Why we keep failing to eradicate this disease, with YouTuber John Green
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We solve the problems we pay attention to. And if we feel like we're paying attention to a problem that not enough other people are paying attention to, that's really exciting in a lot of ways. It's also quite frustrating, right? It means that at dinner, you're a weird company because you only want to talk about one thing.

If you've ever been an entrepreneur or if you want to be one someday, I bet you can relate to what John Green is talking about here. That intense hyper focus that happens when you are truly obsessed with an idea. In the business world, this can really help drive scale, but John is obsessed with something that isn't about business, but offers lessons and inspiration for all of us.

He's trying to help eradicate an entire disease. It would take $25 billion a year, according to the UN, to really eradicate tuberculosis globally, which, I mean, is a lot of money and not a lot of money, right? It's a lot of money in global health. It's not a lot of money necessarily in Silicon Valley. This week on the show, author John Green is here to talk about tuberculosis. It's one of the deadliest afflictions in human history. And even though we have ways to cure it, more than a million people a year still die from it.

John's unrelenting quest to solve this problem is a fascinating case study in how to scale solutions and spur change. You've got to have incredible talent at every position. It's like this huge push. There are fires burning when you're going home. Can you believe it? Such an idiot. And then you go back to, this is totally going to be amazing.

This is Masters of Scale. I'm Jeff Berman, your host.

John Green is a popular content creator behind Crash Course and Vlogbrothers alongside his brother Hank. He's also written popular novels like The Fault in Our Stars and Turtles All the Way Down. His latest is called Everything is Tuberculosis, and unfortunately, it's not another work of fiction. It reveals the complex history of tuberculosis and the ongoing fight against this deadly global disease.

John, welcome to Masters of Scale. Thanks so much for having me. Yeah, I'm super excited to have you, John. You've just written a book called Everything is Tuberculosis, and I think most people thought tuberculosis was already cured. So why in 2025 are we writing and reading about tuberculosis? Well, one of the great challenges we face together is that discovering a cure doesn't mean that everyone gets access to that cure, and we've seen that most glaringly in the case of tuberculosis, which has been curable since the 1950s.

But in the decades since it became curable, we've allowed over 150 million people to die of it. And I think the reason I ultimately wanted to write this book is because I'm so fascinated by the question of how that can happen. Why is that the case?

Well, first off, tuberculosis is not easy to cure. It's closer to curing cancer than it is to curing a sinus infection. It requires four to six months with the newest regimens of daily antibiotics. It's a disease that primarily affects the most impoverished people in the world. Anybody can get tuberculosis. It's airborne, but it disproportionately affects the world's poorest people. And we've just done a terrible job of building systems that reflect the reality that everybody's life has equal meaning. And so

We unfortunately do a terrible job of getting the cure to the people who need it most. There are all kinds of reasons why that breaks down from not developing good enough drugs to not getting those drugs the last mile to the people who need them the most.

But somewhere along the links in the chain, it keeps failing and failing and failing. And that's why we lose over a million people a year to TB. Of all the things that you could choose to spend time on, why has tuberculosis become such a mission for you? I very easily could have written a book about malaria or about HIV or about diabetes or about cancer. I mean, tuberculosis is by no means the only disease of injustice. It's just that for me, it's the exemplary disease of injustice.

It's an illness that has had a huge impact on our history. I mean, one out of every seven people or somewhere in that vicinity has died of tuberculosis of the people who've ever been born.

And so it's a huge part of our history, but it's also a huge part of our present. And it really lays bare the truth of inequitable access to health care in our world, which is that we can come up with all the AI-fueled cures that we want, but if we don't get those cures to the people who most need them, we're just fundamentally failing ourselves. And part of your story and part of the story of the book is about Sierra Leone. How did Sierra Leone become a country where you started spending time and

Can you tell us how tuberculosis really came to be personal for you in that journey? Yeah, absolutely. So my wife and I visited Sierra Leone in 2019 with Partners in Health, the great nonprofit organization, to learn about maternal health there. And then on the last day of our trip,

The folks we were traveling with asked if we could visit a tuberculosis hospital because they had some cases they wanted to consult on. We went to this TB hospital, and the moment we arrived, I was just grabbed by this kid named Henry, which is also my son's name. And he seemed to be about the same age as my son. He looked to be about nine years old. That's how old my kid was at the time. And Henry just started walking me all around the hospital. He was like the mayor of that place. Everywhere we went, people were shaking his hand and rubbing his head and picking him up and giving him hugs and everything.

He was just an incredibly charismatic person. And then we made our way back to the doctors and nurses who were meeting, and they kind of lovingly shooed him away. And I said, whose kid is that? Is that one of your kids? And they said, no, he's a patient. And he's actually one of the patients we're really concerned about because it turned out Henry was responding to antibiotics. That's why he looked relatively well. But they knew he wasn't responding to them well enough and that eventually his infection would roar back. And when it did, they just didn't have any tools to help him.

And so it was really following Henry's story that, as you say, make this personal for me and help me understand that it's not just about a million deaths a year. It's the fact that each of those deaths

million people who are going to die are incalculably valuable, have lives that are as rich and complex as my own, and their griefs grieve on the same universal bones, as Faulkner put it, as anyone else's. One of the lines in the book that really stuck with me is, the cure is where the disease is not, and the disease is where the cure is not.

Henry was at a hospital, so it would seem that the cure is there. What's the challenge there? What do we need to understand about why the cure is not where the disease is? The main challenge is cost. I mean, Henry was told over and over again that it just wasn't cost effective to treat his particular tuberculosis, too complicated, too...

too drug-resistant. The real challenge for Henry was that he couldn't be treated with the first-line antibiotics. They failed very early on. Then the second-line antibiotics failed. And then you end up with this incredibly toxic regimen of injectable drugs. And he endured that needlessly because if he'd had access to a molecular test, they would have known from the beginning that Henry was also resistant to those drugs. And so he needed a personalized, tailored treatment in order to survive

And it was only because Dr. Tefera and the Sierra Leonean Ministry of Health ultimately came to the conclusion that he deserved that and that it was worth the investment that Henry's here with us today.

This is a show called Masters of Scale, and most of the time we interview founders and CEOs, business leaders, or scaling companies or scaled companies, and we're helping our audience extract those lessons and insights so that they can do the same. I just want to scale the challenge for our audience here. Is it just a dollars question? If we had enough money, we could do this, or are there other challenges here that we need to solve for?

So absolutely, if we had enough money, we could do it. But it's a lot of money. It's like $25 billion a year, which I mean, is a lot of money and not a lot of money, right?

It's a lot of money in global health. It's not a lot of money necessarily in Silicon Valley sometimes. But it would take $25 billion a year, according to the UN, to really eradicate tuberculosis globally. The crisis is really everywhere. I mean, we have 10,000 cases of active TB in the United States every year. So there's no place that's immune to TB, but the epicenter of the crisis is India. Almost a third of the people who die of tuberculosis this year will die in India. There's also epicenters in Nigeria, in the Philippines, in Indonesia.

Those are the biggest countries where there's really critical need. The highest rates we see of tuberculosis are in Lesotho, which is a small country in southern Africa where a lot of people work in mining. We know that any exposure to air pollutants makes tuberculosis worse. Also in countries like in West Africa, like Sierra Leone, they have very high rates of tuberculosis because they have very high rates of impoverishment.

We know that when we cut the rates of impoverishment, even without medical intervention, we cut the rates of TB. It's a resource problem on that level. There are also many other aspects to the problem, as I argue in the book, including a social dynamic that's really difficult to get past.

We need to shrink the empathy gap between the rich world and the poor world. This is a huge problem. When we are proximal to suffering as a species, we are so generous. It's a shame that we need GoFundMe to be an addendum to the healthcare system in the United States, but think of how many GoFundMes have paid for everything from dog surgeries to life-saving organ donation operations.

And yet when we're distant from suffering, when we can create distance between ourselves and suffering, we're so much less generous and we're much more likely, frankly, to be monstrous, to think that people are not really people or to think that their lives are not as valuable as ours or there's nothing we can do or that our problems aren't about their problems.

And so I think we have to shrink the empathy gap, one. That's one social problem. This empathy gap strikes me as an especially interesting challenge for us to take on. You help address it through what you do in media. Can you imagine other scaled solutions to closing the empathy gap or shrinking the empathy gap? Well, I think the biggest solution I've seen to shrinking the empathy gap and reducing

Look, I'm not going to say that it's perfect because I don't labor under the delusion that the social internet is good news, but is the social internet. People become proximal to all kinds of suffering that they weren't proximal to before, and that leads to action. It leads to collective action, leads to protest, leads to all kinds of social movements. Sometimes that stuff is messy and complicated, but it's at scale.

And so that's why I've been trying to use my megaphone to get attention for tuberculosis is because I think that the social internet does work at scale. The problem is the people with the megaphones tend not to be people in impoverished communities. I mean, the poorest and most vulnerable among us are the people we're least likely to hear from. I think the solution at scale is some form of many-to-many conversation.

As I think about how the tech world especially approaches these challenges, I'm sort of stuck on this question of, is capitalism up to the task? I mean, I'm a capitalist. We have a flawed capitalism in this country, no doubt, but I believe it's the best economic system we have. I also acknowledge it doesn't solve every problem on its own. We have government for a reason, and we have shared public health goals globally for a reason.

What more can capitalism do to solve the problem before we get to kind of the shared public health challenge for government? Well, I think there are ways that markets can work here, but there are also ways that markets fail here, right? Like the number one way that markets fail is that it's still, from a human health perspective, better to treat tuberculosis than it is to lengthen eyelashes. But from a market perspective, it's better to lengthen eyelashes than it is to treat tuberculosis. And that's a fundamental disconnect between

And the only way to resolve that disconnect, in my opinion, is to have governments or other international authorities involved in reshaping the incentive structure so that it becomes profitable to treat tuberculosis, more profitable to treat tuberculosis than it is to lengthen eyelashes.

What does that mean to change those incentive structures? What needs to happen? So we've seen this a little bit, actually, because between 1945 and 1965, we developed eight classes of drugs to treat tuberculosis because there was a real market incentive to do so. And then between 1965 and 2012, we developed none. And that's the main reason we're in the mess that we're in right now is those 50 years of failure. What was the market incentive in that first window that disappeared in that second window?

Rich people still got tuberculosis in the first window. I think some kind of public-private partnership like that is the way forward. That's the way to do it at scale. That's the way to do it to get the kind of better tools we need because it's true that tuberculosis is curable, but we could absolutely have better tools. I mean, the vast majority of people with TB are treated with the same drugs they would have been treated with in 1965. There are very few diseases for which that's the case.

Like my brother's cancer was treated very differently in 2023 than it would have been in 1965. So we talked about our having a cure for TB, but the reality is we also do have drug-resistant tuberculosis. And drug-resistant tuberculosis is rising, not falling, right?

Right. And so is the threat of the spread of drug-resistant tuberculosis enough to generate the market incentives to spend more to develop new cures or new approaches to tuberculosis, or are we not there yet? Unfortunately, it's not enough on its own because sort of by definition, antibiotics are a real challenge when it comes to incentives, right? Because

From a market perspective, you want a drug that everyone takes all the time. And from an antibiotic perspective, you want a drug that almost no one takes except in cases of everything else failing so that you can protect the antibiotic. And there's just a disconnect there. We have the same problem. I mean, this is not only a problem with tuberculosis. It's a problem with all bacterial infections. I remember I had orbital cellulitis in 2007. This infection between my eye and my brain was quite serious.

I ended up spending 10 days in the hospital at NYU and my infectious disease doctor came in on like the second or third day and said, have you taken a white pill? And I was like, yeah. And he said, did you take any yellow pill? I was like, yeah. He's like, have you taken a green pill? I was like, yeah. And he was like, have you taken a pill that costs $15,700 per pill? And I was like, no. And he was like, well, you're about to. And you can kind of do that in the rich world, right? Where you protect drugs by making them absurdly expensive.

But in a country like Sierra Leone, that's a non-starter. No one will be able to access that medication. I'm about to give you a lot of power. You ready? I'm ready. I'm excited. I mean, and at the same time, reluctant, Jeff, like anyone who's given a lot of power ought to be. Well, with great power comes great responsibility. So here we go.

You, all of a sudden, are in charge of the World Health Organization. Great. What are the first steps you're doing to address tuberculosis? Jeff, to be honest with you, I think the first thing that I'm doing is retiring from my position as the head of the World Health Organization. Well done, you. Okay, so there's two things that I would do.

The World Health Organization has a fundamental problem when it comes to treating tuberculosis, which is limited resources. And the biggest way to fight that is with attention. And so I would go on a huge public relations campaign. I would try to make tuberculosis news again. I would try to make tuberculosis the center of our story again. And not just tuberculosis, but also malaria, other diseases of injustice, cholera, typhoid.

go back to a world where people are aware of these diseases. And then the second thing I would do is shift the priorities a little bit so that instead of just waiting until people are so sick that they come into the hospital, at which point their tuberculosis is often very hard to treat, I would do what's called case finding or a massive search and treat program.

And this is exactly how we eliminated tuberculosis or nearly eliminated tuberculosis in the United States. We sent out these mobile like Winnebago's with chest x-ray machines inside of them all throughout the country to places where there were high rates of TB. We offered people free chest x-rays and then we gave them free treatment if they were positive for TB. And that's how we did it.

And then, so we search, we treat, and then we offer preventative care to those people's close contacts. So we offer one month of preventative antibiotics to their close contacts. So we just stop that chain of transmission in its tracks, and we know that we've stopped it. Now, to start, because of limited resources, we wouldn't be able to do that at scale around the globe, but we would be able to do pilot projects that can prove that you can basically reduce the burden of TB to zero in

even in large communities, like whether that's Karachi, Pakistan, or the entire nation of Lesotho. More with John Green about the latest progress and pitfalls in the fight against tuberculosis in just a minute.

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Welcome back to Masters of Scale. You can find this conversation and more on our YouTube channel.

next set of great responsibility. You may be more reluctant to take this one on. Yeah. But you're now the CEO of Johnson & Johnson. Oh, great. Yeah, I hate that job. Well, you've got it for the next minute or two here.

And you still have a responsibility to balance shareholder returns with stakeholder interests. What are you doing differently than J&J is doing right now? Well, it's really hard because J&J is working within a system, as you say, that has to prioritize shareholder returns. They have a fiduciary obligation to their shareholders to do so.

And yet they also have a pretty broad spectrum of goods and services that they provide to the market. And so it benefits Johnson & Johnson to live by their values. And to Johnson & Johnson's credit, this is something that they've done. John, can we just go just a little bit deeper on Johnson & Johnson in India? Can you explain what happened with the patent there and what it means for people with TB there? Johnson & Johnson had a patent on bedakal in this great

TB drug. But when their patent expired, they filed secondary patents globally, including in India, to extend the life of that patent, which is a very common thing that pharmaceutical companies do. Some activists from India and South Africa came together to file a lawsuit in India to say, actually, this doesn't involve meaningful innovation, and they shouldn't be allowed to file a secondary patent.

And they succeeded. And so Johnson & Johnson wasn't able to file a secondary patent in India, which meant that generic competition for Badaquin could emerge in India. The problem was much of the rest of the world, they had succeeded in filing secondary patents. And so the fight had to continue to make sure that everybody could access Badaquin.

But eventually, J&J abandoned all of their secondary patents on bedaquiline, and today the price of it has dropped by over 55% just in the last year. It's an incredible story. What I would do is I would go to my stakeholders, including my biggest shareholders, and I would say...

Look, we're going to do something slightly out of the box when it comes to disease in really poor countries. And what we're going to do is when we accept public funding for a drug like bedaquiline, we are going to charge whatever the heck we please in the United States and Germany and France.

And then we're going to provide it at cost in poor countries. And the reason that we're going to do this is because it's going to be a PR win for us and because it's a win for human health and it's in line with our values. So why don't they do that? I've tried to make the case. What do you hear when you make that case? The pressure that these folks are under is intense because they're under intense pressure for this quarter and next quarter and the quarter after that. And so what I hear is we're not in a position to do that because we have a responsibility to today's shareholders to

My response to that would be the reason Johnson & Johnson is here is often because it hasn't done a good job of meeting the needs of the day, but is instead focused on the long-term future. And that's true for any corporation that's been around for over 100 years. You know, they've shown a resiliency and ability to understand not just the current needs of the market, but the future needs. Not just current system of values, but a future system of values. And with J&J in particular, I would point to their founders and the folks who

Yeah.

And yet we know that there's something wrong, right? We know there's something wrong because life expectancy is falling in the U.S. And we know that there's something wrong because we're seeing a flattening out of global health improvements. So we know there's a problem. Yeah, I think it's also important to note that this notion that it is financial return above all else as a mission for corporations and obligation for corporate leaders is a relatively new idea. This is only about a 50-year-old idea. And

And to your point, J&J and many other companies have built

century-old businesses in part by focusing on stakeholders other than their shareholders as a key constituency. Absolutely. We're seeing companies today that are thriving because they're treating their employees better than other companies, and they're thinking about their customers above their short-term returns. How do you imagine a world in which pharmaceutical companies are leaning more in that direction? How do we get there? I think we get there by polite

but persistent pressure. And I think we get there through regulation, which I know is a word that many listeners of this podcast hate to hear. And I absolutely understand. Look, I have to interact with worlds of regulation all the time. They can be extraordinarily unpleasant. I get that part of it. But if there is nobody pushing back, there is nobody saying, hey, when you accept $500 million of public money, there has to be some public benefit. If nobody's saying that, then...

We're in trouble. One of the concerns about the United States spending on TB initiatives in other countries is, boy, we got a lot of problems at home. We have crumbling infrastructure. We have environmental issues. We have schools that are underperforming, our kids terribly. And we hear it every day.

Why should the U.S. be prioritizing TB efforts abroad when we have so many problems at home? Well, first off, I'd just point out that the U.S. has never prioritized TB efforts. The criticism of USAID for many years and other related organizations that are funded by the U.S. government is that the vast majority of that money stays in the U.S. one way or another. It pays farmers. It pays...

contractors, it pays, you know, very little of that money ends up abroad. It pays drug manufacturers in the U.S. And so that's the first thing that I'd say, is that it's never been neutral and it's always been oriented toward the interests of the United States. Second thing I'd say is that one of the most effective ways the U.S. has expressed its power over the last 60 years is through its generosity.

Just to state the obvious, it's a very different experience to open up a package of life-saving nutrition bars that say a gift from the people of the United States than it is to experience United States foreign policy in other ways. And so I think this is the best money that we spend, and the vast majority of it stays in the U.S. In fact, I've been critical of how much of it stays in the U.S.,

And so that's what I would say in response is we're talking about a rounding error in the federal budget. And the reason we talk about it a lot is because it's politically divisive. But for many decades, I think the reason it was so strongly supported bipartisanly was because it was such a good use of our resources, such a good way to build goodwill around the world. Yeah. We're also creating a gap globally that China is rushing to fill. Yeah.

I think that's so important to understand. I mean, the folks who have been laid off as a result of the USAID cuts, and I don't mean folks in the United States, I mean folks globally, they're being hired immediately and they're being hired by Chinese aid organizations because China still does understand the benefits of soft power. John, one of the threads that links so many of the entrepreneurs who we have on the show and who...

or in our community is almost no one would choose to do this work. This is a harder path than most, but we are so obsessed with solving a problem or taking on a challenge that we can't not do it. I'm curious for you, what are the pros and cons of becoming obsessed with tuberculosis? Well, I am a very obsessive person. And I think one of the benefits of becoming obsessed with it is that we solve the problems we pay attention to.

And if we feel like we're paying attention to a problem that not enough other people are paying attention to, that's really exciting in a lot of ways. It's also quite frustrating, right? It means that at dinner you're a weird company because you only want to talk about one thing. And also many other people don't yet see how big a problem that one thing is. So that's both a benefit and a cost. I think the biggest cost is you can lose sight of the rest of the world, you know, like...

in becoming obsessed with tuberculosis? Am I still careful to make room for not just like malaria and HIV? Am I still careful to make room for climate change? Am I still careful to make room for the electrification of ovens or whatever? You know, there's so many problems in the world. You got to remember that there are many, many problems. And just because the one I'm obsessed with happens to be my obsession doesn't mean that it's the only one that

matters, it means that that's where I'm focusing my energy and the hope and expectation that other people are focusing their energy on their big problems. What is success for you in this fight, John?

Oh, I would love to live to the day when tuberculosis is not a threat to public health, when tuberculosis is rare and readily cured. I would love to live to see a world where tuberculosis is rare and no longer a global health issue. I would like to see it become like typhoid, a disease that is rare.

that doesn't kill a lot of people. Two questions before we wrap. How's Henry doing today? He's doing great. I just talked to him this morning. I talk to him most days. And he's a junior at the University of Sierra Leone. He's just finishing his final exams now. I'm so proud of him. He's had to do so much work to recover from

Not just tuberculosis, but the time he lost to tuberculosis. You know, when everyone else was in secondary school, he was in the hospital. And so he had to work really, really hard to get to university. And he's doing so, so well. He's also a YouTuber. I would be remiss if I didn't say Google Henry Ryder YouTube and subscribe to his YouTube channel. Like any good YouTuber, he reminds me to tell everybody to subscribe every time I talk about him. We will link to his YouTube in our show notes. Oh, amazing. Thank you.

It strikes me that when someone hears that a problem can be solved with $25 billion a year, it's just such a big number. You know, the idea of contributing a few dollars to an effort, it feels almost hopeless. You know, it's spitting into the ocean. For folks who want to help and are just daunted by the scale of the problem, what do you say to them? What can they do that can make a difference? Well, first, we do spit into the ocean. You know, you got to do that sometimes.

But secondly, I think the biggest thing that can happen right now, and we're starting to see partners in health do this in Lesotho and some other organizations try it as well, is we need to see blueprints for how this is actually going to happen. We need to see blueprints for dramatic reductions in tuberculosis. And that's not on the scale of billions of dollars. That's on the scale of millions of dollars. That's something that I can help out with, right? That's something that you can do a bake sale that helps out with.

And so that's where I think that we really can see a difference at a smaller scale. If we can provide a blueprint for how we eliminate tuberculosis in, say, Lesotho, then that can apply to the entire world. It's just then that's when the big health funders have to come in and help us. Let's hope we get there. Thank you so much for being with us. We appreciate you and all you're doing. Thank you, Jeff. It's been awesome.

We've only scratched the surface about the truly fascinating history of tuberculosis. To learn more, make sure to check out John Green's book, Everything is Tuberculosis. I'm Jeff Berman. Thank you for listening. The Lobatical is for any employees who have been with us for five years to take a vacation. They get a week of extra PTO. They get to pick anywhere in the world that they want to travel, and we allow that to happen for them.

That's Brooke Wright, Capital One business customer and chief people officer at Local, a change marketing company that works with huge corporations in order to facilitate meaningful communication between C-suites and their frontline. We wanted to celebrate them for the time they had invested with us. We liked the idea of a sabbatical, and so we made it us. It's the Lobatical. Local practices what they preach, caring for their employees with the same rigor they instruct their clients to enact.

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