Fever, Feuds, and Diamonds

Fever, Feuds, and Diamonds
Author: Paul Farmer


This is a most ambitious book whose scope goes far beyond its main subject – the Ebola virus epidemic that ravaged West Africa in 2013. Depicting the epidemic as ‘the longest and largest in recorded history’, the author, the iconic face of global medicine, set it against the backdrop of the region’s tumultuous history. With incisive political, military, and anthropological accounts of the area, particularly of Liberia, Sierra Leone, and Guinea, the author makes the strong argument that the legacy of slave trade, colonialism, and post-colonial interference set the stage for the health problems, including the recurrent viral epidemics, that still plague the region. The author asserts that ‘every chapter in the history of West Africa under European rule seems to include yet another cataclysmic outbreak of disease or conflict’, and he attributed this to the colonial emphasis on disease control over medical carewhat he called ‘the control-over-care paradigm‘. The author demonstrated how this entrenched strategy played out during the Ebola epidemic; ‘as deaths mounted’, he wrote, ‘officials remained focused on containment, as if prevention and care were competing tasks rather than complementary ones’. If there is a single key lesson of the book, it is undoubtedly its assertion that a ‘historical understanding‘ of the region is essential if ‘we might do better the next time around‘ (pages xix, xxvii -xxviii, 19, 33 and 270-271, ).

Stone Town Slave Trade 4. Son of Groucho on Flickr. https://www.flickr.com/photos/sonofgroucho/7893932824


The central theme of the book is its detailed historical account of Ebola virus in which the author traced the first description of the filovirus by the Belgian infectious disease doctor Peter Piot in Yambuku, a village in former Zaire. In his exploration of the epidemic in West Africa, the author identified the potential first case as Emile, a toddler who died shortly after falling ill with fever and diarrhoea, and from whom the virus spread and devastated families and villages in a relentless scourge that eventually engulfed the whole region and threatened the subregion. His account also detailed the catastrophic impact of Ebola on healthcare workers, the disease becoming ‘the number one killer of health professionals in this part of West Africa’ where about a thousand were afflicted, and more than half died. The author illustrated this sad situation most poignantly when he said Ebola ‘picked off the hospital’s brave but poorly provisioned nurses and other caregivers like a hidden sniper‘. Equally disturbing was the epidemiological confusion that characterised the first three months of the epidemic when ‘no one suspected that Ebola was the cause’; the author attributed this to the lack of local laboratory facilities, and the mistaken assumption of experts that Ebola was typically a hemorrhaging disease although bleeding was not among its most common manifestations. The failure of these early efforts to define the epidemic justified the author’s portrayal of the initial efforts to contain it as ‘faltering‘ (pages 435-436, 5-15, xii, xix, 27 and 44). 

Ebola in 3D. NIH Image Gallery on Flickr. https://www.flickr.com/photos/nihgov/27910834316

To illustrate the impact of the most recent epidemic on those who went through it, the author applied a unique narrative style in which he provided the perspectives of those who went through the cataclysm. Specifically, the stories of two Ebola survivors, Ibrahim and Yabom, symbolised both the destructive power of the virus, and the inspiring humanity of individuals. Ibrahim, for example, had lost twenty-three members of his family to Ebola, an ‘apocalyptic fate‘ that first struck an uncle who had participated in burying another victim – a typical cultural obligation that helped to fuel the epidemic by serving as a superspreader event. Ibrahim also fell ill after caring for his mother in her terminal illness but survived. Yabom on the other hand had ‘cared for, or helped to bury’ most of her family and relatives before she fell sick with Ebola herself. The author noted that ‘despite what she’d been through, Yabom was somehow able still to see most matters in a positive light‘. The insistent and selfless desire of both Ibrahim and Yabom to help other victims of Ebola was one of the most uplifting features of the whole narrative. Ibrahim, for example, played a critical role in coaxing Mariatu – one of a few children who recovered from Ebola virus – out of her post-traumatic depression. Yabom on the other hand went on to work with children orphaned by Ebola, an activity that she believed helped her own rehabilitation from the catastrophe (pages 23-25, 101, 113-120, 130-143, 146-148 and 175).

Waterloo cemetery. DFID on Flickr. https://www.flickr.com/photos/dfid/22206523784

A considerable part of the book explores the influence of European and American slavery and ‘extractive colonisation‘ on the health practices and infrastructure of West Africa. The author maintained that these heinous activities contributed in large measure to weakening health systems across the region, and in making it a ‘medical desert‘ characterised by ‘the dearth of trained and equipped medical professionals’, and by entrenched unhealthy caregiving practices. The author argued that the colonial emphasis on disease control at the expense of medical care – ‘the control-over-care paradigm‘ – made the region the ‘ground zero for stripping, feuds, and fevers‘, and contributed directly and indirectly to the current-day epidemics. He particularly described colonial health care services as ‘paltry‘ because they conceived of ‘medical care for sick natives’ as ‘mere footnotes‘, and as ‘the neglected stepchild’ of health policy. The author also blamed the region’s colonial and post-colonial history for the ‘armed conflict and forced labour‘ which ‘rolled out the red carpet for rapid human-to-human spread of Ebola in Upper West Africa’. It is therefore no wonder that the three Ebola-ravaged countries the book highlighted ranked ‘among the most medically impoverished nations on the face of the earth’ (page xxi-xxiii, 3, 252, 261-262, 184-186 and 339).

Imperial Federation, map of the world showing the extent of the British Empire in 1886 CC BY 2.0, Link

A major strength of the book is its detailed depiction of the enduring detrimental influence of colonialism and slave trade on West Africa’s economy and healthcare, and how these enabled the emergence of the recent aggressive Ebola epidemic. He chronicled how the slave trade to such places as Haiti, the Americas, and Europe, ‘came to be the beating heart‘ of commerce, and how it significantly impoverished the region. He particularly showed how ‘slavery and its disruptive machinery triggered raids and wars while unleashing epidemics across the region’. The author also referred to the perpetual impact of several European explorative colonial activities such as land appropriation, the conscription of native inhabitants to work on farms and mines, and the ‘making off‘ with the wealth extracted from those places. Significantly, the author noted that the region’s post-abolition history did not fare better because ‘across the region, rulers who resisted European rule were tamed, toppled, exiled, or killed‘. He also illustrated how the world powers and their commercial wings ensnared the region in debt as illustrated by the how US rubber companies dominated the Liberian economy in the early twentieth century, and by how the discovery of diamonds in Sierra Leone in 1930 set the country on a ‘heart-wrenching…course towards self-destruction‘ (pages 199-199, 205, 241, 306-312, 321 and 327).

Slaves. Travis on Flickr. https://www.flickr.com/photos/baggis/10774080706

An enlightening theme of the book is its account of the heroic efforts to control the West African Ebola epidemic, and this provided an insight into the work of the author’s humanitarian charity, Partners in Health (PIH). This narrative highlighted the author’s previous experience of working in ‘several epidemics in medical deserts’ such as Haiti and Rwanda, and it detailed how PIH linked their emergency response to Ebola to ‘efforts to build a proper health system‘. The author delineated the necessary tasks involved in fighting epidemics, from mobilisation of people, resources, and logistics, to the hands-on field work once the team was in place. He described such basic but essential requirements such as setting up offices, recruiting local staff, opening up bank accounts, and negotiating with political leaders. The author also emphasised his overarching principle of managing epidemics – combining efforts of controlling disease outbreaks with those geared at improving the overall quality of healthcare. Whilst the author demonstrated the eventual success of the efforts to control Ebola, he also highlighted the challenges of working in West Africa; this was illustrated by the dismal conditions of the hospital he worked in: ‘it had no walls and seemed more like a bunch of decaying sheds than a permanent structure’, adding that it had no running water, electricity, drainage, an incinerator, a triage area, or a morgue (pages 50 and 60-77).

Ebola treatment unit (ETU) run by Médecins Sans Frontières (MSF). UNMEER on FLickr. https://www.flickr.com/photos/unmeer/16058033560/


This fairly voluminous book almost overreaches itself in its ambitious attempt to bring together – in a most exhaustive approach – the history, economy, politics and healthcare factors that facilitated the emergence, and determined the outcome, of the Ebola virus epidemic. The very sensitively narrated case histories and depictions of the epidemic are detailed and graphic, and they bring home the death and destruction that trailed the outbreak, and the lives it left behind to mourn and rebuild. The chronicle of the long and often brutal history of the region was probably more detailed than it needed to be to make the point that the region’s past has fated its present travails. Some of the stories were also presented piecemeal, and this interfered with the smooth flow of the anecdotes. These apart, the thesis underlying the author’s assertions is powerful and enlightening, and it provides an important perspective of the emergence and spread of all infectious diseases in areas of the world that have gone through the ravages of slavery and colonialism. The idea that the region’s healthcare attitudes were shaped by its past history is empowering, and it opens a way to resolving them.

Overall assessment

The author, an infectious disease specialist and anthropologist, was well-suited to explore the social and cultural dimensions of the Ebola epidemic, and his narrative provides context and perspective to a disease that is shrouded in fear and misconceptions. The book’s clear story-telling depicts the clinical and public health dimensions of the Ebola epidemic, and the author outlines guidelines to address the underlying factors that facilitated its emergence. The book also highlights the dedication and hard work that go into humanitarian medical work, the challenges and risks involved, and the often gratifying results that follow. The book is a helpful insight into a hidden world of medicine, and I recommend it to all doctors.

Book details

Publisher, Place, Year: Farrar, Straus Giroux, New York, 2020
Number of chapters: 10
Number of pages: 653
ISBN: 978-0-374-23432-4
Star rating: 5
Price: £24.72

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