Tuberculosis is the deadliest infectious disease in the world. Why does something that’s curable still kill millions every year? And what does this illustrate about global health disparities? John Green is the author of “Everything Is Tuberculosis: The History and Persistence of Our Deadliest Infection.” Green is also the co-creator of Vlog brothers, which he co-hosts with his brother Hank Green. He joins WITHpod to discuss why tuberculosis is seen as a disease of poverty, what the disease exposes about healthcare inequities, concerns about the Trump administration retracting foreign aid and more.
Note: This is a rough transcript. Please excuse any typos.
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John Green: I think of the story of human health as like this long staircase that we’re walking up. You start out with Hippocrates telling people don’t even bother treating this. It’s totally impossible. And then, eventually, in 1882, Robert Koch figures out it’s infectious and then we develop tools to deal with it. And then we developed chest X-rays and better diagnostics. And then we developed really good antibiotics, and now people are able to be cured of tuberculosis and we’re walking up and up and up the staircase. And I want to be clear. We didn’t take two or three steps down the staircase. We fell down the staircase. That’s what’s happening right now. And we have to pick ourselves up and we have to find a way to start walking up the staircase again.
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Chris Hayes: Hello and welcome to “Why Is This Happening” with me, your host, Chris Hayes.
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Chris Hayes: You know, one of the things we learned about during COVID, that was a really profound lesson for me and that many people have known and written about through the years, but really hit home for me, particularly when I was covering COVID and living it, is that illness and disease isn’t just about the disease, and isn’t just about the microbe, and it isn’t just about the body. And in a truly weirdly intellectually invigorating way, illness, disease, pandemic, infectious diseases are about the totality of society, every fractally recursive element of how a human functions.
From the behaviors we have to the families we have, the societies we have, the friend groups we have, the infrastructures we have, suddenly, all of it is the interconnection of all of it becomes apparent in this kind of terrifying way, but also illuminating. And I honestly think that there’s a weird way in which that forbidden knowledge is part of the strange kind of let us never talk about it again shame and strangeness we have about COVID. That it shows a society naked, and we don’t want to think about that again. And it was also just traumatic at the first level.
But I thought about all this while I was reading this phenomenal new book that I just absolutely loved, called “Everything is Tuberculosis: The History and Persistence of Our Deadliest Infection.” Because it was firing all those exact same neurons in me where I was thinking about how disease works and how illness works is a way of thinking about how human life works and how societies function, how the planet works, and also how inequities function, particularly when it comes to tuberculosis, which is probably the deadliest infection that the world has ever seen and which even though it is one hundred percent curable under the right conditions, continues to kill a shocking number of people.
So that is both the sort of intellectual subject and the moral crusade that’s taken up by author John Green, the very famous author, I might say. And also long time, I don’t know, just figure in all of our digital lives. He’s co-creator of Vlogbrothers, which he co-host with his brother, Hank Green, who we’ve had on the program. This is the first time I’m having John on. Welcome to the program, John.
Chris Hayes: Thanks so much for having me, Chris. It’s great to be with you.
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Chris Hayes: You know, I could feel in this book two things, both the sort of palpitating moral fervor that you feel about the inequities that are caused by this, but also that same sense of kind of intellectual explosion of once you start just tracking this one thing, which is this bacteria that moves between people, you’re kind of tracking everything.
John Green: Yeah. It really feels that way to me. I mean, and I wanted to capture that in the book, some of the thrill of following that story and seeing all these interconnected places, the ways that history is tuberculosis and geography is tuberculosis and politics is tuberculosis. Horace, 2100 years ago said that poetry should delight and instruct, and it’s pretty easy to instruct. It’s harder to delight while instructing, and that was really the goal I set for myself with this book.
Chris Hayes: There’s a bunch of small little facts just to sort of start out that I found that I learned from you in this. One of them was just about the settlement of the West and New Mexico, in particular, but other places, and how key tuberculosis was to their settlement by non-indigenous people.
John Green: Yeah. That’s exactly right. I mean, Colorado Springs, Colorado, Pasadena, California, Asheville, North Carolina, so many cities in America were essentially founded as tuberculosis colonies. And New Mexico became a state partly because of tuberculosis. New Mexico had all the institutions needed to become a state. They wanted to become a state, but Congress kept saying no, largely because of racism, because people living in New Mexico were largely indigenous people or else people who spoke Spanish as their first language. And so New Mexico engaged in a very tactical attempt to bring more white people to New Mexico, and they did that by recruiting consumptives, recruiting people who lived with tuberculosis. And by the time New Mexico finally did become a state, about ten percent of all people living in New Mexico were people living with TB.
Chris Hayes: Okay. The other one that’s really stuck with me that I’ve been sort of telling everyone was that we all know that the assassination of Archduke Ferdinand in what is modern day Serbia, is what started World War I, the first domino that led to World War I. And I also knew from other history books that the assassination attempt itself was hilariously botched and one of the most insane cosmic accidents in which the assassins don’t do it the first time and then just run into him randomly later in the day. But I did not know the TB angle, which is actually a wild, morbid, but I think really salient detail.
John Green: Yeah. It’s important to know that the two people who actually attempted assassination, one of whom threw a bomb that missed the car that he was aiming at and landed by another car. And the other of whom, Gavrilo Princip, who actually did assassinate the Archduke Franz Ferdinand and his wife Sophie, they were both dying of tuberculosis. They were teenagers and they were dying of TB. They knew they were dying of TB and they wanted their lives to be for something. They wanted to have some big heroic act, and that for them became this attempted assassination. And so, I think it’s a little bit of a stretch to say that TB caused World War I, but it was a contributing factor.
Chris Hayes: Yeah. I mean, the idea that you’re undertaking what fundamentally is a suicide mission and you’re doing it when you know that you’re dying of a brutal disease --
John Green: Yeah.
Chris Hayes: -- that resonated with me. Let’s --
John Green: Yeah.
Chris Hayes: I wanted to sort of give a little bit of these like blips because they’re part of what makes the book so sort of enjoyable and delightful even though it’s about an incredibly upsetting topic. But tell us your way in, how you got to this topic.
John Green: Yeah. My way in was visiting a TB hospital in 2019. I had no idea that tuberculosis was still the deadliest infectious disease in the world. I thought of tuberculosis as like a disease that killed British romantic poets, like a John Keats disease. But I was asked by folks who work at Partners in Health to visit a tuberculosis hospital when I was visiting Sierra Leone with my wife in 2019. And when we got there, I met this kid who shared the same name as my son, whose name is Henry, and looked to be about the same age as my son, who was nine at the time. And Henry in Sierra Leone just started walking me around this hospital, and he was this uncommonly charismatic kid.
He was like the mayor of that place. Everywhere we went, people would rub his head or shake his hand and laugh with him. He took me to the lab. He took me to the wards where the patients were, and I’d never seen people that sick before in in my whole life. I mean, I worked as a chaplain at a children’s hospital. I’ve been around a lot of sick people in my life, but I’ve never seen suffering like that before.
And when we finally made it back to where all the doctors were meeting to discuss cases, they sort of shooed Henry away in a loving manner. And I asked whose kid is that? I figured he must be the kid of somebody who worked at the hospital. And they said he’s a patient, and he’s one of the patients we’re really, really concerned about.
And it turned out Henry wasn’t nine like I had imagined. He was, in fact, 17. He was just so stunted by malnutrition and tuberculosis that he looked much younger. And it was really following Henry’s story over the next several years and following his desperate attempt to survive multidrug resistant tuberculosis. That provided my way in. I mean, I came home from that trip just obsessed with TB wondering what was wrong with my information feed, something you write about so beautifully. What was wrong with my information feeds that I had no idea that this scourge continues to kill over a million people every year?
Chris Hayes: So let’s talk about what TB is, because I also realized, and I had read, and I’m a big supporter of Partners in Health and had supported and known the late Paul Farmer a little bit and read the Tracy Kidder biography. And Sherrod Brown, actually, when I profiled him back when he was a congressman, was really focused on this issue, on TB. And yet I realized that --
John Green: Yeah.
Chris Hayes: -- like, I really didn’t actually know very much about it at all. I sort of knew it in the furthest removed sense. So just what is tuberculosis?
John Green: So it’s a bacterial infection. It generally attacks the lungs, although it can attack any system in the body, really. And it’s an airborne disease. It spreads from person to person via droplets that are inhaled from sneezes or coughs, and that’s how it spreads through us. But it’s an uncommon bacteria. It has a very slow dividing rate and so it makes us sick quite slowly. You can live with tuberculosis for months or years or even decades. And the other thing about it is that it has this really thick fatty cell wall. That’s why it divides so slowly as it takes a long time to build its fancy cell wall, and that cell wall is really hard to kill. And so, a strep infection might take seven or 10 days of antibiotics to cure. A tuberculosis infection takes between four and six months of more than one antibiotic given in a certain order, a kind of cocktail of antibiotics that you take every day for months. And in the case of drug-resistant TB that you can take every day for up to a year or even longer.
Chris Hayes: Okay. Here’s the thing that I really didn’t know, was that how many people have the bacteria inside them, but --
John Green: Yeah.
Chris Hayes: -- I just had no idea that this was the case. Like, it really blew my mind. Like, tell us about that.
John Green: Yeah. About a quarter of all humans are infected with tuberculosis right now, and that used to be a much higher number, actually. But now it’s about a quarter. It’s about two billion people in the world right now have a TB infection. But the vast majority of those people will never become sick because the white blood cells in their body surround the bacteria in these things called tubercles. And so that’s where the disease gets its name. And so most people, their immune system will be able to keep the infection in check for a lifetime, and they’ll never become sick, but about 10 percent of people will become sick. And we don’t totally understand why people develop active TB. We know there are risk factors.
One of the biggest risk factors is malnutrition. That’s certainly probably what triggered my friend Henry’s tuberculosis. Other risk factors include HIV infection, having diabetes, anything that harms your immune system. That’s why when Americans hear about tuberculosis, it’s almost always in drug commercials, for immune suppressive drugs to treat autoimmune disorders. They’ll be like get treated for --
Chris Hayes: It really leaps out at you.
John Green: Yeah. They’ll be like, make sure you get tested for tuberculosis, and everyone’s like, that’s still a thing? And, yes, it is still a thing.
Chris Hayes: Yeah. So, and that part of it, and I mean, all disease has an element of randomness to it, which is part of what --
John Green: Yeah.
Chris Hayes: -- drives us insane as a species and what makes it all so difficult making meaning of it, who lives, who dies, who gets sick, who doesn’t. And we even do that now. I mean, you write about the Kurt Vonnegut poem of just humans, you know, asking why, why, why and coming up with their answers. And you see that now, right? A bug goes to the family and three people get it and two don’t. And you’re like, puzzling over it, like trying to construct some rationale around it.
John Green: Yeah. We want to make sense of the world, and we want the story of humans to be a story of human agency, a story of human choice. I argue in the book that tuberculosis actually is a story of human choice. But it’s true that we still see three people get sick in a family and two people don’t and we don’t fully understand why. There’s some randomness to it. But ultimately, you’re overwhelmingly more likely to get tuberculosis if you live in poverty, if you live in crowded living conditions, if you work in a crowded factory that’s poorly ventilated. Like, we know a lot of the risk factors, and they’re the same risk factors that are associated with poverty because, ultimately, tuberculosis is a disease of injustice. It’s a disease that follows the paths of inequity that we blazed for it.
Chris Hayes: Yet it wasn’t always that way —
John Green: No.
Chris Hayes: -- which is another thing I found fascinating. But before we get to sort of the Victorian period, this disease goes back a very long time and has been with us as humans for a while. And across the world too, which I also thought was interesting. It’s not something that started one place where we can kind of trace it. In fact, unlike things like smallpox that conquerors and colonizers brought to the American continents, tuberculosis apparently was here before them. This is a very, very old disease.
John Green: Yeah. It’s been with us for a long time. It’s probably been with us since before Homo sapiens. So there’s some genetic evidence that indicates that tuberculosis has been infecting people, different species of us since about three million years ago. But it’s been in the Americas for at least the last 2,000 years, probably spread to the Americas from Japan via infected seals because tuberculosis has animal carriers including cows and other mammals. And we see it in ancient mummies. We see it in ancient China. We see it in ancient India. We see it in ancient Europe. There’s really no place where we don’t see tuberculosis when we look at the records of humans.
Chris Hayes: And it was confounding and terrifying for all these different cultures.
John Green: Yeah. I mean, Hippocrates told his ancient Greek physician students not to even try to treat tuberculosis, which he called phthisis because it would make them look like poor healers because it was considered an utterly incurable disease. And that that was it. I mean, it was absolutely confounding. We didn’t know if it was infectious or if it was inherited because tuberculosis does spread so slowly. It doesn’t act like a cholera or like a plague. It acts very differently.
And so, lots of people disagreed over whether or not it was an inherited disease or an infectious one, and in areas like ancient China where it was considered infectious, there was actually probably lower rates of tuberculosis than we saw, especially in Europe and North America where it was considered to be a genetic disease that we inherited from our parents.
Chris Hayes: And then there’s this idea that, again, because it’s acting in these strange ways that it’s brought on by behaviors or, I mean, again, this is all pre-germ theory disease. So, all theories of how disease works are kind of fakakta in our modern imagining. But the idea that it was like personality traits or childhood trauma.
John Green: Yeah.
Chris Hayes: All these different kind of theorizations about what did it.
John Green: Yeah. I mean, we still do that, though, right? Like, we still engage in the punitive act of giving diseases a meaning to borrow a line from Susan Sontag. Like, we still blame the sufferer for the disease. My dad got cancer in the 1980’s and people told him that he got cancer because he’d bottled up his emotions. My brother got cancer two years ago, and people told him that he got cancer because he took the COVID vaccine.
Chris Hayes: Right.
John Green: So I don’t think that there’s any way of getting around trying to assign meaning into disease and stigmatizing people living with disease. Unfortunately, that’s been a part of the human story for a long time. But classically, we did associate it with certain personality traits because we thought you inherited your personality the same way you inherited your vulnerability to consumption and that meant being really sensitive. I think that I kind of have a consumptive personality, actually, being a little bit of an Eeyore, a little pessimistic about the fate of the world, but also alive to the poetic beauty of the decaying nature of everything. That was sort of the consumptive personality, and that is, I’m afraid to say, a bit of my personality as well.
Chris Hayes: Well, that sort of period I mean, what happens when industrialization happens to tuberculosis?
John Green: It just explodes. I mean, it explodes in an unprecedented way. I think at the height of the TB crisis in England, about a third of all people were dying of tuberculosis. So it was causing almost a third of all human death.
Chris Hayes: I mean, that’s so crazy.
John Green: Yeah. And it was killing people in the prime of their lives too. It was called the robber of youth because it would kill people in their 30s or 40s. I mean, the richest man of the 19th century died of tuberculosis, Jay Gould. Charles Dickens called it the disease that wealth never wards off. And because you couldn’t stigmatize the disease away because so many people were dying of it and so many rich people were dying of it, so many people within the sort of center of the social order were dying of it.
Instead of stigmatizing it, we began romanticizing it, which is a really strange phenomenon of the 18th century, but we really did heavily romanticize tuberculosis, especially believing that it made you a great artist like Victor Hugo’s friends joked with him that he could be a really good novelist if only he contracted consumption. Lord Byron said he would like to die of consumption because the ladies would say, look at Byron, how interesting he looks in dying. This was a widely, widely held belief that consumption made you a great poet, but it also made you a really beautiful person. It made the skin white and pale, and at the time, especially in Northern Europe and the United States, paleness of skin was closely associated with beauty, especially in women. Made your cheeks rosy and red. It made your eyes wide and sunken. And people would apply makeup and belladonna to their eyelids to try to get that, you know, consumptive look.
Chris Hayes: Yeah. It was like Victorian heroin chic, like consumption chic. And the ladies are hot when they have consumption.
John Green: Yeah. No. I mean, Charlotte Bronte, as her sister was dying of consumption wrote, consumption, I am aware, is a flattering malady. I don’t mean to keep quoting people, but it just astonishes me. There are so many examples of people in the 18th and 19th centuries just assuming, believing that consumption makes you beautiful. There’s a medical textbook where literally in the middle of the chapter on consumption, the author breaks out into poetry about how beautiful consumptive women are. It’s like in a musical where they just break out into song for no reason, but it really happened inside this medical textbook.
Chris Hayes: And part of the argument you make is because this disease is so horrible, so ubiquitous. I mean, there’s a line in the book about how one out of every seven humans who’ve ever died on Earth probably died from consumption. And the levels in the Victorian England are one out of three. And it’s so interwoven, you can’t stigmatize, you romanticize. We’re all kind of working around its presence because the presence itself can’t be expunged.
John Green: Exactly. There was nothing that we could do about consumption. There were some theories about cures, especially traveling. So that’s why people traveled west in the United States. There was this idea that clean, dry air might dry out the wet lungs of consumption. California called itself the land itself the land of new lungs in all these brochures it would send out East to try to get consumptives to come out West and populate California.
But there was nothing that could be done. My great uncle died of consumption. He died of tuberculosis in 1930 when he was 29 years old, and his father was a doctor. And his father, my great grandfather, just had to watch as his son died because there was just absolutely nothing that you could do about it.
Chris Hayes: Yeah. I was reading that portion, my grandmother had TB and —
John Green: Oh, wow.
Chris Hayes: -- was in the sort of country air, was like went up to a sanatorium, I guess they call them. And we still have the letters that my grandfather wrote her, which are really beautiful --
John Green: Wow.
Chris Hayes: -- while they’re apart because they were in love. And it was, I think several years and then she was fine. Again, in the weirdness of the disease, I think this was too early for them to have any real idea of the cure, but it worked, quote, unquote.
John Green: Yeah. No. Sometimes people recover from tuberculosis for reasons we don’t understand. About 25% of people will recover spontaneously, and we still don’t have a great understanding of why. But 75% of people, if their tuberculosis is left untreated, will die. And I think it’s important to acknowledge this isn’t ancient history. I mean, it’s your grandmother’s history. Even in the United States, I met someone yesterday who came up to me and said in 1952, I was born in a sanatorium here in Philadelphia. And it was common for people to live and die in those places like the one that my great uncle lived and died in.
Chris Hayes: So how do we crack the mystery, we humans, about this thing that has been bedeviling us for thousands of years?
John Green: Well, the first thing we figured out is that tuberculosis is definitely infectious. And when we started to understand that after Robert Koch identified the bacteria that causes tuberculosis in 1882, we started to institute public health measures, some of which were very effective. So we stopped spitting as much, like Charles Dickens called America the land of spitters. We stopped spitting as much, which probably did reduce rates of tuberculosis. But we also, once we understood it was infectious, we would take people like your grandmother, and we would often remove them from their families and send them to hospitals for tuberculosis patients, which were called sanitaria or sanatoria. And that that was another strategy we had.
And the other thing is that our food got better. And so as our food got better, as we were less malnourished, as we were less likely to work in crowded conditions, we became less likely to contract active tuberculosis. And so we saw tuberculosis rates go down even before we had a cure because we were treating tuberculosis as an infectious disease. Once we understood that, we began to make real progress.
Chris Hayes: And yet there’s this conception that tuberculosis is kind of a, quote, unquote, white person’s disease and that they don’t have it --
John Green: Yeah.
Chris Hayes: -- in the Global South and this is, again, the sort of Keats, the beautiful 20 consumptive British woman. Of course, that’s hogwash, but there’s a move of the disease’s locus, as I understand it, over time.
John Green: Yes. So racialized medicine was catastrophic in every imaginable way, and to some extent is catastrophic in every imaginable way.
Chris Hayes: Yeah.
John Green: But it was especially catastrophic when it came to tuberculosis because racialized medicine held that only white people could get consumption. And as Frank Snowden writes about a disease that affected the lungs of Black people wasn’t even deemed important enough to be given a name by the white medical establishment. And so it was believed that consumption was either rare or nonexistent in India, in the Philippines, in other colonized regions.
And in fact, what was actually happening is that consumption was spreading at an unprecedented rate in those communities. And as they industrialized, that’s when the real kind of catastrophe occurred. And there was simply no attempts by colonial officials to acknowledge that reality. It would have undermined the whole idea of colonialism to argue that this disease of civilization and whiteness was in fact also a disease of people of color.
Chris Hayes: When does the drug protocol, which is a very intense one, and part of what you write about, is it takes a lot of antibiotics because it is a bacteria for a sustained period of time. So it’s not a trivial thing. It’s not strep throat. It’s not an ear infection. When do we get that such that we have essentially a cure?
John Green: Well, the first antibiotics start to be distributed in the mid-1940s. But by the mid-1950s we have a cure for tuberculosis. People are walking out of sanatoria healed and cured and no longer needing any kind of treatment or medicine for their tuberculosis for the rest of their lives. We start to see a radical reduction in the burden of tuberculosis in the United States and other wealthy countries. We start to see 99% reductions, essentially the elimination of tuberculosis from those communities. And we could have seen that in the whole world. We could have and we still could, but that’s the point at which the story of tuberculosis stops being a story about a bacteria that we don’t know how to kill and becomes a story, like you mentioned in the intro, of human built systems and their failure to include all humans.
Chris Hayes: There are still an astonishing number of people getting sick from tuberculosis and dying. Part of that has to do with the fact that quote, unquote, “normal tuberculosis” is going untreated. But then there’s the additional sort of horror of multidrug resistant tuberculosis. What is MDR?
John Green: MDR-TB is TB that doesn’t respond to some of our first line antibiotics. It’s important to understand that the only reason MDR-TB exists is because between 1945 and 1965 or so, we developed about eight different classes of antibiotics that can treat tuberculosis. And then between 1965 and 2012, we developed none. And we developed none not because it was impossible to develop them but because TB had stopped being a problem in the rich world and there was no profit motive to develop more, and so we developed none. And that made us really far behind the curve. The disease had a very long time to evolve resistance to our first line treatments.
Now those first line treatments that were developed in the ‘40s and ‘50 and ‘60s are still effective at treating most cases of tuberculosis. But drug resistant tuberculosis is a huge threat, not just in poor countries, although it is especially bad in impoverished communities, but it’s a threat to all of us. And part of what’s so horrifying, Chris, about the sudden chaotic abandonment of hundreds of thousands of tuberculosis patients in the middle of their treatment as a result of the U.S. government defunding USAID, part of what’s so horrifying about that is that those hundreds of thousands of people, even if their treatment is only interrupted for a month, and it unfortunately, it looks like it’ll be interrupted potentially permanently.
But even if their treatment is only interrupted for a month, that means a skyrocketing chance of more drug resistance, of their particular infection evolving drug resistance. That’s a catastrophe personally for those individuals. It’s tragic. The vast majority of them will die, but it is also tragic for communities because it means much more drug resistant tuberculosis circulating in those communities, and that should scare all of us.
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Chris Hayes: More of our conversation after this quick break.
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Chris Hayes: How have you been processing the news about USAID as someone who just wrote a book about the fundamental injustice of the relationship between Global North and Global South or rich world and developing world, whatever categories you want to use?
John Green: Well, it’s devastating. I mean, it’s devastating. So many people are going to die. So many people already have died. So many people are going to die needlessly. So many babies are going to needlessly be born with HIV. It’s utterly devastating and it’s hard to process. It’s hard to even know how to respond to it other than saying that this is horrific. Not just the fact of the cuts, but the way they were implemented. The chaotic way they were implemented meant that still means that in many cases all tuberculosis response in in poor communities has just ground to a halt because so much of the infrastructure was funded by the U.S. government, which has long been the most generous funder of tuberculosis response in the world.
And to abandon that long term commitment so suddenly and in such a punitive, inhumane way has just catastrophic consequences. I think of the story of human health as like this long staircase that we’re walking up. You start out with Hippocrates telling people, like don’t even bother treating this. It’s totally impossible. And then eventually, in 1882, Robert Koch figures out it’s infectious and then we develop tools to deal with it. And then we developed chest X-rays and better diagnostics. And then we developed really good antibiotics and now people are able to be cured of tuberculosis and we’re walking up and up and up the staircase. And I want to be clear. We didn’t take like two or three steps down the staircase. We fell down the staircase. That’s what’s happening right now. And we have to pick ourselves up, and we have to find a way to start walking up the staircase again.
Chris Hayes: I’ve been thinking about this in the context of COVID, which I started with, and, again, this is something I knew abstractly and intellectually, but watching COVID develop where it’s like the medical problem is hard enough and I know nothing about it, right? So for me, it’s like it’s all black box. I don’t know what they’re doing there, looking at the little cells, and they’re making their vaccine. I have no idea how they do that. But what was so mind blowing was what they solved the medical problem. They got a safe and effective vaccine. Then we had the human problem.
John Green: Yeah.
Chris Hayes: And it turned out that that was way, way, way harder to solve than the medical problem. And that’s exactly what it is with TB.
John Green: Yeah. It’s a human problem. I mean, in the 21st century, you can’t really say that tuberculosis is caused by a bacteria anymore because we know how to kill the bacteria. We know how to control the bacteria. We know how to prevent tuberculosis infections from even occurring. So you have to grapple with the reality that tuberculosis is caused by humans. It’s caused by human built systems, by their failures, by the systems that include some and exclude others. And that’s the case for COVID as well. I mean, I think of COVID as a disease of injustice just like tuberculosis is. And to me, tuberculosis is kind of the exemplary disease of injustice. That’s why I’ve spent the last five years obsessing over it and writing about it and thinking about it. But there are so many other diseases of injustice.
I mean, I live in Indianapolis. And if you put a map of poverty of Indianapolis and then you put on top of that a map of cancer rates or diabetes rates, it’s the same map. I think that’s really important for people to understand. You don’t have to go to Sierra Leone to see health care inequity and health care injustice. It’s happening here. It’s happening everywhere in the world.
Chris Hayes: Talk a little bit about Henry and Henry’s story because that ends up being a sort of thread of the book. And I will say, multiple times in the book, I’m like, oh my god, if this kid does not survive this book, like --
John Green: You’d never forgive me?
Chris Hayes: I never forgive you. I’m going to throw the book and I’m going to be freaking crushed. Then I kept telling myself the same thing I would tell myself in watching the free solo movie. This is like, they wouldn’t make the movie if he fell. So I was just like --
John Green: Yeah.
Chris Hayes: -- he’s got to be okay.
John Green: Yeah. Well, but I think it’s important to understand that most people who make free soloing a big part of their lives die of one cause. Right?
Chris Hayes: Right. Yeah, right.
John Green: And it’s important to acknowledge similarly that the vast majority of people in Henry’s situation don’t live. Henry’s roommate died. His first roommate when he was a little kid and was first treated for tuberculosis died. Death from drug resistant tuberculosis is common and unnecessary. When I asked one of my heroes, Dr. KJ Seung, how many people would die of tuberculosis if everyone could access good health care, he seemed very confused. And finally, he said, none, John. No one would die of tuberculosis. And so we could live in a world where no one dies of tuberculosis, and instead, we live in a world where people like Henry usually die of tuberculosis when they get sick.
Henry’s story was different. It was different because of Partners in Health. It was different because of a really dedicated group at the Sierra Leonean Ministry of Health, and it was different because he had an extraordinary doctor, Dr. Girum Tefera, who is also one of my heroes. And so Henry, excuse me, it’s tough for me to talk about Henry because I’m not a journalist. And so I care about this kid a lot and I don’t know how to treat him with any level of objectivity. He’s my friend. And he lost hearing in one ear due to a treatment that he didn’t need, that he never should have been on, that if he’d had access to high quality molecular testing, they would have known he shouldn’t have been on. He had to take over 20,000 pills over the course of his treatment, which is common, unfortunately, still.
But he eventually received the kind of tailored personalized, drug regimen that you or I would expect and that everyone deserves. And as a result, he survived his tuberculosis. Today, he is a junior at the University of Sierra Leone. He’s an awesome, awesome young man. He takes care of his family. He’s an advocate for people living with tuberculosis and we’re so lucky to have Henry in the world with us. We are so fortunate that he’s here with us, and yet we make choices that deny people like Henry the fundamental right to being alive and being in the world with us. And that’s what infuriates me and what motivates me every day.
Chris Hayes: What are those choices?
John Green: Well, a lot of systems have to work together to treat TB, right? You need a strong health care system and you need a strong transportation system so that you can transport drugs so you can get the drugs to the people who need them the most. In some cases, you still need refrigeration, so you need electricity sometimes. And, Lakka Hospital is now a very different place than it was when I visited in 2019. It’s now a much safer place to be a patient and be a caregiver. But when I visited in 2019, there was no electricity. There was no consistent running water. The rooms looked like prison cells. There were bars on the windows. I mean, it was a brutal, brutal place to be a kid and a brutal, brutal place to try to get well.
And the systems that have to work are the systems of delivery, the systems of care delivery, but also the systems of resource distribution, right? We didn’t do a good job of getting the newest best drugs. There’s this great drug bedaquiline that Henry was just told you can’t access this drug. You don’t deserve this drug because it’s too expensive for people like you. And so we have to have better resource distribution systems in addition to better health care and transportation systems.
Chris Hayes: How did you connect with Partners in Health?
John Green: I started working with them almost 15 years or about 15 years ago during the Haitian earthquake when the catastrophic Haitian earthquake happened. And I asked a friend who would you support and a Haitian friend, and they said the only people I would support are Partners in Health. And Partners in Health does incredible work around the world, and they really take the approach of accompaniment and believing that every person deserves dignified care. It’s a very different approach from the sort of obsession with cost effectiveness that we often see in the broader health care system. And I understand that resources are limited. But as your friend and mine, the late Paul Farmer, like to say, resources are less limited than they’ve ever been.
Chris Hayes: You mentioned before about your brother getting cancer and going through treatment for that, that your father had cancer. Obviously, the book you wrote, most people are most likely to have read “The Fault in Our Stars” is about cancer and illness. How has this shaped your life and your thinking?
John Green: Well, I spend a lot of time thinking about illness, probably more than the average person, and I certainly write about illness more than most writers. I wrote about OCD in “Turtles All the Way Down.” I wrote about cancer in “Fault in Our Stars.” Obviously, I’m writing about TB here. I’m fascinated by disease, but I’m also a little confused why other people aren’t fascinated by it, to be honest with you. This is what kills over 90% of us. It’s something that we all experience. As Susan Sontag put it, we hold two passports, the healthy passport and the ill passport, and we will all use both of them in the course of our lives.
And so I guess I write about illness because I’m interested in it, but I also think that it’s just super important. I think that my dad having cancer when I was a little kid had a huge impact on me. Hank was too young, I think, to really remember it or experience it as something scary, but I wasn’t. I was I was six the first time he had cancer and then I was eight when he had his recurrence. And my dad is still alive, thankfully. But it was really scary. It was really scary for me and really scary for my mom and I’m sure for my dad as well, although he was less expressive about that maybe.
It was a hard thing to go through as a little kid, as anybody who’s loved someone as a child who was sick knows. And it was hard. It was devastating when my brother got diagnosed.
I mean, my brother is my closest collaborator and my oldest friend and my favorite person. I love him to an unbelievable degree. And my whole professional life, Chris, is being the tail to his comet. So, it was unimaginable to me that that Hank would get sick like that. But it’s something that we will all experience. And the great gift for me in my life has been realizing that we can’t stop illness from happening, but we can help each other feel un-alone in the experience. There’s real meaningful solidarity to be found in accompanying each other through the stuff that we’re going to go through. And, look, we’re all going to go through illness. We’re all going to go through dying and death. And being able to accompany people through that experience and allowing others to accompany us through those experiences is very meaningful in my experience. My first job, I guess, was being a student chaplain at a children’s hospital, and so I learned that lesson very young.
Chris Hayes: It’s funny because I think I have a strong just sort of repression impulse around it all. And I can recognize it.
John Green: Yeah. Well, I think that’s super common.
Chris Hayes: It is common. It’s so common, and I think I work to overcome it. But I remember first learning about the flu pandemic in 1918, I guess. And about the fact that, no one talked about it. It was a sort of buried history and being it’s --
John Green: Yeah.
Chris Hayes: -- so weird that people didn’t talk about it. And then we went through COVID, and there’s this crazy combination of trauma and shame, but part of it is just rebellion against it. We don’t want to think of it because it’s upsetting or --
John Green: Yeah. It’s upsetting, but also, I think it’s a place where humans don’t have a ton of control. And we like stories about war and about love and about places where humans are making choices even if they’re terrible choices. Those are the stories that we’re drawn to. I write in the book about what does it mean that rumors still persist that Alexander the Great died of poisoning when everyone knows he died of typhoid or malaria maybe. But he died of disease. He got sick and he died, which was very common at the time. It’s just that the idea that that could happen to the most powerful man in the world seems absurd to us. It seems absurd that a little microbe could be responsible for killing us. This great animal that’s overcome the tiger and the lion and the bear is still being felled by invisible enemies. It strains the imagination to think about that.
And so I think a lot goes into that desire to deny the reality of illness and the reality of pandemics. But I think part of it is that we prefer stories of human agency. We prefer stories where humans are making choices instead of having those choices made for them by microbes. But I really see history as deeply impacted by the microbe, I guess I would say.
John Green: Yeah. I mean, completely formed by it in in almost every way. But there’s also to me, there’s agency, and there’s also just a kind of I know that I’m going to have to go through illness at some point in my life, but I sure as hell don’t like thinking about it. And I think --
John Green: Sure.
Chris Hayes: -- there’s this will, this denial will, this force that’s so powerful. I mean, I just read an interview with the mother, I mean, a quote in a piece by the mother of the child that died of measles in West Texas who said to other people, don’t get the shots. It’s not worth it.
John Green: Yeah. I know. I saw that too. It broke my heart. I mean --
Chris Hayes: It’s really upsetting.
John Green: Yeah. It break my heart, and my heart breaks for that family. Nobody should have to go through that. But --
Chris Hayes: No. And I’m not saying this to judge her morally. I’m saying it because --
John Green: Yeah. I know. I absolutely understand.
Chris Hayes: In some ways, it’s like part of the life force to sort of refuse to allow the microbe its space by pushing it away.
John Green: Yeah. And I understand that impulse, but I think the problem with that is that sometimes in doing that we also push away the sick. We also push away --
Chris Hayes: Yeah, totally.
John Green: -- people who are living with illness and say, well, we can’t make sense of you right now --
Chris Hayes: Yeah.
John Green: -- and so we’re going to push you to the edge of the social order. And that’s always seemed to me a kind of double burdening of the sick. In addition to having to live with illness, they now have to live with the stigma or this kind of disassociation from the center of the social order.
Chris Hayes: We’ll be right back after we take this quick break.
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Chris Hayes: I wanted to ask you a little bit about your career, if that’s alright.
John Green: Sure. Of course.
Chris Hayes: You’re a really remarkably gifted writer. I’ve read a few of your books. You’re also someone who sort of lived publicly on the Internet for a sort of astonishingly long time. And I wanted to ask about how you understand the arc of digital life or the Internet as someone who is a kind of pioneer of YouTube and now talking to me around my age in your 40s with kids and watching the developments of what has become of digital culture, how you feel about its trajectory?
John Green: Well, I would recommend a new book called “The Sirens Call.” I would. I would. For real. I am concerned about the way that these companies have extremely successfully monetized our attention and I’m concerned about the way that our attention is fracturing and I don’t think we understand what this moment means very well yet. When you’re living in the middle of history, as my friend Stan once told me, you often don’t know what it means. And we are very much living in the middle of a technological revolution. I liked the Internet a lot --
Chris Hayes: Same.
John Green: -- and I believed in the Internet to a remarkable degree. I was incredibly naive about the power of the Internet. I thought that the power of the Internet would be a democratizing force in the world and that it would essentially destroy fascism through making information freely available. That was utterly naive.
Chris Hayes: How do you think about reading and writing too? Because you’re someone who talks on to a screen, but you also write, and I also talk on to a screen and I write. I love writing because it’s different, a different set of muscles. I find it so much more efficient to get information from reading than watching videos. I mean, that’s just like an empirical fact. But I’m somewhat worried again. I’m edging into Abe Simpson territory here, but about this sort of post literate Internet that we’re going to get where everything is video. And because --
John Green: Yeah.
Chris Hayes: -- 20 years ago, the Internet was very literate and very writerly focused. And I wonder just how you think about writing and writing’s importance and reading’s importance.
John Green: Well, I also fear that I am going to verge into Abe Simpson territory, and I don’t want to be an old man yelling at a cloud. And I think there are lots of wonderful ways to learn. I’ll give you an example. There’s lots of data that audiobooks might be a more efficient way to retain information --
Chris Hayes: Totally.
John Green: -- than reading with your eyes. And so I don’t labor under the delusion that eye reading is the only way to --
Chris Hayes: Totally.
John Green: -- ingest information in a in a meaningful way. That said, I think there’s something to be said for long form content, for spending a lot of time with somebody and with their voice. And that’s what I love about reading is that reading and writing for me are both this wonderful collaboration. When I’m writing, I’m trying very hard to make a gift for the reader. I’m trying to make something for someone that will mean something to them, that that they can bring their deepest self to. But then the reader also has to give me a gift back, which is to bring that deepest self to the work. And I hear every day from people who do that for my stories or my books, for people who tell me reading “Turtles All the Way Down” made me think about my own obsessive thought spirals. And as a result, I sought mental health care or people telling me reading the “Fault In Our Stars” made me think about my brother who died of cancer and my relationship with him and how difficult it was to lose him.
It’s so generous of people to bring that deep, big stuff to my stories, to bring the stuff that really matters to my work. And so I think of it as a mutual gift exchange where I have to give everything that I can to the story, and then I have to ask that the reader do the same.
Chris Hayes: How often do you, I mean, obviously, you were going to Sierra Leone for this book. How often are you traveling abroad or going to places that are on the wrong side of this sort of logic of global inequity?
John Green: Fairly often. I’ll be back in Sierra Leone later this year to celebrate the completion of construction of the new maternal hospital that has been funded partly by our community. I’ll be in Peru learning about tuberculosis next month. So. I love the opportunity to learn from folks. A lot of times we think of aid as a one way street like rich countries provide aid to poor countries, and that’s the exchange. But in fact, the exchange should be and can be so much more interesting and important. We have so much to learn from the Sierra Leonean health care system. Sierra Leone has $46 per person per year to spend on health if they spend the same percentage of their GDP on health care that the U.K. or Germany does.
Chris Hayes: Jesus.
John Green: And yet, they are able to provide some health care, right? I mean, and part of that is because there are efficiencies that we just haven’t figured out in the United States.
I’ll give you one example, community health workers, people who go out into the community, who are trusted by their neighbors, and who are able to identify high risk pregnancies, make sure that folks with TB are able to access their medication, make sure that folks with HIV are able to access medication. Those community health workers are really the backbone of the health care system.
Well, we need something like that in the United States desperately. We need people who are trusted by their neighbors to be able to give health information so that they can trust that information. Something is very broken, as you pointed out earlier, about the way that we are distributing information in our health care system because there’s so much that people don’t trust. And I think that community health workers can be part of that solution. So we should really be learning from and with and exchanging expertise across these boundaries. And that’s what I try to do when I’m traveling, is to spend a lot more time learning than I spend trying to teach.
Chris Hayes: Your writing has always been deeply humanist, I would say, in a way that I really align with and really like. I mean, I think your kind of worldview. This is a tough time sometimes to retain the sort of the foundational face (ph) of that worldview, I find. I don’t know if you’re going that way --
John Green: Yeah.
Chris Hayes: -- but it’s like --
John Green: Oh, yeah. No. It’s really hard. It’s really hard to be in favor of humans right now, Chris.
Chris Hayes: Yeah. Well, in favor of humans and also think that humans have something special and sublime about them such that they can connect with other humans in ways that mean they don’t always just go to the lowest common denominator and act with the mob or pursue their worst grudges and bigotries or act selfishly, that everyone really is capable of doing this incredible thing, which is forming connections with each other for some higher purpose. And we all have that and that different institutions, societies, forms of culture, forms of communication, rhetoric, structures of government might cultivate that instinct or might destroy it. And right now, I feel like I’m watching it being destroyed.
John Green: Yeah.
Chris Hayes: And it’s a little bit of a crisis of faith, if I’m being honest. And I’m just wondering how you’re experiencing it as I think someone who has a similar kind of faith. I mean, a sort of very animated by a real moral vision of the world, but also a faith that you can persuade people with reasons and get them to care.
John Green: Yeah. I believe humans can be good news. I don’t know that we are good news, but I think we can be. And I’m sorry about your crisis of faith, and I do, to some extent, share it. I really do. I understand what you mean and that, this moment, in particular, it feels like the forces that would argue that some human lives are more valuable than others have become very powerful. And that’s hard. I guess where I find my hope is in looking at examples of how we have worked together with astonishing generosity and compassion and sacrifice. I see this over and over again in the human story. We are capable when we are close to suffering, when we let ourselves become proximal to the suffering of others. We are extraordinarily generous and compassionate.
And when we create distance between ourselves and others, we can be absolutely monstrous. When we think of human beings as being like us, we are compassionate. And when we think of human beings as being fundamentally different from us, we are monstrous. And so to me, those coexist. They coexist within each of us. They coexist within our social order. And it falls to us to fight for the parts of us that are compassionate. I totally understand what you mean. It feels like we’re living at the end of history. It feels like we’re living in this sort of final terrible moment. But this is not the end of history. This is the middle of history. And what our job is, what falls to us, is to write a better end.
Chris Hayes: John Green is author of numerous books, including his latest, which is fantastic. I really recommend you read it. You’ll read it very quickly. “Everything is Tuberculosis: The History and Persistence of Our Deadliest Infection.” John, thank you so much. This was awesome.
John Green: Thank you, Chris. I really appreciate it.
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