A virus in a medical desert

Book review of FEVERS, FEUDS, AND DIAMONDS: Ebola and the Ravages of History

In the early months of 2014, a team of medical professionals from the global health organisation Doctors Without Borders began tracking a troubling outbreak, centred 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. 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 organisation Partners in Health, Mr 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 Mr Farmer and his colleagues at Partners in Health to the region. As he writes in 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.”

Mr 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. These opening scenes imply a predictable template of public health heroism, laced with gruesome descriptions of Ebola’s devastating impact on the human body. But the book deviates from those conventions in a number of surprising ways. To begin with, the Ebola virus is less of a relentless killer. “With the exception of one Liberian-born US citizen,” Mr Farmer points out, “every American who fell ill from the strains circulating in West Africa survived. So did most Europeans.”

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,” Mr 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. The book is structured almost like a time-twisting prestige television drama.

The book swerves back 500 years, all the way to the origins of the trans-Atlantic slave trade. For more than 200 pages, 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 Mr Farmer calls “rapacious extraction — of rubber latex, timber, minerals, gold, diamonds and human chattel.”

FEVERS, FEUDS, AND DIAMONDS: Ebola and the Ravages 

of History

Author: Paul Farmer

Publisher: Farrar, Straus & Giroux

Price: $35 

Pages: 653

Mr 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 emphasised disease containment — quarantines, segregationist building codes — over direct medical care, an approach that would govern much of the initial response to Ebola.

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. Mr 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 arose 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.

Mr Farmer begins the final section of the book 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. But Mr Farmer invokes it to point to a broader landscape, more political than biological: “This was not,” he 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 — he has given us an invaluable map.

©2020 The New York Times News Service