In 2013, Ebola slowly began spreading in West Africa, killing the majority of people it infected. The disease, caused by a filovirus, eventually swelled to become an epidemic and reached the United States when a volunteer American healthcare worker was medivacked to a Texas hospital. There the infection spread from the patient to his nurses. But thanks to excellent care and infection control, they survived—and the disease advanced no further. The fact that most Europeans and Americans who contracted Ebola during the 2014-2016 outbreak lived, while most Africans died, recapitulated a long-established pattern. During the 1967 Marburg epidemic (caused by a related filovirus), 90 percent of infected Africans died, while 75 percent of infected Europeans and Americans survived. In Fevers, Feuds, and Diamonds: Ebola and the Ravages of History (just published by Farrar, Straus and Giroux, 688 pages), Kolokotrones University Professor Paul Farmer, co-founder of Partners In Health, traces the origins of these startling differences in survival.
To readers gripped by the current global pandemic, which has ripped back the veil on health inequities in the United States itself, Farmer’s story will be both familiar and new. In West Africa, colonialism’s primary purpose, he writes, was to “rip riches from the earth and export them for profit.” The extractive trades included “initially, slaves and gold, and then rubber, iron ore, oil, bauxite, hardwoods, diamonds, and more” taken from the shores of Guinea, Liberia, and Sierra Leone to the Americas and Europe. In the later chapters of the book, Farmer recounts this history.
But in 2104, when he arrived in Freetown, the capital city of Sierra Leone, Farmer knew almost none of this background. What compelled him to learn it was what he observed in Ebola treatment units for patients: a pervasive approach that emphasized containment over care.
Ebola, as Farmer explains, is a survivable disease. The dominant Western belief that the disease liquefies the internal organs as the patient bleeds out through every orifice is “mostly myth,” he says (a fiction he attributes to Richard Preston’s 1994 book, The Hot Zone). Most Ebola patients die of dehydration before their immune defenses can defeat the virus. Modern care, including restoration of fluids and electrolytes using IVs, can save many lives, perhaps even most. But that kind of care, taken for granted in places like the United States, was not the standard that Farmer observed when he arrived in Sierra Leone, even in the best-equipped facilities.
Farmer is well positioned to make both a moral and practical argument for change in the region. Through Partners In Health (PIH), he has for decades been a global-health evangelist. The organization began with hands-on work in Haiti, and then showed how diseases once thought incurable can in fact be treated, even in resource-poor settings. PIH first demonstrated this by targeting tuberculosis in Peru, proving that carefully administered drug combinations could cure patients. The same has proved true of HIV, which is no longer a death sentence thanks to the efforts of PIH, philanthropies like the Gates Foundation, and the support of a man who is now a household name: Anthony Fauci, S.D. ’09, the director of the National Institute of Allergy and Infectious Diseases. (Fauci worked with then-president George W. Bush to establish PEPFAR, the President’s Emergency Plan for AIDS Relief, which has saved more than 18 million lives to date in 50 countries. Farmer describes him in the book as “Big-hearted, physically compact, curious, hard-driving, compassionate, inclusive…,” and says, “During the West African Ebola crisis, just hearing his robust Brooklyn accent on the phone reliably dropped my blood pressure by 20 points.”) Farmer and PIH have also been instrumental in helping to build a model healthcare system in Rwanda that has doubled life expectancy in that sub-Saharan country: deaths from HIV, TB, and malaria have plummeted 80 percent in the past decade.
If what is needed is better equipment, hospitals, and trained staff, why dwell on the history of the region? Farmer asks and answers that question himself: historical understanding, he writes, can help “decipher unfamiliar and often hostile responses to disease-control efforts…[and] call out outlandish claims from experts and novices alike. Historical understanding can even help us show respect for people native to West Africa. And if history can enlighten us in these ways, we might do better the next time around.”
A theme of Fevers, Feuds, and Diamonds is that the extractive trades rend the social fabric in lasting ways that lead to conflict and even war. They enrich people outside Africa, but impoverish the local inhabitants. The slave trade is an obvious culprit, which fueled local conflict, as tribes discovered they could profit from the sale of captives from enemy tribes. Less obvious is the origin of the disease-containment strategy that dominates public-health decisions in West Africa to this day. “When international alarms are sounded,” writes Farmer, “it’s rarely as a summons to international caregivers to rush in with medical supplies and relief. It’s more like the grim peal of the leper’s bell.” In the 2014 outbreak, clinicians and staff feared not just for their own safety—that Ebola would pick off “the hospital’s brave but poorly provisioned nurses and other caregivers like a hidden sniper”—but that such alarms would “trigger calls to shut down hospitals and clinics.” International SWAT teams sent in to aid in the crisis “counted fewer nurses than epidemiologists, researchers, managers, health educators, communication specialists, and soldiers”—as well as consultants expert in containment strategies—but not in giving care to patients.
Farmer tells the story of Humarr Khan, a respected physician in Sierra Leone who led efforts there to treat Ebola. When he became ill with Ebola, even he did not receive the kind of care that a Westerner would—despite the availability of potentially curative Western medicine directly at hand. Farmer’s account of Khan’s death is especially telling. In the aftermath, discussions about “the quality of care proceeded as if West African clinical deserts were somehow immutably arid and suddenly and forever cut off from the rest of the globe.” This “hermetic fiction” was largely focused on preventing transmission across international borders, Farmer acknowledges, but nevertheless “surreal” in the historical context, since the region has been and remains deeply connected to the rest of the world, not least through the trade in diamonds from Sierra Leone.
Farmer is unsparing in his assessment of the international response—though to be fair, he is also hard on himself. When he describes the arrival of the U.S. 82nd Airborne, “a sharp-looking group with handy helicopters” whose arrival he attributes to pleas for assistance from Medicins Sans Frontieres (MSF—in English, Doctors without Borders), he wonders at the fact that some of MSF’s leaders “seemed to disparage the tools and skills of critical care—‘Dialysis machines? Ventilators? Infusion pumps?’—even well after some of their own volunteers had been saved by them.” Farmer is no less a warrior than the members of the U.S. 82nd Airborne; it’s just that while he is advocating for patient care—fighting ferociously to save lives—others adopt regional bureaucratic conventions that attempt to seal the disease into the country, restricting it to the native population.
The question that Farmer seeks to answer in his book is why these countries—Guinea, Liberia, and Sierra Leone—and not others, suffer repeated epidemics. Weak health systems are part of the problem—he calls these countries “deserts” in terms of public-health, clinical care, and medicine—but are insufficient to explain the difference. “There can be no understanding of this medical wasteland, and its vulnerability to Ebola,” he writes, “without knowledge of [their] shared and distinct histories….”
Their shared history has long involved rapacious extraction and forced labor regimes. Rapacity on this scale requires and foments violence, resulting in more illness and injury. In the health-care arena, many of the terms of current debates about what’s possible and what’s not were set in the era of colonial rule. That’s where control-over-care strategies originated, and yet another reason recent calls to restore colonialism are even more disturbing than the preposterous success of imperial propaganda. The rural poor, the great majority in all three Ebola-afflicted nations until war drove them into towns and cities, were rarely viewed as deserving of medical care under colonial rule—even as a therapeutic revolution gathered force in Europe and North America.
Social medicine, Farmer argues, is less about “individual behavior, local culture, and traditional beliefs and practices” (as is often claimed by professionals trained in the biological sciences), and much more about consequential policies, events, and forces: the “ravages of history” of his subtitle.
This truth has been laid bare by the coronavirus epidemic (which arose largely after this book was written) and what Farmer terms “the erroneous banality that a pandemic afflicts all people alike. Here comes coronavirus, the great leveler: none of us is immune, we’re all at risk. But the quaint notion that respiratory pathogens do not discriminate—because we all draw breath—is almost never true, and it’s already proven false as regards this new coronavirus. In some corners of the United States,” he wrote in the epilogue, crafted in early April, “the racialization of the COVID-19 outbreak has already shriveled trust to the size of a sour lemon.”
This inequality is an echo of what he describes in West Africa, which will carry for some readers a startling moment of self-recognition. Farmer compares Western medicine’s “blame-the-victim” stigmatization of African customs—whether of washing the dead, caring for the sick, or of eating potentially infected bushmeat (sometimes to avoid starvation, at the risk of transmitting disease)—by calling attention to a Western tradition:
As war has ravaged the region in recent decades, many of those who sifted through its red soil for diamonds or other trafficked treasures were laborers who did so under coercion. Traffickers included modernizing chiefs, the always-trading Mandingo, Lebanese diamond dealers, warlords, politicians, and others held to have a heavy hand in the extractive trades—or who simply hoped to profit from war. But the more we learn about the shadowy dealings of these big men, the more it becomes clear that some of their patrons and many of their clients are us. Where do De Beers and other diamond peddlers find most of their customers today? In the United States, where the natives practice exotic marriage rituals that involve a powerful superstitious belief in the symbolic power of diamonds.
Farmer is not singling out the diamond trade as an explanation for the Ebola epidemic. But the ensuing, continuous healthcare disaster in West Africa was “entirely predictable: “[S]eldom if ever has such a small patch of our planet had to endure so much extraction for so long.”