Published in 2023, this is by Abraham Verghese (pronounced Verg-eeze). He's an interesting author, who describes himself as a "perennial outsider". He was born in Ethiopia to Christian parents from Kerala, India. He always felt drawn to both medicine and literature, and admired the stories of doctor-turned-writer Somerset Maugham, but after beginning his medical training in Ethiopia, he had to flee in 1973 as a result of civil unrest. He migrated with his parents and two brothers to the United States, where he worked as an orderly in a hospital. He eventually completed his medical studies in Madras (now Chennai), full of admiration for his Indian teachers, whose skill seemed to him like "wizardry". He then returned to the US to practise medicine in various capacities. He wrote a couple of memoirs in the 1990s, but his first novel was published in 2009, when he was already in his fifties.

I listened to the audio-version of this (all 31 hours and 16 minutes of it). It's read by the author, and aside from a couple of slightly off versions of British Isles accents, he did a beautiful job, varying tone, pitch, and speed very nicely.

Most of the story is set in the west-facing bit of southern India, predominantly in Parambil, Travancore. In 1956, the Malayalam-speaking regions of Travancore, Cochin, and Malabar formed the state of Kerala. But that's a long way into our story. We also have substantial sections set in Madras (now Chennai), and the sculptures of Mahabalipuram, in Tamil Nadu, feature a couple of times. (My meagre experience of this rich area is here.)


Mahabalipuram, 2005



It is a very atmospheric work, conveying the beauty of the watery landscape and the rhythm of the seasons very poignantly. Water, as I'll explain in a minute, is a bit of a two-edged sword for many of the characters, but the element's capacity for connection -- literally and figuratively -- is an effective symbol that recurs throughout the pages.

It's nothing if not panoramic, this story... We cover the period from 1900 to 1977, and a good chunk of social, economic, and political history passes before our eyes (or ears): Child marriage; infant mortality; the caste system; colonial corruption; epidemics, famines, and floods; world wars, with Indian soldiers fighting, and Madras bombed; independence; opium addiction; the coming of electricity and the radio; the expansion of education and railways and coffee plantations; the rise of communism in Kerala; the Naxalite insurgency; the changing role of women...

Grounding all this is our key family. Right at the beginning we meet a 12-year-old girl, who is about to be married to a 40-year-old widower, and will from that day live on his estate. It's not a horror story. He's taciturn, but he's kind, and ready to wait; such marriages are normal in the society of the day. But of course she has no choice, and we feel this acutely...

She evolves into the matriarch. Big Ammachi. And she's the most interesting character by far. She travels hardly at all, and her life is wholly domestic. Yet she is curious, open, and always compassionate. Her service to her family is unstinting, her love unbounded. Yet she will rebuke her adult son when she needs to. She's not afraid to give God a piece of her mind from time to time either. Yet she is a faithful Christian, and she hangs doggedly on to hope through the many tragedies that beset her. And Heaven knows, there are many, almost oppressively many, tragedies in this story: Death by water; death by accidental impalement; death by untreatable illness; thwarted pregnancies; thwarted ambitions; thwarted loves... Through it all Big Ammachi remains rock-solid.

She is probably the most rounded of the characters because she is based on Verghese's mother, who -- in response to a request from her granddaugher -- filled 157 pages with illustrated memories of her girlhood in Kerala. (There's much more on this background here, along with some wonderful photos.)


The beautiful Kerala backwaters

But the narrative also brings us other women who are memorable for various reasons. Big Ammachi's mother is ill-treated once she becomes a widow, and eventually ends up living with her daughter and her husband (he's never named, as far as I can recall, and is always referred to as Big Appachen).

Big Ammachi's son, Philipose, marries Elsie. She's an unconventional woman by the standards of her day. An artist, she is determined not to marry unless she finds someone who will support her creativity, and not condemn her to an endless round of domesticity, and she thinks Philipose, who's a writer, will understand this need. Well, he turns out to be a bit disappointing in that respect... But then, he labours under a disability, and feels a little inferior to her, and they have lost their first child, and he starts taking opium to deaden the pain from an injury, and everything is at sixes and sevens... I was never quite sure about Philipose. There was something about his abrupt transitions that I could never quite believe.

The final feisty female is Mariamma, the child of Elsie and Philipose (or is she...?) She's the one who is finally able to make choices. She goes to medical school, much to Big Ammachi's delight, and battles on, through the humiliation of sexual harassment and the heartbreak of a boyfriend who has joined the Naxalites, to become a skilled surgeon and budding researcher.

Which brings me to the medical aspects of the book. With which it is PACKED... There are many, many, many medical emergencies, and they're all described in literally gory detail. I listen to books while I'm cooking, and it was uncanny how often haemorrhages and surgical procedures corresponded with food preparation... I'm not squeamish generally, but the juxtaposition was a bit unsettling sometimes.

There are two key medical threads. One is leprosy. The other is neurofibromatosis type 2... Except they don't know it's that until right at the end. Most of the way through, it's referred to as "the Condition", and it's a total and tragic mystery. It is marked by an aversion to water and a marked propensity to die by drowning (instances of which crop up repeatedly in succeeding generations). Both characteristics are due to the sufferer's inability to balance, and -- when disoriented -- to tell up from down, making it very difficult to deal with a non-solid medium. There's a full scientific discussion of the malady here, and I won't even attempt to summarize it, but this narrative thread does represent something of a triumph on Verghese's part. I think Saloni Sharma (whose insightful review is really worth reading) expresses it very well: "He takes what could have been a myth or even superstition -- what is, definitely, a family’s well-kept secret -- and turns it into scientific enquiry."

So these threads are critical, but we encounter many other medical crises in the narrative, and sometimes I felt as though the story had been constructed around them, as though it was a kind of fictional instruction book.



I enjoyed the story, there's no doubt about that. I wanted to find out what happened to the characters (and the denouement, which I won't reveal, is heart-breaking).
I also thought some of the political commentary was quite astute. How difficult it always is to move towards justice, whether it's breaking away from colonialism or breaking away from the caste system... Even the generous will be blamed if they are implicated in systemic injustices; those you are trying to help may not always like the WAY you are trying to help them; there's much room for hurt and misunderstanding.

And there are many moving moments: Big Ammachi silently taking leave of everyone on the last evening of her life, for example; and the opening and closing sequences, which both feature a mother and daughter (four generations in all).

But I wasn't as enthusiastic as many appear to be... Oprah Winfrey, whose capacity for getting people to read I really admire, says: "It is one of the best books I have read in my entire life, and I have been reading since I was 3!" Former President Obama put it on his Favorite Books of 2023 list. I didn't quite feel that way.

Despite all the drama, there's something just a tad flat about it. Not enough tension, perhaps, between essentially "nice" people and the darkness of many of the social evils around them. Not enough ambivalence in the characters. Not enough desperation.

Perhaps this is what Santanu Bhattacharya is picking up on: "In looking at the past through a wide lens, the book papers over problematic practices of the time... The feelgood feels a bit too good after a point."

Saloni Sharma also pinpoints this: "The book... attempts to tackle questions of caste, class, race, and gender, sometimes settling for easy resolutions... While the author’s desire to set right historical wrongs is laudable, the story sometimes glosses over or softens difficult bits, like in its rose-tinted treatment of child marriage, in the slow-blossoming romance between Big Ammachi and her strong, silent, and brooding husband."

Maaza Mengiste highlights a possible reason for that: "The psychological and emotional growth that could have fostered deeper understandings and greater revelations remains unexplored... The novel’s authority lies not in the excavation of psychological ambiguities, but in the dawning awareness that each character is beholden to something much more powerful and more encompassing than emotional turmoil: the physical bodies they inhabit."

So, definitely not "one of the best books I have read in my entire life", but interesting nevertheless. Worth your time. Just make sure you schedule your tomato sauce so that it doesn't coincide with one of the haemorrhages...