Released in 1994, The Coming Plague: Newly Emerging Diseases in a World Out of Balance is a nonfiction book by science journalist Laurie Garrett. It examines the stories of infectious disease outbreaks from the mid-to-late twentieth century and offers assessments of the social, biological, and ecological factors surrounding epidemic disease transmission. Garrett, a leading writer on science and public health issues, has been awarded the Pulitzer Prize for her reporting and the George Polk Award for her books, including her influential 2003 assessment of global public health, Betrayal of Trust. The Coming Plague was well received, earning a place on the New York Times bestseller list.

This study guide uses the 1995 edition from Penguin books.

Summary

The Coming Plague addresses an unfolding crisis in global public health, illustrated by the repeated emergence of previously unknown diseases. Garrett paints the picture of this crisis using three main types of analysis: storytelling about outbreaks of emerging diseases, assessments of public health agencies’ attempts to treat or eradicate known diseases, and explorations of the root issues that underlie the emergence of new diseases and the challenges facing global public health.

The book begins with the story of an outbreak: an epidemic in Bolivia of a previously unknown disease, a hemorrhagic fever caused by the Machupo virus. The Machupo story paints a pattern that repeats throughout the book: A sudden outbreak of an unknown illness is faced by a team of doctors and researchers who try to isolate and identify the microbe responsible, trace the microbe’s transmission from its natural habitat or reservoir species, and work to come up with viable treatment options. Following this pattern, Garrett narrates the outbreaks of several horrific epidemics in the mid-to-late twentieth century, including the Marburg virus, meningitis, Lassa fever, Ebola, Legionnaires’ disease, AIDS, toxic shock syndrome, and hantavirus.

Garrett also traces the concerted efforts by public health agencies to address existing diseases, focusing especially on smallpox and malaria. One of the broad narrative arcs of the book traces the shift in attitudes among public health officials from excited optimism to grim realism from the 1960s to the 1990s. Early in the period, expectations were high that humanity’s technical prowess and growing medical knowledge would allow them to relegate every major infectious agent into oblivion. This optimistic view was reinforced by the success of the global program against smallpox, which was eradicated through a massive vaccination campaign. Other diseases proved far more difficult, though. Efforts against malaria appeared to have some initial effect, but the disease roared back in a broader and more virulent form. The same was true with other old diseases considered beaten, like tuberculosis, which began to see a rise in drug-resistant cases during the latter half of the 20th century. Eventually, the difficulties of dealing with the AIDS epidemic and the emergence of new understandings of microbes’ biological complexity left public health officials with a less optimistic outlook but with a better sense of the challenges ahead.

Emerging from these stories is a picture of the complex and intertwined factors that bear upon the global health crisis. The Coming Plague examines the causes behind the sudden rise in emerging diseases stemming from humanity’s ecological incursions. Garrett encourages her readers to conceive of humanity and microbial life as locked in ecological systems together, and anything that humans do to upset the balance of those systems provokes a response from the microbes, who have complex genetic defenses capable of answering our incursions with tremendous force. By pushing ecological boundaries through our invasion of new habitats, humanity has brought itself into areas where microbial overspill from other species is increasingly likely. Further, by the overuse and misapplication of antibiotic and antiviral treatments, humanity has pushed some bacteria and viruses into states of adaptation where they can now overcome almost any medicinal treatment.

Garrett examines the root causes of outbreaks and amplifying factors that allow them to spread more efficiently in human populations. These amplifying factors include many transformations that marked human society in the 20th century: increasing urbanization, the rise of more permissive sexual cultures, the growing use of injected drugs, and ever more intertwined networks of global trade and travel. In many cases, even social adaptations that humans regard as hallmarks of progress have tended to open the door for microbial infections to have a broader sweep. The solution, Garrett suggests, is to understand our place in the vast and complex ecology of our planet—and particularly with regard to microbial life—and to think through the consequences of our shifting social practices so that appropriate steps can be taken to mitigate our risks against the next big outbreak.