As the fierce heat of early June descends like a heavy mantle upon the plains of South Asia, it brings with it a trial as ancient as the rivers tha
Why are we still not on track to end TB despite decades of scaling up TB services? By Dr Tara Singh Bam
Over the past several decades, TB control programmes have made significant progress in expanding diagnosis and treatment services. Success has traditionally been measured by programme indicators, such as detecting 70% of estimated TB cases and successfully treating 85% of those diagnosed. Achieving these targets has rightly saved millions of lives.
However, a fundamental question remains:
If we have continued to meet these programme targets, why is TB still the deadliest infectious disease in the world?
The answer is that scaling up diagnosis and treatment alone is not enough to end TB. We have become better at treating disease, but not at preventing it, as millions continue developing TB every year.
1. Untapped local leadership and political will
Local leaders, particularly mayors, are critical to accelerating TB elimination. While national governments set policies, local governments drive implementation. By prioritizing TB in local development plans, strengthening prevention (including tobacco control and nutrition), expanding early screening, mobilizing local resources, coordinating across sectors, and ensuring equitable access to TB services, local leaders can significantly accelerate progress towards ending TB.
2. The root causes of TB are not being addressed
Most new TB cases are driven by tobacco smoking, harmful alcohol use, undernutrition, diabetes, and HIV infection. These risk factors are well established through scientific evidence and are recognized by global and national TB control strategies as critical areas for intervention. Collectively, they account for millions of new TB cases each year, making them essential targets for comprehensive TB prevention and control. Globally in 2024, an estimated 0.97 million incident cases of TB were attributable to undernutrition, 0.93 million to diabetes, 0.74 million to alcohol use disorders, 0.70 million to smoking and 0.57 million to HIV infection.
Example: A person with diabetes who smokes has a much higher risk of developing TB. If the health system only treats TB after it develops but does not support smoking cessation or diabetes management that individual remains at high risk of recurrent disease, while many others continue to develop TB for the same reasons.
3. Health systems remain reactive rather than preventive
Most TB programmes begin once someone becomes sick. By then, the individual may have already transmitted TB to family members, co-workers, or the wider community.
Example: A patient who develops a persistent cough may wait several months before seeking care. During that time, they may unknowingly infect several household members. Earlier detection through proactive screening could have prevented additional cases.
4. Screening strategies remain too limited
Many countries continue to rely on passive case finding or targeted screening among selected high-risk populations such as HIV infected, refugees, prisoners. While these approaches are important, they are unlikely to identify all infectious cases.
As countries move towards TB elimination, broader and more systematic mass screening approaches particularly in high-burden communities may be required alongside strengthened contact investigation and preventive treatment.
5. Social and economic barriers continue to fuel TB
TB is closely linked with poverty, overcrowded housing, poor nutrition, and limited access to healthcare. Even when diagnosis and treatment are provided free of charge, patients often face indirect costs such as transportation, lost income, and food insecurity.
Example: A daily wage worker may delay seeking diagnosis because attending a clinic means losing a day's income. This delay increases both disease severity and community transmission.
6. Universal health coverage is still incomplete
Many countries have not fully incorporated TB prevention and care into universal health coverage. Financial constraint remains a major barrier to early diagnosis, treatment completion, and preventive care.
Ending TB requires ensuring that no individual faces financial barriers to accessing diagnosis, treatment, preventive therapy, nutrition support, or management of associated conditions such as smoking, diabetes and HIV.
7. Prevention remains underinvested and fractured
TB programmes continue to devote most resources to diagnosing and treating disease, while comparatively less investment is directed towards preventing new infections and reducing risk factors.
Effective prevention includes tobacco control and cessation services, reducing harmful alcohol use, diabetes prevention and management, HIV prevention and treatment, nutritional support, TB preventive treatment for eligible populations. These interventions not only reduce TB but also improve overall population health.
8. Funding is often viewed too narrowly
Limited funding is frequently cited as the primary constraint to TB control. While additional investment is important, the issue is also how countries mobilize and allocate resources.
Domestic financing opportunities are often underutilized. Health taxes on tobacco, alcohol, and sugar-sweetened beverages can generate substantial revenue while simultaneously reducing major TB risk factors.
Example: Increasing tobacco excise taxes reduces smoking prevalence, a major driver of TB while generating additional government revenue that can be reinvested in TB prevention, primary healthcare, and universal health coverage. This creates a "double dividend" for public health.
9. Progress is not fast enough
Despite improvements in diagnosis and treatment, the decline in global TB incidence remains too slow to achieve the goals of the End TB Strategy. Without stronger prevention efforts, countries will continue treating millions of new cases each year instead of reducing the number of people who develop TB.
Moving from TB control to TB elimination
Ending TB requires a fundamental shift from a treatment-centred model to a prevention-oriented, people-centred, and multisectoral approach. While high-quality diagnosis and treatment remain essential, they must be complemented by coordinated action across sectors that address the underlying drivers of TB.
This means strengthening programme coordination and integrated service delivery between TB programmes and tobacco and alcohol control, diabetes and HIV services, nutrition programmes, universal health coverage, social protection, and initiatives that address housing, poverty, and other social determinants of health.
In simple terms: Treating TB saves lives today. Preventing TB saves lives today and protects future generations.
Ending TB requires more than high-quality diagnosis and treatment. Countries must ensure equitable access to TB prevention, systematic screening, early diagnosis, prompt treatment, and integrated services that address the major risk factors and social determinants driving the epidemic.
The path to TB elimination is clear: Prevent All TB, Find All TB, and Treat All TB. Prevention must become the first line of defence, every person with TB should be identified early, and everyone diagnosed should receive timely, high-quality care and support.
Achieving this goal requires strong political leadership beyond the health sector. Local leaders, particularly mayors, are uniquely positioned to mobilize resources, coordinate multisectoral action, and create healthier communities that prevent TB, improve early detection, and ensure quality care for all.
(Dr Tara Singh Bam is Global Health Editorial Advisor for CNS and Honorary Principal Advisor for Prevent-Find-Treat ALL TB to end TB campaign. He leads Vital Strategies as Asia Pacific Director (Tobacco Control). He is also the Board Director of Asia Pacific Cities Alliance for Health and Development (APCAT) and former Asia Pacific Director of International Union Against TB and Lung Disease - The Union)
However, a fundamental question remains:
If we have continued to meet these programme targets, why is TB still the deadliest infectious disease in the world?
The answer is that scaling up diagnosis and treatment alone is not enough to end TB. We have become better at treating disease, but not at preventing it, as millions continue developing TB every year.
1. Untapped local leadership and political will
Local leaders, particularly mayors, are critical to accelerating TB elimination. While national governments set policies, local governments drive implementation. By prioritizing TB in local development plans, strengthening prevention (including tobacco control and nutrition), expanding early screening, mobilizing local resources, coordinating across sectors, and ensuring equitable access to TB services, local leaders can significantly accelerate progress towards ending TB.
2. The root causes of TB are not being addressed
Most new TB cases are driven by tobacco smoking, harmful alcohol use, undernutrition, diabetes, and HIV infection. These risk factors are well established through scientific evidence and are recognized by global and national TB control strategies as critical areas for intervention. Collectively, they account for millions of new TB cases each year, making them essential targets for comprehensive TB prevention and control. Globally in 2024, an estimated 0.97 million incident cases of TB were attributable to undernutrition, 0.93 million to diabetes, 0.74 million to alcohol use disorders, 0.70 million to smoking and 0.57 million to HIV infection.
Example: A person with diabetes who smokes has a much higher risk of developing TB. If the health system only treats TB after it develops but does not support smoking cessation or diabetes management that individual remains at high risk of recurrent disease, while many others continue to develop TB for the same reasons.
3. Health systems remain reactive rather than preventive
Most TB programmes begin once someone becomes sick. By then, the individual may have already transmitted TB to family members, co-workers, or the wider community.
Example: A patient who develops a persistent cough may wait several months before seeking care. During that time, they may unknowingly infect several household members. Earlier detection through proactive screening could have prevented additional cases.
4. Screening strategies remain too limited
Many countries continue to rely on passive case finding or targeted screening among selected high-risk populations such as HIV infected, refugees, prisoners. While these approaches are important, they are unlikely to identify all infectious cases.
As countries move towards TB elimination, broader and more systematic mass screening approaches particularly in high-burden communities may be required alongside strengthened contact investigation and preventive treatment.
5. Social and economic barriers continue to fuel TB
TB is closely linked with poverty, overcrowded housing, poor nutrition, and limited access to healthcare. Even when diagnosis and treatment are provided free of charge, patients often face indirect costs such as transportation, lost income, and food insecurity.
Example: A daily wage worker may delay seeking diagnosis because attending a clinic means losing a day's income. This delay increases both disease severity and community transmission.
6. Universal health coverage is still incomplete
Many countries have not fully incorporated TB prevention and care into universal health coverage. Financial constraint remains a major barrier to early diagnosis, treatment completion, and preventive care.
Ending TB requires ensuring that no individual faces financial barriers to accessing diagnosis, treatment, preventive therapy, nutrition support, or management of associated conditions such as smoking, diabetes and HIV.
7. Prevention remains underinvested and fractured
TB programmes continue to devote most resources to diagnosing and treating disease, while comparatively less investment is directed towards preventing new infections and reducing risk factors.
Effective prevention includes tobacco control and cessation services, reducing harmful alcohol use, diabetes prevention and management, HIV prevention and treatment, nutritional support, TB preventive treatment for eligible populations. These interventions not only reduce TB but also improve overall population health.
8. Funding is often viewed too narrowly
Limited funding is frequently cited as the primary constraint to TB control. While additional investment is important, the issue is also how countries mobilize and allocate resources.
Domestic financing opportunities are often underutilized. Health taxes on tobacco, alcohol, and sugar-sweetened beverages can generate substantial revenue while simultaneously reducing major TB risk factors.
Example: Increasing tobacco excise taxes reduces smoking prevalence, a major driver of TB while generating additional government revenue that can be reinvested in TB prevention, primary healthcare, and universal health coverage. This creates a "double dividend" for public health.
9. Progress is not fast enough
Despite improvements in diagnosis and treatment, the decline in global TB incidence remains too slow to achieve the goals of the End TB Strategy. Without stronger prevention efforts, countries will continue treating millions of new cases each year instead of reducing the number of people who develop TB.
Moving from TB control to TB elimination
Ending TB requires a fundamental shift from a treatment-centred model to a prevention-oriented, people-centred, and multisectoral approach. While high-quality diagnosis and treatment remain essential, they must be complemented by coordinated action across sectors that address the underlying drivers of TB.
This means strengthening programme coordination and integrated service delivery between TB programmes and tobacco and alcohol control, diabetes and HIV services, nutrition programmes, universal health coverage, social protection, and initiatives that address housing, poverty, and other social determinants of health.
In simple terms: Treating TB saves lives today. Preventing TB saves lives today and protects future generations.
Ending TB requires more than high-quality diagnosis and treatment. Countries must ensure equitable access to TB prevention, systematic screening, early diagnosis, prompt treatment, and integrated services that address the major risk factors and social determinants driving the epidemic.
The path to TB elimination is clear: Prevent All TB, Find All TB, and Treat All TB. Prevention must become the first line of defence, every person with TB should be identified early, and everyone diagnosed should receive timely, high-quality care and support.
Achieving this goal requires strong political leadership beyond the health sector. Local leaders, particularly mayors, are uniquely positioned to mobilize resources, coordinate multisectoral action, and create healthier communities that prevent TB, improve early detection, and ensure quality care for all.
(Dr Tara Singh Bam is Global Health Editorial Advisor for CNS and Honorary Principal Advisor for Prevent-Find-Treat ALL TB to end TB campaign. He leads Vital Strategies as Asia Pacific Director (Tobacco Control). He is also the Board Director of Asia Pacific Cities Alliance for Health and Development (APCAT) and former Asia Pacific Director of International Union Against TB and Lung Disease - The Union)
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On demand of our readers, I have decided to release E-Book version of "Trial of Pakistani Christian Nation" on website of PCP which can also be viewed on website of Pakistan Christian Congress www.pakistanchristiancongress.org . You can read chapter wise by clicking tab on left handside of PDF format of E-Book.