Fevers, Feuds, and Diamonds: Ebola and the Ravages of History

Farmer, Paul

Primary Category: Literature / Nonfiction

Zander, Devon

Date of entry: Mar-19-2021

Summary

Fevers, Feuds, and Diamonds is Paul Farmer’s latest work exploring the connection between health and the social and historical structures that surround it. Focusing on how and why Ebola spread in West Africa in 2014, the book is difficult to categorize — it is not only temporally expansive, ranging from the late 15th century to the present day, but it also combines elements of a memoir, an anthropological treatise, and an abbreviated historical text with powerful calls to action in over 500 pages.

Stemming partially from a desire to fulfill a “personal penance for inaction” during the early days of the outbreak, Farmer chooses to learn about Ebola from “the personal histories of the Ebola dead, of survivors, and of their caregivers.” Harking back to his days as a college anthropology major, many of the book’s themes, embodied in its title, are introduced via these in-depth interviews. His two main subjects, Ibrahim and Yabom, are Ebola survivors who, after initially recovering from their illness, make it their work to support other Ebola survivors. Through their words and narratives, we witness some of what it was like to experience the civil strife that predated the outbreak, see how Ebola expanded from isolated cases to clusters and communities, how family members sick with the disease were cared for, what it meant to survive Ebola, and now what it means to live with its sequelae. Translation for Farmer was provided by Dr. Bailor Barrie, one of his former students, whose story as a medical student in Sierra Leone during its civil war soon becomes part of the narrative, as well. Through the words of these three people, pieced together over many extensive conversations, a narrative is developed, allowing those most impacted by Ebola to tell its story.

Farmer interweaves his first-person perspective with their stories, emphasizing his role in 2014 and how Partners in Health became involved in assisting in the outbreak. While working in West Africa during the Ebola epidemic, late one night, Farmer mixes up Liberia and Sierra Leone. Realizing how different their histories are, he vows to “make amends for my ignorance” and transitions from storytelling on the personal level to history-telling on the country level. To ensure that he, and we, never mix them up again, Farmer traces the histories of Sierra Leone, Liberia, and Guinea in four chapters. During this section, he refers back to the book’s title, taking on the effects of the rise of imperialism, colonization, the use of sanitation/Pasteurian principles, the impact of resource extraction, and much more on each of these nation’s stories and relationships with Ebola. As he describes it, “if you want to understand the magnitude and dynamics of this Ebola epidemic, in other words, think in terms of fevers, feuds, and diamonds.”

Fevers, Feuds, and Diamonds is bookended with reflections on COVID-19 in the introduction and epilogue. In the introduction, he reflects on the book’s “obvious implications for our response to COVID-19” and how COVID-19, though different in many ways, shares certain similarities with Ebola — among them, the speculative nature of its origins and the fact that it is a zoonosis. Most importantly, according to Farmer, treating and managing it will require understanding many of the same “cultural complexities and... challenges” that treating Ebola required. After taking us on a journey through West Africa and up to 2014, Farmer writes an epilogue reflecting on how the central crisis of Ebola was the prioritization of “containment over care” whereas COVID-19 has become a crisis of containment. To him, writing this on April 10th, 2020, and to the reader reading it a year later, COVID-19 is seen as partially a disease of healthcare workers’ exposure, and partially a disease of social inequity, but completely a disease whose management, treatment, and eventual control will be defined by the “staff and stuff and spaces and systems” in place and who has access to them. Even with this pandemic at the forefront of our minds, Farmer reminds us that Ebola should not be off our radar just because a new disease is on it— there continue to be outbreaks of Ebola in the Congo. Ultimately, Farmer’s words leave you thinking — about this pandemic, about the past, and about the connections between them. If only to prompt more thought, one of Farmer’s last comments is also his most powerful: “If there’s indeed a lesson to be learned from Ebola, it may be this one: for everything we do, or say, in pandemic time, let’s keep asking the same question. Might this help?”

Commentary

Rudolf Virchow once wrote: "Medicine is a social science, and politics is nothing but medicine on a large scale. The physicians are the natural attorneys of the poor, and the social problems should largely be solved by them." Ever his disciple, Farmer refrains from quoting him in this publication, but Virchow’s influence is apparent. From being unafraid to take on complex logistical social challenges such as setting up an Ebola treatment unit or connecting survivors to social services to conducting interviews with those most affected by the disease in order to draw conclusions about it, Farmer frames his approach to medicine much as he frames his anthropology: a “history from below,” where those most impacted get to define the agenda.

Fevers, Feuds, and Diamonds uses the book’s essential elements— Farmer’s personal observations in 2014; the interviews with Ibrahim, Yabom, and Dr. Bailor Barrie; and the abbreviated history of Guinea, Sierra Leone, and Liberia — to make a few related arguments. First, Farmer introduces the idea of Ebola as being a disease of caregivers: healthcare workers, family members, religious leaders, and burial teams. Because of this, any Ebola mitigation policy that centers itself on “no touch” principles will be doomed to fail, for it is unreasonable to expect loved ones and healthcare workers conditioned to help not to touch someone in need of assistance (something Farmer experiences firsthand after rushing to the aid of child infected with Ebola without wearing proper protective equipment). Second, for there to be functioning healthcare, there needs to be “staff and stuff and spaces and systems” in place. Without any of these components, true medical care and treatment cannot be delivered. Third, creating a “containment over care” paradigm where infection control is prioritized over clinical care is inhumane and continues a dangerous legacy of colonial approaches to healthcare, where the management of the spread of disease is prioritized over individuals’ welfare. Relatedly, a “research over care” paradigm where treatment is delayed until more research is conducted similarly does not put the patient and their care first (notably, Farmer tempers this with the importance of conducting research simultaneously during care to learn if interventions are actually efficacious). Fourth, any form of nihilism—“treatment nihilism” in Ebola or “containment nihilism” in COVID-19 — can contribute to a defeatist attitude when trying to tackle complex problems.

Ultimately, Farmer's biggest contribution is the fresh perspective he brings to the outbreak narrative. Breaking from Richard Preston’s portrayals of Ebola in his book, The Hot Zone, he simplifies a disease that has been written about extensively in the popular media. Farmer takes the Western press to task for allowing the narrative of Ebola and its spread to be placed in the paradigm of a “perfect storm” of contributing factors, as the “storm” had been building for some time and was largely ignored by the same press. He also calls into question public health terms that are often thrown about — superspreader, bushmeat, traditional burial practices — and questions how and why we use these phrases. During our current pandemic, it is refreshing to have these statements questioned and be asked to reflect on what exactly we mean when we say them.

Publisher

Farrar, Straus and Giroux

Place Published

New York

Edition

2020

Page Count

653