I was ten when I learned I had tuberculosis. I didn’t have symptoms, but the tests showed an infection. I knew that my grandpa Vasya coughed more than he talked, but everyone blamed it on chain smoking. Besides, that was the kind of cough all men over forty had back when the Soviet Union started to crumble. A few years earlier, I had been feverish for days straight. Pale, I lay on the couch, buried under blankets. Alyona, my older sister, handed me a yellowish pill. It tasted nothing like the sweet little vitamin C drops my mom usually gave us for colds. “Will this stop me from rotting alive?” I asked my sister. She stared at me with teenage angst, then decided it was kind of funny and slapped my hand. “It’s an antibiotic to kill your sickness,” she said. The fever persisted for a few more days. I lay there with no strength, trying to imagine the place where the farthest galaxy ends. Then, all of a sudden, my head stopped hurting. It started to spin instead, and my whole body grew light, so light. The next morning I woke up healthy, but with the weight of my own mortality on my shoulders. I knew I would die someday, and I’d had a glimpse of how it might feel.
Years later, I sit in a small exam room at Providence St. Vincent Medical Center. My doctor searches for the right words. She tells me that I shouldn’t worry, that I'm one of two billion people infected with tuberculosis, that it's completely curable these days. For the next three months, I'll need to systematically kill the pathogen with a cocktail of first-line antibiotics—RIPE, they call it. Rifampin, Isoniazid, Pyrazinamide, Ethambutol. Her words don’t surprise me, but I still feel the weight of them pressing down on me. It’s as though I’m in the galley of a submarine on a dive gone wrong; the fluorescent hum of the lights and my own pulse fill the room. I remember that I’m in the process of dying.
A quarter of the world's population is infected with tuberculosis, just like me. Mycobacterium tuberculosis grows slowly inside its host, and the immune system has plenty of time to build defenses against the pathogen. But TB bacteria have thick walls, making them formidable opponents. White blood cells can't break through to kill them, so they build walls of their own—calcified tissue that encases the bacteria in spheres called tubercles. The isolated bacterium hibernates inside these tubercles, feeding on dead tissue. This type of infection is known as latent tuberculosis, and it may never cause trouble. The tubercles keep the bacteria contained, preventing the spread of infection. In only 5 to 10 percent of cases will the immune system fail and the person get sick. In all other cases, the bacteria sits dormant in the body—like the seeds of a civil war—waiting patiently for the right moment to begin their deadly work.
Most RIPE drugs are over fifty years old—roughly the age of my internal systems. Rifampin attacks the bacteria and turns your bodily fluids orange. You piss orange. You sweat orange. You spit orange. Your organs, whether they like it or not, get flooded with poison designed to kill intruders. It's a full mobilization against a common enemy. And like any war, good guys suffer and die. You'll feel lousy at best. At worst, you'll feel like an absolute wreck and want to go back to your old peaceful life. But there's no going back. The main thing is to get rid of the uninvited bacteria. If you stop taking the antibiotics or skip doses, the bacteria will develop resistance. The antibiotics will keep overloading your kidneys and liver, keep wreaking havoc on your microbiome, without touching the pathogen.
I was still ten when my fear of death slowly dissolved in the thrill of daily life. I learned to melt lead plates from car batteries in a tin can over a fire, pouring the scalding silver liquid into a wet matchbox and watching it harden into useless rectangles. Splashes of hot lead flew everywhere, and my hands soon became covered in burns: perfect white-red circles, kisses from molten lead. With my cousin Vovchik, who preferred pouring molten lead into a tablespoon, I traveled to the city dump to harvest old car batteries, our main source of lead plates. At the dump, foul-smelling strangers approached us, questioning our right to be there. "What does elecampane look like?" they asked us. "What does a python eat for breakfast?" We didn’t answer, walling ourselves off with thick silence. The strangers discussed what should be done with us while we stayed quiet and tried not to hear their plans. They locked us in a shed, and it took several hours before we managed to kick out the window. Nobody chased us, but we ran home as fast as we could. After this, I knew for certain: every person carries death inside them—and not necessarily their own. That day, I saw my own death reflected in the eyes of one of those strangers.
Some microorganisms help digest sugars. Some influence your mood. Some are just waiting for the right moment to attack. They have only one thing in common: they all settled here illegally. The antibiotic—with a fifty-year track record of successful genocide—kills bacteria without distinguishing their function or origin. Often, after the first course, bacteria that process toxic salts and prevent kidney stones disappear forever. The remaining space is often taken over by fungi and pathogenic bacteria that are immune to antibiotics.
Eventually, the antibiotics wipe out the gut bacteria that produces serotonin. They can’t tell the difference between the microbiome responsible for keeping you in a good mood and the bacteria hiding out in tubercles. Just to be safe, they nuke everything living, like the bacteria that break down fiber and regulate your immune system. Then comes the post-antibiotic fallout: depression, anxiety, brain fog, apathy, irritability. You got rid of the dormant bacteria, the potential threat, but now you don't even want to be alive.
The doctor in the Providence exam room waits for my response. She has no doubt I'll agree to treatment, but there's protocol: she needs my consent to prescribe the antibiotics. She's already started writing the prescription. My answer is just a formality. There is no answer other than yes.
How can I torch a part of the organism that's been with me my entire conscious life? How can I kill the volunteers who’ve been doing their invisible work all this time? How will my life change after I wipe out half my microbial community because there's a potential threat to the "better half" of my cellular community, led by my rational brain? How will my identity change?
If I think about it, tuberculosis is the only thing that still connects me to my family, the only thing I inherited from my grandpa Vasya. Sure, I'll still have his DNA, but that unique microorganism community, built up over years, will be gone. I know this sentimentality is unscientific and stupid, that this bacterium is too ruthless to allow these kinds of thoughts, but I can’t shake them. They’re not even thoughts, really. More like sensations. Because thoughts are the rational brain's department, and the antibiotics will hurt the brain least of all. The brain is ready to make sacrifices, but they won’t be its sacrifices. The brain is just solving a problem, the way any efficient manager minimizes risk.
I've lived my whole life with the tuberculosis bacterium. My internal system was built and shaped around the presence of a pathogen, forming the microbiome inside me. Once I finish the antibiotics, my body won’t be the same. This is an archive of my life (good and bad) that will disappear forever. Should I let the pathogen potentially devour my cells, or destroy the evildoers along with the civilians?
My brain echoes the doctor's arguments. You can't take the risk. For just three months the fluids in your body will change color, you'll sink into depression, but you'll eliminate the potential danger and get the chance to build a new, healthier community. Antibiotics are the only way out.
The exam room is getting stuffy. It's a simple decision, and I need to make it now. I know it’s the right decision, but I'm slow to answer the doctor. For me, the decision stops being about health. It becomes a question of identity: How badly do I want to become a better version of myself? How badly do I want to destroy the Soviet pathogen and grow a new community of beneficial native microorganisms inside?
The doctor has no doubt. My brain has no doubt. But some small part of me doubts. Resists. Maybe it's exactly the part that's meant to die.
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