Homeland Elegies: A Novel

by Ayad Akhtar

  “Let’s just try to stay the course, Dad. Get through this.” He nodded. “I was thinking maybe we call Sultan and ask if he could come and spend next week here?” Sultan was one of my father’s oldest friends, a member of the same medical school class cohort—like Latif Awan—that came to America in the late ’60s. When his wife died, in 2010, he quit medicine to start a restaurant in Omaha, where they’d settled. He and my father spoke almost daily.

  “I don’t need Sultan,” he said gruffly.

  “I have to be in New York on Monday. If Sultan can be here until I get back on Thursday, you’ll have someone here to support you.”

  “I’ll be fine.”

  “Dad, you need support. I would, too, if I was in your shoes. It stands to reason.”

  He scowled, pulling the mug from his mouth: “Why do you always talk like that?”

  “Like what?”

  “Stands to reason.”

  “I just meant—it makes sense that you would need support. Anyone would. It’s normal.”

  “Then just say that.”

  “I thought I did.”

  “Simpler is better. Someday you’ll learn that.”

  He looked away and drank. “Do you think I was a good father?”

  “What?”

  “I said, do you think I was a good father?

  “What’s the connection?”

  “I’m just asking. I want to know.”

  “I mean…yes.”

  “That’s what you tell your friends? When you talk about me? That I was a good father?”

  “My friends?”

  “Your friends—or when you write about me.”

  “I haven’t written about you, Dad.”

  “Not yet.—So, what? Do you say good things?”

  “I mean, sure.”

  “Sure?”

  “Mostly. I mean, who says only good things about anything? What are you worried about?”

  “I’m not worried. I want to know what you really think. About me. As a father.” His directness was disarming. “Was I okay, at least?”

  “You were better than okay. I don’t wish you were any different.”

  “But…”

  “Sometimes I think you could have been happier.”

  “I’m fine.”

  “You and Mom.”

  “What about us? We were fine. You don’t know everything about us.”

  “I’m just saying.”

  “What? What are you saying?”

  “Dad. You asked me. I’m telling you—”

  “Telling me what? That I wasn’t happy? Who’s happy?”

  “Why are you getting mad?”

  “I’m not.”

  “You sound mad.”

  “Well, I’m not.”

  “I’m just saying, maybe you could have let yourself be happier. Then maybe you and Mom could have…enjoyed each other more. And maybe that would have been nice. That’s all I’m saying.”

  “Mr. Head Shrinker,” he quipped sarcastically as he got up. He walked into the bathroom and turned on the shower. Then I saw him appear in the doorway again. He said something I couldn’t hear over the rushing water.

  “I can’t hear you, Dad.”

  He pulled the door shut behind him and repeated himself: “I don’t know if you realize. You have land in Pakistan.”

  “Okay…”

  “I’m just telling you. I want you to know. After partition with India. They gave my grandfather one hundred acres.”

  “In Jhelum. Yeah, I know.”

  “No, that’s the family house. Two acres, maybe,” he said dismissively. “I’m talking about a hundred in Bahawalpur. Beautiful land. Mango groves.”

  “Okay.”

  “That hundred was split between three sons when he died. One of those sons was your grandfather. When he died, I got sixteen acres, my sisters got the other sixteen.”

  “Why are you telling me this?”

  “So you don’t care about your land in Pakistan?”

  “It’s not my land.”

  “Not yet.”

  “You’re starting to freak me out.”

  “Why?”

  “Land back home? Are you a good father? Is there something you’re not telling me?”

  “I’m telling you about your land in Bahawalpur.”

  “Sixteen acres. Mango groves. Got it.”

  He grunted in response, lingering a little longer at the door, his hand on the knob.

  “Is there something else?” I asked. He shook his head and disappeared inside.

  5.

  Father was on his best behavior for the rest of the week, and his case seemed to follow suit. Three specialists took to the witness stand on Thursday, two to endorse the medical logic behind his guidance to Christine and her mother and a third who tried but was unable to effectively deny it. I sensed the jury’s disappointment at the turn things were taking, as they heard testimony that clearly challenged a bias against Father they’d already formed. On Friday morning, as Hannah predicted, Chip Slaughter announced to the court he planned to call only one witness—because Friday’s afternoon prayer was scheduled at the local mosque for shortly after twelve o’clock, and Slaughter didn’t want to be the reason the defendant missed his “Muslim worship.” The interjection caused a flurry of objections and concern, with both counselors ending up in a private conference in the judge’s chambers. But when they returned, the only consequence was a short speech from the judge about the irrelevance of the defendant’s religious views, and even the correction seemed to serve Slaughter’s ends.

  Both days, a man with a huge, ruddy face and chin-length shocks of steel-gray hair kept coming in and going out of the courtroom. This was Thom Powell. To me, he didn’t bring to mind the Quaker on the box so much as some wastrel mascot of the Constitutional Convention—which is to say that Father’s whole “evil twin” thing actually did make sense. In the sickly light of the courtroom, his broad, bony face was pitted, with blotches of magenta. Father would explain to me later that Powell had been on high alert since learning of Corinne Hollander’s testimony. He’d driven up from Madison to assess whether it might not be better to pull the plug and settle, even at this point—the number would be painful—rather than risk another malpractice loss. From what I could gather of his demeanor—and the affirming, encouraging looks he traded with Hannah throughout the session—it certainly appeared to me like he wanted to keep fighting it.

  After we adjourned on Friday, neither Father nor I availed ourselves of the chance to offer our Muslim prayers. After lunch, as we were checking out at the front desk, Father asked if I would pay for his room. He was a month behind on his Amex payments, he explained when Brynne stepped away from her computer. He didn’t want to risk having the charge declined. It didn’t occur to me to be concerned; I told him I was fine to pay.

  The route back to Elm Brook took us through Wonewoc and Spring Green, small towns with libraries I wanted to visit on the way. Republicans in Madison—where they controlled both houses as well as the governor’s mansion—were more than a decade into a sustained attack on the state’s intellectual infrastructure: school funding was dwindling; history and philosophy and literature and music and sociology departments were being shuttered; libraries found themselves each year with less money for fewer books and programs. It was the damage being done to libraries that I took personally, and I was resolved to do something, however humbly, about it. I’m not sure it’s worth telling here the story of exactly how it was I came to the idea of visiting municipal libraries in my travels around the country and giving away money. Suffice it to say it’s what I’d started doing a few months after Riaz made me rich. Five hundred dollars meant a library wouldn’t have to stop buying the best new novels coming out after July; as little as a thousand could keep a book club going for another year. I knew almost nothing about most of the communities I visited; usually, I was there to speak at a college or support a small production of one of my plays. But the towns of W
onewoc and Spring Green were different. The former is home to an author, David Rhodes, who has written what I consider some of the finest fiction about rural American life since Sherwood Anderson; as for the latter, I’d been there already a half dozen times. Spring Green was the unlikely site of one of the nation’s finest outdoor classical theater companies. Tiny as these towns were—with populations of 816 and 1,637 respectively—each mattered disproportionately to the cultural life of my home state.

  It was over an hour to Wonewoc, part of it on the interstate, the rest by way of a county road carved through the heart of the Driftless Area, a rugged, stream-rich region named for its escape from the flattening glacial drift of the last Ice Age. Father wanted me to drive and offered to navigate. He held the phone, which directed us along a narrow, undulating road, past fields of soybeans, alfalfa, cornstalks, mud. Cows tottered on pitched pastures through which—as in some early Dutch landscape—a teeming brook tumbled or a knotted, solitary trunk stood watchful guard over acres and acres of empty rolling space. The land seemed to have been shaped for effect, the bluffs and ridges releasing views of a sky that looked bigger, bluer, filled with vivid, rippling clouds. There was majesty here, and it imbued even the endless parade of dilapidated barns and neglected homes—all as Hannah had described over dinner—with natural dignity.

  Father wasn’t paying much attention to the scenery. He’d been on the subject of Reliant and Thom Powell for much of the ride, and as we turned onto a sloping dirt road—which our handheld navigator promised would save us ten minutes—he started in with a story about Powell I found hard to believe at first. And this despite having heard so many anecdotes from my father over the years about unethical medical practices: the overbilling, the phony drug trials, the aggressive diagnoses, the unnecessary procedures. Nothing could have prepared me for the tale he would tell me now:

  Before joining Reliant, Powell had worked for Chiroh Health, a similar health-care company just across the state line. In the early ’90s, Chiroh purchased a cardiology practice not dissimilar to Father’s, run by a doctor named Rex Dumachas. Tall, blond, dashing, Dumachas had played college baseball at a Big Ten school—All-American—before going to medical school and ending up in interventional cardiology. Dumachas approached his job as an athlete would—driven by the competition, reveling in the physical demands—and his surgical output reflected it. Some weeks, upwards of eighty patients would come through his operating room to have their arteries widened and stents put in, an unheard-of number, Father explained.

  Dumachas had been working at this prodigious pace for two decades, and by the point of his medical group’s sale to Chiroh, Dumachas’s handiwork was the stuff of local legend. But there were also murmurs of darker things. For years, Father had heard that Dumachas was more than a little too eager to cut you open and send you a bill. Some called him greedy. Having offered a number of second opinions for patients who weren’t convinced they needed the procedures Dr. Dumachas was suggesting, Father concluded the same.

  In fact, greed didn’t even begin to cover it.

  For fifteen years, Dumachas had not only performed unnecessary procedures on his patients, he had also used those unnecessary procedures to harm them. Gaining access to their coronary arteries, he would go in with his catheter and intentionally abrade an area along the healthy arterial lining. This created a future site of plaque buildup and eventual heart disease, each such abrasion worth at least a half million dollars in billable follow-up for a decade to come. It was criminal conduct, of course, but it didn’t come to light until after Chiroh bought the practice—bought it in large part for the extraordinary cash flow produced by these criminal activities, which Chiroh was not aware of and which were discovered, Father said, only because of an affair with an OR nurse gone awry. A participating accessory in his scheme, Dumachas’s jilted mistress took her revenge by alerting the administrative authorities; an internal review of patient records followed and found the recurrence of heart disease in precisely the same spot on the same coronary artery in over 2,500 patients. Statistically implausible at best.

  Here’s the Thom Powell part: Dumachas’s patients were now Chiroh customers; Chiroh owned this problem. For a publicly traded company, disclosure of such an indefensible travesty would have wiped out the stock price, to say nothing of the potential billions in settlements the company would owe if it somehow survived that initial hit. It was of paramount importance to Chiroh that no word of Dumachas’s crimes got out.

  Powell was a corporate generalist—a tax lawyer who’d found his way to litigation and later into administration by way of business school. He’d managed operations and logistics for a cable company in Tennessee and helped steer a multistate food services operation through bankruptcy before going to Chiroh to work in risk management. Here was the strategy Powell developed to manage the crisis: An unexpected round of layoffs was announced, a position or two from every level of the organization, including doctors; this was the shot across the bow intended to sow fear and set the stage for later compliance. Separately, Rex Dumachas was quietly offered a generous severance, contingent on his leaving the profession for good. (The last thing Chiroh wanted was for him to start up with his shenanigans somewhere else, get discovered, and have the trail lead back to them.) As another condition of his severance, Dumachas furnished a list of everyone in the organization he knew to be aware of his conduct. Not only were these employees not fired; to a person, they were also offered signing bonuses on contract extensions—but only after signing ironclad NDAs. In short, Dumachas retired early in Arizona, and those aware of the harm he’d done to his patients were rewarded for their silence. The crisis was managed; the stock price continued to rise; Powell got a promotion. It was shortly after all this that Reliant Health poached Powell away, and it was during the Powell years that Reliant grew into the juggernaut that would purchase Father’s group and eventually go public.

  Father learned of the Dumachas crisis from an enemy Powell had at Reliant, a fellow administrator worried about—what else!—his job. At that point, there was no love lost between Father and Powell, and the tattling administrator was trying to shore up support for his own position with doctors in the group. In Father, he found a sympathetic ear, for though Father had been an early advocate of being bought out by Reliant, it hadn’t taken him long to change his mind. Powell ran the company the way he’d handled the crisis at Chiroh: with ruthless focus on the twin corporate values of increasing share price and limiting liability. Medical care was almost an afterthought. And yes, Father had dealt with corporate, nonmedically trained administrators his whole career, but Powell and his crew were different. This was a new breed he saw coming into the profession: the in-house counsel elevated to decision maker, the bean counter ennobled by an MBA, the resident financial functionary whose contributions to staff meetings included advice on ways for employees to help the company avoid excessive tax depreciation on fixed assets. These were corporate zealots—“fanatics of the data” was Father’s coinage—as fixated on spreadsheets as he thought they should have expected doctors to be on patients, but it was clear that patients, like stationery expenses, were just another line item. “Quality care”—like the company’s name itself—was just copy, an advertising slogan to be plastered across the billboards and brochures that showed multicultural, multigenerational families smiling at sun-soaked kitchen tables.

  Now, Father had been complaining about Powell and the corporate medical model for years, and I’d long since concluded—ungraciously—that his problems were mostly about his ego. After all, he’d been the group leader before the corporate buyout, and now he was just another employee. He had taken the money; what did he expect? But hearing him unload about Powell on the way to Wonewoc, I started to see a different picture, a bigger picture, one that showed him in a more generous light and began to make new sense of his plight in that La Crosse courtroom. He’d insisted on doing the job as he believed it should be done. If patients everywhere were more an
d more discontent, it was—he thought—because doctors like him had ceded autonomy to managers like Powell, who apparently didn’t care, fundamentally, whether their patients lived or died—as long as the company wasn’t sued.

  As we rolled off the dirt road and onto the asphalt byway that led into town, I asked why he hadn’t gone public with what he knew about Dumachas and Powell’s cover-up. “It was leverage,” he said with an evident hint of defensiveness. “I wanted to make things better for us, the doctors. So we could do our job.”

  “But what about all those patients?”

  “It’s terrible.”

  “But I’m guessing they still don’t even know what happened to them.”

  “How could they?”

  “Didn’t you think they deserved to know?”

  “You think I should’ve told them? How?”

  “I don’t know. Talk to a journalist. The authorities. Somebody.”

  “With what evidence? Patient records are private. Everybody signed nondisclosures.”

  “There’s ways around that stuff. Subpoenas, litigation. Whistle-blowing.”

  “—Subpoena? From who?”

  “I don’t know, Dad. A grand jury, I suppose.”

  He glared at me with visible disgust: “I start creating that kind of trouble? Powell would have buried me. Buried. Who benefits from that?”

  “Yeah, but still—”

  “What still?”

  “When nobody says anything, that’s how people can keep doing stuff like this.”

  “What are you, a child?”

  “What is that supposed to mean—”

  “You think I didn’t go over this in my own mind?”

  “I’m not saying that.”

  “I did. I thought about it. And I did what I thought was best.”

  “And what was that?”