In 'Fevers, Feuds And Diamonds,' Paul Farmer breaks down assumptions about Ebola

Suppose you're participating in one of those word-association tests, where someone gives you a word and you're to respond with the first things that enter your mind. Your word is "Ebola."

Unless you're an infectious-disease expert, what might pop into your mind are phrases like "bleeding from the eyes and mouth," and "90 percent death rate," coupled with images of horrific contagion set in remote African villages. That's an almost inevitable takeaway from reading Richard Preston's best-selling “The Hot Zone” ("you are almost certainly doomed" if you catch Ebola, Preston claimed) or watching movies based in viral sensationalism.

Anthropologist and physician Paul Farmer, based at Harvard Medical School, turns this view of Ebola on its head in his eye-opening, densely detailed, and riveting “Fevers, Feuds and Diamonds: Ebola and the Ravages of History.” Only rarely, in fact, do Ebola patients bleed out, and the death rate need not come anywhere near 90 percent. Supportive measures like restoring lost body fluids go a long way in saving lives, because they give a person's immune system time to kick in and can lead to recovery from the fever, vomiting, and severe diarrhea that often do characterize the illness.

"We have to stop telling ourselves horror stories about an unstoppable mutant virus," Farmer writes, "because those stories often legitimate our inaction." In fact, there's a great deal that can be done to save Ebola patients — if only the sufferers are deemed worth saving.

The book centers on the Ebola outbreak of 2014 in three West African countries, Guinea, Liberia and Sierra Leone — nations that are medically impoverished. When people began in late 2013 to fall ill in Guinea with Ebola, the illness, transmitted through sweat, saliva, vomit, feces, and other bodily fluids, spread rapidly and soon crossed borders. Blame rained down on individuals, families and communities who were described by international agencies as willfully resisting sensible public health measures. Caretaking of very ill loved ones, and preparing the body for burial of loved ones who had died no matter the cause, were portrayed as exotic "traditional" behaviors; this in turn allowed sufferers to be blamed for resisting Western knowledge and for contributing to their own misery.

The truth, as Farmer makes crystal clear, often with an incandescent anger that shines through even his measured words, is much different. Yes, the disease — just like coronaviruses — is spread in part through caregiving. But the base fact is this: Ebola swept through these nations in a catastrophic way more because of a history of inequality than because of viral biology.

As Farmer recounts, in 1884 at a palace in Berlin that would later house the headquarters of the Third Reich, European powers divvied up huge swaths of Africa and proceeded to rule them with a stunning combination of racism and greed. By 1902, 90% percent of Africa was controlled by Europe (though not without fierce local resistance movements). This was "extractive colonialism" by the Europeans, writ large, and intertwined in all sort of ways with the terrible history of extraction of Africans themselves in the slave trade. In the late 19th and 20th centuries, extraction was focused not only on the diamonds mentioned in the book's subtitle, but also on rubber, minerals and timber and, crucially, human labor — including forced conscription in World War I. By 1918, Farmer reports, nearly half a million soldiers "from 'French Africa' had served during the war." Liberia, by contrast, was founded by Americans and is often described as free of the white supremacy forced on African colonies. Farmer, though, explores how "the country's sketchy reputation as a beacon of decency in a racist world" was further tarnished by — even there — practices of Black slavery.

And then, there was the havoc of prolonged civil war in the 1900s, in both Liberia and Sierra Leone. Millions of people, their lives disrupted, ended up in refugee camps. Farmer's long descriptions of war are punishing, explaining how this violence emerged from the disruptions of colonialism. The destruction of all this history — extractive colonialism plus war — set the stage for Ebola's rampage through the region.

When it comes to Ebola in 2014, “Fevers, Feuds and Diamonds” is no armchair account. With his colleagues in Partners in Health, the organization he co-founded, Farmer traveled to West Africa and worked at some of the hastily erected medical units for Ebola patients. What he sees is a pattern that, in the telling, becomes a central theme of the book: "control over care." That is, a stated policy (one with a sadly long history) from international crisis responders that the urgent focus must be on containment — isolating individuals, families and communities to control the virus. To focus instead on care is both too dangerous for clinicians and too likely to fail anyway.

Yet, again, the facts scream otherwise. With one exception, Farmer writes, "every American who fell ill from the strains circulating in West Africa survived. So did most Europeans." Let me underscore the point: Wildly different mortality outcomes emerged from the same strain of Ebola, depending on care that was or wasn't available depending on your country of origin.

In this grim tale, it's a relief to read about the West African survivors of Ebola who work to help others rebuild their lives. The stories of Ibrahim Kamara and Yabom Koroma, Sierra Leoneans who endured sorrowful family losses as well as terrible illness, Farmer conveys partly in their own words. It makes for two gripping chapters. Farmer credits his friend Ibrahim with inspiring him to write the book.

Only Paul Farmer, I think, in his ability to write so knowledgeably and with such love and hope for all of humanity, could coax me to read 526 pages of text about a viral outbreak during a viral pandemic. (Confession: I only skimmed the nearly-100 extra pages of footnotes in the back.) Farmer is modest in print, but his story (conveyed also in his previous books) is compelling. He's worked tirelessly for decades in places like Haiti and Rwanda to aid crisis recovery and build strong public-health networks.

Farmer closes the book with a section penned in April 2020 that takes on ugly truths surrounding the coronavirus pandemic we're dealing with now. (Anthony Fauci, by the way, is his mentor and friend and appears throughout the book.) Farmer writes about "the grotesquely differential rates of infection and death within the United States," given how hard COVID-19 has hit Black Americans and, we now know, Latinx and Indigenous Americans as well.

Farmer's words remind us of the harsh reality in this country: "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."

From Farmer we learn that the world needs not only a COVID vaccine, but something much more: a rejection of global racial inequalities and an embrace of investing seriously in the care of all people.

Barbara J. King is a biological anthropologist emerita at William & Mary. Her seventh book, Animals' Best Friends: Putting Compassion to Work for Animals in Captivity and in the Wild, will be published in March. Find her on Twitter @bjkingape.

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