I started with an image, wrote my way into The Covenant

Vivid and magnificent, The Covenant of Water is a sublime example of immersive storytelling. In some ways, it is also an ode to his physician’s profession though the story did not come to him all at once, its author, Abraham C. Verghese, says to Sucheta Dasgupta

The Covenant of Water is a kind of a medical mystery. What led to the idea of writing this book? Did you have the storyline ideated beforehand or did it develop in the course of the writing of the book?

I usually start with a mood and an image. Then I sort of write my way into the story. In the beginning all I had was the image of a young girl getting married. I think it’s been wonderful in my lifetime to see the way many medical conditions that just had labels, in 10 years began to be completely understood, and then in 30 years, they had a treatment. So I knew that much. And I wanted the story to be over several generations. At some point, because water was such a recurring image, it came to me to try to use this disease which is a rare condition. Because I teach medicine, I keep a lot of rare diseases in my back pocket, so to speak, which I pull out to quiz medical students and residents, and this condition (neurofibromatosis type 2) was one of them. Neurofibromatosis type 2 is a disorder where people inherit the propensity to many different tumours but especially the ones affecting nerve supplying the ear causing problems in balance and also deafness.

How long was this book in the making? What kind of research did you have to do to write this book?

It’s 14 years since my last book but I would say it’s been about 10 years I have been working on it. In terms of research, on one hand, I was setting it in a place which I was familiar with [Kerala], because I had spent all of my summer vacations here and during my medical college days I would visit my grandparents, but on the other hand, it is not the same as being born in a place [the author is Ethiopia-born], and being fluent with everything about a place. But then again the research is the easy part. The hard part is stopping and writing.  

In your story, doctors are an archetype of the noble social reformer. That breed of the medical professional is close to extinct now. For instance, the national rural health mission in India is woefully understaffed. Do you think that with the advent of AI in the medical profession will change irrevocably? What do you think is needed to restore the medical profession to its proper role?

I am describing a particular period in time which is from 1900 to 1976, and medicine is very different in that time. I am describing the prototype of the physicians who were there at the time. In America where I practise, it has become clear that we do not have enough doctors to do the job so we use physician extenders like physician assistants and nurse practitioners. We also try to get people to rural areas and it is not easy because doctors want to raise their children, too, and send them to good schools, so I think it is a universal problem. I do think AI has great potential in the ability to make sure your resources are going to the right places; that your medications are stocked in proportion to the need. I am hoping that it will be a way to reduce, at least in America, the huge burden of documentation that is placed on doctors here so much so that we tend to end up being highly paid clerical workers rather than physicians.  

Death punctuates the ten chapters of your book at regular intervals. What was going through your mind when you wrote the death scenes? Did you borrow a leaf from the great masters while writing them?

Death punctuates not only my novel but our life itself. Life is a terminal condition even though we are in denial all the time. Life expectancy itself was abysmal in pre-Independence India; both my own grandmothers lost sons to typhoid and rabies. I was not conscious of any influence at the time of writing but you are, in a sense, a product of what you read, and I really like Gabriel Garcia Marquez and [William] Faulkner. The Death of Ivan Ilych by Leo Tolstoy also affected me a lot when I read it.
 
Do you think the pandemic and its toll has led to an appetite for publishing and consuming death and grief writing?

Well, that is an interesting thought. But if there was any such trend, the industry quickly lost interest. I do know that the pandemic generated a lot of readers.

An interesting aspect of your novel is your exploration of the various English dialects, like the Glassgowan or the Newcastle dialects, and the working class lifestyle there. What gave you the impetus to do this?

It was all in the service of my aim to give an accurate depiction of the world between 1900 and 1927 and in many ways this was unavoidable. You see, the Indian Medical Service was founded by the British and it was fun for me to delve into that world: I have friends in Edinburgh and Newcastle who helped. Along with the publication of this novel I had to do an audiobook and an audiobook means I had to perform the book.

You wear the twin hats of a physician and a writer. How do you compare the two?

In my mind there are no different hats. I am all physician looking out at the world with the eyes of a physician. Being a physician gives you a ringside seat to a lot of human drama. It is hard not to think about it. Books are a form of truth telling. The best books instruct us about life. For instance, the narration of the condition of the black people in Uncle Tom’s Cabin is what made slavery unpalatable. The Citadel, written by the Scottish physician, A.J. Cronin, published in 1937 and dealing with the subject of medical ethics, again triggered so much outrage that it led to the creation of the National Health Service. So novels are as powerful an instrument of social change as Louis Pasteur’s discovery of microbe theory.

What are your next writing projects?

I feel incredibly lucky to have produced this book. I have a wonderful day job that keeps me busy and just because this one has been successful I see no compulsion for me to go out there and repeat it. Just because you have done a few, it doesn’t really get easier. You still need to do it all over again and you still have to face the blank page.