- Infectious disease has shaped the course of human history.

And as the last couple of years remind us, it continues to do so.

Today's guest puts the focus on more than just the viruses and bacteria that cause illness.

She turns our attention to societal factors like race, gender, and class, to understand the anti-science rhetoric and politics that shape so much of the modern world.

She's Vidya Krishnan, this week on Story in the Public Square.

(inspirational instrumental) Hello and welcome to A Story in the Public Square, where a storytelling meets public affairs.

I'm Jim Ludes from the Pell Center at Salve Regina University.

- And I'm G. Wayne Miller with The Providence Journal.

- This week, we're joined by Vidya Krishnan, an award-winning journalist.

She has covered health and science for 20 years, including reporting for The Atlantic, The Los Angeles Times, The Hindu and The British Medical Journal.

Her new book is "Phantom Plague: How Tuberculosis Shaped History".

She joins us from India.

Vidya, welcome to the show.

- Thank you for having me.

- So tuberculosis, why write a book about this disease and its history?

- I did not intend to write the book because it's, I feel the same way.

And, but I was reporting for, at that time I was working for The Hindu and there were a lot of tuberculosis cases in India, which I was reporting on, but you know, like a journalist with 300, 400 word stories, and it was not enough to capture what, what was being done to the society.

But also it's an ancient plague.

It has its own history.

And I just went down a rabbit hole, which initially started as my own reading.

But then I just found obscure episodes in medical history.

And it kind of came together as a book.

It took me a while to get there though.

- So for an American audience that might not have a lot of familiarity with TB, other than the skin test that they might get.

If they're, if they're traveling overseas, it's rare in the United States, but it is not rare in other parts of the world.

Can you talk to us about the prevalence of tuberculosis globally?

- TB is I, if I'm not wrong, there are 7,000 cases in the U.S. as of last year, but in India, which is where most of the tuberculosis patients live, there were millions of cases.

I'm getting the number wrong.

There are 10.4 million globally, but out of it, 2 million live in India.

And even within this, there is something called drug-resistant TB where modern antibiotics don't cure this disease anymore.

And what's happened is likely now with the COVID, with the infectious respiratory diseases, it spreads very quickly in an interconnected world.

So that's what's happening.

Even though it's prevalent mostly in the global south, which is India and South Africa, Philippines, it's spreading slowly.

And it's one of those, it's a pathogen that is slow, but it's relentless.

And because antibiotics don't work anymore, it's more scarier in its current form than it was a century ago.

- So again, for those in our audience who might not be familiar with TB, can you just give us a brief overview of the epidemiology, what it does, what the symptoms are and, and how it's transmitted and, and the fact that in many cases without proper treatment, it's, it's deadly.

Just give us an overview, Vidya.

- Thank you for that question.

There are actually three popular myths about tuberculosis, that it's a disease of the poor, it's a disease of the past and that it's curable.

And at this point, none of those three things are true.

It's not a disease of the poor.

It is actively spreading and it infects anyone who comes in that climate.

It is not curable any longer because we have these versions of drug-resistant tuberculosis.

And what happens with TB, it's a master mutator, the pathogen, it can get into your body and it can wait for months, sometime years.

In some cases, even decades waiting for the body's immunity to fall before the bacteria starts acting up.

So globally, what happened is the HIV epidemic of the nineties was a huge springboard for TB because HIV does immunocompression.

So the virus suppresses the immunity and the bacteria TB then just ravages the body.

And which is why South Africa, which had a terrible HIV burden is one of the worst affected countries with tuberculosis.

It has a burden second only to India.

And it's, it's one of those pathogens where it, it spreads, it just thrives in conditions that in countries like India, or even in ghettos, where people are made to live in houses which are not well ventilated and places where, again, the poor, the poor people don't have access to healthcare and nutrition.

So you don't just need medicines to cure the disease.

You actually need nutrition and you need clean housing and ventilation.

And in, in big cities of the world, which is, which is why the, the book is set between New York and Mumbai in different, a hundred years apart, but in big mega cities of the world, the pathogen just thrives.

- So you mentioned New York and Mumbai and, and we'll get to that in more depth in a moment, but the book opens in Rhode Island.

And as you know, we are here in Rhode Island, and it opens in Exeter, Rhode Island in the late 19th century with Mercy Brown.

I've written about Mercy Brown as we discussed before, before we did the show.

So I, I know that story.

And I think a lot of people in Rhode Island know that story, but a lot of people don't know this story.

Tell us about Mercy Brown and why, why her case was so important.

- Well, I was, I started working on the book in 2016 because of a court case.

And I was just at that point, just reading all the material that I could lay my hands on.

And I still remember sitting in my newsroom coming across this paper in New England Journal of Medicine, which was about vampire panics.

And it was kind of the open sesame for my book, because it's such a, as we said at the start of this conversation, TB's such a difficult conversation to have with someone, it's not a, not a sexy disease.

And it's, it's very difficult to get a reader interested in TB and here I had a vampire panic and it was like, I, I was very happy with the opportunity to mix the fabulous with the mundane, which is what the story of Mercy Brown was.

The fact that the fact that, you know, people could be driven to act in such a way where they are this, you know, just digging up graves was also, to me, very stock parallel with, this is the early years of the coronavirus pandemic.

And we were, again, seeing people behave just in panic, completely unreasonably in all sorts of ways in India, there was a very brutal lockdown, but also people when they're, when they're scared, they behave very weirdly with each other.

So we had a lot of antagonistic behavior from the rich towards the poor.

So, you know, we had cases where rich people would ask their staff to change their clothes at the door.

And there was all sorts of unscientific and bizarre, magical thinking because, you know, you're just afraid.

And what, what you don't understand, you feel, and Mercy Brown captures all of it in, in such a, in such a beautiful parallel to work with as a writer.

I, I felt like I, like I said, I still remember reading that paper years ago.

And I was like, this is, this is how I'm gonna open the book.

- So Mercy Brown died of tuberculosis and was placed in storage for lack of a better word for, because it was during the winter, but she was exhumed, brought out of where she was after her death and what was observed frightened people and, and really fed into the vampire myth.

Talk about that piece of, of the Mercy Brown story.

- So she, her body had not decomposed because she had been kept in a crypt as was customary during winter.

And the family was waiting for the, for it to, for the ice to thaw before they could give her a proper burial.

And of course, when they went digging up, this, this one family had many members showing similar symptoms and dying.

And back when Mercy Brown was alive, that her neighbors thought of TB not to be contagious, but hereditary.

So it "ran in the family" and three members of the Brown family dying was proof enough.

So the villages decided to dig her up and because her body had not decomposed because of her frigid winter, how, how the village folk interpreted that to mean was that she was crawling out of the grave and infecting her brother who was also showing at that point similar symptoms.

And it had sent the whole village in panic and Exeter wasn't the only place I talk about it in the first chapter of my book, how Exeter and Mercy Brown was the most publicized case of vampire panic, but it wasn't the only one.

There were many cases and many families who, who, who could not find a way to explain why young, completely healthy people were suddenly dropping dead.

And I am fascinated by the magical thinking, how, how we groupthink and explain away diseases before modern medicine.

But then again, there is such a beautiful parallel we made now in the third year of the pandemic we had, we have anti-vaxxers in the U.S., but also in India, there are so many cases of magical thinking where there is just a science denialism, and which is, which is also why I kind of wanted to talk with, start talking about this completely out-of-ordinary episode from medical history, because, you know, the, the, the weird and obscure and bizarre episodes of our past are actually a very good middle to see what we are doing even today in across the world.

The U.S. has its own version of anti-vaxxers and science denialism.

And in India, our government has been pedaling yoga as a cure for coronavirus, and we keep repeating these mistakes and which is actually why I wanted to center this story before we went deeper into the conversations.

- When did you start writing, or researching and writing Phantom Plague?

- I, I started reporting on it in 2014 for newspapers and I, it initially began, Phantom Plague initially began as a long-form essay for Caravan Magazine, who it's a brilliant Indian magazine that I write for.

But at some point, because I was reading all sorts of history and, you know, global politics, I had like 25,000 words, and I did not want to commit to the book at that point because I was reporting on the Rohingya crisis in Bangladesh at that point.

And at some point my friends just sat me down and had an intervention and said that I need to stop talking about TB over dinner and start typing.

- And, you know, I, I, I ask because the, the implications that you draw in the book and, and, and obviously in our conversation here, and also in some of the other reporting that I've seen you do in various outlets, really draws a distinction or, or a comparison between our experience in the pandemic and the historic experience with, with tuberculosis, would the book have been different, you think, if we had not had this experience of the last few years?

- You know, I wrote the first draft of the book in May 2019.

And unfortunately I did not have to change my editors when the pandemic hit.

And then we went into lockdown in India, in March, and we had a conversation with my publishers at Hachette, and we decided not to include coronavirus in the book just for this reason, because we keep making the same mistakes.

And unfortunately, even down to the final chapters of the book, which focuses on access to medicine, we did not have to change a lot because I feel like our politicians and global health institutions have been very reliably and very predictably biased when confronted with a pathogen that's mutating, and that's evolving and thriving.

We have a health system that is not nimble footed.

And then it's also anchored down by our own racial biases and scientific biases.

And we decided not to include COVID in the book, but with that distance, this question almost always is brought up in my interviews that the, that COVID is not mentioned in the book, but everything that applies, that I talk about not just applies to COVID, but also applies to HIV.

So we keep repeating the same mistakes.

So.

- Well, one, I noted in a piece that you wrote for Neiman Reports at Harvard, and I'm gonna quote it here.

You wrote, "Phantom Plagues started a conversation "about the role of race, gender "and caste in perpetuating plagues.

"As we grapple with the pandemic, "we can no longer ignore the suffering wrought by a global "approach to health that doesn't care for the most "vulnerable among us.

"Everyone deserves access to safe and humane healthcare."

We could spend an entire episode, probably a several episodes just unpacking that one paragraph, but in the case of tuberculosis, how have race, gender, and caste affected the, the perpetuation of that disease?

- So thank you for that question with caste.

Again, it's such a beautiful parallel.

I consider it a privilege to, I live between the U.S. and India and in the U.S., you, there is more literature that documents health deficits in refugees and immigrants and African-American communities starting from maternal mortality, but also in COVID.

These communities have been disproportionately affected.

And that's exactly just so perfectly true for lower caste communities in India who work menial jobs and don't have access to information or internet or legal aid or schools.

And they are also ghettoized.

So they don't have access to, you know, housing, which allows ventilated housing or parks for children to play in.

And so the, the caste aspect, the caste and race aspect, of course, what it does is takes the vulnerable communities and just squishes them in a small land mass and Mumbai is a perfect example of it, but it happens around the world, in the U.S., in, in the book, I compare the situation of slums in India to the Chicago housing projects.

But the next portion of it was, it's just become impossible to talk about infectious diseases without talking about race and racial discrimination, because global health organizations, which is the WHO and the WTO, The Gates Foundation, they're all based in the global north and over and over and over again with HIV but with also TB, what we see now is as antibiotics become less and less effective with TB, what they're doing is Indian patients who are profiled in the book don't have access to newer therapies because these therapies are under patent monopolies, and essentially, and they are all taxpayer invested.

So the R&D was initially by American taxpayers, NIH invested in new TB medicines, much the same way as we see with COVID technologies as well, but they're not available to the places where the disease are the most.

So post-colonial black and brown nations in Asia and Africa have the most infectious diseases.

But what we do is wall them in, and we save the medicines for if the, what happens if drug-resistant TB infects patients in the U.S., or in Europe.

And a perfect example of this was Ebola.

Ebola had been spreading in African, West-African nations forever.

And I happened to be in Seattle when there was a nurse who would come back and, or she was infected.

And very quickly we arrived at solutions.

And it kind of, the book kind of forces a conversation about the moral core of an argument that basically legislates medicines, the same way we talk about iPhones or refrigerators.

And it's no longer tenable because as, again, as COVID has shown, if infectious diseases, especially respiratory infectious diseases are spreading, it doesn't matter that they are ricocheting in India or in Mumbai for now, the world is connected.

I mean, you know, Indian diaspora lives everywhere, and airports are taking these diseases very quickly everywhere.

So we kind of, I hope the reader takes away from the book, this conversation about how we regulate our medicine does not suit the, the demands of the global health.

You know, the, the insecurities that we face globally, and we are also facing climate change.

Now they will not be solved by us being myopic and greedy and trying to save medicines when what we need is to share medicines.

- Vidya that that was really, really well put.

And, and obviously we agree, you use a term and you're right about a term, the toxic, "toxic kindness of philanthropists" in your book.

And that, that has stuck in my head.

Can you break that down for us?

It sounds, what it doesn't sound like, it's a hindrance to the cause.

And, you know, we think of philanthropy as always doing good, and there's really no downside to it, but that isn't necessarily true.

So if you could break that, that phrase down for us, that would be great.

- Thank you for that question again.

So philanthropy, one of the things I really want to reader to think about the book is how we cannot solve our problems in global health with charity, but more importantly, Asian and African countries are not asking for charity.

Everything we know about medicine, we know from experimentation on colonial subjects, in the U.S. we know about medicine from experiments on slaves.

So, so we can't look at medicine as something that belongs to the Western world because they are genius.

And with philanthropy, the problem essentially is that it's, it's, I'm quoting Chinua Achebe, the Nigerian poet, an author, who says that charities is the opium of the rich.

And that's why we are with Gates Foundation.

I don't know if you saw the news around the second wave in India, India was devastated by second wave and India is The Gates Foundation's largest laboratory.

And it begets this question, where is all that money going that its foundation is throwing in into India instead of, you know, instead of equipping Indian structures, instead of passing the mic, philanthropic organizations speak for the nations.

So there is this conversation in global health about talking about plagues in tropical regions and post-colonial nations mostly as "not overcomeable" because they don't listen to us.

But the problem here is not, you know, the whole point of tropical medicine within global health emerged as a research subject when medicine became a tool of colonial expansion.

And yeah, and I, it's a long winded way to come back to charity.

Charity essentially enforces the same, the same unequal power symmetry, even as we speak with COVID, there have been donations for COVID vaccines, but most of African nations who have received these donations, especially from U.S. and Canada, none of them are mRNA vaccines.

Many of these donations, we have found given to nations when they're close to expiry, and none of it actually even has the interest of protecting the health of the most precious assets of our country, which is our, our people, and black and brown people again, are disproportionately affected by this.

I personally believe that we do have a very toxic situation with philanthropy, just, you know, just reinforcing and perpetuating plagues, because it's never enough it's, you know, in a, in a pandemic or tuberculosis is also a pandemic, it's spread around the world.

We just don't use that word.

In a pandemic, what we need is decentralized vaccine supplies.

But what we have is a situation where Geneva WHO has control of co-vax facility.

So India manufactures the bulk of the vaccine and ships it to Geneva, which then decides how much goes to Africa and Asia.

And this it's like, you know, your houses of fire and you have centralized water supply, and we wouldn't do it if we value black and brown lives the same way.

And that's, that's the core of why philanthropy is a problem.

- You know, Vidya, we've got about two minutes left here, but it seems like what you're talking about is really an issue of justice.

And so, you know, we're, I think we're all familiar now with the idea of, of social justice and even environmental justice.

But this seems to be an issue of health justice, is that, is that valid?

- Absolutely.

I recently wrote for Boston Globe where I said that in a world where pandemics are the norm, the fight for our medical rights are, is, the civil liberties just is the fight of our lifetime, for the 21st century, because disease after disease, we are seeing that us twice, so now we don't have colonial, like India was ruled by Britain, but we don't have, you know, empires now, modern day empires are big pharma, big philanthropy and big tech.

And between the three, big tech saw so much misinformation spread during the pandemic.

Big pharma has made money hand over fist in billions of dollars as people have died and big philanthropy has just under guarded the situation.

And unless we go back to the structural root of these problems, we are going to be stuck in these parallel forever pandemics.

Your part of the world has a different pandemic.

And my part of the world also has a different pandemic right now.

- Vidya.

We've got literally about 15 seconds.

You know, what's the prospect for folks living with drug-resistant tuberculosis.

Is that a death sentence?

- No, I won't be optimistic because there are medicines.

This is a preventable curable illness.

This does not need to be a death sentence exactly the same way as COVID, now a vaccine-preventable disease, does not need to be.

We just need to get to a point where the wealthy countries are willing to share the technology or allow Asia and Africa to buy the technology.

This gridlock over vaccine has to end.

- Well Vidya, this is a hugely important conversation.

We're so grateful for you for joining us today.

The book is Phantom Plague.

It's an important read.

That is all the time we have this week, but if you wanna know more about Story in the Public Square, you can find us on Facebook and Twitter or visit pellcenter.org, where you can always catch up on previous episodes.

For G. Wayne Miller, I'm Jim Ludes asking you to join us again next time for more Story in the Public Square.

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