This transcript has been edited for clarity.

Eric J. Topol, MD: Hello. This is Eric Topol for the Medicine and the Machine podcast. I’m thrilled today to welcome Steven Thrasher (@thrasherxy), the Daniel H. Renberg Chair of social justice in reporting at Northwestern University Medill School of journalism. He has a new book called The Viral Underclass that we’re going to talk about. Welcome, Steven.

Steven Thrasher, PhD: Thanks so much for having me, Eric. It’s nice to see you outside Twitter.

Topol: Same here. Before we get to the book, I thought we’d talk a little about your background. I know you grew up here in California. Take us through that to New York University (NYU), to when you worked for Saturday Night Live (SNL). Tell us about the earlier part of your career and upbringing.

Thrasher: I grew up in Oxnard, in Southern California, and moved to New York City when I was 17 to go to film school at NYU. I did work at SNL as a college senior and during my first year out. It wasn’t as glamorous as it might sound. I was a writers’ research assistant on the “Weekend Update” desk my first year and then a staff writers’ assistant.

I worked in film production for years. Most formative for me was working on a film called The Laramie Project, about Matthew Shepard. The film itself was based on an oral-history approach to theater, making a play about the murder of Matthew Shepard, by the Tectonic Theater Company. Eventually, I ended up as a staff writer for The Village Voice, where I was covering the same-sex marriage movement throughout the country. I started writing about HIV and AIDS during those years.

I ended up at Northwestern, where I have this great job in the journalism school that focuses on social justice journalism and LGBTQ people. I also have an appointment in the medical school where I work at the Institute for LGBTQ Health and our Center for AIDS Research. So I try to continue my journalism and also conduct peer-reviewed research, and sometimes I blend the two techniques. I’m privileged to teach journalism students about health, medicine, and LGBTQ people, and sometimes teach medical students about how to communicate.

Topol: It’s quite a rich background. When you were thinking about writing The Viral Underclass and trying to get to the intersection of how viruses like HIV and COVID have a devastating effect on people of color, the disabled, the impoverished, and so on, when did you come to this eureka idea that you should devote a lot of effort to this? I know you’ve been an investigative journalist, but when did it occur to you that this really needed to be dissected?

Thrasher: Shortly before I began my PhD, I was working on what I thought would be my last journalism story, which I’m still working on 8 years later: the story of a young man named Michael Johnson who’d been arrested for alleged HIV exposure and transmission. He was facing life in prison. It was a case that brought up almost every disaster of health and the carceral state and Black America. It also brought up many issues around sexuality.

Through that case, I started understanding the ways that criminal justice was a poor way to deal with public health. I also saw the ways that anxieties about race and sexuality and disease can get heaped on people. Michael’s story was being reported in Australia as if he were somehow a global menace to HIV, when 40 million people around the world are living with HIV. It became apparent to me pretty quickly that I might be working on this for a long time.

The month I started graduate school, I started writing for The Guardian. When Michael Brown was killed in Ferguson, Missouri, they sent me there. Ferguson had a higher rate of AIDS than the surrounding region, and I started seeing this overlap of the ways that particularly Black Americans were facing policing, concentrations of poverty, police violence, arrest, and also HIV and AIDS. These maps were overlapping quite a lot.

That was my first “aha!” moment. I wrote my dissertation about this relationship. It was called “infectious Blackness.” I wrote about the relationship of prosecuting HIV and how and why HIV and AIDS had become so lodged in Black America within the United States. I looked at before and after the advent of antiretroviral medications, and how we actually saw a greater disparity in who was living with AIDS after the medications were introduced. HIV medications did not iron out these disparities.

That was the basis of my doctoral work. When I finished it, I was trying to figure out what would become of it and whether I would make a book out of it. I started in this job at Northwestern and I found out that I could actually write a trade book. So I was trying to figure out what form it would take when the COVID pandemic happened.

I didn’t know if I would still have a job. I didn’t know if there would be a book to sell. I didn’t know who was going to live or die from this pandemic. My agent very wisely looked at my dissertation, the last chapter of which was called “The Viral Underclass.” I had ended my dissertation in an open and hopeful way, looking at activists who are trying to repeal the laws that criminalize HIV.

There was a debate among them about the viral underclass — a term that had been coined by someone who started a group many years before to talk about HIV criminalization in general. This group of activists was saying that if we started having HIV laws that said everyone’s getting prosecuted for it but people who have an undetectable viral load should not be, this would create a viral underclass. They were pointing out the ways that people who still had detectable viral loads were going to become even more criminalized. But the reason people have detectable viral loads is often because they’re poor. They don’t have consistent access to medication, often because they’re homeless.

Tanya, my agent, said to think about using that as an analytic. So that was another big “aha!” moment, because I realized as COVID cases and COVID deaths were escalating in March and April of 2020, they were happening in cities I was quite familiar with because they were in areas where there were also high concentrations of HIV and AIDS.

In a way, this didn’t fully make sense because the novel coronavirus and HIV are very different viruses in many respects, in how they transmit and the timeframes they work in. But the concentration of cases was in similar places. That was when I realized that a framework of a viral underclass could help us understand why very different viruses affect similar populations, even if the particularities of those viruses are quite different.

Topol: The independent replication of a second virus with the same remarkable themes was extraordinary. But the United States seems to be especially vulnerable, poised to have these inequities because of its lack of any universal healthcare access, unlike any other industrialized nation.

Thrasher: Those of us who studied these things were terrified in February and March and April of 2020 because it was like we were living in a house of kindling, and we saw the match coming.

My point of entry of concern was rooted in thinking about AIDS, poverty, and race. And the history of that in the United States is that medications became available in 1996, but they didn’t get to some other countries for another 7 years. Yet, even within the United States, we had this horrible racial disparity. In 2016, the Centers for Disease Control and Prevention (CDC) projected that if things did not change, 1 in every 2 Black gay men like me would become HIV positive in our lifetimes.

HIV is so slow acting. From the time people become infected, it can take 5, 7, 10 years for them to become seriously ill. It could take maybe as many as 15 years for them to die, if they’re not treated. Yet, there are still people in the Mississippi River Delta showing up in emergency departments with end-stage AIDS symptoms and only living for a couple more weeks before they die. There’s no reason for that to happen, except that these are people who’ve never seen a doctor, and they’ve already been discarded by society in all kinds of ways.

Knowing the context of that and how we’ve had medication for this virus for about 26 years now, and knowing how prevalent HIV still is in certain sectors of the United States, made me terrified about what would happen with COVID, particularly given that it’s a much more efficient virus that transmits much more easily, and that it would be coming into a healthcare system that would be totally overwhelmed with dealing with it.

Topol: There’s no question about that. I wonder if you could go back for a moment. I know about the work you did with Michael “Tiger Mandingo” Johnson was very impactful. You begin your book with that, and it’s a theme throughout the book, The Viral Underclass. He had a 30-year jail sentence that was reduced to 5 years. Did your writing about his situation help him get out early?

Thrasher: I believe that the reporting we did at BuzzFeed did help. He had mostly been portrayed as a monster and he had very negative press coverage. Almost everyone in his life had abandoned him. He wasn’t able to get much help. The first 2 years I worked on the case, the national organizations would not touch it. The National Association for the Advancement of Colored People (NAACP), the Human Rights Campaign, the National Gay and Lesbian Task Force, not even the American Civil Liberties Union (ACLU) or the AIDS organizations would have anything to do with him.

It was a dynamic that shamefully reminded me of when the NAACP would not take cases where charges of rape had come into the equation. Those were the cases when people often ended up being lynched or executed. The Scottsboro Boys did not get representation from them and ended up being executed.

I was able to tell Michael Johnson’s story much more fully. And a lot of activists came up around him and started helping him. Armed with some of the things I had reported, they were able to raise money, got another attorney to help, and mounted a successful appeal. The sentence was overturned.

One thing I wish the court had ruled on, which they put to the side, was the unconstitutionality of the laws themselves — that they are needlessly and cruelly impacting people who have something that’s considered a disability under the Americans with Disabilities Act. Yet, these laws are leaving people in prison for life. But I feel very happy and proud that I played a role as a reporter to bring out information that was helpful for getting him out of prison.

Topol: That’s gratifying to hear. When you’re an investigative journalist and you can help enable action like that, that’s got to be rewarding, that you can effect change, especially cutting 25 years off a prison sentence in a man who was recklessly put in prison and given such an extreme sentence.

Thrasher: Thank you. The day he got out of prison was one of the greatest days of my life. I felt happy that he wanted me to be there. As a reporter, you often don’t get to see the end of your stories. His story goes on, and he’s doing well and living his life. But it’s rare that you get to report on something that seems unsolvable and get to see it come to its conclusion. Recently, he sent me a picture of himself holding my book. I’m happy that I got to see him get out and go on his way.

Topol: Now, you wrote about the 12 interconnected social vectors between HIV and COVID. Could you speak a bit about that? These are all such vital forces in our lives. You may not be able to run through all 12 of them but I’m interested especially not only about racism, individualized shame, and capitalism, but also the prison state — the carceral state — speciesism, obviously ableism, the myth of White immunity. Touch on your thoughts about these connected vectors.

Thrasher: When I was working on my dissertation, I was thinking about HIV criminalization and race. And this project expands on that. I see race as a factor but there are all these other ways that a viral underclass is made. Particularly, I think the COVID-19 pandemic creates an opportunity for a lot of solidarity with White people and with people who’ve been affected in different ways.

There are 12 different ways a viral underclass is perpetuated across different kinds of viruses and, within the United States, across different presidential administrations. The Trump administration was extremely reckless and irresponsible in all kinds of ways with COVID. But the death toll under the Biden administration is now about 150% of what Trump’s was. There are multiple reasons for that. But a strong one is that our carceral state hasn’t changed. The United States has 4% of the world’s people but we have about 25% of the world’s incarcerated people. At times, we’ve had about 25% of COVID cases and 25% of COVID deaths. We have about 35% of monkeypox cases.

The prison itself is such an important vector in spreading disease. It brings people together who are already predetermined to have all kinds of health outcomes and economic instability and puts them all in one place. The prison itself can become a site of transmission — it happens with HIV but also with hepatitis, tuberculosis, and most recently, of course, COVID-19, because COVID is so casually transmitted. It moves freely in these spaces. And with jails more than prisons, people are coming in and they’re leaving, and they’re coming in and they’re leaving. So the jails themselves are these transmission points.

But they also create what I call secondary engines, so that once somebody has been incarcerated, they’re put into all these other vectors that make them likely to have bad health outcomes. Once you’re incarcerated, you’re much more likely to become homeless, particularly because of the terms of the Welfare Reform Act from the Clinton administration that said that people who’ve had drug arrests — not even convictions, just arrests — cannot live in public housing. That’s one of the reasons Black homelessness increased so much in the 1990s. When people are incarcerated, it becomes almost impossible to get work in the formal economy, certainly work that gives you enough money for health insurance and good health outcomes.

The prisons are creating these secondary engines, particularly among Black people. That’s one of the reasons that AIDS rates for Black Americans are still higher than they ever were for White Americans before there were medications, and even though we’ve had medications for around 25 years.

Speciesism was probably the biggest learning curve for me in writing this book. I don’t remember where I first heard about it. I have many friends who are animal studies scholars. But, of course, like everyone who studies viruses, I’ve been going beyond my comfort level and crash-course learning everything I could about COVID 3 years ago, and crash-course learning about orthopoxviruses and monkeypox this summer.

It’s important to understand the role of nonhuman animals and where they came from but also the relationship that creates their ongoing transmission. HIV is largely believed to have jumped into humans from simian immunodeficiency virus when colonialists in the 1920s were pushing African porters into what’s now the Congo. It was probably when extracting those resources and killing bushmeat that people butchering the animals had the virus come in through cuts in their bodies. This is a common form of transmission that still happens now in slaughterhouses and on factory kill floors when people acting as butchers cut themselves. It’s a major way that viruses jump into human beings.

I wanted to understand this relationship more. Speciesism is a way that human beings imagine ourselves to be at the top of a pyramid. We see ourselves as the best animals, if we even think of ourselves as animals, dominating all others. One of the people I talked to in the book, Alice Wong, says there’s a real case for thinking that viruses are the superior organisms. They’re certainly much more efficient than humans. We should have a respect for them and for other animals.

As climate change pushes more living beings onto a smaller chunk of the globe, we’re going to have potentially many more zoonotic jumps. Monkeypox didn’t come from monkeys but comes from other animals. We need to understand these relationships and not see human beings as having to dominate all other animals with no sense of respect or boundaries. We need to give up space to other creatures so that we don’t go into their territory and create conditions that can lead to viral transmission.

For me, thinking about the interdependence that happens with disabled patients and the way disabled people have a sense of interdependence — not independence but understanding that we have connections to one another and we’re negotiating with one another. Seeing ourselves as interdependent with other species can help us create better conditions through which viruses are not flowing so freely and spilling into human beings in ways that can be so deadly for us.

Topol: It’s a critical point with all the different reservoirs that have been established to exist with COVID as an example, not just white-tailed deer but hamsters and cats and all sorts of mammals, where there’s a reservoir and potential spillover or incubation of new variants that could come back to haunt us.

I am impressed that you didn’t leave us with all these downers about how bad things are, how the structural inequalities are overpowering. But you came up with the idea of a map. This could be a map for worldwide liberation. Maybe you could expand on that.

Thrasher: Viruses have taught me a lot. I’ve been thinking about this since I first started getting into gay activism and AIDS activism. I realized that I’m the beneficiary of all this work that was done by people in the AIDS Coalition to Unleash Power (ACT UP) and people who were organized around AIDS in the 1980s and 1990s. There’s been huge political benefit from that. ACT UP has informed all kinds of social movements, including the Black Lives Matter movement and the Occupy Wall Street movement. Movements don’t always have immediate success. We saw the president get behind canceling some student debt that resulted from activism work that began during Occupy Wall Street 11 years ago.

So I have almost a sense of survivor’s guilt. I try not to embrace that, but knowing that so much of my life as a gay man and the culture that I’m part of is predicated upon the horrors of AIDS in the ’80s and ’90s has given me a bit of survivor’s guilt.

I try to think of the viruses as teachers. They teach us unwittingly, but there are lessons we can learn from them about how to organize our world better at a practical level. What AIDS activists did to respond to AIDS is one of the reasons why billions of people have now been vaccinated for COVID relatively quickly, because the activists upended the process through which vaccines and medications underwent regulatory review and got them into people much quicker, when they could save millions of lives.

In that way, I believe that viruses have taught us a lot. But as we think about climate change, as we think about the migration patterns that are going to be caused by climate change and other political problems we’re facing, I think viruses give us this map of understanding that there is no distinct me and distinct you. There’s always this organic material that potentially can be transmitting between us, and our fates are linked to one another.

There are practical ways to think about it that go beyond nations. With the monkeypox outbreak this summer, a Nigerian doctor saw monkeypox behaving differently and thought there was probably some kind of mutation that made it start to move through sexual activity in Nigeria in 2017. He wrote a paper about it and asked for resources to study it, and the world mostly ignored him. The United States certainly ignored him. Had the United States been supportive of research happening in other parts of the world that doesn’t directly affect us, we might not be dealing with the monkeypox outbreak now.

Viruses are continually telling us that the fates of people on the globe are connected to each other. The risk we always have is not the same, but our fates are connected to one another. As we think about climate change and the changes that are going to happen in the world, there are lots of lessons that we’ve had in the past few years. The most powerful to me is that we’re always going to have a connection to one another, whether we like it or not. And the borders that we imagine to be very strong around gender, race, or nationality are fictions. The viruses can cross between them, and they give us a map for learning how to work with one another in an interconnected way.

Topol: If only we would take the right kind of action to learn about and understand our interconnectedness. To wrap things up, I wonder where you go from here. You’ve written this extraordinary book. It was just published in August. You must be thinking about what’s next besides, of course, your teaching and the lucky students you have in classes at Northwestern. Where will you concentrate your efforts in the next chapter of your career?

Thrasher: Most immediately, I am enjoying teaching and having time to spend with students. I have been working on monkeypox this summer, and many of the lessons I learned from COVID and from writing this book are applicable to monkeypox. I did get to write some contextual things, but also, in a very brass-tacks way, I was figuring out how to get information out to the community and how to help people quickly get vaccinated.

I have a couple of projects that I’m thinking through next. One is about the role of Black police officers in the United States. I started working on this before the pandemic and realizing that policing plays a big role in how viruses transmit. Many of the social injustices that I saw happening because of police seem to be ameliorated when more Black police officers were in actual jobs and also were depicted in fiction.

Hennepin County, where I reported on George Floyd, is around 82% White. There are three people running for sheriff; two are Black and one is South Asian. So I’m working on some things around that.

And then I’m going back to what was the original version of this book in a way, where I was writing about the Michael Johnson case in relation to my family and being a queer person. I’m working on something about when we think relationships are legitimate and illegitimate. But I am doing a lot of talking about my book this year and trying to make sure that COVID isn’t forgotten, and to make sure monkeypox doesn’t get abandoned prematurely here in the States.

Topol: Absolutely. Just because the case numbers are going down, that’s certainly a long way from getting control of monkeypox. And as you’ve aptly pointed out, young people now may think this was an every-100-year pandemic perhaps, and they don’t have to worry about another one for the rest of their lives.

I believe that we know better but, unfortunately, because of climate change and the environment and so many other factors, we’re going to be facing the families of viruses we’ve already seen; the mutations on top of the viruses that have resulted in, as you said, monkeypox; or the recrudescence of polio. This has just been a wake-up call as to infectious diseases. I never knew anything about infectious diseases until I had to become a COVID-ologist to see if I could help.

All the things that you just mentioned sound alluring. Your ability to go deep and explain is a great quality. I hope you’ll have a chance to get into each of those topics you just mentioned. We all will benefit from it.

Thanks so much for the great work you’ve done already. The Viral Underclass is an important contribution that I hope all the medical community benefits from. Thank you so much, Steven.

Thrasher: Thank you. It was my real honor to be here.

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