They Are All Henry: On Everything Is Tuberculosis

I enjoyed John Green’s Everything Is Tuberculosis as an audiobook. I learned many new things, and I think it’s cool that a fiction writer decided to write a book on global health. It is moving and sincere—I cried many tears. And I think it succeeds at what it is trying to do: make the moral stakes of fighting tuberculosis vivid and impossible to ignore.

But I am an effective altruist, and my EA journey very much started in the global health space. I found parts of the book not just unconvincing, but actively misleading, and that matters when the stakes are this high.

We are in triage, whether we like it or not

Global health is not a world where everyone gets everything they need if only we cared more. We are in triage every second of the day.

When Green says things like “we should allocate more money to TB care,” that statement is incomplete to the point of being dangerous. More money for TB means less money somewhere else, and often that somewhere else is malaria, diarrheal disease, or childhood malnutrition. 1.5 million people die from TB each year, but 1.2 million die from diarrheal diseases, 600,000 from malaria, and childhood malnutrition is an underlying cause in nearly half of all child deaths. Curing some children of TB often means other children, elsewhere, will die of some other completely preventable and curable disease.

In a triage like the one we are in, cost-effectiveness is not a technical, abstract concept we pursue because it sounds nice. It is the only honest way to confront the fact that resources are limited and that our choices kill or save people at scale. The reasons Green writes so beautifully of—moral urgency, dignity, injustice—are not reasons to disregard cost-effectiveness. They are precisely the reasons to do it better, more carefully, and with better data.

We don’t get to just look away from the numbers.

Henry is not an argument against cost-effectiveness. He is the argument.

Much of the book’s narrative arc and emotional force comes from the story of one individual, Henry Reider, who survived multi-drug resistant TB in Sierra Leone. And at various points in the book, it feels like Green tries to argue against cost-effectiveness with Henry’s story.

But Henry’s story is precisely the reason we do cost-effectiveness analyses. Saving two lives is better than saving one, because the other person you save is Henry too. The purpose of cost-effectiveness isn’t to turn real people into abstractions; it’s meant to prevent us from—all too easily—deciding that the lives of the children who are not written about in best-selling books matter less. Without it, do we allocate resources based on whose story we happened to hear, whose suffering was made vivid to us?

I don’t think that’s the morality Green wanted to sign up for.

“Not cost-effective” just means “too expensive”

A recurring move in the book is to pit “cost-effectiveness” against something that otherwise seems good, which makes caring about cost-effectiveness seem a moral failing. But we have discussed the moral picture already. What I additionally don’t understand is: Aren’t we just saying that it’s too expensive?

“That 10 million dollar mansion on the hill is really nice, but it’s not cost-effective for me and my husband.” That would be a really silly thing to say, but if we want something to stop being “not cost-effective,” there are only two options: make it cheaper, or come up with the money to buy it anyway.

And it is important to remember that the money comes from actual people writing actual checks. For a country like Sierra Leone, the GeneXpert cartridges for precision molecular testing of TB that cost $24.88 obviously are not cost-effective—they are simply too expensive. That’s why the developed world spends billions every year to help the developing world in causes like this. If we were to ignore “cost-effectiveness”—how does Green propose we come up with more money to buy these cartridges? Is it from malaria bednets, your neighbor’s Medicare, or the bank accounts of you and me, either via higher taxes or personal donations? I don’t ask this metaphorically or out of derision; some actual people have actual jobs where they are responsible for deciding these things!

In the meantime, yes, we should absolutely also work to bring the prices of those cartridges down—through innovation, scale, policy, and competition. Pointing at “cost-effectiveness” as the villain just doesn’t make any sense.

What if there is no villain?

The book leans heavily on the idea that TB persists because of prejudice, greed, or price-gouging villains. And I’m sure sometimes that’s true. But TB disappeared in the US and the rest of the developed world not because pharmaceutical companies suddenly became virtuous in the 1950s, but because we got rich. We could afford X-ray machines in vans. We could afford the antibiotics that killed TB bacteria. Heck, we got so rich that we could afford to fund the research that led to the discovery of those antibiotics. Most people didn’t have to work so hard for their living that they had time to access healthcare.

For most of human history, tuberculosis, malaria, parasites, and early death were the norm. Green even discusses extensively the fact that TB was widespread in the US not so long ago. I very much think of illness not as a systemic failure, but of health as a systemic miracle. I suspect that forgetting this leads people who grew up in developed Western countries to misdiagnose many problems.

We should absolutely help Sierra Leone develop, so that citizens of Sierra Leone can also afford a $25 medical bill without a blink of an eye like me. But that is a project of development, not of finding someone to blame.

John, join us and sign the 10% pledge

The book has no call for action of any sort, and I think that’s a missed opportunity. Green has built a massive platform around this cause, and the book makes a powerful case that TB deserves attention. So: what next?

I think John Green should sign the 10% pledge. Or at least, he should allocate 10% of his earnings from this book towards donations. I think this would not only be good because of the lives that the amount can save, but also because it feels different when you are allocating your own money, instead of calling for “us” or “society” to change something. When it is your money, you have to personally confront the global triage that we are in. Is it better to send cash to the mother in Uganda who desperately needs to pay off her children’s school fee debts, or to fund TB treatment in Sierra Leone, or to buy insecticide-treated malaria bednets? Or even if you have decided that your cause is TB—which treatments, which interventions, which populations? It’s worth spending time over these decisions because they really, really matter in the lives of actual people.

I think you should join us in this confusing, heartbreakingly difficult, and rewarding endeavor. We owe it to people like Henry—and to the millions of others we’ll never hear about—to think carefully, face tradeoffs honestly, and accept responsibility for the lives our choices cost as well as the ones they save.