The Coming Plague

Author: Laurie Garrett

Synopsis

This remarkably farsighted book is effectively a clarion call for humanity to face up to the ‘dangerous diseases‘ which are ‘constantly threatening to explode into epidemics‘, and which ‘might one day lap at the shores of the planet’s richest nations’ (page 221). Delving deep into the makings of epidemics, it explains why they seem to emerge inexplicably, and why it is incredibly hard to restrain their frenzy. The author portrays their devastating ferocity with illustrative examples of catastrophic epidemics, from Ebola to HIV. She makes a strong argument for humanity to view microbes as predators in a war in which the pathogens have the upper hand, just as she warns of a future in which the most pernicious viruses will become even more devastating when they attain airborne capacity (pages 602-603). She warns that unless we take the threat of microbes seriously, and change our behaviour, we should ‘brace ourselves for the coming plague‘, one which we may be unable to ‘stave off or survive‘ (pages 620 and 618).

The imperative message at the core of the book is simple; human activities instigate epidemics. With very well-made arguments, the author asserts that our ‘voracious appetite for planetary dominance and resource consumption‘ prepare the ground for epidemics because they ‘put every measurable biological and chemical system on earth in a state of imbalance‘ (page 550). With several unambiguous examples, she outlines the process whereby human encroachment into the ‘ecological niches‘ of microbes provokes them to jump from their natural hosts into humans…with devastating consequences (pages 551, 371, and 384-385). A quintessential case is the emergence of Bolivian haemorrhagic fever which followed the widespread use of DDT; by wiping out the vulnerable short grasses, the herbicide enabled the proliferation of the taller grasses on which the field mouse, the host of the virus, subsists (pages 27-28). Similarly, the emergence of Lassa fever was the result of human activity; by eating or driving away the large rat, Rattus rattus, villagers unwittingly facilitated the proliferation of Mastomys natalensis, the smaller rat that hosts the virus (page 91). 

The author dedicated a major part of the book to the portrayal of the evolution and impact of several epidemics, in each case graphically illustrating how the overwhelming numbers and sheer aggressiveness of microbes mark them out as superior to humans  (pages 618-619). She gave several examples of many rapidly destructive viruses such as Marburg, Lassa, and especially Ebola, ‘the second most lethal disease of the twentieth century’ (page 105). She underscored the almost limitless capacity of viruses to mutate and evade our immune system, illustrating this with the example of influenza; she caricatures this virus as ‘a sort of microbial chameleon‘ which frequently alters its genetic makeup and produces new pandemic strains which strike ‘at least once in every human generation’ (page 155). The book also examined very historical epidemics, for example cholera, bubonic plague or the black death, and the Spanish influenza pandemic of 1918 which ‘sickened over one billion people worldwide…killing more than 21 million‘ (pages 105, 157-158, and 237-242).

Of all the viruses the author explores, her analysis of HIV was most cogent to her argument that preventing ‘the next great plague‘ requires a thorough understanding of how the AIDS epidemic emerged (page 362). Noting that the successful global spread of HIV was facilitated by technological advances and inimical lifestyles, she worried about other microbes exploiting similar conditions in future (page 362). Like many previous viruses which ‘seemed to suddenly appear out of nowhere’, the author argued that HIV had co-evolved with its simian hosts perhaps for centuries before it eventually crossed species into humans (page 373-384). She explored every dimension of the AIDS epidemic, graphically showing how factors such as rapid urbanisation and modern behaviours, the so-called ‘microbial amplifiers‘, created the ideal ecologies for HIV to thrive (pages 370, 212-214, 245, 610-620). She also used the case of the AIDS epidemic to observe, rather sadly, that ‘the human factors responsible for the spread of the virus would resist change‘ (page 389).

As a contrast to the dominance of viruses over humans, the author recounted numerous riveting stories of how humans have successful responded to emerging epidemics. With breathtaking narratives, the author related the heroic adventures of so-called ‘disease cowboys‘ such as Karl Johnson, Ron MacKenzie, Pat Webb, Merl Kuns, Jordi Casals, Joel Bremen, Pierre Sureau, and Peter Piot. She depicted their daring feats in some of the most inhospitable terrains where they would map territories, conduct exhaustive surveys, perform autopsies, isolate zoonotic hosts, and identify new viruses. They would go to ‘enormous lengths’ to achieve their goals, for example collecting and studying more than 640 animals in their attempts to pin down the life cycle of the Lassa fever virus (pages 24 and 91). Equally impressive is the staggering multinational and multidisciplinary cooperation that comes into force to tame daunting epidemics; the Ebola epidemic for example would pull in personnel from eight countries and more than 500 skilled investigators, and would indirectly cost $10million (page 116). She extracted several lessons from such efforts, such as need to be ‘calm in the face of epidemics’ (page 29).

At the heart of the very grim subjects of this book are stories that capture a wide range of human emotions. The author, for example, ably depicted the joy and satisfaction that trailed the eradication of smallpox, just as she aptly portrayed the disappointment and heartbreak of the failed efforts to eradicate malaria (pages 40-52). She depicted the anguish of realising that the ‘abominable‘ sterilization facilities at a ‘well-intended but fatally primitive‘ hospital was the genesis of the first Ebola epidemic (pages 128-129). She reproduced the sense of pride that accompanied landmark microbial achievements by the likes of Anton van Leeuwenhoek, Louis Pasteur, Alexander Fleming, Jonas Salk, and Joshua Lederberg, just as she captured the sense of fear and panic that grips virologists when they accidentally inoculate themselves with hazardous viruses; this sense of dread is typified by Geoffrey Platt, the virologist who contracted Ebola in the high security Porton Down laboratory when his hand slipped and he accidentally injected his thumb with infected blood (pages 36 and 133-135).  

 

Opinion

With a keen eye on the big picture, and replete with fine data, this book exhaustively covered a wide range of epidemic-related subjects. Sparing no aspect of the epidemics it reviewed, the messages of this book are profound. For a non-scientist journalist, the author exhibited an astonishing familiarity with the minute details of microbes and their ecology. With edge-of-the-seat narrative, she takes the reader into the heart of each hair-raising epidemic, vividly describing the ravaging march of the microbes, the destruction of lives, and the heroism of the scientists who face up to the dangerous plagues. The lessons she extracted, more than two decades ago, are uncannily prescient today, the prediction of ever worsening plagues sadly becoming actualised.

Overall assessment

This is an exhaustive study of a subject central to healthcare, and a guide to contemporary concerns about viruses. It places epidemics in context, depicting not just their clinical and epidemiological manifestations, but also portraying their wider cultural, social, economic, and ecological dimensions. Whilst the book is more than two decades old, the contents are incontrovertible and still germane today. It accurately predicted the recurrent epidemics that have since occurred, detailing the resistant attitudes and behaviours that predispose to them. The author’s admonishments and foresighted recommendations are as valid today as when the book was published. The lessons in the book are fundamental to healthcare, and I recommend it to all doctors.

Book details

Publisher, Place, Year: Penguin Books, London, 1994
Number of chapters: 17
Number of pages: 750
ISBN: 978-0-14-025091-3
Star rating: 5
Price: £14.63