We all love epic sagas! We share the joys and heartaches, and watch as generations of a family live out their lives with twists and turns. Epic novels often touch us deeply because they define a particular place and time, and the beauty of the human story. ABRAHAM VERGHESE’s latest novel, The Covenant of Water, is such a book. It has received rave reviews, and Oprah Winfrey says, “The Covenant of Water is truly one of the most gripping, exquisite novels I have ever read.” Here the author is interviewed by TARA KHANDELWAL of Books and Beyond about the writing process, medicine, Kerala, this family saga, and how place and history have come together in this epic book.

Q: Dr. Abraham Verghese’s latest book, The Covenant of Water, is a 700-page family saga spanning the years 1900 to 1977. It is set in Kerala, and follows three generations of a family that suffers from a very strange affliction—in every generation, one person dies by drowning, in a family that belongs to a Christian community that traces itself back to the time of the apostles. And we enter the story with the pre-teen Big Ammachi being married off to a 40-year-old man. Water plays a very big part in this novel, which is on The New York Times 100 Best Books of 2023.

Hello Dr. Verghese.

AV: Hello and thank you. It’s so nice to be with you.

Q: You mentioned that this book came about when your niece asked her grandmother (your mother) a very simple question: “What was it like when you were a girl?” In response, your mother, who was in her 70s, wrote a 40-page manuscript with illustrations, with a family tree and anecdotes, that became the inspiration for this book, and the source material. So, can you tell us how much of your mother’s manuscript is in the novel, and how did it all come together?

AV: My mother was a very talented artist, and when my niece asked her this question, she was taken aback. How does she describe to this young girl, growing up in America, what her life was like in India, then moving at a young age to Africa to teach, then to America to teach? So, she began to write. It was actually 120 pages of a school notebook with beautiful illustrations. It was a little treasure for all our family, and we made many copies.

It wasn’t till she was in her 90s, and I had finished two other books that I picked it up again. I was reminded of how rich the culture and community were in the period she was describing, and I decided to set my story there. Mom was very excited and she became my number one research assistant. Even a few weeks before she died, she was calling me up to tell me some new story she had remembered. Unfortunately, she didn’t live to see the book published.

Even though I drew on that manuscript for inspiration, I didn’t use her actual stories. Instead, I used my familiarity with the situation. Every summer we would go to Kerala. I went to medical school in Madras, and I would go back to my grandparents’ houses. I used my grandmothers for inspiration.

The book is really about strong, heroic women the world doesn’t recognize; unheralded heroes. Their families recognize it. These are women who’ve gone through incredible hardship. Both my grandmothers lost sons in their teens—one from rabies, one from typhoid—and somehow, despite everything, they kept going because of their faith, because of their inner strength, and they kept the family together. My mother’s document was the beginning, then calling on my own memories, and the rest is fiction.

Q: So, the starting point was the grandmother figure. We see Big Ammachi as a 12-year-old, then we see her evolving, growing up, and having her own children. I was very interested in how you came up with this mysterious condition that impacts the family over every generation; it drives a lot of their actions.

AV: I’m not the kind of writer who knows the whole story before I begin. I always begin with a feeling, an image. With this book, the image was a young bride, and I kept pushing it forward. I did know I wanted the story to be at least three generations, because I enjoy epic novels. And one of the thrilling things about being in medicine for a long time, is that I’ve seen diseases that we only had a name for; then, after 15 to 20 years, we understand the mechanism; then after another 10 years, we have a diagnostic test; and then we have a treatment. That’s a wonderful evolution.

Also, the novel is set in Kerala. That’s important, as for me geography is destiny. Water is such a ubiquitous metaphor in Kerala. You can’t escape the fact that water is everywhere; water is the great circulatory system that connects everybody, and the monsoon is the beating heart that pumps water around.

As a long-time teacher of medicine, I always keep in my back pocket a collection of rare diseases that I think about. Anytime there’s a slow moment on the wards, I bring it out as a question to my students and residents. For example, what hereditary disease causes drowning? This was a disease I have known about for a long time and it’s rare. When I started to write this novel, it occurred to me that, in this land where everybody swims before they walk, how interesting if I give them a genetic condition that makes them avoid water, and despite that, end up drowning. So, it came about a little bit by serendipity and a little bit by my knowledge of this condition. But writing is mysterious. You don’t really know what the subconscious is doing. It’s busy making connections, and then you become aware of it at some point.

Q: You have really brought the beauty of Kerala to life, the whole texture of the place. I want to go back a little and know more about you. When did you start writing?

AV: I was always a voracious reader, and I would say that’s a prerequisite to be a writer. I think I had a sense of how high the bar is, the threshold you must cross. But I was in love with medicine and had no dreams of becoming a writer. I was training in infectious diseases in Boston just as HIV exploded in America. And I finished my training just when the virus was finally discovered and there was a test for it. I was moving to a small town in Tennessee, and everybody said with a rural population of 50,000, I might see one HIV patient every other year. Instead, in a very short time, I was treating 100 patients. The great mystery was, why did this small town have so much HIV?

As it turned out, it wasn’t a big mystery. I understood what was happening very quickly; it was an American story of migration, happening in every small town. Young men growing up in small towns leave for the same reasons you and I leave small towns—for jobs, education, opportunity. But they were also leaving because they were gay and didn’t want to live that lifestyle under the close scrutiny of their friends and relatives. So they went to the big cities, San Francisco, New York, Miami. And at some point the virus found them, and then they were sick and coming back home. So I was there at the tail end of this journey, taking care of them. And I wrote a scientific paper describing this phenomenon of migration. It was widely recognized because it claimed that this was happening in every small town. But I felt the language of science didn’t begin to capture the heartache of this journey, the tragic nature for the families, or my own heartache at taking care of young men who were my age and dying because there was no treatment. It was the most moving experience of my life.

So that was the moment I became a writer; I decided I wanted to tell that story. I discovered that writing is hard, but I also discovered that I enjoyed trying and enjoyed when it worked. I was never in a hurry, I’m a slow writer. So, I became a writer quite by circumstance.

Q: And now, you’re one of the most celebrated writers in the world. How did you hone your craft from that first experience? There is a lot of passion, a lot of emotion that went into the writing, and it shows in the empathy you have for your characters. Did you have any mentors or get feedback to help you hone your writing?

AV: Well, thank you for saying I’m a celebrated Indian writer. It’s hard for me to feel that, as I'm still the same person I was when I began. I’m incredibly lucky because it's very common for people to write great novels that are not recognized in their lifetime or never recognized. You need a lot of luck, and I’ve been very fortunate. I don’t have a master plan. My goal is always a good story, well told, and that’s it. I’m not trying to advance a theme or a religious doctrine, just a good, compelling story, the kind that I would enjoy reading.

Also, most people don’t realize how important a great editor is. I’ve been very blessed to have wonderful editors for my novels. Sometimes my medical training makes me want to write too much technical stuff, but then the editor will say, no, this is interesting. It’s a combination of luck, perseverance, hard work. I never expected it. It’s really God’s grace.

In terms of role models, I have so many. I’ve always loved John Irving, Faulkner, Dickens, Gabriel Garcia Marquez, George Eliot… I mention some and it sounds like I’m neglecting others! I tend to like ornate prose. Many people think of Somerset Maugham when they think of physician writers. I love Somerset Maugham, but his was a reporting style; he gave accurate reporting and he let you construct the rest, whereas my style is wanting to do the reporting but also get into the reader’s head and at the heart of the conflicts of their personalities.

Q: It makes editors like me very happy when you say that, because very often it’s a collaborative process.

AV: Yes, and the other important collaborator is the reader. Where does a book exist? Not on the bookshelf! The writer provides the words, the reader provides their imagination, and somewhere in a middle space the fictional dream emerges. It very much belongs to the reader, and every reader has a slightly different fictional dream. They visualize the characters differently.

The great joy of writing for me is not so much the success of the book, but the reader’s fictional dream. You write in isolation, you write for hours, nobody knows, nobody sees you. Everybody thinks you’re a terrible person because you don’t show up for their engagement or anniversary. If I were a brain surgeon and said, “I can't come to your function because I’m in the operating room,” nobody has a problem. But when you say, “I can’t come because I’m writing,” they say, what kind of person is this? My point is that you write in isolation, and you’re picturing the moment a reader, someone like you, enjoys the book, and the fictional dream they make is wonderful. That’s the reward! That’s who we’re writing for. We’re writing for the person who is engaging with our words. That’s priceless.

The great joy of writing for me is not
so much the success of the
book, but the reader’s fictional dream.

Q: I love that thought. Every reader imagines it so differently, and it’s such a personal activity—I love reading because it’s so intimate. You’re right there in the story, in the characters’ heads, right from big Ammachi to her children, and Philipose, her son, and Philipose’s wife. They are all characters with such unique journeys and there are lots of nuances. You meet somebody like Digby, a Scottish surgeon who comes to India to practice, and he’s swept up in the culture and inevitably his life is intertwined with the other characters.

Which character is your favorite, which one do you relate to the most, and which one was the hardest for you to write?

AV: Good questions! Because they’re my creations, at some level they’re all precious. But Philipose is the one I identify with the closest, because he is the most reflective. When the book was reviewed by The New York Times (it was a good review), the critic said all the characters seemed too good to be true, and I disagree with that. First, the world is mostly people trying to be good. Nobody wakes up in the morning deciding to be evil. It’s more like people wind up doing wrong things, and with any luck, like Philipose, they develop insight and seek redemption, they try to correct what they’ve done wrong.

I think all my characters are flawed, they all make mistakes. Human beings are flawed but nobody thinks themselves evil. They’re motivated by what they think is perfectly acceptable and rational. So, I identify with Philipose, maybe because he’s the male. I had to work hard to imagine a woman’s thoughts, but with Philipose I could get as close as I could.

The character that was most difficult for me was Elsie, because she disappears from the story, so she’s a bit of a cipher, a bit of an unknown. On the one hand, I wanted to describe her in a way that the reader could fully imagine, yet I had to keep part of her unseen. That was a bit tricky and took a lot of work.

Q: My favorite character is actually Elsie, who is Philipose’s wife; first, because she’s such a vibrant woman and an artist, and second, because I really liked seeing the dynamic between her and Philipose change after marriage, her role as a mother, and then the whole mystery element. I think she was the most fascinating character of the book.

Also, I could not get over the ending, I could not sleep at night. It was the most vibrant scene. Despite being a long book, at no point does any of it feel irrelevant; I was so invested in each character’s journey. There were so many heartbreaking moments and at one point I had to shut the book and put it down for a bit.

What was the thinking behind constructing all these hardships, so many losses?

As a physician, I’m much more tuned to the fact that
life is a terminal condition, we are all going to die.
Most people live in denial of the degree
of misfortune and tragedy out there.

AV: I would argue that there weren’t that many losses, compared to the reality of life in that era, 1900 to 1976. Both my grandmothers lost a child. Can you imagine losing teenage boys; one from rabies, one from typhoid? As a physician, I’m much more tuned to the fact that life is a terminal condition, we are all going to die. Most people live in denial of the degree of misfortune and tragedy out there. Admittedly, there might be more in the story of one family than you are comfortable with, but that’s pretty common.

I didn’t really plot those deaths. It just suddenly seemed to be the way it was going to happen. And I was as sad as you were. Every time I would revise some of the scenes, I was in tears. They were heartbreaking to me, because they felt real. I don't think I ever manufacture tragedy for the sake of it. It always felt true to the plot, organic to the story.

Q: And, the way the medical conditions drive the plot forward is fascinating and part of how the story comes together. Leprosy still carries some stigma and there’s so much fear about contracting it. Your character, Dr Roon, sets up a leper colony and treats them like his own. He’s not afraid of being infected. Why did you choose to include leprosy in the book?

AV: As an infectious disease physician, leprosy fascinates me. It’s a slow infection and difficult to treat because the bacteria divide so slowly that the drugs that work against cell division don’t affect them. I remember as a child being scared seeing lepers in the street. Fortunately, it’s less common now. It was only in medical school that I understood through our leprosy rotations that the soul of the person has nothing in common with the very scary exterior. That’s the great tragedy of leprosy—not only do you have a condition that’s paralyzing your nerves, and gives you a grotesque appearance, but you are completely rejected by society in a way that’s even more deadly than the disease itself. So, it’s always been a fascinating condition to me. It was very common during the time I was describing.

Every time I would revise some of the
scenes, I was in tears. They were
heart breaking to me, because they felt
real. I don't think I ever manufacture
tragedy for the sake of it. It always felt
true to the plot, organic to the story.

Q: Reading about it reminded me that it was a real thing when I was a child.

Among the many themes in the book, there is the pre-teen Big Ammachi marrying an older man, then finding her own way and creating a family through everything; there is the character of Digby who represents colonial India and even feminism; and you have written about caste, addiction, and sexual assault. Was it a challenge for you with so many themes and characters, to do justice to them all?

AV: You want to make sure you don’t tax the reader. One of my writing teachers used to say that the reader is carrying a backpack and climbing up a mountain. You want to be sure that anything you put in that backpack is something they need when they get to the top of the mountain. If they get all the way up, and they don’t need it, they’re going to be very upset with you. The length of a book is also an issue; yet, what a shame if length dictates the stories you publish! A story needs to be as long as it needs to be.

There were other minor characters who were really interesting, but by the time we saw the true arc of the story, it became clear that they didn’t advance the plot and were distracting. So, I would like to think that most of the people in the book are advancing the plot in some way, or shedding light on some aspect of the story, and therefore necessary.

One of the most gratifying things I heard was from Oprah Winfrey, who said she got so absorbed in the book that at one point she looked to see how many pages were left, not because she was impatient with it, but because she didn’t want it to end. For a writer, that’s the most magical thing. If you’re engaged in the story, you don’t really care how long the book is, you don't want the experience to vanish.

Q: I had the same experience. I am a fast reader, and I had to tell myself to slow down. I was so sad when the book ended. I’m going to reread it after some time and rediscover the characters.

I want to talk about the “Oprah effect.” I follow her book club, and I have never seen her gush about a book so much or go into as much detail as she did with your book. How did it feel for you to have Oprah vouch for this book?

AV: It was unreal, obviously. I loved the idea of Oprah picking the book, and her enthusiasm was amazing. I don’t know what to say other than to be enormously grateful. She's helped me come to terms with what has happened with this book. I don’t know that I can ever write a book like this again. It took a long time to write, and a lot of hardship in finally getting there. I’m just trying to relish the phenomenon. I have friends who are not readers, but they are so enamored with Oprah that they have read every one of her 104 selections. She has done more for reading in America, and maybe outside of America, than anybody I know. Mark Twain said that the difference between people who don’t read and won’t read is no difference at all.

I’m not the kind of best-selling writer. I’m not writing popular murder mysteries where everybody’s waiting for your next one. With the kind of book I write, it’s God's grace if it comes out any good. I've been very lucky.

For a writer, that’s the most magical thing.
If you’re engaged in the story, you don’t
really care how long the book is, you don't
want the experience to vanish.

Q: Obviously it takes a lot of patience, and you also have a demanding day job. So, for people who want to write books, how do you manage the time between writing a book and a demanding job?

AV: I'm not in a hurry-I don't have to turn out another book and another book, I can take my time. I have many writer friends who pay the bills by virtue of the next book, and that’s a lot of pressure. I’ve never felt that pressure. In my early years, medical schools were not giving me time to write, but at Stanford they have been very supportive of my writing. They see it as the equivalent of a research scientist going to their lab. I’m a slow writer, and I’m not as regular as I could be, but somehow the pages add up and one day I finally have a finished manuscript.

Q: It’s about that persistence.

Thank you so much for taking the time to speak with me. I really do hope that you write your next book soon.

AV: Thank you very much.