security guard approached. “Sir, you can’t lie down here.”

  “I’m sorry,” I said, gasping out the words. “Bad…back…spasms.”

  “You still can’t lie down here.”

  I’m sorry, but I’m dying from cancer.

  The words lingered on my tongue—but what if I wasn’t? Maybe this was just what people with back pain live with. I knew a lot about back pain—its anatomy, its physiology, the different words patients used to describe different kinds of pain—but I didn’t know what it felt like. Maybe that’s all this was. Maybe. Or maybe I didn’t want the jinx. Maybe I just didn’t want to say the word cancer out loud.

  I pulled myself up and hobbled to the platform.

  It was late afternoon when I reached the house in Cold Spring, fifty miles north of Manhattan on the Hudson River, and was greeted by a dozen of my closest friends from years past, their cheers of welcome mixed with the cacophony of young, happy children. Hugs ensued, and an ice-cold dark and stormy made its way to my hand.

  “No Lucy?”

  “Sudden work thing,” I said. “Very last-minute.”

  “Oh, what a bummer!”

  “Say, do you mind if I put my bags down and rest a bit?”

  I had hoped a few days out of the OR, with adequate sleep, rest, and relaxation—in short, a taste of a normal life—would bring my symptoms back into the normal spectrum for back pain and fatigue. But after a day or two, it was clear there would be no reprieve.

  I slept through breakfasts and shambled to the lunch table to stare at ample plates of cassoulet and crab legs that I couldn’t bring myself to eat. By dinner, I was exhausted, ready for bed again. Sometimes I read to the kids, but mostly they played on and around me, leaping and yelling. (“Kids, I think Uncle Paul needs a rest. Why don’t you play over there?”) I remembered a day off as a summer camp counselor, fifteen years prior, sitting on the shore of a lake in Northern California, with a bunch of joyous kids using me as an obstacle in a convoluted game of Capture the Flag, while I read a book called Death and Philosophy. I used to laugh at the incongruities of that moment: a twenty-year-old amid the splendor of trees, lake, mountains, the chirping of birds mixed with the squeal of happy four-year-olds, his nose buried in a small black book about death. Only now, in this moment, I felt the parallels: instead of Lake Tahoe, it was the Hudson River; the children were not strangers’, but my friends’; instead of a book on death separating me from the life around me, it was my own body, dying.

  On the third night, I spoke to Mike, our host, to tell him I was going to cut the trip short and head home the next day.

  “You don’t look so great,” he said. “Everything okay?”

  “Why don’t we grab some scotch and have a seat?” I said.

  In front of his fireplace, I said, “Mike, I think I have cancer. And not the good kind, either.”

  It was the first time I’d said it out loud.

  “Okay,” he said. “I take it this is not some elaborate practical joke?”

  “No.”

  He paused. “I don’t know exactly what to ask.”

  “Well, I suppose, first, I should say that I don’t know for a fact that I have cancer. I’m just pretty sure of it—a lot of the symptoms point that way. I’m going to go home tomorrow and sort it out. Hopefully, I’m wrong.”

  Mike offered to take my luggage and send it home by mail, so
I wouldn’t have to carry it with me. He drove me to the airport early the next morning, and six hours later I landed in San Francisco. My phone rang as I stepped off the plane. It was my primary care doctor, calling with the chest X-ray result: my lungs, instead of being clear, looked blurry, as if the camera aperture had been left open too long. The doctor said she wasn’t sure what that meant.

  She likely knew what it meant.

  I knew.

  Lucy picked me up from the airport, but I waited until we were home to tell her. We sat on the couch, and when I told her, she knew. She leaned her head on my shoulder, and the distance between us vanished.

  “I need you,” I whispered.

  “I will never leave you,” she said.

  We called a close friend, one of the attending neurosurgeons at the hospital, and asked him to admit me.

  I received the plastic arm bracelet all patients wear, put on the familiar light blue hospital gown, walked past the nurses I knew by name, and was checked in to a room—the same room where I had seen hundreds of patients over the years. In this room, I had sat with patients and explained terminal diagnoses and complex operations; in this room, I had congratulated patients on being cured of a disease and seen their happiness at being returned to their lives; in this room, I had pronounced patients dead. I had sat in the chairs, washed my hands in the sink, scrawled instructions on the marker board, changed the calendar. I had even, in moments of utter exhaustion, longed to lie down in this bed and sleep. Now I lay there, wide awake.

  A young nurse, one I hadn’t met, poked her head in.

  “The doctor will be in soon.”

  And with that, the future I had imagined, the one just about to be realized, the culmination of decades of striving, evaporated.

  PART I

  In Perfect Health I Begin

  The hand of the LORD was upon me, and carried me out in the spirit of the LORD, and set me down in the midst of the valley which was full of bones,

  And caused me to pass by them round about: and, behold, there were very many in the open valley; and, lo, they were very dry.

  And he said unto me, Son of man, can these bones live?

  —Ezekiel 37:1–3, King James translation

  I KNEW WITH CERTAINTY that I would never be a doctor. I stretched out in the sun, relaxing on a desert plateau just above our house. My uncle, a doctor, like so many of my relatives, had asked me earlier that day what I planned on doing for a career, now that I was heading off to college, and the question barely registered. If you had forced me to answer, I suppose I would have said a writer, but frankly, thoughts of any career at this point seemed absurd. I was leaving this small Arizona town in a few weeks, and I felt less like someone preparing to climb a career ladder than a buzzing electron about to achieve escape velocity, flinging out into a strange and sparkling universe.

  I lay there in the dirt, awash in sunlight and memory, feeling the shrinking size of this town of fifteen thousand, six hundred miles from my new college dormitory at Stanford and all its promise.

  I knew medicine only by its absence—specifically, the absence of a father growing up, one who went to work before dawn and returned in the dark to a plate of reheated dinner. When I was ten, my father had moved us—three boys, ages fourteen, ten, and eight—from Bronxville, New York, a compact, affluent suburb just north of Manhattan, to Kingman, Arizona, in a desert valley ringed by two mountain ranges, known primarily to the outside world as a place to get gas en route to somewhere else. He was drawn by the sun, by the cost of living—how else would he pay for his sons to attend the colleges he aspired to?—and by the opportunity to establish a regional cardiology practice of his own. His unyielding dedication to his patients soon made him a respected member of the community. When we did see him, late at night or on weekends, he was an amalgam of sweet affections and austere diktats, hugs and kisses mixed with stony pronouncements: “It’s very easy to be number one: find the guy who is number one, and score one point higher than he does.” He had reached some compromise in his mind that fatherhood could be distilled; short, concentrated (but sincere) bursts of high intensity could equal…whatever it was that other fathers did. All I knew was, if that was the price of medicine, it was simply too high.

  From my desert plateau, I could see our house, just beyond the city limits, at the base of the Cerbat Mountains, amid red-rock desert speckled with mesquite, tumbleweeds, and paddle-shaped cacti. Out here, dust devils swirled up from nothing, blurring your vision, then disappeared. Spaces stretched on, then fell away into the distance. Our two dogs, Max and Nip, never grew tired of the freedom. Every day, they’d venture forth and bring home some new desert treasure: the leg of a deer, unfinished bits of jackrabbit to eat later, the sun-bleached skull of a horse, the jawbone of a coyote.

  My friends and I loved the freedom, too, and we spent our afternoons exploring, walking, scavenging for bones and rare desert creeks. Having spent my previous years in a lightly forested suburb in the Northeast, with a tree-lined main street and a candy store, I found the wild, windy desert alien and alluring. On my first trek alone, as a ten-year-old, I discovered an old irrigation grate. I pried it open with my fingers, lifted it up, and there, a few inches from my face, were three white silken webs, and in each, marching along on spindled legs, was a glistening black bulbous body, bearing in its shine the dreaded blood-red hourglass. Near to each spider a pale, pulsating sac breathed with the imminent birth of countless more black widows. Horror let the grate crash shut. I stumbled back. The horror came in a mix of “country facts” (Nothing is more deadly than the bite of the black widow spider) and the inhuman posture and the black shine and the red hourglass. I had nightmares for years.

  The desert offered a pantheon of terrors: tarantulas, wolf spiders, fiddlebacks, bark scorpions, whip scorpions, centipedes, diamondbacks, sidewinders, Mojave greens. Eventually we grew familiar, even comfortable, with these creatures. For fun, when my friends and I discovered a wolf spider’s nest, we’d drop an ant onto its outer limits and watch as its entangled escape attempts sent quivers down the silk strands, into the spider’s dark central hole, anticipating that fatal moment when the spider would burst from its hollows and seize the doomed ant in its mandibles. “Country facts” became my term for the rural cousin of the urban legend. As I first learned them, country facts granted fairy powers to desert creatures, making, say, the Gila monster no less an actual monster than the Gorgon. Only after living out in the desert for a while did we realize that some country facts, like the existence of the jackalope, had been deliberately created to confuse city folk and amuse the locals. I once spent an hour convincing a group of exchange students from Berlin that, yes, there was a particular species of coyote that lived inside cacti and could leap ten yards to attack its prey (like, well, unsuspecting Germans). Yet no one precisely knew where the truth lay amid the whirling sand; for every country fact that seemed preposterous, there was one that felt solid and true. Always check your shoes for scorpions, for example, seemed plain good sense.

  When I was sixteen, I was supposed to drive my younger brother, Jeevan, to school. One morning, as usual, I was running late, and as Jeevan was standing impatiently in the foyer, yelling that he didn’t want to get detention again because of my tardiness, so could I please hurry the hell up, I raced down the stairs, threw open the front door…and nearly stepped on a snoozing six-foot rattlesnake. It was another country fact that if you killed a rattlesnake on your doorstep, its mate and offspring would come and make a permanent nest there, like Grendel’s mother seeking her revenge. So Jeevan and I drew straws: the lucky one grabbed a shovel, the unlucky one a pair of thick gardening gloves and a pillowcase, and through a seriocomic dance, we managed to get the snake into the pillowcase. Then, like an Olympic hammer thrower, I hurled the whole out into the desert, with plans to retrieve the pillowcase later that afternoon, so as not to get in trouble with our mother.

  —

  Of our many childhood mysteries, chief amon
g them was not why our father decided to bring his family to the desert town of Kingman, Arizona, which we grew to cherish, but how he ever convinced my mother to join him there. They had eloped, in love, across the world, from southern India to New York City (he a Christian, she a Hindu, their marriage was condemned on both sides, and led to years of familial rifts—my mother’s mother never acknowledged my name, Paul, instead insisting I be called by my middle name, Sudhir) to Arizona, where my mother was forced to confront an intractable mortal fear of snakes. Even the smallest, cutest, most harmless red racer would send her screaming into the house, where she’d lock the doors and arm herself with the nearest large, sharp implement—rake, cleaver, ax.

  The snakes were a constant source of anxiety, but it was her children’s future that my mother feared for most of all. Before we moved, my older brother, Suman, had nearly completed high school in Westchester County, where elite colleges were the expectation. He was accepted to Stanford shortly after arriving in Kingman and left the house soon thereafter. But Kingman, we learned, was not Westchester. As my mother surveyed the Mohave County public school system, she became distraught. The U.S. census had recently identified Kingman as the least educated district in America. The high school dropout rate was somewhere north of 30 percent. Few students went on to college, and certainly none to Harvard, my father’s standard of excellence. Looking for advice, my mother called her friends and relatives from wealthy East Coast suburbs and found some sympathetic, others gleeful that their children no longer had to compete with the suddenly education-starved Kalanithis.

  At night, she broke into tears, sobbing alone in her bed. My mother, afraid the impoverished school system would hobble her children, acquired, from somewhere, a “college prep reading list.” Trained in India to be a physiologist, married at twenty-three, and preoccupied with raising three kids in a country that was not her own, she had not read many of the books on the list herself. But she would make sure her kids were not deprived. She made me read 1984 when I was ten years old; I was scandalized by the sex, but it also instilled in me a deep love of, and care for, language.