Although a cure was discovered in 1945, tuberculosis (TB) remains the world’s most fatal infectious agent—only briefly overtaken by COVID-19 for three years. With increasingly effective treatments discovered from 1952 onward, it would be expected if TB no longer posed a major threat. Nevertheless, despite being preventable and curable, TB was the direct cause of 1.25 million deaths out of 10.8 million infections in 2023 alone. While other diseases may claim more lives overall, TB’s persistence is unique in the fact that it could have been eradicated decades ago if provided the political attention and global investment it requires, rendering it a critical global health issue.
TB is a highly infectious bacterial disease that commonly affects the lungs and is typically spread through airborne particles. Although 25 percent of the global population has been infected by TB, only five to ten percent of those infected will experience the potentially fatal symptoms of coughs, chest pain, fatigue, fever, and more. Entirely unpredictable, the disease can remain latent for the majority of its victims, while in others, ravages the lungs, kidneys, brains, spine, and skin for others. Nevertheless, the “cure” is the use of daily antibiotics, such as isoniazid, or rifampicin, for four to six months. Unfortunately, the failure to comply with the full duration of treatment or incorrect prescription of drug regimen will exacerbate the effect, facilitating the evolution of the bacteria into its multidrug-resistant form.
While TB has historically been prevalent in developing countries, the disease has also made a recent reemergence in the United States. Despite the US goal to have TB be eliminated by 2035, cases have been significantly increasing since 2020 across all age groups, reaching a newfound peak in 2023 that has not appeared since 2013. US policymakers fail to recognize the value of addressing this global disease through a global strategy, rather than concentrating policy focus and medical access at a national scale.
Yet, developing countries face a higher need of help to reduce TB cases. While many countries have been ravaged by TB, Peru highlights the ongoing need for sustained global efforts to combat this curable and preventable disease. Despite its relatively average population size, Peru is second in TB cases within the Americas and globally first in multidrug-resistant tuberculosis (MDR-TB) cases. Unfortunately, the nation is a stark reminder of how developing countries disproportionately suffer when diseases are met with global neglect.
Death Has Roots
Older theories proposed that TB appeared in the Americas following Spanish colonization in the 16th century, as was the case with many diseases introduced to the continent. However, paleoanthropologists analyzing Peruvian human remains discovered bacterial genome sequences hinting that TB infections originated from marine mammals prior to European contact. Whether transmission occurred through physical contact during hunting or consumption, sufficient evidence has yet to confirm the marine mammal theory.
Nevertheless, the historic disease proceeded to ravage Peruvian populations in the late 1990s and early 2000s.The disease existed long beforehand, but limited diagnoses and lack of global comparisons delaying recognition of its disproportionate TB burden. In 2001, Peru was recognized as having among the highest TB incidence rates in the Americas, with over 400,000 cases diagnosed (from 1991 to 2000) and only around 50 percent treated accordingly. However, these concerning morbidity rates were initially acknowledged in 1972, with 192.3 cases for every 100,000 in Cayetano Heredia Hospital alone. While the constant fatality of the disease would cause the assumption that TB-combatting programs only began in the 2000s, policies for TB prevention and treatment have been continuously evolving since 1972. For comparison, the United States and United Kingdom were at an estimated 10 cases for every 100,000 in 1992, underscoring Peru’s disproportionate TB burden.
Thus, the centuries-long fight against a curable, preventable disease persists in Peru, reflecting a broader global failure to eradicate tuberculosis despite decades of treatment efforts.
The Plague Persists
While policies have been consistently updating and adjusting according to the development of new drugs since 1972, Peru persists to host 13 percent of TB cases globally. In 2022 alone, 2493 new cases of drug-resistant tuberculosis cases (DR-TB) were revealed, with an over 60 percent treatment dropout compared to the 18.5 percent in 2019. With worsening statistics in treatment and infection alike, there is little surprise that DR-TB is regarded as the highest priority of Peru’s public health issues.
However, the invasion of COVID-19 caused a sudden halt in Peru’s effort to combat TB. The pandemic ravaged the Peruvian population, as the country held the world’s highest COVID-19 fatality rate. With 5,977 deaths per million citizens, it greatly surpassed Bulgaria’s 4,001 (ranked second) cases—Peru was unparalleled in its death toll. By the “end” of the pandemic, the country of 33 million had witnessed over 2.2 million cases and more than 200,000 deaths. The disease had not simply devastated Peru, it had undone decades of progress with other haunting diseases, like TB. Consuming the nation’s healthcare equipment, medications, and hospital space, the country lacked the means to allocate necessary funding toward the battle against TB. Potential cases went unnoticed during the lockdowns, forcing infected individuals to remain isolated, and therefore, undiagnosed and untreated.
The “end” of COVID-19 was celebrated globally, but Peru’s return to “normalcy” was far from simple. While the World Health Organization (WHO) had previously recorded a low of 117 TB cases per 100,000 people in 2020, that number rose to 173 by 2023. As the world recovered from the impact of COVID-19, Peru was left to confront a familiar enemy, now more resilient than ever.
Health is a Human Right
While Peru has been historically commended for its management of tuberculosis, the journey has failed to show success proportional to its efforts. While programming began with the directly observed treatment, short course (DOTS) in 1980, results were poor from the lack of workers, resources, and medicines, which was worsened by patients’ financially lacking the ability to complete the treatment to its entirety.
In response, Pedro Suárez became Peru’s Director of National TB Programming in the 1990s, collaborating with the Pan American Health Organization (PAHO) and the WHO to establish the country’s first official national TB guidelines in 1991. These advances focused on properly training health workers to efficiently prevent, diagnose, and treat TB, while expanding access to the DOTS program at the local level. Although Suárez stepped down as director in 2004, continued funding from the Global Fund, support from the non-governmental organization (NGO) Socios en Salud, and the adoption of DOTS-Plus (an enhanced version of DOTS) helped make TB more effectively treatable. Increased budgets enabled the development of a nine-month drug regimen, expanded outreach efforts to actively search for TB cases within communities, and the acquisition of more advanced diagnostic equipment.
Efforts and programs have been consistently updated according to funding and new technology; nevertheless, case numbers remain significantly larger compared to other nations' progress. However, the disease persisting reflects a greater complexity of the environmental and social factors plaguing Peru, including poverty, overcrowding, immunocompromised populations, and the isolation of indigenous communities.
Poverty surpasses the ability to purchase medication and diagnostic examinations, limits access to transportation for consistent check-ups, worsens food insecurity, and hinders overall treatment adherence—factors overlooked in global policy. With food insecurity alone, malnutrition is globally recognized as a risk factor to TB, with only ten percent of TB patients in southern African cities are from food-secure households. Transportation is essential to the success of TB programs, as it affects not only patients’ ability to access healthcare facilities, but also health authorities’ capacity to provide proper clinical management due to communication and information barriers.
When only 45.93 percent of indigenous communities are within one hour of a healthcare facility and 15.44 percent are over eight hours away, health has become a privilege.
Healing the Future
As stated by Executive Director of Peru’s Department of TB Prevention and Control, Dr. Julia Rosa María Ríos Vidal, “We also have to work on the multi-sectoral response, making a commitment to face tuberculosis and making people understand that tuberculosis is a social problem.”
NGOs like Socios en Salud (Partners in Health), demonstrate the need to adapt treatments to the socio-cultural realities of each country. Since the mid-1990s, Socios En Salud has implemented various programs to address the distance-related barriers, such as TB Móvil and Mochila TB. In collaboration with the Peruvian Ministry of Health, the NGO has focused on increasing accessibility and training community health workers for long-term sustainability. Through TB Móvil, a blue truck that offers free testing for TB and COVID-19—reaching more than 210 people daily. Similarly, Mobila TB is a backpack machine with the capacity to test up to 80 people daily for TB. This device has further enabled for mobile testing and early-on diagnoses among previously unserved communities, including rural neighborhoods, prisons, and shelters.
While Peru plans to expand molecular laboratory techniques, empower vulnerable communities, and further integrate the WHO End TB Strategy, the United States is threatening to cut US$9 billion in global aid programs, undermining decades of progress. As stated by WHO Director-General, Dr. Tedros Adhanom Ghebreyesus, in response to potential funding cuts: “We are living through the greatest disruption to global health financing in memory.”
Although Peru has been burdened by TB for decades, its death toll was historically overlooked until it became a global tragedy. And while national policies and international support have been steadily improving, proposed cuts on global aid threaten to undo that progress. Given that USAID has assisted Peru’s efforts to eradicate TB (and its variations) for over 60 years, these funding cuts would severely limit testing and treatment. Nevertheless, with US TB cases rising since 2019, including a 15.6 percent increase from 2022 to 2023, it becomes evident that TB is not solely Peru’s issue—but a global one. Without a united effort, this curable and preventable disease will continue to pose a threat to millions worldwide.
