Written by Michael J Stephen

The breath of life 

Review by Jennifer Thorley

“There is nothing living which does not breathe nor anything breathing which does not live”, wrote influential physician William Harvey in 1653. Taking an average of 7·5 million breaths per year—600 million in a lifetime— our lungs are synonymous with life, connecting us inextricably to one other as well as to the world around us. And yet, while the heart has stolen the spotlight in literature and music as the cultural embodiment of our emotions, and the brain is revered as the seat of our thoughts and desires, the lungs have typically been overlooked in cultural and scientific discourse alike. 

“Usually only someone who is short of breath gives the lungs a second thought”, writes author Michael J Stephen in Breath Taking. A pulmonologist and director of the Adult Cystic Fibrosis Center at Je!erson Health (Philadelphia, PA, USA), Stephen argues that we neglect the lungs at our peril. “With growing urbanization, extreme mobility, and a plethora of new bacteria and viruses emerging, lung health serves as a bellwether for what is happening in society worldwide.” Landing in the midst of the global COVID-19 pandemic, Stephen’s timely treatise explores the power and fragility of this vital organ, taking us on a journey through time, from the very origins of oxygen on earth to reflections on the future of humanity in a world threatened by climate change, poor air quality, and emerging pathogens. 

This broad-ranging perspective allows readers to take a step back and appreciate the undulating history of respiratory medicine. From early controversies around the connection between smoking and lung cancer, the identification of environmental hazards such as asbestos, and early failures in lung transplantation to the identification of the mutations causing cystic fibrosis and the emergence of protein modulators to treat the disease, and improved transplantation success rates, Stephen charts the extraordinary progress of recent decades with awe. “Every pulmonary disease now has a horizon that was once unthinkable in its promise”, he writes. 

Nevertheless, the singularity of the lungs’ role at the interface between the body and the external environment engenders a particular vulnerability to injury and infection. “Our lungs are the lynchpin between our bodies and the outside world”, writes Stephen. And, although they have evolved a complex and finely coordinated immune system to function at this vital nexus, increasing globalisation and mobility are rendering our air increasingly communal and posing unprecedented challenges for our lungs. While this concern might have been brought into sharp focus by the COVID-19 pandemic, Stephen explains that the burden of respiratory diseases was already substantial and often underappreciated. For example, in the USA, lung cancer kills more people per year than the three other leading causes of cancer death (breast, pancreatic, and colon) combined, and yet receives about half the federal funding. Respiratory pathogens are also the leading cause of death in low-income countries, causing about 4 million deaths each year, disproportionately among infants and children. And yet, respiratory diseases are often stigmatised, and viewed as ‘dirty’ or the result of lifestyle choices such as smoking. “Ignored, underfunded, and forgotten”, writes Stephen, “this is the medical history of lung disease”. 

Undaunted by this apparent disregard, Stephen seeks to combat these biases and inspire the reader with his own enthusiasm for pulmonary medicine. Taking a careful and holistic approach, he delicately interweaves evolutionary biology, history, philosophy, and medical science with patient stories, often relating first-hand experiences from his own clinical practice. While Stephen’s accounts of the astonishing scientific progress of recent decades are both authoritative and informative, it is these rich clinical vignettes that truly breathe life into his narrative, both showcasing the author’s skill as an emotive storyteller and instilling in the reader a newfound respect for the value and vulnerability of the lungs. From the resilience of the 9-year-old patient with cystic fibrosis who was only able to receive a life-saving lung transplant after a fraught campaign to change the law, to the courage of a 9/11 clean-up worker who went on to develop pulmonary fibrosis, these enduring accounts remain with the reader long after the last page has been turned. 

As progress in respiratory medicine approaches new horizons, Stephen ends with both hope and a note of caution—to no longer take our lungs for granted. While he underscores the value of personal actions such as avoiding smoking, ensuring the air quality of work and home environments, and engaging in exercise, he believes that only by collective action to protect the environment and fight climate change can we ensure our ability to continue breathing healthily. According to Stephen, the lungs hold the key not only to our origins as a species, but also to our future survival on this planet. 

Grove Atlantic, 2021 pp 336,  ISBN 978-0802149312