22 SUNDAY, DECEMBER 13, 2020IN THE EARLYmonths of 2014, a team of
medical professionals from the global
health organization Doctors Without Bor-
ders began tracking a troubling outbreak,
centered in Guéckédou, a city of 200,000 in
southern Guinea near the country’s bor-
ders with Liberia and Sierra Leone. The af-
fliction 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 virolo-
gists in Lyon identified the killer: Zaire
Ebola.
In July of that year, the medical anthro-
pologist 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 out-
breaks 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 col-
leagues at Partners in Health to the region.
As Farmer writes in his new book, “Fevers,
Feuds, and Diamonds: Ebola and the Rav-
ages of History,” by the time he arrived in
the capital city of Freetown in late Septem-
ber, “western Sierra Leone was ground
zero of the epidemic, and Upper West Afri-
ca was just about the worst place in the
world to be critically ill or injured.”
Farmer begins his book with a harrow-
ing 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 pa-
tients: They still had to reach their beds,
but could barely walk and looked disori-
ented. The older one, retching uncontrolla-
bly 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 as-
sumed 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 predict-
able template for the book: a memoir of
public health heroism, laced with grue-
some 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. citi-
zen,” Farmer points out, “every American
who fell ill from the strains circulating in
West Africa survived. So did most Euro-
peans.”
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 in-
volve 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 Si-
erra Leone lacked these health care essen-
tials. “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 experi-
mental 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 Ka-
mara 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 extrac-
tion 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 Farmerkeeps the focus tight on his two protago-
nists, only illuminating the wider geopoliti-
cal context when it directly influences
their life stories.
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-Atlan-
tic slave trade. For more than 200 pages,
Farmer shifts into historian mode, and the
book drops much of its initial focus on dis-
ease and public health, turning instead to-
ward 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 “rapa-
cious extraction — of rubber latex, timber,
minerals, gold, diamonds and human chat-
tel.”
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 cen-
turies-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 rub-
ber that turned Liberia into the United
States’ primary supplier of latex. Most
tellingly, he traces the origins of the “con-
trol-over-care” ideology that emerged
around the turn of the 20th century, as Eu-
ropean agents emphasized disease con-
tainment — 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, tech-
nically speaking, the same, but in the read-
er’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 thewide-angle view of the region’s ravaged
history. The looping structure is not with-
out its flaws: Several sequences are re-
peated almost verbatim, and a slightly
pared-down version of the historical inter-
lude might have made the book even more
powerful. But the overall effect is nonethe-
less illuminating.
Reading “Fevers, Feuds, and Dia-
monds” in the annus horribilisof 2020 inev-
itably begs the question of how the Ebola
outbreak compares with the coronavirus
pandemic. Farmer’s account of the 2014-15
period contains some obvious foreshad-
owing: Dr. Anthony S. Fauci appears in a
supporting role; a television personality
named Donald J. Trump rails against Pres-
ident Barack Obama’s handling of the cri-
sis 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 Af-
rica, from a longstanding failure to invest
in basic health infrastructure and support-
ive 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 “Fe-
vers, 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 ter-
rain 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 particu-
lar. But Farmer invokes it to point to a
broader landscape, more political than bio-
logical: the violent conflict and material in-
equalities that inevitably play a role in de-
termining whether a virus destroys a hu-
man 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. 0A Preventable Epidemic
Structural and historical inequalities led to Ebola’s devastating toll.
By STEVEN JOHNSON
FEVERS, FEUDS, AND DIAMONDS
Ebola and the Ravages of History
By Paul Farmer
653 pp. Farrar, Straus & Giroux. $35.
PHOTOGRAPH BY DANIEL BEREHULAK FOR THE NEW YORK TIMESSTEVEN JOHNSONis the author of 12 books, most
recently “Enemy of All Mankind: A True Story
of Piracy, Power, and History’s First Global
Manhunt.”
Health care workers at an Ebola treatment center in 2014 in Kailahun, Sierra Leone.