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SUNDAY SCIENCE: THE PLAGUE THAT WON’T DIE  
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Pria Anand
November 27, 2025
The New York Review of Books
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_ As my recent diagnosis shows, tuberculosis is not a relic of
medical history. It remains the leading infectious cause of death
worldwide—and America is hardly immune. _

Edvard Munch: The Sick Child I, 1896, Munchmuseet, Oslo

 

REVIEWED:

Everything Is Tuberculosis: The History and Persistence of Our
Deadliest Infectionby John GreenCrash Course, 198 pp., $28.00

Phantom Plague: How Tuberculosis Shaped Historyby Vidya
KrishnanPublicAffairs, 300 pp., $30.00

By the time Mercy Lena Brown was born, in 1872, her New England
farming community was becoming a ghost town. Young farmers were
leaving the barren, rocky soil for jobs in the city, and the people
who remained were suffering an outbreak of consumption, which seemed
to move through households with no clear pattern, causing one out of
every four deaths in the area.

Of the nine members of the Brown family, Lena’s mother was the first
to die of consumption, in 1883. Seven months later Lena’s sister
Mary Olive, a twenty-year-old dressmaker, died too, becoming so pale
and emaciated in the final days of her illness that she knew in
advance to choose the hymn she wanted sung at her funeral.

Lena’s brother, Edwin, a store clerk, fell ill next. Desperate, he
went west to Colorado Springs, following the prevailing medical wisdom
of the time that dry air and sunshine could arrest the illness. They
didn’t. He returned home after eighteen months, weaker than ever,
and by then Lena, who had been well when he left, was gone too, her
own consumption the “galloping” variety. Edwin’s dreams became
even more fevered. “She haunts me!” he called out in his sleep.

After Lena’s death, in 1892, an article in _The_ _Providence
Journal_ reported that neighbors “besieged” her father, George,
insisting that Edwin’s symptoms were a sign of something
otherworldly: some spirit must be sucking the life from his thinning
body. Because he fell sick after his mother’s and Mary Olive’s
deaths, and because he quickly worsened after Lena’s, the three
Brown women were the chief suspects. The only way to save his life,
the neighbors told his father, was a morbid practice that had caught
on in New England in reaction to the gothic horrors of consumption:
exhume the bodies of his mother and sisters before Edwin entirely
wasted away.

Four local men dug up the remains of the three Brown women. By then
Lena’s mother and sister had been dead for nine years, and only
their skeletons remained. Lena had died in the winter, and her body
had been left in a crypt until the spring thaw softened the frozen
earth enough for burial. Her doctor was enlisted to perform an
autopsy; her body was still largely undecomposed. From beneath
Lena’s rib cage he removed her liver, the twin pink slabs of her
lungs, and her heart. This he slit open with a scalpel to find that it
was filled with dark clots of rotting blood.

To the neighbors, who had watched many of their own loved ones waste
away of consumption, the heart seemed like proof: Lena had been
feeding on the living, sapping their blood and leaving them wan and
feeble. They burned her liver and heart to ash, which they mixed with
water and administered to Edwin as an exorcism and cure. He died two
months later. In the end, only George and one of his seven children
survived the disease. Lena’s lungs, the doctor later told a local
newspaper, had been filled with “diffuse tuberculous germs.”

Lena’s death and exhumation—and a cultural history of this
tradition of disinterment, common throughout eighteenth- and
nineteenth-century New England—are recounted in careful detail in
the Rhode Island folklorist Michael Bell’s _Food for the Dead
_(2011). Drawing on decades of census data, death records, newspaper
clippings, and oral histories, Bell argues that this model of
disease—consumption caused by a vampiric spirit—had an internal
logic no different from the explanations of doctors and scientists at
the time. The myth could explain why the disease clustered in certain
houses, cursing entire families. And it accounted for the visceral
horror of the affliction, the way it consumed each of the body’s
vital organs in turn.

A decade before Lena’s death the German physician and microbiologist
Robert Koch, informed by the nascent germ theory of disease, had
discovered the bacterium—_Mycobacterium tuberculosis_—that causes
consumption. But the first antibiotics were not discovered for another
half-century, and the medical establishment, loath to attribute
consumption to a pathogen that could not yet be treated, was slow to
accept Koch’s explanation. Instead doctors clung to the older theory
that consumption was caused by damp lungs, prescribing
therapies—like Edwin’s sojourn in the West—intended to desiccate
their patients’ failing bodies: “What cures and hope for recovery
were medical practitioners offering their consumptive patients?”
asks Bell.

If you judge by sheer number and kinds of treatments, they offered a
great deal. But if you measure the effectiveness of these treatments,
then, unfortunately, they were still groping in the dark.

Among these treatments were leeches and opium, warm sea air and cold
baths, milk from the breasts of a pregnant woman, and dried seaweed
placed beneath one’s pillow.

Therapies have changed, but tuberculosis remains the leading
infectious cause of death worldwide. Nearly a century and a half after
Koch’s first attempts to devise an inoculation, we still have no
effective vaccines. Globally, one in four people carries tuberculosis,
though most are neither contagious nor symptomatic. In the United
States, where the prevalence is closer to three in one hundred, the
disease thrives primarily in the conditions created by social
injustice: overcrowded prisons, for instance, or temporary shelters.
Yet programs to curb the spread of TB are among those hit hardest by
both the Trump administration’s closure of USAID and its assault on
the National Institutes of Health, attacks that are projected to lead
to millions of avoidable TB deaths over the coming decade.

Tuberculosis can seem inscrutable, a protean disease that can settle
in virtually any organ in the body. In the lungs it causes the bloody
cough and gasping breath that ravaged the Brown family; in the
lymphatic system it causes swollen masses that can press on the soft
muscles of the vocal cords, robbing victims of their voices; in the
guts it causes raw, bleeding ulcers and obstructed bowels. The disease
is airborne: colonies of bacteria are exhaled from the lungs of a
person with pulmonary TB in a fine mist of particles that can linger
suspended in the air for hours. How long the bacteria survive in the
air depends on the surrounding conditions; in spaces with poor
ventilation—an enclosed car, for instance, or a windowless
room—they can last hours or even days.

Our lungs are a strange paradox: they are protected by the hard
carapace of our ribs but also tremendously exposed to airborne
bacteria, which can slip in with a single breath. To prevent
infections, the labyrinthine passages that make up each lung are lined
with white blood cells. But _Mycobacteria tuberculosis_ are
impenetrable. Each cell is surrounded by a thick barricade made of
fats and proteins. In the lungs they are consumed by white blood cells
but not digested, surviving undisturbed as more white blood cells
arrive to wall off the infection, forming scarred balls called
tubercles. Here the bacteria can live for decades or even a lifetime,
forming a latent infection and replicating slowly within an unwitting
host, undetected until they take advantage of an aging or suppressed
immune system to explode into full-blown consumption. A multitude of
factors can determine whether a person living with latent TB is likely
to develop the active disease, as Lena, her mother, and her siblings
did, or whether they will survive into old age with an infection that
remains latent, as her father probably did. Malnutrition, pollution,
and illnesses like HIV and diabetes can all contribute to TB
activation.

Fossils show the marks tuberculosis leaves on bones, tiny holes that
resemble the work of termites, the result of the human immune
system’s futile attempts to ferret out islands of bacteria lodged in
the hard tissue. In hips or wrists, the disease knits joints together
into an immobile mass. In spinal vertebrae, which are particularly
prone to tuberculosis because they are traversed by innumerable tiny
arteries that can deposit the bacteria deep into each bone, the holes
cause successive vertebrae to collapse into one another until the
spine contorts into a painful curve. The telltale hunched back of
spinal TB is immortalized in ancient Egyptian tomb paintings, ivory
carvings, and the bodies of unearthed mummies.

The earliest evidence of tuberculosis comes from the Natural Trap
Cave, in northern Wyoming’s Bighorn Mountains. The cave lies along
an ancient game trail that connects the mountains with lower-lying
grazing lands. Shaped like an iceberg—the small opening is about the
length of a compact car, while the floor, nearly a hundred feet below,
is as wide as a cruise ship—the cave is nearly invisible from the
snow-covered ground above it. Its unusual shape has made it
particularly interesting to paleontologists: the steep fall caused the
deaths of innumerable animals, and the temperature at its floor never
rises above forty-two degrees Fahrenheit, preserving their remains.
Among the animals that have died there since the last ice age—dire
wolves and woolly mammoths, American cheetahs and an ancient species
of camel that once wandered the American West—are a multitude of
Pleistocene bovids, from bighorn sheep to long-horned bison, with the
eroding bones and genetic traces of tuberculosis.

We once thought tuberculosis arrived in humans with the advent of
agriculture, acquired from cattle as hunters and gatherers became
settled farmers during the Neolithic revolution. The bovine form of
the disease—caused by the closely related _Mycobacterium
bovis_—can jump the species barrier to humans through unpasteurized
milk, causing an infection that is clinically indistinguishable from
one caused by the human variant.* But more recent studies suggest that
_Mycobacterium tuberculosis_ and _Mycobacterium bovis_ evolved
separately, from an even more ancient common ancestor long before the
Neolithic Period. As far back as we can imagine, TB has been a human
disease.

I practice neurology at a so-called safety-net hospital—a
designation unique to the deeply flawed and segregated American health
care system—where the many inequities that drive tuberculosis
infection rates are evident. “Safety net” is a euphemism for
hospitals that care for people who, because of their health insurance
or lack thereof, their citizenship status, or their bank balance, are
denied care everywhere else. Nearly all my patients are in some way
displaced, and more than half recently arrived in the United States.
My hospital includes centers for refugee health, the treatment of
addiction, and the treatment of trauma.

Roughly once a year I care for someone whose tuberculosis has entered
their brain, resulting in a vicious meningitis that can clot the
arteries and cause strokes, dangerous swelling, and inflamed
tuberculous abscesses of the brain that often look at first glance
like tumors. Still, I have always felt removed from TB, as though it
were a curious relic of medical history rather than a contemporary
plague.

But early in my first pregnancy, when I felt it only in the wave of
nausea that woke me every morning, my own blood tested positive for
TB. That week doctors X-rayed my lungs to be sure I wasn’t
contagious, a lead vest laid over my belly to protect the baby. My
lungs were clear, my infection was latent, and my baby was
unscathed—the spongy layer of placenta that funnels nutrients from
pregnant bodies into a fetus also keeps many infections at bay—but
if I ever require chemotherapy or another immunosuppressive
medication, I will need to be treated to make sure my tuberculosis
does not become active.

The treatment regimen for an active tuberculosis infection is crude:
months of toxic antibiotics that have the potential to harm nearly
every part of the body. One of the treatments can strip the nerves and
leave patients’ feet numb and tingling, while another turns both
tears and sweat orange—patients are advised not to wear white
T-shirts when taking the drug. Both medications can damage the liver.
The treatment can take anywhere from three to nine months depending on
the drug combination, and once it has begun, a patient cannot miss a
dose. The first-line drugs we use to treat TB were all developed
decades ago—one more than a century ago—and many of our
second-line treatments for drug-resistant TB were originally developed
to combat other infections before they were repurposed for the
burgeoning plague of consumption.

How the world treats—or fails to treat—tuberculosis has everything
to do with where the disease takes its greatest toll. In his new book
_Everything Is Tuberculosis: The History and Persistence of Our
Deadliest Infection_, John Green writes, “TB doesn’t just flow
through the meandering river of injustice; TB broadens and deepens
that river.”

Green, an unlikely source for an instructive book on TB, is perhaps
best known as the author of _The Fault in Our Stars_, among other
young adult best sellers. Online he is the cohost of the Vlogbrothers,
a wide-ranging YouTube channel that, since 2007, has featured spots on
everything from _Harry Potter_ to microfinance. Green’s interest in
twenty-first-century TB came about by accident, he writes, on a visit
to Sierra Leone as part of a philanthropic program focused on the
global maternal mortality crisis. In the coastal town of Lakka, he
spent time at a tuberculosis hospital and met a teenager with a
drug-resistant strain whose painful experience forms the central story
of the book. _Everything Is Tuberculosis_, Green told _The New York
Times_, is intended to foster awareness among American readers who
would otherwise remain entirely ignorant of the communities ravaged by
the disease.

Green uses the disease as a way to see more clearly the many
injustices that have shaped our world. In Sierra Leone, where it is
epidemic, TB is a product of centuries of British colonial rule. One
Sierra Leonean physician tells Green to look at a map of the railroads
if he wants to understand why the country is so impoverished. By
extension, Green seems to imply, there is nothing inevitable about the
ravages of tuberculosis; rather, it was fertilized by the devastation
that colonialism left behind: housing insecurity, malnutrition, and
poverty.

At times _Everything Is Tuberculosis_ feels thin, a litany of
historical and cultural anecdotes from New Mexico’s statehood to the
Stetson cowboy hat, both born of the same “travel cure” that sent
Lena’s brother, Edwin, west in search of open air. (Green notes that
California became known as the “land of new lungs.”) The book
never does the messier work of reporting and research to explain how
colonization or development might propel an epidemic—why a
country’s colonial-era train system or overcrowded cities are just
as implicated in the spread of TB as any feature of the bacteria
itself. Among the book’s greatest strengths is its bibliography,
which includes a reference to Vidya Krishnan’s heftier _Phantom
Plague: How Tuberculosis Shaped History_.

_Phantom Plague_ tells the story of tuberculosis in India, where
roughly a quarter of the world’s tuberculosis cases are found and
where Krishnan has spent more than a decade reporting on the ways that
antibiotic overuse, housing policy, casteism, and patent law have
collided to create an epidemic of drug resistance, including TB
strains that one Mumbai doctor calls “totally drug
resistant”—TDR–TB. “The global battle against
tuberculosis…will be won, or more likely lost, in India,” writes
Krishnan.

Krishnan calls her book a “biography of the bacteria,” but it
often reads more like a history of medical science itself, the story
of tuberculosis bound up with that of germ theory. Krishnan traces
Koch’s intellectual lineage from Ignaz Semmelweis, the unlucky
Hungarian obstetrician who was ostracized from the medical
establishment for suggesting that invisible “cadaverous particles”
carried on doctors’ unwashed hands might be responsible for a
devastating infection killing the women under his care, to Joseph
Lister, the English surgeon who first said that surgical instruments
ought to be sterilized.

The book includes fascinating digressions. Spittoons were
counterintuitively introduced to curb the spread of tuberculosis and
other infectious diseases once germ theory was widely accepted. And
Sir Arthur Conan Doyle, who supplemented his floundering medical
practice with popular writing, wrote a scathing rebuke, after being
turned away from one of Koch’s lectures, of his earliest attempts to
devise a remedy for tuberculosis.

But _Phantom Plague_ is strongest when it shifts to our own time,
examining policies that, Krishnan argues, have driven the long-lasting
crisis:

One bad decision at a time, the global TB epidemic has been socially
constructed by us—humans who are reliably small-minded, casteist,
and racist every time we face a pathogen that is highly unpredictable,
mutating, and thriving.

One chapter examines housing policy in Mumbai, particularly the
construction of “vertical slums,” airless high-rises designed to
crowd the impoverished as close together as possible, well away from
the city’s fabulous wealth but still within “serving distance.”
“No city in the world had segregated the rich from the poor, the
lower caste from the upper castes, as efficiently as Mumbai,”
Krishnan writes. The buildings are perfect breeding grounds for
tuberculosis. As one young woman living with drug-resistant TB tells
Krishnan, you can get it “just by breathing” in certain parts of
the city.

Despite more than a century of scientific advancement and the
development of countless antibiotics, when it comes to TB
twenty-first-century medicine is not unlike the New England
townspeople digging up graves in search of a ravenous spirit. Krishnan
blames the epidemic of drug resistance on doctors who dose antibiotics
incorrectly or prescribe drug regimens without testing their patients
to find out what their disease is likely to respond to. Among her most
agonizing examples are the stories of two young women who were treated
for months with a toxic drug that had no effect on their tuberculosis
but rendered them profoundly deaf.

Worse still are the pharmaceutical companies that have produced
remedies for the drug-resistant strains but have made them
inaccessible where they are most needed, offering meager donations of
medications in lieu of a sustainable pricing model, and arguing that
people in India and other TB-endemic areas lack the health literacy to
take them correctly. (Krishnan makes analogies to the early rationing
of antiretroviral therapy for those with HIV, which was withheld from
much of the world for racist reasons, including the presumption that
people living with HIV in Africa couldn’t tell time and would not
remember to take a twice-daily pill.) “Inherent in that argument,”
one American scientist tells Krishnan, “is the fact that infectious
diseases that affect poor people could someday affect rich people—or
white people…. We, the rich and the white, want to save these
medications for _us_, for _later_.”

While Green hopes to close the sympathy gap by bringing the stories of
tuberculosis to readers oceans away, Krishnan is more direct. Her
book, she writes, “has one intended audience: readers who have the
good fortune to have remained ignorant of TB but can ill afford to be
so any longer.” To imagine that Black and brown people, incarcerated
people, and poor and unhoused people are somehow uniquely vulnerable
is to be ignorant of TB’s long history, forever linked with our own.
“No one is safe,” she writes, “until everyone is.”

Iwas born in the United States, but I spent my first four years in the
urban India that Krishnan writes about, and stories of tuberculosis
are enshrined in my family mythology. One great-aunt nearly lost her
hands to a childhood TB infection that ravaged her joints, yet she
learned to write despite her pained, frozen fingers. In what was then
British-occupied India, where nearly all Indian women married young
and bore children without ever learning to read, she studied economics
and became the principal of a college. In the US my latent disease
makes me an anomaly, but it also makes me feel part of a larger,
ancient lineage. Yet even though I am a doctor, even though I am not
contagious, I have kept my condition a secret until now, afraid of
some nebulous stigma.

The autumn I was diagnosed, I left work early on a Thursday afternoon
and drove an hour south from my hospital in Boston to visit the Rhode
Island grave of Mercy Lena Brown. More than a century after her
burial, Lena’s grave has become something of a pilgrimage site. When
I visited, the headstone was piled with offerings—some acorns and
pennies, a freshly cut pumpkin, a bouquet of zinnias. The stone itself
has been stolen so many times that it is bolted to the ground with an
iron strap. Nearby is the crypt from which Lena’s body was exhumed.
The cemetery is tidy, but the crypt, shaded by an overgrown swamp oak,
is wild, its wooden door hanging loose from its hinges, and its stone
walls blooming with starbursts of lichen.

Over the years, souvenir hunters have chipped away at Lena’s
gravestone, stealing bits of marble as eerie mementos, but her epitaph
remains: “Mercy L., daughter of George T. and Mary E. Brown, died
January 17, 1892, aged 19 years.” Neither a vampire nor a martyr,
just a girl who suffered before she died, one of an uncountable
number.

*Koch himself got it wrong in his Nobel Prize lecture in 1905, when he
ridiculed the “supposed menacing dangers of bovine tuberculosis,”
which he was certain could not be transmitted to humans.

_PRIA ANAND is a neurologist and the author of The Mind Electric: A
Neurologist on the Strangeness and Wonder of Our Brains. She teaches
at Boston University and practices at Boston Medical Center. (December
2025)_

_THE NEW YORK REVIEW was launched during the New York City newspaper
strike of 1963, when the magazine’s founding editors, Robert Silvers
and Barbara Epstein, alongside Jason Epstein, Robert Lowell, and
Elizabeth Hardwick, decided to start a new kind of publication—one
in which the most interesting, lively, and qualified minds of the time
could write about current books and issues in depth. _

_Readers responded by buying almost every copy and writing thousands
of letters to demand that the Review continue. From the beginning,
the editors were determined that the Review should be an independent
publication; it began life as an editorial voice beholden to no one,
and it remains so today._

_Silvers and Epstein continued as co-editors until her death in 2006,
and Silvers served as sole editor until his death in 2017. Since 2019
Emily Greenhouse has edited The New York Review, and it remains the
magazine where, across twenty issues each year, the major voices in
world literature and thought discuss books and ideas. In addition to
the print magazine, the NYR Online publishes thorough and
wide-ranging essays about politics national and global, film, art, and
the cultural preoccupations of the day._

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HOW PROPUBLICA INVESTIGATED A BIRD FLU OUTBREAK IN AMERICA’S
HEARTLANDNAT LASHPROPUBLICAEarly this year, bird flu ripped through 80
farms in Ohio and Indiana. Using genetic markers, wind simulations,
satellite imagery, property records and more, we found that the virus
could’ve been airborne.November 18, 2025

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