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

“Humanity’s ancient enemies are, after all, microbes. They didn’t go away just because science invented drugs, antibiotics, and vaccines […]. And they certainly won’t become extinct simply because human beings choose to ignore their existence.”

One of Garrett’s primary goals in The Coming Plague is to convey to a popular audience the scale and scope of humanity’s challenges in its war against microbial. The optimism which had previously pervaded the science and health communities had largely dissipated, but in the wider public sphere, a heady sense of optimism about medical progress still prevailed. Garrett wants people to know that, at least as far as microbial disease is concerned, optimism would be unwarranted at this point.

“From then on, Johnson stressed the need for calm in the face of epidemics, for reason, science, sound clinical training, and the ability to work with a team of diverse expertise. These were lessons passed on […] to a whole generation of infectious disease ‘cowboys.’”

Here we have one of the first mentions of the idea of a “disease cowboy.” It refers to a group of doctors who traveled worldwide doing on-field research on tropical diseases and responding to outbreaks. Such experience enabled them to attain a broad range of skills and a wide familiarity with microbial life and its effects, an experience that Garrett sees as lacking in much modern medical education.

“Imbued with profound optimism, coupled with the post-World War II American ‘can do’ attitude, the world’s public health community mounted two ambitious campaigns to eradicate microbes from the planet. One effort would succeed, becoming the greatest triumph of modern public health. The other would fail so miserably that the targeted microbes would increase both in numbers and in virulence, and the Homo sapiens death toll would soar.”

In this quote, Garrett gives one of the clearest expressions of her theme of optimism versus realism. Here she explains the beginning of the narrative arc upon which the scientific community will move from the mid-20th century to its end. The spirit of optimism she describes above would, over the course of several decades, give way to a more realistic perspective on the challenges involved. The two campaigns she mentions are the one against smallpox (which was successful) and the one against malaria (which was unsuccessful).

“Panic does not always go hand in hand with epidemics, nor does its scale correlate with the genuine gravity of the situation. Indeed, history demonstrates that population responses to disease are rarely predictable, often peculiar, and always key features of frustration for disease detectives who must sift through public accounts to find clues to the origin and cause of the epidemic.”

In dealing with Garrett’s theme of social factors in disease transmission, one recurring factor throughout her stories is the idea of panic. Reports of an outbreak of disease spark panic in the public, which often sways how political administrations handle their oversight of the public health crisis and rarely in helpful ways. Even in the case of doctors and researchers, Garrett highlights the challenge they face in keeping themselves from panicking since progress against a disease will only come from a calm and measured application of the scientific method.

“From Pol Pot’s reign of terror in Cambodia to the Cold War-manipulated battlefields of Central America, the world’s poorest countries spent extraordinary amounts of money on domestic military operations and warfare. And the microbes exploited the war-ravaged ecologies, surging into periodic epidemics.”

Another social factor at the root of many disease outbreaks is war and regional instability, which the second half of the 20th century frequently saw, especially in the global south. Such events are prime opportunities for microbial invasions into the human population because they cause the mass migration and mixing of some groups that bear a particular microbe with other groups that have no immunity against it. Further, war (and the resultant disruptions in food supply and medical care) generally leave people in a more vulnerable immune state than they would otherwise be.

“[…] McNeill saw stages over time in human relationships with the microbes, but he linked them not so much to economic developments as to the nature at any given moment of the ecology of a society. He argued that waterborne parasitic diseases dominated the human ecology when people invented irrigation farming. Global trade routes facilitated the spread of bacterial diseases, such as plague. The creation of cities led to an enormous increase in human-to-human contact, allowing for the spread of sexually transmitted diseases and respiratory viruses.”

Referencing the scholar William McNeill again, Garrett points out that our current back-and-forth battle with microbes is nothing new. Rather, it is a feature of human history. Most of humanity’s great leaps of progress have also represented massive transformations of the human/microbial ecology, and the consequences of those changes have always followed shortly afterward in the form of new waves of disease.

“As was the case with Lassa, poorly run hospitals operating under conditions of extreme deprivation were the amplifiers of microbial invasions. What might have otherwise been an individual illness, limited to one or two cases of Ebola, was magnified in a hospital setting in which unsterile equipment and needles were used repeatedly on numerous patients.”

One of the ironies of the stories of outbreaks is that medical infrastructure often played the role of an amplifier for a disease. This was particularly the case in areas that were understaffed or undersupplied, where equipment and treatments were not used as intended and so became vectors of transmission rather than agents of healing. This plays into one of the larger ironies of the book, which is that the very things that are supposed to represent humanity’s best intentions and mark our continued progress turn out to be the things that spark new epidemics.

“They soon discovered that microbes could share genes with one another that made them more formidable human enemies; many viruses not previously thought to do so could cause cancer; some microbes possessed the ability to chemically manipulate the human immune system to their advantage; and there were viruses that could hide for years on end inside human DNA.”

In this quote, Garrett expresses the surprising complexity of the way microbes interact with genetic information. Far from providing humanity an advantage over them, understanding their genetic abilities has instead proven that they are far more formidable enemies than we anticipated. The optimism which pervaded genetic science in the 1970s eventually faded (at least regarding infectious disease) and gave way to a healthier sense of realism based on these findings.

“As was the case in ancient Rome, it was healthier to remain in the villages and small towns of the developing world […] than to live in the filthy, unwieldy metropolises. The average child living in a typical developing-country urban slum was forty times more likely to die before his or her fifth birthday of a preventable infectious disease than was a typical rural child in the same country.”

This quote provides a glimpse of the social effects of poverty that play into the rise of epidemics. Poverty, especially urban poverty, brings with it risk factors like a dense population, little access to clean water or waste removal, low levels of medical care, and poor nutrition. These factors create the conditions that make devastating infectious disease outbreaks more likely.

“But AIDS was unique. It touched every nerve that polarized Americans: sex, homosexuality, race (Haitians), Christian family values, drug addiction, and personal versus collective rights and security.”

In this quote, we see the theme of social factors arise again. Garrett is explaining why government officials so often dragged their feet in responding to the public health crisis of AIDS, swayed by social stigmas associated with the disease. The specific mention of Haitians regarding race is in reference to an early cluster of cases among Haitians that emerged around the same time as those in the gay communities of California.

“[The researchers] reached a set of conclusions: HIV had been present in remote regions of Central Africa for a long time, infecting small numbers of people. The social customs of traditional village life limited the spread of HIV and other sexually transmitted diseases, they argued, as extramarital and premarital trysts were condemned and virtually impossible to conceal in the claustrophobic atmosphere of the tiny communities scattered throughout equatorial Africa.”

Here Garrett explains the best theory for the emergence of AIDS (at least at the point of her writing in the mid-1990s), namely that it had long been an endemic human virus of the HTLV family, present across central Africa. While some mutations may have made it more virulent along the way, the real problem was the opportunities for rapid expansion followed by massive social changes in the 1970s in Africa, including the breakdown of traditional social mores that would have kept the transmission of HIV in check. Once again, it was a social factor exerted by humanity on the ecological balance that caused HIV to grow to epidemic proportions.

“Between 1970 and 1975 the world offered HIV an awesome list of amplification opportunities: multiple partner sexual activity increased dramatically among gay North American and European men and among African urban heterosexuals; needles were introduced to the African continent on a massive scale for medical purposes; […] heroin use, coupled with amphetamines and cocaine, soared in the industrialized world; […] and governments all over the world turned their backs, convinced, as they were, that the age of plagues and pestilence had passed.”

Following the same train of thought as the previous quote, this one explains why the window from 1970 to 1975 kept appearing in the researchers’ data as the period in which HIV exploded from obscurity to a global outbreak. Even without finding a spillover event or a “patient zero,” they could trace conclusions about what caused the virus to take off at such an exponential rate. Garrett explains that the root of it all was a conflux of multiple opportunities offered by human social changes, which the virus took full advantage of.

“Physicians and scientists working outside the field of bacteriology in the 1990s generally assumed that, as had been the case before, another class of antibiotics would be developed and the problem would go away. But they were wrong. ‘There’s nothing on the shelf. Nothing in the pipeline. If we lose vancomycin we’re going to be back to the 1930s with staph,’ Jarvis said.”

Here Garrett quotes CDC bacteriologist Bill Jarvis on the issue of drug resistance. As bacteria were progressively able to adapt and develop defenses against antibiotics, fewer and fewer of the drugs worked to restrain bacterial infections. The only hope was to keep on discovering or inventing new antibacterial compounds. Still, at the time of The Coming Plague’s writing, the antibiotic vancomycin was essentially the only bullet left in the chamber. It was no sure thing that bacteria would not adapt to that as well.

“[…] Lappé occasionally lapsed into a grim global ecological description of the crisis […]: ‘Unfortunately, we played a trick on the natural world by seizing control of these [natural] chemicals, making them more perfect in a way that has changed the whole microbial constitution of the developing countries. We have organisms now proliferating that have never existed before in nature. We have selected them.’”

Garrett quotes Mark Lappé of UC Berkeley, the author of the 1981 book Germs That Won’t Die. Lappé’s book had been widely criticized as too alarmist when it was published, but within a decade, most scientists had come to the point of agreeing with his assessment. In this quote, he is expressing the dire results of humanity’s ecological interventions against bacteria, particularly in using antibiotic compounds against them more concentratedly than was ever the case in nature. Our attempts to treat infections led directly to the development of bacteria that cannot be treated.

“Warfare and civil strife, religious persecution, economic necessity, and natural disasters prompted tens of millions of families and individual laborers to migrate within countries and between nations. […] With this mass movement came great risk for malaria. Most of the migrating humans either came from nonmalarious regions and had no immunity or were moving between areas inhabited by distinctly different strains or species of parasites.”

In her assessment of malaria’s resurgent spread, Garrett examined the social factors which played into its rise. Poverty and social upheavals result in the movements of people and, thus, the intermingling of populations, which provides opportunities for malarial infections to spread. Once again, social factors which caused human-driven ecological disruption led directly to the growth of disease transmission.

“Carballo saw a confluence of social factors at play in the emergence of HIV in societies: marginalization, social alienation, poverty, and discrimination. In his mind, they united to form a social bridge across which HIV traveled into one society after another.”

Here Garrett expresses the conclusions of one AIDS researcher, Manuel Carballo, of the Global Programme on AIDS. Social factors play into a disease’s emergence and its continued spread, and factors of poverty and discrimination act as amplifying effects. As HIV-affected populations were marginalized by society, they were often relegated to ever more impoverished conditions, thus restricting them from proper care and putting them in contact with other classes of people who had also been pushed to the margins of society and to whom the virus would then begin to spread.

“Not only had America’s cities sunk to Third World levels of childhood vaccination and access to health care, but its surveillance and public health systems had reached states of inaccuracy and chaos that rivaled those in some of the world’s poorest countries.”

This is one of Garrett’s statements of the idea she calls “thirdworldization.” The systemic poverty and lack of public health infrastructure common in many developing countries were not limited to those countries. In various times and places in the United States, conditions in some areas would deteriorate to levels at or below those experienced in developing nations, with all the concomitant effects of poor public health.

“All ‘new’ diseases must first be noticed by someone who has the insight and courage to sound an alarm and set in motion a thorough investigation. And once in place, investigations are best conducted in an atmosphere of candor and collectivity, rather than the secrecy, backbiting, rivalry, and mutual contempt that had unfortunately characterized many other scientific pursuits of emerging microbes.”

Here Garrett expresses some of the lessons learned from earlier failures in epidemic response. A proper response requires at least three major elements: a system in place that can notice and report the outbreak of a new disease, an ability to launch a proper investigation in response to that outbreak, and a culture of scientific collaboration rather than competition in seeking answers to it. Unfortunately, many of the epidemic responses detailed in the book failed on one or more of these elements.

“The lesson of macroecology was that no species, stream, air space, or bit of soil was insignificant; all life forms and chemical systems on earth were intertwined in complex, often invisible ways. The loss of any ‘rivet’—even a seemingly obscure one—might imperil the physical integrity of the entire ‘plane.’”

This quote is part of Garrett’s explanation of the “Rivet Hypothesis,” which postulates that human interventions in natural ecologies are like removing rivets from a plane while in flight, leading to a point where the loss of even a single additional rivet will bring the whole system down in collapse. Since humans and microbes exist in an ecological relationship of this sort, humanity must understand and assess the probable impacts of their behavior on microbial environments.

“In other words, bacteria altered themselves not just through a process of random, error-prone reproduction that eventually yielded a surviving strain—the classic Darwinian view. In addition, they changed themselves, in some concerted manner, without reproducing.”

One of the surprising findings of bacterial genetics was that their capacity for adaptation and building drug resistance was not limited to the Darwinian pattern of random mutation and the survival of the fittest. Rather, many bacteria had internal defenses which they could draw on—usually in the form of plasmids of extra DNA—and which offered capacities like the ability to build stronger cell walls or resist certain chemicals’ actions. As such, bacteria could adapt to drugs much faster than if it were only a question of random evolutionary processes.

“And along the peripheries of human battle and despair lurked the unexpected. In the flora and fauna of remote ecospheres they resided, human events affording them ever-greater opportunities for jumping from the ancient hosts to the warring Homo sapiens.”

In this quote, Garrett addresses the potential for new diseases to arise from humanity’s continued push to take over new environments like rainforests. The sheer biological diversity of those places, coupled with the fact that human populations have not had significant contact with them before, makes it ever more likely that a microbe living in a reservoir species will be thrust out of balance and brought into contact with humans who have no natural immunity to it.

“Ultimately, humanity will have to change its perspective on its place in Earth’s ecology if the species hopes to stave off or survive the next plague. […] Microbes, and their vectors, recognize none of the artificial boundaries erected by human beings.”

This is a statement on Garrett’s conclusion about the way forward: Technological innovation alone will not be enough to keep up with microbial abilities and adaptations. What is needed, then, is for humanity to reassess the way it interacts with the world around it. Understanding that we live in an ecological balance with microbial life, and responding with the appropriate foresight and prudence to that reality, is the only thing that can stop major epidemics from emerging and spreading.

“By the year 2000 all of humanity was supposed to be immunized against most infectious diseases, basic health care was to be available to every man, woman, and child regardless of their economic class, race, religion, or place of birth. But as the world approaches the millennium, it seems, from the microbes’ point of view, as if the entire planet, occupied by nearly 6 billion mostly impoverished Homo sapiens, is like the city of Rome in 5 B.C.”

In tracing her theme of the collapse of optimism, Garrett expresses the counterintuitive notion that all of our apparent progress over centuries of civilization has not gotten us any farther regarding our relationship with microbes than we were millennia ago. This underscores her larger point, namely that our focus should not solely be on the medical aspects of infectious disease, expecting that new technologies and the pace of human progress will keep us ahead of the microbes; rather than we need to gain a new perspective on the ecological balance that exists between us.