India’s Long War on a Very Old Killer

Tuberculosis will not vanish by decree, but India’s unfinished battle against it is reshaping public health.

Tuberculosis is as old as civilisation and as stubborn as poverty. The disease scarred Egyptian mummies long before it stalked the slums of modern megacities. Two millennia later, it remains one of humanity’s deadliest infections, killing about 1.25 million people a year and sickening more than 10 million worldwide. In India, which shoulders more than a quarter of the global burden, tuberculosis is a test of governance and the promise of development itself.

TB spreads invisibly, riding droplets released when an infected person coughs, sneezes, or even speaks. Around one in four people globally carry the bacteria in latent form. Most never fall ill. But when immunity falters because of malnutrition, diabetes, HIV, stress or age, the disease can erupt. Untreated, TB kills more than half its victims. Worse, the bacterium is learning to outwit medicine. Multidrug-resistant TB, which defies the two most commonly used first-line drugs, and extensively drug-resistant TB, which resists even more powerful treatments, are spreading. In 2023 some 400,000 people developed multidrug-resistant TB worldwide, with India contributing a large share.

The disease is also more protean than commonly assumed. TB is often imagined as a lung infection marked by coughing blood. Yet it can lodge almost anywhere: lymph nodes, bones and joints, kidneys, the spine, even the brain. This extrapulmonary TB is harder to detect because its symptoms mimic other illnesses. In India roughly one in five TB patients has this form, with higher proportions among children and people living with HIV. Studies suggest women are disproportionately affected.

Demography complicates matters further. TB prevalence rises steeply with age, and adult men suffer pulmonary TB at roughly three times the rate of women. Yet among young people aged 15 to 24, infection rates between males and females are strikingly similar. The pattern hints at delayed diagnosis, stigma and unequal access to care.

Against this backdrop India set itself an audacious goal. In 2018 it declared that TB would be eliminated by 2025—five years ahead of the United Nations’ Sustainable Development Goal and a decade before the World Health Organisation’s own target of 2035. The deadline was knowingly unrealistic. Its purpose was to shock a complacent system into action, mobilise political will, and turn TB from a neglected affliction into a national priority.

Improved Diagnostics

The response has been substantial. India’s National Strategic Plan for TB Elimination fused new science with digital governance and social support. Diagnosis, once a weak link, has improved dramatically. For decades the backbone of testing was sputum microscopy, a blunt tool that missed up to half of all cases. Today rapid molecular diagnostics such as GeneXpert and Truenat, combined with AI-assisted chest X-rays, can confirm infection and detect drug resistance within hours. From only a handful of machines a decade ago, India now operates more than 6,000. In 2023 alone, 25.1 million people were tested. A 100-day national campaign identified more than 700,000 new patients, many of whom would previously have remained invisible.

Treatment has been transformed too. Traditional therapy required six months of daily pills, while drug-resistant TB demanded up to two years of toxic injections with dismal success rates. Newer drugs such as bedaquiline and delamanid are safer and more effective. Regimens like BPaLM - a four-drug combination - can cure many drug-resistant cases in six to nine months, with success rates approaching 90 percent in controlled settings. Such advances do not merely shorten suffering; they reduce the chance that patients abandon treatment and seed further resistance.

Prevention, however, remains the hardest frontier. The century-old BCG vaccine protects children from severe disease but offers little defence for adults, who account for most transmission. India is investing heavily in new TB vaccines and adult immunisation strategies, with several candidates moving through clinical trials. Yet the most powerful preventive tool is also the simplest: food. Undernutrition accounts for nearly half of India’s TB cases, weakening immune systems and trapping households in a vicious cycle of illness and poverty. Recognising this, the government’s Nikshay Poshan Yojana provides Rs. 1,000 per month in nutritional support to TB patients. By late 2024 it had reached more than 11 million people, underscoring that calories can be as important as capsules.

Digital infrastructure has stitched these efforts together. The Nikshay portal tracks millions of patients in real time, flagging missed doses and treatment gaps. A parallel initiative, the Pradhan Mantri TB Mukt Bharat Abhiyan, enlists volunteers known as Ni-kshay Mitras to ‘adopt’ patients, offering food, financial help, or simply companionship. Such community engagement matters because more than half of TB patients first seek care from private doctors. Their participation has grown steadily: over 600,000 now notify cases through Nikshay, ensuring patients are linked to free diagnostics, medicines and nutrition support rather than falling through the cracks of an unregulated market.

Since 2015 India’s TB incidence has fallen by about 18 percent, and deaths by roughly 24 to 25 percent. In 2023 the country reported a record 2.5 million notified cases. Cure rates for drug-resistant TB have climbed to around 70 percent, a remarkable improvement on a decade ago. Researchers have sequenced 10,000 TB bacterial genomes, laying the groundwork for sharper diagnostics and more personalised treatment.

Incremental Improvements

Yet progress is patchy. A handful of states account for a disproportionate share of cases. Uttar Pradesh alone reported about 0.56 million in 2024, more than one-fifth of the national total, while Maharashtra added nearly 0.19 million. Targeting molecular testing hubs, drug-resistance work-ups, and nutrition transfers in such hotspots yields faster gains per rupee spent, particularly in high-burden districts where delays are deadliest.

Even so, the arithmetic is sobering. The World Health Organisation estimates India’s TB incidence in 2023 at 195 cases per 100,000 people. Elimination is defined as fewer than one case per 100,000 - a reduction of roughly 99 percent. To reach that threshold would require annual declines of nearly 10 percent. India’s current pace is closer to 3 percent.

But that failure need not be fatal to the mission. The systems India has built will continue to save lives well beyond 2025. Wider access to modern tests in rural areas, better funding stability, and sustained engagement with vulnerable groups could accelerate progress. A breakthrough adult vaccine would change the trajectory altogether.

TB strikes hardest between the ages of 15 and 45, cutting down people in their most productive years and threatening India’s much-vaunted demographic dividend. Delays in diagnosis are often driven by fear and stigma rather than ignorance. A young construction worker in Delhi waited weeks to seek help, worried about lost wages and social judgement. By the time he arrived at a clinic, his disease was advanced, his treatment longer, and his family’s income already damaged. Every untreated case ripples outward, impoverishing households and communities alike. Testing and treatment are free; delay is the most expensive option of all.

Economically, the case for persistence is overwhelming. Every Rs. 100 invested in TB care yields several times that amount in avoided illness, preserved incomes and higher productivity. Socially, the disease exposes fault lines of nutrition, housing and inequality. Politically, it tests whether sustained attention can outlast headline-driven campaigns.

India has beaten daunting diseases before. Few believed polio could be eliminated in a country of its size and diversity. Yet through door-to-door vaccination, relentless monitoring, and international cooperation, it was done. TB is more complex, slower, and more deeply entwined with poverty. But the lesson endures: determined states, mobilised communities, and patient investment can bend even ancient curves.

With more than a quarter of the world’s TB burden, India is a laboratory for the global fight. Success here would reverberate across Africa and Asia; failure would slow progress everywhere. The 2025 deadline may slip into history, but the long war against tuberculosis will shape India’s health, economy and moral standing for decades to come.

(The author is a scientist with the Department of Biotechnology, Government of India. Views personal.)