Book Reviews

Outbreaks and Outcomes

Plagues thrive on more than just pathogens

By Graeme Wood | December 21, 2020
UNICEF-managed child care at the Ebola Treatment Center. Kasomo Kavira, a caregiver at the UNICEF-managed Ebola Treatment Center in the Democratic Republic of Congo, in 2019. Photo: World Bank / Vincent Tremeau
UNICEF-managed child care at the Ebola Treatment Center. Kasomo Kavira, a caregiver at the UNICEF-managed Ebola Treatment Center in the Democratic Republic of Congo, in 2019. Photo: World Bank / Vincent Tremeau

Fevers, Feuds, and Diamonds: Ebola and the Ravages of History by Paul Farmer; Farrar, Straus and Giroux, 688 pp., $35

A fitting look-on-the-bright-side epitaph for the year 2020 might be this: At least it wasn’t Ebola. But in 2014, it was Ebola, if you lived in West Africa. An epidemic of the disease, best known in the press for graphic descriptions of deliquescent organs and bodies leaking blood, hit Liberia, Guinea, and Sierra Leone. People lined up outside clinics, carrying their loved ones in their arms as they moaned and soiled themselves with bodily fluids. By the time the outbreak ended in 2016, over 11,000 people had died, about five percent of them health-care workers. The disease trickled overseas in small numbers, but it didn’t cover the planet. If it had, you’d remember.

The core insight of Paul Farmer’s history and memoir of the Ebola epidemic is a clinical one. If you contracted Ebola in West Africa, you probably died. If you contracted Ebola and somehow made it to the United States—or another “medical oasis”—you would very likely have the worst week or two of your life, then survive. Ebola tends to kill so-called “wet patients,” ones in the phase where vomiting and diarrhea rob them of fluids, and the patient dies from shock. (Catastrophic bleeding, while graphic, is actually quite rare, and doctors were surprised at the survival rate for American patients.) If you can replace those fluids intravenously—a straightforward task for a modern hospital—you can probably survive long enough to fight off the infection. (The hospital might also need to be equipped to manage multiple organ failure.) If you live in a “medical desert,” you might get oral rehydration salts in liquid form (street name: Gatorade), but if you do, you’d better hope you can keep them down long enough to survive.

Farmer, a physician and medical anthropologist at Harvard Medical School, finds this disparity galling. “How many of these deaths were caused more by the virulence of social conditions than by the virulence of the pathogen?” In 1987, he and a few other doctors co-founded a medical N.G.O. called Partners in Health, which hydrates medical deserts by developing local medical systems. He arrived with Partners in Health in Sierra Leone in 2014, and frankly describes its worst-hit areas as “a hellhole.”

Easily the best parts of this memoir are about patients and colleagues, and a vision of medical care in a local partnership. It is possible to overstate the condescension of “aid workers” as a class, but if you have ever been in the African bush and seen them blast past you in an air-conditioned SUV—or if you have ever heard how much some of these people get paid—you will have a sense of just how estranged too many of them are from the population they ostensibly serve. Farmer and his team were, by his account, fully integrated into Sierra Leone and sensitive to its cultures—more inclined to employ local staff, and less inclined to order around West Africans from a position of presumed superiority.

The insensitivity of most of the rest of the world is an instructive contrast. Just as in 2020, when China was criticized for its pangolin-loving ways, and for the wet market that may have spread the coronavirus to humans, West Africans were condemned for their alleged love of fruit-bat soup, and for washing the bodies of the dead—in other words, for cultural practices that caused or accelerated the spread of disease. These exotic practices were savage, and the cultures that practiced them should “just stop,” according to prevailing Western attitudes at the time. (Now that Americans have discovered that they have their own superspreading cultural practices—motorcycle rallies, political campaigns, gender-reveal parties—one hopes their condescension will be more muted in the future.) The supposed index patient, the first person known to have caught Ebola, was not a known bat-muncher. He was a small child. And washing the bodies of the dead is, as the anthropologist Paul Richards has noted, an act of love, duty, and respect. In the West, at least since the time of Antigone, we have believed that one honors the dead sometimes even at the expense of the living. There is nothing exotic about it. In the end, the respectful approach taken by Farmer and others was much more effective than attempts to persuade West Africans to suspend some of their more dangerous practices.

What characterized the Ebola outbreak, Farmer says, is a familiar global-health posture toward outbreaks of contagion in medical deserts. The paradigm is “control-over-care”: try to contain the contagion, rather than contain it and care for those afflicted. You can (attempt to) contain an epidemic by closing borders or, for that matter, sealing off and essentially ignoring a plague-stricken neighborhood. Unsurprisingly, poor places tend to get contained, and rich ones cared for. “When international alarms are sounded, it’s rarely as a summons to international caregivers to rush in with medical supplies and relief,” Farmer writes. The aid came, but the care did not. “It’s more like the grim peal of a leper’s bell.”

Leper’s bells serve a purpose, when there is leprosy about (and Ebola is quite a bit worse than leprosy). But Farmer says containment can’t work unless accompanied by ordinary medical care. Just as every psychiatrist knows that the best medications for a patient are those a patient will actually take, a competent infectious disease doctor knows that the best public health measures are the ones people will actually follow. The message of containment to those in the contagion zone is that Ebola will get you, and not me, if you follow the rules. “Local clinicians began to fear that they and their patients were, to use the scholarly term, screwed,” Farmer writes. To replace care with just a leper’s bell is an invitation to distrust and disobey medical advice, to circumvent quarantines, and ultimately to let the contagion blossom and escape confinement.

As a scholar, Farmer focuses on the social dimensions of health. He has a grim recitation of the contradictory or culturally clueless reports that characterized the early public health messages. The public in West Africa was told not to eat plums (not a commonly eaten fruit there); not to play with baboons (not a common creature). “Go to a hospital,” they are told one day. Then “don’t go to a hospital, as there’s no known treatment for Ebola.” All this “ham-fisted hectoring” led to even further suspicion. As with the coronavirus in the United States, public health messaging sounded like a glitching robot spewing random advice, and the result was that everyone wanted help but no one knew where to get it, or whom to trust.

Viewed from the United States, Farmer reminds us, the Ebola epidemic looked no less scary, even though the threat to the public was negligible. When a few Ebola patients made it to America, there was a brief but general freak-out—a preview, in retrospect, of the paranoia and irrationality that characterizes the current pandemic. A few relief workers came back with the disease, and some (including Donald Trump) protested their admission into the United States. A Liberian man, Thomas Eric Duncan, collapsed outside his apartment building in Dallas and died of Ebola a few days later. I was in Dallas then. The next day, a Liberian cab driver who lived in the same complex drove me to the airport and offered me a sealed bottle of water for the road. I mentioned this incident at a party in New York that night, and the other guests scattered like crows.

The fat middle of Farmer’s book is an extended discussion of the history of West Africa, with special interest paid to public health, colonialism, and a gruesome record of civil war and extractive industry. The history is meant to illuminate the recent past, sometimes poetically: the “majestic” cotton tree at the center of Sierra Leone’s capital is, he writes, “a silent witness to long years during which Freetown failed to be truly free.” My own Freetown days preceded the epidemic by a few years, so the description strikes me as absurdly dark way to think about the central sight in the most beautiful city in West Africa. He’s right that Freetown saw years of unfettered institutionalized racism, and literally fettered humans, and that the medical desertification of West Africa is part of this legacy. (Farmer’s Harvard colleague Nathan Nunn estimates that the legacy of the slave trades accounts for nearly half of the disparity between the wealth of Africa and the wealth of the rest of the world.)

For the epidemic of 2013­–16, however, I found this history a dim illumination. Medicine is, for one thing, a new science (physician and writer Lewis Thomas asserted that 1927 was the year when doctors began saving more patients than they killed), so the overwhelming effect of colonialism was to immiserate the subjugated societies in a general, and not specifically medical, way. More important, colonialism—with Farmer’s other bugbear, neoliberalism—is such a vast global process that it is nearly impossible to pin down as a causal factor for any single tragedy today. These -isms are the background, not the causes, because like “industrialization” or “the Enlightenment,” they explain everything, which is the same as explaining nothing. They are best invoked as a sort of descant over the melody of more proximate causes of hardship, and with due deference to the variation in how their legacies can shake out. Rwanda, a country Farmer knows well, has developed impressively in the last 20 years, in spite of a very dark colonial history and an equally dark postcolonial history. Evidently these histories do not determine destiny, even if they affect it.

Farmer’s approach leaves a great deal of hard social science left to do. It is nevertheless important: Does the story of Ebola start with a description of its clinical presentation? Or its molecular mechanisms, and a diagram of its spike protein? Or does it start with the story of the terrain on which its victims live, and why Maforki, Sierra Leone, and not Medford, Massachusetts, was a hellhole? Farmer’s case for more of the latter, and less of the former, is sound, and I hope to see more of it.

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