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51 pages 1 hour read

Laurie Garrett

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

Nonfiction | Book | Adult | Published in 1994

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Introduction-Chapter 3Chapter Summaries & Analyses

Introduction Summary

Garrett begins the book with a sketch of her Uncle Bernard’s medical service during World War II, contrasting his experience with tropical diseases and the vanishing familiarity with such illnesses in modern medicine. With the rise of antibiotics and vaccinations in the mid-20th century, often achieving significant milestones in the eradication of disease, many medical professionals fell into a casual optimism that devastating epidemics would soon be a relic of the past. However, by the late 1970s and early 1980s, those blithe assumptions were being shaken. Outbreaks of new hemorrhagic diseases in Africa terrified news audiences around the globe, and the widespread transmission of AIDS in the United States began to wake medical experts up to their own complacency. Even so, the global response to the AIDS epidemic was not encouraging, being marked by slow responses, victim-blaming, and inconsistent efforts to stem the tide.

Some scholars, like William McNeill, were advocating a more nuanced view of the relationship between medical progress and disease. Rather than an optimistic upward trajectory, the use of new medical technologies like antibiotics also came with significant risks because it allowed for the possibility of bacterial agents evolving into something even more difficult to stop. Garrett quotes McNeill as saying, “[…] [t]he more we win, the more we drive infections to the margins of human experience, the more we clear a path for possible catastrophic infection” (6). Humanity’s relationship with microbes—our “ancient enemies” (10)—must be understood not as a linear path but as part of the complex network of back-and-forth adaptations that come from living in a microbial ecosystem.

Chapter 1 Summary: “Machupo”

The chapter opens with a description of Karl Johnson, a young physician, lying in the throes of a life-threatening illness in a hospital in Panama. It then skips back to a year earlier, in 1962, to Johnson’s placement as a virologist with the Middle America Research Unit and an assignment to go to Bolivia. With him was Ron MacKenzie, a pediatrician and epidemiologist whom the Bolivian authorities drafted to investigate a mysterious outbreak in the eastern borderlands of their country. The initial survey confirmed that a hemorrhagic disease was spreading rapidly, and Johnson persuaded his skeptical superiors to design and provide a simple, makeshift lab that they could deploy in the jungle villages near Machupo, where the outbreak was centered. Joined by Merl Kuns, an ecologist, they brought their equipment to the town of San Joaquin, populated by former cowboys of wealthy Brazilian landholders, the latter of whom had been expelled during the revolutionary period a decade before.

The team got to work on their analysis, quickly discerning that the disease was both extremely lethal (with a 50% fatality rate) and borne by a viral agent. Within the first two months in the field, however, the disease struck the researchers. MacKenzie and Johnson both had to leave the site, ending up in an American hospital in the Panama Canal Zone, where they suffered in agony before slowly recuperating enough to rejoin Kuns in Bolivia. Doing painstaking ecological surveys, Kuns narrowed down the candidates for the animal that was serving as the vector for the virus, eventually identifying it as a large gray bush mouse. This mouse had overrun the area in recent years after having its habitat disrupted when the now-unemployed cowboys of San Joaquin had resorted to cutting down the jungle and planting corn to feed themselves. This was compounded by the fact that the local cat population—which would have controlled the mice—had died off at the same time due to an aggressive government DDT-spraying campaign. The mystery of the Bolivian virus was solved, and Johnson would go on to train a whole generation of infectious disease “cowboys” (Garrett’s term), passing on lessons like “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” (29).

Chapter 2 Summary: “Health Transition”

Garrett offers a historical assessment of the way that the mid-century optimism of scientists in the 1950s and 1960s was challenged by the stubbornness of biological and logistical realities. The near-eradication of polio led medical experts to predict a similar trajectory for malaria, in which human expertise, coupled with hard work, would bring an end to the disease: “Few scientists or physicians of the day doubted that humanity would continue its linear course of triumphs over the microbes” (30). Part of this optimism, however, was due to ignorance: medical science was only just beginning to gain an understanding of microbial evolution, genetics, and the operations of the immune system, all of which turned out to be exponentially more complex than was originally assumed. Bacteria were thought to be well-understood, but no one had yet reckoned with just how adaptable they were against antibacterial defenses. Further, the artificial distinctions made within medical fields of study—grouping illnesses into categories like “tropical diseases”—were unhelpful in promoting broad scientific understandings of how diseases worked.

Riding the crest of this wave of optimism, the medical community set its sights on two great goals: eradicating smallpox and malaria. In the first instance, success was rapid, marking “the greatest triumph of modern public health” (40). The swiftness of the victory over smallpox, however, was not easy. It required a massive, coordinated, global effort, leaning largely on the rule-breaking perseverance of “disease cowboys” like Daniel Tarantola and Don Francis, who hunted down the final outbreaks in remote jungles and deserts to vaccinate vulnerable populations, sometimes against their will. The aim of eradicating malaria was far less successful, bogged down by biological adaptability and diminishing funding. While major progress was made in eliminating malaria-carrying mosquitoes in some areas by spraying DDT, the use of the chemical made other ecological problems worse and even led to the emergence of DDT-resistant insects. Governments lost confidence in the effort, and the progress that had been made was rapidly eclipsed by the resurgent disease, now rendered more dangerous thanks to the resistance it had developed.

Chapter 3 Summary: “Monkey Kidneys and the Ebbing Tides”

The focus here is on efforts to combat three global outbreaks in the late 1960s and early 1970s: the Marburg virus, bacterial meningitis, and yellow fever. The Marburg virus, a previously unknown disease, came to the world’s attention when factory workers in Marburg, Germany, suddenly came down with alarming symptoms, soon matched by those of a veterinarian in Yugoslavia. The victims all worked with a species of vervet monkey imported from Africa. The virus was isolated and studied by Jordi Casals of Yale University, who could not match it to any previously known disease. Despite massive efforts to identify the reservoir species wherein the virus naturally resided before jumping to monkeys, no firm conclusions could be drawn. The threat of future Marburg outbreaks, therefore, remained ever-present and unpredictable.

Not long after, a serious meningitis outbreaks threatened the Brazilian city of São Paolo, caused by a bacterium that could be passed from person to person through the droplets expelled in respiration. The bacteria attacked the brain’s lining and killed at least a tenth of its victims. Joe McCormick, working for the CDC under Karl Johnson, studied the outbreak and discovered that it involved two different bacterial strains, Type A and Type C, one of which was new, and both of which had only limited treatment options. The epidemic had already claimed 11,000 victims and was spreading rapidly, so at McCormick’s insistence, Brazil launched a massive public health campaign and vaccination effort, successfully slowing the disease’s advance. Questions remained, however, as to where the virulent new strain of meningitis—Type A—had come from.

In the case of yellow fever, optimism was high that the disease could be eradicated since both insecticide and vaccination looked like promising avenues against it. It had already effectively vanished from many urban areas when cities began covering the water supplies where mosquitoes would lay their eggs. However, progress slowed when it became apparent that multiple mosquito species could carry the virus, sometimes with long latency periods. By the end of the 1950s, yellow fever was resurgent across vast swathes of South America, where officials had previously thought it had been eradicated. Research into a 1970 outbreak in Africa could not reveal the source of the epidemic, and government funding was pulled from what had once been considered a promising venture.

Introduction-Chapter 3 Analysis

The introduction and opening chapters display all three of Garrett’s forms of analysis: her commentary on the social and ecological factors that play into disease management (in the Introduction), her depictions of the events in disease outbreaks (Chapters 1 and 3), and her accounts of broad-scale public health initiatives (Chapter 2). All three of these forms populate the chapters of The Coming Plague, though not in any ordered pattern. This section of chapters, as well as the next, focuses predominantly on Garrett’s storytelling, as she narrates the events of various epidemics around the world. In most cases, a single epidemic will dominate the entire content of a chapter (as in Chapter 1); in other cases, a chapter will address several different outbreak stories (as in Chapter 3). Beginning the book with a higher percentage of outbreak stories allows Garrett to bring her readers along slowly, expanding their familiarity with the circumstances of epidemiological research before delving into the biological and social complexities of human/microbe ecology.

All three of Garrett’s major themes appear in these opening chapters. The theme of Ecological Perspectives on Microbial Infections is touched on in the introduction but appears in greater force in Chapter 1 when the roots of the Machupo outbreak are revealed. Human interventions in the environment around San Joaquin, Bolivia—specifically, cutting down the forests to use the land around the town for cultivation—brought humans into greater contact with the mouse species that served as a vector for the disease. Humans disrupted an ecological balance, and disease was the result. The theme of Social Factors in Disease Transmission also plays into the Machupo story when one considers that revolution and unemployment led to the clearing of the forests in the first place. Ecological themes also appear in Chapter 3, as human interventions with insecticides push mosquito species into adaptations that allow them to survive and spread microbes of even greater virulence than before.

Social Factors in Disease Transmission play a large role in Chapter 3, particularly in discussing meningitis’s spread in and around São Paolo. São Paolo is one of many major cities in the global south, which has attracted the growth of massive urban slums, called favelas in Brazil. The residents of these favelas are often poor, living in densely populated, unhygienic conditions. The infrastructure to support clean water, sewage systems, trash removal, and medical support is lacking in many such areas, and so diseases like bacterial meningitis have expansive opportunities for spreading. As in many places, these social conditions in the favelas are part of a systemic cycle that is difficult to break out of and promotes continued human/microbe ecology disruptions.

The third theme, relating to The Movement from Optimism to Realism, forms the core content of the Introduction and Chapter 2. When Garrett wrote The Coming Plague in the mid-1990s, much of the public health community had already realized the complex challenges and dangers that lay ahead, after having walked through their inadequate responses to AIDS, malaria, and other epidemics. In much of the wider public mind, however, a spirit of optimism about medical progress was still largely present, boosted by optimistic feelings about the world in general as the Cold War ended and Western economies started to boom. Garrett’s book is intent on performing the public service of tempering that spirit of optimism regarding medicine and disease, so she puts it plainly in her Introduction: “Humanity’s ancient enemies are, after all, microbes. […] And they certainly won’t become extinct simply because human beings choose to ignore their existence” (10). Chapter 2 expands on this theme, tracing the mood of public health officials from the heady days of the polio and smallpox campaigns to the failures and missed opportunities in other epidemics. A sense of realism had set in by the 1990s, not because scientists felt that humanity had overestimated its technical prowess but rather because they had underestimated the microbes. With a growing sense of the complexity of microbial adaptability, a healthy respect arose. Garrett’s hope is that understanding the dangers microbes still pose will lead to a higher level of watchfulness and more prudence in assessing our ecological impacts.

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