Good evening, and have I got a factoid for you, courtesy the website of the Centers for Disease Control and Prevention, USA – “TB bacteria can live in the body without making you sick”. You can carry the TB germ in your body, yet not sicken nor infect others as you saunter around on your daily business – it's called latent tuberculosis. You wouldn’t develop the disease so long as your immune system remains strong.
Two in every five Indians have latent TB
Now, the book under review quotes the World Health Organization saying latent TB is found in every fourth human walking the face of this bountiful Earth – on average. In India, we’re told, the latent form of TB is found in 40% people, or on average two of every five. Of these, who knows how many fall ill and have to get DOTS, the standard treatment for TB (not the drug-resistant kind). Alarming, as you might expect; particularly for this reviewer who lives in Mumbai, a city with a long history in which TB figures all too prominently. As for a personal angle, well.
A few years ago, my relative, a white-collar office worker also based in Mumbai, got TB - the ‘active’ form. While she was cured in the course of time, the infection made her suffer and disrupted her life.
Like it or not, we are in this together
The book says, “Every year, 10.4 million (1.04 crore) new cases of tuberculosis are reported globally… Nearly 2.8 million of the afflicted – more than anywhere else in the world – live in India”. They span income groups, from the poor to the middle-class (like my cousin) to, say, Amitabh Bachchan, who in 2000 was diagnosed with TB in the spine, and who recovered. That’s another of the powerful points driven home in this book: Like it or not, we are in this together, we are connected. (A point we should be particularly receptive to, we who have been through three waves of the COVID pandemic.)
One of the points which the book under review lands like a nice big block of concrete is that TB is not alien, nor has it ever been, to ‘people like us’; it is not a disease exclusive to ‘people like them’. To my mind, TB has become as democratic a pain as any gaping manhole that claims the life of a pedestrian in the monsoon, no matter the size of his or her bank balance.
The suffering of TB is preventable
The book says the tragedy is that much of the suffering - and deaths - attributable to TB is preventable. The book takes names and holds accountable the processes and people behind the “medical apartheid” in which “preventable and curable diseases, such as TB, are thriving while lifesaving medicines remain in a stranglehold” – foundational is the World Trade Organization’s imposition in the 1990s of a non-negotiated, one-size-fits-all patent treaty on the Global South, coupled with pressure tactics to ensure cheap generic versions of expensive new TB drugs are blocked for as long as possible – for what else but humongous profits. Here, the author brings out a racial angle; we are told, “The majority of dying patients are brown or black, while a significant number of patent owners are not… drug patents are often not only unfair but also racist.”
Further sharp and well-voiced diagnoses map “the regulatory capture of health resources by multinational corporations”, even as “authoritarianism, xenophobia, and science denialism” add to the crisis. These interwoven themes forcefully drive the book from chapter to powerful chapter, mapping the global ecosystem that nurtures TB and helps it grow.
This is the big picture view, which also takes in the history of medicine from magical thinking onwards to germ theory, taking note of the work produced by Semmelweis, Pasteur, Lister and Koch, among others. We are brought to the present day, a perverse closing of the circle where old drugs are proving ineffective against ‘drug-resistant’ kinds of TB, and where research on new drugs is scant.
The author has provided ‘closeups’ of what a community ravaged by TB goes through; the author’s excellent reportage from a housing colony in Mumbai, which is dark, poorly designed mass-housing stemming from what the author implies is class-discriminatory urban planning. For me, this section produced a feeling of empathy along with a reassessment of my privilege.
Yet another layer: Taking governments to task, which seem to prioritize drug manufacturers and their shareholders over people in need of cheap, good medicines, the author makes a robust critique of public health policies abroad and in India.
TB in literature in particular, and culture in general
Talk of this book being ‘interdisciplinary’. There is even a look at literature and culture, and how they were affected by the rise of TB. Vampire scares and vampire tales like Bram Stoker’s Dracula were inspired by the rise of this ‘plague’ and faded away when it became curable, thanks to medical advances. And among the most fascinating bits in this book – there are several on every other page – is this: as it became common knowledge in the United States that spit spreads TB, women’s skirts became shorter, partly to keep them from sweeping across spit-stained sidewalks; sartorial adjustments were easier to make than getting the spitters to stop, most of the spitters and the cops and judges prosecuting them being men.
If you were to say “A-ha!” out aloud for every illuminating bit from this book, you would soon be in need of a packet of throat lozenges. All the aha-moment material also maps the TB crisis from medical, legal, political, race/class and cultural angles. This is a genuinely fascinating diagnosis, not infotainment. And while diagnosis implies the possibility of a complicated cure, I won’t offer spoilers.
TB in India
India being among the countries worst affected by TB, Phantom Plague devotes considerable attention to our country. In this connection, the author quotes American health expert Jennifer Furin, who has told the Indian media that the Indian government’s “policy of drug rationing” is geared towards saving the drugs “for the rich”. This apparently has been the policy for a long while. Coming, however, to the current government of India: “Soon after coming to power in 2014, the (Narendra) Modi administration cut budgets to flagship health programmes, including those for HIV/AIDS and tuberculosis interventions…” A double whammy, this, as HIV/AIDS takes away the immunity of patients, leaving them susceptible to TB infection.
Moreover, as the current administration moved to reduce the influence of foreign-funded NGOs in India; as part of this exercise, the government fired the bulk of TB experts “who had been funded by international donor organizations and consulting with the health ministry – en masse… for being foreign funded”.
Third, we are told the non-availability in India of new and effective medicines has led to many deaths. In this connection, we are given the story of Shreya Tripathi, who perished for want of a drug named bedaquiline. In this connection, at another place in the book, we are told the current administration “has been unwilling to antagonize American pharmaceutical companies by issuing a compulsory license” for new-gen TB drugs… Instead, the health ministry has “requested” Johnson and Johnson and Otsuka to grant voluntary licenses to Indian manufacturers. In a heartbeat, both companies denied the request”. A compulsory licence, apparently, is a legal clause using which a government can cite a health emergency and force a patent holding company to let other companies replicate its drug. This makes the drug more freely available and for cheap.
The author brings rigorous research and quietly impassioned writing to bring us the stories of a few other Indians coping with TB. We are given the moving, inspiring story of Nandita Venkatesan. She had TB; was put on a course of drugs that also included an old-time drug called kanamycin. It produced a side effect in Nandita; it took away her power of hearing. (We are told that as side-effects go, this is common; yet it was unknown, apparently, to health authorities who’ve been prescribing kanamycin for years.) We are taken through Nandita’s ordeal of facing the devastating effects of both TB and toxic drugs. We are shown how she suffered, survived, and was cured eventually. Further, we are given the inspiring story of Nandita, along with South Africa’s Phumeza Tisile, who also lost her hearing to kanamycin, having been aided by Medécins Sans Frontières to file “a patent challenge to bedaquiline at the Mumbai patent office”. At one place, the book tells us that India is where the “war against TB” will be won or lost. It’s a sobering point.You will notice this review has few direct quotes from the book; that’s because I couldn’t decide which ones to put in. Call it a problem of plenty: there being so many quotable bits on every other page, I was tempted to put in whole chapters. That would have kept us here for, I don’t know, a few days. So, best perhaps to sum up in this fashion: Every so often, you get books which are warm enough to make the scales of jadedness drop from your eyes. One such book is Phantom Plague. If you want to read only one book on the TB crisis foisted upon the world’s citizenry, this is it.