The wins are there but the underlying reality remains, writes Professor Kogie Naidoo as she likens TB to a bridesmaid awaiting its turn to garner attention. The analogy is relevant given the overwhelming number of new TB infections and deaths each year globally for a disease persistently sitting in the shadow of other communicable and non-communicable diseases.
Mycobacterium tuberculosis was first identified as the causative agent of tuberculosis (TB) over one hundred and forty years ago and has for decades been preventable and curable. Despite this, TB is currently the world’s leading cause of death from a single infectious agent.
In 2021, within just months, COVID-19 accrued over US$10 billion for research and over US$100 billion for vaccine development. Whereas TB, which killed more than 4 000 people daily, received only about $1 billion annually for research. This includes less than $200 million for TB vaccine development. TB remains a significant anomaly. Relevant yet marginalised, TB is the ever-patient bridesmaid awaiting its turn.
Let me be clear, this is not to pit one against the other, but TB has grown weary of the runner-up title.
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A leading killer
“Globally, the absolute number of people falling ill with TB decreased in 2024 for the first time since 2020 following 3 consecutive years of increases,” according to the World Health Organization’s (WHO) Global Tuberculosis Report 2025. The number of deaths caused by TB also fell in 2024.
However, tuberculosis has consistently remained the leading cause of death in South Africa. Science has also shown the consequences of the weighty HIV-TB co-infection burden, particularly in our country. This is despite the irrefutable gains from a country boasting the world’s largest HIV treatment programme and TB policies such as Targeted Universal Testing. Still, among people living with HIV, TB is responsible for a staggering 70% of all deaths. Given the size of South Africa’s population at approximately 63 million people, its share of TB deaths worldwide is striking and is simply unacceptable. WHO data shows that of the over 1.2 million TB deaths, around 54 000 were reported in South Africa.
Nearly 30 000 people in Cape Town metro were diagnosed with TB in 2024. That is more than the total number of TB cases reported across the entire US, UK, France, and Canada combined. @tbproof.bsky.social
TB incidence in South Africa remains stubbornly high and the burden is also unevenly distributed, with some geographic areas affected more than others. The official unemployment rate is sitting on 31.9%, according to the latest data issued by Statistics South Africa. This triggers a harsh socio-economic ripple effect that relentlessly feeds the TB epidemic, poverty, food insecurity, homelessness and social ills among others.
South Africa’s overburdened public healthcare system is fatigued, but TB is not just a medical issue, it is a symptom of a society that is malfunctioning. Thus, social relief must be part of the conversation to help drive meaningful change toward eradicating TB. The WHO’s End TB Strategy directly emphasises this, calling for “bold policies and supportive systems, requiring government stewardship and community engagement.” Added to this, the WHO’s new TB guidelines, for the first time, highlights the issue of TB and nutrition. Among others, now recommending “provision of food assistance to prevent TB in household contacts of people with TB in food insecure settings”.
The missing TB cases
A sore point for TB researchers remains the nameless, undiagnosed TB cases. We simply do not have sufficient and definitive answers on why those at the highest risk are falling through the cracks, remaining unidentified and therefore undiagnosed.
Almost half of all estimated TB cases in South Africa have an unknown outcome. This happens for two main reasons. First, many people who become ill with TB do not get tested. Second, some who do get tested do not return to their healthcare facility to receive their results, meaning that, if they test positive, they are not started on treatment immediately.
To be fair, accountability is a two-way street between patients and the healthcare system. In South Africa, the results from sputum and GeneXpert tests vary from 24-hours to 3-days. In both instances, a patient must return to the same clinic or hospital to receive their results. If they do return and test positive for TB, they are initiated on treatment immediately. When people are not diagnosed or do not return for treatment, it simply fuels ongoing TB transmission. And so the cycle continues. Regular, decentralised, community-wide point of care testing and treatment for TB, irrespective of the presence of TB symptoms, may help plug some of these gaps. But these strategies are costly, resource intensive, and require technologies that we currently do not have access to.
What to do
This post COVID-19 pandemic world is under immense pressure from sustained and unpredictable geo-political conflict, competing research funding priorities driven by the United States’ funding cuts, and continued attacks on science.
In the face of this, TB researchers, clinicians, programme implementers, and funders must urgently double down on key priorities to end TB. We must be buoyed by the many hard-fought gains, including more efficient diagnostics, the development and roll out of novel drugs, shorter treatment regimens, and the promise of TB vaccines designed to improve patient outcomes.
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This would mean sustaining the momentum of our gains toward effectively combating TB associated morbidity and mortality and toward reducing TB incidence.
The wins are there but the reality remains. And that is, that each time we make gains in the goal of eradicating TB, the finish line shifts. This World TB Day, we must solidify these gains with renewed vigor. Investment in science, innovation, and in evidence-based programme implementation to better diagnose, treat and prevent TB, is non-negotiable. COVID-19 redefined what rapid and collaborative scientific action can achieve. TB reminds us what happens when that urgency is absent. Thus, always the bridesmaid, never the bride.
*Professor Naidoo is Deputy Director at the Centre for the Aids Programme of Research in South Africa (CAPRISA), Director of the CAPRISA-SAMRC HIV-TB Pathogenesis and Treatment Research Unit, and a Member of the WHO HIV Clinical Guidelines Development Committee.
Note: Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.
