The Coming Plague by Laurie Garrett: Summary & Notes

Front cover of The Coming Plague by Laurie Garrett.

In short

Even though The Coming Plague was first published in 1994, it’s probably more relevant today than ever. It’s a long book, with close to 800 pages, where each chapter describes a different outbreak, or a different disease – from AIDS, Marburg, Ebola to Legionnaires’ disease. The Coming Plague also clearly shows how changes in our environment, and the destruction of nature and animal habitats, is a big risk for future diseases and pandemics. At times it does really feel like Laurie Garrett had a crystal ball for the coronavirus and pandemic, and that makes this book all the more incredible.

Book Summary & Notes

All text between quotation marks is taken directly from the book.

“We always want to believe that history happened only to “them,” “in the past,” and that somehow we are outside history, rather than enmeshed within it. Many aspects of history are unanticipated and unforeseen, predictable only in retrospect: the fall of the Berlin Wall is a single recent example. Yet in one vital area, the emergence and spread of new infectious diseases, we can already predict the future — and it is threatening and dangerous to us all.”


“In those early days before bacteria became resistant to antibiotics, such doses were capable of performing miracles, and the Army doctors were so impressed with the powers of penicillin that they collected the urine of patients who were on the drug and crystallized excreted penicillin for reuse on other GIs.”

“Nature isn’t benign,” Lederberg said at the meeting’s opening. “The bottom lines: the units of natural selection — DNA, sometimes RNA elements — are by no means neatly packaged in discrete organisms. They all share the entire biosphere. The survival of the human species is not a preordained evolutionary program. Abundant sources of genetic variation exist for viruses to learn new tricks, not necessarily confined to what happens routinely, or even frequently.”

“As humans improve their lots, McNeill warned, they actually increase their vulnerability to disease. “It is, I think, worthwhile being conscious of the limits upon our powers,” McNeill said. “It is worth keeping in mind that the more we win, the more we drive infections to the margins of human experience, the more we clear a path for possible catastrophic infection. We’ll never escape the limits of the ecosystem. We are caught in the food chain, whether we like it or not, eating and being eaten.”

“[M]egacities were arising in the developing world, creating niches from which “virtually anything might arise”; rain forests were being destroyed, forcing disease-carrying animals and insects into areas of human habitation and raising the very real possibility that lethal, mysterious microbes would, for the first time, infect humanity on a large scale and imperil the survival of the human race.”

Health Transition

“Science really suffers from bureaucracy, ”Arita would later declare, adding, “If we hadn’t broken every single WHO rule many times over, we would never have defeated smallpox. Never.”

“Eradication took eleven years, involving about a hundred highly trained professionals and thousands of local health workers and staff worldwide. It was achieved at a cost of $ 300 million. 29 On May 8, 1980, the World Health Assembly formally declared that “the World and all its peoples have won freedom from smallpox, which was a most devastating disease sweeping in epidemic form through many countries since earliest times, leaving death, blindness, and disfigurement in its wake and which only a decade ago was rampant in Africa, Asia, and South America.”

“A new global iatrogenic form of malaria was emerging — “iatrogenic” meaning created as a result of medical treatment. In its well-meaning zeal to treat the world’s malaria scourge, humanity had created a new epidemic.”


“The source of both horribly lethal viruses — Marburg and Ebola — remains a complete mystery.”

The American Bicentennial

“Global pandemics were, in fact, a hallmark of influenza that spanned recorded human history. Charlemagne’s conquest of Europe was slowed by an A.D. 876 flu epidemic that spread across the continent and claimed much of his army. Many suspected influenza epidemics followed, though history can only vaguely discriminate between ancient accounts of influenza and other respiratory diseases. In 1580, however, the world was clearly hit by a major pandemic that followed trade and early colonial routes across Africa, Europe, and the Americas. So devastating was the epidemic that “some Spanish cities were said to be nearly dispopulated.”

“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.”

“After describing the Black Death plague of medieval Europe, Hudson warned that “when we grant that our knowledge of existing microscopic pathogens is deficient, we necessarily grant the possibility at least of a return of the great epidemics of the past…. the possibility exists that a deadly and common organism could emerge that is easily spread from person to person and that might be aloof to all available therapeutic and preventive methods.”


“The microbe is nothing; the terrain everything.” — Louis Pasteur

“Over the long course of history, McNeill said, pathogenic microbes sought stability in their relationships with hosts. It was not to their advantage to wipe out millions of nonimmune human beings in a single decade, as happened to Amerindians following the arrival of Columbus and Cortez. With the Europeans came microbes to which the residents of the Americas had no natural immunity, and McNeill estimated, “Overall, the disaster to Amerindian populations assumed a scale that is hard for us to imagine. Ratios of 20:1 or even 25:1 between pre-Columbian populations and the bottoming-out point in Amerindian population curves seem more or less correct.”

Microbe Magnets

“Cities, in short, were microbe heavens, or, as British biochemist John Cairns put it, “graveyards of mankind.” The most devastating scourges of the past attained horrific proportions only when the microbes reached urban centers, where population density instantaneously magnified any minor contagion that might have originated in the provinces. And microbes successfully exploited the new urban ecologies to create altogether novel disease threats.”

“Four diseases that seemed to William McNeill and other medical historians of the 1970s to have gained particular benefit from the urban ecology over the previous 2,000 years were pneumonic plague, leprosy (Hansen’s disease), tuberculosis, and syphilis. As far as could be discerned from historical records, these were rarely — if ever — seen prior to the establishment of urban societies, and all four exploited to their advantage human conditions unique to cities.”

“Houses of both male and female prostitution, activities mainstream societies often labeled “deviant” such as homosexuality, orgies, even religiously sanctioned sexual activity, were common in the ancient cities of Egypt, Greece, Rome, China, and the Hindu empires and among the Aztecs and the Mayans. The double standard of chastity in the home and risque behavior in the anonymity of the urban night dates back as far as the beginning of written history.”

Hatari: Vinidogodogo (Danger: A Very Little Thing)

“Medical research money per se was not usually a partisan matter in the United States. Republican Nixon started the War on Cancer, Democrats Johnson and Carter bolstered funding for cancer and heart disease research, and in emergencies — Legionnaires’ Disease, Swine Flu, Ebola fever — resources had been found quickly, regardless of which party controlled the Congress and White House. 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.”

“Like Marburg, Ebola, Lassa, Machupo, the 1918–19 influenza, and a variety of other viruses described in this book, the HIVs and SIVs that seemed to suddenly appear out of nowhere — dropped from the sky, as Hoyle would have it — actually existed in various forms in nature for decades, or centuries.”

“From the microbial point of view, shrinking primate habitats and mixed troop behavior opened the possibility for cross-species transmission among three or more monkey / chimp species. In such an environment various SIV strains had ample opportunity to move from immune hosts to vulnerable simian species. And an immune species that thrived alongside Homo sapiens, such as vervet African green monkeys, might conceivably serve as an SIV / HIV conduit, carrying viruses back and forth between mixed monkey troops and humans. It was speculation, of course. No one could be certain how the immunodeficiency viruses zoonotically moved among primates in ancient Africa.”

The Revenge of the Germs, or Just Keep Inventing New Drugs

“Consider the difference in size between some of the very tiniest and the very largest creatures on Earth. A small bacterium weights as little as 0.00000000001 gram. A blue whale weighs about 100,000,000 grams. Yet a bacterium can kill a whale…. Such is the adaptability and versatility of microorganisms as compared with humans and other so-called “higher” organisms, that they will doubtless continue to colonise and alter the face of the Earth long after we and the rest of our cohabitants have left the stage forever. Microbes, not macrobes, rule the world.” — Bernard Dixon, 1994

“Staphylococcus wasn’t the only bacterial organism that was successfully using plasmids, jumping genes, mobile DNA, mutations, and conjugative sharing of resistance factors to overcome whatever drugs Homo sapiens threw at them. In fact, by 1993 nearly every common pathogenic bacterial species had developed some degree of clinically significant drug resistance. And over two dozen of these emergent strains posed life-threatening crises to humanity, having outwitted most commonly available antibiotic treatments .”

“Such emergences of drug resistance usually took place in communities of social and economic deprivation. Poor people all over the world were more likely to self-medicate, purchasing antibiotics on the black market, over the counter in many countries, or borrowing leftovers from relatives. Without consulting often costly physicians, and certainly in the absence of expensive tests that could determine the drug sensitivities of the bacterial strains with which they were infected, the world’s poor were compelled to guess what drug might cure the disease that was ravaging their children or themselves. This state of affairs guaranteed that a sizable percentage of the human population were walking petri dishes, providing ideal conditions for accelerated bacterial mutation, natural selection, and evolution.”

“The basic problem with the antibiotic approach to control of pathogenic bacteria was evolution. Long before Homo sapiens discovered the chemicals, yeasts, fungi, and rival bacteria had been making antibiotics and spewing the compounds around newly claimed turf to ensure that rival species couldn’t invade their niches. The rivals, of course, had long since evolved ways to rapidly mutate to withstand such chemical attacks. So rivals would make different chemicals, their foes would mutate again, and the cycle repeated itself countless times over the millennia. Humans simply accelerated the natural process by exposing billions of microbes at a time to drugs derived from the natural chemicals, and doing so with less lethal efficiency than had the microbial competitors in their ancient microscopic turf fight.”

“It was the physicians’ job, Lappé said, to individuate decisions on a patient-by-patient basis. The mission of the doctor was to cure individual cases of disease. In contrast, public health’s mission required an ecological perspective on disease: individuals got lost in the tally of microbial versus human populations.”

“It’s incredible,” Lappé said. “You can go into a hospital and you will have a four in a hundred chance of getting an infection you’ve never had before, while in that hospital. In some hospitals the odds are one in ten. What you will get in that hospital will be much worse than what you would have been contaminated with at home. They are the most tenacious organisms you can imagine. They can survive in the detergent. They can actually live on a bar of soap. These are organisms that are part of our endgame.”

“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 never existed before in nature. We have selected them. We have organisms that probably caused a tenth of a percent of human disease in the past that now cause twenty, thirty percent of the disease that we’re seeing. We have changed the whole face of the earth by the use of antibiotics. By the 1990s, when public health authorities and physicians were nervously watching their antimicrobial tools become obsolete, Lappé’s book was out of print. But everything he had predicted in 1981 had, by 1991, transpired.”

“Campbell liked to remind fellow malariologists of the old British colonial scourge, blackwater fever. It was the British who figured out how to mix quinine with water and cover the bitterness with Bombay gin. The result — the gin and tonic — went a long way to prophylaxing the British Army against malaria. But overuse of quinine, both medicinally and in heavy gin-and-tonic doses, created the new disease of blackwater fever. Victims urinated dark fluid, ran high fevers, felt miserable, and often — 25 to 50 percent of the time — died. It was decades before British physicians figured out that blackwater fever was an iatrogenic disease. After repeated episodes of malaria, each of which was treated with escalating doses of quinine, the nonimmune Europeans fell ill with what they thought was another infectious disease. Scientists eventually determined that quinine caused blackwater fever. Overuse of the powerful drug to counteract malaria led to quinine’s attachment directly onto the membranes of red blood cells. The protruding quinine molecule attracted the attention of the immune system, which misinterpreted its presence on the red blood cells as an indication of an alien invasion. Antibodies and T-cell killers attacked the quinine-labeled red blood cells, killing them. The dying blackwater fever patient was, thus, the victim of his own medical attempts to cure malaria.”

“From all of this Campbell reached two conclusions: “Life cannot be made into policy guidelines from Geneva,” and “Malaria is a disease that responds to antimalarial drugs.” The definition of malaria, then, was that it was a disease whose existence was proven by reversing it with drug treatments.”

“People who lived or worked in the forested areas were constantly bitten by mosquitoes. For centuries an ecological balance existed between the humans and the parasites, via the mosquitoes. A large percentage of the humans would die of the disease during infancy, but survivors, who were “vaccinated” every day by mosquitoes that injected parasites into their blood, were immune, or, as Kent Campbell would put it, tolerant. Efforts to eradicate malaria severely disrupted that balance. Temporarily successful mosquito control programs eliminated the daily “vaccinations,” and immunity immediately disappeared. Prophylactic use of antimalarials fended off disease, but also lowered immunity. In periodic times of drug scarcity, surges of malaria cases could be seen.”


“Before the London meeting the GPA staff had reviewed all the legal and political activities surrounding AIDS and concluded that they were witnessing, in slow motion, many of the same social responses that had followed the arrival of the plague in fourteenth-century Europe. In both cases there were actually three different social epidemics within the larger biological epidemic. First, with the initial emergence of the microbe — plague bacteria or HIV — came denial in all tiers of society. The tendency was to ignore the microbial threat, or assume only “they” — some distinct subpopulation of society — were at risk. The microbes exploited such denial, spreading rapidly while humans made no attempts, through their personal or collective behaviors, to block any of the avenues of transmission of the organisms.”

“The second social epidemic was fear. Some event in the biological epidemic would suddenly shock a society out of its state of denial, propelling people into a state of group terror.”

“Eventually, the Programme staff knew, the social epidemic of fear usually yielded to a wake of repression. Fear-driven government response was usually irrational, prompting attacks on the victims of disease, rather than the microbes. During the plague such fear-driven repression led to the wholesale slaughter of Jews and of women accused of witchcraft.”

Nature and Homo sapiens

“That humanity had grossly underestimated the microbes was no longer, as the world approached the twenty-first century, a matter of doubt. The microbes were winning. The debate centered not on whether Homo sapiens was increasingly challenged by microscopic competitors for domination of the planet; rather, arguments among scientists focused on the whys, hows, and whens of an acknowledged threat.”

“Thanks to changes in Homo sapiens activities, in the ways in which the human species lived and worked on the planet at the end of the twentieth century, microbes no longer remained confined to remote ecospheres or rare reservoir species: for them, the earth had truly become a Global Village.”

“Evolution was a very dynamic and active process for microbes housed in an insect’s midgut. Some viruses changed very slowly over time, probably because they possessed extremely accurate mechanisms for replication and repair of their genetic material. But there were insect-borne viruses that were capable of sorting and resorting their chromosomes, shuffling RNA about seemingly at random. And under conditions of co-infection of an insect by more than one species of microbe, exchanges might occur. The end result could be new mutant organisms.”

“Many insect-borne viruses were thought to have originally been plant microbes that, thousands of millions of years ago, infected insects as they fed on plant nectar. In the 1990s, amid evidence of rising rates of genetic change in many plant microbes, concern was expressed about the possible emergence of new species that might be absorbed by insects. In such a scenario, a microbe that was genuinely new, to which humans had no natural immunity, might quite suddenly emerge. Genetic change in plant microbes was accelerating due to agricultural practices that exerted strong selection pressures on the microbes; to changing geography of plant growth due to international trading of plant seeds and breeding practices; and to the deliberate release of laboratory genetically altered plant viruses that were intended to offer agricultural crops protection against pests.”

“As the Homo sapiens population swelled, greater opportunities would present themselves for both viral spread and mutation. It seemed perfectly reasonable therefore to assume that the evolution of microbes capable of infecting Homo sapiens would accelerate, perhaps dramatically.”

Searching for Solutions

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. Rapid globalization of human niches requires that human beings everywhere on the planet go beyond viewing their neighborhoods, provinces, countries, or hemispheres as the sum total of their personal ecospheres. Microbes, and their vectors, recognize none of the artificial boundaries erected by human beings. Theirs is the world of natural limitations: temperature, pH, ultraviolet light, the presence of vulnerable hosts, and mobile vectors. In the microbial world warfare is a constant. The survival of most organisms necessitates the demise of others. Yeasts secrete antibiotics to ward off attacking bacteria. Viruses invade the bacteria and commandeer their genetic machinery to viral advantage.”

“An individual microbe’s world — its ecological milieu — is limited only by the organism’s mobility and its ability to tolerate various ranges of temperature, sunlight, oxygen, acidity or alkalinity, and other factors in its soupy existence. Wherever there may be an ideal soup for a microbe, it will eagerly take hold, immediately joining in the local microbial pushing-and-shoving. Whether transported to fresh soup by its own micro motor and flagellae or with the external assistance of wind, human intercourse, flea, or an iota of dust makes little difference provided the soup in which the organism lands is minimally hostile and maximally comfortable.”

“We are in an eternal competition. We have beaten out virtually every other species to the point where we may now talk about protecting our former predators,” Joshua Lederberg told a 1994 Manhattan gathering of investment bankers. “But we’re not alone at the top of the food chain.” Our microbe predators are adapting, changing, evolving, he warned. “And any more rapid change would be at the cost of human devastation.”

“The world really is just one village. Our tolerance of disease in any place in the world is at our own peril,” Lederberg said. “Are we better off today than we were a century ago? In most respects, we’re worse off. We have been neglectful of the microbes, and that is a recurring theme that is coming back to haunt us.”

“While the human race battles itself, fighting over ever more crowded turf and scarcer resources, the advantage moves to the microbes’ court. They are our predators and they will be victorious if we, Homo sapiens, do not learn how to live in a rational global village that affords the microbes few opportunities. It’s either that or we brace ourselves for the coming plague.”

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