The Coming Plague

"I met Laurie during the Aids epidemic because she used to come to all the major HIV/Aids meetings. I remember her sitting and listening to the scientists debate and argue about different aspects of HIV and Aids. She comes at the issue of plagues more from a historical viewpoint, coupled with scientific discoveries that provide us with a warning that things may get worse. She goes through the past epidemics—Lassa fever, Ebola, HIV, malaria. She then points out that there are a lot of plagues that are still around us. Not only have we not solved them but, if we look at what’s happening within those plagues, things could get worse. She talks about antibiotic resistance and changes in tuberculosis and malaria that make them more difficult to treat. Recently Garrett wrote a book about the Ebola virus epidemic, one of the coming plagues she had talked about in her earlier book. “What if HIV mutated into a virus that was resistant to all of the drugs? That’s a possibility” We now have more than 25 drugs to prevent and treat HIV infection and yet HIV still persists. Do we now believe that even if someone gets infected, they can be treated or even cured? There is an open discussion in the scientific community about curing HIV—even as we still see millions of new infections and deaths each year. Many believe that with widespread use, the current drugs to treat HIV infection will soon get drug resistance and the epidemic will once again take off at an accelerated rate. You have to ask, ‘Was Laurie Garrett correct when she talked about The Coming Plague ?’ I think what she is saying is that we’ve gotten too complacent. Science has given us a great deal of confidence that we can solve these problems, but, even as those discoveries are made, we have to confront the fact that infectious agents mutate and that they can mutate into resistant organisms or even new organisms. There are now strains of tuberculosis that are resistant to every known treatment combination. What if HIV mutated into a virus that was resistant to all of the drugs? That’s a possibility. What if that new virus was going to keep spreading and keep the epidemic going? Or what if HIV recombines with another more infectious virus? Garrett is like a prophet saying, ‘Okay, let’s look at these diseases that existed in the past and what could happen if the infectious disease mutated or recombined with another virus to become an entirely new agent. Wouldn’t we have a new plague threatening us?’ And, just as in the Old Testament, I don’t think people always want to hear the message of a prophet. I partially experienced this overconfidence early in my training. I was a paediatrics resident in San Francisco, and one of the professors that I really liked—a fantastic teacher called Moses Grossman—was an infectious diseases specialist. I asked my fellow residents why they weren’t going into the field of infectious diseases. They said, ‘It’s a dying field. We’ve got vaccines and antibiotics and everything is under control.’ That was 1967. Think about what has happened between 1967 and now. We’re dealing with new infectious diseases and a threat of bacteria that are increasingly resistant to multiple antibiotics. There are issues of antibiotic resistance that we didn’t think were possible. We have infectious diseases for which we have no vaccines. In that book, Laurie is not only compiling the history of plagues but also talking about science and its ability to answer or not answer the new threats that we are likely to encounter. This is another example of how if you neglect one disease, another disease that’s been around a long time—and is partially contained—such as tuberculosis, can re-emerge as a major threat. When HIV isn’t diagnosed or is treated late, the immune system is deficient and tuberculosis—which is contagious not through sexual activity but through physical contact—spreads in people with HIV. Standard drugs that were used to treat tuberculosis don’t work now because you don’t have the synergy between the immune system and the drugs. You have, in many areas of the world— including the US—multiple drug-resistant tuberculosis and a type of tuberculosis, emerging now, which is resistant to all drugs. And it’s occurring not just in patients with Aids but is being transmitted to healthcare workers through physical contact and through aerosolization. Unlike HIV, tuberculosis is much more contagious when taking care of patients. So you’ve got this serious problem emerging, a secondary epidemic, which was totally unanticipated because of HIV and not paying attention to it. Then you have people saying they’re not going to worry about it because it’s occurring in countries where there’s a high rate of HIV infection. But there have been instances where people have travelled on an airplane and were exposed to tuberculosis by an infected passenger. Again, that’s part of Laurie’s book. Because of scientific advances, because of technology, because of people being able to travel, we are at much greater risk of some new plague emerging or a worsening of an existing plague. Yes. We can’t forget about public health. We have got to adhere to fundamental and historically sound public health principles. Most importantly, you have to respect these infectious diseases and not feel that we can control them simply by creating a new antibiotic. The dangerous side—which I think has to be raised—as in historical times (and this has remained relevant for HIV), is that when diseases are contagious and you want to protect yourself from them you may think that the best way to do that is to ostracise the people with the infectious disease. That is the risk you run when you become adamant about controlling disease using isolation. You don’t have to go that far. We should be intervening at early phases of infection and doing simple things because complex science usually answers the issues of diseases when they are advanced. I call that downstream. To me, upstream is prevention. With the Ebola epidemic—which is repeatedly mentioned in some of these books—one of the solutions to keeping that from spreading is teaching people early on to recognise what Ebola is and then providing inexpensive interventions such as soap and water and latex gloves. It’s that simple. That virus probably would not have spread as far as it did in a recent epidemic, had those simple public health principles been available. There are measures that can be taken that are already available and don’t require new discovery. We see that in some of the historical examples. Some of these diseases disappeared at the time people realised that you had to have sanitation—that the diseases were coming from contaminated water. Then you forget about that, and you have a cholera epidemic in Haiti in 2010 and again in 2016—because, in spite of all the money that was put into Haiti after the earthquake, they didn’t provide basic sanitation and clean water for the people. The cholera epidemic came from the UN troops that were there to keep the peace. The real solution to preventing that from happening would have been to pay attention to basic public health principles of sanitation."

"Yes. And it is very much a book of its time. Laurie Garrett is a journalist, so this is not strictly a scientific book about viruses, but it’s about the human behaviours and social conditions that encourage emerging infections. She was onto the fact that the infections we catch are not just down to bad luck. It’s the things we do and the way we live that are mainly the problem. So, if we altered our way of life, perhaps we could prevent these infections. For example, a third of the world’s population drink contaminated water by necessity, and obviously this predisposes to diarrheal diseases. Yet governments in wealthy countries appear to be doing very little to improve the situation. Garrett draws the human population explosion and increasing urbanisation together with the fact that microbes can spread much more easily when people are crowded together. Of course, this is true of SARS-CoV-2 at the moment; the more people that are crowded into confined spaces, the more these viruses are going to have a field day. She’s pointing out that epidemics are at least partly due to our lifestyle, and that there are things that we could do to prevent them. We just don’t take epidemics seriously until they happen. At the time The Coming Plague was published, it was a big eye opener and it became a bestseller. People were talking about it but people in westernised, wealthy countries didn’t do anything about it. This is highlighted again by the SARS-CoV-2 pandemic. Basically, if governments don’t see a pandemic as an immediate threat, not only do they not prepare, they don’t help other countries to prepare. I think people in rich, westernized countries always imagine that these things are just not going to happen to them. Until quite recently that may have been true. But with rapid air travel, you can get from one side of the world to the other in 24 hours, unwittingly carrying a microbe with you. So any epidemic anywhere in the world is a global issue. The Coming Plague came out just when I was writing my first book about viruses, The Invisible Enemy: A Natural History of Viruses , and it certainly stimulated me to get on with it. Yes, I think I should have him for plagiarism! Certainly that’s the message. However, you can repeat it ad infinitum. Governments tend to be so short term they’re generally only looking to fund what’s likely to be important in the next five years. If they can put it on the back burner, they will, and with pandemic preparedness they generally do. So it is disappointing that the West was not better prepared for the COVID-19 pandemic, but not surprising. Even when COVID-19 started in China, nobody in the West took it very seriously. If we’d started preparing for it right then, in December last year, then we might be in a better position now."