In the early months of 2014, a team of medical professionals from the global health organization Doctors Without Borders began tracking a troubling outbreak, centered in Guéckédou, a city of 200,000 in southern Guinea near the country’s borders with Liberia and Sierra Leone. The affliction had cholera-like symptoms, and seemed unusually lethal. Initial observers suspected that it might be a recurrence of Lassa fever, caused by the Lassa filovirus endemic in West Africa. But by March, the sheer body count — and a few telltale symptoms — began pointing toward a more deadly pathogen. Blood samples were dispatched to France on an overnight flight and on March 21, a team of virologists in Lyon identified the killer: Zaire Ebola.
In July of that year, the medical anthropologist and physician Paul Farmer learned that his friend Humarr Khan, one of the leading infectious disease experts in Sierra Leone, had succumbed to the Ebola virus, a death that sent shock waves around the global health community. Through his organization Partners in Health, Farmer had done heroic work over the years fighting tuberculosis in Peru, AIDS in Rwanda and many other outbreaks in similarly poor countries around the world.
Khan’s death and the virus’s devastating march through West Africa in the summer of 2014 soon brought Farmer and his colleagues at Partners in Health to the region. As Farmer writes in his new book, “Fevers, Feuds, and Diamonds: Ebola and the Ravages of History,” by the time he arrived in the capital city of Freetown in late September, “western Sierra Leone was ground zero of the epidemic, and Upper West Africa was just about the worst place in the world to be critically ill or injured.”
Paul FarmerCredit...Partners In Health
Farmer begins his book with a harrowing first-person account of an October 2014 visit to an Ebola treatment unit in Liberia’s capital, Monrovia. “We encountered two brothers who were leaving the triage area, just a few yards from where we stood,” Farmer writes. “Tall and thin, the brothers were inside the red zone but not yet patients: They still had to reach their beds, but could barely walk and looked disoriented. The older one, retching uncontrollably as watery stool ran down his legs, was the first Ebola patient my friend and I had seen shrivel up before us. His sunken eyes and withered skin made him look elderly, but I guessed him to be in his early 30s, maybe younger. We saw him sink into a squat while his brother struggled to hoist him back to his feet. The younger man, who couldn’t have been much more than 20, was covered with vomit, which I’d assumed was his brother’s. But then he, too, began to gag and heave, even as he tried to steady his trembling, stumbling sibling.”
These opening scenes imply a predictable template for the book: a memoir of public health heroism, laced with gruesome descriptions of Ebola’s devastating impact on the human body, in the style of Richard Preston’s best-selling Ebola chronicle from the 1990s, “The Hot Zone.” But “Fevers, Feuds, and Diamonds” turns out to deviate from those conventions in a number of surprising ways. To begin with, the Ebola virus is less of a relentless killer than it is in Preston’s account. “With the exception of one Liberian-born U.S. citizen,” Farmer points out, “every American who fell ill from the strains circulating in West Africa survived. So did most Europeans.”
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Farmer notes that even severe cases of Ebola rarely produce the horror-film symptoms featured so prominently in Preston’s “Hot Zone”: patients bleeding from their eyeballs, their organs liquefied in a matter of hours. Most cases instead involve fluid and electrolyte loss caused by vomiting and diarrhea, which can often be treated with basic supportive and critical care, like intravenous fluid replenishment or dialysis. Ebola was so lethal in upper West Africa not because the virus itself conveyed an inevitable death sentence, but because countries like Liberia and Sierra Leone lacked these health care essentials. “For all their rainfall,” Farmer writes, “their citizens are stranded in the medical desert.”
Much of “Fevers, Feuds, and Diamonds” is devoted to explaining how that “medical desert” came to be, a quest that leads to the book’s most notable departure from the “Hot Zone” template. Instead of a disease thriller or a straight memoir, Farmer’s book is structured almost like an experimental novel, or a time-twisting prestige television drama. The chronology loops back on itself multiple times.
We follow Farmer’s initial foray into the outbreak in West Africa, and then rewind twice to track the life histories of two Ebola survivors whom he meets: Ibrahim Kamara and Yabom Koroma, each of whom had lost more than a dozen relatives to the virus. Deeper forces rumble beneath these individual narratives — the brutal extraction capitalism of the diamond and latex business, the mayhem and terror of Sierra Leone’s decade-long civil war, including the notorious “Operation No Living Thing” attack on Freetown in 1999 — but Farmer keeps the focus tight on his two protagonists, only illuminating the wider geopolitical context when it directly influences their life stories.
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But once he returns those two narratives to the original timeline — Freetown, late 2014 — the book swerves back 500 years, all the way to the origins of the trans-Atlantic slave trade. For more than 200 pages, Farmer shifts into historian mode, and the book drops much of its initial focus on disease and public health, turning instead toward the many ways Guinea, Liberia and Sierra Leone, their borders carved out by European overlords, had been crippled by five centuries of what Farmer calls “rapacious extraction — of rubber latex, timber, minerals, gold, diamonds and human chattel.”
This history is as powerfully conveyed as it is tragic. Farmer takes the reader through many fascinating episodes: the early “back to Africa” movement in the 1800s that led to the founding of Freetown and the nation of Liberia itself; the centuries-long obsession with the Human Leopard Society, an underground network of shape-shifting Africans that supposedly practiced cannibalism and ritual murder; Harvey Firestone’s successful attempt to circumvent the British monopoly on rubber that turned Liberia into the United States’ primary supplier of latex. Most tellingly, he traces the origins of the “control-over-care” ideology that emerged around the turn of the 20th century, as European agents emphasized disease containment — quarantines, segregationist building codes — over direct medical care, an approach that would govern much of the initial response to Ebola.
By the time the chronology returns to the events covered in the opening chapters of the book — Operation No Living Thing, Khan’s death, Farmer’s initial encounter with the two brothers dying of Ebola in Monrovia — the facts recounted are, technically speaking, the same, but in the reader’s mind, they have been transformed from isolated symptoms into a much more profound diagnosis, both by the intimate histories of Yabom and Ibrahim, and by the wide-angle view of the region’s ravaged history. The looping structure is not without its flaws: Several sequences are repeated almost verbatim, and a slightly pared-down version of the historical interlude might have made the book even more powerful. But the overall effect is nonetheless illuminating.
Reading “Fevers, Feuds, and Diamonds” in the annus horribilis of 2020 inevitably begs the question of how the Ebola outbreak compares with the coronavirus pandemic. Farmer’s account of the 2014-15 period contains some obvious foreshadowing: Dr. Anthony S. Fauci appears in a supporting role; a television personality named Donald J. Trump rails against President Barack Obama’s handling of the crisis on Twitter. But in a way, the lessons of 2014 are almost the inverse of what we have experienced in 2020. The death toll from Ebola, in Farmer’s account, arose from the medical deserts of upper West Africa, from a longstanding failure to invest in basic health infrastructure and supportive care. Covid-19, by contrast, is a story about how a disease managed to cause such destruction in what should have been a medical oasis: a failure of control, not care.
Farmer begins the final section of “Fevers, Feuds, and Diamonds” with a quote apparently uttered by Louis Pasteur on his deathbed: “Le microbe n’est rien, le terrain est tout.” The microbe is nothing, the terrain is everything. If indeed Pasteur said the line, the reference to “the terrain” was an allusion to the “terrain” of the human body, and to the immune system in particular. But Farmer invokes it to point to a broader landscape, more political than biological: the violent conflict and material inequalities that inevitably play a role in determining whether a virus destroys a human life, or leaves it relatively unscathed. “This was not,” Farmer writes, “a history of inevitable mortality that resulted from ancient evolutionary forces. … It was the contingent history of a population made vulnerable.” For that terrain — and the ravages of history that created it — Farmer has given us an invaluable map.