Everything Is Tuberculosis: The History and Persistence of Our Deadliest Infection

During the 1980s, active TB was commonly observed among patients who also had HIV/AIDS since the latter disease affected the immune system’s capacity to resist TB growth. This rapidly drove a crisis of death across the Global South, in which TB was killing patients faster than doctors could anticipate. Despite the crisis, little was done to bolster TB treatment in the countries that were most affected by a lack of access to healthcare resources. Instead, investment was placed solely in HIV treatment research, which made the disease survivable in Global North nations. Meanwhile, life expectancy dropped in countries like Lesotho because of the lack of access to effective TB and HIV treatments.

The Global North explains this lack of access away as the fault of the Global South nations, which failed to develop their infrastructure and healthcare systems to operate according to Global North standards. This only proves that racism persists in the field of public health, even though the Global North’s claims have no basis in reality. By the mid-2000s, public programs would finally give poor countries access to effective HIV treatment. Furthermore, these programs enabled the development of transportation systems, which aided the dispersal of treatment. These solutions came too late, however, for the millions of people who died in the 20-year period between the start of the crisis and the date that treatment became more accessible.

Green argues that TB is above all “a disease of vicious cycles” (159), exacerbating poverty, healthcare, nutrition, and stigmatization. TB amplifies the injustice of inequitable access.

Henry’s experimental treatment, a cocktail of drugs devised around his comorbidities, was finally secured through the financial aid of Partners in Health, a nonprofit partner that supported Lakka. The success of the drug would allow Henry to become a case study for greater access to drugs that treat drug-resistant TB. While waiting, Henry wrote poems, including one titled “Golden Axe,” about warriors trying to find refuge in battle.

Green summarizes his discussion thus far by stating that Henry’s TB was the result of historical and systemic choices to let TB spread across Sierra Leone. Henry responded to those social forces by making a choice of his home: to stay at Lakka and trust in the struggling healthcare system.

Henry’s treatment arrived at Lakka in a piecemeal fashion. Dr. Girum began the treatment at once, though no one was sure if it would make him better.

Though his symptoms improved over the next week, Henry remained cautious of the treatment’s success. This was underscored by the enforced isolation he endured during treatment. One month later, Henry was walking again and gaining weight. Several months later, the bacteria were absent from Henry’s sputum. Henry’s parents were authorized to visit him again when he was much less infectious. Henry’s father apologized to Dr. Girum, to which he responded that he would have done the same in his position.

Henry finally went home after his new treatment showed steady signs of improvement. He would continue treatment for the next year, but his return home marked the happiest moment of Isatu’s life.

As they started to overcome their experience with TB, Henry and Isatu began to face their next challenge—impoverishment. Isatu told Henry that this challenge was a “constraint,” but what mattered to her was seeing him alive.

Against the cynicism of vicious cycles, Green observes that Henry survived TB because of the existence of virtuous cycles. This manifestation of Henry’s virtuous cycle will go on to save more lives in the future.

Green narrates another virtuous cycle that transpired in Peru in the 1990s. With no national TB program in place, activists pushed the government to implement DOTS in the country. According to the World Health Organization, however, DOTS guidelines provided no special treatment for patients who had drug-resistant TB because it was not cost-effective. Working against the increasing spread of drug-resistant TB, Partners in Health began to operate in Lima, where they offered personalized treatments and support to step in where the government had failed. They did this in the hope of proving the feasible treatment of multiple drug-resistant TB in poor countries, thus kicking off a virtuous cycle. By 1998, a large majority of their patients were cured, driving reforms in the World Health Organization’s DOTS guidelines. When it was discovered that the patents on multiple drug-resistant TB treatments had expired, Partners in Health initiated the development of generic drugs that would make the treatment vastly more accessible.

Green also shares the story of Phumeza Tisile, a South African woman whose initial diagnosis of TB had been missed by microscopy tests. When she was correctly diagnosed with TB, the illness was already advanced enough to resist the impact of antibiotics. During the three years of her treatment, which was influenced by Partners in Health’s work in Peru, Phumeza lost her hearing in both ears but was finally cured and received a cochlear implant. Because of her experience, Phumeza became an advocate for TB patients, protesting Johnson & Johnson’s efforts to extend their patent over bedaquiline in India. Her complaint succeeded, and bedaquiline became more accessible in India. Further protests by other activists and health groups ensured that the drug also became accessible in other low-income countries. The work that Partners in Health did in Peru eventually led to millions of recoveries due to greater access to bedaquiline.

There remains a challenge to make other treatments for drug-resistant TB accessible since the companies holding their patents refuse to look outside their scarcity and profit-motive mentality. Green calls for systemic reforms that help reframe healthcare not as a market-oriented industry but as a basic human priority.

The virtuous cycle doesn’t just enable one to recover from TB: It frees them up to pursue the opportunities that TB hindered them from reaching, such as education and work. Henry, for instance, went on to continue his schooling. He was eventually accepted to the University of Sierra Leone to study human resources. Henry and Isatu now live in a small new house that they were able to secure with the help of crowdfunding. Isatu likewise revitalized her reselling business with the surplus from their crowdfunding campaign.

Henry also went on to start a YouTube channel, where he could share stories of his life and show his perspective of Freetown. He uses the profits from his channel to raise funds for different causes, including improved water utilities and healthcare. He frequently shares videos of Lakka to raise awareness around the hospital’s efforts to treat TB. This awareness campaign extends to sharing his experience as a survivor of TB. Green regularly speaks with Henry, who has become friends with Green’s son, Henry.

Green urges the reader to view illness and healthcare not just as a biomedical issue but as a sociological one, too. The causes of illness should always be seen as interdependent with the social factors that determine health, from food supply to equitable access to goods and services. Without those determinants, patients are disincentivized to complete treatment. Green shares his own experience of availing of a treatment for a small injury at home. He traces the various systems required to make that treatment as accessible and convenient as possible, from the electrical utilities that would help him maintain the efficacy of his treatment to the educational system that would ensure the skills competency of the healthcare workers administering the treatment.

Green points out that this luxury is not universally available. If it were, TB death would become a historical fact instead of a present reality. Green calls for systemic reforms that include the impoverished in receiving essential treatments against common illnesses like TB. These reforms also include improving the social determinants of health, comprehensively improving the quality of life so that healthcare is both accessible and convenient. By excluding the impoverished and restricting access to effective treatment, humanity itself becomes the reason why TB remains the deadliest and most common disease in the world.

Green recommends a comprehensive plan developed by anti-TB advocates called “search, treat, prevent” (STP). This plan not only treats patients infected with TB but also ensures that the chain of transmission is cut before the illness spreads further. It also saves money in the long run by reducing the need for continued expenditures as TB is eliminated. The alternative is to let TB go on as one of the world’s most prolific killers, giving rise to the long-feared superbug. Ultimately, Green calls on the reader to act toward addressing the social determinants of health so that humanity becomes the cure for TB, instead of the cause.

Green discusses the way that his obsession with tuberculosis has affected his work as a writer. His early success in young adult fiction gave him a massive platform to share his interests with the world. He is also cautious of the ways that his use of that platform can unintentionally harm others, which has made him more careful about using it over the years. Discussing the TB crisis on that platform has helped his access to that platform feel more useful. It has also helped him become more aware of the landscape of the TB crisis as it develops. He shares some examples of developments, like the creation of a mobile app called TB Hunters that helps implement the STP plan in Lesotho.

On the other hand, TB researchers are starting to see an increasing resistance to bedaquiline in new strains of TB. This increases the risk of TB all over the world, even as bedaquiline still remains out of reach for millions of people.

Green proposes a way to fathom the 1,250,000 people who die each year from curable diseases. He reminds the reader of Henry and how his life has gone on post-recovery. Henry’s deft use of social media has earned him recognition at his university. Green also shares a link to Henry’s YouTube profile. Green urges the reader to see the shared humanity between themselves and Henry and to relate their experience of life to that of Henry’s. He asks the reader to multiply that by 1,250,000 and then urges them to help in the fight against diseases of injustice.