Chapter 2 of Abraham Verghese’s latest novel, The Covenant Of Water, describes a wedding. I doubt if my paternal grandparents’ wedding, in a similar church with similar rites, was anywhere near as dramatic as this one, but the scene brought back fond memories of my beloved Amma (as we called her, rather unusually). She, too, was more or less a child bride. She, too, was diminutive. She, too, inherited her husband’s son from his first marriage. I cannot remember the last time a novel evoked such personal memories for me.

Over six months after the publication of Covenant, Verghese hardly needs an introduction. The book remains on The New York Times and National Indie best-seller lists, half-a-dozen international editions are already out and, of course, American talk show host Oprah Winfrey’s enthusiastic promotion of her 101st book club pick has no doubt vastly expanded its fame and reach.

Covenant is the fourth in the series of books that have firmly established Verghese as a writer of note. His debut novel, the fascinating and best-selling Cutting For Stone (2009), and his two highly acclaimed works of non-fiction, also described as memoirs, The Tennis Partner (1998) and My Own Country (1994), each broke new ground in multiple ways. His short stories have been published in a number of prestigious journals. He has also been a regular contributor to well-known publications like The New Yorker, The New York Times and The Atlantic for many years, writing mainly on topics he cares deeply about: health and healthcare.

Verghese still identifies himself primarily as a physician, often affirming that medicine is his first love and that being a physician is central to his personality, in many ways to his very being. He says he does not see his writing as a separate activity. For him, both doctoring and writing emanate from the same deep interest in humanity, from the experience of witnessing people at particularly eventful moments in their lives and being part of those moments.

He is board certified in three medical specialties—internal medicine, pulmonary medicine and infectious diseases—and continues to practise, teach and train. He is currently the Linda R. Meier and Joan F. Lane Provostial Professor of the Theory and Practice of Medicine and vice-chair of the department of medicine at the Stanford University School of Medicine, US. He has received several awards and honorary degrees over the years, was presented with the 2015 National Humanities Medal by then U.S. President Barack Obama and is an elected member of the National Academy of Medicine as well as the American Academy of Arts & Sciences.

I recently unearthed my 1995 article about Verghese after the publication of his first book, My Own Country. That was obviously the first time I had interviewed him. I was amused to see that I had then written, “It is difficult to fully grasp the fact that the childhood friend from Addis Ababa, with whom you travelled to and from school in a car pool, played outside church on Sundays, paraded in fancy dress costumes at birthday parties, exchanged Hardy Boys and Nancy Drew collections, discovered The Beatles and, later, re-established connections during college days in Madras, had metamorphosed into an internationally successful writer…” How much more amazing it all seems now. 

Abraham Verghese (front row, fourth from left, in tie) and Ammu Joseph (extreme right) in Addis Ababa, Ethiopia, with the community of Syrian Christian teachers and their families in the late 1950s-early 1960s.
(Courtesy: Abraham Verghese/Ammu Joseph)

Verghese has contributed a great deal to the growing acknowledgement of the essential role of medical humanities and ethics in the training of doctors. He is widely recognised for his advocacy of hands-on, interactive patient care, including physical examinations and bedside conversations with patients and their families, as a vital part of not just diagnosis but also the healing process. He regularly pays tribute to his teachers at the Madras Medical College, acknowledging their role in helping him to appreciate the value of bedside medicine.

He has popularised ideas such as the “conceit of cure” versus the value of care and the “iPatient” in the computer as opposed to the real human being in the hospital bed. He often says he learnt to distinguish between healing and curing while taking care of HIV+ patients in the early days of AIDS; that is when he came to really understand how a physician can—and must—facilitate healing even in the absence of a cure. He believes it is important for doctors to rediscover why the profession was once called the “the ministry of healing”. His consistent emphasis on healing was further explored in Oprah Winfrey’s six-part series with Verghese for her Super Soul podcast earlier this year.

The concept of the “iPatient” was clearly laid out in his 2008 article in The New England Journal Of Medicine, titled ‘Culture Shock: Patient As Icon, Icon As Patient’. According to him, the patient in the bed had become a mere icon for the real patient in the computer. He has continued to speak and write about this concern, despite some pushback from what he sometimes refers to as the medical-industrial complex. Some of his articles on the subject in the popular press carry fairly explicit headlines like ‘Treat The Patient, Not The CT Scan’ and ‘How Tech Can Turn Doctors Into Clerical Workers’ (The New York Times, 2011 and 2018, respectively).

Among the several people he often quotes is William Osler, a famous physician, who said: “It’s much more important to know what patient has the disease, rather than what disease the patient has.” In other words, he says, who the patient is matters. His focus on the human being—in his medical practice and in his writing—is perhaps why a 2009 article about him in the Stanford Magazine was evocatively headlined ‘The Human Whisperer’.

An American of Indian origin, Verghese was born in Ethiopia to parents who were among the large community of Syrian Christians from Kerala who served as teachers across the country from the mid-20th century onwards, and grew up in Addis Ababa. His medical education was spread across Ethiopia, India and the U.S., while work has seen him move across U.S. states: Massachusetts, Tennessee, Texas and now California.

Cutting For Stone was partly set in the land of his birth. In Covenant, he returns to the land of his ancestry to tell an epic story spanning eight decades that follows the fortunes and misfortunes of a Malayali family based in rural Kerala across several generations.

After a busy six months of touring with the book within the U.S. and elsewhere, Verghese will soon be heading to India. He has been invited to be the keynote speaker at the Bangalore Literature Festival in the first week of December. He spoke to Lounge about his writing and his life in medicine:

The manuscript your mother left behind, describing her life in Kerala as a young girl in response to a question from your niece when she was a child, obviously played a major role in the genesis of The Covenant of Water. I’m curious about how much of the location and the characters (at least key ones) emerged from her informal, illustrated memoir.

Mom wrote and illustrated that notebook in her 70s. We took great pride in it. It’s a family heirloom. But it was only after I had written three other books, by which time she was in her 90s, that I came back to it. Her writing reminded me how rich Kerala would be as a setting for a story. There are obviously great writers from Kerala and great novels set there, but I felt the rituals of the small, insular Christian community were still somewhat exotic to many, perhaps even to some readers in India. I used very few of mom’s anecdotes directly; but the point of view of a young girl, of women like my grandmother and great grandmother, was inspired by that notebook. Mom was alive when I began and helped me with the research. Sadly, she did not live to see it completed.

Considering that you were born in Ethiopia and have never actually lived in Kerala (except for summer holidays during your childhood and teenage years), and that you also have a very demanding day job in the US, it was really brave to take on the challenge of basing a novel in so distant a location. What gave you the courage to do that?

It was daunting. Like you, Ethiopia is where I spent my childhood. We did, however, spend most summers in Kerala. This is the late 1950s, early 1960s, pre-electricity, pre-indoor plumbing—a great adventure that I loved. And my upbringing in Ethiopia (as well as yours) was with a largish community of Malayali Christian teachers, all hired to teach in that ancient Christian land. Your father taught in the Theological College but was also priest for our own church service conducted in Malayalam! So we were being brought up in a Malayali Christian tradition, albeit with a different geography. It is so similar to the second and third generations of our diaspora growing up in the Gulf or elsewhere. Also, during my college and medical school years in Madras [now Chennai], I again spent the long holidays with my grandparents. So Kerala wasn’t some unknown foreign place. I don’t have the advantage of a writer who grew up there and is fluent in Malayalam. Still, I was in a better place than writers like, say, Leon Uris, or James Michener, or many others who had much less familiarity with the exotic places they set novels. I also had access to relatives, to scholars in Kerala, and to the treasures of libraries and archives.

As I read the tome, I got the impression that it includes less about medicine than your previous books, including your first work of fiction, ‘Cutting For Stone’, did. But perhaps you introduced the parallel stories of Dr Digby Kilgour and Dr Rune Orqvist partly to allow for medicine to be part of the narrative?

I never consciously thought about the story as needing to have a certain proportion of medicine or “introducing” characters for that reason. My goal is always the same with any novel—a good story well told. “Write what you know” is an old adage. So much of my life has now been lived within the profession, looking in and out. And what is medicine but “life++” or life at its most acutely observed, life shown in relief in moments that matter the most? We are all shaped by what we have seen and done and it inevitably informs what you write.

Do you think the inclusion of a Scot and a Swede ensures some level of connection/identification for Western readers of the book?

Not at all. How could one write a sweeping novel about 1900-1970 in India without characters who were Western? After all, the Indian Medical Service (IMS) was created and run entirely by the British. All the medical schools they founded (including Madras Medical College, where I studied) had only British professors at the outset, and so many of our colonisers were Scots. By the time I was in medical school, they were long gone, but the system of education remains theirs. The legacy is so strong, comically strong in many arcane and archaic rituals we can’t let go. Similarly, the individuals who first carved out and developed vast estates on the slopes of the Western Ghats were expatriates of many nationalities, not just British. In my research I came across Swiss and Swedish nationals and others. So the thought of “inclusion of a Scot” to cater to Western readers never occurred to me. I was being true to the times. And here we are, Ammu, communicating in English, and not Malayalam (or Amharic); this interview will appear in an Indian periodical in English. We are products of the pervasive legacy of our colonial occupiers and exploiters. I read, write and think in English; the majority of readers of novels in English are in the West, or they are in their former colonies like America, India, Australia, New Zealand, South Africa—to name a few countries where Covenant Of Water is doing extremely well. So, in that sense we are all “Western readers.”

It’s interesting that we get to know Big Ammachi’s actual name only half-way through the book. And also that you decided to call her Big Ammachi rather than Valiyammachi, the Malayalam equivalent, even though you do use words like Kochamma and Chedethi as honorifics for other characters. Was there any particular reason for your decisions about her identity and appellation?

I liked the idea of her being nameless, a reflection of her lack of agency as a 12-year-old bride. It is only when she is revealed to her adoring stepson as a matriarch, a force of nature, that she is named. I picked “Big Ammachi” because I wanted a memorable name, and this moniker played against the fact that she was tiny—far from physically big. Valiyammachi would have been accurate but tedious with repetition; it might not have latched on to the reader’s imagination. Big Ammachi has struck a chord with many readers; I wonder if she would have to the same degree with some other name.

While reading the book I couldn’t help wishing that one could get to know some of the other major characters better. Is that one of the downsides of such an expansive book—that it is not possible to develop characters beyond a point because the plot has to move on?

A novel is a collaborative act between writer and reader. The writer provides the words and a reader provides their imagination; characters develop attributes in a reader’s mind well beyond what writers might have intended or imagined. So each reader has their unique take on the book, and I have little control over that—it belongs to them. The book, as (Marcel) Proust says, becomes an “optical instrument” that the readers use to examine herself or himself.

While reading the book I couldn’t help wishing that one could get to know some of the other major characters – especially Elsie – better. Is that one of the downsides of such an expansive book – that it is not possible to develop characters beyond a point because the plot has to move on?

A novel is a collaborative act between writer and reader. The writer provides the words and a reader provides their imagination; characters develop attributes in a reader’s mind well beyond what writers might have intended or imagined. So each reader has their unique take on the book, and I have little control over that—it belongs to them. The book, as Proust says, becomes an “optical instrument” that the readers use to examine herself or himself. I will say that with Elsie, it was in the nature of her character for her to choose to disappear because of her stigmatizing illness. So her absence from the point of view of all the other characters for such a long time is part of the plot. I didn’t feel limited by page count—she is as imagined as I could make her. There are major characters I eliminated completely from the book because, as the book evolved, their trajectory seemed tangential to moving the story forward and it would add to the page count. I have stuck a quote from my wonderful editor Peter Blackstock above my computer: “The book needs to be as long as it needs to be.”

You have thrown caste into the mix in the book. Did your mother refer to caste in her memoir? Was the status of Pulayas and their relationship with Syrian Christians an issue you were conscious about while growing up or something you discovered later in life? Why did you think it was important to bring this aspect of society, which persists despite the anti-untouchability movement launched a century ago in Kerala, into the story?

Yes, mom mentioned Pulayas in describing her influences as a child, including the girl who walked her to her first “school” but sat outside till class was over. I was certainly aware—as you too must have been—of caste when I visited my grandparents’ households, so visible with those who worked for them. For my grandparents, it was just the way things were, whereas I found it shocking. My parents, who had a foot in both worlds, could see my point of view even if they could not explain it. I didn’t “throw caste into the mix”; it would be impossible to set a novel in India in that time period—1900-1976—in that kind of a Christian family without addressing the unchristian paradox of caste, because it was so obvious and prevalent.

A bench from Verghese’s grandmother’s house, the inspiration for the spot where Baby Mol in ‘The Covenant of Water’ presided over the household.
(Courtesy Abraham Verghese/Facebook)

It is really impressive that you managed to weave quintessential Syrian Christian places and events such as the Parumala Church and the Maramon Convention into the story. Did this come from personal connections or through research?

Thank you! Parumala Church has been very important to our family. My grandfather was a deacon there, and on his way to being a priest before he married and became a schoolteacher. My father and his siblings served as altar boys at Parumala, where as you know the first Saint of our church was a priest, then a bishop. Dad’s family house was very close to Parumala and we went every Sunday when we were there. My father, now at 96, living in Boston with my older brother, still stays up late on Saturday nights to watch the live broadcast of the Eucharist performed on Sunday mornings in Parumala, in the very church where his parents and much of his family are buried! The place is a touchstone for me every time I visit Kerala, often to fulfil a vow I took. I will be in Kerala at the end of this year, and the visit to Parumala is the main reason I am going to Kerala.

Considering the span of the book – 1900-1977 (almost four score and ten years) – and the several generations of the primary, secondary and extended families involved in the story, I’m surprised you didn’t consider including a family tree (or trees), in addition to the map of Kerala, in the book. Was this a deliberate decision?

Many readers have expressed the same desire, for a tree, or a glossary. We might do that in the paperback, but as an appendix at the back of the book, along with a glossary of ethnic terms. I’m not a fan of a list of dramatis personae or a family tree at the front of the book, beforethe reader has read the opening line. For me, to see such a thing is off putting. I believe the writer has to be able to create whatever he or she wants the reader to see with words. It is a lot for the reader to hold in their mind.

Nearly 15 years after your last novel, close to 30 years since your first book, would you say the publishing world—and the book promotion process—has changed quite a bit since your last close encounter, especially in terms of the importance of social media now? If so, does this make the post-publication period more hectic for authors than before?

Yes indeed, things have changed. Even before Covid, the book tour as I knew it had almost disappeared. There are now so many influential podcasts whose hosts don’t need you to leave the house, and similarly, journalists can interview you live on Zoom. If one is lucky enough to have a publisher send you on the road for a book tour these days, it consists of a few key cities, far less radio than ever, and typically connecting those visits with a show or event or book festival (as with my upcoming visit to the Bangalore Lit Fest). On this tour with Covenant, we honed in especially on the iconic independent book stores in America. I have had a relationship with those indie booksellers; they hand-sold my books to customers and created a word of mouth that began with my first book. I feel very grateful to them.

It seems to me that your stature and aura as a doctor, especially one seen to have made it a mission to bring back the human element in medicine that had almost been displaced by technological advances and aids, has a lot to do with your public appeal and, possibly, with the allure of your books. Can you see yourself writing a book that has nothing to do with medicine in the future?

Well, that is hard for me to respond to. On the spectrum of medicine, from basic molecular research at one end, and clinical care/patient experience on the other end, my research has gravitated to the latter, to the humanistic aspects of care of patients. Peabody, a famous American physician of the last century, said long ago, “The secret of the care of the patient is caring for the patient.” And William Osler, another giant, said it was less important to know what disease the patient had; one needed to know what patient had the disease. I am drawn to that tradition in medicine. What I do and write about in academic medicine is easily understood by and quite relevant to people outside of it; so there is some overlap of my physician role and the public role as you put it. I would argue that any compelling and popular novel inevitably has something to do with medicine if it tackles life, death, suffering. So my answer would be no, I can’t see writing a book where those elements don’t creep in.

And finally, are you likely to stick to fiction from now on or do you think you might return to non-fiction at some point?

Honestly, I am not sure when I will write in book form again, or in what genre. I will write; I always write. But the phenomenal reception of Covenant gives me pause. (I refer to America, where it has been on the hardback best-seller list for six months now as I write.) How do I top that? How do I get the stars to align this way again? That seems impossible. A new book is hard enough; you start from zero, and your previous success doesn’t generate one word for you on the blank page. You have to prove yourself once again. I have been very lucky. And fortunate not to have tried to make a living from books—I couldn’t have! I am too slow a writer; writing would not have paid the rent or sent the kids to college. So, in short, for the moment I have decided not to take an advance or enter a contract for a new book. The obligation weighs you down and adds to the pressure. I hope to write again, but I feel no compulsion to turn out book after book.

Ammu Joseph is an independent journalist and author based in Bengaluru. A blog on her visit to Ethiopia more than 50 years after she left the country as a teenager can be found here.