As the story unfolds, young Mariamma becomes a doctor and begins to unravel the mystery of “The Condition.” Her investigation reveals it to be Von Recklinghausen disease and uncovers surprising truths about her own parentage. The novel concludes with Mariamma discovering that her mother, Elsie, is still alive but living with leprosy at the leprosarium under Digby's care, having faked her death to protect her daughter from the disease.

Themes

• Family legacy and intergenerational trauma

• Love and loss across generations

• Faith and spirituality in the face of adversity

• Medical progress and human understanding

• Cultural and social changes in Kerala, India

• The pervasive presence of water and its symbolism

• The search for identity and belonging

Setting

Set in Kerala, on India's lush Malabar Coast, The Covenant of Water spans nearly eight decades from 1900 to 1977. This extensive timeframe allows readers to witness the transformation of Kerala through the eyes of three generations, from British colonial rule to India's post-independence era.

The story primarily unfolds in the fictional town of Parambil, where the family's 500-acre estate serves as a central backdrop. Other significant locations include a leprosarium run by a Swedish surgeon and various medical facilities that reflect the novel's exploration of progress in medicine. The narrative also touches on larger cities like Madras (now Chennai), providing glimpses into urban life in early 20th century India.

Verghese vividly portrays Kerala's unique landscape, where water is omnipresent – from rivers and backwaters to the Arabian Sea. This aquatic setting is integral to the plot, as each generation of the family grapples with a mysterious affliction causing deaths by drowning. Through this watery lens, the author paints a “shimmering evocation of a bygone India,” capturing the region's natural beauty, cultural richness, and socio-economic changes over time.

Characters

• Big Ammachi (Mariamma): The central character and matriarch of the family. Married at 12 to a 40-year-old widower, she grows into a strong and capable woman who oversees the family estate. Her life spans most of the 20th century, witnessing tremendous changes in India and her family. Big Ammachi's faith and love remain constant throughout her extraordinary life.

• Big Appachen: The 40-year-old widower who marries young Mariamma. He becomes a loving husband and father, working alongside Big Ammachi to manage their estate. His character represents the older generation and traditional ways of Kerala.

• Philipose: Son of Big Ammachi and Big Appachen. He grows up to become a celebrated writer and marries Elsie. Philipose's life and mysterious drowning are central to the family's story and the mystery of “The Condition."

• Elsie: Wife of Philipose and an accomplished artist. Her disappearance and the revelation of her true fate are key elements of the plot. Elsie's story intertwines with the themes of love, sacrifice, and the impact of disease.

• Mariamma (younger): Daughter of Elsie and Digby, raised as Philipose's daughter. She becomes a doctor and ultimately unravels the mystery of “The Condition.” Her journey of discovery forms a significant part of the novel's later sections.

• Digby Kilgour: A Scottish doctor who immigrates to India. His life becomes intertwined with the family's through his relationship with Elsie and his role as Mariamma's biological father. Digby represents the outsider's perspective on Indian society and the medical advancements of the era.

• JoJo: Big Appachen's son from his first marriage. His tragic drowning introduces the concept of “The Condition” to the story.

• Baby Mol: Daughter of Big Ammachi and Big Appachen with developmental disabilities. Her presence in the story highlights themes of family care and societal attitudes towards disability.

• Dr. Rune Orqvist: A Swedish surgeon running a leprosarium. He plays a crucial role in Digby's story and represents the medical community's efforts to treat leprosy.

• Shamuel: A member of the pulayar caste and foreman of Parambil. His friendship with Big Appachen illustrates the complexities of the caste system in Kerala.

Quick facts

• The novel spans 77 years, from 1900 to 1977, following three generations of a family in Kerala, India.

• It was selected for Oprah's Book Club in 2023 and became an instant New York Times bestseller.

• The story was inspired by the life of Verghese's mother, Mariamma, to whom the book is dedicated.

• A central mystery in the book revolves around a family affliction called “The Condition,” where at least one person in each generation dies by drowning.

• The novel's main character, Big Ammachi, is married at age 12 to a 40-year-old widower.

• Verghese, a physician himself, incorporates medical themes and progress throughout the narrative.

• The book explores the caste system in India and the British colonial presence, among other social themes.

• It took Verghese over a decade to write The Covenant of Water.

• The novel's cover art was created by Kelly Winton, with illustrations by Thomas Verghese.

• Oprah Winfrey optioned the film rights to the book in January 2024.

About the Author

Abraham Verghese is a renowned American physician, author, and professor born in Ethiopia to Indian parents in 1955. He completed his medical training in India and the United States, specializing in infectious diseases. Verghese's experiences treating AIDS patients in rural Tennessee during the 1980s profoundly influenced his career and writing. His commitment to humanism in medicine led him to develop innovative approaches to medical education, emphasizing bedside skills and patient-centered care.

As an author, Verghese has published four critically acclaimed books, including two memoirs and two novels. His debut work, My Own Country, chronicled his experiences with the AIDS epidemic and was adapted into a film. His first novel, Cutting for Stone, became an international bestseller. Verghese's latest novel, The Covenant of Water, was selected for Oprah's Book Club and remained on The New York Times bestseller list for 37 weeks. His writing often explores themes of displacement, medical ethics, and the human experience in healthcare.

Currently, Verghese holds a prestigious position at Stanford University School of Medicine, where he serves as the Linda R. Meier and Joan F. Lane Provostial Professor and Vice Chair of Medicine. He is also the founder and director of Stanford's Presence program, which promotes the importance of human connection in medical practice. Verghese's contributions to medicine and literature have earned him numerous accolades, including election to the National Academy of Medicine and the American Academy of Arts & Sciences.

Verghese is a sought-after speaker and advocate of modern medicine. He has given a TED talk on the importance of touch in healthcare and co-hosts the Medscape podcast “Medicine and the Machine.” In 2015, President Barack Obama awarded Verghese the National Humanities Medal for his efforts to emphasize compassion in medicine and his vivid portrayals of the human drama in healthcare.