What Ebola Can Teach Us About Covid-19

14 min readDec 13, 2020

Photo: John Moore/Getty Images

In 2014, an Ebola virus began to spread throughout Sierra Leone, Liberia, and Guinea. The pandemic took the lives of tens of thousands of people and offered acute lessons in infectious disease response and human nature — lessons that we would do well to remember today.

Anthropologist and physician Paul Farmer, MD, PhD, the co-founder of Partners in Health (PIH) and a Kolokotrones University Professor of Global Health and Social Medicine at Harvard Medical School, experienced the pandemic firsthand as PIH was one of the aid groups to respond to Ebola in West Africa. His ambitious new book, Fevers, Feuds and Diamonds: Ebola and the Ravages of History, looks back at the pandemic and even further into the history of three affected countries to examine how historic tragedies like the slave trade and civil war have consequences that reverberate for decades.

One of the lessons of the 2014 Ebola pandemic, Farmer argues, is that so much of what might have helped was never tried — that the deadliness of the pandemic could have been lessened. As the world careens into yet another wave of Covid-19 cases, the message resonates. Elemental spoke to Farmer about his book and the current Covid-19 pandemic.

This interview has been edited and condensed for clarity.

Elemental: Your book dives deep into the history of Sierra Leone, Liberia, and Guinea, including significant focus on the slave trade. What was your motivation for making this history such a major part of your book?

Paul Farmer: Ninety-nine percent of the experience of the Ebola epidemic was dealing with the immediacy of the patients’ needs. But as the months went by, there was more and more thinking about how this has happened before. We really need to understand the ways in which not only history set us up for these kinds of problems, but how forgetting history also sets us up. It’s the same now: A novel coronavirus is by definition new, but it’s not like we never met another coronavirus or never had a previous pandemic. Every time we think we’re seeing something new it’s either not new or there’s something old about it.

You point out early on that there were disparities in the Ebola fatality rates in West Africa. There were volunteers from other countries, including the U.S., who fared better than locals after getting the disease. You write that some of the deaths that occurred in West Africa could’ve been lessened and that so much of what might’ve helped was never tried. What were those factors?

The numbers are striking. I mean, really, no white American died of Ebola, and it’s not because of some genetic reason. It was all because they were airlifted to safety. It was mostly the basics. You have renal insufficiency, you might need dialysis, for one. Maybe you need help breathing.

If you think about all of the efforts that we made around Covid-19 patients to improve the quality of ICU care, that’s basically what has saved a lot of lives. Yes, we’re going to get new and specific therapies. The new therapies should have been used more aggressively [during Ebola], and the old and fairly reliable ones were also not used. That was the biggest regret that I have, that so many of the old things we should’ve done weren’t tried.

You mention in the book that when it comes to controlling a pandemic, the focus can’t just be on containment. Clinical services also have to be a huge part. Are there clinical services gaps now?

This is an ongoing conversation, and it’s one that, of course, for me as an infectious disease doctor, reminds me of every other conversation we’ve had about every infectious pathogen. If we lead with care, then containment is a lot easier. But if you’re leading with containment and people are distrustful of care, or really doubt that you’re going to be working to provide it, then that’s why we see these kinds of [distrustful] responses again and again.

I think that if you look inside the United States, who mistrusts vaccines the most? Who has reason to? You can’t get through medical school in the United States, I hope, without learning about Tuskegee. And that is the kind of understanding that I was seeking in West Africa. I wanted to learn more about, well, why would they be mistrustful? I found plenty of reasons.

“You just know if you keep studying epidemics that a lot of it is repeat.”

As your book underscores, time and time again whether it’s with HIV/AIDS, Ebola, or Covid-19, we discover that social disparities shape outcomes. It feels like a lesson we need to keep relearning every single time this happens. What can be prioritized to change this?

Well, I wish there were a more exciting way to say that the top priority should be health system strengthening. In Rwanda, 10 years after its war and genocide, they’ve built a health care delivery system that is publicly supported, meaning by the public treasury. Of course, it’s supported by other groups; Partners in Health has been working there for 16 years. But really, they built it. And that hasn’t really been the case [everywhere].

Liberia, as I mentioned in the book, [had] really 50 practicing physicians. That’s like the equivalent of six in the city of Boston. I can’t even go to the bathroom in my office [at Harvard Medical School] without bumping into six physicians on the way. So I think the top priority is actually that boring part: building health care delivery systems able to provide care, and also, of course, prevention. Getting that health care delivery system and the basics out there, we need that in the United States. They need it desperately in Sierra Leone. They need it in Rwanda.

I think that’s [the case] in the United States, too. We put a ton of resources in it, but it doesn’t function as a national care delivery system very often. There are parts of it, like the VA system is a national care delivery system, but it’s for veterans. So I think a lot of these same challenges exist in some of the more affluent parts of the world.

Yes. That struck me in reading the parts of the book about the people you worked with who survived and the people who didn’t. The Ebola pandemic was such a traumatic experience, and then it can feel like people sort of move on to the next thing or the next news event.

I can understand we humans forget the really painful stuff. I mean, I am all for it. I don’t have any complaints for myself or others for wishing to forget the really painful parts. But the lessons, that’s a different story. Obviously I want the people whose experience I’ve featured to live on. I want their memories to live on. But the lessons that we’ve forgotten again and again, every time this happens, I don’t think we could afford to forget those lessons. They come back and bite us again as they are now.

Do you feel like the world is making the same mistakes or making new ones?

They’re old mistakes and new settings, right? For example, why is it okay for us to not even know what contact tracing is? I mean, after all, it was around throughout the Ebola epidemic. And it’s not like I’m saying, “Hey, isn’t contact tracing great?” In fact, it’s described in the book as not being very great. But we have to remember that every time we see a new epidemic like this, there’s going to be some things that are new and many things that are not.

I remember writing [a line in the book] that there’ll be some new things, but most of the stuff you’re going to see with Covid-19, you’ll find it in this book. I almost didn’t put that in there because it sounds cocky or overly self-assured or something, but you just know if you keep studying epidemics that a lot of it is repeat. What’s always new is that people are different, societies mutate, the pathogens also mutate, but the social mutations are always important.

You write about how experts can be quite territorial. Do you feel that that has improved?

Half of the meetings that I attend are really territorial. It’s like my colleagues, one of them is into, let’s say, germicidal ultraviolet light. And that’s all he talks about. And one of them’s into vaccine development. That’s all he talks about. And one of them’s into the history of previous epidemics and that’s all she wants to talk about. But if you can’t integrate that knowledge, you really can’t get your arms around the problem.

That’s why in the book I’m such a cheerleader for social medicine. More than anthropology or infectious disease or history, social medicine is only about trying to pull these various strands of analysis and understanding together. And so it’s not one of those turf war type things. You see the best of people during these crises, but you can sometimes see the warts and all.

What is your team seeing on the ground in West Africa in regards to Covid-19?

I’ve been following it very closely. I have spent some time in Rwanda during Covid-19. What I can say is there had been fewer cases than we anticipated and also lower case fatality rates.

Some of that people are attributing to, “Well, the age structure of the population is younger,” but I think there’s actually been some really concerted effort to learn the lessons from Ebola and other epidemics and apply them. In Rwanda I’m sure it’s true, and I really believe it’s true in Liberia and Sierra Leone. Because even though they didn’t have an Ebola epidemic, it was by the skin of their teeth, because it’s been right over the border in Eastern Congo several times in recent years. Having been there during those years in Rwanda, they have tens of thousands of contact tracers. They did a vaccination campaign on their Western flank. And there’s just a lot more preparedness there because of the proximity of Ebola.

I would go to rural areas of Rwanda where there’s a lockdown, which is really hard on people, and even in their homes and outside their homes, they’re wearing masks. They’re practicing social distancing. And it was easy to get tested. So, it’s not like, “Oh, it’s their age structure, or there’s no reporting.” It’s not only that. It’s that there are a lot of people working hard with limited resources to do a better job than what they’ve seen elsewhere.

“When it comes to some things, it’s better to legislate and demand.”

You wrote the epilogue of the book, which talks about Covid-19, in April. In some ways it acknowledges that people are adhering to measures where we’d expect much more resistance. Has your perspective changed at all since then?

Well, I’ll have to go back and reread it, but I’m not very impressed now. I think what I was trying to say is that if we can convey clearly and honestly the gravity of the situation, that we’re going to see people who can respond, responding. Meaning, if they live in a big house and they have a job where they can work from home and understand how to protect themselves through these old-school public health measures, they’ll do it.

I think that’s what has happened and what is still happening. Of course, as a professor who works at a university, I see the challenges of enforcing — if that’s the right word — rules and regulations. Humans are humans. Young humans are young humans.

I’m very disappointed in the way things have gone, but I’m also not a Covid-19 shamer. I don’t really see that that works very well. In fact, one of the things that really struck me was in the middle of the Ebola epidemic — which was really quite frightening of course — there’s this daily experience washing over you where you’re thinking, “Oh my God, what’s going to happen? Oh, my God, what should we do?” I tried to maintain some of that in the book, to preserve honesty. We didn’t know what was going to happen. I remember hearing about some of these rather draconian rules around caregiving, funerals, shutdowns. I remember them being resurrected later in the course of that epidemic and thinking, how are people going to accept this?

What I saw and tried to describe toward the end was some people were relieved that they couldn’t help their family members. It wasn’t like anyone ever said to me, “Dr. Paul, I’m really relieved I don’t have to help my daughter bury my mother or whatever.” No one said that, but I was there long enough and I was close enough to some of these people, to be quite confident that that’s what I saw. That people were anguished, suffering so much, but they were also frightened and with reason.

In other words, what I’m saying is if someone said to me, “Okay, mask suggestion or mask mandate?” I’m going to go with a mandate, because humans are humans. I’m in the middle of helping run some of these responses [and I can forget] a mask. Everybody can forget. I’m just saying when it comes to some things, it’s better to legislate and demand.

We need to take care of each other more. These last few months have been discouraging because of all the conflict. There’s conflict every day about Covid-19. To politicize mask-wearing is such a loss, because this is really not a political act. And now we have to depoliticize it.

I’m talking to you at a particularly hard point in this pandemic. I’m curious, as someone who has been present for multiple pandemics up close and who has seen the ups and downs, what advice do you have for people who are really feeling at a loss right now?

I’ll tell you the advice that I give to contact tracers. What I tell them again and again is that the message we need to have for each other and for the strangers we call on the phone has to be, “We got you.” It may sound like a platitude or pedestrian, but it’s not a platitude to say “We got you. We’re here to look out for each other.” In the United States there’s been so much division, but also so much solidarity. After I turned in the book there was the murder of George Floyd. There was a great deal and remains a great deal of solidarity. It’s the popular expression that it is not okay, that we have to change, that we have to be better.

Maybe I just need to be an optimist to do this kind of work. But I really do think that as much of a cliché as it is, that the arc of history is long, but it does bend towards justice. And sometimes we have to really, really push hard to make sure that arc bends more quickly. And I think that’s where we are as a nation.

What Ebola Can Teach Us About Covid-19

Written by Asaralobunechi