I’ve been listening to John Green’s new book Everything is Tuberculosis: The History and Persistence of Our Deadliest Infection.  It’s an absolutely fascinating deep dive on a disease I didn’t know a lot about.  With the exception of the first few years of the Covid pandemic, TB is, and always been, the number one killer of people world-wide. 

TB has shaped the course of wars, even playing a part in the assassination of Archduke Franz  Ferdinand which precipitated the start of WW1.  TB helped establish euro-centric beauty standards; since side effects of TB include pale complexion, unnatural thinness, and enlarged eyes, the deaths of young,   wealthy, influential artists to TB established an aesthetic ideal and sense of tragic romance that permeated the 18th and 19th century, and is still with us today.  Pasteurized milk is a byproduct of a search for a cure for TB.  We even owe the Adirondack Chair to TB, developed as it was to allow patients to lay unmoving outside while they breathed in fresh air—  for a long time, the most common treatment regimen prescribed to those who could afford to do nothing all day.

As much as I love pasteurized milk and the ability to  recline outside, it’s tragic that TB remains the number one killer of people world-wide, because it’s curable.  That’s the main reason why most of what I knew about TB was from 19th century literature. In the Global North, we can diagnosis TB before it becomes symptomatic, which dramatically improves the rate of recovery.  Over 90% of TB cases can be cured with first round antibiotics.  Drug resistant TB can be cured with more robust antibiotics, and there are therapies beyond that to treat the relatively few cases of TB that become chronic.

But the story is very different in the Global South, where countries have been so stripped of resources that their governments cannot fund TB care and must rely on help from outside.  In addition to the stigma patients receive from their families and communities (TB, like many diseases, is something many folks believe is a result of moral failing or self-infliction), western mentalities and models of care can also harm patients.  Patients with treatment resistant TB are labeled as “noncompliant” for not taking their medications according to directions, though medical noncompliance is common among many people who take medication, even in the US. 

The solutions raised for this noncompliance include things like giving everyone the same initial treatment instead of testing and then prescribing treatment based on what strain of TB a patient has (a solution that can increase the risk of developing drug resistant TB), or solutions like forcing patients to come to the clinic daily (sometimes a two hour walk from their homes) to take meds under supervision.  These solutions ignore or exacerbate the real barriers people face in receiving treatment. 

Barriers like supply chain instability, which mean the clinic may not have the meds their patients need even if patients can get there.  Barriers like job loss because it’s hard to hold down a job and also spend so much of the day walking to and from a clinic.  Barriers like hunger.  One of the side effects of TB is hunger suppression.  One of the ways you know treatment is working is that a patient’s hunger comes back ravenously as the body attempts to make up for the previous deficit.  But in communities where food is also insecure, many patients cannot tolerate healing because they have no resources to feed themselves, and it’s better to be sick than starving.  Who could be compliant in the face of all of that?

Another important barrier is the cost of diagnosis and treatment.  I encourage you to read the book if you want a fuller explanation of this, but basically, like treatment for a lot of diseases across the world, the folks who can most afford TB treatment are those who least need it.  And those who most need TB treatment are those who can least afford it.  Many of the reasons for this are “cost effectiveness”.

And so, it becomes a Vicious Cycle, one where patients can’t get the testing they need to make treatment easier, which means their disease is more advanced and treatment becomes more difficult, and therefore they are less able to be compliant with the terms of that treatment, and because they are less able to be compliant there’s less goodwill and funding to care for them, especially when it comes to more expensive treatments.  And so it continues not to be “cost effective” to treat the deadly disease. “Cost effective” as determined by who, though? 

But that cost calculation is changing.  Around 2000, it was discovered that the patent on many of the drugs used in treating more advanced TB had expired, but no one had tried to create inexpensive generic versions because they believed there was “no market”.  But of course there was a market—many people living with drug resistant TB were desperate for treatment. The “market” just wasn’t generally wealthy. Soon, non profits and others worked to kickstart generic manufacturing of these antibiotics. Survivors and civil society groups pressured drugmakers as well, and the price of a two-year course of curative treatment quickly dropped from $15,000 to $1,500.

Ten years later in South Africa, a college freshman named Phumeza Tisile had her running career cut short when she contracted TB.  After hospitalization and nearly four years of failed treatment after failed treatment, she was finally able to access the advanced generic drugs, and was cured.  Today Phumeza is a sociologist and a leading voice in the fight against TB.  In 2023 she and her team successfully argued in an Indian court that Johnson & Johnson’s attempt to extend an expiring 2013 patent on their TB drug bedaquiline was a money grab instead of representing meaningful innovation.  Though the ruling was only good in India, pressure from global health organizations and TB activists convinced J&J to allow generics of bedaquiline to be made, the price of which dropped by 60% almost overnight.

This virtuous cycle has dramatically expanded access to treatment by lowering its cost: drug resistant was labeled as too expensive to treat in the 1990s, when it cost over $15,000 per patient. Organizations like PIH were able to drive that cost down to $1,500 by the late 1990s. Thanks to the efforts to lower the price of bedaquiline, that price has dropped further. In 2023, the endTB trials—funded by Unitaid, Doctors Without Borders, and PIH—found that around 90 percent of MDR-TB cases could be cured for about $300 per course, a 98 percent reduction in price from the 1990s.

I’m telling you this because I believe Holy Saturday is this place, is this choice.  Holy Saturday is the decision place.  Holy Saturday is situated between Good Friday and Easter Sunday, between death and resurrection.  Between the worst thing that ever happened and the best thing that every happened.  The worst of human impulses and the best of human redemption.  Most of our lives are lived in this middle place, between the terrible thing and the joyful thing.  And as we sit in this place we can choose, we get to choose: do we want to be part of the Vicious Cycle, or do we want to be part of the Virtuous Cycle?

Maybe you think you don’t get to choose.  Maybe you think that life is just happening to you and that you’re a small player in the scheme of things.  And you likely are a small player, but that doesn’t mean your part is small.  After all, one drop of rain waters a seed, and many individual drops of rain together water a whole garden.  Small players matter.  We get to choose. 

Even in the middle of so much viciousness, there are Virtuous Cycles happening all around us.  Did you hear about the thousands of Israeli Air Force Reservists and veterans who signed a letter to their government this week saying they will no longer participate in missions in Gaza, a letter that other Israeli groups, including other military leaders, have signed on to?  Regular people making a choice, choosing to change how they participate.[i]  Choosing Virtuous Cycles instead of vicious ones.

Did you see this week’s news story about the independent bookstore in Michigan who needed to move their stock to a new store?  They asked their community for help and several hundred people showed up.  The volunteers formed a human chain, handing the books to one another across several blocks to the new location, where the volunteers stacked the books on the new shelves in the same order as the old store.  Can you imagine moving a whole store and having no boxes to unpack or stock to organize?  This incredible act of solidarity for a community bookseller took 2 hours total, moved 9,100 books, and saved the small store thousands of dollars in moving costs.[ii]  Just regular people making a choice to participate in a Virtuous Cycle.

And finally, in our own backyard.  Did you happen to follow the local schoolboard election earlier this month?  A disgruntled community member has been trying to force the schoolboard to implement a policy about who can use what bathrooms.  A bathroom policy would be guaranteed to hurt Trans students—either they force Trans students to use bathrooms they don’t feel safe in, or they allow students to use the bathroom that aligns with their gender identity and the district is opened to outside interference from anti-Trans groups, further impacting the wellbeing of Trans students in the district. 

Instead of being forced into a lose/lose decision, the schoolboard has simply refused to take the issue up, saying such a policy impacts so few students that their focus is better spent on policies with greater reach.  So, for the last three elections, this disgruntled community member has been trying to run for schoolboard, which is their right.  And the people of Webster Groves keep saying a resounding “NO”.  No, we don’t agree with your harmful stance on Trans kids.[iii]  Just regular people choosing to participate in a Virtuous Cycle.

There are Virtuous Cycles happening all around us.  And we get to take our small effort and participate in them.  We get to usher the world toward goodness and truth, small resurrections as we wait for the bigger resurrections we hope for.  Because that’s the thing, isn’t it?  Resurrection is coming.  It is.  It always is.  Whatever cycle we personally feel like we’re in.  Whatever cycle the world is in.  Resurrection is coming.  It might not be on our timeline, and it might not look like what we expect—after all, even the people who knew Jesus most intimately were surprised by his resurrection.  But it is coming.  Resurrection is coming.  We do not wait in vain.

My hope is that we be people who water the seeds of justice planted in the garden of the world, and enough drops to flood the world with love.  May we be bringers of Virtuous Cycles.  May we choose to participate in the resurrection we await.  May it be so.  Amen.