Phantom Plague: A conversation with the author Vidya Krishnan
By Shashika Bandara
Phantom Plague released in February 2022, focuses on tuberculosis, its global history, reasons behind our failure to eradicate TB including colonial and neo-colonial global structures and national practices. The book covers the story of TB from 19th century New York to present day Mumbai. The book paints a picture of the impact of TB and outline where the challenges are in a narrative story telling format, which invites readers to place themselves in this global historical journey.
In this article we speak with the author Vidya Krishnan, who lives and works in India. She has been a health journalist for nearly two decades., We’ll talk to her about her journey and her inspiration to tell this important story of TB. Also, we will delve into the challenges she recognized and where the solutions may lie.
Vidya, to open the conversation and to learn a bit about you, could you tell us a bit about what motivated you to write this meticulous and incisive book on TB, its history, and contemporary challenges?
I’d been reporting on HIV & TB when, in 2016, a teenager moved courts to access Bedaquiline, a new therapy for drug-resistant TB. She died, from a curable disease, trying to access medicines that were manufactured in India, but rationed because of patent monopolies. To me, this was a case of ‘death by red tape’ and I could not stop thinking the sheer injustice of it.
I have no single reason to write this book except the injustices that I observed, not just in TB but also in COVID and HIV and many other infectious diseases. We keep repeating the same mistakes- plague after plague- and so I decided to write about it, going all way back to Ancient Egypt and tracing the journey of the pathogen.
As you began writing, did you have an idea to choose a book format, or did it evolve?
This book began as a longform essay for Caravan magazine. At some point, I realized I had written 25,000 words and I had a book. For various personal reasons, I did not want to commit to a book at that stage but I kept reporting. Everything you read in the book are stories that I was not allowed to publish in Indian media- which does not like criticizing the government.
Before I knew it, I had 90,000 words and nowhere to tell this story. Thankfully, my friends convinced me to write a book proposal and things kind of snowballed from there. I was visiting McGill for the Summer Institute and Madhu Pai, and many of his students, were generous to allow me access to the libraries- sometimes on their IDs. By the time I was writing the concluding chapters, I had won the Nieman Fellowship and was at Harvard University. Being able to access the Widener Library was..like magic. It allowed me to do a deep dive into the history of plagues and meander into storylines about how TB has impacted humanity through generations.
Diving into the book, you have started from a deep historical perspective, you speak to the colonial and neo-colonial impact and also the lack of effort by country governments such as India. Can you speak to these elements in your book?
The book is structured in a way that I could explain the story to myself. To explain why that teenager, in 2016, was being denied access to Bedaquiline, I had to go all the way back into history.
This book was never simply about TB. It is about the interplay of race, medicine, and politics. I wanted to tell a story- using TB as a case in point- to explain why global health is in a deeply fragile place right now, as we enter the third year of the pandemic. This is also the reason I start my book in 19th Century New York, because developing countries are making the same mistakes that developed nations made 200 years ago. So, there was a parallel to be drawn especially because we find ourselves living in a time of historical amnesia.
Secondly, India’s storyline about TB would remain incomplete without the context of how British Raj government its colonies. We cannot talk about infectious diseases without talking about race, class, caste, and gender. Politics of infectious disease management is inextricably linked to race. We saw it with Ebola where there was no urgency for a vaccine as long as the virus was boomeranging in African nations. Soon as cases started appearing in the U.S. and Europe we found vaccines. We are seeing these themes repeat with COVID-19.
Infectious diseases infect black and brown nations disproportionately. And global health order wants to “control” disease in these developing nations without caring for the patients. I want the reader to think hard about medical apartheid and racial injustice in health policies, especially policies around infectious diseases. Infectious disease politics comes with a very un-flattering view of black and brown nations. So, this is a conversation we need to have right now and a conversation that the book wants to force.
Absolutely, we definitely need to have more discussions around these dichotomies in how we treat people based on the countries they live in. I want to ask you about the country governments as well. You have mentioned the role of national governments that impact TB treatment and access to medicine – can you speak more about that?
This cannot be laid at the feet of any one government. Successive governments in India have let TB patients down. The current Indian government is not really acknowledging the magnitude of the problem. There is only so far you can go by sweeping it under the rug, thinking the disease affects only lower-caste communities or poorer people. But that’s not the case any longer.
Vidya Krishnan, author of the Phantom Plague (picture credit; Aravind Krishnan)
I cannot call out American pharmaceutical companies for keeping newer medicines in patent monopolies without calling out the Indian government- which manufactures Bedaquiline at a fraction of the cost in Indian factories, while Indian patients die by the thousands. India is considered ‘the pharmacy of the world’. We ship Bedaquiline globally but without a meaningful access program for Indian patients. There is nothing I have heard in the last five or seven years reported in this book, from a policy perspective, that adequately addresses this hypocrisy in Indian government’s policy.
The current Indian government perhaps does not the bad press from admitting its TB crisis. Perhaps, after 75 years of independence, India does not want to be seen as a country that is sick – but that is the case. India has the highest TB burden in the world and the policy interventions by the government are severely lacking. India is not necessarily a poor country. It is a rich country with a lot of poor people.
So, how did you connect these dots, in terms of writing? You have used this style of narrative story telling can you speak on why you used that style?
I grew up on stories from Mahabharata and Ramayana. And Eastern storytelling is.. vast and fanciful. The book has a Russian doll of stories- one within the other. I deliberately did not want to write a book about science- which is treated like broccoli that you slip in the food. The science is incidental. I wanted the reader to be captivated by the stories of people. There is nothing more powerful than a good story- it cannot be defeated. I did not want to put fact after fact after fact-- which is what I do as a journalist.
This is not a book written for people who have a stake in health sector or TB or medicine. It is written for someone who does not need to know anything about history, medicine, or politics. The book is now out and it belongs to the reader. It is for them to say whether I did this well or not.
So now that the book is out there and many are reading it, what change do you hope that the book would make?
The most important thing for me to de-jargonize the TRIPS agreement. It is an obnoxious way of denying someone medicine-- using fancy language that only lawyers can understand to make medicines less accessible. I cannot wrap my head around this bizarre law that was made by conglomerates and wealthy nations, and left fragile, post-colonial democracies to suffer in the wake of it. The vaccine injustice being faced by black and brown nations, where most COVID19 deaths are now happening, is the most recent example of this terribly unjust law. The TRIPS laws affect every single person in the world. It is important for all of us to understand it and demand it to be renegotiated it in a way that treats lives in the Global South as equal.
I would also love for the toxic injectables to be phased out. These drugs make one in four patients deaf and wouldn’t get marketing approvals by today’s standards. We have a situation in which newer, humane therapies like Bedaquiline are locked in patents and preventable/curable diseases are turning into nightmare superbugs but we still want to protect patent monopolies. I really want the reader to think hard about medical apartheid and racial injustice that underlines global health policies.
This interview was conducted and written by Shashika Bandara, the Editor-in-Chief of McGill Global Health Perspective.