Decades of Progress, Undone: The Structural Failures Behind America's Tuberculosis Resurgence

For most Americans, tuberculosis belongs to a different era — the sanitariums of the early twentieth century, the grainy black-and-white photographs of crowded tenements, the cough that defined a generation's suffering. That perception has made the disease's quiet return all the more dangerous. Between 2020 and 2023, TB case counts in the United States rose for the first time in decades, and preliminary surveillance data suggest the trend has not reversed. Public health officials are sounding alarms that few in the general public are prepared to hear.

"We spent years celebrating the decline," said one senior epidemiologist at a state health department in the Southeast, who requested anonymity to speak candidly about institutional pressures. "The moment we started treating TB as a solved problem was the moment we began losing the infrastructure to fight it."

A Surveillance System Built for Yesterday's Epidemic

The United States relies on a patchwork of state and local health departments to identify, report, and respond to tuberculosis cases. That architecture made reasonable sense in an era when case counts were falling predictably year over year. Today, however, epidemiologists describe a system that is chronically underfunded, inconsistently staffed, and structurally ill-suited to detect transmission in the communities where TB is now spreading most aggressively.

According to data from the Centers for Disease Control and Prevention, TB disproportionately affects people experiencing homelessness, those living in congregate settings such as correctional facilities and long-term care homes, and individuals born outside the United States. Yet surveillance resources have not kept pace with the demographic and geographic reality of the current epidemic. Contact investigation — the painstaking process of identifying and testing everyone who may have been exposed to an infectious case — requires trained personnel, dedicated funding, and time. All three are in short supply.

"There are jurisdictions in this country where a single public health nurse is responsible for managing every active TB case in the county," noted Dr. Renata Osei, an infectious disease physician and TB researcher at a university-affiliated public health institute. "That is not a surveillance system. That is a person doing the best they can with nothing."

The Policy Vacuum That Followed the Decline

The erosion of TB infrastructure did not happen overnight, nor did it happen by accident. It was, in many respects, the predictable consequence of political and budgetary decisions made during the long years of declining case counts. Federal appropriations for TB control programs remained essentially flat for more than a decade, even as inflation steadily eroded their real-world purchasing power. Several states consolidated or eliminated dedicated TB programs entirely, folding their functions into broader communicable disease units that lacked specialized expertise.

The consequences of those choices are now visible in the data. States that maintained robust TB programs — including California, New York, and Texas, which together account for a substantial share of all domestic cases — have generally fared better in identifying and containing transmission. States that allowed their programs to atrophy are now scrambling to rebuild capacity they should never have dismantled.

Public health advocates have also pointed to the COVID-19 pandemic as an accelerant. Between 2020 and 2022, TB surveillance was significantly disrupted as health department staff were redeployed to pandemic response, routine screening was suspended, and patients with symptoms were less likely to seek care. The result was a cohort of undiagnosed cases that seeded new chains of transmission — the effects of which are still being tallied.

Who Is Being Left Behind

The human cost of these failures is not distributed equally. Interviews conducted for this article — with patients, community health workers, and clinicians working in federally qualified health centers across five states — reveal a consistent pattern: the people most likely to contract TB are also the least likely to be reached by the systems designed to find and treat them.

Marcos Delgado, a 47-year-old construction worker in Houston who was diagnosed with active TB in 2022, spent nearly four months experiencing symptoms before receiving a correct diagnosis. He had visited two urgent care clinics and one emergency department during that period. "Nobody asked me about TB," he said. "They gave me antibiotics for a chest infection and sent me home."

Delgado's experience is not unusual. Clinician awareness of TB outside of high-volume urban centers has declined alongside case counts, creating diagnostic delays that allow infectious individuals to remain undetected in their communities. For a disease that spreads through the air, those delays have consequences that extend far beyond the individual patient.

What Reversal Would Actually Require

Epidemiologists and policy experts consulted for this report were largely aligned on the structural changes necessary to arrest the resurgence. Their recommendations converge on several themes: sustained and dedicated federal funding for TB control that is insulated from the political cycles that have historically produced boom-and-bust patterns of investment; mandatory training requirements for clinicians in high-prevalence areas; modernized laboratory infrastructure capable of delivering faster and more comprehensive diagnostic results; and a genuine commitment to addressing the social determinants — housing instability, incarceration, poverty — that create the conditions in which TB thrives.

None of these interventions is beyond reach. The United States has the scientific knowledge, the clinical tools, and the institutional capacity to end TB domestically within a generation. What has been lacking, experts argue, is the political will to treat a disease affecting marginalized populations as a genuine national priority.

"TB is not a mystery," said Dr. Osei. "We know how to find it, how to treat it, and how to prevent it from spreading. The question is whether we are willing to invest in doing those things consistently, for every community, not just the ones with political visibility."

The answer to that question will determine whether the current resurgence is a temporary setback or the beginning of a longer and more damaging reversal of progress that took decades to achieve.