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

by John Green

We are powerful enough to light the world at night, to artificially refrigerate food, to leave Earth’s atmosphere and orbit it from outer space. But we cannot save those we love from suffering. This is the story of human history as I understand it—the story of an organism that can do so much, but cannot do what it most wants.

Still, over a million people died of tuberculosis in 2023. That year, in fact, more people died of TB than died of malaria, typhoid, and war combined.

Covid-19 displaced tuberculosis as the world’s deadliest infectious disease from 2020 through 2022, but in 2023, TB regained the status it has held for most of what we know of human history. Killing 1,250,000 people, TB once again became our deadliest infection. What’s different now from 1804 or 1904 is that tuberculosis is curable, and has been since the mid-1950s.

We know how to live in a world without tuberculosis. But we choose not to live in that world.

“Where are the drugs? The drugs are where the disease is not,” Dr. Mugyenyi said. “And where is the disease? The disease is where the drugs are not.”

Today, we understand tuberculosis as an infection caused by bacteria. TB is airborne—it spreads from person to person through small particles contained in coughs, sneezes, or exhalations. Anyone can get tuberculosis—in fact, between one-quarter and one-third of all living humans have been infected with it. In most people, the infection will lie dormant for a lifetime. But up to 10 percent of the infected will eventually become sick, a phenomenon we call “active TB.” People are especially likely to develop active TB if they have a weakened immune system due to other health problems like diabetes, HIV infection, or malnutrition. In fact, of the ten million people who became sick with TB in 2023, over five million also experienced malnutrition. And because the disease spreads especially well in crowded living and working conditions like slums and poorly ventilated factories, tuberculosis has come to be seen as a disease of poverty, an illness that walks the trails of injustice and inequity that we blazed for it. The world we share is a product of all the worlds we used to share. For me at least, the history and present of tuberculosis reveal the folly and brilliance and cruelty and compassion of humans.

“Nothing is so privileged as thinking history belongs to the past.”

Looking at history through any single lens creates distortions, because history is too complex for any one way of looking to suffice.

In the Global North, we still sometimes hear about the benefits of colonialism, how it brought roads and hospitals and schools to colonized regions, but this perspective is not supported by strong evidence. In 1950, life expectancy in Britain was sixty-nine. In Sierra Leone, after 150 years of colonial rule, life expectancy was under thirty, relatively similar to the life expectancy of premodern humans who lived five thousand or fifty thousand years ago. In general, colonial infrastructure was not built to strengthen communities; it was built to deplete them.

It is a strange fact of human history that we tend to focus so little on disease. In my college survey course about the history of humans, I learned of wars and empires and trade routes, but I heard precious little of microbes, even though illness is a defining feature of human life. As Virginia Woolf wrote in On Being Ill, considering “what wastes and deserts of the soul a slight attack of influenza brings to light…it becomes strange indeed that illness has not taken its place with love, battle, and jealousy among the prime themes of literature.”

“Pain is in the body. It leaves no trace for the historian, unless complaints about it are recorded.” But I wonder if we also ignore illness because of our bias toward agency and control. We would like to imagine that we captain the ships of our lives, that human history is largely the story of human choice. Perhaps this is why rumors have swirled for millennia that Alexander the Great died of poisoning even though he almost certainly died of typhoid or malaria. We simply don’t want a world where even the most powerful emperor can be felled by mere infection. But history, alas, is not merely a record of what we do, but also a record of what is done to us.

TB was one of the few infectious diseases present in both the Americas and Afroeurasia before the Columbian Exchange began in 1492; archaeological evidence indicates that TB was in the Americas at least two thousand years ago,[*1] and it has been present in China for at least five thousand years. But recent genetic evidence indicates that the story might go back much further—our species is perhaps three hundred thousand years old, but it seems that other species of hominids were being infected with consumption-like illnesses three million years ago. In fact, tuberculosis is listed in Guinness World Records as the oldest contagious disease.

In ancient China, TB was known by a term that translates to “lung exhaustion.” In ancient Hebrew, TB was called schachepheth, meaning “wasting away,” and is mentioned in the Tanakh. The famous Greek doctor Hippocrates wrote about TB, too, which as we’ve learned was known in Greek as phthisis, derived from a word meaning “to decay.”

All these names—whether they focus on the destruction of the bodily palace or physical disappearance—reference an important facet of tuberculosis, which is weight loss and wasting caused by lack of appetite and extreme abdominal pain. This is also why TB was widely known as “consumption” until the twentieth century—it seemed to be a disease that consumed the very body, shrinking and shriveling it. Over eight hundred years ago, Daoist priests began referring to the illness as shīzhài, or “corpse disease,” because the illness transforms a living being into a cadaver.

Unlike many other diseases, for most of human history, consumption appeared indiscriminate, killing the rich and the poor, the foolish and the brilliant.

Right now, over two billion people have been infected with a microorganism called Mycobacterium tuberculosis. This speaks to just how infectious tuberculosis can be: The average untreated case of active tuberculosis will spread the infection to between ten and fifteen people per year.[*2] One might acquire TB on a crowded city bus, or from lying next to a sick person at night, or working near them. Less commonly, we can also contract tuberculosis from other mammals—by eating infected seal meat, or by drinking raw milk from infected cows.

M. tuberculosis grows so slowly because it takes a long time to build its unusually fatty, thick cell wall, which is a formidable enemy to the immune system. White blood cells struggle to penetrate the cell wall and kill the bacteria from within. In fact, it’s so hard for infection-fighting cells to penetrate the bacteria’s cell wall that, instead, white blood cells usually surround it, creating a ball of calcifying tissue known as a tubercle.[*3] The TB bacteria can survive within these tubercles, replicating very slowly, consuming dead tissue as food. This type of infection, sometimes known as latent tuberculosis, will often last a lifetime without ever making a person sick. Most people infected with TB will never become ill because the tubercles will continue to hold the bacteria within them, preventing active disease from developing. But in 5 to 10 percent of infections, the immune system can’t produce enough white blood cells to surround all the bacteria with tubercles, and M. tuberculosis is able to grow and grow within the lungs or elsewhere. The body is slowly overwhelmed by infection (and the immune system’s resulting inflammation), eventually leading to death.

Most active tuberculosis illnesses occur within two years of initial infection, but sometimes the infection can lie dormant for decades before suddenly exploding into active disease. Often, the factors leading to active disease are clear—a compromised immune system from HIV, malnutrition, stress, or air pollution all might trigger the disease into life. 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. But other times the causes are mysterious—something in the body’s balance shifts, and slowly the body is overwhelmed with bacteria.

Once the disease becomes active, its course is extremely unpredictable. For reasons we don’t fully understand, some patients will recover without treatment. Some will survive for decades but with permanent disability, including lung problems, devastating fatigue, and painful bone deformities. But if left untreated, most people who develop active TB will eventually die of the disease. Their lungs collapse or fill with fluid. Scarring leaves so little healthy lung tissue that breathing becomes impossible. The infection spreads to the brain or spinal column. Or they suffer a sudden, uncontrollable hemorrhage, leading to a quick death as blood drowns the lungs.

Classically, what we now understand to be TB was seen as several different diseases. From the pancreas to the spinal cord to the lymphatic system to the brain, a tuberculosis infection can cause a wide array of illness, from brain swelling (tuberculous meningitis) to the rupture of infected lymph nodes through the skin (scrofula) to tuberculosis of the bone, which can cause lifelong disability through destroying hip, spine, or limb bones. TB affecting the spine, known as Pott’s disease, is a common and terribly painful cause of a hunched back (the fictional hunchback of Notre Dame suffered from Pott’s disease).

When Henry first got sick, he was treated—like almost everyone diagnosed with TB in poor countries—with the RIPE drugs,[*2] a combination of Rifampin, Isoniazid, Pyrazinamide, and Ethambutol. You probably don’t need to remember the names of these drugs, but it’s worth noting that all four of them are over fifty years old, and many forms of tuberculosis have developed resistance to one or more of the drugs, a condition known as drug-resistant TB, or DR-TB.

When I was initially diagnosed with an anxiety disorder in the late 1980s, the first SSRI medications were very new. Pathological anxiety was not seen primarily—at least among my peers and caregivers—as a biomedical phenomenon, but instead as an overdeveloped personality trait. It was as likely to be healed by faith as by science. (In fact, I found great relief from my anxiety through religion and ritual.) Today, in my community, anxiety is more likely to be imagined as an illness to be treated through the healthcare system. I would argue this shift happened largely because the healthcare system got better at treating anxiety—not only with pharmaceutical interventions (although those have been very effective for many, including me) but also with stronger evidence-based therapy practices like exposure and response prevention therapy for obsessive-compulsive disorder or cognitive behavioral therapy for general anxiety disorder. And so we must remember that illness is not only a biomedical phenomenon, but also a constructed one, and how we imagine leprosy or OCD or tuberculosis matters. In a place where the formal healthcare system is not particularly effective at treating an illness, it is easy to imagine how more trusted spaces and people—like churches and faith healers—can be a better bet than doctors and hospitals.

A few years after Favor’s death, and just over a decade after the civil war ended, Sierra Leone was devastated by an outbreak of the hemorrhagic fever Ebola. The already fragile healthcare system completely collapsed. Because most clinics lacked clean water and protective equipment like gloves and masks, many healthcare workers were infected with Ebola. At least 221 Sierra Leonean healthcare workers died of Ebola between 2014 and 2016, including many of the nation’s most experienced physicians, nurses, and community health workers. Ophelia Dahl, co-founder of Partners In Health, has described such crises as “acute-on-chronic.” Chronic impoverishment and failures of resource distribution fuel acute crises like the Ebola epidemic. Ebola is difficult to treat even in rich countries but was almost impossible in Sierra Leone in 2014.[*3]

“Death is natural. Children dying is natural. None of us actually wants to live in a natural world.”

Treating disease—whether through herbs or magic or drugs—is unnatural. No other animals do it, at least not with anything approaching our sophistication. Hospitals are unnatural, as are novels and saxophones. None of us actually wants to live in a natural world. And yet we tell ourselves that some—and only some—lives end naturally (which really means “acceptably” or “well”). We construct ideas about what constitutes a good time and manner of death. I recently asked my ten-year-old daughter what constituted a natural death. “Well, you have to be old,” she said. “At least seventy-five. And you should probably be asleep.”

There were simply too many cases for consumption to be understood as a disease caused by immorality or weakness. Something had to be done—if not about the disease, then at least about our imagining of it. And so, in the eighteenth and nineteenth centuries, Europeans came to romanticize consumption, to see the illness as beautiful and ennobling. It’s tempting to imagine this romanticization as the opposite of stigmatization—rather than discounting people as stigma does, romanticization lifts them up as paragons of beauty or intellect or some other virtue. But really, I see these as complementary strategies used to make the sick into an “other,” a group of people fundamentally distant and different from the rest of the social order. Mental illness, for example, is often romanticized as bringing on creative genius or other superpowers. Brilliant detectives like Sherlock Holmes and Adrian Monk are portrayed as having their powers of detection enhanced by their obsessive thought spirals even as they are also stigmatized for their eccentric and off-putting behavior.

Imagining someone as more than human does much the same work as imagining them as less than human: Either way, the ill are treated as fundamentally other because the social order is frightened by what their frailty reveals about everyone else’s.

It was an illness of the breath, of the place where the body interacts with the atmosphere, a process so sacred that the Hebrew word ruach, the Chinese word chi, the English word spirit, and the Inuit word sila all derive from words meaning breath or breathing. Breath is life—respiration is the most visible and irrefutable sign that we are still here. To inspire is to breathe in; to expire is to breathe all the way out.

Women with consumption were believed to become more beautiful, ethereal, and wondrously pure.

Patients with active tuberculosis typically become pale and thin with rosy cheeks and wide sunken eyes due to the low blood oxygenation and fevers that often accompany the disease, and these all became signals of beauty and value in Europe and the United States. Henry David Thoreau wrote in his journal, “Disease and decay are often beautiful—like the pearly tear of the shellfish or the hectic glow of consumption.”

“The beauty of women is greatly owing to their delicacy, or weakness.” One romantic word to describe the beauty standard—delicacy—followed by a stigmatizing one—weakness.

“As a fat person, I used to wish for a wasting disease like tuberculosis. It’s…it’s messed up.” Dozens of people replied to that comment with their own experiences of being complimented for weight loss associated with life-threatening illness, or their fantasies of tapeworms and other illnesses that would shrink their bodies. The idea of becoming sick in order to look healthy or beautiful speaks to how profoundly consumptive beauty ideals still shape the world we share.

If the pale, thin, wide-eyed, rosy-cheeked beauty standard has proven astonishingly durable, the conflation of whiteness with consumption would prove even more devastating to human health and equity.

And so 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.

How might the contemporary story of tuberculosis be different had we listened to African American physicians like Dr. A. Wilberforce Williams, who noted over a century ago that the real cause of TB was not race but “poverty, bad housing, bad sanitation, bad working conditions, long hours, high rent, [and] poor food”?

This was the world in which Black people lived with tuberculosis in the U.S.—one where they were told by the medical establishment that their illness was caused by weaknesses and susceptibilities inherent to their race, or else by freedom and citizenship itself. And so even after we understood that TB was an infection, we continued to blame it on the sufferer, but with a radically racialized and stigmatic lens that caused more harm to the ill than even previous forms of stigma.

Framing illness as even involving morality seems to me a mistake, because of course cancer does not give a shit whether you are a good person. Biology has no moral compass. It does not punish the evil and reward the good. It doesn’t even know about evil and good.

Stigma is a way of saying, “You deserved to have this happen,” but implied within the stigma is also, “And I don’t deserve it, so I don’t need to worry about it happening to me.”

And even when there’s no evidence of a clear link between character and illness, we will invent one: It was long believed, for example, that cancer resulted from social isolation, or from bottling up one’s feelings. Even when these explanations are cruel and dehumanizing, we embrace them—because tiger got to sleep, and bird got to land, and man got to tell himself he understand.

Tuberculosis is so often, and in so many ways, a disease of vicious cycles: It’s an illness of poverty that worsens poverty. It’s an illness that worsens other illnesses—from HIV to diabetes. It’s an illness of weak healthcare systems that weakens healthcare systems. It’s an illness of malnutrition that worsens malnutrition. And it’s an illness of the stigmatized that worsens stigmatization. In the face of all this, it’s easy to despair. TB doesn’t just flow through the meandering river of injustice; TB broadens and deepens that river.

I once asked a tuberculosis doctor, KJ Seung: Of the 1,300,000 people who will die of TB this year, how many would survive if they had access to the kind of healthcare I have? After all, while TB is often curable now, it remains a very difficult disease to treat, especially in cases of extensive drug resistance. And people in wealthy countries do continue to die of TB, albeit rarely—in the U.S., around five hundred people will die of TB this year. In Japan, over a thousand. “How many would die if everyone could access good healthcare?” he asked me, as if he seemed confused by my question. “Yes,” I said. “None. Zero. Zero people should die of TB.”

And this is why I would submit that TB in the twenty-first century is not really caused by a bacteria that we know how to kill. TB in the twenty-first century is really caused by those social determinants of health, which at their core are about human-built systems for extracting and allocating resources. The real cause of contemporary tuberculosis is, for lack of a better term, us.