Book review of “The Viral Underclass: The Human Toll When Inequality and Disease Collide” by Steven W. Thrasher

The prosecutor, for his part, aggressively portrayed Johnson, one of few Black students at the suburban St. Louis university he and some of his accusers attended, as a public health menace. The jury found Johnson guilty under a 1988 state law stating that people with HIV who fail to disclose their status to sexual partners could face felony charges. And the judge ultimately sentenced the young man to 30 years in prison — longer than the state’s average sentence for second-degree murder.

As a journalist for outlets including BuzzFeed, Thrasher delved into Johnson’s case over several years. In “The Viral Underclass,” the story provides the narrative through line for Thrasher’s argument: that the “isms” that define so much of life in America — racism, ableism, capitalism — have not only caused some to suffer disproportionately, and unnecessarily, but have also led society to blame individual “bad actors” for viruses’ devastating toll. In other words, members of the viral underclass are not only most likely to contract diseases such as HIV and covid-19, they are also disproportionately punished for it, a process that largely absolves the country’s classist and racist policies and institutions.

Thrasher borrows the term “viral underclass” from a 2011 statement by Sean Strub, a longtime activist for LGBTQ equality, who coined it as a way of acknowledging the discriminatory effects of legal sanctions and other policies around HIV. Such practices resulted “in the creation of a viral underclass of persons with rights inferior to others, especially in regard to their sexual expression,” Strub wrote.

In broadening the scope of this concept, Thrasher shows that such logic can be self-reinforcing. Instead of fighting for a more affordable and equitable health-care system that would expand access to HIV drugs and dramatically lower the risk of transmission, for instance, we lock up lone men like Johnson who have faced various challenges, including, in his case, dyslexia and economic hardship. In Thrasher’s telling, Johnson serves as a convenient scapegoat for society’s sins.

The stories of a few brave, virus-afflicted people living — and sometimes dying — at the margins of society are central to Thrasher’s book. Those also include Lorena Borjas, a leader in Queens’s transgender immigrant community who helped countless others, most of them transgender people, cope with police harassment, sexual violence, homelessness, HIV infection and other health concerns. Struck by covid early in the pandemic, Borjas resisted medical care from a system that she knew posed distinct humiliations and risks for trans people and Spanish speakers like herself. Ultimately, she grew so ill, she had no choice but to seek medical help. Her story tragically shows how the cruelties and inequities of our society can work to compound individual vulnerability to illness over time — as we concentrate all the diverse forms of prophylaxis, or protection, in the hands of some, leaving others almost entirely bereft.

Thrasher, who holds a journalism professorship at Northwestern University focused on LGBTQ research, notes that the American response to the pandemic has been defined by uneven access to some of the most well-known forms of protection: masks, drugs and vaccines. Yet he points out that other forms are far more diffuse and entrenched — and can be more powerful. Those include quality health care, stable housing, jobs with the flexibility to work from home, literacy and computer savvy. “Prophylaxis is often kept from people in the United States if they are already considered disposable,” he says. “Then, when they become infected by a virus, their diagnosis makes them even more marginalized, if not untouchable.” There are, for example, stunningly higher rates of AIDS in the Black population. Two decades after effective drugs became available, in 2015, there was a higher per capita rate of AIDS among Black people than there ever had been for White people, Thrasher notes. This is a direct consequence not just of unequal access to treatments but also of all the other factors, great and small, that prevent people from needing those treatments in the first place.

Thrasher structures most chapters around a theme — the disastrous implications when White people believe they are immune from disease, for example, or unequal access to protection — accompanied by an anecdote or personal story. At times, the book feels like it’s suspended between memoir and public health tome. Nevertheless, the sometimes sprawling nature of the storytelling, and Thrasher’s liberal acknowledgment and incorporation of many of his friends and colleagues (as well as his past journalism and relationships), ultimately work in the service of one of his main points: that we are all more interconnected and reliant on one another than we always realize.

Yet I still wanted more depth in some places, and shorter detours in others to keep the focus on what is freshest and most revelatory. I could, for instance, have done without a lengthy recounting of the plot of the 2019 South Korean film “Parasite,” which takes up much of his chapter on capitalism.

Ultimately, this book is at its most searing when Thrasher shows, by the numbers and by the people, how various public health crises have compounded in America to create the viral underclass — and then, too often, to blame them for their own suffering. To that end, Thrasher’s recounting of Johnson’s and Borjas’s stories is particularly powerful. So are his examples of how various inequities and public health concerns have so often overlapped during covid — with devastating results. He points, for instance, to a report finding that 80 percent of the people who died of covid in Texas correctional facilities as of November 2020 were in pretrial detention and had not been convicted of the crimes for which they were being held. I craved a bit more original reporting and analysis of this kind.

Michael Johnson was released from prison in 2019 after an appeals court deemed his initial trial unfair. True victories on behalf of the viral underclass are rare, however. And Thrasher hints at how rapidly — how virally, in fact — the underclass can expand, especially as climate change heightens the likelihood of new (or old) viruses finding a home in the human species. We are all more vulnerable and intertwined than we realize, he writes in an eloquent epilogue — with the line between the exposed underclass and those who consider themselves “immune” unsteady as the shifting sand.

The Human Toll When Inequality and Disease Collide