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BOOK REVIEW

The Shape of Plagues to Come

Robert L. Dorit

Twenty-First Century Plague: The Story of SARS. Thomas Abraham. viii + 165 pp. Johns Hopkins University Press, 2005 (first published by Hong Kong University Press in 2004). $24.95.

Many of us have a romanticized view of the living world as a peaceable kingdom in which only the occasional excesses of Homo sapiens disturb the balance. But, as Thomas Abraham makes clear in Twenty-First Century Plague, the reality is less benign. We, the more than six billion people on this planet, who represent the single largest threat to the world's biological diversity and to Earth's capacity to self-regulate and self-correct, are, ironically, ourselves threatened: We're a vast and vulnerable target for transmissible diseases, low-hanging fruit for any infectious agent able to invade a human host.

For most of our history as a species, we have lived in small, nomadic and relatively isolated assemblages spread thinly on the ground. Yet in the past 600 years (only 30 generations), and particularly in the past 200 years, the human population has increased dramatically in size and density; never before have so many lived in sedentary agglomerations. Combine that trend with the speed and ubiquity of travel over long distances and with the vast global inequities in the distribution of primary and preventive health care, and you have the makings of an epidemiological perfect storm.

Twenty-First Century Plague is a ringside account of the world's recent encounter with the emerging infectious disease SARS (severe acute respiratory syndrome). Engagingly written by an accomplished journalist, the book traces the spread through the human population of a relatively obscure coronavirus, one that previously had infected only animals such as palm civets and ferret badgers. The epidemic began in Guandong Province in China in the fall of 2002 and spread swiftly around the world, infecting more than 8,000 people by the following summer and killing nearly 1 in 10 of them. As the book makes clear, the SARS outbreak was chilling, not so much because of the number of afflicted individuals—which comes nowhere near the toll of HIV or previous influenza outbreaks—but because of what it revealed about our ability to respond to new infectious agents.

How did we do? The verdict is, at best, mixed.

Maddening political, personal and institutional obstacles prevented the sharing of critical information; Abraham is at his best describing the human hurdles to an effective response. In an era in which information could circle the world within seconds, the SARS virus initially outraced vital knowledge about treatment and control. Doctors in Guandong quickly developed basic containment procedures against the spread of SARS, but that information was not conveyed even to health workers struggling with the virus elsewhere in China, let alone to those in the rest of the world. The authorities in the affected countries lost valuable time worrying about the effects that news of the local outbreak might have on their economies and on their personal, national and political reputations. Abraham, who has a keen reporter's eye, moves beyond the press releases extolling international collaboration and preparedness to expose the dissembling and the politicking.

But he also finds a number of heroes: the country doctors and health workers who rushed into affected areas knowing full well that the virus had already infected and killed some of their coworkers; the epidemiologists who traced an outbreak in Hong Kong; the scientists who managed to identify the virus within weeks of the first reported case outside China. Many laboratories coordinated their efforts so that the sequencing of SARS could be completed by mid-April 2003. The epidemic flamed out, first in Vietnam and eventually around the world, and by early July the World Health Organization declared it contained.

In retrospect, this new disease was checked relatively quickly. The success can be attributed in part to the national and international agencies charged with detecting and responding to outbreaks, which reacted courageously but inconsistently. Their efforts were frequently obstructed by individuals and ministries outside the health system. But we also caught a lucky, and unusual, break: SARS, although potentially lethal, is not highly transmissible.

Abraham rightly urges us to demand that the lessons gleaned from the SARS outbreak be incorporated into plans for epidemic surveillance and response. We can be virtually certain that the system will be tested again and again—not by deliberate acts of bioterrorism, where most of our attention is currently focused, but by emerging diseases. Scientists around the world are keeping a wary eye on a new strain of bird influenza capable of moving from its avian hosts into the human population. Other less well-known infectious agents are making similar tentative excursions into our species, probing for weaknesses in our immune defenses. SARS may presage new and more dangerous battles in the long evolutionary struggle between Homo sapiens and its pathogens. Somewhere on the planet, a new organism is evolving to exploit six billion specimens of ready prey.


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