Author: Abraham Verghese
This book is an account of one doctor’s journey of personal and professional discovery during the AIDS epidemic in America. The book revealed the challenges of practicing medicine during a rapidly evolving epidemic, and of looking after people dying of a relentless and stigmatising disease. The book portrayed the care the author provided, almost single-handedly, to the first cases of AIDS in a hospital in rural Tennessee, an area that witnessed an influx of homosexual men who had been struck down by HIV in the larger cities. The narrative centred on the compassion and empathy that enabled the author to see his patients as human beings, exploring their personal lives, and pushing himself to his limit in their service. It also explored the wider dimensions of the AIDS epidemic, illustrating the fractures it wrought to society, from the discomfiture of families of AIDS victims, to the ‘acts of deceit and betrayal of trust’ in long-term relationships (page 139-140 and 218). The book is also an autobiographical narrative, charting the author’s experiences as a foreign doctor practicing clinical and academic medicine in America, and how this coloured his personal life, and determined his professional choices.
A major theme in the book was the picture of AIDS in rural America at the peak of the epidemic. The author traced it to young ‘native sons‘ who had left in the 1970’s in an ‘elaborate migration‘ to the larger cities such as New York and San Francisco; there, they could ‘live an openly gay life’, and indulge in ‘rampant sexuality and exhilaration’. The author described their return back home, struck down by AIDS, as a ‘circuitous voyage‘ which ended in death (pages 393-402). The picture he painted of AIDS afflicted victims was graphic, his own first case for example being a man with candida plaques and Kaposi’s sarcoma in his mouth, enlarged lymph nodes in his armpits and groins, and a lace-like pattern of pneumocystis on his chest X-ray (page 83). Many of his patients however did not fit this stereotypical profile of young homosexual men, and this is exemplified by his patient Will Johnson, an elderly man who acquired HIV when he was negligently transfused with unscreened infected blood during life saving surgery; he then unsuspectingly, and heartbreakingly, transmitted the infection on to his wife (page 245-248).
The most striking feature of the book is the author’s single-minded commitment to the care of his patients. His compassion for them was evident at all times, such as when he said he wanted to convey to one of his patients ‘how much I felt for his situation, how much he moved me, how I could not fathom how one man could bear all this suffering’ (page 341). He perceived his role to extend far beyond the basic patient-doctor relationship, describing how he felt impelled to ‘minister’ to their souls and psyche, and to pay attention to their families and social circumstances (page 272). Whilst he found the lack of effective treatments for AIDS frustrating, it did not constrain his efforts at providing what he called ‘total care‘, pledging that ‘there was a lot I could do, a lot I had to do, for our patients’, such as offering hand-holding, counselling, moral support, platitudes, and homilies (pages 262 and 271-275). His profound empathy however meant that he was deeply hurt when his patients suffer or die, admitting that being close to them ‘made the ordeal of illness costly and painful to me’ (page 365). It was therefore with elation and a sense of empowerment that he welcomed the arrival of AZT, a drug he prescribed more for the hope it provided, than for the cure it delivered (page 298).
The major hurdle that hampered the author’s care for his patients was prejudice, and this was painfully most acute when it was displayed by fellow healthcare practitioners. He illustrated this the example of the health care practitioners who physically distanced themselves from one of his patients, treating him as dirt, and making him to feel like a pariah; and the endoscopist who was short and grumpy with another of his patients (pages 279-280 and 255). He was also chagrined by the hostility of fellow healthcare practitioners who could not understand why he was so committed to his patients; for example, because he kept an AIDS patient in the ICU, a nurse confronted him with what he termed ‘naked, ignorant, and shameful prejudice’ (page 160). He also believed he was specifically ‘tainted‘ because of the sexual orientation of his patients, a situation which made him feel alienated and exiled (pages 309 and 324). His disappointment was made more overwhelming when his friends and family perceived his commitment to AIDS patients as something shameful, rather than something noble (page 168).
Allied with the author’s commitment to his patients is his intense curiosity about the intimate details of their personal lives. This extreme interest made him to visit his patients at home and engage them and their families in lengthy and detailed conversations. At one level, he wanted to compare their sense of societal alienation, arising from their sexual orientation, with his own as a doctor in a foreign country (page 58). He was particularly intrigued by the minutiae of their sexual practices, but he argued that this was ‘not a matter of prurient interest‘ because it helped him to understand how AIDS came to the rural towns, and it gave him a sense of their exposure to opportunistic infections (pages 126 and 115). Curiosity however seems embedded in his nature, admitting that he was also interested in his patients’ stories ‘for their own sake…fascinated by the voyage that had brought them to my clinic door’ (page 126).
Apart from being a study in AIDS care, the book is also an autobiography of sorts because the narrative repeatedly delved into the author’s personal experience as a foreign doctor working in the American healthcare system (pages 14-20). This reflection was particularly relevant in the context of his experience with AIDS in rural towns; it was specifically in such areas that many foreign physicians like him could find work. He went on to recount the kind of poorly supervised, ‘gruelling‘ work which such doctors endured under ‘appalling‘ conditions, but he also noted that they often established reputations as ‘sound doctors‘, and they were generally ‘well-received‘ (pages 18 and 22). His own experience in rural Tennessee accurately reflected this; the people turned out to be trusting, and they readily accepted him into ‘their world’ (pages 41-42). Indeed he felt so much at peace in Johnson City, ‘the geography in which my dreams were set’, that he called it ‘my own country‘ (pages 46 and 230). Nevertheless, reflecting on the hidden prejudices he perceived, even within his Indian community, he wondered if there was ‘ever going to be a place in this world for me to call my own?’ (page 308).
The author’s first-hand account of caring for AIDS patients is detailed and meticulous, sourced from contemporaneous records. It reflected compassion and empathy of the highest standard, aimed as it was at a reviled group, and coming at a high personal and professional cost. The prose is exceptional, although it tended to include overly detailed descriptions of settings, road trips and the backgrounds of patients. The book gives an accurate reflection of the impact of AIDS, not just at the level of the afflicted individual, but at the wider family and societal levels. The contents are clearly the result of the author’s keen curiosity and interest in the human dimensions of illness and suffering. It was however difficult to understand, on strictly clinical grounds, the author’s almost salacious interest in the minute details of his patients sexual lives. That not withstanding, the narrative is enlightening, and the lessons in compassionate care instructive.
This book details the commitment of one doctor to stand by his patients, loathed by the public and by many in healthcare. It demonstrates what ambition and commitment can achieve in the face of challenges when this is driven by compassion that transcends prejudice. The book depicts how to care for the individual patient in the midst of an epidemic of growing proportion, illustrating that there is the capacity to care even when there is a lack of definitive cure. These are worthy lessons for healthcare and I recommend the book to all doctors.
Publisher, Place, Year: Vintage Books, NewYork, 1994
Number of chapters: 31
Number of pages: 432
Star rating: 4