The Exchanges

Q And, and, and part of your story and part of the story of the book is, is about Sierra Leone. How did Sierra Leone become a country where you started spending time? And, and can you tell us how, how tuberculosis really came to be personal for you in that journey?

A 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, uh, 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, ah, he was, 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 hel…

AI assessment note: “it was really, uh, following Henry's story that, that helped make, as you say, make this personal for me”

Q who, who are, are scaling companies, are scaled companies, and we're, we're helping our audience, um, Uh, extract those lessons and insights so that they can do the same. Um, I, I just want to scale the challenge for, 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?

A So absolutely. If we had enough money, we could do it, but it's a lot of money. It's like twenty five billion dollars a year, which I mean is a lot of money and not a lot of money, right? Like it's like, uh, It's, it's a lot of money in global health. It's not a lot of money necessarily in Silicon Valley sometimes, but it, it would take twenty-five billion dollars 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, the epicenter of the crisis is India. Almost a third of the people who die of tuberculosis this year will die in India. Um, there's also epicenters in Nigeria, In the Philippines and Indonesia. And so those are the, those are sort of, 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, have, 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 probl…

AI assessment note: “If we had enough money, we could do it, but it's a lot of money.”

Q John, can we just go, go, uh, Just a little bit deeper on, um, Johnson & Johnson in India. Can you, can you explain, um, what, what happened with the patent there and, and what it means for, for people with TB there?

A Sure. So, Johnson & Johnson had a patent on Badakowin, this great TB drug by, 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 bodacolin could emerge in India. The problem was much of the rest of the world, they had succeeded in filing secondary patents, and so, uh, the fight had to continue to make sure that everybody could access bodacolin, but eventually J&J abandoned all of their secondary patents on bodacolin, and today the price of it has dropped by over 55%. 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 binaculine, We are going to charge whatever the heck we please in the United States and Germany and France, and then we're going to, we're going to provide it at cost in…

AI assessment note: “generic competition for bodacolin could emerge in India... price of it has dropped by over 55%”

Q This empathy gap, um, Strikes me as a, an especially interesting challenge for us to take on. Um, you help address it through, um, what you do in media through your writing and, and, and, um, talking about what's happening in the world, uh, telling stories. Um, are there, can you imagine other scaled solutions to closing the empathy gap or shrinking the empathy gap?

A Well, I think the biggest solution I've seen to shrinking the empathy gap and 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, uh, is the social internet. Um, you know, people become, 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. Um, 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, you know, 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, uh, when it, when it comes to the social internet.

AI assessment note: “biggest solution I've seen to shrinking the empathy gap... is the social internet”

Q spending on, uh, TB initiatives in other countries is, boy, we got a lot of problems at home. Um, we have crumbling infrastructure. We have, um, environmental issues. We have schools that are underperforming our kids terribly. Um, and, and, you know, it can, I hear it, right? We hear it every day. Why should the US be prioritizing TB efforts abroad when we have so many problems at home?

A Well, first off, I'd just point out that the US has never prioritized TB efforts. And of that, you know, not much ends up outside the US. So, you know, the, the, the criticism of USAID for many years and, and other related organizations that are funded by the US government is that the vast majority of that money stays in the US one way or another. It pays farmers, it pays, uh, contractors, it pays, you know, very little of that money ends up abroad. Um, and it pays drug manufacturers in the US. And so, um, that's the first thing that I'd say, is that it's always been, it's, 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 US has expressed its power over the last 60 years is through its generosity. You know, uh, It's just to state the obvious, it's a very different experience to open up a package of, uh, 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.

AI assessment note: “one of the most effective ways the US has expressed its power... is through its generosity”

Q Of all the things that you could choose to spend time on, why has tuberculosis become, um, such a focus for you, such a, such a mission for you?

A I very easily could have written a book about malaria, or about HIV, or about diabetes, or about cancer. I mean, you know, cancer is also a disease of injustice, and so 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, uh, has had a It has 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 healthcare 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.

AI assessment note: “it's just that for me it's the exemplary disease of injustice.”