The Quiet Resurgence of Tuberculosis
How unprecedented migration flows are shaping the epidemiology of Tuberculosis and emerging diseases.
A modern outbreak story with ancient roots
Tuberculosis (TB) is often framed as a disease of the past. The term evokes images of early-20th-century public health initiatives or distant developing countries. But that narrative is dangerously misguided. Today, TB remains the world’s deadliest infectious disease. The story of TB in the United States is not only historical; it is unfolding right now, in real time, across communities that rarely imagine themselves at risk.
Unprecedented immigration flows, changing global health landscapes, and biowarfare are now bringing this deadly disease back into the modern public health discussion in the United States.
What Exactly Is Tuberculosis?
Tuberculosis is caused by Mycobacterium tuberculosis, a slow‑growing, uniquely resilient bacterium transmitted through airborne respiratory particles. Once inhaled, it can lie dormant for months or years before causing disease, a biological patience that has made TB one of history’s most enduring pathogens.
TB most commonly attacks the lungs, but it can also infiltrate the brain, kidneys, bones, and virtually any organ system. Symptoms range from fever, chronic cough, and weight loss to night sweats and fatigue. Untreated, it can be fatal, but with proper diagnosis and a multi‑drug antibiotic regimen, it is curable. The challenge is not the lack of treatment; it is the lack of timely diagnosis.
Evidence of tuberculosis in humans dates back to between 8,000 and 10,000 years. The true turning point, however, came in 1882, when Robert Koch, a rural German physician from Clausthal in the Harz Mountains, identified Mycobacterium tuberculosis, transforming TB from a mysterious wasting illness into a scientifically defined infectious disease. His discovery provided the first definitive proof that a specific microbe caused tuberculosis, opening the door to targeted diagnosis, public‑health surveillance, and eventually treatment.
The accuracy of tuberculosis diagnosis advanced rapidly after Koch discovered the bacillus in 1882. That same year, scientists identified its acid‑fast nature, a breakthrough that made the organism visible under the microscope. A decade later, the arrival of X‑rays in 1895 gave clinicians their first real window into the lungs. By the mid‑20th century, the development of purified protein derivative (PPD) added a new tool for detecting immune response to TB exposure.
In the 1940s, by pairing chest X‑rays with the newly developed PPD skin test, the U.S. Public Health Service launched large‑scale studies that finally clarified a crucial distinction in tuberculosis. They showed the difference between latent tuberculosis infection, in which the bacteria are present but remain dormant and cause no symptoms, and active tuberculosis disease, in which the bacteria multiply, produce symptoms, and can be transmitted to others. That distinction, established nearly a century ago, remains the backbone of modern TB control.
Research emanating from the Pasteur Institute in France in the first quarter of the 20th century resulted in the development of the Bacille Calmette-Guerin (BCG) vaccine. By the 1950s, global campaigns in developing countries and later trials spread to European countries. Interestingly, despite widespread global adoption of the BCG vaccine, trials in the United States demonstrated little to no effectiveness (net reduction under 5%). Due to this reason, the American public health authorities determined that, due to the lack of effectiveness of the BCG vaccine and the then low risk among “nonreactors”, there was no justification for widespread indication for its use in the country. The BCG vaccine surpasses the worldwide usage of any other vaccine, with over 4 billion doses applied, second only to the COVID jabs.
Only about 10 to 12 countries worldwide do not routinely administer the BCG vaccine; oddly enough, these countries have the lowest tuberculosis incidence in the world.
Additionally, the development of streptomycin in 1943, followed by combination antibiotic therapy, dramatically reduced TB mortality in high‑income countries and reshaped global expectations about the disease’s curability.
But globally, TB never disappeared. It simply concentrated in regions with poverty, overcrowding, malnutrition, and limited access to healthcare. In 2024 alone, an estimated 10.7 million people fell ill with TB, affecting men, women, and children across every continent. Despite this appalling data, tuberculosis remains the pandemic no one is talking about. It is a slow, relentless crisis that kills more than a million people every year.
Mycobacterium tuberculosis is unlike any other bacterium. Its waxy, lipid‑rich cell wall makes it extraordinarily resilient, allowing it to survive inside macrophages and slip into a dormant state that can last for years. This ability to persist silently, what we now call latent tuberculosis infection, is ancient. TB has been identified in Egyptian mummies over 3,000 years old, with DNA evidence showing the same long‑term latency we recognize today. Even older skeletal lesions, dating back to Neolithic remains more than 7,000 years old, reveal that this pathogen has been hiding inside human bodies since the dawn of settled life. Its gift for latency, immune evasion, and long survival is the reason tuberculosis has endured across millennia.
This biological armor is why TB requires months of combination therapy and why incomplete treatment fuels drug‑resistant strains. TB’s evolutionary strategy is simple: survive long enough to spread. And it has perfected that strategy over thousands of years.
Epidemiology of TB
We’ve established the pathology of TB; what about the epidemiology? Where are people dying from this disease, and how is it being spread?
Here are some key global realities of this disease: TB remains highly infectious, rising antibiotic resistance is making treatment longer, more toxic, and more expensive, while HIV co-infection significantly increases the risk of developing active TB, therefore, allowing many cases to remain undiagnosed and fueling silent transmission.
Only in 2024, tuberculosis claimed an estimated 1.2 million lives worldwide, a staggering toll that continues to unfold almost entirely out of public view.
Here is what the data shows:
The burden fell heaviest on Asia, where 703,445 people died
Africa: 436,775 deaths
South America: 21,034 deaths
Europe: 14,724 deaths
Oceania: 13,667 deaths
North America: 9,155 deaths
These are not abstract figures. Each of the 1.2 million represents a person with a name, a history, a family, responsibilities, ambitions, and a place in the world. Every number marks an empty chair at a table, a silenced voice, a future abruptly cut short.
I didn’t see emergency headlines. I didn’t see the world pause or hold its breath the way it did during the COVID years. No daily briefings or dashboards watched in real time, and no reckoning with the scale of loss. TB continues to kill at pandemic levels, yet it unfolds in silence and remains largely ignored.
In high‑income countries, tuberculosis exposure clusters in a handful of well‑defined high‑risk settings. The greatest vulnerability lies in crowded group environments, such as homeless shelters, correctional facilities, and densely packed low‑income housing, where prolonged indoor air sharing allows TB to spread efficiently. Yet another major driver often receives far less attention: frequent travel to, or extended stays in, regions where TB remains common, including parts of Asia, Africa, and Latin America. In developed countries, this repeated exposure abroad is one of the most significant contributors to new TB infections.
You might be thinking that this isn’t very statistically significant for the United States. Think again. In 2023, the U.S. reported 9,633 TB cases, up from 8,332 in 2022, continuing a multi‑year rise following the pandemic‑related dip in 2020.
For decades, the United States saw a consistent decline in TB cases. But recent CDC data reveal a reversal of that trend. The data indicates that the incidence rate as of 2023 has risen to 2.9 per 100,000. Note that the graph above does not include data from the last two years. Data from 2024 indicates an additional rise in cases.
The CDC defines a large TB outbreak as one containing 10 or more cases. In 2024, they reported large outbreaks in 6 different states.
In early February 2026, a San Francisco Catholic high school abruptly suspended classes after a tuberculosis investigation uncovered three active cases and more than fifty latent infections among students and staff. The San Francisco Department of Public Health responded by launching a large‑scale contact investigation at Archbishop Riordan High School.
Almost simultaneously, two additional active TB cases surfaced at the Camp East Montana immigration detention facility in El Paso, Texas, one of the nation’s largest federal detention centers.
This matters for several reasons. Firstly, TB is resurging after years of decline. Secondly, cases are increasing across multiple states, not isolated to a single region. Lastly, the large-scale population and mobility dynamics of global transmission over the last half-decade have played a central role.
I recently discussed this topic with Dr. Mary Talley Bowden on her podcast.
We discussed factors influencing the unusual rise in tuberculosis incidence and the chilling realities of the downstream effects of public policy. The first and most notable of them is the unprecedented migration flow the United States experienced over the last half-decade. During this period, border authorities reported more than 11 million border encounters involving individuals attempting to cross into the United States unauthorized. Some estimates suggest that the actual number of individuals who crossed in these conditions during this period far exceeds the cited figure, potentially tens of millions of unscreened individuals.
It is a material fact that a large number of the people who attempted to or successfully entered the United States unauthorized throughout the migration crisis of the past 5 years have come overwhelmingly from high-burden TB countries.
About a year ago, Kansas recorded one of the sharpest spikes in tuberculosis cases in recent U.S. history. New CDC data showed the state’s TB rate jumped 148% in a single year, driven largely by what became one of the largest documented outbreaks in the country. I wrote about this when it was first announced, noting the scale of the surge and the early CDC indicators that signaled how quickly the situation was escalating, citing also the alarming reality that 76% of TB cases in 2023 originated from non-US-born persons.
This illustrates a basic “biopolitikal” truth: immigration policy is directly correlated to public health outcomes, determining patterns of screening, surveillance, and vulnerability and directly influencing how diseases like TB circulate in a society.
Immigration Medicine
For over 130 years, the United States has understood this principle. One of the earliest examples of this is the Immigration Act of 1891, which specifically states that any “persons suffering from a loathsome or a dangerous contagious disease” may be denied entry into the United States. This marked the earliest piece of legislation in American history to include health screening standards for immigration. It also established the basis upon which facilities such as Ellis Island, which was established a year following the passage of the Immigration Act. Establishing medical examinations of aliens at ports of entry.
The United States has been screening for tuberculosis at its borders for more than a century. Ellis Island is the most iconic example of a place where physicians watched new arrivals climb the stairs, scanning for the signs of active pulmonary TB, and where a sprawling hospital complex treated thousands who would otherwise have had no access to care. But Ellis Island was not the only front line. Along the U.S.–Mexico border, a similar system emerged with the same intention: to keep active TB from entering the country.
Formal medical inspections at the southern border began in the 1910s, when the U.S. Public Health Service expanded its authority to examine all persons entering the country. The Immigration Act of 1917 codified the “physical and mental examination of all arriving aliens,” including professional requirements for medical officers who examined them. Early screenings were simple and clinical. Inspectors looked for chronic cough, fever, wasting, or other visible signs of infectious disease. Tuberculosis was a central concern, but the technology of the time limited the extent of detection.
That changed in the late 1930s and early 1940s, when chest radiography became a standard tool for identifying pulmonary TB. By this period, major ports of entry, including El Paso and Laredo, Texas, as well as San Ysidro, California, had installed fluoroscopic X‑ray units specifically to evaluate individuals suspected of having tuberculosis. These screenings were targeted rather than universal, but they represented a major leap in border‑based public health. For the first time, the United States could detect TB not only through symptoms but through imaging.
By the late 1940s and 1950s, chest X‑rays had become routine for many categories of entrants, including workers in the Bracero Program and applicants for long‑term visas. Border stations operated permanent radiographic facilities, and the U.S. Public Health Service used them to identify active TB cases, provide treatment when possible, and prevent the spread of infectious disease in crowded labor camps and transit hubs. In many ways, the southern border became a second Ellis Island.
By the 1960s, the system had modernized again. TB screening shifted from on‑site border X‑rays to pre‑arrival medical exams, a model that remains in place today.
This is a reality that goes far beyond the threat of tuberculosis. Immigration medicine has served as a protective barrier to the invisible threat of emerging infectious diseases for years. This is still true today.
The United States has required medical screening of immigrants before arrival since the late nineteenth century, when the Public Health Service first deployed U.S.-appointed physicians overseas to examine migrants before embarkation. Over the early twentieth century, this practice gradually formalized into a global network of designated physicians, which would eventually become the modern Panel Physician Program. The contemporary framework took shape after the 1944 Public Health Service Act and the creation of the CDC in 1946, which later assumed responsibility for issuing the Technical Instructions that govern today’s overseas screening system. Across all these iterations, the core principle has remained constant for more than a century: medical screening should occur before a migrant reaches the U.S. border.
The United States admits roughly one million new legal permanent residents each year, and every applicant must undergo tuberculosis screening as part of the immigration medical exam. About 600,000 are screened inside the country through the civil surgeon network, a system of roughly 5,000 physicians designated by USCIS. The remaining 400,000 applicants complete their exams overseas through the panel physician network, a global system of about 760 CDC‑designated panel physicians operating across five continents.
The U.S. is not alone in this approach. Canada, the United Kingdom, Australia, and New Zealand also require TB screening for many categories of incoming migrants, relying on their own networks of approved physicians and pre‑entry testing programs. Together, these systems form a global lattice of TB surveillance, one of the largest coordinated screening infrastructures in modern public health.
No modern figure shaped the fight against tuberculosis more than Dr. Paul Farmer, co‑founder of Partners In Health. His work in Haiti, Peru, and Rwanda redefined what was possible in TB care, especially for multidrug‑resistant TB, which global health institutions once dismissed as too costly or too complex for poor countries.
Colleagues often recall one striking detail: Farmer (the then leading expert on TB) rarely wore a mask when treating patients with active TB. A way of saying, I am here with you, not above you.
Several books capture the full weight of tuberculosis. Mountains Beyond Mountains by Tracy Kidder discusses the significance of Paul Farmer’s work. The Remedy by Thomas Goetz traces the stories of Robert Koch and Arthur Conan Doyle. Tuberculosis: The Greatest Story Never Told by Frank Ryan explores the scientific breakthroughs and evolution of the pathogen. Others include David Quammen’s Spillover, Farmer’s own Fevers, Feuds, and Diamonds, and John Green’s Everything Is Tuberculosis.
The stories of tuberculosis are far more common than we allow ourselves to imagine. Over lunch the other day with an old friend from Melbourne, I mentioned that I was writing about TB. Without hesitation, he told me that his mother had battled a severe case she acquired at the age of three in England and that his aunt had died from the disease. Two cases were revealed in a casual conversation over a meal. TB is just like that, hidden in plain sight and woven into family histories.
During my years as a panel physician in the world’s busiest TB screening center, I learned to recognize the disease almost before the tests did. When you see patient after patient, day after day, you start to understand the subtle ways tuberculosis reveals itself in the posture, the breathing, the quiet fatigue that doesn’t match the age.
One morning, in the middle of a packed waiting room, a single patient caught my attention. Nothing obvious. Just a look I had come to know too well. I asked him to step aside for further evaluation, guided by instinct more than anything else. That moment changed everything. His results later confirmed what was likely the first extensively drug‑resistant TB (XDR‑TB) case detected in the panel‑physician system.
After years of COVID Operation-driven disruption, delayed diagnoses, missed screenings through massive unauthorized immigration, fractured public‑health capacity, and the massive administrations of COVID vaccines that definitely weakened immune systems, the conditions for TB resurgence are in place.
This is the real perfect storm. TB rises wherever vigilance falls, and the warning signs are already here. The question now is whether we choose to act or allow history’s oldest airborne killer to regain ground.
FIN
Biopolitiks by Dr. Alejandro Diaz
About Me
I am a Pediatric Allergist / Immunologist and Global Health Expert with extensive international experience, most recently named Chief of Pediatric Medicine at The Wellness Company. I have delivered conferences in over 30 countries around the globe on topics of medicine, migration, biosecurity, and related topics. This includes prestigious venues such as the White House, the US Capitol, the Romanian Parliament, the European Parliament in Brussels, the Mexican Senate of the Republic, the United Nations in Geneva, and the Japanese Parliament, among others.
My career encompasses diverse roles in healthcare, including private practice, health systems, and advisory positions for medical service companies, governments, and government entities worldwide.
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