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The inequality of an epidemic in Paul Farmer’s ‘Fevers, Feuds, and Diamonds’

A Doctors Without Borders health worker in protective clothing carries a child suspected of having Ebola in a treatment center in 2014 in Paynesville, Liberia.John Moore

Nurse Mbalu Fonnie and Dr. Humarr Khan were two of the hundreds of health care workers who fell ill and died while treating Ebola patients in West Africa in 2014. It was discomfiting, while reading now about their travails, to visit an American big box store where everyone was masked and protections were stacked on the shelves.

As Ebola ramped up in Sierra Leone, Liberia, and Guinea, not only was such PPE scarce — clinics and hospitals were, too. The disease was deadly, highly contagious, and moved swiftly toward populous cities. With exceptional empathy and care, Paul Farmer takes us through his experience with that health crisis and the difficult history that made those populations particularly vulnerable in his new book, “Fevers, Feuds, and Diamonds.”


Farmer, of Harvard Medical School and Brigham and Women’s Hospital, is a physician, anthropologist, MacArthur Fellow and founding director of Partners in Health, the nonprofit that provides health care and training in Haiti, Peru, Rwanda and other nations. Since April, it has taken care of Massachusetts’s COVID-19 contact tracing.

Certainly, Farmer had no idea when he began to tell the story of his experiences a 2014 pandemic half a world away that another would be sweeping the globe in 2020. Or that it would affect America so drastically that Anthony Fauci, who in his post at the CDC helped treat Americans with Ebola, would now be a household name.

The book begins as a true-life medical thriller, with Farmer being drawn into the Ebola outbreak by medical colleagues in the region. Farmer recounts the headline-making worldwide panic and cancelled flights, all serving to isolate West Africa.

Farmer describes the affected nations as being medical deserts with ad-hoc, unequipped treatment centers and under-protected staff. Sick and dying Ebola patients arrived in droves. Despite its bloody reputation, Ebola generally causes high fevers and excessive vomiting and diarrhea. These body fluids transmit the disease, so families caring for sick relatives, or a taxi driver ferrying someone to a clinic, could easily become infected.


Farmer repeats a mantra that what is needed to provide health care is staff, stuff, space and systems. In this trio of West African nations, they were mostly absent. As the World Health Organization dawdled in its response — nearly 1000 people would die before they called an emergency meeting to discuss allocating resources — NGOs like Partners In Health and Doctors without Borders (MSF) jumped in at the request of local authorities.

Ebola’s rapid transmission and lethality were uniquely terrifying. At first, woefully under-equipped clinics were little more than death traps, a place where officials hoped the sick and dying would go to contain the disease. If there is one lesson to take from Farmer’s book, it’s that he calls for care over control. Care for patients first, and controlling the disease will follow. Even in an emergency. Even in a pandemic.

Part of this is practical: people who were sick were afraid to go to a clinic where everyone was dying, nor would their family members want to take them there. But that would cause the infection to spread. Part of it is humanitarian: letting a disease burn itself out will kill so many people. With Ebola, Africans who were infected died by the thousands, while the Americans and Europeans who got sick and were airlifted home got health care that saved their lives. Doesn’t every patient deserve that same effort?


If America has better equipped hospitals, why doesn’t Liberia or Sierra Leone? The nations are rich in resources, particularly diamonds. But there has been, Farmer notes, “a great reversal of fortunes between Africa and the Americas.” To understand how that came to pass, he undertakes a thoughtful chronicle of the region’s history, stretching back 500 years.

It serves as a primer for those who may not know much about West Africa. The slave trade began a tradition of wealth extraction that has never ended. In addition to human trafficking, these port nations have traded wood, latex, diamonds. Of course, colonial powers took most of the profit.

But all true history is complicated, and Freetown in Sierra Leone was begun as a settlement of free blacks. Liberia was founded with the noble intent of free Black Americans returning to Africa. Yet Freetown fell under British control and its racist practices; Liberia’s American expatriates and their descendants drew lines between themselves and native Africans. All along, international conglomerates practiced extractive capitalism, often mercilessly, with weapons.

Farmer follows these narratives from the beginning as if the future is open. At any turn, I hoped, the next conflict would favor native populations. Instead this is a relentless tale of hundreds of years of riches being siphoned off and sent away, of military power used against citizenries, of nations unable to build.

If what we want in this moment is insight from this brilliant doctor about pandemics, he wants us to see that they do not occur in isolation. America and European nations created the systemic inequality that left West Africa bereft and vulnerable. And systemic inequality leads to very different health outcomes. He urges us to right the balance, provide needed care.


He also goes a step further. To really remedy what has happened to West Africa will not be cured by training more nurses or, as he does so well, telling the stories of Ebola survivors. He writes, “seldom if ever has such a small patch of our planet had to endure so much extraction for so long. That injury, illness, and death has ensued was the entirely predictable result of a centuries-long chain of injustices. Breaking these chains will require more than symbolic justice or public denunciations of the guilty, more than truth and reconciliation. It will require reparations.”

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

by Paul Farmer

Farrar, Straus and Giroux; 688 pages; $35

Carolyn Kellogg is former Books Editor of the Los Angeles Times.