[Editorial] Tuberculosis at a crossroads

Tuberculosis at a crossroads Article Info Publication History: Published April 2026 DOI: 10.1016/S2214-109X(26)00071-9 External LinkAlso available on ScienceDirect External Link Copyright: © 2026 Published by Elsevier Ltd. Linked Articles - Estimating the epidemiological and economic impact of providing nutritional care for tuberculosis-affected households across India: a modelling studyThe Lancet Global HealthJanuary 14, 2025 - Effects of reductions in US foreign assistance on HIV, tuberculosis, family planning, and maternal and child health: a modelling studyThe Lancet Global HealthOctober, 2025 - The tuberculogenic environmentThe Lancet Global HealthMarch, 2026 - Nutritional supplementation to prevent tuberculosis incidence in household contacts of patients with pulmonary tuberculosis in India (RATIONS): a field-based, open-label, cluster-randomised, controlled trialThe LancetAugust 8, 2023 Download started OkThis World Tuberculosis Day, as ever, the world has everything it needs to end tuberculosis in our lifetimes. Yet in 2024, 1·23 million people died of tuberculosis, indicating that tuberculosis persists as the world's deadliest infectious disease. 10·7 million people developed active tuberculosis disease, up from 10·3 million in 2020. With recent cuts in development assistance, there is a serious risk of backsliding on a solvable issue, with one estimate attributing a potential 606 900 additional tuberculosis deaths between 2025 and 2030 across 55 countries directly to the cuts. In 2024, USAID bilateral funds accounted for over 20% of all funding for tuberculosis programmes; more broadly, the US accounted for 50% of all international donor tuberculosis funding from 2015–24. In the short time since the cuts, 16 countries have reported a severe impact on their national tuberculosis programme technical support, nine on the procurement of diagnostics, and seven on the of procurement on anti-tuberculosis drugs. Yet tuberculosis cannot be ended by medical treatment alone, nor reliance on Ministries of Health or National Tuberculosis Programmes. Most tuberculosis burden falls amongst people who do not have the means to avoid risk factors such as overcrowding, undernutrition, or other conditions of poverty. Tuberculosis particularly affects people with pre-existing conditions such as diabetes, weakened immune systems, tobacco and alcohol use, and underweight. And occupational exposure to indoor and outdoor air pollution further increase susceptibility. As Mikaela Coleman and colleagues suggested last month, these wide-ranging factors constitute a so-called tuberculogenic environment, in which structural conditions increase the risk of exposure, disease progression, and death, and create vulnerability at both the individual and community level. They argue that ending tuberculosis requires a complex systems approach involving many non-health actors in fields such as employment, agriculture, finance, and education, because necessary interventions are extremely heterogenous, from promoting local regenerative farming to properly ventilating work environments and reprioritising budgets in low-resource settings. On budgets, one analysis estimated that every US$1 spent on fighting tuberculosis could yield $46 in economic benefit. Tuberculosis often affects healthy, working-age people who are removed from the labour pool, and the loss of income combined with high out-of-pocket treatment costs can be catastrophic for families. Basic interventions do not have to be expensive. The RATIONS trial, published in The Lancet in 2023, noted that a simple nutritional intervention could prevent 39–48% of all tuberculosis cases in a household during 2 years of follow-up. Modelling suggests that such an intervention is very likely to be cost-effective in a high-burden country such as India. Monitoring indicators like nutritional statistics offer a simple low-cost way tuberculosis programmes can begin to map a path towards tuberculosis elimination. Poverty status, BMI, HIV status, diabetes, and access to food are all health indicators that point strongly towards an individual's risk of developing active tuberculosis, but which are not regularly incorporated into tuberculosis assessments on an individual or country level. Monitoring them will show policy makers which interventions will prove most cost-effective when seeking to alleviate the tuberculosis burden. Gains are being made. Between 2015 and 2024, Africa reduced active tuberculosis cases by 28%, with a 46% reduction in deaths. In fact, over this period 65 countries reduced tuberculosis deaths by at least 35%. In 2024, 5·3 million people at high risk of tuberculosis received preventative treatment, compared to 4·7 million in 2023. It's important to celebrate this progress, but to recognise that the elimination of tuberculosis by 2030 in the current financial climate will require greater efforts to coordinate a multitude of stakeholders across sectors. Like maternal mortality, a high tuberculosis burden is a bellwether for system failure. Aligning cross-sectoral policies using frameworks such as complex systems thinking could be the key to unlocking action.