More than 1 million people die of tuberculosis every year. They don't have to.

Vox

19-03-2025

covers health for Vox, guiding readers through the emerging opportunities and challenges in improving our health. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo, and STAT before joining Vox in 2017.
Tuberculosis is no longer the threat it once was in the US and Europe, but the disease is still killing more than 1 million people worldwide every year. Gamma-Rapho via Getty Images
Humanity's battle against tuberculosis has been one of slow and imperfect progress. The disease no longer kills one in seven people in the US, as it did in the 19th century. But look elsewhere and its burden is still terrible: TB killed more than 1.2 million people in 2023, likely making it once again the deadliest infection on Earth, after it was briefly supplanted by Covid-19 during the pandemic.
And as John Green, the YA author, YouTuber, and author of the new book Everything Is Tuberculosis: The History and Persistence of Our Deadliest Infection, told me in an interview: 'That number is about to go up.'
As part of its evisceration of US international aid, the Trump administration is ending funding for its global TB programs. The US is the world's largest single funder of tuberculosis treatment, and the spending cuts quickly interrupted medical care for TB victims. And any delay in treatment can lead to worse outcomes for patients and makes it more likely the bacteria will evolve to resist antibiotics.
'All of this is a direct result of the decisions made by the US government,' Green told me. 'Allowing tuberculosis to spread unchecked throughout the world is bad news for all humans.'
There may be as many as 10 million additional TB cases by 2030 because of the cuts, depending on how deep they ultimately are, according to one initial estimate. An additional 2.2 million people could die in that worst-case scenario.
It's difficult to know what's happening on the ground, as ongoing lawsuits try force aid funding to resume and the Trump administration itself has given conflicting information at times. One TB program director told The Guardian last week their funding had still not resumed despite receiving a reassurance from the administration that it would.
The funding freeze is not only a threat to people in the developing world who live with tuberculosis as an ever-present threat, Green told me — it also poses a risk to the US itself. Right now, Kansas has 68 active TB cases, one of the largest US outbreaks in recent history. One estimate from the Center for Global Development finds that US TB cases will rise in parallel with cases in the rest of the world. That won't just increase health care costs — it will increase the risk that TB will become more drug-resistant and therefore deadlier to people around the world, including in the US.
I spoke with Green about the history of one of humanity's oldest infectious diseases, the threat posed by the Trump administration's cuts, and what concerned people can do in response.
Our conversation is below, edited for clarity and length.
What is the state of tuberculosis right now? Why do people in the US and other wealthy countries often think of it as a disease of the past, a problem that has been solved?
I used to think of it as a disease of the past as well. I thought of TB primarily as the disease that killed John Keats, and then we figured out a solution to it, so now it's not a threat anymore.
But in fact, tuberculosis is still the world's deadliest infectious disease. It kills over 1.2 million people per year. That number is about to go up. It sickens about 10 million people per year. Around a quarter of all living humans have experienced a TB infection.
Now, the vast majority of those people will never become sick. They'll have what we call latent TB, where these clumps of white blood cells form what are called tubercles to surround the bacteria and keep it in check. But in about 10 percent of people who experience a TB infection, they will become sick.
We understand some of the risk factors for developing active TB disease. They include malnutrition, other health problems like diabetes, or HIV infection. But we don't fully understand why some people develop active TB and others don't.
You call the disease 'weird' in your book. What is weird about TB?
The weirdest thing about TB is the cell wall that the bacteria builds. It builds this really thick, fatty cell wall.
That takes a long time to build, so TB has an extremely slow growth rate compared to other bacteria; in some cases, hundreds of times slower. That means that it sickens us slower because it takes a long time to overwhelm the body's defenses.
This is one of the reasons why tuberculosis used to be a narratively convenient disease, a disease that was the subject of so many books. It was a narratively compelling disease because it tends to take a life slowly over the course of months or years, rather than all at once like a disease like cholera or the black plague.
Classically, we understood death as something that occurred very early on in life because about half of people died before the age of 5, or something that occurred late in adulthood, in your 50s or after. Tuberculosis killed so many people in their 20s and 30s that it was called the robber of youth. But it also killed people early in childhood and late in adulthood. It killed indiscriminately.
To some extent, it still does. I mean, 218,000 kids are going to die of tuberculosis this year.
What's so frustrating to me is that all of those deaths are unnecessary because we've had a cure since the 1950s.
This disease has been with us forever. It was even glamorized to an extent in earlier generations. But then there was a transition when it became more stigmatized — it became associated with being dirty and poor. How did that happen?
Until 1882, at least in Northern Europe and the United States, it was generally believed that tuberculosis was an inherited genetic condition. But in 1882, the German doctor Robert Koch proved that tuberculosis was in fact caused by bacteria. The moment it became an infectious disease is really the moment that our imagining of the disease changed radically.
Instead of being a disease of wealth and civilization, it became a disease of poverty. The implications of this were huge because it meant that we could control tuberculosis by trying to control the bacteria that caused TB. But it also meant that we wanted much more control over the lives of people living with tuberculosis.
We started to understand them very differently. We started to see people with tuberculosis as a threat to the social order.
At the same time, by the middle of the 20th century, we developed vaccines and cures. How did our perception of TB continued to change — and how did race increasingly factor into it?
TB had long been understood by Europeans as a racialized disease. It was widely believed in Europe and in the US among white doctors that only white people could get consumption because it was a disease of civilization. To acknowledge that consumption was common among people of color and colonized people would have been to undermine the entire project of colonialism itself.
After we understood the disease as infectious, it became racialized in a different way, where it came to be argued that people of color were uncommonly susceptible to tuberculosis. Instead of believing that it was impossible for them to get tuberculosis, people started to argue that their susceptibility to tuberculosis was owing to some factor inherent to race.
Now, we knew this was hogwash from the beginning. There were lots of doctors, including African American doctors and researchers, pushing back against this notion. They argued, correctly, that the actual cause of tuberculosis was crowded living and working conditions, poor pay, malnutrition — all the stuff that today we know does cause tuberculosis.
But the racialization of the disease was so profound that it's still shaping who lives and dies of tuberculosis.
Today, how does tuberculosis look in the United States versus a place like Sierra Leone, which you cover extensively in your book?
Starting in the 1940s, we began to develop treatments for tuberculosis that were very powerful. We created combinations of multiple antibiotics that, given over the course of several months or even years, could cure tuberculosis. This disease that had always been one of the leading human killers suddenly became curable.
Unfortunately, we did a really poor job of distributing this cure to the places where it was most needed. As a result, we've seen the development of extensive drug resistance for tuberculosis, and we've seen a huge amount of ongoing suffering from the disease. The Ugandan HIV researcher Dr. Peter Mugyenyi said of HIV drugs in the year 2000: 'Where are the drugs? The drugs are where the disease is not. And where is the disease? The disease is where the drugs are not.' And that's very much the case with tuberculosis as well.
If you or I got tuberculosis tomorrow, even if we had a complex drug-resistant case, we would get access to the best personalized, tailored treatments of antibiotic cocktails we would need in order to cure our TB. But for someone like my friend Henry living in Sierra Leone, when he got really sick in 2019 and 2020, those drugs weren't available to him.
So even though his TB was very curable, his life was at risk — not ultimately because of a lack of technology, but because of failure to get the technology to the places where it's most needed.
In the book you called TB both a form and an expression of injustice. It seems to me that TB is one very striking example of a pattern of injustice that applies across a lot of diseases.
Yeah. I think it's really important to acknowledge that tuberculosis is not the only disease of injustice. Hepatitis is a disease of injustice. Malaria, HIV, cancer are diseases of injustice. When my brother got cancer, one of the first things he said to me was that there was a 94 percent cure rate if you have access to treatment, and about a 5 percent cure rate if you don't.
It's very hard to grapple with the fact that the real cause of a huge percentage of human death is injustice — the failures of human-built systems.
There are many deaths that we simply don't have the technology or the tools to prevent. But there are many, many, many, many deaths that we do have the technologies and tools to prevent. It's important to understand that as a justice problem, as an equity problem, as a failure to appropriately apportion the resources that we as a human species have developed.
It breaks my heart. It's devastating. I'm often asked whether I think people are good. Like, at the end of this book, do I think people are good? And I can't answer that question.
What I can say is I think people are capable of extraordinary generosity and compassion and sacrifice. When people are proximal to suffering, they show an extraordinary capacity for giving. And when people are not proximal to suffering, when people don't let themselves become close to the suffering of others, they can act monstrously.
There has been imperfect progress on global health, but progress nonetheless. But now the US government is pulling back from the global health commitments that have helped make that progress possible. What does this mean for TB specifically?
The United States has long been the most generous donor when it comes to fighting TB, and now essentially all tuberculosis-related funding has been cut. That's catastrophic on a number of levels. To my Republican friends and congressional representatives, I try to compare it to the 2008 financial crisis when the capital markets just froze, and it was very hard to get them to start working again.
In many communities, that's what's happening as a result of this sudden, chaotic, very unpredictable, haphazardly rolled out funding freeze. Hundreds of thousands of people have seen their treatment interrupted, and we know that's a catastrophe, not only for those individuals, many of whom will die, perhaps most of whom tragically will die, but also because it means that they will develop drug resistance.
Even a couple of weeks without getting access to your medication means a skyrocketing chance of drug resistance. Even if they're able to get back on treatment, the relatively inexpensive treatment that worked before may no longer work. That means more cases of extensively drug-resistant tuberculosis circulating in communities.
It's also a threat to the United States. We have 10,000 cases of active tuberculosis in the US every year. We have a tuberculosis outbreak right now in Kansas. Tuberculosis anywhere is a threat to people everywhere and allowing tuberculosis to spread unchecked throughout the world is bad news for all humans. It's bad news for human health.
We've made so much progress in human health during my lifetime. The year I graduated from high school, 12 million children died under the age of 5. Last year, fewer than 5 million did.
It's easy to feel like that progress is inevitable or natural or somehow it was always going to happen. But it wasn't always going to happen. It happened because millions of people worked together to make it happen, because we decided collectively to value children's lives more and to work hard to protect them.
Now what we're seeing is the first regression of my lifetime when it comes to overall human health. We're seeing it in the United States where life expectancy has been going down. We're about to see it globally where tuberculosis cases, by one estimate, will increase by 30 percent over the next couple of years, leading to 13 million people getting sick every year instead of 10 million and leading to hundreds of thousands more people dying.
All of this is a direct result of the decisions made by the US government.
I feel like it's hard for people to understand the feedback loop that's potentially in play here that can put our health at risk because diseases are spreading elsewhere. I think it's also hard for us to take the long view.
I'm curious where you think that failure comes from? And have you seen anything that's sort of effective in overcoming that?
I think we have to bridge the empathy gap. There's always an empathy gap between every person, right? I don't know what it's like to be you. I don't know about your joys and sorrows. And even when I do, I can only kind of situate them in my own experience. I can only relate to it through my own eyes because those are the only eyes I get to see through for the whole time that I'm here.
And so there's always an empathy gap, but that empathy gap grows or shrinks based on how close you allow yourself to be to the suffering and joy of others. And so you know when my uncle gets sick, I'm going to respond to that very differently than if I hear through the grapevine that someone else's uncle is sick. And for me, the empathy gap is also a social justice gap.
The further the rich world feels from someone's life, the less likely the rich world is to intervene. So for me, it's about shrinking that empathy gap everywhere we can so that we understand that the lives of other people, even other people whose lives may feel distant from ours are just as real and just as important as ours, that their joy and grief and longing and loss is as real and profound as ours is.
I try to do that in the book by telling Henry's story because you can talk all day about what a great investment tuberculosis response is, and it is a great long-term financial investment. You can talk all day about how many people are dying of TB every year. All that just boils down to statistics. And the statistics don't decrease the empathy gap, at least for me. And so I wanted to tell a human story at a human scale because I feel like that's what really changes our perspective.
What options are available to people like Vox readers, who want to contribute in some small way to making these problems better?
It sounds meaningless and everybody says it, but it's true. When you reach out to your congressional representatives insofar as you're lucky enough to have some say in your governance, it really matters. What funding we've been able to claw back for USAID is a result of people reaching out to their senators and representatives and those senators and representatives in turn reaching out to Secretary [of State Marco] Rubio and saying, 'This is ridiculous. This can't happen.'
It's really, really important that people in power hear that it is unacceptable for the United States to walk away from its long-term commitments to global health and human health, and that it's unacceptable for the United States to break its promises. They need to hear it's also bad for America. It's bad for farmers who provide food aid. It's bad for overall human health in the United States. We're seeing our own numbers of tuberculosis cases go up every year, and that will accelerate now.