International epidemiologists at the World Health Organization closely monitor the list of the world’s deadliest infections. Right now, to no surprise, COVID-19 sits on top of that list.  

There was no party to celebrate this dubious achievement, of course, no raucous fans taking to the streets chanting “we’re #1!” Similarly, there were no mournful fans of the #2 disease, tuberculosis (which had been #1 for six straight years), sitting in the bleachers with tears slowly running down their cheeks. And new estimates suggest that maybe the standings could even be reversed. 

The college basketball metaphor doesn’t fit in this case; the only appropriate aspect is the mournful people in the bleachers, left out of the action. Because, with TB, we’re talking about a disease that has killed an uncountable number of people since it first appeared on the planet several thousand years ago. 

In the US, we don’t hear much about TB because, of the 1.4 million people who died of TB in 2019, only 611 lived here. When the COVID-19 pandemic arrived, many of us didn’t know what to do because a virulent infection hadn’t plagued us in generations. But elsewhere, in many low- and middle-income countries, the suffering from TB is more readily found. The contagious respiratory infection is the most common cause of death in South Africa. In India, there are more than 2.6 million cases every year and there is a national system online that tracks TB diagnosis and treatment. 

When the COVID-19 pandemic hit India, the government instituted a nationwide lockdown. After several months, its TB tracking system revealed that TB diagnoses and treatment had plummeted. The Indian Ministry of Health responded with an intensified outreach effort to locate people with TB who were not getting diagnosed and treated. They were mostly successful; by December 2020 TB treatment and enrollment were off by only 12%. 

Other countries fared much worse. Researchers estimated that the first 12 months of the COVID-19 pandemic set back global efforts to eliminate TB by at least 12 years. While the world now has a handful of effective COVID-19 vaccines and a number of promising potential treatments, there is not even one single TB vaccine with similar effectiveness. Most of the TB drugs are decades old and drug resistance is spreading in many parts of the world.  

There are glimmers of hope. A new drug, part of a new treatment for highly drug-resistant strains of TB, was approved in 2019 and has either been approved for use or operational research in the countries with the biggest caseloads of resistant TB. New data shows that patients treated with this new regimen remain TB-free for at least two years afterward. And India’s efforts show that we can achieve success in TB control, as long as efforts are backed by political will. 

For many people in the U.S., there is a desire to return to “normal,” to return to college basketball games and its annual “March Madness.” But in the more impoverished parts of the world, returning to normal includes the perils of TB. If we can figure out the game plan for beating the COVID-19 pandemic in just over a year, it is past time to flex our scientific muscles and vanquish TB.