The poverty trap that kills a million people a year | Madhukar Pai

You are listening to In Pursuit of Development with Dan Banick. There's a disease that kills more than a million people every year. It has done so more or less for as long as we've kept records. We know exactly what causes it. We know how to diagnose it. We know how to cure it. It nevertheless has once again become the world's leading cause of death from a single infectious agent ahead of HIV-AIDS and malaria. I'm talking about tuberculosis, TB. This is not just a health story. It is a development story. TB thrives precisely where development has failed. If you want to understand why development matters, why inequality kills and why the social determinants of health are not a footnote but the main story, TB is one of the clearest windows we have. Today I'm joined by one of the world's leading experts on this disease and on the broader systems of power and neglect that allow it to persist. Madhukar Pai is a professor and Canada Research Chair in Epidemiology and Global Health at McGill University, where he directs the McGill Global Health Program and the McGill International TB Center. But before I bring Madhu in, let me set the scene because the numbers, once you really sit with them, are truly staggering. According to the World Health Organization's most recent global report, an estimated 10.7 million people fell ill with TB in 2024 and 1.2 million people died from it. To put that in perspective, TB killed roughly twice as many people last year as HIV-AIDS. It sits among the top 10 causes of death worldwide and the overwhelming majority of those deaths, around 87% of all cases, are concentrated in just 30 countries, with eight nations accounting for two-thirds of the global total. India, Indonesia, the Philippines, China, Pakistan, Nigeria, the Democratic Republic of the Congo and Bangladesh. What makes this so striking and so very frustrating is that TB is not a mystery. It is not a new pathogen we are still trying to understand. Robert Koch, the German physician and microbiologist, identified the bacterium in 1882. We have had a vaccine for over a century. We have treatments that can cure roughly 90% of cases. And still, here we are. The answer to why, my guest argues, lies not in the laboratory, but in the political economy of development itself. The choices societies make about who deserves investment, who suffering is visible, and who's is not. Indeed, the question is no longer whether we know what works, but whether there is enough political commitment, funding, and institutional seriousness to act on it. That is where my conversation with Madhu broadens. Once we ask why proven solutions are still not implemented at scale, we are drawn into the deeper politics of global health. Our discussion therefore moves beyond TB to examine one of the most urgent and contested issues in global health and development, what it means to decolonize global health in a world shaped by entrenched power asymmetries, donor dependence, and stark inequalities over who funds, who decides, and who bears the consequences. We also end with a reflection on Paul Farmer, whose presence runs through this conversation even in his absence. Paul was a physician, anthropologist, activist, and professor at Harvard. And for many people in this field, including Madhu and me, a mentor. He co-founded Partners in Health, the organization that helped redefine what dignified community based care could look like in some of the world's poorest settings. He built hospitals in Haiti and Rwanda, treated drug resistant TB in Peru when much of the global health establishment argued it was not worth the cost, and spent his entire career insisting that people living in poverty deserve the same quality of care as anyone else, not as an actor charity, but as a matter of human rights. Paul passed away in February 2022 at just 62 years of age. That loss is felt even more sharply today, at a moment when many of the principles he stood for are under renewed strain. Thank you as always for the generous feedback, so many of you continue to send me after each episode. It means a great deal to me to hear how these conversations are resonating with listeners around the world and to see that the podcast has become truly global in its reach. If you find this episode valuable, please do share it on social media and within your networks as that helps the show reach even more people who care about these issues. I'm Dan Banik and you are listening to In Pursuit of Development. Madhu, in preparation for this discussion, I actually read the 2025 World Health Organization report and I have to say I was actually quite stunned with the figures. More than 10 million people in the world are diagnosed with this condition. A million or more people die every year from TB and yet you write in your work and as I also saw in the WHO report, it is preventable, it is curable, but it is one of the largest killers in the world. What's going on? What explains this? I think if you wanted a one word answer, Dan, I think that would be neglect because it's truly a disease that impacts the most impoverished people even within global South countries. Even within India, for example, it would be the most poorest quintiles that would be dying of TB and the world hasn't done enough to lift people out of poverty. TB is a beautiful sign of social nalice and neglect. Wherever you have poverty, TB will thrive. Wherever you have wars and conflicts, TB comes back. Wherever you have social disruption, TB comes back. Even in the rich part of the world, like where I am now in Canada, we still have TB outbreaks in the indigenous communities where housing is a problem, where nutrition is a problem, where there is still poverty. So whether it's the rich world or whether it's the poor world, TB tracks beautifully with social determinants and if TB still thrives, then it is not a medical problem anymore. To me, it has never been a medical problem. We know how to take care of it. Bast chunks of the world has gotten rid of it, right? There's not a lot of TB in Norway, not is there a lot of TB in Canada outside of the indigenous communities. So we know for a fact how to take care of TB and it will and can easily go down. China managed it. The just economic development and doing a better job. China's TB rates have plummeted in the last several years. So I refuse to believe that TB somehow is an inevitable fact of life. I think it thrives because we've allowed it to thrive. And if you wanted to, we can turn off the tap. So let's talk a little bit about the medical aspect of TB, Madoo. So how does one get it? Is it through coughing? It's through that spread of the bacteria, right? It's very much like COVID, right? It's very much like COVID, aerosol, airborne and classic airborne respiratory infection. And so yes, coughing will produce release a lot of bacteria into the air and someone in the same room can can inhale it. Even just tidal breathing for a long time will will will emit enough MTP. And so when we inhale it, most of us will have the immune immune system to take care of it. So we don't have to worry about it. But a small proportion will go on to end up with TB disease. And obviously the more immunosuppressed you are, like HIV, or people on immunosuppressive medicines, the greater the risk of them acquiring TB disease. And that's the primary mechanism. What explains the immunity we have? Is it the BCG vaccine that we got as infants? The BCG vaccine is at best a modest vaccine that primarily protects small children. And by the time we are adults, it has very little value, certainly in the in the high TB burden part of the world, right? So the vaccine sucks, unfortunately, and that's one of the last few things that need to be fixed and Gates MRI and others are investing millions in a new TB vaccine that is now in phase three trials. But there is a vaccine right now, Dan, and as someone who worked with Amartya Sen, you will enjoy this a lot. And that is food. So if you go and give food to families impacted with TB, they have dramatic impact on both the patients as well as their family members. So the risk of family members developing TB from the actual patient in the house is cut by half. So you mean there's a direct link between under nutrition and getting TB? Very, very direct link between under nutrition and TB, getting TB and dying of TB and some of the best work on this has come from India. All in the recent past, they did a beautiful trial called Russians, where they gave food baskets every month to families living with TB. All people with TB got food baskets for themselves, which was great. And that led to very few deaths and amazing recovery among the patients. But among families, they randomly allocated food baskets to half the family members of some half the households and the other households didn't get anything, which is the normal practice. It's a trial that shouldn't have been done in the sense. I was thinking about an ethical... No, it was all looked at. And the results published in Lancet were quite dramatic. So those families that received the food baskets for their family members have the incidence of TB during the follow-up period. So effectively food immunized them against developing TB. So there was a lovely editorial along with the paper saying, food is the vaccine we always wanted. So simple, $10 a month food basket with grains and vitamins and lentils. But just to tell you how powerful just nutrition is as a social determinant, it is the number one driver of TB. So this is really a disease of poverty. Absolutely. And I was just looking at the figures from that World Health Organization report from last year, 2025. And I think was it 87% of the burden is in 30 countries with India heading with 26, 27% Indonesia, Bangladesh, Pakistan, Nigeria. So what explains this? You know, I'm a little puzzled because if you think about India and we both know the country relatively well, there is inequality, obviously, but there's also tremendous success in development, poverty reduction, talking about food. There are lots of nutrition programs that the government undertakes, some of the largest social protection programs in the world. What explains that India is the leading sort of home for TB? Yeah, I think historically, incidents in India was sky high because of poverty and under nutrition. And yes, things are getting better in India on all of the development indices that you spoke about. But India still has a very high rate of under nutrition. I mean, the former prime minister called stunting. National shame. National shame. So India still does not get that part right. Having said that, they've invested a lot in social protection. So anyone who's diagnosed to have TB and notified to the government gets 1000 rupees a month, every month during the TB treatment, right? So these are cash transfers that India launched several years ago under prime minister's leadership. And it is now one of the largest cash transfer schemes in the world for tuberculosis. Of course, Brazil has its own cash transfer program that has got major impact, as you know, but that's not only about TB. It's about social development as such. Whether it's conditional or limited to TB or not limited to TB, we know for a fact that social protection works. Whether you give it as food, whether you give them additional food supplements to the public distribution system, like the ration system, or whether you just give cash. Regardless of the mechanism of social protection, absolutely works for TB. It's almost as if TB is designed to be very sensitive to social protection because it is so, it's the most marginalized people who are impacted. Even small amounts of social protection seem to make a big difference to their lives, right? We just published a piece in Lancet Public Health and we called it social protection for tuberculosis works. How can we make it universal? It's not that we don't know or we don't have the evidence. What I think we need to do is to get it to reach scale. If every family with TB automatically gets cash or other food or other benefits, social protection, we will see a massive decline in TB deaths and incidents. But the numbers are staggering, right? How do you get something to, you know, one plus million households on a yearly basis? And how do you even go beyond families impacted the TB? There's still the tap is wide open. So long as it's under nutrition and poverty, the tap is wide open and we can try as much as we can to mop the system. We need to close the tap. And right now, social protection is one way to close the tap. A good vaccine, if it does plan out, will be another way to close the tap. But we are not there yet. But still, I'm wondering, Madhu, why is it that many of the other countries in the global south don't have this high disease burden? What did China do to reduce it? I mean, obviously, you could say China's development path with social protection, etc. must have helped. But why is it that many other African countries don't have the same burden as Nigeria? One aspect has to do with poverty, under nutrition, etc. The other aspect, of course, has to do with seeking treatment and the costs of treatment, access to hospitals, etc. But first, if you can address why is it that some countries, as they are equally poor, if not poorer, don't have the same problem? So some of them may have much more, what shall I say, less fragmented health systems. Anyone who knows India knows this whole public-private problem, right? Problem solution, however, you'd need to think about it. We published a new piece in the Lancet for World TB Day, where we looked at patient pathways to care in multiple countries. And it's just fascinating to look at the differences between countries, right? On average, if you end up with TB in India, you start coughing and you have all the basic symptoms, people will go to three, four different providers typically. Why? Because they don't know they have TB. They just think it's a cough. So they go to the local pharmacy around the corner, pop in some antibiotics, wait it out. Because they can't afford to take time off work or they go to a local healer. They go to an Ayurvedic Ayush practitioner. They go to an informal provider, someone who's not trained in formal medicine and still is practicing. And by the time all these folks do their remedies, whatever their remedies are, typically scatter shot coughs and herbs, antibiotics, steroids. And we've shown that as well with the Jishnudas and our work on mystery clients. We've sent mystery clients pretending to have TB into multiple countries, clinics. And invariably, we find that providers hit you with a lot of scatter shot therapies. That's because they don't know what it is. They think it's just a regular cough that it will disappear. I don't blame them. But all that means is that multiple visits and about two months is passed before TB gets detected. Now, during that two months, if you have TB, you infect a lot of people. So transmission continues to be thriving in those environments. Imagine having cough in a crowded slum like Daravi in Mumbai. How many million people live there in such close quarters? On the trains. Or on the trains of Mumbai, or the buses of India. So the opportunities for transmission are enormous. If you have lung TB, pulmonary TB, and if you're blowing up millions of TB bacteria in the air, you will be spreading it dramatically. So in India's health system, given the monopoly of providers doing their own thing, right? Anyone from a chemist, pharmacist, all the way to a highly qualified doctor in a fancy five star hospital, everybody in between is practicing medicine. And the patient generally is bounced around. They go from pillar to post, which is what the patient journey analysis clearly shows. They finally wind their way to the TB diagnosis, by which time not only have they transmitted the infection to a lot of people, many of them have severe lung damage. So there is no growing understanding that TB, even if you're quote unquote, cured, you still deal with a lot of residual problems. We call that post TB lung syndrome. And that is quite devastating to a lot of people. They never really get cured in that sense, even though they are no longer bacteriologically sick. They deal with a lot of mobilities afterwards as well. In other countries, in the African region, HIV is a critically important determinant, right? There, HIV and TB track together like cousins, right? They're always together and that shapes the thing. So China, I think, not only lifted millions of people out of poverty, they also streamlined the diagnosis and treatment of TB even within their health system. They did the basic things, right? They followed the Dots program. They got the testing done and they had a centralized China CDC running the TB program. And together, I think it made a big difference, right? So India not only will have to worry about the social determinants, India will also need to figure out how to get quality TB care to all people, regardless of where they end up. Private, public, wherever they go, they need to be seen. Wherever they go, they need the social protection. The Indian government alone cannot swing this because half of India's care happens outside the government. So no matter how well the Indian government does, they're still leaving half of the TB unaddressed if they don't worry about what's happening in the world outside. And there is a challenge. Yeah, a couple of points, Madhu. I was thinking that if you are in one of these high burden settings, and if I was a medical doctor and somebody came to me at the cough, I mean, I should ideally suspect TB first, right? So I would have just thought that let's first get that out of the way. So I'm sure a simple test would showcase whether somebody has TB or not. That's the first thing. The other thing I wanted to ask you is, since we're talking about India, a few years ago, the Indian government launched the world's largest health insurance scheme, the Ayushman Bharat. And this was supposed to revolutionize health care access because it is so expensive. Do you think these kinds of big social protection programs, particularly health insurance, do they have the potential of doing something about this problem? Great question. My reading of the Ayushman Bharat is that it's designed more for secondary care and hospitalizations. TB is really a primary care problem. Like you said, you wake up with cough and fever. You don't have to go to any hospital. Ideally, you should be diagnosed quickly within the community, right? Wherever you are, you're living in a village. How can you do that quickly and cheaply, Madhu? Right now, just last month, the WHO endorsed a very cheap molecular test with a tongue swab. Just scrape the tongue like we did with COVID. Yeah. And then you can three and a half dollar molecular test. But until recently, TB diagnosis was not easy at the primary care. All we had was to provide a spit, right? Spute them from the lung, put it on a slide and read under a microscope. The old fashioned way that Robert Koch did in 1882. That microscopy in some way still persists despite all these decades and centuries that have gone by. So that's the test that needs to disappear. Microscopy is no longer fit for purpose. We need a rapid molecular test like we did for COVID, right? The PCR test is the right way to do it. And it can also rapidly detect drug resistance. So right now, a lot of advances have happened in TB diagnosis. And treatment is can be shortened even for drug resistant TB. We have very good medicines that can bring down the treatment duration to six months. Earlier, we used to treat drug resistant TB for two years. And that was pretty painful and quite miserable and toxic that has been done. I'm confident that that medicines and tests are not the rate limiting step. It's the social determinants that are unaddressed. And it's this health system problem. That TB is primarily a problem that should be managed with the primary care. And that's where the system is weakest. Once you reach a district level or a hospital, most people know how to take care of TB, right? You can get a chest x-ray done, you know, see the x-ray is abnormal. That is not where the problem lies. The problem lies with primary care. And so how to integrate TB better into general routine primary care services. And that's where I think Ayushma and Bharat as ambitious as it is, it does not do an adequate job of covering primary care. And primary care, I think, is India's weak spot because of the diversity of providers, because of all of this heterogeneous mix of health care, including unqualified practitioners and pharmacists behaving de facto like health care providers, right? They're just dispensing medicines. They are, and a poor patient will go to a pharmacy first. Give me something for my back pain. Here you go. Give me something for my cold. Here you go. So I think if India manages to get the primary care infrastructure better, then I think we can handle TB and many other conditions better at that primary care level. And primary care level also should be critical for diabetes, hypertension, a million other things that need to be and could be easily managed at that level. If you and I felt sick, the last place we want to go to is a hospital, right? We want to go to our family doctor ideally. That's where much of our problems should be managed. Rarely should we ever require anything higher than that. And we want to live a life where we don't need to see the inside of a hospital. Indeed. Madhu, I want to elevate our discussion to the global level. Not that we haven't been talking about the global level already, but global health and the increased calls that you also have been a part of to decolonize global health. So firstly, we have to you have to tell my listeners what you mean by decolonizing global health. That's the first thing. But also just using TB as an example, I have apps, Madhu, on my phone, you know, for nutrition, for all of these things. I've been giving talks about apps for snake bites and anemia detection. You would think in this day and age that with technology, etc., that these things would be easy to detect, right? Not that that cumbersome test that you were talking about. So which brings me to what I don't know if this is a conspiracy theory or what, but I keep hearing that a lot of diseases that many groups in the global south face are typically not addressed or neglected, etc. Because these are not problems we face in our parts of the world. And thereby the urgency of doing something about it is not seen to be there. So using TB as an example, Madhu, help us understand what you mean by decolonizing global health. Great question. And decolonizing has multiple meanings. As a political scientist, you know, when countries were colonized and the colonizers had to be removed, that was this violent process of decolonizing, right? So for example, India, getting rid of the British, the partition and all the bloody stuff that happened that divided India and Pakistan. So that's an example of what decolonizing could look like politically. But decolonizing is also removing any vestiges of the colonial empire within one's mind, decolonizing one's mind. Famous authors in Africa have spoken about this, the internal racism that is built into people and the need to decolonize our minds, but also the power systems that are still in place, right? In the indigenous context, for example, in Canada, we are living on indigenous land. So decolonizing for indigenous people means they need to recover their land back. It's as simple as that. It's also an element of reparations. Decolonizing for indigenous people is to recover their land that was stolen from them. So I think we need to acknowledge first and foremost that global health, as we see it today, is a descendant of colonial medicine. In the past, it was all about how do we keep the white European colonizers alive when they went into these exotic tropical countries? Tropical medicine. Tropical medicine came from there, right? Malaria, yellow fever, all of that has that same overtones, right? And so tropical medicine eventually became international health, right? For a long time, that's what it was called. Today, international health is being replaced by most part and most global North universities with the term global health, where they are kind of acknowledging that international seems, you know, rich world, helping the poor world, kind of a narrative, and they want to say it's a lot flatter than that. But it's not really flat, right? It has never been flat. It has never been flat. And the COVID pandemic is the most traumatic example of how unequal global health is. As you and I were getting our second doses and third doses of the first class vaccines, first class mRNA vaccines, huge parts of the world were completely left out. They've never seen an mRNA. There's inequality, lack of resources, maybe a bit of an arrogant attitude. We know best your local knowledge isn't important, which I've seen in many parts of the world. I was reading this book, Decolonizing Global Mental Health. You know, even psychiatry has, you know, the way in which we understand problems is the problem as I see, right? So we're using our Western lens to diagnose and treat people. So we are not paying enough attention to local knowledge. Is that the problem? So the epistemic is one symptom of this. I think what is underneath all of this is the extraordinarily power asymmetry that pervades global health and development. Look at the United States right now as we speak. They wear the number one donor nation bar none. USAID disappeared in a few weeks. You know, the entire aid structure is crumbling and millions of people are dying as a consequence of this. So the biggest question is how did global health become a charity case that the rich world tries to save the poor world, right? How did it become this white savioristic enterprise, which now can be gotten rid of at a second's notice? Somebody sitting in Washington, DC have pulled the plug and somebody far, far away is dying because they can't access HIV treatment or malaria treatment. That is unfair. That is not how it should be. Global health should not be how Americans are feeling charitable or not on a given morning or what Canadians are doing or not doing. Global health should be what countries are doing to support themselves. So to me, power is the key, Dan. Power is the key. That is why in our Lancet piece that I sent you, we're talking about shifting power. So long as Washington, DC or Oslo or Ottawa has the power, nothing in global health will ever change because it is always this top down approach of what I think you should do, what I believe your problems are. And these are our priorities for funding and you are the beneficiary. You accept it, you take it. And by the way, we may close it down next month. Sorry, good luck to you. You can survive on your own, right? That ways of thinking all permeates from this empire that was built on the shoulders of colonialism continues to be colonial in its architecture. It's reforming the architecture. That is what decolonizing global health really means for me. It seems to me, I mean, I get your point, but it seems to me there may be an inbuilt contradiction because it is almost like saying, we know what to do. We need your money. But the donors are saying, you can't have my money unless you do certain things that my taxpayer wants you to do. Right. So it's that that is one aspect. The other aspect, Madhu, which I am a little unsure about is do we always know what is the right thing to do? The evidence is it always clear? Because sometimes you could have a test, you could do a RCT, you could do clinical trials and arrive at a decision. But in many situations, local indigenous knowledge may have an alternative solution that is, I believe, often easily dismissed by Western science. And it is often dismissed because no studies have been done. There is no evidence. So is that also what you're pointing to is this, you know, mumbo jumbo that we we think is mumbo jumbo, you know, I've been doing a study with a postdoc of mine on witchcraft elites, you know, which are easily dismissed. But witchcraft is extremely important for the local communities in Malawi. It is the social glue. Yeah, yeah. I'd like you to please reflect on that, that contradiction in terms of funding, aid, USA, et cetera, without conditionality and the other aspect in terms of the evidence. You're absolutely right. The global health has to evolve from global South country, saying we have the agency, we know what needs to get done, and we will invest our own resources in fixing it. Right. India, as you know, well, who long good takes money from anyone doesn't need it is doing whatever they need to do in India. They are in the leadership role. So is China. So is Brazil. So is South Africa, more for most parts. So is Indonesia. So is Rwanda. So is Thailand. So any number of countries are exercising their agency, prioritizing their own diseases the way they want to using their own local knowledge and their own domestic resources. Like, for example, India's TV program no longer takes money from anyone. Right. And India has dramatically increased domestic investment. It's amazing to see how much India is investing in research and in technologies. I mean, India recently had an AI summit that had 200,000 people attending. It's just phenomenal to watch. Right. So the India that I grew up in is not the India today. So India today is a donor country, if you wish. So I think that is the trajectory we should all head to. But the poorest, smallest countries in the Africa region, for example, are still donor dependent. And I think in some sense, to address this, we really need to start talking about a reparation plan because these countries were intentionally impoverished or still being impoverished as we speak because of the colonial extraction that has left that continent, what it is today. So what are the reparations that the rich global North countries owe to these countries that were colonial damages? Now, you saw that in the climate arena, there is a loss and damage fund. Right. So reparations are explicitly being discussed. It's still not there. I mean, they're still discussing the mechanisms. But at least, at least, the notionally, they've agreed. The British Medical Journal's BMJ Global Health recently published an entire series on reparations and global health this year. Can you read that? And they're talking about structurally what reparations will look like. Do you really think the US government will do reparations? I mean, I mean, I don't see the global North countries even touching this. With the UN resolution recently on slavery. Exactly. Three countries voted against 52 abstained. Yes. Yes. And mostly European countries, Canada, Australia, US countries that have benefited. And I'm told it's because of the fear of reparations. That's it. That's it. That's exactly right. So to me, it's easy to blame an African country and say, why are you not spending more on your own problems? Well, we left us impoverished. So you have a responsibility, right? So I'm not willing to give global North countries a free pass. I hope, yeah, we're done. You take care of yourself now. Well, then what about all our wealth that we inherited through settler colonialism and slavery and all of those colonial structures that are still making us so powerful? So so that's one important thing. Your question about evidence base is a beautiful one. Dan, I think countries are thoughtfully using it, right? For example, you spoke about mental health. Have you heard of this amazing friendship bench model of mental health care in Zimbabwe? No. So there's a whole book called Friendship Bench and there's a movie called Friendship Bench. So Dick Sinchibanda is this Zimbabwean psychiatrist. And he realized that there's never going to be enough psychiatrist to take care of the mental health problems in Zimbabwe. So he recruited grandmothers to sit on a bench and just talk to people who are in need of of counseling and support. And that model has been amazing in terms of its ability to scale because it uses grandmothers who are otherwise unoccupied and are willing to contribute to this society. It's it's culturally acceptable to sit and chat with someone on a bench. I think they have really and destigmatized it mental health, right? Because stigma is still a big deal for mental health. Most people don't want to seek care. So I think if you can tap into the local wisdom, indigenous communities everywhere will tell you they are better place to take care of climate crisis than anyone else because they've always seen themselves as stewards of their land that they have the deepest insights on how to protect the water, how to protect the land, the way they rotate the crops, the way they fish and harvest in a sustainable manner rather than an exploitative manner. I think everybody would agree that for climate change, we need to go and learn from indigenous communities on how to save our our ecosystem for for humankind. I think there are things to do. India, for example, has an entire ministry dedicated to indigenous Indian medicines, medical systems, right? So there's lots happening there that I think can be done. The most important thing is global South countries need to make a commitment to say we have the agency. We will take care of our problems. We will invest more in our own health and and we will also manufacture our own vaccines so that we are not waiting for charity when the next pandemic comes, right? People were left waiting for years for a for a for charity that never came. So that's why Africa, CDC and Africa Union are so keen on regional manufacturing of medicines, vaccines, tests so that they are no longer in in need of charity or aid. I think all the destruction of USAID has forced them to move even faster. So as much as I agree with you, I sympathize. I see the main point. So there's decolonizing global health agenda, Madhu. I also see that this there's a risk that we are not actually demanding more of some of the local governments, right? So you can't just blame the global north. There's also lots and lots of examples of countries, governments, presidents, prime ministers, prioritizing vanity projects rather than focusing on health. Right. So we have to remember that. But since we're getting to us, the end of the conversation, Madhu, I want to to talk about our common friend, Paul Farmer, the late Paul Farmer, the brilliant Paul Farmer, the kind, gentle mentor, wonderful, wonderful man who passed away all too soon, only 62 years of age. And in this world that we live in and all of the things we've been talking about, Madhu, so far with with decreased aid funding and decolonized health, he was the man who showed a very important way out of this mess. And that is also one of the many reasons why he's so sorely missed, because one of the things Madhu, he told me repeatedly is how important it is to invest in the not so attractive long term commitment of training, of setting up hospitals, training doctors. These don't make for fancy reports to donors about, you know, how many people have been vaccinated. But these are extremely important. This kind of capacity building, even the capacity building is a buzzword now these days. And the fact that he was building hospitals, that he co-founded partners in health. So I want us to end our conversation by reminiscing and reflecting on the legacy of Paul Farmer and why a person like him is extremely needed today. Desperately needed today. I always wondered what he would have said in this ongoing crisis right now, right, in the last year or so. It's been one horrifying thing after another. Too many things have been broken. I think he had enormous moral clarity, as you know, right? His moral clarity was the one that attracted a lot of us to him because he could cut through all the bullshit and come right down to it. And I think when he passed away, I wrote a piece in Forbes on all the lessons that Paul has taught all of us, not just me or you, but hundreds and hundreds of people. And it was almost like a tribute. And we kind of listed 10 big lessons that Paul taught us. I won't go all of them. But to me, some of the major things that he taught me was that, you know, global health often fails even at the level of the imagination. And if you can't even imagine something, surely you're not going to execute it. So when people told him, oh, HIV cannot be treated in Africa, he said, no, it can't. When they said drug resistant TB cannot be treated in Peru, he said, nothing doing. They deserve the same treatment. Or Ebola. Ebola, right? So every time there was pushback that this is not possible, he set the bar high because he wasn't socialized for scarcity in his mind. All of us rapidly become socialized for scarcity. We set a low bar for some people and we set a higher bar for ourselves. And Paul could overcome that problem. And I think at the base of all of this is that he believed that every person is a person and therefore worthy of everything that human beings should be getting. So I think he was at its deepest human rights advocate because it's the human rights that make you then say, OK, why should I not get HIV treatment just because I'm black, because I'm Haitian? Why should I not be eligible for drug resistant TB because I'm Peruvian? So it didn't really he broke through all of that by saying, I don't care who you are. You're a person and you're worthy of health care. You're worthy of whatever health care means and whatever it should be benefits it should bring to you. So to me, he set us all on that path of universal human rights and therefore universal health coverage, the HIV drug resistant TB didn't matter. I think the other thing that we all learned from him is that it takes a lot more than just medicines to cure someone, right? The accompaniment of just basic community health workers staying with you in a period of crisis and helping you has become a global movement, right? If you look at community health workers, I think that is one of the best thing community health workers can do just to accompany people in their complicated journey, whether it's maternal health care, whether it's a child who is sick, whether it's a long treatment of TB or the never ending treatment of HIV. Accompanyment has really been the heart of what Paul and partners in health have demonstrated and the whole army of community health workers who are supporting the systems is now being used in rich countries like the United States, right? That model is being translocated from Haiti and Peru and Rwanda back to the United States. It's like a complete full circle moment, right? That they pioneered all that work and then they realized that the United States needs it as much as anyone else. So I think these were all the big contributions that he made and the work continues down since I'm on the board of trustees of PIH. I can tell you they are unrelenting. They are still working in multiple countries and they now have new champions like John Green. I hope you can invite John Green on your podcast. You know, not only is he a celebrity author and novelist, but he's also written this wonderful book called Everything is Tuberculosis, which is a bestseller. And John and others have contributed money to create a massive, beautiful maternal hospital in Sierra Leone. So I think work continues. I mean, Paul, all the people that he inspired, none of them have given up in any way. The organization is, you know, going through its own tough times because of what's happened with US government funding. But they are pushing back. They are doing everything they can to keep things going. In addition to Paul being the wonderful guy he was, and he was just such a caring soul, is also his ability to do more with less, you know, to develop cheaper forms of treatment or to even build hospitals in very difficult circumstances like Haiti, Rwanda. I wondered whether you could briefly mention his work related to TB with his former colleague, Jim Kim, who also then became the president of the World Bank. What was it that they did that reduced the costs significantly? So if you watch the movie Bending the Ark, which I highly recommend to everyone, I play it all the time in my global health class. I find it so uplifting is that they realized that most of the drug-assistant TB medicines were off-patent. There was no logical reason why they should be so unaffordable. And so they worked with multiple partners to lower the price of those medicines. But I think the biggest contributions, Dan, were not all of those. The biggest contribution was a refusal to listen to the usual cost-effectiveness arguments. They really pushed back and say, OK, so if you had drug-assistant TB in Boston, then it is fine for you. You will get treated. Nobody will tell you that it's not cost-effective. But if you had TB in Peru or Haiti, a drug-assistant TB, then you invoke the cost-effectiveness argument to deny them treatment. That is morally unjust. I think it is that thinking that I don't care who you are, where you are. If you have drug-assistant TB on a humanitarian basis, you need to be treated. And we can show you that it is still cost-effective to treat you, then let you die. Because if you took at the societal cost of losing all these people, then there is no question. Every dollar spent on TB gives you a return on investment of about $45 globally. That math has been done. And I'm part of that publication as well. So TB primarily kills young people, young adults. And you lose the workforce in your country. You lose young men and young women who are future leaders. So I think he just has his refusal to accept a low bar for TB or HIV. And today we don't even talk about it. Right back then people said, oh, HIV is not cost-effective to treat HIV. And today everybody who needs HIV treatment by and large is getting it even in the poorest parts of Africa. Right? Why? Because people like Baal and PIH refuse to accept that we would set a very low bar for them and we would set a high bar for ourselves. I think the victory was a moral victory and then came everything else that followed. Right? So to go back to my original point, you have to even imagine a world by universal healthcare as possible. You have to imagine a world where everybody had access to COVID vaccines during a pandemic. We failed, but you have to begin with that imagination. Right? That everybody with HIV will get antiliteroiles, that everybody with drug resistance TB will get the six month oral treatment that we have today. If you are unwilling to even start there, then everything that you do subsequently will be some watered down version of it. That would be far, far from adequate for people. I think that is Baal's biggest lesson. Do unto others in some way that you would like to be done unto yourself. And what did he say in his famous quote, if healthcare is a human right, then who is human enough to have that right? He believed that everybody was human enough and that was good enough for him. Then what followed naturally was if you're a human and we accept that you're a human, then if we accept that help is a human right, then you have a right to health and healthcare. And it doesn't matter if it's TB, HIV, I don't care what it is, you have a right to it. And then that's simple. Once you internalize that, then it's a more a question of mechanics, right? Who's paying for it? Who's delivering it? Health worker, not health worker. All the rest is details. He won the battle at the level of the imagination and the moral clarity. And that simplicity is what continues to appeal to me even today. Madhu, this was great fun to see you, to chat with you and reminisce about Paul, but also talk about TB. Thank you very much for coming on my show today. Brilliant. Thank you, Dan. You're such a good host. Thank you for listening to In Pursuit of Development with Professor Dan Banick from the University of Oslo. Please email your questions, comments and suggestions to inpursuitofdevelopment.com.