What tuberculosis reveals about India’s urban health systems

Tuberculosis rarely appears overnight. It develops slowly at the intersection of impoverishment, precarious livelihoods, and fragile health systems. Each case tells a larger story — not just about infection, but about the conditions in which people live and the systems meant to protect them. On World Health Day, TB serves as a stark reminder that if “Health for All” is to mean anything, it must include those whose health risks are produced by the way our cities’ systems are built and governed.

Nearly 35% of the population now lives in urban areas, and cities continue to expand as people arrive in search of work, education, and opportunity. From construction workers and factory labourers to domestic workers, delivery personnel, street vendors, students, and service-sector employees, migrants sustain the economic engine of India’s cities.

Urban risks

Urban India is often assumed to have better healthcare infrastructure than rural areas. Yet cities also concentrate risk. Overcrowded housing, poorly ventilated workplaces, long working hours, pollution, informal employment and weak social support systems create conditions that drive poor health outcomes. For infectious diseases such as tuberculosis, these are not peripheral concerns — they are central.

India continues to bear the largest burden of tuberculosis globally, accounting for nearly one-fourth of the world’s TB cases. The disease is caused by Mycobacterium tuberculosis and spreads through airborne droplets from people with active pulmonary TB. In India, where exposure is common, infection alone does not necessarily lead to disease. For most people, the immune system contains it. Disease develops when vulnerabilities converge: malnutrition, overcrowding, physically demanding work, untreated co-morbidities and delayed access to care.

TB can therefore be read as a proxy indicator of how well health and social systems function.

Missed opportunities

TB unfolds through a series of missed opportunities. Early symptoms often go unrecognised or untreated. Delays in diagnosis and interruptions in treatment increase the risk of transmission, severe illness, and drug resistance. Each stage represents a point where effective public health systems could intervene. Where nutrition support, social protection, adequate housing, and accessible primary healthcare are in place, TB is more likely to be detected early and treated successfully. Conversely, rising TB incidence, treatment interruptions and multi-drug-resistant TB often point to deeper failures in surveillance, follow-up, pharmaceutical regulation, and the broader systems that sustain health.

TB can no longer be framed only as a disease of the poor; it is increasingly an urban public health challenge. In a pathways study of multi-drug-resistant TB patients in Mumbai (Bhattacharya et al., 2019), people often navigated complex and prolonged care-seeking journeys, moving between multiple providers before receiving the correct diagnosis and treatment. Delays, fragmented care and financial burdens not only worsened outcomes but also prolonged transmission within households and communities.

These are not isolated stories. They reflect wider structural problems in India’s urban health landscape.

Urban primary healthcare remains fragmented and unevenly distributed. While the National TB Elimination Programme provides diagnosis and treatment through designated centres, a large proportion of urban residents seek care from private providers. Data integration between public and private sectors remains incomplete, making continuity of care difficult.

Migration adds another layer of exclusion. Migrants frequently change residences, move between worksites, or travel back to their home. Many lack documentation linked to their current residence or stable access to social protection. This can disrupt treatment, delay care, and make follow-up difficult.

The geography of services also matters. Informal settlements, peri-urban industrial zones, and construction clusters often remain underserved by accessible primary healthcare, reliable transport, and essential public services. For residents in these settings, seeking care may mean lost wages, long travel times, and uncertainty about where to go.

Health as a right

This is where the language of health as a right becomes critical. If health is indeed a right, access to care cannot depend on whether a person has address proof, speaks the dominant language, or is settled enough to fit neatly into administrative categories. The promise of “Health for All” cannot be realised through systems designed primarily for stable, documented, and visible populations. 

TB, then, is more than a disease to be controlled. It is a diagnostic tool for the health of our systems. If India is serious about building healthier cities, healthcare must be portable, primary care strengthened, and disease control programmes integrated with neighbourhood-level services.

Ending TB will require building urban systems that make health possible — when ‘health for all’ starts not only when people fall sick, but for those not visible to policy and for those whose labour sustains the city while their health remains marginal to its planning.

Aruna Bhattacharya is a medical anthropologist and public health expert specialising in urban health systems. She is based in Bengaluru. 

Published – April 07, 2026 01:21 am IST