Medicine

Review: The Covenant of Water

/ rtrube54 / 4 Comments

The Covenant of Water, Abraham Verghese. New York: The Grove Press, 2023.

Summary: The story of three generations of the family of Big Ammachi of Parambil, the ever present reality of “the Condition” resulting in a drowning in every generation, a story both of love and the hope in advances in medicine.

Twelve year old Mariamma has been engaged in a brokered marriage to a forty year old widow, the owner of a 500 acre estate near the town of Parambil. Her mother tells her, “The saddest day of a girl’s life is the day of her wedding….After that, God willing, it gets better.” I began reading with a sense of foreboding of what would happen to this girl in the house of this man. And I was surprised. At the wedding, he runs away, mortified that she is a mere child. But they wed. And he leaves her to her own room, and lets her learn the management of the household, lets her mature, lets her bond with his son, JoJo, and lets her realize that he has loved her by providing her time to come to love him. And so begins this incredible story spanning three generations within the Mar Thoma Christian community of South India.

When JoJo falls into what is little more than a puddle and drowns, she learns of “The Condition.” It explains the distance of the house from the river, the fact that her husband will not travel on the water. She is shown a genealogy. Every generation has a death from drowning. And JoJo’s name is added. Eventually Mariamma, who has become Big Ammachi, a capable manager of her household, bears another child, a girl with a developmental difficulty leaving her a perpetual child. Baby Mol brings perpetual love and an uncanny prescience about events. Fifteen years pass, and at a point of giving up hope, Big Ammachi has a son, named Philipose.

Philipose has the condition. Sent to college in Madras, he soon quits due to deafness that impedes his ability to follow the lectures. On the carriage home, he meets Elsie Chandy, an artist, and is smitten. They’d had a brief encounter when Philipose risked his life carrying a dying child on a river barge during floods to the nearest hospital, and was given a ride home by Elsie and her father. He strives to educate himself and becomes a writer, producing a column, “The Ordinary Man” widely followed throughout the country. Eventually, through a broker, Elsie’s family agrees to the marriage. It seems like a beautiful love affair, that sadly ends with the tragic death of their child Ninan. They blame each other and Philipose, injured trying to rescue Ninan, falls into opium addiction. Elsie leaves but returns when she learns Baby Mol is pining for her, and in failing health. Philipose and Elsie are intimate once and it is soon evident that Elsie is pregnant. As she approaches delivery, she has a seizure. Big Ammachi assists in a difficult breech birth, nearly costing the mother her life.

The baby is named Mariamma, after her grandmother. Soon after her recovery, Elsie disappears after going to the river to bathe, her body never found. Philipose sorts out his life, becomes an exemplary father, and continues his writing work, turning over his estate to Shamuel, and eventually, Shamuel’s son Joppan, to operate. Big Ammachi has dreamed of both a hospital in Parambil, and that her grand-daughter would become a doctor and find the cause of “The Condition” that plagues her family.

The book also involves a parallel plot line in which a young Scottish doctor, Digby Kilgour, goes to India to acquire surgical experience. Working for an incompetent superior, he has an affair with the superior’s wife, ending in a tragic fire that only he survives, with his right hand badly burned. A couple, grateful for an earlier medical intervention on his part, shelter him and connect him with a doctor working with lepers, who operates on his hand. He is helped by a young girl who helps him recover fine movements in the hand through drawing. Through much of the novel, we wonder what the what the connection of this plotline is with the main plotline of Big Ammachi and her family. Hang in there. There is one.

The story spans the period from 1900 to 1977. India goes through huge transformations through this time that serve as a backdrop for the novel, from a British colony par excellence to an independent country, seeking to modernize amid political ferment, with the electrification of the countryside and advances in medicine and modern technology. We get some sense in the novel of how this presses against traditional caste divisions, particularly in the relations between the family of Big Ammachi and Shamuel and his son Joppan.

I found the writing particularly engaging. It felt to me that Abraham Verghese writes with the same reverence for his characters that he has for his patients (he is a Professor and Vice Chair of the Department of Medicine at Stanford). One senses a deep sympathy for his characters, even as they struggle with tragedy, estrangement, and the vicissitudes of life and death. He portrays a community shaped by faith, love, and purpose. And he conveys the noble possibilities of the medical profession, evident in Rune Orquist, the doctor of a leper mission who operates on Kilgour’s hand, and in Mariamma, and the professors who train her. To read Verghese is to read a consummate story weaver who has thought deeply about the human condition in its frailty and fallibility, in the powerful bonds upon which our lives and loves depend, and in the hopes and holy aspirations that represent the best in human striving.

Review: The Song of the Cell

/ rtrube54 / 2 Comments

The Song of the Cell, Siddhartha Mukherjee. New York: Scribner, 2022.

Summary: A history of the advances of cell biology including the cutting-edge innovations that allow for the modification or implantation of cells, creating in essence, a new human.

There was a time when those who studied organic life did not understand that a fundamental component of all living things was the cell. And then Hooke in England and van Leeuwenhoek in Amsterdam used their primitive microscopes to look at water droplets and tissue and saw–cells. Not only that, these early cell biologists realized all living organisms were constituted of one or more cells that are the basic structure on which all of life is organized.

Siddhartha Mukherjee, a cancer researcher, takes his readers on a step by step narrative unpacking the basics of cell biology (and pathology) for a lay audience. He takes us through the different structures within the cell and the incredible phenomenon of cell division. He traces how cells develop into living organisms from a tiny clump to a blastocyst to a living human being or other creature.

Perhaps the most fascinating section of the book is that on the nature of blood. He describes the different components of blood–red cells, how blood clots, and the intricacies of the immune cell and how self recognizes non-self, and what happens when self fails to recognize non-self and when self thinks self is non-self. Later, we learn that all the different components of our blood arise from a single type of stem cell.

Amid the story (and the writing) came the pandemic. Mukherjee remarks that it came at a time when cell biologists were celebrating breakthroughs in understanding immunology. And COVID-19 unraveled so much of what we thought we knew, once again showing us how much we’ve yet to learn. Here as in the rest of the story, Mukherjee intermixes personal narratives, sometimes tragic, with the science.

He takes up how cells work together. There are the “citizen cells” of the heart muscle, pulsating in rhythm for decades. There are the “contemplating cells,” the neurons, and the fascinating role of microglia in pruning away unused connections, creating the particular ways we are “wired.” Then there are cells within key organs that maintain homeostasis, those in our pancreas our metabolism, in our kidneys, our salt levels, and our liver, metabolizing harmful chemicals like alcohol.

An underlying theme that Mukherjee draws to a focus at the end are the ways we intervene to modify cells. It may be the interventions to halt and destroy cancer cells, runaway cells that cannot turn off their multiplication and trick the body to not recognize the foreign, yet non-foreign, invader destroying it. We’ve pioneered IVF techniques and, in the case of one researcher at least, genetically edited and embryo (and went to prison for it), resulting in the first gene-edited baby. The use of edited stem cells to reverse sickle cell anemia, to reverse osteoarthritis and a host of other therapies suggest the possibility of “new humans,” or at least renewed ones.

There are always the questions of how far to go with such things, questions that often arise only after we realize something is possible. Mukherjee explores the boundaries between maintaining and restoring health and the enhancements that somehow change who we are. What is most troubling about the latter augmentations is that they reflect a certain privilege not open to all, creating the potential for two races, those of super-humans and then ordinary humans. How long will it be before they are viewed as sub-human?

Aside from these sometimes fascinating and sometimes vexing questions is the sheer wonder Mukherjee describes, aptly called the “song” of the cell. Often, his writing sings and soars, and one finds oneself saying, “how wondrous.” Sometimes the song descends as well, as we learn of the microbes that invade us or the cancer that consumes and wastes us. Sometimes the song is beautifully complex, like a baroque fugue, and other times chaotic, difficult to make sense of, as are many of the intricacies of various cancers. This was a stunning work, leaving me in a state of wonder, even with all the mysteries of the cell yet to be unraveled.