All podcasts / People I (Mostly) Admire / Summary

The Deadliest Disease in Human History

2025-05-10 - source - Read full transcript

Steve Levitt (host)John GreenMorgan Levey

Key insights

Tuberculosis kills more people per year than HIV, malaria, typhoid, and Ebola combined, despite being fully curable since the 1950s.

About 10 million people get sick with TB annually and roughly 1.25 million die, a toll Green expects to worsen in coming years even as the U.S. sees only a few hundred deaths a year. Green frames this as 'the exemplary disease of injustice' because the cure exists but isn't where the disease is.

tuberculosis-injustice

TB persists in poor countries mainly because of a resource-allocation problem, not a scientific one.

Between 1965 and 2012 no new TB drug classes were developed, so patients in places like Sierra Leone still get the same 1960s-era first-line drugs, and the $15 test to check for drug resistance is judged too costly to run routinely against competing priorities like malaria and mental health care.

tuberculosis-injustice

Nineteenth-century Europe romanticized tuberculosis, rather than stigmatizing it, because it struck rich and poor alike and was believed to be inherited rather than infectious.

Figures like Byron, Keats, and Charlotte Bronte described consumption as beautiful and creativity-enhancing; Dickens called it 'the disease that wealth never warded off.' Green argues that when a society can't push a disease's sufferers to the margins through stigma, it instead elevates them as 'more than human,' which is no less dehumanizing.

disease-romanticization

Robert Koch's 1882 proof that TB was bacterial, not inherited, triggered rapid social change, from clean-shaven fashions to shorter hemlines, out of fear of invisible germs.

Koch injected material from an infected animal into a growth medium, then into a second healthy animal, establishing a chain of transmission. The discovery was accepted unusually fast for a scientific claim, but Koch later overreached: he announced a 'cure' (tuberculin) that a then-unknown country doctor, Arthur Conan Doyle, proved was not a cure at all but a diagnostic test.

disease-romanticization

Green's YouTube-audience pressure campaign against Johnson & Johnson's bedaquiline patent-evergreening led to a 55 percent price cut within about a year.

J&J had filed secondary patents on a drug-delivery mechanism to extend its 20-year monopoly on bedaquiline, a key multi-drug-resistant TB treatment developed largely with U.S. government funding. After Green's 2023 video mobilized his 'Nerd Fighters' fanbase and J&J publicly dismissed the criticism, the company signed away its secondary patents within days and later dropped them in every country.

pharma-patent-incentives

A similar public pressure and shareholder-activism campaign against Danaher, maker of the GeneXpert TB test, cut developing-world test prices 20 percent.

Danaher was charging roughly double to triple production cost for tests in poor countries. Green bought Danaher stock to gain standing at shareholder votes and ran a factual, non-hostile public campaign; a company executive told him the ask would cost Danaher about $110 million in bad publicity, which Green said he'd accept if necessary.

pharma-patent-incentives

Levitt proposes government patent buyouts as a policy fix that preserves drug-innovation incentives while eliminating the access problem, and argues its absence is a government failure, not a market failure.

Governments would calculate a firm's expected monopoly profit on a patented drug, pay it as a lump sum, and release the drug into the public domain for generic production. This keeps ex-ante incentives to innovate intact while maximizing ex-post access; Levitt cites Michael Kremer's advance-market-commitment mechanism for Covid vaccines as the same idea run in reverse, and suggests the European Union, not the U.S., is currently the more plausible actor.

pharma-patent-incentives

Aggressive anti-pharma activism carries a real risk: it can blunt firms' future incentive to develop drugs for diseases of poverty.

Levitt raises this directly as a weakness in Green's campaigns - if activism prevents firms from ever recouping R&D costs in poor markets, they may simply stop investing there, which he ties to the 50-year gap (1965-2012) in new TB drug development. Green agrees it's a real and unresolved worry.

pharma-patent-incentives

Green found a durable sense of purpose in TB advocacy that his earlier, more removed philanthropy (funding a Sierra Leone maternal-health hospital) didn't fully provide.

After achieving all his career goals as a novelist, Green describes a meaning vacuum; his TB work is anchored by a personal friendship with Henry, a young Sierra Leonean who survived multi-drug-resistant TB, whereas his hospital philanthropy was driven more by trust in Partners in Health's judgment about effective resource use than by personal connection to the cause.

creative-work-and-purpose

Green deliberately released a free, condensed Crash Course video on TB before publishing the book, betting that free video content doesn't cannibalize book sales.

He points to his prior book, The Anthropocene Reviewed, which he gave away almost entirely as a free podcast yet still sold 650,000 copies, as evidence that the physical/intimate act of reading a book has value distinct from consuming free video or audio content.

creative-work-and-purpose

Levitt argues nonprofit CEOs are systematically underpaid relative to talent, and that donor-driven overhead-ratio thinking causes this.

He argues nonprofits face a talent market shared with for-profit companies but are constrained by donor norms that penalize spending on staff, unlike for-profits where 'minimize costs at the expense of talent' would never be accepted strategy. He cites Sendhil Mullainathan and Marianne Bertrand's finding that oil-company CEO bonuses tracked oil prices (luck, not skill) as evidence that for-profit CEO pay is often mis-set too, cutting against the idea that for-profit pay is simply the correct market benchmark.

nonprofit-compensation

Books referenced

Everything Is Tuberculosis: The History and Persistence of Our Deadliest Infection - John Green - Green's nonfiction book on tuberculosis, its history, and the injustice of who gets cured and who dies; the central subject of the episode.
The Fault in Our Stars - John Green - Referenced as Green's breakout novel; he tells the story of a terrible early draft ending (literally tying the protagonist to train tracks over a trolley-problem obsession) that his longtime editor talked him out of.
Turtles All the Way Down - John Green - Referenced alongside The Fault in Our Stars when discussing the 'crash' Green experiences after finishing a big creative project; he developed Labyrinthitis, a debilitating inner-ear illness, after this book's release.
The Anthropocene Reviewed - John Green - Green's prior book, almost all of which he gave away free in podcast form before publication; still sold 650,000 copies, which he cites as evidence a free video/audio version doesn't cannibalize book sales.

Media referenced

Crash Course tuberculosis video - other - A free, beautifully produced hour-long video on Green's Crash Course YouTube channel, released before the book as a condensed version of it; has over two million views.
Raj Shah Never Wastes a Crisis - podcast - Earlier PIMA episode referenced by a listener question about why nonprofit CEOs are paid less than for-profit CEOs; Levitt recounts asking Bill Gates why the Microsoft CEO is paid so much more than the Gates Foundation CEO.
The Rest Is History - podcast - Tom Holland's podcast; Holland is teased as the guest on the next episode, discussing a novel in which Byron is literally a vampire.

Companies

Johnson & Johnson - Held the patent on bedaquiline, a key multi-drug-resistant TB drug, and filed secondary 'evergreening' patents to extend pricing control; target of a 2023 campaign by Green's YouTube fanbase (the Nerd Fighters) that led J&J to drop its secondary patents, cutting the drug's price by 55 percent.
Danaher - Maker of the GeneXpert TB diagnostic test, sold to poor countries at roughly double to triple production cost; after Green became a shareholder and ran a public pressure campaign, Danaher cut prices 20 percent, letting the Global Fund buy millions more tests per year.
Partners in Health - Nonprofit Green trusts and defers to on strategy; helped build a maternal-health hospital in Sierra Leone funded substantially by Green's own donations and fundraising (over $25 million).
Global Fund - Global health financing body that was able to purchase millions more GeneXpert tests annually after Danaher's price cut.
Rockefeller Foundation - Raj Shah, its president, is the subject of the listener question about nonprofit CEO pay discussed in the closing segment.
Walmart - Levitt's anecdote: Walmart's fast disaster-relief logistics boost employee morale according to internal surveys, which he uses as a parallel to how ethical behavior can serve Danaher's long-term interests.

Techniques and frameworks

DOTS (directly observed treatment, short-course) - The decades-old, low-cost standard TB drug regimen (a few hundred dollars per patient per year) used as the default treatment in resource-poor countries like Sierra Leone, regardless of whether a patient's TB is drug-resistant.
Patent buyout / advance market commitment - Levitt's proposed policy fix: governments calculate a firm's expected monopoly profit on a drug, pay that as a lump sum to buy out the patent, then release the drug into the public domain, preserving R&D incentives while eliminating the access problem; he cites Michael Kremer's advance-market-commitment work on Covid vaccines as the mirror-image version already used.
Public pressure / shareholder activism campaign - Green's playbook against pharma pricing: mobilize his YouTube audience publicly while staying polite and factual, and become a shareholder to have standing at leadership votes, framing the ask as cheaper than the bad-publicity cost the company itself quoted him.

Summary

John Green returns to People I (Mostly) Admire, three years after his first appearance, to discuss his new nonfiction book Everything Is Tuberculosis and the activism campaign it has fueled. The conversation opens with the staggering scale of the disease: roughly 10 million people fall ill with TB each year and 1.25 million die, more than the combined toll of HIV, malaria, typhoid, and Ebola, even though TB has been curable since the 1950s. Green frames this as "the exemplary disease of injustice" - not a scientific problem but a resource-allocation one, since the same 1960s-era drugs remain standard care in poor countries and a $15 drug-resistance test is often judged unaffordable to run at scale.

A substantial middle section traces TB's cultural history: its romanticization by Byron, Keats, and the Brontes in an era when it was believed to be an inherited trait of the sensitive and refined rather than an infectious disease, and how Robert Koch's 1882 discovery of the causative bacterium upended both the science and the culture (goodbye beards, hemlines rose) almost overnight. Green tells the almost-too-perfect story of Koch overreaching with a false "cure," only for an unknown English country doctor, Arthur Conan Doyle, to be the first to show it was really a diagnostic test - a story Green says he couldn't have invented if he tried.

The episode's core is Green's activism playbook and Levitt's economic critique of it. Green mobilized his large YouTube fanbase (the "Nerd Fighters") against Johnson & Johnson's patent-evergreening of bedaquiline and against Danaher's markup on its GeneXpert TB test, in both cases combining public pressure with polite, fact-based messaging (and, with Danaher, buying stock to gain a shareholder voice). Both campaigns won real price cuts. Levitt pushes back with a textbook economist's worry: if activism prevents firms from ever profiting in poor markets, it could blunt future R&D incentives, pointing to TB's own 50-year drought in new drug development (1965-2012) as a cautionary precedent. Levitt then offers his own policy fix: government patent buyouts, paying firms their expected monopoly profit as a lump sum in exchange for putting the drug in the public domain, which he argues aligns both the incentive to innovate and the incentive to distribute widely, and which he sees as more a failure of government than of markets or firms.

The conversation turns personal as Green describes how his TB advocacy, anchored by his friendship with a young Sierra Leonean TB survivor named Henry, has given him a sense of purpose that eluded him even after achieving his childhood dreams as a novelist - and that felt more present than his earlier philanthropic work funding a maternal-health hospital in Sierra Leone, which he describes as driven more by trust in Partners in Health's judgment than by personal connection. He also discusses the economics and creative tradeoffs of giving away a free Crash Course video on TB ahead of the book's release, arguing (based on a prior book's experience) that free video content doesn't meaningfully cannibalize book sales because reading demands a different, more intimate kind of attention.

The episode closes with a listener-question segment with producer Morgan Levey, where Levitt argues nonprofit CEOs are systematically underpaid because donor norms punish spending on staff even though talented nonprofit leadership can multiply the impact of every donated dollar, and notes that for-profit CEO pay itself is often mis-set, citing research showing oil-company CEO bonuses tracked oil prices rather than genuine performance.

Notable Quotes

"We let this cure be where the disease is not, and we let the disease be where the cure is not. I find that reprehensible." - John Green

"Tuberculosis exists because we allow for it to exist. And to me, that makes it the exemplary disease of injustice." - John Green

"Romanticization is not a favor that we do to people... from their perspective, they just wanted to be people." - John Green

"A bunch of what C.E.O.s get rewarded for is luck instead of skill. And I think that leads to them being overpaid." - Steve Levitt

"What I'm hearing is that you need me to cost you $110 million in bad publicity in order to make this change. And I will do that if I have to." - John Green