1. RUNNING HEAD: The Coming Plague by Laurie Garrett
Book Review of the Coming Plague by Laurie Garrett
James Nichols
In Partial Completion of Master of Science in Nursing
Epidemiology NURS 6213
Arkansas Tech University
Russellville, AR

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Introduction
Laurie Garrett’s work The Coming Plague is a comprehensive chronological history of
the efforts of the Center for Disease Control in cooperation with other agencies efforts to
quantify, categorize, investigate and contain emerging pathogens since World War II. The
Coming Plague’s epic setting takes the reader from the rain forest of Amazonian South America
to the African Congo, from the World Health Organization headquarters in Geneva to the Center
for Disease Control in Atlanta. The Coming Plague is a pivotal work for those interested in and
entering the field of nursing because it shows in detail how the science of epidemiology is
applied in the field differentiating theory and classroom from the brutal reality of the field.
Garrett’s work is detailed and encyclopedic having over 620 pages of text and another 100 pages
of foot notes.
Description
Chapter 1 focused on the investigation of Bolivian Hemorrhagic Fever in the San
Joaquine region of northern Bolivia near the headwaters of the Amazon River. The book details
how scientist step by step defined the disease, investigated each possible vector by capturing and
cataloging most of the local flora and fauna then by the process of elimination and testing
determined that the disease had been caused by a specific rodent who had entered the ecosystem
of the villagers only when they had begun attempts at farming and thus began clearing large
portions of swamp in order to raise crops thus forcing the rodents into the village where they
urinated on the dirt floors spreading the disease (Garrett, 1995). The details of the inventive
nature and problem solving skills of the team at the most basic level demonstrate the can do
spirit of the front line scientist who thousands of miles from the supply line have to improvise in

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order to accomplish the task. The cure for the disease it turned out was proper rodent control in
the form of traps.
Chapter 2 focused on the efforts to irradiate three diseases polio, small pox and malaria.
The irradiation effort for small box took two decades, the cooperation of the world’s two most
powerful super powers- The United States and The Soviet Union and a substantial amount of
funding. By systematically vaccinating at risk populations and then focusing their efforts on
active cells in the remaining active areas, the last of which was in Bangladesh, the World Health
Organization was able to eradicate one of the most powerful killers of mankind in our history.
The eradication effort for Polio was similar in that it required massive immunization efforts. The
final unsuccessful immunization attempt was for Malaria. The text states that the primary reason
for failure was a lack of commitment and funding at a specific point in the late sixties and early
seventies when the virus with the use of insecticides and medication had been almost contained.
But because of a lack of funding the pathogen which resides in the guts of mosquitos had the
time to become resistant to the medication and the mosquitos had time to become resistant to the
insecticide. Once the resistance to the primary medications and insecticide occurred resistance to
all later curative measures became easier. The actual deaths from Malaria increased after 1975
because of the attempts at eradication. This chapter demonstrates how health policy and funding
can have both positive and negative effects on the health of the population. It also shows how
that by eradication of a percentage of a population in a pest or a microbe the environment is open
for the rapid multiplication of the small percentage of the population that remains, this in a
rapidly reproducing population allows for an amazing rate of change or mutation in the
remaining population and thus rapid onset of resistance.

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Chapter 3 discusses the investigation of such exciting emerging diseases as Ebola,
Yellow Fever and Brazilian Meningitis. The book focuses on the investigation of the early Ebola
virus in Africa. The first reported incident of Ebola was not in Africa but in Marburg Germany in
1967 where employees of a vaccination manufacture the source of the outbreak was determined
to be the veret monkey’s used at the facilities for testing. The disease of course caused massive
diarrhea and bleeding around the eyes and other orifices’ and had an alarming fatality rate. It was
also highly contagious. As a result special quarantine procedures were set up for all primates
coming from Africa. The next appearance of the disease was when two Australians students
trekking through South Africa contracted the disease in 1975 the source could not be determined.
Brazilian Meningitis occurred in San Palo, Brazil in 1972. Brazilian Meningitis was a very
contagious bacteria that focused on the brain and spinal cord causing massive neurological
damage in one of the major population centers of Brazil. The onset of the disease or the shift
from being non-symptomatic to having fever, pain neck stiffness and dizziness was a matter of
minutes then the descent into comma and death took only twelve to twenty hours. The CDC
created a vaccine and over three million people were vaccinated in twelve days. The infection
rate plummeted. Another 12 million were vaccinated in there days in April. The giant
vaccination campaign brought the Brazilian Meningitis outbreak to a conclusion by 1976.
Yellow fever in West Africa was slowed by the use of DDT which curbed the population of the
mosquito that carried the diseases but as in malaria the mosquito became resistant to the DDT
and the yellow fever reemerged in the region. This chapter demonstrates how success and failure
are marginal in the field of epidemiology in the case of Brazilian Meningitis the disease could be
contained by developing herd immunity in the population. In the case of the Ebola virus the
disease was contained by monitoring and isolation of the infected and the fact that the contact the

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disease had with the human population was small allowing containment. The Yellow Fever
example showed that in some circumstances that the contact with the human population is so
large that with no way of limiting it and no way of providing immunity to the population efforts
at containment for eradication are limited.
Chapter 4 focused on a Lassa fever outbreak in West Africa in 1969. The extremely
contagious disease infected medical staff with amazing consistency. While Lassa had
hemorrhagic traits and presentation much like Ebola-Marburg it after observation under electron
microscope was found to be a different virus than Marburg. A survivor of the disease donated
plasma that in many cases boosted the victim’s immune systems increasing survival. Once again
CDC collected and catalogued the fauna and flora in the region to try to find the carrier of the
disease allowing it to interface with the human population. A particular rat was found to be the
carrier. A side story in this chapter develops around the transport of victims into other countries
for treatment and the paranoia and fear that these disease cause. At one point Henry Kissinger
had to fly an Apollo space capsule in a military aircraft to transport a victim.
Chapter 5 returns to the Ebola story line. In 1976 an employee of a mission hospital in
Zaire came down with Ebola after visiting the northern parts of Zaire. The highly contagious
disease spread among the staff and villagers surrounding the hospital. All attempts at treatment
by conventional means were ineffective. The CDC investigated sending blood samples to labs
for identification it resembled the Marburg virus but had small differences it was later named
Ebola-Zaire. CDC sent the same team that had found the Bolivian – Hemorrhagic fever vector to
Zaire and they began the same methodical cataloging of all possible vectors and reservoirs from
the local fauna and flora. Another outbreak was reported on the Sudan side of the border and
another team from CDC was sent to investigate. The book goes into detail about the difficulty of

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getting supplies, transport, working with the local political and military leadership in the
paranoid and fear of the epidemic. The search for a vector or reservoir proved pointless after ten
years of searching in the area none could be found. A finding that the isolative pygmies who live
in the Cameroon rain forest had antibodies for Ebola which leads to the conclusion that the
creature that harbors the disease is native to the deep rain forest possibly the giant bats of the
region.
Chapter 6 focuses on 1976 as America focused on its Bicentennial it was the best of times
and the worst of times for the CDC. The Legionaries Disease showed the best of US
Epidemiology while the Swine Flu scare showed the failure of reaching too far. The swine flu
issue revolved around the death of one soldier at basic training at Fort Dix New Jersey the rapid
onset of symptoms and the death of the soldier had lead the CDC to conclude that he was the
victim of a very virulent and contagious form of flu similar to the 1918 Spanish or Swine flu
epidemic that had circled the world and killed 21 million people worldwide. In response the
CDC set in place a very ambitious and expensive plan to vaccinate the entire population of the
United States. The problem is that the effort had problems such as the virus causing illness in a
certain batch, the vaccine companies wanting absolute immunity from law suit in regards to the
vaccine and the perception of the American public that the entire matter was a waste of time
because the flu season that year was no worse than usual. The Legionnaires case was the
opposite at the American Legion convention in Philadelphia people were dying from acute
pneumonia 29 victims 82% of cases. The CDC tracked the disease down to the air conditioning
system and identified the bacteria in a matter of weeks showing their best. The Swine Flu
debacle would haunt the CDC and public health for decades.

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Chapter 7 One side line to chapter 7 was the Soviets wondering around a CDC research
station in Sierra Leonne trying to get samples of Lassa fever reportedly for use in their
weaponazaiton program. The chapter also described the unintended results of the Marshall plan
as it changed entire social / economic systems as well as the geography of the developing world.
Moving people, animals, insects and diseases out of the environments they were accustomed to
into new environments causing the inevitable conflict and disease that would result. Also, social
change such as the end of colonization in Africa created change such as the regime of Idi Amin
forcing 80,000 natives of the Indian subcontinent out of his country upon his becoming President
of Uganda in 1972; this left the region without adequate medical staff for decades.
Chapter 8 covers genetics from Watson, Cricks and Franklin’s discovery of DNA at
Oxford in 1953 to McClintock’s discovery of transposition in gene sequence to Temin’s
discovery of reverse transcription to Baltimore’s discovery of a virus link to cancer. Oncogenes
and the similarities in these cancer causing genes in animals and humans was also discussed.
This chapter is a good primary on how genetics works at a basic level so in later chapters a more
in depth discussion of the adaptability of diseases can be discussed.
Chapter 9 discusses that fact that until the last century human beings lived in rural
settings, the shift to the urban environment the creation of homo urbanius to use the catch phrase
has changed humanities interaction with pathogens as well. The text reviews that it was only
after the creation of sanitation in the form of available potable water in cities and the disposal of
human waste in the form of sewage and garbage that mankind was able to trump disease and
create the massive human colonies we see today in mega cities. The book speaks of the great
plague of 1346 and 1666, the tuberculosis in London before the great fire, the periodic cholera
epidemics in the American Colonies before the First World War and the current Tuberculosis

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plague in South Africa. Also, the massive poverty in the third world is discussed and the lack of
any real health care in these areas. The larger purpose of this chapter is to point out the increased
exposure and risk that an urban population is at in comparison to a rural, isolated and
decentralized population. Also, the effects of economics upon disease process both intentional
and unintentional is again reviewed
Chapter 10 discussed the increase in Sexually Transmitted Disease in the 70’s and the
increase in diseases transmitted by injecting drugs both in the United States. Also was discussed
was the emergence of sexually transmitted diseases in Africa. Discussion of the development of
antimicrobial resistance in the STD’s was also discussed. The focus of this chapter was the
increased sexual activity in the period and the related increase in the spread of STD’s related to
the multiple sexual partners and extremely mobile society. Also, was discussed was the
environment of the injection drug user, the sharing of needles and the resulting resistant diseases.
This chapter sets the stage for the AIDS epidemic in the early 80’s.
Chapter 11 continues the STD theme by introducing the origin of the HIV virus and the
spread of AIDS to Europe and then America. In the early 1980’s in both New York, Los Angeles
and San Francisco multiple gay men were coming down with a immune suppression disorder that
allowed opportunist infections such as pneumocystis, candida and other bacteria and fungi to
overwhelm the individuals immune system. Dr.’s in oncology were at the forefront of the disease
as one of the trademarks was Kaposi Sarcoma which was one reason the disease became coined
as a “gay cancer”. The chapter also focuses on the attempts to isolate the cause of the virus one
theory was that it involved the use of stimulants this was later disproved. Half of the individuals
diagnosed with the syndrome were dead within 24 months. Autopsies showed significant tissue
necrosis. Funding for research into the cause of the epidemic was wanting at the federal level as

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the Regan administration avoided the issue. The disease was reported to be spread by blood
transfusion and the hemophilic population of the United States were at risk this was reported in
1982. Blood industry executives did little to protect the supply until after 1986 by that time a
large percentage of the hemophilic population had been infected by HIV. In 1983 it was
discovered that the mechanism of the disease was a lowering of the T cell count in the
individuals it was also proven at Tulane that the disease was spread by blood contact and sexual
contact as wives of hemophiliacs had contracted it from their husbands. That same year the
Pasteur Institute in France isolated the virus at around the same time American labs had isolated
what would be later proven to be the same virus. In early 1983 a heterosexual disease that would
later be proven to be identical to the AIDS virus would be found in Uganda. It would be called
“Juliana’s disease”. The African version of the disease would be mainly heterosexual in
causation and was common all over Kenya. Research found that Simian species in Africa had
similar viruses to HIV 1 and HIV 2. Two lab workers had gotten the Simian versions by bites
from lab simians proving that transfer of these viruses across the species was possible. One
simian variant was found in Chimps that matched closely with that of the human HIV. It was
only in 1986 near the end of the Reagan administration that the president personally gave a
speech pledging to combat the disease. This chapter demonstrates the dangers of political
decision making in a strategic environment. As a disease as dangerous as HIV should have been
treated as a threat to national security and not politicized.
Chapter 12, reviews the toxic shock syndrome issue of super absorbent tampons. The
introduction of super absorbent tampons allowed for the development of deadly staphylococcus
bacterial blood infections. This chapter goes through the domestic US investigation of the
outbreak, the interaction with the Proctor and Gamble Company and other manufactures, the

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interaction with the press in the crisis and the conflict between private researchers and the CDC
during the investigation.
Chapter 13 focuses on the emergence of antimicrobial resistant pathogens as a result of
the overuse of antibiotics and other antimicrobial. The chapter reviews the beginning in 1960 of
methicillin resistant staphylococcus. Explanations are given of how using various methods that
bacteria and virus can simply absorb DNA and RNA sequences from other bacteria and viruses
in order to obtain the necessary mechanisms or traits to resist the effects of almost any tool that
humans have to fight infections. Efforts to limit the use of antibiotics and antimicrobials in order
to slow the emergence of resistant strains are discusses. The use of antimicrobials is credited
with speeding up the elimination of the less efficient members of the species and allows for the
faster replacement of old with the new. An example was that Vancomycin resistant Enterococcus
accounted for only 0.4 % of hospital infection in 1989 by 1994 that had increased to 13.6%.
Another concern noted was the lack of new antibiotic and antimicrobials in the drug
development pipeline. The book states that many bacteria, fungus and virus have developed the
ability to activate thick shells that can actually live in Clorox bleach and others have developed
the ability to actually pump out the very medications that we use to defeat them. Other issues are
that the developing world that needs the meds most can’t afford them and can’t distribute or
accurately administer the medications due to a lack of infrastructure.
Chapter 14 focuses on the government’s involvement in the containment of disease and
the politics of health care. Examples are Cuba’s permanent lifetime quarantine of HIV positive
individuals. Other issues addressed are the staggering cost of AIDS medications and the lack of
access to these medications in Africa. The economic cost of AIDS to the economies of Africa is
also discusses.

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Chapter 15 discusses the Hanta virus in America. The Hanta virus was first noted in 1993
in the Navaho reservation of Arizona. Two otherwise healthy young individuals died of
respiratory distress in less than 24 hours. The CDC with state and local authorities used the same
techniques used in Africa and South America to collect the Fauna and Flora in the area and came
to the conclusion that the common field mouse was the reservoir and that by sweeping the floors
the individuals had allowed the virus along with the dust to be inhaled. The chapter also focuses
on the problems the stigma of the “Navaho disease” caused the people of the region. This chapter
helps focus on the cultural and political issues and brings home the fact that these disease are in
our own backyard.
Chapter 16 this chapter focuses on the fact that microbes are everywhere pointing out that
98.6 million living organisms have not been identified. Also, it is stressed that the level of
extinction on the planet is rapidly increasing. The loss of the biodiversity is rapidly accelerating
the pace of change and threat to humanities very survival. An example given was Lyme disease
where the deer tick who usually infects the deer population bites a human and gives them the
Lyme disease instead. It was also noted that the population is far exceeding the estimates of our
maintainable population.
Chapter 17 review whose efforts to monitor, prepare and understand the changes to help
humanity adapt and survive the future.

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Conclusion
The Coming Plague provides chapters that presents real life scenarios that are the equal
of any case studies in the best text book on microbiology and epidemiology. The field of
emergent epidemiology is critical to the survival of mankind. With a population of over six
billion and a sustainable habitation level of only six hundred million in our world the “revenge of
the germ” is inevitable. As Nobel Prize Winning Microbiologist Joshua Lederberg stated “The
virus is the single largest threat to man’s dominance of the planet”.

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Reference
A. Garrett, L. (1995). The Coming Plague. Penguin Books. New York. N.Y.