Everything Is Tuberculosis

ROMAN MARS: This is 99% Invisible. I’m Roman Mars. You may know John Green as a YouTuber, a podcaster, or a mega best-selling young adult novelist. But John’s writing goes way beyond novels. His latest book is a nonfiction deep dive into one of the oldest and deadliest threats to humankind. 

JOHN GREEN: You know, if you told me, six years ago, that my next book would be about tuberculosis, I would have been duly surprised. I did not think of tuberculosis as being really much of anything. I thought it was a disease of the past–a disease that killed the guy in Red Dead Redemption 2, not a present tense phenomenon. 

ROMAN MARS: Tuberculosis is, in fact, the single most lethal infectious disease in the history of the world. It’s been infecting and killing humans for millennia. But what makes the story of TB so maddening and what drew John to the topic is that the disease is still killing over a million people a year, despite the fact that we already have a cure. John’s book is called Everything Is Tuberculosis, and in it he describes how foreign policy and corporate greed make TB so hard to eliminate. He also explains the history of tuberculosis and all the unexpected and fascinating ways TB has shaped our world. I really love this book. It is both heartbreaking and triumphant. It is full of fun facts and sober realities. And I really just wanna have John on the show to talk about all the stuff he learned while writing it. 

So, let’s start at the very basics. I realized when I was reading this that I didn’t have a full grasp of what tuberculosis actually was. So, could you tell me about it–as a sort of biological entity–what it does to you? How does it spread? 

JOHN GREEN: Yeah, so it’s a bacterial illness. But it’s a weird bacteria. It’s a bacteria with a really thick cell wall that takes a long time to make. And so, relative to other bacteria, it grows very slowly. Like, I think in a lab environment, it doubles every day, whereas something like E. coli will double every 20 minutes. So, it’s an unusual bacteria, but it also– That thick cell wall makes it hard for infection fighting cells to penetrate. And so usually what actually happens is that a bunch of white blood cells will surround some bacteria and kind of wall it off in what’s called a “tubercle,” which is why we have the word “tuberculosis.” I think it’s technically pronounced “tubercle,” but I don’t like pronouncing it that way. It seems wrong. 

ROMAN MARS: But this weirdness is one of the reasons why it’s kind of both persisted and sort of inveigled its way into culture over thousands and thousands of years. And I’m really fascinated by this. And I am also fascinated by the idea of–before people knew of it as a bacteria–how it was conceptualized. Can you talk about some of the things that you found about how ancient civilizations treated this odd bacterium?

JOHN GREEN: Sure. So, we’ve had tuberculosis or diseases very similar to it for probably all of human history and even further back in the story of people–back to Homo erectus. And so we’ve had a long time to imagine tuberculosis. And over the years, we’ve imagined it lots of different ways. Some people saw it as a contagious illness from the beginning in ancient China and ancient India. It was often seen as contagious. Some people saw it as an inherited illness; especially in Northern Europe and the United States, it was seen as a genetic disease that was associated with certain personality traits. If we go all the way back, we don’t know that much about how we saw tuberculosis. But we know that it’s probably responsible for around one in seven of all human deaths of the 120 billion people who’ve ever lived. About one in seven have died of TB. 

ROMAN MARS: And this is by far the championship killer of humans, correct? 

JOHN GREEN: Yeah, yeah, it’s winning the all-time race in terms of infectious diseases. But it’s also winning the current race, which is especially discouraging, because this year TB will be our deadliest infectious disease, just as it has been for most of human history. 

ROMAN MARS: Yeah. So, tell me about that period of time where tuberculosis was actually called “consumption,” when it was perceived as a genetic malady–a poetic and romantic malady. Could you tell me about that because the real symptoms of tuberculosis–coughing up blood and extreme weight loss–those don’t sound beautiful or poetic. 

JOHN GREEN: Yeah, so tuberculosis has always been a highly stigmatized disease, like any disease that’s seen as very serious and threatening. But at the height of what one person called the “frightful tuberculization of humanity”–at the high of the industrial revolution–tuberculosis was killing about a third of all people. It was killing rich people, poor people… Charles Dickens called it the “disease that wealth never warded off.” It was a disease that could strike anyone anywhere. And so we couldn’t stigmatize it away. We couldn’t say, “Well, this is just a disease of the poor or just a disease of drunk people or just the disease of this marginalized group or that vulnerable group because it was a disease of everyone.” And so, for a period of about 150 years, especially in Northern Europe, it was also a hugely romanticized disease. And consumption was widely seen as an inherited disease. And it was a disease that made you literally more beautiful–made your skin pale and your cheeks rosy and your eyes wide. Even as her sister was dying of tuberculosis, Charlotte Brontë wrote, “Consumption, I am aware, is a flattering malady.” And it was also seen as a disease that made you into a genius. I remember Percy Shelley wrote John Keats when Keats was dying and said, “Well, this consumption is a disease that tends to strike people who write good verses as you have done,” which I find especially interesting because Shelley knew that he also had consumption. So, in some ways, Shelley was like, “You know who else is good? Me.” 

ROMAN MARS: [LAUGHS] Okay, so in the U.S. and Europe, consumption made you this beautiful genius. But then there was a shift from that thinking to seeing it as more of an infectious disease experienced by people who are not privileged. And that shift happens starting in the late 1800s, when scientists discover that tuberculosis is actually a bacteria. 

JOHN GREEN: Yeah, almost like a light switch. Very few things in history are like a light switch, and I’m exaggerating when I say it’s like a lightswitch. It was really, like, a decade. But that’s relatively short. You know, I often have people say to me, “I wasn’t aware that consumption and tuberculosis were the same disease.” And I tell them that that totally makes sense because the way consumption was imagined culturally–as this ennobling disease that made you beautiful, it made you sensitive, it made you write beautiful poetry–is completely different from the way we imagine tuberculosis today. And those are all cultural constructs, but of course that profoundly shapes not just how people live with the disease but also who lives with it and who dies of it. And so, once we understood that TB was infectious, we started to immediately or almost immediately see it as a disease of poverty, of crowded working and living conditions, and of the cities that were called these “tubercular factories of urbanity” or whatever. 

ROMAN MARS: Right. And so once people in the U.S. and Europe figure out that TB is contagious, that leads to this sudden fixation on cleanliness. Can you tell us more about that? 

JOHN GREEN: Oh yeah, an obsession with hygiene. I mean, I think I republish in the book a poster that said, “Do not kiss babies! Your kiss of affection brings the risk of infection!” And that was a big thing–don’t kiss babies–which is, you know… If you’ve ever had a baby, you wanna just gobble them up. But also clean shaves became very popular because there was this so-called “revolt against the whisker,” as people believed that there must be an untold number of bacteria crawling in those whiskers. Little did we know, of course, that half of all human cells are in fact microbial and don’t even belong to us. 

ROMAN MARS: Okay, so this is kind of the part of the story–when people have some purchase as to what causes TB and how it spreads–that I feel like the everything is tuberculosis part of your book, Everything Is Tuberculosis, comes about. We’re talking the very late 1800s, early 1900s. And we start to see the disease influencing the built world and design. So, can you tell me some of the various ways in which everything is tuberculosis? 

JOHN GREEN: Yeah, I mean, tuberculosis shaped history, just as history shapes tuberculosis. And so everything from the Adirondack chair, which was invented to give people living with TB a chance to sit at a very specific position so they could ostensibly get more oxygen into their lungs, to the great state of New Mexico… New Mexico had all the institutions needed for statehood and was seeking statehood. And the U.S. Congress turned them down again and again because so many people in New Mexico did not speak English as their first language or were indigenous people. And the U.S. just didn’t want to include a state like that, to be frank, because of racism. And so people in New Mexico were like, “Man, we got to recruit some white people if we’re gonna become a state.” And the way they did that was by reaching out in cities to people who were living with consumption or tuberculosis and saying to them, “Hey. Come to New Mexico. Big skies. Clean air. Dry air. You can dry out those wet lungs of yours.” And it worked. It was a big part of the reason why–not the only reason obviously–Congress finally relented and brought New Mexico into the union. And by the time New Mexico did become a state, over 10% of all people in the state were people living with tuberculosis. 

ROMAN MARS: And one of my favorite things from this part of the book is the story about tuberculosis and cowboy hats. 

JOHN GREEN: Yeah. Cowboy hats definitely wouldn’t exist–or at least not as we have them today–because John B. Stetson was a hat maker living in New Jersey when he got sick with tuberculosis and was told to go west. And when he went west, he eventually recovered. We don’t know why about 25% of people will eventually recover from their active disease and go on to live long, healthy lives. But some do. We’ve never understood that and still don’t fully. But John B. Stetson was one of those who recovered. And when he recovered, the first thing he thought was, “I think I can improve these hats.” And that’s how he came up with the Stetson hat. 

ROMAN MARS: Because, heretofore, what were hats like in the West? 

JOHN GREEN: So, they had, like, coonskin caps in the west, which were literally bug-infested, right? Disgusting. And then they had straw hats that were brought up from people who lived in Mexico or Texas, which worked great, except when it rained, when they weren’t particularly waterproof. And so John B. Stetson was like, “Oh, I can solve this problem–easy. I’m literally a hat maker. I know how to do this.” 

ROMAN MARS: [CHUCKLES] Okay, so another invention that you write about that’s related to TB is the sanatorium, which is a type of building that we don’t see built or used anymore but was a huge part of society during the late 1800s. Can you talk about the sanatorium boom in Europe and the U.S.? 

JOHN GREEN: I mean, nowadays, these sanitoria… I don’t know if this is your relationship with them, but they’re primarily, like, urban exploring spaces. 

ROMAN MARS: [LAUGHING] Exactly, yeah. 

JOHN GREEN: You know? Like, they’re mostly sort of abandoned buildings in the middle of weird places that 27 year olds go to feel alive. 

ROMAN MARS: That’s right. 

JOHN GREEN: But at the height of the sanatorium craze, there were almost as many hospital beds in the United States in sanitoria as there were in all hospitals combined. These huge buildings where people living with TB would be sent or would go in order to try to recover their health–these places were all often in rural places or in… Mountain air was one way that people tried to respond to TB. Dry air was another way. California advertised itself as the “land of new lungs” to try to encourage people. I think almost as many people went to California seeking treatment for TB as went to California during the gold rush, actually. So, it was quite a movement of people all around. 

ROMAN MARS: And all they’re doing inside these sanatoria is just sequestering people to rest with their tuberculosis. It’s not really a treatment center. 

JOHN GREEN: No, it was a rest center. So, they would call it curing. And you would have to cure for eight or ten hours a day. And when you were curing, you’d often be outside trying to take in the sunshine. But you couldn’t move. You were discouraged from talking in many cases. You were discouraged from having visitors because that could excite your nervous system, which was seen as worsening TB. And so it was a really highly, highly controlled life. 

ROMAN MARS: So, let’s talk about the cure for tuberculosis. At what point did people figure out how to fight it rather than just live with it? 

JOHN GREEN: We didn’t have a cure until the 1940s, when the first antibiotics were synthesized. And that was just a game changer for tuberculosis. I mean, when my great uncle died of TB in 1930– His name was Stokes Goodrich. And when he died of TB, there was just nothing that could be done. They put him in a sanatorium. He had the best care that money could buy, and he died anyway. And that was the story over and over again. But once we started developing antibiotics in the 1940s and then eventually by the early 1950s realized that we could use these antibiotics in concert with each other as a kind of cocktail–we could not only treat the disease and have it retreat, but we could cure it! And in that moment, hundreds of thousands of people who were living in sanitoria were suddenly able to go home–live their lives. It was an utter miracle–a scientific miracle of the highest order. Between 1945 and 1965, we developed seven or eight different classes of antibiotics that can fight TB. It was this hugely successful period in the fight against the disease. 

ROMAN MARS: In the 70 years since we found a cure, tuberculosis has been effectively wiped out in Western countries thanks to a combination of prevention, widespread TB testing, and powerful antibiotics. But throughout the Global South, not only has TB persisted, it is thriving. After the break, we’ll talk about how a disease with a cure can still be killing millions of people and what the future of TB might hold. 

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ROMAN MARS: We are back with John Green talking about his new book, Everything Is Tuberculosis: The History and Persistence of Our Deadliest Infection. So, you read about how, even though TB has been deadly for so long and still is, we have developed some very effective ways for preventing TB and surviving the infection. So, can you talk about that? 

JOHN GREEN: So, there’s just the functional advance of the drugs themselves, but there’s also advances in terms of how we distribute that stuff. So, in the 25 years since I graduated from college, TB deaths have dropped by about 50%. And a lot of that’s due to investment, especially by the U.S. government. The U.S. government has long been the leading funder of TB research and also TB response overall. Also, other governments stepping up have played an important role in places, from Sierra Leone to the Philippines. So, that’s the key to distributing this stuff at scale. But there’s also been other major innovations in terms of our ability to detect TB earlier and then also to offer preventative care. So, we can offer a shorter course of antibiotics to somebody who’s been exposed to TB to make sure they never get sick. And that can be a very effective way of stopping chains of transmission. 

ROMAN MARS: Yeah. Another key component to tuberculosis–because the way it functions biologically–is, like, detection is almost as important as the drugs to treat it. Can you talk about the role of detection when it comes to tuberculosis? 

JOHN GREEN: Yeah, detection is super, super important. It helps to detect the disease earlier because then you don’t have permanent lung damage. And we have these wonderful tools that we’ve had for a long time, called chest x-rays, where you can tell pretty quickly if someone has tuberculosis. We also have now, over the last 10 or 15 years, developed these incredible molecular tests that, in about two hours, can tell you not just if someone has TB but which antibiotics their TB will respond to. Total game changers. Unfortunately, they’re really expensive. I was in a lab once in Sierra Leone, and I saw their GeneXpert machine. And I said, “Oh, you have a GeneXpert machine. That’s so cool.” And he was like, “Yeah, if only we could afford the tests.”

ROMAN MARS: Oh, my god. Well, what really struck me when I was reading your book is that there’s a real contrast between the West and the rest of the world. 1.25 million people still die of TB every year, mostly in the global South. And that number is insane to me because this is a disease that we cured. So, why is TB still a problem for so much of the world? 

JOHN GREEN: Right, so there’s a lot that goes into this question. TB is a curable disease, but it’s not easy to cure. Like, when we think about antibiotic-related bacterial infections, a lot of times we’re thinking about, like, a strep infection in our throats or that kind of thing, which can be treated with seven to ten days of antibiotics. TB requires at least four months of daily antibiotics taken in a very specific cocktail–often six months–sometimes longer. And it is onerous because we still often use a strategy called “directly observed therapy,” where you have to be seen by a someone who isn’t in your family taking your medication each day. And if for some reason you couldn’t get to the clinic–if you were too sick, if you couldn’t afford transportation, or whatever that is–then you wouldn’t be able to access your medication and you could experience an interruption in treatment. 

ROMAN MARS: Right. And you actually talk about one patient that you met at a TB hospital in Sierra Leone. And you get into how his story shows exactly how incredibly expensive and hard it can be to access good treatment. So, tell me about meeting Henry.

JOHN GREEN: Yeah. So, in 2019, my wife, Sarah, and I were visiting Sierra Leone with Partners in Health to learn about the maternal health care system there, which Sarah and I have been working with PIH on strengthening with the government for a long time. And on the last day of our trip, a couple of the doctors we were traveling with asked if we could visit the TB hospital. And when I got there, I opened the car door. And this kid was right there, and he just physically grabbed me by the t-shirt and started walking me around the hospital. And I learned that his name was Henry, and that’s also my son’s name. And he looked about the same age as my son. And I just was immediately taken with this kid. He was so charming and charismatic. And he took me to the lab. He took me to the wards. I was astonished by how sick people were. I had never… You know, I’ve worked in hospitals and stuff, but I’d never seen that many people that sick in one place before. And he took me to the kitchen where the food was made. And then eventually we made our way back to the doctors, and they kind of shooed him away. And I said, “Whose kid is that? Is that one of y’all’s kids?” And they said, “No. That’s one of the patients we’re really concerned about actually.” And it turns out that Henry wasn’t nine like my son was. He was 17. His body had just been stunted by malnutrition and then by TB, and… I mean, Henry probably first got sick when he was five or six with TB. And he started to get treatment, but then that treatment was interrupted, which happens sometimes. And when that happens, you have a much higher chance of developing drug-resistant TB. And that’s what happened to Henry. He developed a strain of tuberculosis that was resistant to our first-line antibiotics. And when I met him, he seemed to be in good health. But the doctors already knew that the second-line antibiotics were failing–that they’d succeeded in pushing back the disease but now the disease was beginning to roar back. When those second-line antibiotics fail–it was called the “injectable regimens”… When those injectables fail… You know, I had one doctor tell me that’s when you put the stethoscope down–that there’s just not much you can do. And that is the case for the vast majority of people who are like Henry. 

ROMAN MARS: Yeah. It’s really heartbreaking. One of the other obstacles that countries run into is the exorbitant cost of care. The GeneXpert TB testing machine that you talked about–which costs about $25 to test one person–that’s more than half of what Sierra Leone spends on healthcare per person each year. And then there’s the greed of the pharmaceutical companies, which can charge whatever they want to for life-saving drugs. But you also say that there’s been some successful pushback against that. 

JOHN GREEN: Yeah, so f 1966 and 2012, we didn’t develop any new drugs to treat tuberculosis, which was a real catastrophe. But then in 2012, we did develop some new ones, the most important of which is probably bedaquiline, which is a drug that was… The research and trials for it were funded primarily by public money, primarily by the U.S. government. But the patent is actually owned by Johnson & Johnson, a pharmaceutical company. And when their patent expired, they tried to file a secondary patent–not on the drug itself but on a compound that makes the drug more effective. And TB activists in India very smartly went to court and said, “Look, this is not real innovation. This is just a company trying to extend its patent forever. And after they extend their patent because of this compound, they’ll find another compound to extend the patent for. And we’ll never get this drug’s price down.” And price is a huge barrier–I mean a huge, huge barrier. This is why people are dying–it’s because of price. I mean, getting the drugs where they need to be is a challenge, but price is the biggest barrier. And the Indian court was like, “Yeah, there’s no real innovation in this compound. This is just an attempt to evergreen a patent.” And so, in India, it became possible to get generic bedaquiline. But in almost all of the world, there was still the secondary patent stopping generic production. And lots of people came together and pressured Johnson & Johnson to abandon their secondary patents, which–to their credit–they eventually did completely so that now the price of bedaquiline, in just two years, has gone down by over 60%. 

ROMAN MARS: So, we are living in a particularly devastating moment right now for tackling TB. Since January, the Trump administration has cut USAID and pulled the U.S. out of the World Health Organization. We’ve eviscerated international aid programs that funded treatment for tuberculosis. And there’s also looming threats to drug research. And even here in the U.S., where we’d almost eliminated TB, we’ve been seeing cases rise in the last several years. And as someone who’s been looking closely at the history of TB, I’m curious how this moment is landing for you. 

JOHN GREEN: Yeah, I mean, you know… Not to put too fine a point on it, but I would like to live in a world where whatever the deadliest infectious disease is, it’s one we don’t know how to cure, right? At least then it’s a technology problem, not a culture problem, not a failure of human built systems, and not a failure of extractive capitalism. It’s just that we don’t have something figured out yet. With TB, we have it figured out. We know what to do. We’ve done it before. And then, almost all at once, there’s been this absolute devastation of watching us walk away from that progress. And not just… And the real problem is that you don’t just walk away from progress, you embrace regression. That’s what we’re doing right now. We’re embracing an actively worse world. 

ROMAN MARS: And how do you see these cuts hitting people in the world with TB? 

JOHN GREEN: It’s just devastating. I mean, we’re going to see the number of people who die from TB go up. Every single person right now who’s had their treatment interrupted… And we don’t even know how many people that is, but it’s tens of thousands–hundreds of thousands. Every single one of those people–even if they get back on medication in the next few weeks–it’s likely that, in many of those cases, that medication won’t work anymore because the bacteria will have had an opportunity to evolve resistance. And to have done that so chaotically, so suddenly, without any warning, across the board, with an ax rather than a scalpel–I don’t know how to express the devastation I feel. I mean, I don’t feel hopeless. I don’t feel despair. I refuse to feel hopeless. But it’s been a long time since I was this discouraged. 

ROMAN MARS: What are some of the things that have happened specifically that you’ve seen sort of, like… What has been shut and changed? What sort of protocols have been altered? What is it that is causing this regression?

JOHN GREEN: So, almost immediately, there were stop work orders issued related to almost all TB response, HIV response, and malaria response. But the word was that there were exceptions for life-saving medication. That’s what everyone was told. Now, functionally, as far as I could tell–and I have a lot of friends in this space and I work with a lot of people–very little money was actually moving, if any. And so you can say that life-saving medication is flowing, but it wasn’t. Instead, I would get pictures from friends of warehouses full of TB medication just rotting in the warehouse for want of a continued work order. And then, more recently, all or almost all TB response was just cut completely–just ended. And that’s the case for malaria response as well–for a huge percentage of our HIV response. And it’s just devastating. So many people are gonna die. 

ROMAN MARS: Just like you, I am incredibly discouraged by this moment. It feels like an unimaginable amount of cruelty to allow this stuff to happen. And I don’t want to put you in a position where you have to provide us with hope, but could you share anything that you’re feeling in terms of what could be done–what would put us on the right path? 

JOHN GREEN: Yeah. I mean, the nature of being a person is that you feel like today is the last day of human history because it’s the last day of the human history you’ve lived through. It feels like the end of the story. “I started out zero, and then I ended up 47. And that’s the story of my life.” Right? But of course, that’s not the story of my life, hopefully. Hopefully, this isn’t the last day. This is not the end of the story. It feels like the end of the story because it’s the last bit I’ve lived through. But it’s the middle of the story. And so that’s why we have to fight and scrap and continue to be hopeful–because it is the middle of the story. And I really believe that the end of the story for tuberculosis is the end of tuberculosis–this disease that has been with us for the whole 300,000 years that we’ve been here. How amazing would it be to be able to live in a world where that’s no longer a public health threat? Well, we can live in that world. And right now we’re taking steps away from living in that world, but those aren’t the last steps we’re ever gonna take. 

ROMAN MARS: John, I’ve had such a great time talking with you. I really loved it, and I love the book so much. 

JOHN GREEN: Thank you for having me. Thank you for offering to read the book and for just being such a kind soul in the world right now. 

ROMAN MARS: 99% Invisible was produced this week by Christopher Johnson and edited by Kelly Prime, mixed by Martine Gonzalez, music by Swan Real and George Langford. Cathy Tu is our executive producer, Kurt Kolstad is the digital director, Delaney Hall is our senior editor. The rest of the team includes Chris Berube, Jason De Leon, Emmett Fitzgerald, Vivian Lay, Lashma Dawn, Joe Rosenberg, Jacob Medina Gleason, and me, Roman Mars. The 99% invisible logo was created by Stefan Lawrence. We are part of the SiriusXM podcast family, now headquartered six blocks north in the Pandora building in beautiful Uptown, Oakland, California. 

You can find us on Bluesky, as well as our own Discord server. There’s a link to that as well as every past episode of 99PI, including one where I talked to John Green about his book and podcast, The Anthropocene Reviewed, which is actually one of my favorite episodes. You will find it at 99pi.org.