What makes Phantom Plague a fine revelation of a known adversary, the tuberculosis bacteria

In the book, Vidya Krishnan joins the dots between the inaccessibility of drugs, human folly and prejudices that come in the way of clinical care

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Mumbai is India’s tuberculosis hotspot, and while the victims do cut across social classes, the poor bear the brunt of the pestilence. (Credit: Unequal Scenes/Johnny Miller photography)

Written by: Kaushik Das Gupta

6 min readNew DelhiJul 2, 2022 01:32 PM IST First published on: Jul 2, 2022 at 01:32 PM IST

In 2020, as the coronavirus ravaged the world, another microbe took a toll of about 1.5 million lives. In that year, “more people died from TB, with far fewer people being diagnosed and treated or provided with TB preventive treatment compared with 2019, and overall spending on essential TB services falling,” the World Health Organization noted. Unlike the novel coronavirus, the tuberculosis bacteria is a known adversary. Humankind’s battle against it goes back several centuries. That the pathogen remains intractable in large parts of the world has much to do with a lethal combination of ignorance, inequality, and policy deficits. Vidya Krishnan’s Phantom Plague: How Tuberculosis Shaped History is a searing account of humankind’s failure to eliminate its oldest scourge.

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India, Krishnan tells us, is critical to the fight against tuberculosis. “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,” she writes. India accounted for more than 30 per cent TB deaths in 2019. The tragedy is that much of it is preventable. The victims do cut across social classes but the poor and the marginalised bear the brunt of the pestilence, a vulnerability that has much to do with their living conditions as well as the failure of the country’s medical system to provide timely diagnosis and care.

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In one of the most telling chapters in Phantom Plague, Krishnan takes us to Building Number 10 in Natvar Parekh Compound in Mumbai’s East Ward. Ostensibly a slum development project, the housing complex is a “visual reminder of many of Mumbai’s greatest challenges: the desperate shortage of real estate, a growing population crisis and brewing public health nightmare that lurks in poorly-designed urban housing”. Krishnan quotes medical researchers to reveal a horrific factoid: at least one member in the match-box-shaped single-room dwelling unit has drug-resistant tuberculosis. The unwelcoming and claustrophobic tenements, such as Building No. 10, are petri dishes for tuberculosis. Maharashtra is India’s tuberculosis hotspot. About a sixth of India’s drug-resistant TB patients live in the state, nearly half of them in Mumbai. Two hundred of the more than 1,200 extra drug-resistant TB — an extremely lethal form of the disease — patients live in the Maximum City. As in several infectious diseases, the spread of tuberculosis has much to do with human folly and prejudices. A large number of doctors, Krishnan’s study shows, are ignorant of the protocols to treat drug-resistant TB.

What makes Phantom Plague a riveting read is Krishnan’s ability to join the dots: between the prejudices that hobbled the efforts of the early innovators and the ignorance that still holds sway in sections of the medical establishments; between the power of big pharma, patent regimes and policy deficits in several countries, including India, that combine to lock a large number of poor out of affordable healthcare; between ill-planned housing projects and the spread of infection; between HIV and the spread of TB.

Phantom Plague: How Tuberculosis Shaped History; by Vidya Krishnan; Penguin, Viking; 320 pages; Rs 799

Phantom Plague is simultaneously a work of medical history, anthropology, and epidemiology. We are introduced to doctors and scientists who pioneered the battle against microbes. There is a moving account of the maverick Hungarian doctor Ignaz Semmelweis whose insistence that doctors helping women deliver babies must wash their hands with lime before conducting their procedure earned him the displeasure of his colleagues, leading to his ostracisation and death in an asylum. Posthumously, however, Semmelweis would be feted as the “saviour of mothers”. By washing hands before assisting women deliver babies, doctors would obviate chances of infection leading to a drastic fall in the death of women from childbed infection. Other well-known trailblazers, such as Joseph Lister, Robert Koch and Louis Pasteur, also find a place in Krishnan’s account.

In a little more than 250 pages, Phantom Plague lays out the changing character of the war against the disease. The medical advances in the last 150 years have made TB a curable disease. But the knowledge boom seems to elude not just patients, but also policymakers and doctors. Most patients in Building No. 10, for instance, were prescribed common antibiotics as the first line of treatment which made their condition even worse.

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In chapters on two patients, Piya and Shreya, Krishnan brings alive the trauma of those suffering the lethal form of the disease. The contrasting fortunes of the two — Shreya succumbed to the disease — also frame the lack of choices that make the battle of the poor against the disease a near-impossible one. The book shows how the patent system prevents access to life-saving drugs, making patients from poor households depend on the generosity of pharma majors. That’s why Krishnan’s book is an important addition to the recent debate on patents on life-saving therapies and preventives, occasioned by the COVID-19 pandemic.

At the same time, Phantom Plague is a wake-up call to governments, including in India, to apply correctives to policies — rationing system for extra drug-resistance TB medicines, for instance, that was partially corrected after a Delhi High Court directive — that keep healthcare out of the reach of large sections of people, recent initiatives like Ayushman Bharat notwithstanding.

As Krishnan points out, “Much like those who suffered from HIV/AIDS in the early years of the disease, Indian TB patients must grapple with a horrible reality: available drugs do not work for them, and newer medication is out of reach”.

Her work is a must-read for students of medical policy, epidemiologists, medical journalists, and all those who yearn for a more humane society.