THIS IS A WORK OF FICTION, and all the characters are imagined, as is Missing Hospital. Some historical figures, such as Emperor Haile Selassie and the dictator Mengistu, are real; an attempted coup did occur in Ethiopia, but five years earlier than the one I describe. The Colonel and his brother are loosely based on the real coup leaders. The details of their capture and the words at the Colonel's trial and before he was hung are from published reports, particularly Richard Greenfield's Ethiopia: A New Political History; John H. Spencer's Ethiopia at Bay: A Personal Account of the Haile Selassie Years; the published work of Richard Pankhurst for historical backdrop; and Edmond J. Keller's Revolutionary Ethiopia: From Empire to People's Republic. A remarkable physician by the name of John Melly died after being shot by a looter, but his dialogue with Matron is imagined. The Ibis and other bars are inventions. The LT&C school is imagined; any resemblance to my wonderful school (where Mr. Robbs and Mr. Thames encouraged my writing) is not intentional.
The following sources, books, and people were invaluable: The birth scene and the phrases “white asphyxia” and “in the obscurity of our mother's womb” are inspired by the wonderful memoir of the late great Egyptian obstetrician and fistula surgeon Naguib Mahfouz, The Life of an Egyptian Doctor, as is the idea of the copper vessel. Nergesh Tejani's essays describing her experiences in Africa with version clinics and with fistula, as well as our correspondence, were extremely helpful. I consulted the published work of Dr. Reginald Hamlin and Dr. Catherine Hamlin, pioneers of fistula surgery. As a medical student, I would see them and was very aware of their work. Recently, I had the opportunity to visit the “Hospital by the River,” which is also the title of Catherine Hamlin's lovely memoir. The fistula surgeons in my book are not in any way based on the Hamlins. The late Sir Ian Hill was in fact the dean of the medical school, and if I use his name, and that of Braithwaite, in the book, it is as a tribute to two people who took a chance on me. The attempted hijackings of the Ethiopian Airlines jets during the 1960s and 1970s are historical facts; one would-be hijacker was my senior in medical school; she and her fellow hijackers perished in the attempt. The present prime minister of Ethiopia, Meles Zenawi, was one year my junior in medical school; he became a guerilla fighter, ultimately leading the forces that toppled Mengitsu. The heroism of the security crew and the incredible skill of the pilots are very real. Ethiopian Airlines remains, in my opinion, the safest and best international airline I have flown, with the most hospitable and dedicated flight attendants. Louse-borne relapsing fever was studied by the late Peter Perine and the late Charles Leithead, and I had the pleasure of seeing patients with both men when I was a student.
For information about Teresa of Avila, and the description of Bernini's statue, I drew on Teresa of Avila: The Progress of a Soul by Cath-leen Medwick. Even after seeing the original in Rome, I found Medwick's descriptions so insightful. Any of St. Teresa's words that I quote, as well as the ideas about faith and grace, and the idea of Sister Mary Joseph Praise reciting the Miserere at her death and the idea of the inex-picably sweet scent, are based on Medwick's account of the life of Teresa. The words “celestial billing and cooing” are from H. M. Stutfield quoted in Medwick's book.
The line “I owe you the sight of morning” is by W. S. Merwin from the poem “To the Surgeon Kevin Lin,” originally published in The New Yorker. A limited-edition print of this poem prepared by Caro lee Campbell of Ninja Press and signed by William Merwin hangs in my office. I owe a great debt to physician, writer, and friend Ethan Canin for first inviting me to the Sun Valley Writers Festival and thereby introducing me to Reva Tooley and the remarkable people who gather there.
The line “her nose was sharp as a pen” is from Henry V, Part II and relates to my belief that it represents Shakespeare's astute clinical observation, which I described in “The Typhoid State Revisited,” in The American Journal of Medicine (79:370; 1985).
My own impressions of Aden and my memories of sitting in khat sessions were aided by the most vivid descriptions in Eric Hansen's wonderful book Motoring with Mohammed: Journeys to Yemen and the Red Sea and also Eating the Flowers of Paradise: One Man's Journey Through Ethiopia and Yemen by Kevin Rushby. The image of the woman with the charcoal brazier on her head and also the wheelbarrows transporting people come from Hansen's book.
The Italian occupation, the description of Aweyde, and many aspects of the Italian-Ethopian conflict, including the desire to win by any means—Qualsiasi mezzo—were informed by Paul Theroux's wonderful Dark Star Safari: Overland from Cairo to Capetown and many other sources.
“Squared her shoulders to the unloveliness” is a paraphrase of James Merrill's line in the poem “Charles on Fire”: “No one but squared The shoulders of his unloveliness.”p>
Bliss Carnochan showed me an early edition of his Golden Legends: Images of Abyssinia, Samuel Johnson to Bob Marley and helped me see how Western ideas about Ethiopia were shaped.
I and countless Commonwealth medical students admired Bailey and Love's Short Practice of Surgery; Stone's imagined textbook is based on Bailey and Love, and the wombat and the appendix story is from there. As a student I was impressed with the photograph of Bailey and his nine fingers. Other than that, the character of Stone has no connection with Hamilton Bailey, who practiced only in England before retiring.
“A careful decision was needed so as not to blunder again. It was often the second mistake that came in the haste to correct the first mistake that did the patient in” and “A rich man's faults are covered with money, but a surgeon's faults are covered with earth” are both from Aphorisms and Quotations for the Surgeon by Moshe Schein. For these and many other surgical notions, I owe Moshe, maverick surgeon, brilliant teacher, author of several wonderful surgical textbooks, essayist, and friend. He not only read early drafts but also introduced me to the community of surgeons on SURGINET I delighted in, learned from, and borrowed ideas from their musings, particularly the vasectomy details, which made for a series of memorable exchanges. Karen Kwong shared with me her experiences (and those of her husband, Marty) as a trauma surgeon, and she was a careful reader of the manuscript both early and at the end. Her long, thoughtful e-mails were precious, and I cannot express to her sufficiently my gratitude and admiration. Thanks also to Ed Salztein, Jack Peacock, Stuart Levitz, and Franz Theard. I met Thomas Starzl when I was a Chief Resident in Tennessee and have since renewed the acquaintance. He is truly a surgeon's surgeon, and his pioneering work establishing the field of liver transplantation is no fiction; I refer to him in the book in tribute. Thomas Stone is his fictional contemporary. Francisco Cigarroa, president of the University of Texas Health Science Center, San Antonio, was kind enough to let me watch as he performed a liver transplant on a child. The remarkable group in San Antonio, led by Glenn Halff, who make liver transplant appear almost routine, are part of Starzl's legacy—until very recently, it was fair to say that every liver transplant surgeon in the world was trained by Starzl or by someone who trained with Starzl.
“Birth, and copulation, and death / That's all the facts when you come to brass tacks: I've been born, and once is enough” is a partial quote form T. S. Eliot's Sweeney Agonistes.
“Indeed to think of life as tragic is a posture of delusion, for life is uniformly worse than tragic” is a line from Heinrich Zimmer's The King and the Corpse, edited by Joseph Campbell, as is “Not only our actions but also our omissions become our destiny.”
“They saw in the plague a sure and God-sent means of winning eternal life” is from Camus’ The Plague.
I am greatly indebted to the late Ryszard Kapuscinski's take on a city and a country which I thought I knew well. Details of the Emperor's court, the palace, the funding of the health departments, the Amhara character, the motorcycle escort, the Minister of the Pen, and the palace intrigues were things most residents knew about and had in some cases seen firsthand, but Kapuscinski's particular talent was, as an outsider, making those things more visible to us, which he did in his extraordinary book The Emperor.
“The crookedness of the serpent is still straight enough to slide through the snake hole” is paraphrased from one of the Bhakti poems in Speaking of Siva, edited by the late, great A. K. Ramanujam.
For information about the Carmelites I thank Fred de Sam Lazaro and Eliam Rao and the incomparable Sister Maude. There is no convent of Carmelites to my knowledge in Egmore.
The details of the the Rock of East Africa, AFRS Asmara, are from http://www.kagnewstation.com/.
For the scenes of the escape from Asmara, I thank Naynesh Kamani, who was my senior in medical school and who made that heroic walk; he read the manuscript and had many corrections and suggestions. I was greatly influenced by Thomas Kennealy's wonderful novel To Asmara, with its observations about the Eritrean guerrilla camps which Kennealy appeared to have visited; he remains a champion of the Eritrean people. I should state that my affection is equal for both Ethiopia and Eritrea, and I have dear friends in both places.
“As if I had given him the greatest gift a man could ever give another” is a paraphrase of a line in Raymond Carver's “What the Doctor Said,” from New Path to the Waterfall.
For the scenes at the tuberculosis sanatorium, I am indebted to Jean Mason's “The Discourse of Disease: Patient Writing at the ‘University of Tuberculosis,’ “ which I was fortunate to hear at the Psychoanalysis and Narrative Medicine Conference, University of Florida, Gainesville, in 2002.
“May no English nobleman venture out of this world without a Scottish Physician, as I am sure there are none who venture in” was said to be a toast used by William Hunter, M.D., the elder of the Hunter brothers. I have paraphrased this as a toast that B. C. Gandhi uses.
“Call no man happy until he dies” is what the Athenian Solon tells Croesus, the wealthy king of Lydia, according to Herodotus. These are words that Sir William Osler quoted on hearing the news of his beloved son Revere's death at Flanders. The imagined nursing textbook that describes Sound Nursing Sense is a recasting of one of Osler's aphorisms.
For the information on psychosomatic ailments among Ethiopians, I am grateful to my friend Rick Hodes, M.D., internist, writer, and mensch. His life in Ethiopia is a story of its own. Thanks to Thomas “Appu” Oommen for his incredible recollections of his time in Addis as a schoolboy and later as a journalist, and of the period of the coup. An e-mail Appu shared with me from Yohannes Kifle gave me great insight into Kerchele. My parents, George and Mariam Verghese, shared their memories, and my mother made extensive notes just for my use. To them I have dedicated this book.
In the course of writing this novel over several years, I consulted many other works, most of which I hope are listed in the bibliography, and any failure to acknowledge a person or source is something I would like to correct. The scene of Genet's damp gift to Marion was inspired by a similar scene from a novel or short story whose authorship I cannot recall; similarly, the metaphor of Aden as a city at once dead yet alive like maggots on a corpse (or words to that effect) is one that I would love to attribute to a source.
I am grateful to the extraordinary Advisory Board in San Antonio that allowed us to build a Center for Medical Humanities, but even more grateful for the personal friendships I formed with its members. Steve Wartman, my tennis partner and friend, recruited me to San Antonio when he was dean. Edith McAllister was my teacher, my coach, my inspiration, and the person who understood better than anyone the need I had for protected time, even if it meant my leaving; in my next life my ambition is to come back as her. For Marvin and Ellie Forland and for Judy McCarter, words cannot do justice to the support and love they gave me; to hold a distinguished professorship named after Marvin, and a distinguished chair named after Joaquin Cigarroa Jr. (both consummate internists), was the greatest honor. Judy remains my counselor and conscience; with every passing year I grow in admiration of her wisdom. Thanks to UTHSCA, to the extended Cigar roa family, Bill Henrich, Robert Clark, Jan Patterson, Ray Faber, Tom Mayes, Somayaji Rama-murthy Deborah Kaercher, the late David Sherman, and so many others who made it a special place to work; so also to Texas Tech, El Paso, where this work first began. Dr. Erika Brady of Western Kentucky University's folk studies department was an expert in matters ranging from Alpha Omega Alpha to Religio Medici to details about prayers and dress; I could always rely on her research. Michele Stanush also helped me with research, and I am most grateful.
My Wednesday-morning brothers (Randy Townsend, Baker Duncan, Olivier Nadal, Drew Cauthorn, Guy Bodine, and especially Jack Willome) and their wives (and especially you, Dee!) gave me love and faith and held me accountable. “No greater love …”
Tom Rozanski, neighbor, colleague, and urologist, gave me advice on the vasectomy scene as well as other surgical issues, for which I am most grateful. Rajender Reddy and Gabe Garcia helped me think through issues related to hepatitis B.
Anand and Madhu Karnad, my dearest and oldest friends, read and heard many sections of this and all my previous books over the years; they gave and continue to give me love and sustenance, and I know I have a home wherever they are.
I am grateful to John Irving for his friendship all these years. I have learned so much from him both in our correspondence and in his published work.
Ralph Horwitz, M.D., chairman of medicine at Stanford, created a home for me; I am so grateful for his vision and his and Sally's friendship. I thank my brother, George, and his wife, Ann, and the Kailaths, as well as Helen Bing, for introducing me to Stanford's charms years before I dreamed of coming here.
My lovely wife, Sylvia, spent hours entering the changes that I would write on the manuscript and did this several times over the years. She more than anyone, but also Tristan, Jacob, and Steven, put up with my absences from society and sustained me through the ups and downs in the writing of this book. Gracias mi amor; con los años que me quedan …
Mary Evans, my agent, sold my first story to The New Yorker before we met in person, and she has kept the faith with me since those days in Iowa in 1991. Her discerning eye and wise counsel have made a writer of me, and her friendship has made me a better person. Robin Desser had a hand in my first book, and it was a privilege to get to work with her on this one. Robin saw this book through its many iterations and spent innumerable hours with it and with me, and I am so indebted to her. I have often thought that the grace, passion, humility, and extraordinary skill she brings to her craft are attributes she shares with the physicians I most admire. My thanks also to Sarah Rothbard, Robin's wonderful assistant. I am most grateful to Sonny Mehta for his enthusiasm for this story and his steadfast support of my writing.
Medicine is a demanding mistress, yet she is faithful, generous, and true. She gives me the privilege of seeing patients and of teaching students at the bedside, and thereby she gives meaning to everything I do. Like Ghosh, every year, at commencement, I renew my vows with her: I swear by Apollo and Asclepius and Hygieia and Panaceia to be true to her, for she is the source of all … I shall not cut for stone.
Abraham Verghese,
Stanford, California, June 2008