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

Several years before the book, Green and his wife, Sarah, were in Sierra Leone to study national maternal and neonatal healthcare. Before flying back to the United States, their guide made a detour to Lakka Government Hospital, a TB facility supported by a global health organization called Partners in Health, to consult the staff. Green had little awareness of TB at the time, imagining it as a disease of the past.

Green met a boy named Henry—Green’s son’s name. Henry toured Green around the hospital to show him the research facilities. The hospital reminded Green of a prison with its inferior utilities and barred windows, harkening to its past as a leprosy isolation facility.

Green assumed that Henry was the son of a staff member, but a doctor clarified that Henry was a patient at Lakka. Henry only resembled a child because of malnourishment, but he was 17 years old. Henry was on antibiotics, though the doctor was not optimistic that treatment would succeed. After learning this, Green realized that he started thinking of Henry differently.

Green asked Henry about his treatment and the pain and hunger that come with active TB treatment. In the present narrative, Green refers to another Lakka patient named Marie who was severely affected by hunger and dreamed of eating as the infection weakened. At Lakka, food resources were sometimes so scarce that patients stopped treatment to quell their hunger. This worsens infection.

The nurses at Lakka assured Green that they would fight for Henry’s well-being because of the adversity he’d faced in his early life. During his time at Lakka, Henry’s most frequent visitor was his mother, Isatu. Green was not assured that Henry would be okay.

After his visit to Lakka, Green grew obsessed with the history of TB. He found ways to link any topic of conversation to TB.

John B. Stetson moved out to the American West after contracting TB: The dry air of the rural West was considered TB treatment. He settled in St. Joseph, Missouri, where he successfully recovered. While living there, Stetson noticed that residents needed a new kind of hat that would resist bug infestation, unlike the coonskin cap, and that would be waterproof, unlike the straw hat. Stetson invented the cowboy hat in 1865, commonly called the Stetson.

New Mexico became part of the United States in 1912 after a successful campaign to draw white English-speaking consumptives from neighboring territories.

World War I was triggered by the assassination of the Austro-Hungarian Archduke Franz Ferdinand by Gavrilo Princip. Princip and his co-conspirators had TB, making them eager to commit a revolutionary act on Serbia’s behalf before the disease killed them. Though they were apprehended and incarcerated, Princip and his co-conspirators died of TB.

Green cautions against suggesting that TB necessarily caused these historical developments since history is complex. What is more important to his book is the question of how culture has grown around the phenomenon of TB.

Contrary to popular belief, Sierra Leone is especially wealthy due to its varied mineral reserves. Following its independence from the British Empire in 1961, Sierra Leone attempted to shift away from its extraction-dependent economy since many of the mining companies remained owned by foreigners. The struggle for independence accounts for the country’s present-day impoverishment. This is evident in the country’s railway system, which isn’t designed to connect the country’s towns and cities but to transport minerals to seaports for exportation. Colonial development deprived local communities of the infrastructure necessary to achieve a stable quality of life.

Green traces Sierra Leone’s colonialist history, which began with the British terrorizing the local population before the country even became an imperial protectorate. This was exacerbated by the transatlantic slave trade throughout the 18th and 19th centuries, when hundreds of thousands of men, women, and children were kidnapped and sold as enslaved people. At the end of the 18th century, some enslaved people were emancipated by the British Empire for their service in the American Revolutionary War. Led by a Black Loyalist named Thomas Peters, they settled in Freetown, the capital of Sierra Leone. This became the British Empire’s go-to settlement location for emancipated people, especially once slavery was outlawed in 1807. The descendants of these settlers became known as Krio, which is also the name of their language.

Green argues that while Sierra Leoneans are economically poor, they possess the wealth of multidimensional diversity. Their vulnerability to crisis owes itself to the historical exploitation of West Africa by European colonizers, who coveted the region’s material resources.

Isatu was born seven years after Sierra Leone gained independence from the British Empire. Green draws a complex portrait of Isatu’s childhood. She grew up in a village where malnutrition was common, but she found joy in her education, religion, and social circle. This was interrupted by a civil war in 1991. The war threatened the lives of her entire community, prompting her family to move to Freetown for safety. Isatu met Henry’s father in Freetown and became pregnant with Henry just as the war reached the city. By the end of the war in 2002, Isatu cared for Henry and his younger sister, Favor, instead of pursuing higher education.

Green suggests that humanity shies away from discussions of disease because the pain associated with illness contradicts the bias toward human agency. While it is commonly known that people have experienced TB for at least 5,000 years, genetic studies show that other hominid species have experienced diseases resembling TB for millions of years. Green cites references to TB in ancient Chinese and Greek medical literature, which underscore its symptoms. TB infected rich and poor people alike. American railroad magnate Jay Gould, English King Henry VII, and Eleanor Roosevelt all died from TB.

The varied manifestations of TB caused different classical cultures to provide their own theories on what caused the illness, from overexertion to fatigue. The Persian scholar Ibn Sina was the first to propose that TB was caused by “foreign organisms,” though no effective treatments would result from his speculation for 700 years. Early treatments included rest, the application of buzzard fat to the chest, and bloodletting.

Green traces the strangeness of TB to the microorganism Mycobacterium tuberculosis (M. tuberculosis), which is present in more than 2 billion people in the present day. M. tuberculosis has an extremely slow growth rate, taking longer to manifest illness in an infected person. Its slowness enables it to develop thick cell walls that resist conventional immune system responses. Instead of destroying the microorganism, the white blood cells inadvertently fortify it, creating a tubercle. This gives the bacteria enough space and time to grow without manifesting symptoms, a condition known as latent TB. In some cases, the bacteria attach themselves to the lungs, which causes the active illness that leads to death. This can happen between two years and several decades from the initial infection. Factors that influence active TB include a compromised immune system, exhaustion, and air pollution. Most people who have active TB die, while others experience unpredictable responses, including permanent disability.

In 1804, effective local remedies existed for certain tropical diseases, like malaria and smallpox. People could not yet trust in surgery, given the lack of sanitation infrastructure and protocol. Illness was generally perceived as an imbalance between four humors in the body. Diagnosis was reached by detective-like observation and patient history. Doctors derived a set of symptoms that pointed to infection with TB, including weight loss, intense perspiration, and the coughing of blood. The last of these symptoms remains cultural shorthand for TB infection today. Green points out, however, that TB can infect other organs, too. This deterred the belief that TB was the cause of so many deaths during this time.

As a young boy, Henry was energetic and outgoing. His increasing lethargy at age six concerned Isatu. Isatu was already facing the burdens of paying for both of her children’s schooling, especially after Henry’s father left them. Henry’s first microscopy tests came back negative for TB; Green points out that microscopy is an unreliable method for TB diagnosis. It was only later that both Henry and Isatu were diagnosed with TB. They traveled to the clinic each day for the standard treatment of four medication drugs.

Henry was responding well to medication until his father demanded his removal from treatment for religious reasons. Green attributes Henry’s father’s skepticism of healthcare to the recent end of the civil war, which had left much of the country’s healthcare infrastructure in a substandard state. Green also calls attention to the way people frame illness in their imagination, citing the stigmatization of people who had leprosy in medieval times. More recently, Green’s view of his own experience with pathological anxiety has shifted from thinking of it as a personality trait to viewing it as a treatable illness. The shift only occurred because treatment has improved.

Henry was put back on medication when his father’s faith-healing treatment failed. Soon, Favor was diagnosed with a benign tumor in her larynx. Despite her attempts to raise money, Isatu was unable to afford the surgery. Favor died at age seven, devastating Henry.

In the 2010s, Sierra Leone was struck with an outbreak of Ebola. This caused the national healthcare system to collapse, killing many industry professionals. As a result, an influx of global funding helped develop treatment units to contain the crisis. Once the crisis started to die down, funding halted, which prevented researchers from completing projects that would have helped prevent further crises. Rather, the crisis ended while the country’s healthcare system remained depleted.

Despite his fervent wish to return to school and live a “normal life,” Henry saw his condition worsen during the Ebola outbreak. In 2016, a chest X-ray showed that his disease had advanced. Had the molecular tests available in rich countries been accessible to Henry, he would have discovered that he had drug-resistant TB, a strain that inoculated the bacteria against at least three drugs on the first two lines of treatment. Because this strain was not identified, Henry was given standard treatment, which led him to grow sicker. The TB reached his lymphatic system, and after two years of treatment, Henry was diagnosed with the drug-resistant strain. He was transferred to Lakka, the only facility that treated the strain. Lakka had the reputation as the hospital where TB patients died.