Dialogues: a conversation with Vidya Krishnan

Dialogues is a new series from the Global Health Matters podcast where we bring you interviews featuring fresh perspectives on global health issues. The goal of each Dialogue is to break through our echo chambers that exist in global health through in-depth, thoughtful conversations. 

In this episode of Dialogues, host Garry Aslanyan speaks with Vidya Krishnan, a health-focused Indian investigative author. Vidya’s book, “The phantom plague: how tuberculosis shaped history” (PublicAffairs Books, 2022), is about how history shaped tuberculosis, especially in India, and how tuberculosis transmission persists because of conditions such as poverty, crowding, a lack of political commitment and poor public policies. She notes in her book that “poverty is the disease, tuberculous is the symptom.” This conversation reminds us, as global health professionals, of many challenges on the long road ahead toward the ultimate goal of tuberculosis elimination and the importance of community engagement.

 

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Transcript

Vidya Krishnan [00:00:00] The diagnosis came before the launch of the first edition of the TV show Kaun Banega Crorepati, the Indian version of Who Wants to Be a Millionaire. Wealth or caste cannot protect anyone from the miseries that are inflicted upon the inner cities. Tuberculosis is no longer a disease only of the poor or an abstract threat from history. In India, where the rich and the poor live less than a sneeze away, their destinies hopelessly intermingled, it is the daily business of life.

Garry Aslanyan [00:00:38] Welcome to Dialogues. I’m Garry Aslanyan. This is a special series of the Global Health Matters podcast. In this series, I’ll be blowing open some of the echo chambers that exist in global health. To help me in this quest, I have invited thoughtful and inquisitive individuals from different walks of life. Each of them has explored and written about global health issues from different disciplinary perspectives. I hope this dialogue series will give you, the listeners, an opportunity and space to step out of your daily routine and contemplate global health issues through a different lens. So let’s get started. 

Garry Aslanyan [00:01:21] For our second dialogue episode, I’m joined by Vidya Krishnan. Vidya is a health journalist and author based in Goa, India. Vidya invested a significant amount of her writing career investigating and documenting the impact of tuberculosis on Indians of all walks of life. In her book Phantom Plague: How Tuberculosis Shaped History, she weaves together a multitude of narratives over time, starting in 19th century New York, to modern day Mumbai. She explores questions about the interplay of race and caste in policies that influence the spread and control of tuberculosis in our day and age. 

Garry Aslanyan [00:02:19] Hi, Vidya. How are you?

Vidya Krishnan [00:02:24] Very well, Garry. Thank you for having me.

Garry Aslanyan [00:02:28] Where do I find you today, Vidya?

Vidya Krishnan [00:02:29] I’m in Goa, in India.

Garry Aslanyan [00:02:33] Great. Welcome to the show. Vidya, I wanted to start by asking what really motivated you and inspired you as a journalist to investigate interlinkages of science and society.

Vidya Krishnan [00:02:50] I grew up in Bhopal, which is a city in central India, and I grew up right after Bhopal was the centre of the world’s largest industrial disaster in 1984, when a pesticide factory leaked an intermediary substance and it poisoned and killed half the city from cyanide poisoning. And there was a long court battle at the end of it. Then no one apologized and no one was held accountable and no one actually was really rehabilitated. And everything about my journalism I have learned is from that one single epic story, which includes law and justice and politics and advocacy and all playing out in a small town, and that was the backdrop against what I grew up and everything I write about, which is, I don’t think it’s about science or medical history or race or politics, it’s actually about the interplay of these things. And I believe the only place these things tangibly come together is in literature where, as a writer, I simply just have to believe that nothing can beat a good story.

Garry Aslanyan [00:04:16] Vidya, I’m curious, is tuberculosis only a professional interest or you’ve had a more personal encounter with the disease?

Vidya Krishnan [00:04:27] If you mean that if I or someone in my life has had tuberculosis, no, not my immediate family. But is this personal? Yeah. Yeah. You don’t spend eight years on a story without it getting personal. And I also live in the country. I mean, while I was reporting on this book, I’ve lost a lot of friends to this disease, but I also live in a country where there is so much of tuberculosis and yet somehow people are just blind to it. And this book, when I started writing the book it wasn’t commissioned. I didn’t have a publisher. I simply had to write because I saw so much of it and I was working for a newspaper at that point and it just doesn’t do justice after a while to write 300, 600 word stories about something this huge in scale. And at some point I just realized I was essentially colonized by these stories and I tried to not write this book for a long time, but then I could not stop thinking about it and I do believe that stories cull writers out of people, and that’s what happened with me.

Garry Aslanyan [00:05:49] That’s interesting. And you take readers in your book through a trip or a journey which starts in the past, and you highlight how history has shaped TB (tuberculosis). Why did you feel the historical perspective is valuable and how could it challenge our understanding and inform our actions in combating TB today?

Vidya Krishnan [00:06:17] I personally think historical perspective is always valuable, but it’s particularly valuable when we are going through these mega events like plagues and famines and wars, because people tend to search very desperately for answers to make sense of things that can’t be made sense of essentially. I spent a lot of time reading history at that point, and I’d say all of it benefited from my reading of history, all of my reporting, because essentially we as societies and human beings are just predictable creatures and about how can history help in combating TB, TB was and has gone back to being the number one infectious disease killer and every plague before this one has taught us the same thing, that no one will be safe until every last one of us is. I feel like a stuck record saying this over and over again, everywhere I speak. But it was quite surreal to see the science denialism and the racism and casteism in my country, all of the things I had read about, the xenophobia, all of it just came to life in the past three years. If we don’t act collectively, because infectious diseases more than anything else, it’s about collective destiny. If we are greedy and if we think in these myopic ways, I don’t see any way we will prevail over these pathogens, despite all the fruits of modern medicine.

Garry Aslanyan [00:08:07] Interesting you mention that, because in this season we’ve recorded a couple of specific History Matters episodes and our audience really loved those episodes. It’s so important to know history, as you say. It was really interesting for me to learn from the book about the influence of the housing policies in Mumbai on the spread of tuberculosis. Let’s hear more about this from your book.

Vidya Krishnan [00:08:42] That aerial shot of the slum clusters is now known as the “trigger photo” within DFY (Doctors For You). It was the first time the DFY staff could visualize the scale of the health crisis. The photograph resembles a densely stacked honeycomb. There are fifty-nine rooftops, tiny squares, and red arrows coming out of them. Against each arrow, DFY researchers have put a number – to reflect how many TB patients live in each building. The markings get denser, more clustered, on the lower floors.

Vidya Krishnan [00:09:13] One building in particular stands out – building number 10 of the NP Compound. Researchers have found fifty-one drug-resistant (DR) TB patients in one building in one of the most sprawling ghettos – an exceptional find, even for a country like India. It was the equivalent of finding fifty-one people suffering from a rare cancer, all neighbours. At least one member of every family living inside building number 10 had drug resistance responding to the antibiotics. 

Vidya Krishnan [00:09:44] Poverty is the disease, TB is the symptom. The global fight against TB will be won, or more likely lost, in India because a century of bad housing policy decisions has meant that Mumbai’s rich residents live in their gated luxury archipelago of enclaves high in the sky, while keeping the poor residents of Mumbai in serving distance as their cooks and drivers and security guards and lift operators. Together, but separated more than ever. For the bacteria, this is a great opportunity to thrive. 

Garry Aslanyan [00:10:22] What do you think is the learning from the experience in Mumbai that could benefit other cities to not make the same mistakes?

Vidya Krishnan [00:10:34] Thank you for that question. What’s happening in Mumbai today was happening in New York in the 20th century. The Industrial Revolution led to decentralised housing, which made the city, the ghettos, a petri dish for tuberculosis. And globalization simply outsourced these dirty jobs to dingy places far away to, essentially, countries like mine. So why Mumbai is where we see this happening is Mumbai is the financial engine of India. But what’s happening in Mumbai is just a microcosm of what’s happening in every big megacity of the world. We are connected. Every part of the world is connected to every other corner with airports, and we all have to deal with this question. Are the poor who live amongst us, especially in big cities, the refugees, the workers who migrate from smaller towns to bigger ones, are they meant to live in sub-human conditions and what does it mean for the society collectively if you force a certain section of your society to live in these sub-par conditions? When I was reporting in Mumbai, I met this doctor who was the medical superintendent of Suri Hospital, which he jokes that if tuberculosis was a religion, Suri would be Mecca. It’s the largest tuberculosis hospital in Asia. And I now know from living in Mumbai, by reporting the book I lived there, and I lived in a posh neighbourhood in Mumbai, but I’d head out to the ghettos, report and come back to my safe distance. But then this is increasingly more and more fragile. And what the housing crisis in Mumbai teaches me essentially is this is not a coincidence, all of this is wilful neglect. We live in congested cities, but we are so segregated by race and caste and class, and pathogens don’t respect these boundaries and we just have to stop thinking, if we are to combat them, we have to change how we think about them as well. And a lot will begin with making sure that we have better housing for poor people, but unfortunately, in my country, we have a situation where Bollywood romanticizes this living in slums and we live in a society that is blind to the pain that’s just inflicted in different neighbourhoods.

Garry Aslanyan [00:13:17] “Bollywood romanticizes living in slums”. This is the first time I’ve ever heard this. How did that happen.

Vidya Krishnan [00:13:20] Well, you know Slumdog Millionaire which won the Oscar?

Garry Aslanyan [00:13:25] Right.

Vidya Krishnan [00:13:26] Well, it was very famously based in Dharavi, which is the biggest slum in Asia. And also we have in Bombay, if you are a tourist, they take you on Dharavi Tour, like as a tourist, you can just go there and see how poor people live. And everything about this is just so ugly and exploitative and so blind to the living conditions.

Garry Aslanyan [00:13:56] Vidya, interwoven in your book are the stories of several patients who you have encountered, and you mentioned how you visited and talked to them. Why, in your opinion, is it so paramount to anchor our efforts to eliminate tuberculosis within these stories?

Vidya Krishnan [00:14:15] Again, thank you for that question. I think one of the reasons why this book has done well is because I am not a student of medicine, so I did not approach this biography of a bacteria from a medical point of view. So I did not see these people as patients, I saw them as people, with dreams and families and mortgages and dogs and who just got caught in this very ugly turn of events in which they just had no control. And why is it paramount? When you see the patient and not the person, what is implicit in that, and I see a lot of that happening in India, is that you see the person as a disease carrier. I was in the United States when the Trump administration was in charge, and with infectious diseases, it you don’t see the patients as people, that’s the slippery slope we get to. I actually believe that seeing past this infection and looking at the person’s life is important because, more than anything else, it requires compassion, and I believe compassion is an absolute necessity in global health. It’s also the most missing component in our TB policy. And I don’t mean compassion as an indulgence or as a moral stand, I literally mean it as an urgent need to look at a policy that addresses infectious diseases, especially in developing nations, because if we don’t very carefully incorporate compassion into policy, we end up with something like DOTS [directly observed treatment, short-course]. DOTS was just, from the very beginning, unkind to patients. It was to expect the patient to turn up at a doctor’s clinic day after day after day. Even if they get fired from their jobs. If you’re standing in front of the building, you are visibly a TB patient, so you get ostracized. And this lack of thought, essentially, of course it’s at a philosophical and profound level great to be compassionate, but the way I see it, it makes the policies inefficient. It’s the biggest proof that the DOTS policy failed.

Garry Aslanyan [00:16:43] So another fascinating observation you made in your book is the tension between accessibility of antibiotics and also the inequity that can arise if access is limited. Could you tell us more about this situation in India?

Vidya Krishnan [00:17:01] I think, Garry, tension is a very charitable word, I would not use the word tension here. It’s just so morally fraught to deny someone medicine for someone in the future. And there is just no way you can say this without answering the question. Every time I’ve met an Indian doctor who says this to me, I’ve asked them: give me a visual of what does the patient in the future look like? Is it a rich upper caste, Hindu Brahmin, man or woman? In my country, but essentially at a global scale, why we want to save antibiotics is when a drug resistant tuberculosis reaches Seattle and Geneva and places like those, and you want to save the medicine for all rich white people or upper caste Hindus in my country, and there is just no way that we can talk about this without addressing the fact that in every system the rich will get the treatment. It’s the poor. It’s the lower caste people, or people belonging to different races, who will be left behind, and I personally find that abominable.

Garry Aslanyan [00:18:19] And Vidya, what do you think should be done about this?

Vidya Krishnan [00:18:22] I mean, almost immediately for TB, I will say that we just simply have to not enforce patent panoplies. It’s a global health emergency of a scale... Everything that happened in COVID has been happening for decades with TB. In India, the entire TB programme got “Covidized”, down to the helpline of the Ministry, and infections and respiratory diseases don’t simply go away. So the first thing we need to do is look at how technology is transferred, because vaccines and drugs first and foremost, it’s technology. It’s somebody’s intellectual property. And I feel like TB elimination cannot, will not be achieved if the medicines, the latest most humane therapy, is locked in a patent panoply. And again, the most frustrating part of this is that all of the new therapies in tuberculosis actually came out of a genuine public collaboration. Universities, student money, philanthropies put in money, a bunch of the late stage clinical trials on Bedaquiline were done in India and South Africa, so patients also pitched in. And it’s really unfair that you use patients for research, but then when it’s time to... and all of these drugs came out of industrial scale subsidies to pharmaceutical companies, and others in patent panoplies. So that’s the most urgent thing I’d say.

Garry Aslanyan [00:20:03] Vidya, you make a statement, “There is no public in public health any longer.” Could you expand on this?

Vidya Krishnan [00:20:11] Yes, Garry. I genuinely believe there is no public in public health. That is little health either - there is a lot of cash. Yesterday I was at a conference where I learned that during the pandemic... In India there’s this reputation that there are a lot of tech billionaires in India. But because of the pandemic, we now have more pharma billionaires than tech billionaires. We minted out a new billionaire every nine and a half days during the pandemic, and this is not just true for India, but of course it’s true for India and it’s true for the rest of the world as well. If there was public in public health, there is just no way that vaccines that have been brought to market with investment, heavy investments from publicly funded universities and taxpayers, will just be handed to pharmaceutical companies, just for a song. We let millions of people die from a preventable vaccine curable disease, and that really should make us question everything about the structure that we are trying to defend. It’s a very cruel thing to have medicines and not share it, and I don’t know how to explain it other than just say that there is neither public nor health and there are just profits.

Garry Aslanyan [00:21:47] You wrote your book before the actual pandemic and yet, as we just talked about, we saw history repeated itself in some of the aspects. What are the two lessons from your exploration you’ve taken on board that could change the outcome of future pandemics.

Vidya Krishnan [00:22:08] I know we are negotiating a pandemic treaty now, which also looks very... The dice just seems loaded against post-colonial, very fragile nations, and the two lessons are that... The first and the most obvious one is that we have to decentre manufacturing because our supply chains are just too broken. Every continent should be able to manufacture for itself and supply itself and intellectual property cannot be a hurdle for it. The pandemic was a perfect time for countries to issue compulsory licenses, like the US government did for anthrax soon after the anthrax attacks after 911. So rich countries actually do get to use the flexibilities in the law. It’s the poor nations, it’s the post-colonial nations, that are not allowed to. And the second lesson, this is my personal pet peeve about I don’t understand why we think we can fund global health through philanthropy. We cannot. We simply just cannot. It’s not a coincidence that a global health order, which is entirely managed by very few foundations to fund it, then we result in global emergencies, then we look at billionaires for solutions because we’ve not created systems in peacetime. So in wartime, we look at saviours to come and save us. And also the thing about casting yourself as the saviour is that you are expected to do some saving when a crisis hits. Organized philanthropists are also equally responsible for getting us in this position because they have poured in so much money over the years in states like Uttar Pradesh in India where, during the second wave, bodies were floating in our rivers because people had by then run out of space in the graveyards and Hindus were pushing bodies in Ganga, Ganges, which is our mythical river, which Hindus believe will give you nirvana, eternal salvation. So if you can’t give them a pyre at the end, you push these bodies in the mythical rivers, and that’s why I say in India we had a 14th century plague. Surely the government is responsible in every country where organized philanthropy is a pillar to make health care possible. It’s not feasible. It’s very dangerous.

Garry Aslanyan [00:24:59] So just so that I’m clear, what was the second lesson Vidya?

Vidya Krishnan [00:25:03] The second lesson simply was to fund our own health. As a taxpayer-funded, no philanthropy involvement in it. It’s just my business with my government.

Garry Aslanyan [00:25:15] I understand. Vidya, in our search for book authors from low- and middle-income countries, we have not found many. Why do you think it’s so important for journalists or writers like yourself to share the stories of their own people, like you have done in this book?

Vidya Krishnan [00:25:34] I’m a writer, so I’m biased towards stories. I feel like every story is important to give us a comprehensive picture of this mosaic that we take as a global health order, which actually is very over-represented from very limited parts of the world. That’s why it’s important for every story to be recorded, but more than every story, the stories of the lowest common denominators. It’s important. Again, I’m a writer, I believe that having a granular information from all perspectives actually is important to make us compassionate, and make room for each other’s stories.

Garry Aslanyan [00:26:23] Thank you. Finally, TB still remains with us, and there is still a lot of work to be done with tuberculosis, but have you seen any pockets of hope and promise of progress.

Vidya Krishnan [00:26:40] Yes. Yes. I actually do remain very optimistic at this point. One of the sheer sparkles in this process is the patient networks that have come together and the advocacy, they have led from the front. Two patients, Nandita Venkatesan and Phumeza Tisile from South Africa, challenged successfully Johnson & Johnson’s patent on Bedaquiline. And it’s so heart-warming to see these kind of changes, people finding each other, learning each other’s story, finding strength in each other’s story. And the other silver lining because of the pandemic is that is now more conversation about infectious diseases, more than I’d seen in the 7-8 years I was reporting on this book before the pandemic, and most of all, in countries like India there has been significant expansion of molecular testing. All of this actually gives us a strong network to build on, to end, or to at least try to meet the targets we set ourselves to eliminate TB. I do believe we have all the tools to do it, it’s just a question of whether we are going to prioritize doing what the right thing is to do.

Garry Aslanyan [00:28:11] Thank you, Vidya, for joining me today and sharing your reflections and your work. It was a great conversation.

Vidya Krishnan [00:28:21] Thank you. It was really nice to meet you.

Garry Aslanyan [00:28:24] Vidya explores tuberculosis through a societal lens as an Indian living in one of the countries with the highest incidence of tuberculosis in the world. I take away from my conversation with Vidya a new appreciation for a complex range of factors that influence this disease, something we all think we know but we don’t always account for when thinking of how to tackle this age old public health issue. From housing policies to decisions on patent rights, achieving progress in combating tuberculosis is no easy task. Vidya’s conversation also reminds us of the ongoing colonial remnants and commercial interests that have a direct influence on the achievement of health equity. A positive development from earlier this year is the adoption of a historic Declaration by Member States at the 78th United Nations General Assembly. The Declaration gives momentum to ending tuberculosis by 2030 and providing life saving treatment to 45 million people.

Garry Aslanyan [00:29:34] Let’s hear from one of our listeners.

Maria Teresa Bejarano [00:29:41] Thanks to Garry and TDR for producing excellent podcasts. I have liked in particular the last one about the stigma, the fear and the inequalities and the lack of knowledge that relates to Chagas disease and its spread numbers. This is a very good way of bringing humanities to global health. I wanted to also call your attention for a podcast about climate change and health that promotes health arguments for climate action and the health co-benefits of mitigation, because we need to ensure that there is evidence for the health centre response to climate change in order to mobilize resources and financing for action.

Garry Aslanyan [00:30:29] Thank you, Maria Teresa, for your recommendation and for listening to the Dialogue. In Season one, we had an episode on climate change, but I agree there is so much more we can discuss. To learn more about our Dialogue series and the content of this episode, visit the episode web page where you will find additional readings, show notes and translations. Don’t forget to get in touch with us via social media, email or by sharing a voice message with your reflections on this episode.

Elisabetta Dessi [00:31:02] Global Health Matters is produced by TDR, a research programme based at the World Health Organization. Garry Aslanyan is the host and executive producer. Lindi van Niekerk and Obadiah George are content technical producers. Priya Joi is the curator of the Dialogue series. The podcast editing, communication, dissemination, web and social media designs are made possible through the work of Maki Kitamura, Chris Coze, Elisabetta Dessi, Izabela Suder-Dayao and Chembe Collaborative. The goal of Global Health Matters is to produce a forum for sharing perspectives on key issues affecting global health. Send us your comments and suggestions by email or voice message to TDRpod@who.int, and be sure to download and subscribe wherever you get your podcasts. Thank you for listening.