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Prologue: Lungs = Life

The lungs are a mysterious and even mystical organ. They are our connection to the atmosphere, the organ that extracts the life force we need to exist. We have acknowledged this power for centuries. The Hebrew word ruach literally means “breath,” but also means “spirit of life.” In the book of Job, the prophet’s friend Elihu declares, “the Spirit of God has made me, and the breath of the Almighty gives me life.”1 This same concept is embodied in the New Testament, where the apostle John says that Jesus “breathed” on his disciples, giving them the Holy Spirit.2

The life-giving power of the breath is acknowledged very early in the Bible: in the second chapter of Genesis, line 7 reads, “the Lord God formed man from the dust of the ground, and breathed into his nostrils the breath of life, and the man became a living being.”3 Ancient Egyptian cultures also recognized the importance of the breath, the evidence of which we see today in the many ancient statues that had their noses broken off but otherwise were left untouched. This defacement was no accident, but a deliberate act by conquering groups to take the life, in this case the breath of life, away from these icons.4

Ancient knowledge about the power of the lungs was not limited to the Western world. Buddhism and Hinduism were based on an understanding of the potency of the breath. According to these disciplines, studying and harnessing the breath was the only recognized way to nirvana. Thich Nhat Hanh, a Vietnamese Buddhist monk, summarizes this ancient philosophy well in his 1975 book The Miracle of Mindfulness: “Breath is the bridge which connects life to consciousness, which unites your body to your mind.”5

The emphasis on the breath is not a thing of the past for Eastern religions; breathing continues to occupy a central role in their teachings today. The Hindu name for the breath is prana, which, like the western ruach and Holy Spirit, is not just a word for air, but an acknowledgment of the breath as the ultimate life force. This knowledge is spreading back to the West through disciplines such as yoga and mindfulness, but also through techniques aimed at improving endurance, and even intimacy. These practices demonstrate that the mind and the heart follow the lungs, not the other way around.

Civilizations throughout history have equated the breath with the soul, using one term to refer to both. In ancient Egypt, it was ka; in Zulu, umoya; in ancient Greece, pneuma; in Hinduism, prana. In his 1653 Lectures on the Whole of Anatomy, William Harvey, the famous seventeenth-century British physiologist, stated simply but profoundly, “Life and respiration are complementary. There is nothing living which does not breathe nor anything breathing which does not live.”6

As an organ, the lungs must do an incredible amount of work all day, every day. With an average respiratory rate of fourteen breaths per minute, and an average volume of 500 milliliters of air per breath, a typical adult inhales and exhales 420 liters of air every hour. In one day, the total is roughly 10,080 liters, a tremendous amount of gas for every human on this planet to utilize. Yet, in the absence of lung disease this work is effortlessly integrated into our lives, happening without any conscious effort.

With a signal from the brain, the diaphragm contracts downward, expanding the lungs in an instant. In this way, the breath of life is drawn into the body, and contained in it are millions of oxygen molecules. The lungs seamlessly pass the oxygen off to the red blood cells, which, with the help of the heart, deliver these molecules of life to the cells of the brain, muscle, kidneys, and other organs. Continuing the circuit, carbon dioxide, produced as oxygen is consumed by our tissues, is whisked through our veins and back to the lungs, and then expelled into the atmosphere as the diaphragm now relaxes. It is a beautiful circle of reuse and recycle, appropriately termed circulation, with the lungs as the centerpiece, the lynchpin connecting the body and the outside world.

That oxygen, life, and lungs all came into our world in relatively close succession is no coincidence. Only with oxygen and some means of extracting it are all things possible—thinking, moving, eating, speaking, and loving. Life and the breath are synonymous. Significantly, our arrival into the world as infants is considered a success when we take our first breath outside of our mother’s womb, and our leave-taking occurs when our last breath is expelled.

We are not the only ones breathing, of course. Breathing is the mechanism for harnessing the life force all over the Earth, and every organism above the level of microscopic anaerobe respires, including every single fish and animal, as well as all plants. Plants are known as oxygen producers because of photosynthesis, but they, too, constantly breathe, consuming oxygen to fuel their energy needs at the same time photosynthesis is occurring. We all utilize this communal resource called the atmosphere together.

There is something transcendent in the very structure of our respiratory system. It begins in the trachea, the single wide tube that accepts air after it comes in through the mouth or nose. The trachea branches into the bronchi of the right and left lungs, with the airways continuing to divide into increasingly smaller tubes, finally opening, deep in our lungs, into grapelike clusters called alveoli, the actual site of gas exchange. This structure, taken as a whole, resembles a tree, with its trunk and progressively smaller branches emerging into their site of gas exchange, leaves. Other examples of this configuration in nature abound—streaks of lightning converging into a single bolt only to diverge again as they approach the ground; the tributaries of a riverbed unifying into one main waterway; the human body itself, branching from its trunk to arms and legs, then fingers and toes. The lungs tap into something universal in their structure, maximizing uptake of the life force that surrounds all of us.

Science is beginning to investigate in a serious manner something humanity has known for centuries—that the breath can be used to heal the body. Every year more papers are being published on the healing power of the breath. Evidence of improvement in patients with asthma, chronic obstructive pulmonary disease, chronic pain, depression, and even cancer has been demonstrated. The scientific evidence has started to go even deeper, to the level of our blood, and even our genes. In those who practice breathing exercises, levels of inflammatory proteins in the blood are significantly lower, especially under certain types of stress. Mobilizing the power of the breath has also been shown to turn on anti-inflammatory genes and turn off pro-inflammatory ones, including genes that regulate energy metabolism, insulin secretion, and even the part of our DNA that controls longevity.7 Looking down the generations, those of us who practice breathing exercises today may well pass on more disease-resistant genes to our descendants tomorrow.

There is also something about the lungs—beyond their role in disease prevention—that is essential to our existence and future survival. The lungs are our youngest structure evolutionarily, having developed as our ancestors emerged from the ocean some four hundred million years ago, well after the heart and other organs had evolved. In addition to being the central organ at both birth and death, they are also the body part we must accommodate in the future if we are going to colonize other planets, or even stay alive on this one, with its radically changing climate and the constant threat of respiratory pathogens. Like our other organs, the lungs are under unconscious control of our brain, but unlike our other organs, we can control them consciously if we choose.

With this element of control, the lungs are hailed at present as an important focal point for the health and progress of society as a whole. We live in a time of extraordinary change, with technology and medicine bringing unheard-of advances in the last hundred years. Average human lifespan has recently doubled, the number of people on Earth tripled. At the same time, we have naturally held onto the same emotions of anxiety and distrust that helped us survive at a time when we faced completely different threats than we do now. For us to move forward as a people and as a planet, we are going to have to become more trusting, more cooperative. The lungs are the organ that could help us make this transition.

Though the lungs are a powerful organ, they are nonetheless badly overlooked and ever more threatened today. The heart has stolen the spotlight in our songs and literature as the embodiment of our emotions and passions. The brain is revered as the seat of our thoughts and desires, credited with our success as a species and celebrated for its complexity. The skin is pampered, a reflection of our beauty in youth and wisdom in old age. Our reproductive system offers the magnetism of sex and the miracle of birth. Usually only someone who is short of breath gives the lungs a second thought.

In the medical world, the statistics demonstrating that the lungs are an ignored organ are stark. Every year, lung cancer kills more people than breast, pancreatic, and colon cancer (the next three leading causes of cancer death) combined, and yet lung cancer receives about half the funding that breast cancer does from the National Institutes of Health (NIH) and other government agencies.8, 9

Meanwhile, the outcomes of many lung diseases are devastating. Idiopathic pulmonary fibrosis (IPF) is a scarring disease of the lungs—one that most people have never heard of—that affects thirty thousand patients every year, about the same as cervical cancer. Funding for research on IPF is poor, and to date not a single drug has definitively been shown to extend the lives of people with the disease. The 50 percent survival rate is horrible, with most patients dead within about four years of being diagnosed.10 This is worse than most cancers. Except, of course, for lung cancer, that other underfunded, under-recognized condition.

The list of other, similarly neglected diseases includes chronic obstructive pulmonary disease (COPD), inhalation injuries, and asthma. A stigma is attached to many lung diseases and is kept there by some strong biases. The most obvious one is the association with smoking, a major causative factor for both lung cancer and COPD. We have demonized not just tobacco, but smokers as well. A subtle but corrosive prejudice also exists against people suffering from asthma, a condition that is falsely linked to inner cities and an unclean lifestyle. Tuberculosis has infected more than one and a half billion people in the world, about a quarter of the world’s population, but has the “dishonor” of being associated with homelessness.11 Lung illnesses, as a whole, have been unfairly categorized as dirty diseases, and the afflicted as unworthy of our attention. Ignored, underfunded, and forgotten: this is the medical history of lung disease.

The neglect has had serious consequences. Respiratory diseases, which include asthma and COPD, are among the top three leading causes of death both in the United States and worldwide. In America, these lung conditions traditionally trailed heart disease, cancer, and cerebrovascular disease as causes of death; however between 1980 and 2014, according to the Centers for Disease Control and Prevention (CDC), heart disease decreased by 59 percent, stroke by 58 percent, and cancer deaths by 24 percent, while chronic lower respiratory diseases increased by 40 percent.12 The data is even more alarming for the period between 1965 and 1998, during which death rates from COPD increased by an enormous 163 percent, even as all-cause mortality declined by 7 percent.13 In 2008, respiratory diseases in the United States for the first time replaced stroke as the third-deadliest disease, and it has kept that place ever since.

These statistics on the exploding burden of lung disease, dismal as they are, would be welcome in many other countries. Respiratory infections are the leading cause of death in low-income countries, where infants and children under five make up a disproportionate share of the four million deaths each year.14,15 Globally, toxic indoor and outdoor air pollution are an issue for three billion people, and together these problems are responsible for eight million premature deaths each year. Ninety-one percent of people in the world live in places where air quality fails to meet World Health Organization standards.16 All of these statistics point to a significant international health crisis.

Lung diseases show no signs of abating, nor do the persistent, alarmingly high smoking rates or the worsening air quality driven by climate change and pollution. Even more worrying, crises that pose a threat to the breath and lungs have grabbed headlines recently, from the lethal wildfires in California, the Amazon, and Australia, to the strange respiratory illness from vaping, to of course the devastating 2020-coronavirus outbreak that shut down the global economy and killed hundreds of thousands. These catastrophes show that we have not taken potential threats to our air seriously enough.

In the face of these challenges, some innovative doctors, scientists, and advocates are working extraordinarily hard to prevent and cure lung diseases. Given what we now know about genetics, biology, and medicine, there is no better time in history to be on the front lines of that fight—or, if you must, to be a patient with lung disease. The stories in this book illustrate the uniqueness of our current moment, showing how we’ve gotten to where we are with the lungs, and also pointing the way to a bright future.

1. Holy Bible, Job 33:4 (New Revised Standard Version).

2. Ibid., John 20:22.

3. Ibid., Gen 2:7.

4. Julia Wolkoff, “Why Do So Many Egyptian Statues Have Broken Noses?” CNN.com, March 20, 2019, https://www.cnn.com/style/article/egyptian-statues-broken-noses-artsy/index.html.

5. Thich Nhat Hahn, The Miracle of Mindfulness: An Introduction to the Practice of Meditation (Boston, MA: Beacon Press, 1999), 15.

6. C. D. O’Malley, F. N. L. Poynter, and K. F. Russell, William Harvey Lectures on the Whole of Anatomy, An Annotated Translation of Prelectiones Anatomiae Universalis (Berkeley: University of California Press, 1961), 204.

7. Manoj K. Bhasin, Jeffrey A. Dusek, Bei-Hung Chang, et al., “Relaxation Response Induces Temporal Transcriptome Changes in Energy Metabolism, Insulin Secretion and Inflammatory Pathways,” PLOS One 8, no. 5 (May 2013): e62817.

8. National Institutes of Health, “Cancer Stat Facts: Common Cancer Sites,” National Cancer Institute, Surveillance, Epidemiology, and End Results Program website, accessed July 31, 2019, https://seer.cancer.gov/statfacts/html/common.html.

9. National Institutes of Health, “Estimates of Funding for Various Research, Condition, and Disease Categories,” NIH website, https://report.nih.gov/categorical_spending.aspx.

10. David J. Lederer and Fernando J. Martinez, “Idiopathic Pulmonary Fibrosis,” New England Journal of Medicine 378 (May 10, 2018): 1811–1823.

11. Rein M. G. J. Houben and Peter J. Dodd, “The Global Burden of Latent Tuberculosis Infection: A Re-Estimation Using Mathematical Modelling,” PLOS Medicine 13 (October 25, 2016): e1002152.

12. Centers for Disease Control and Prevention, “Mortality Trends in the United States, 1900–2015,” CDC website, accessed July 31, 2019, https://www.cdc.gov/nchs/data-visualization/mortality-trends/.

13. Romaine A. Pauwels and Klaus F. Rabe, “Burden and Clinical Features of Chronic Obstructive Pulmonary Disease (COPD),” Lancet 364, no. 9434 (August 2004): 613–620.

14. World Health Organization, “The Top 10 Causes of Death,” WHO website, accessed May 8, 2020, https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death.

15. Forum of International Respiratory Societies, The Global Impact of Respiratory Disease, 2nd ed. (Sheffield, UK: Sheffield, European Respiratory Society, 2017), 7.

16. World Health Organization, “Air Pollution,” WHO website, accessed July 31, 2019, https://www.who.int/airpollution/en/.