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

by John Green

the wealthiest individual in human history was likely Mansa Musa, the fourteenth-century ruler of West Africa’s Malian empire.)

But history, alas, is not merely a record of what we do, but also a record of what is done to us.

tuberculosis is listed in Guinness World Records as the oldest contagious disease.

Immunosuppressive drugs that treat autoimmune disorders like Ulcerative Colitis can also cause TB infections to become active disease, which is why Americans often hear tuberculosis listed among potential side effects in drug commercials.

To try to understand the state of medicine in this era, I sometimes think of the eighteenth-century physician Johann Storch, whose patient histories were the subject of Barbara Duden’s brilliant book The Woman Beneath the Skin.

I want to pause here to note a defining feature of humans, which is that we like to know why things happen, especially why really bad things happen. And if a reason is not immediately apparent, we will find one. I am reminded of a poem in Kurt Vonnegut’s novel Cat’s Cradle: Tiger got to hunt, Bird got to fly; Man got to sit and wonder, “Why, why, why?” Tiger got to sleep, Bird got to land; Man got to tell himself he understand. Vonnegut reminds us that we are both inclined toward curiosity and inclined toward arriving at some kind of comprehensible conclusion.

One analysis quoted in Vidya Krishnan’s Phantom Plague found that “roughly 15% of all deaths in London before 1730 were due to the disease, a percentage that nearly doubled [by] the early 1800s.”

The Indian poet Sukanta Bhattacharya died at just twenty of tuberculosis in 1947. Bhattacharya wrote gut-wrenchingly of the Bengal famine, which was orchestrated by British colonial authorities and resulted in the deaths of perhaps three million people. Bhattacharya’s death was probably hastened by his own experiences during the famine—as we’ve seen, malnutrition can trigger a tuberculosis infection into active disease. “Our history will be shaped by / Hungry stomachs,” he wrote. An Indian newspaper referred to him as “the John Keats of Bengal,” and like Keats he was credited with a wisdom beyond his years tightly linked to his suffering.

TB revealed itself to be not a disease of civilization, but a disease of industrialization; of crowding and intermingling in huge cities with packed tenements and factories where coughed-up particles could linger in the stale air.

History is often imagined as a series of events, unfolding one after the other like a sequence of falling dominoes. But most human experiences are processes, not events. Divorce may be an event, but it almost always results from a lengthy process—and the same could be said for birth, or battle, or infection. Similarly, much of what some imagine as dichotomous turns out to be spectral, from neurodivergence to sexuality, and much of what appears to be the work of individuals turns out to be the work of broad collaborations.

Koch had proven the bacterium caused anthrax by isolating the bacteria and establishing a chain of transmission, which still remains an important tool in bacteriology and virology.

As late as 1880, white American physicians still argued that consumption did not occur among Black Americans, who, it was claimed, lacked the intellectual superiority and calm temperament to be affected by the White Plague. But after Koch identified Mycobacterium tuberculosis in 1882, all that changed.

(Koch essentially invented the concept of using white mice for experiments),

There’s even emerging evidence that one’s microbiome may have a relationship with thought itself through the gut-brain information axis, meaning that at least some of my thoughts may belong not to me, but to the microorganisms in my digestive tract. Research indicates that certain gut microbiomes are associated with major depression and anxiety disorders;

Conan Doyle went home to England and within a decade published his first Sherlock Holmes story, all about a detective who uses reasoning and evidence to reach rigorous conclusions about causes of death, meaning that Holmes’s work was not so distant from that of his author.

The United States of America, Charles Dickens once noted, was “a nation of spitters.” People spit on trolleys and on sidewalks, on restaurant floors and even in the home. Many public health efforts focused on discouraging or even outlawing spitting (public spitting continues to be illegal in many American municipalities), which likely did have some effect on rates of transmission.

In the U.S., entire cities were founded by and for people with tuberculosis, including Pasadena, California, and Colorado Springs, Colorado. Southern California came to be known as especially salubrious, and tens of thousands of people relocated there—a movement of people rivaling the Gold Rush. These “lungers,” as they were known, settled in western towns and the sanatoria that sprung up within them. If patients survived, they often stayed in their new hometowns and began families, reshaping the geography of the United States.

kids with bone-involved TB often contract it from drinking contaminated cow’s milk.

In Sweden, the physician Jürgen Lehmann became intrigued by a paper indicating that exposing tuberculosis to aspirin caused M. tuberculosis to take in more oxygen; he hypothesized that a different acid compound might inhibit the bacterium’s growth by slowing its metabolism. This turned out to be true, with the compound para-aminosalicylic acid (commonly known as PAS) proving the most effective at inhibiting the bacteria’s growth.

graduate students at Rutgers University, including Albert Schatz and Elizabeth Bugie, isolated an antibiotic known as streptomycin, publishing their findings in early 1944. American soldiers with severe infections began receiving the drug a year later. The first patient died. The second survived but was blinded (an occasional side effect of the medication). The third patient was a critically ill young Army officer named Bob Dole, who would survive, and go on to become a U.S. senator, Republican nominee for president, and noted Viagra spokesperson.

TB death rates plummeted—in the U.K., rates of tuberculosis deaths fell by 90 percent in the decade after streptomycin was first introduced.

The discovery of two more antibiotics—ethambutol in 1961 and rifampin in 1966—led to the advent of that RIPE protocol, and soon people began to proclaim that TB was on the edge of eradication.

There is a benefit to systematizing healthcare, to treating everyone like they are everyone else. But there is also a cost.

The real issue is not that TB is uncommonly good at selecting for resistance. The real problem is that in the forty-six years between 1966 and 2012, we developed no new drugs to treat tuberculosis.

This strikes me as one of the stranger choices in human history. Humans, a species that simply can never have enough, somehow decided that five or six anti-TB drugs would be plenty. Why? New classes of drugs to treat bacterial infections are not easy to find, but we know they are possible to find. In the last couple decades as economic incentives have shifted, we’ve been able to develop powerful new medications to treat TB, including bedaquiline and delamanid.

When markets tell companies it’s more valuable to develop drugs that lengthen eyelashes than to develop drugs that treat malaria or tuberculosis, something is clearly wrong with the incentive structure. And we are not stuck with that incentive structure. I know, because the two most recent drugs developed to treat TB, bedaquiline and delamanid, were both funded primarily by public money.

So why wasn’t Henry on bedaquiline? Although most of the money that went into developing bedaquiline came from the public (much of it from the U.S. government), the drug was owned and patented by Johnson & Johnson, which had a monopoly and therefore absolute control over the price. A course of bedaquiline can be produced profitably for $130,[*5] but during their monopoly Johnson & Johnson charged much more than that for a course of bedaquiline, making the drug far out of reach for the Sierra Leonean Ministry of Health. As a result, bedaquiline wasn’t available to Henry, so he received the injectables.

because we haven’t done a good job creating a wide array of TB treatments, a highly infectious and totally resistant strain could emerge. It probably wouldn’t sweep through Earth in a matter of weeks or months—we must remember that TB divides (and sickens) quite slowly relative to most other pathogens, and that it primarily sickens those with immune systems compromised by malnutrition, concomitant illness, or poor living conditions. But TB could once again become the fully global crisis it was until seventy years ago.[*1]

Cancer care even within the U.S. remains wildly inequitable and littered with all manner of price gouging, but no one questioned whether treating my brother’s lymphoma was “cost-effective,” even though it cost a hundred times more than it would’ve to cure Henry’s tuberculosis.

These deaths seemed to be associated with the emerging pandemic now known as HIV/AIDS. In 1985, physicians noted high rates of active tuberculosis disease among HIV-positive patients in Zaire and Zambia. Because untreated HIV lowers resistance to infection, TB infections are far more likely to progress to active disease as the immune system weakens, and that weakened immune system allows TB to kill quickly.

between 1985 and 2005, roughly as many people died of tuberculosis as in World Wars I and II combined.