The Coming Plague: Newly Emerging Diseases in a World Out of Balance

by Laurie Garrett

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The Coming Plague Summary

The Coming Plague by Laurie Garrett is a 1994 nonfiction book about the history of global epidemic diseases from the 1960s to the 1990s.

  • The book describes a number of key cases that have shaped how humans handle epidemics, including hemorrhagic fever in Bolivia, Marburg in Germany, and AIDS across the globe.
  • Garrett uses case studies to detail the multi-disciplinary, international approach required to combat modern epidemics.
  • New epidemics tend to arise from changes in how humans interact with their environments. New environmental conditions, such as urbanization, result in new outbreaks.


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Last Updated on February 25, 2021, by eNotes Editorial. Word Count: 1223

Laurie Garrett’s The Coming Plague is a nonfiction account of historical disease epidemics. It covers the causes of epidemics, many of which are related to human actions, human responses to epidemics, and the biology of microbe evolution and adaptation. Social movements such as urbanization and gay rights are also put into the context of disease development. Some accounts are success stories; others are cautionary tales.

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In 1962-64, Bolivia experienced a new type of hemorrhagic fever with a horrifying fifty-percent mortality rate. An international team of medical personnel set up makeshift facilities in an environment with no utilities. Through extensive lab testing and examination of animal specimens, they identified the infectious agent as a virus that passes through mouse urine. A campaign of mouse-trapping ended the epidemic and created a new method of fighting disease: the deployment of a team with diverse skills in medicine, science, and detective work.

Another example of success is the coordinated global effort to eradicate smallpox that concluded in 1980. A corresponding failure was the effort to eradicate malaria, which is mosquito-borne and more difficult to diagnose. When US-led funding for malaria eradication ended in 1963, the disease had been nearly vanquished around much of the globe, but it soon returned in a form resistant to known methods of treatment.

In 1967, Germany experienced a new viral infection called Marburg that was eventually traced to ill monkeys imported for lab use. The virus jumped to the humans studying monkey cells and spread outward from there. The World Health Organization (WHO) recommended new guidelines for the importation and quarantine of test animals, but the precise cause and origins of Marburg remain mysterious. Other unsolved epidemic origins include antibiotic-resistant meningitis in Brazil in 1974 and yellow fever in Nigeria in 1970.

Several epidemics originating in Africa were amplified by medical practices such as reuse of syringes. Lassa fever first appeared in 1969, and Ebola appeared simultaneously in Zaire and Sudan in 1976 and again in Sudan in 1979. Communication difficulties slowed contact between teams and limited their ability to get needed supplies. Moreover, poverty and equipment shortages made the recurrence of these diseases inevitable.

The United States contended with two potential outbreaks in 1976: Swine Flu and Legionnaires’ Disease. While Legionnaires’ Disease was investigated with scientific rigor, Swine Flu was handled disastrously. Politicians adopted alarmist language about a coming pandemic, and in March 1976 President Gerald Ford requested funding for mass vaccination. When manufacturers refused liability for a rushed vaccine, Congress passed legislation that allowed the government to absorb liability for any adverse effects. This irrevocably changed the relationship in the United States between vaccinations, the public, and the judicial system: where once the public good took priority over individual rights, now the individual’s right of choice was paramount.

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Diseases have always evolved in relation to people, especially as urban centers developed. “Population density instantaneously magnified any minor contagion that might have originated in the provinces,” Garrett explains. “And microbes successfully exploited the new urban ecologies to create altogether novel disease threats.” While developed nations experienced their worst epidemics—tuberculosis (TB), cholera, syphilis—in the nineteenth century, the twentieth century saw the greatest urban population growth in the world’s poorest nations.

By 1975-80, certain cultural and medical practices made an epidemic likely: needle-sharing, higher levels of sexual promiscuity, and blood banking/transfusions using unsterilized blood. Political unrest, such as a 1979 war between Tanzania and Uganda, devastated economies and led to famine and refugee movement. In this environment of vulnerability, a new disease ravaged the immune systems of marginalized populations. Given the name AIDS in 1982, the syndrome appeared in epidemic levels in homosexual men and injectable drug users in the United States and Western Europe and in heterosexual couples in Africa.

In the United States, AIDS research funding was limited, because many victims were from stigmatized populations. Though AIDS began to manifest in hemophiliacs who depended on donated plasma, no changes were made in the US’s policies on blood bank screening until late 1984. In Zaire, Project SIDA led Africa’s AIDS research from 1984 until 1991, when it was closed due to civil war. SIDA research identified pregnancy transmission and the reuse of needles for vaccines and medications as causes of AIDS in children.

Epidemics weren’t only caused by new microbes, though. Familiar infections could mutate and spread with deadly effect, such as the form of staph bacteria that appeared in 1975 with the ability to trigger Toxic Shock Syndrome (TSS). TSS was initially linked to the use of superabsorbent synthetic-fiber tampons, which served as a culture medium for bacterial growth. Over time, the new strain of staph became endemic at low rates. Nearly every common bacterial illness has developed some antibiotic resistance, largely due to overuse of certain treatments, inconsistent self-medication, and preemptive antibiotic treatment of animals. Development of new antibiotics and manufacture of old ones is limited because they yield little profit.

Epidemics usually don’t occur in isolation. As AIDS swept through Africa, vulnerable nations were already fighting resource-sapping outbreaks of drug-resistant TB and malaria. AIDS often struck people in their economically productive years, magnifying the disease’s impact on poverty. In traditional cultures, women kept agricultural economies alive but had no legal rights upon a husband’s death. Destitute widows often turned to prostitution, and by 1991 more women in Africa were infected by AIDS than men. The resulting slowdown of economic and population growth led to diminishing life-expectancy rates and high death rates among noninfected AIDS orphans. In Asia, as AIDS spread via sex work, blood banks, and shared needles for drug use, simultaneous epidemics of dengue, hepatitis, resistant TB, malaria, and cholera limited available public health resources. After the fall of the Soviet Union in 1991, infrastructure decay and increased mobility led to higher rates of STDs, suicide, and vaccine-preventable disease.

Poor Americans saw a similar decline in health, with contributing factors including rising homelessness, cuts to social services, and increases in formerly managed infectious diseases. In 1986, the Center for Disease Control’s drug-resistance tracking program was eliminated and many states slashed their TB prevention and control budgets. The rise in treatment-resistant TB was then fought with costs far greater than the supposed savings gleaned from cuts to prevention programs.

Meanwhile, new and deadly illnesses continued to emerge. When healthy young Native American individuals began to die of sudden respiratory illness in 1993, a joint investigation by the Indian Health Service and the Native American community identified a virulent new strain of hantavirus. Carried by mice, the virus began to infect people when environmental factors led to a boom in mice populations.

Interactions between humans and their environments influence or intensify many diseases. A devastated ecology could allow new disease to emerge—such as Lyme disease, a bacterial illness carried by ticks that emerged in 1975. Global warming has led to toxic algal blooms that carry resistant cholera and has also permitted a vast expansion in mosquito distribution—and therefore in mosquito-borne disease. In the five years predating the 1994 publication of The Coming Plague, American and international scientists raised concerns about epidemic preparedness.

Disease emergence, Garrett concludes, is “inextricably bound to human rights.” The globalization of travel and economics has led to broader dispersals of microbes, raising the risk of epidemics. To improve the health of the developed world, nations must also invest in improving the health of people living in vulnerable and impoverished areas around the globe.

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