Tuesday, July 8, 2014

Cutting for Stone by Abraham Verghese

Source of book: Borrowed from the library

I experienced the first part of this book as an audiobook during an extended drive for an out-of-county case. However, this book is long - 541 pages in the hardback edition. That makes for a long listen, and not one that I could really share with the kids. Thus, lacking another long solo drive in the immediate future, I checked out the print edition, and finished it on my vacation.

Unlike movies, books don’t generally get content ratings. If it did, this one would probably qualify as R: Depictions of Surgical Violence. Abraham Verghese has the experience necessary to write convincingly about medicine, as his first (and to a degree continuing) career is as a physician. He currently serves as a professor at Stanford University Medical School, following three decades as a practicing physician.

Verghese’s first two books were non-fiction. The first, My Own Country, told of his experiences during the first days of the AIDS epidemic, while the second, The Tennis Partner, addressed the issue of drug abuse within the medical professions.

Cutting for Stone is Verghese’s first novel, and it draws significantly on his own experiences. Like his protagonist, Verghese is of Indian descent, but was born and raised in Ethiopia. After beginning his medical training there, he fled to the United States along with his family during the civil unrest and coup that form a central part of the book. After finishing his medical training in India, he, like his character, served in hospitals serving low income neighborhoods. 

I had a difficult time trying to decide exactly what approach I would take to this review. There are too many ways to view the book, too many potential themes, and too many details to process in a short space. Rather than stick to one approach, I am going to throw a few out there and see what happens.

The book is, in my opinion, laid out largely along the lines of a classical tragic play, with the inciting force, turning point, and ultimate catastrophe at the end. To be fair, it isn’t a complete catastrophe, but it is pretty close. The protagonist, Marion, has a fatal flaw - the love for a girl (who eventually becomes a woman) who doesn’t love as deeply or as patiently as he does. So that is one potential viewpoint.

Another idea I had was to look at it as a series of passionate relationships that never really got a good start or had a chance to grow. Of the three great passions, two end in tragedy, with the woman (eventually) dead, and the man greatly damaged. The third one, though, is a great and glorious romance. (More about that later.) The theme of the book could therefore be “If Only…”

Using this view, it is the love that develops between Marion’s biological parents that is never spoken until it is too late that starts the whole sequence of events in motion. Had either of them just said something, tragedy could have been avoided.

Likewise, had Marion’s passion for Genet either been consummated earlier, or had she been patient, or had Marion just been able to walk away emotionally, things would have been much different.

In contrast to these stillborn relationships is the great romance between Ghosh and Hema. It too is on the verge of being a mere question of what might have been, had tragic circumstances not intervened to prevent Ghosh from leaving for America without declaring his love for Hema. He had been pining for her since their medical school days, but she was always aloof. When he finally does declare himself, she laughs at him, not realizing how serious he is - or indeed knowing her own feelings. However, as they are bound together by the need to care for Marion and his twin brother after their mother’s death and their father’s desertion, they have the time to overcome the initial misstep, and develop a charming and believable romance.

In my opinion, Ghosh and Hema are the best characters in the book. I found them human, real, sympathetic, flawed, and the sort of person that I would love to know in real life. Hema is strong, confident, competent, and has both an acid tongue and a genuinely compassionate spirit. Ghosh too has a tenderness about him that belies his crusty exterior. He ultimately is the one who risks himself and suffers as a result of doing the medically compassionate rather than the politically expedient thing. More than anyone else - and in contrast to Marion’s biological father - he puts his own dreams and fears aside for the needs of the helpless, ill, and abandoned.

Another potential angle occurred to me after I finished, and I am still on the fence as to whether it applies or not. I am inclined to think that, although the author isn’t misogynistic, the book itself is quite negative about female sexuality. Or perhaps I might better say, “female initiated sexuality.” The two tragic relationships are ruined in large part by female initiated or pursued intercourse. In the one case, this results in a death, and the other in a near death. By contrast, Ghosh pursues Hema, not the other way around, and this one ends happily for both parties.

If Verghese had shown any disdain for women elsewhere in the book, I could have just accepted this as retrograde views of gender and sexuality, but I just don’t see that anywhere else other than in these particular instances. His female characters are complex, neither vixens nor angels, and he takes them all seriously in how he fleshes them and their motivations out. So I am unable to decide. Did he just formulate the plot, and wrote the relationships to further that, or did he start with the premise of dangerous female sexuality and work out from there?

These are my ideas about overarching themes, but there are an abundance of sub-themes that add much to the book.

First, Verghese makes one of his own concerns central to the book. As a physician, he advocated for improvement of bedside manner, and a return to a concern for the patient, rather than just charts and checklists. As Thomas Stone (Marion’s father) puts it in his textbook, “What is the only treatment in an emergency administered by ear? Words of comfort.” Throughout the book, the focus is on the treatment of patients with kindness and compassion, regardless of the status of the patient.

Much of the book is set at a (fiction) Mission Hospital in Ethiopia. There, on a shoestring budget, the overworked staff take on all comers, serving anyone who is in need, from the head of state to the beggar. Later, Marion gets a job working in a hospital in an impoverished section of New York City, which serves mostly African Americans mired in poverty. Like many government hospitals in my home state of California, it gets all the trauma patients: gunshot and knife wounds, bad vehicle accidents, and so on. Although the details occasionally overwhelm the narrative, the book makes a solid plea for a more compassionate view toward the provision of care for the least wealthy here and abroad.

The book also gives a good bit of space to Ethiopian politics. The coup and unrest are central to the events of the author’s life, and are likewise crucial in Marion’s own story.

It isn’t just the politics, though. Verghese lovingly paints the details of Ethiopian society and culture. Some of it is colorful and alluring, and some of it is just depressing. I noted the question of the approach to female sexuality. I should perhaps correct myself and say that Verghese also portrays the retrograde views and actions of that culture all too well. I do not get the impression he approves, though.

Much of this feels so repulsive to modern Western readers, but it is not that far removed from our own history. Prostitution is an everyday occurrence in the book. Any and all of the men are able to, and often do, take advantage of the abundance of affordable harlots in town, and the culture just accepts it. More than that, even those women who are “respectable” will engage in the practice whenever needed to keep food on the table during times of need. Particularly heart wrenching is the character of Tsige, one of my favorites. After her child dies, and she is abandoned by her husband, she opens a shop and restaurant. Still, to get the funds to start her business, she sells her body. Worse than that, she just seems to take it as a matter of course - as do most lower income women - that they will have to put out to get by. Their vaginas and their hands are equally necessary for sustenance. I won’t quote the description of an encounter between Ghosh and his maidservant here, but I found it devastating in the blase attitude of the servant. But maybe Doug Phillips wished he lived in that culture.  As Marion notes about his early teen years, he alone was ignorant of the fact that most of his male peers had long ago undergone a sexual initiation with a barmaid or a servant. It was just a matter of course. Set the table, and spread your legs. Try not to get pregnant. As I have noted previously, this used to be the way things were throughout the world. Women were viewed primarily as objects of men’s pleasure - even by women. We just tend to ignore that part of history all too often.

For the most part, Verghese writes quite well. I noted a bit of a weakness toward over description, particularly when it comes to medical stuff. I am married to a nurse, so I probably found it more understandable and more interesting than the average person, but it did tend to stall the narrative occasionally.

Some critics have also criticised the book for taking too much time giving background on minor characters. I disagree with this assessment, but that is probably because I tend to read longer classics for fun. I loved that Verghese took the time to explore the pasts of most of the characters, and wouldn’t wish him to have cut out any of it.

That leads me to another theme, which comes to mind. All of the major characters are orphans in some way. Each has suffered a devastating loss or abandonment. These losses drive their character, and in turn lead to the tragedies that fill this book. A fear of further loss or hurt, or anger at a betrayal causes poor decisions that cause more loss and pain, and on down the line.

Perhaps, then, one can end on a related idea: it is only when love and heartbreak is risked that love and reconciliation can occur. What might have been becomes reality only through great risk and a persistence in love.

This is an excellent book, and I am glad I took the time to read it.

Note on a few zingers:

I couldn’t work these great lines into the rest of the review, but they were so good that I remembered them from the audiobook well enough to look them up later.

First, Ghosh, in his single days, has a recurring issue with painful urination (as I said, warning for medical grossness…), and blames it on his one unprotected sexual encounter as a young man. The prophylactic treatment was to squeeze and ointment up into the urethra. As Ghosh puts it, “it felt like a penance invented by the Jesuits.)

The second comes from Almaz, Ghosh’s servant. She is greatly devout, but still gets hassled by the local clergy. After having to beat off sexual advances from one with her umbrella, she tells Marion, “when I’m dying, go to the Merkato and get me two priests. That way, just like Christ, I can die with a thief on either side of me.”

One final bit. All fans of Star Trek are familiar with the Ferengi, an acquisitive, hyper-capitalist race introduced in The Next Generation series. Imagine my surprise to find out that the word comes directly from the word used to describe foreigners in Ethiopia. That’s right, they are all “Ferengi.” Presumably, Verghese well knew this term as he and his family were ferengi, as were others of Indian descent and the sizable Arab population. Interesting bit of trivia.

Note on Female Genital Mutilation:

For anyone who might doubt exactly why female genitals are mutilated in certain cultures, this book makes it explicitly clear. The whole point is to reduce female sexual pleasure, and thus (presumably) desire. Although the means are extreme, most cultures seem to have a mortal fear of female sexual expression. While male sexual desire is seen as normal - and even desirable - female desire is seen as aberrant and dangerous. Thus, when Genet loses her virginity, it isn’t her partner who pays a price. She is the one who is mutilated.

Although it isn’t nearly as extreme, I have pointed out in my series on Modesty Culture that we follow the same instincts. Sex outside of marriage is believed in our heart of hearts to be almost exclusively a female-caused failing, and thus we blame females for it, and inflict all the punishment and rules and shaming on them. 

Note on a “Cardiac Massage”:

I have an incredibly strong stomach, most of the time. The exception is that I am not great around my own blood if it is coming out rapidly. (The first time I donated blood, I didn’t have them wrap it thoroughly, and I opened the wound when wrestling with my now brother-in-law. I looked down and saw my soaked sleeve. My girlfriend (now wife) had to catch me before I fainted.

Now, Amanda, on the other hand, works in the ICU, and she can stick a needle in herself without flinching.

There is a scene, early in the book, that describes a “cardiac massage.” This sounds so innocuous, doesn’t it? Actually, this is less a nice rub and more Indiana Jones and the Temple of Doom. You crack the chest open and squeeze the heart directly to keep circulation going. It is a last ditch effort, and rarely successful. One is also described in entirely too loving detail in this book. Good lord, it was intense and difficult, even for me, and I already knew about how it worked!

So anyway, my wife has done this more than once. One time, she came home and described it all to me, and couldn’t help but quip:

‘Last night gave new meaning to "I still hold your heart in the palm of my hand."’

Nurses have such terrible gallows humor...

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