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Tuberculosis, an infectious disease caused by Mycobacterium tuberculosis, has plagued humanity since before recorded history and, globally, is still the leading infectious cause of death. As social and economic conditions began to improve in Europe and North America in the late 19th century, tuberculosis rates began to decline in the late 1800s and early 1900s and in the 1930s public health experts began to speculate about the possibility of elimination of this dread disease. Later, with the discovery of antimicrobial agents effective for the treatment of tuberculosis, the elimination of the disease seemed achievable. Plans for tuberculosis elimination were advanced, first to take advantage of the closing of no-longer-needed tuberculosis hospitals and sanatoriums to fund an aggressive drive against tuberculosis in the 1960s and then to take advantage of the retreat of tuberculosis into focal pockets in the United States and strive for elimination in the 1980s. None of these calls for elimination was heeded, and, to the contrary, categorical federal funding for tuberculosis was eliminated in 1972.

The price of the neglect reflected in the funding reductions was a resurgence of tuberculosis throughout the United States. This increase in tuberculosis incidence was greatest in places where the tuberculosis and human immunodeficiency virus epidemics overlapped and where new immigrants from countries with high rates of tuberculosis tended to settle. However, without question the major reason for the resurgence of tuberculosis was the deterioration of the public health infrastructure essential for the control of tuberculosis. It has been estimated that the monetary costs of losing control of tuberculosis were in excess of $1 billion in New York City alone. Not only was the increase in the number of cases of tuberculosis great concern, but also of rising concern was the specter of multidrug-resistant tuberculosis, a form of the disease that requires treatment with less effective, toxic, and expensive drugs and that is often fatal.

In the past 6 to 7 years the decline in number of cases of tuberculosis has resumed, and all-time lows in both the number and incidence of cases have been achieved, clearly a laudable achievement. The question now confronting the United States is whether another cycle of neglect will be allowed to begin or whether, instead, decisive action will be taken to eliminate the disease. At a minimum, strategies for tuberculosis control will have to adapt to a declining incidence and the changing health care environment. For example, the private sector is becoming increasingly involved in both tuberculosis treatment and tuberculosis prevention, which will require effective programs of training and education for private sector clinicians, patients, and targeted segments of the general public. The increasing reliance on managed care will require changes in approaches to tuberculosis treatment but will also offer opportunities to ensure quality of care through effective contracts and clinical standards. Health departments will need to develop approaches to integrating tu



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