I thought I was when I moved from New England to Cleveland, where I had to learn to talk a little slower, and that unfamiliar people who smiled and said “hi” as they passed me in the hallways were not mentally unstable – as I had been raised to believe in the Northeast – but were, in fact, just being friendly. In reality, it wasn’t until I traveled to other countries on faraway continents and tried to immerse myself in foreign cultures, however briefly, that I learned what it felt like to be an outsider.
The primary locale for much of the novel Cutting for Stone, by Abraham Verghese, MD, is a small hospital in Addis Ababa in Ethiopia. Mission Hospital goes by the misnomer Missing Hospital for the entire book, setting the tone for the doctors, nurses, and patients who justify its existence. Sister Mary Joseph Praise arrives from Madras, India, after a harrowing journey by sea during which her fellow novitiate and best friend from nursing school dies of typhoid fever, and she meets the English surgeon who will alter her course to this hard-to-find hospital, Thomas Stone. The path of our lives, it turns out, can veer quickly – prey to the randomness of fate, love, and disease.
At Missing, they are joined by two other foreign physicians, Kalpana Hemlatha (Hema), the hospital’s obstetrician and gynecologist, and Abhi Ghosh, an internist cum surgeon, both also from Madras. We meet the foursome in medias res, in the mid-1950s, after they have been working together for years, as Sister Praise is trying to give birth to the twins who will be the novel’s focus, Shiva and Marion (named for Marion Sims, the 19th-century surgeon from Alabama). Sister Praise… giving birth? Yes and – spoiler alert – Stone is the father, though genetically only, as he flees the hospital soon after Shiva and Marion arrive. Fate intervenes yet again as the delivery does not go smoothly. Sister Praise develops disseminated intravascular coagulopathy, exsanguinates, and dies, leaving the parenting of the orphaned twins to Hema and Ghosh.
Oh, my fellow nerdy hematologists, I knew I’d draw you in with the DIC reference. In truth, this book is rife with hematology references, from the anemia many of the patients develop due to malnutrition and/or parasitic infections, to the myeloid metaplasia (confirmed by none other than Maxwell Wintrobe!) and secondary acute myeloid leukemia that leads to Ghosh’s death.
And while I would love to be able to report that the hematologic aspects of the novel carry it from beginning to end, in truth they are but bit players in a broader story of tropical medicine, the cobbling together of health care with limited resources, and this notion of being an outsider.
The twins come of age recognizing their “otherness” against this backdrop. That Hema and Ghosh are not their biologic parents is frequently acknowledged, as is their societal position relative to their Ethiopian patients, and their relationship with the government amidst a failed coup. The twins start this story literally inseparable – they are conjoined, and seem to communicate without even speaking – but over time even view the other as being foreign. After Ghosh’s death, this time it is Marion who flees, following Stone’s path to America, as Shiva remains behind to assist Hema with gynecologic surgery, and to become internationally recognized for fistula repair, despite his lack of a medical degree.
Marion applies to and secures a surgical residency at a fictitious hospital in the Bronx in New York, Our Lady of Perpetual Succour. It is made clear from the outset that this hospital is staffed by international medical graduates and that, according to a co-resident, while “rich” hospitals take care of the poor in a way that is considered “noble,” at Our Lady, their care is “shameful. The work of untouchables.”
They refer to Our Lady as an “Ellis Island” hospital, and contrast it to the “Mayflower” hospitals – the teaching hospitals for big medical schools. Their hospital cares for under-represented minority populations and represents “the worst nightmare” of residency for graduating American medical students. The Mayflower hospitals care for the rest of the population and use patients at Our Lady only as sources for organ donation. The prototypical Mayflower hospital cited in the novel is the one where I trained.
A few years ago, I was at a conference with two colleagues from U.S. institutions, both wildly successful academically by any metric, and both having been raised and educated in Europe prior to completing their post-graduate training in America. As the three of us chatted, the conversation turned to the obstacles each of them had to overcome to attain his current position. They commented that I really had no idea how much harder they had to work than me, as physician immigrants, to “make it” in America.
They’re right. But thanks to Dr. Verghese, I’m a little closer to getting it.
Dr. Verghese writes with such insight, and passion, about community hospitals in underserved areas, it is clear he has more than just a passing knowledge of the international medical graduate experience in America. He is a gifted storyteller, and I am not ashamed to admit I’m jealous of his skills.
Those of us who are doctor- or nurse-writers (please allow me the brief fantasy of including myself, if only for this book review, in that group) tend toward a lean, chronological, and linear narrative akin to the H and Ps and progress notes we write in patients’ charts. We are often guilty of eschewing extraneous descriptors, character development, or our own emotions in favor of patient-problem-solution pieces. Dr. Verghese crafts people and places with such talent, and injects so much feeling into his stories, that as I was reading Cutting for Stone, my own mood would rise and fall with those of the people he invented, and I regarded my colleagues who had come from other countries in an altogether different light.
Cutting for Stone is a terrific read, if only as a reminder of the medical technology we take for granted, and to treat those outsiders (however they are defined) with more respect, and more care.
The content of the Editor’s Corner is the opinion of the author and does not represent the official position of the American Society of Hematology unless so stated.
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