The Covenant of Water

Book Title: The Covenant of Water

Author: Abraham Verghese

Publication Details: Grove Press, 2023, 715 pp., $32.00, hardcover

The Covenant of Water expansively tells the story of a multigenerational family in Parambil, in Southeastern India. The saga begins with the marriage of a 12-year-old girl to a much older man in 1900. This girl becomes the matriarch of a family that grows into community leaders through good deeds and values despite multiple tragedies linked to a medical mystery. We learn of “the condition” early in the book, but the medical mystery is not resolved for some time. The fact that the author is a physician is occasionally clear in the specific and accurate descriptions of anatomy and procedures, but this is not a medical book. It is not written for a medical audience, and those with no medical background will enjoy it as much as those trained in medicine. This is a story of genuinely good people working to make a corner of the world better for those around them. The characters, of which there are many, are not very nuanced; but we move through extended time, so this is easily forgiven. Do not be intimidated or dissuaded by the length of the story; it is compelling, captivating, and not difficult to finish.

Although the main story is of the family in India, several parallel stories begin independently and link up only later in the book. Through these parallel narratives, we learn the impact of colonialization, the caste system, the conflict with Pakistan, and the ongoing dissent with the ruling government. Although a few tangents seem to dead end, overall the effect is of a deeper understanding of the political, societal, and cultural influences on the central characters.

Family medicine educators are consistently reminding medical learners to consider aspects of the patient’s presentation that extend beyond the individual and their personal medical history. We seek to know the patient’s context: Who is in their life now, or earlier, that influences their current state of health and disease, and what is their generational/family history? With the strength of its narrative, this book affirms the importance of those perspectives.

The granddaughter of the first character we meet becomes a physician and figures out the source of “the condition” that is responsible for multiple losses over the three generations. She would not have been able to do that without a genogram kept over the years, which was saved and updated by the matriarch. By following the inheritance of the affliction and identifying the circumstances around each death, the author attests to the importance of a deeper family history than is often gained with a genogram, which is difficult to recreate in the era of electronic health records.

Although a genogram may in some ways be a forgotten art and tool, the context of the individual in family and community is always influential and often the key to understanding, diagnosis, and individualized treatment. The healers in the book, both physician and nonphysician, inherently understand this and demonstrate the influence of context on the characters’ health and well-being. Several characters are physicians and are portrayed in a positive light as empathic individuals who seek to understand, and even live with, their patients. Even the marriage broker understands the importance of context and family history: “Every family has secrets, but not all secrets are meant to deceive” (p. 714). But the marriage broker’s corollary to that statement is the notion that “what defines a family isn’t blood, but the secrets they share” (p. 714). Before understanding the medical explanation for “the condition,” the family keeps it secret. This attempt to protect family members only puts them at increased risk; they misinterpret the effects of the condition and therefore fail to adequately safeguard against it. Only when secrets are shared does a full explanation of the condition emerge as well as ways to protect against its ill effects. A final reveal in the book evidences the layers of secrets that often exist in families. This revelation attests to both the hope and melancholy that accompany disclosure. But, as we also learn the secrets, we join in becoming “one big, bloody, happy family” (p. 715).