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Alison Stewart: This is All Of It. I'm Alison Stewart. You might remember Abraham Verghese as the doctor who wrote the mega-selling bestselling novel, his debut, Cutting for Stone, which was on the New York Times bestseller list for more than two years. After its publication, Verghese went right back to being a doctor, and he remains the vice chair of the Department of Medicine at the Stanford University School of Medicine. Dr. Verghese just published a new novel, his first in about 14 years. It's a generation spanning epic that unwinds over the course of 80 years and 715 pages. It is titled The Covenant of Water.

The story begins in the year 1900 in Kerala, India, with a 12-year-old girl who has entered into an arranged marriage to a widower with a son. As she gets older, she becomes known as Big Ammachi, and her relationship with her husband evolves into love. She does discover he has been keeping a secret from her. His family has something they call the "condition." Each generation, it seems, someone is fated to die by drowning. As Big Ammachi family grows, it seems that tragedy is destined to befall them. That is, until one of Big Ammachi's descendants goes to medical school and tries to get to the bottom of the mysterious condition.

In a starred review, Publishers Weekly says Verghese outdoes himself with this grand and stunning tribute to 20th century India. In their starred review, Kirkus says simply, by God, he's done it again. The Covenant of Water is available now at your favorite local indie bookseller, and Dr. Abraham Verghese joins me now to discuss. Abraham, it's so nice to meet you.

Dr. Abraham Verghese: Likewise. Very nice to hear you.

Alison Stewart: Have you been writing this over the course of 10 to 14 years, or did you set aside time to sit down and write another novel?

Dr. Abraham Verghese: I think I spent a couple of years just relishing the feeling of having finished one. I think the blessing of my day job is that I don't have to churn another one out and another one out to pay the bills. My advice to writers is not facetious, but get a good day job that you love. It took me a while to get going again, and then it's about a decade, I would say.

Alison Stewart: This book spans three generations, from 1900 to around 1977. Was that always the scope of the story, or did the story just keep expanding and keep going?

Dr. Abraham Verghese: No, I always knew that I wanted to set it in Kerala, which is this unique land full of water and rivers and lagoons and backwaters. I knew that I wanted at least three generations to allow this condition to play out. I knew it would be a pretty big book, but when you try and really convey the characters in three generations, it takes a bit of doing. It doesn't happen in a slice of life kind of description.

Alison Stewart: The condition was where you started?

Dr. Abraham Verghese: Yes. This is very much the community that I come from, my parents come from, although I was born in Africa, and there's so much arranged marriage because we are Christians who believe our Christianity came from St. Thomas the Apostle landing on the shores of India in 52 AD. In this very insular community with intermarriage and arranged marriage, it's often the case that a family's reputation-- a girl's reputation, is sullied by the most casual remark, "Oh, that family has convulsions. Oh, there's lunacy in the family." Some of these things might actually be true. There's a great deal of investment in secrecy, and I've always been intrigued by rare medical conditions.

I keep them in my back pocket and trot them out to ask questions of residents. This condition is a real condition where-- and I won't tell you much more than that, but where people drown inauspiciously in the most shallow waters, places where you shouldn't be drowning, like bathtubs and ponds. To give a family in a land full of water, to give them a condition that makes them shun water or stay away from it, and yet manage to drown, I thought was a fascinating mystery, a conceit that runs through the whole book.

Alison Stewart: You mentioned that you question your residents about these various conditions and afflictions. Are you someone who believes in narrative medicine?

Dr. Abraham Verghese: Yes, I'm not an exponent of it. The term has become very loosely used. I am a big believer that in order to really put ourselves in the shoes of our patients, literature in general, if I want to teach them about child abuse, I can send them to a textbook, or I can have them read Dorothy Allison's Bastard Out of Carolina. If I want to teach them about end of life, I could send them a textbook on palliative care, or have them read The Death of Ivan Ilych by Tolstoy. In that sense, I'm really a believer in humanities, in medicine, in that sense, yes.

Alison Stewart: My guess is Dr. Abraham Verghese. The name of the new book is The Covenant of Water. How do you organize a book of this size, and over this period of time with so many characters? This is a very nuts and bolt question. Are you an outline person? Are you a notecard person? Are you a post-it person?

Dr. Abraham Verghese: Such an important question because I wish I could plan the book out entirely, and I'm envious of writers who manage to do that. Someone I look up to, John Irving, knows the last and first line of every chapter, and knows how the book ends. He has said to me, "Abraham, if you're making this up as you go along, if you don't really know what's going to happen, then you're not a writer. You're just an ordinary liar." [laughs] I certainly try, but what happens is I have these elaborate outlines on a whiteboard, and then when I put a character under pressure, there's a maxim in writing that character is determined by decisions taken under pressure.

I put my characters under pressure, and then they react in a way that makes me have to go and erase the whiteboard and replot. I think eventually we get to the same place. There's a point where I know the whole story, but I find it by writing less, by plotting and just seems to be my way.

Alison Stewart: The book begins with this 12-year-old girl married off to a widower adult man, who has a son not much younger than she is. At first, they're strangers. As years pass, the relationship seems to have real love and tenderness associated with it. Yet, there is this secret. Why do you think he has kept a secret from Big Ammachi, his secret from his wife, until it's too late?

Dr. Abraham Verghese: His feeling, I think, was that she already knew, or at least the people who arranged the marriage knew. I should also mention another thing that I think trips up listeners, and it's always worthwhile explaining, my grandmother was married at 12, my great-grandmother even younger, but they were being married to 9 and 12-year-old boys. They entered this household where they became children of the household, and they became so close to their mother-in-laws who were like their mothers, and who kept really close taps in them. Someone told me about my grandmother telling her mother-in-law, "Ammachi," which means grandmother, "that irritating boy, can we send him away?"

That boy was her future husband.

At some point, the marriage changes. I was just invested in this idea of how families become burdened with these secrets, and how secrets can tie them together or, in their revelation, tear them apart. I've seen hints of that in families in Kerala, and I took that and ran with it a bit.

Alison Stewart: What does the name Big Ammachi signify?

Dr. Abraham Verghese: Ammachi just means grandmother. Big Ammachi is Big Grandmother, which is ironic because she's a very petite, tiny lady, and comes there as a very humble bride and remains so. I really wanted to write a character who there's so many mother characters who tend to be evil or somehow flawed, and I wanted to find a character or portray a character whose simple faith, whose daily ritual is heroic. The world would never know about it, but in her constancy, in her love for her kids, in her devotion to everything about the household and her husband, achieves a sainthood, to use a phrase that doesn't quite apply to her.

It made me want to celebrate who she was to the point where people started to call her Big Ammachi partly as a joke to start with, but then it became real, because she was the big matriarch of the family.

Alison Stewart: What did you want to explore about faith in this book?

Dr. Abraham Verghese: I'm not sure that I'm ever proselytizing or have any message, but I've been struck by the solid faith of my forefathers, my parents. There's something about the ritual itself that is healing and strong. It's curious. When we were children, we were taken to these long two and a half hour services in a language that not even my parents understand because it's an ancient Aramaic derived language called Syriac. The priests know it, nobody else knows it. We're all sitting there, and I think most of our children got pushed away from religion for that reason. It just seemed so boring but most of us negotiated our way back at some point. Recently in Fremont, California of all places, I went to one of our churches, there's enough of a community that there's this church and the service was in Syriac. They also do an English service, but this one was in Syriac. My goodness, I felt goosebumps. I still didn't know what they were saying, but it was so familiar.

There was something very soothing about being with my community and hearing these tones of my childhood. I think I'm just observing more than I'm ever trying to espouse a cause or push people towards something. In showing, these families and their solid faith and how it carries them through troubles, I think we all learn something. We carry away something about our own lives.

Alison Stewart: Are you someone who believes that science and faith can coexist?

Dr. Abraham Verghese: Oh, absolutely. I never thought that they needed to be opposed to each other. The very definition of faith is belief in the absence of proof. In that sense, it's not that different from many scientific hypotheses that we carry around. Of course, we're looking for proof, and maybe one day we get the proof or we don't. Speaking of which, I thought was fascinating, in the novel Include Medicine, the way we have a condition that's unlabeled, but by the end of it it has a name and it's biology is understood. We're at that stage now. There are things we don't know 70 years from now, they'll look back at us and think, wow, those guys are really simpletons. It's all evolving, both science and faith I would say.

Alison Stewart: There is a lot, medicine is a big part of this book. When you're writing, what's important for you to keep in mind? You have all this medical knowledge, but you need to incorporate it so that a literary audience can feel engaged.

Dr. Abraham Verghese: I think that I see medicine as a life plus plus, and I think we all bring a curiosity about things that are procedural. Set of novels and a radio station, a police station, a hospital, and always people are, I like as a reader to hear about procedures. Tom Clancy and the working of submarines. You are right. It's a fine line. You don't want to overdo it. You don't want to just do it for the sake of titillation. You want to take the reader into a medical entity that serves the story. Ultimately, that is, my only goal is a good story well told.

Alison Stewart: Before we wrap, I do have to say, the beginning of the book is about Big Ammachi, I hope I'm saying it correctly. Then we get over to meet a Scottish doctor named Digby, who comes to Madras to study. Give us a taste of who Digby is.

Dr. Abraham Verghese: As was common in the time, many of the physicians, especially those in the medical schools and teaching were actually colonials. They were British or from the UK, and so it would be hard to write a novel with physicians without including those kinds of physicians. He typifies someone who came with the Indian Medical Service and learned a lot by doing that and also gave good service. He was an important character in the novel

Alison Stewart: You'll learn more about Digby and Big Ammachi by reading The Covenant of Water. It is out now. It is by Dr. Abraham Verghese. Abraham, it was lovely to meet you.

Dr. Abraham Verghese: Thank you for having me, Alison. Truly an honor.

Alison Stewart: This is All Of It.

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