The global tuberculosis (TB) response is at a crossroads. In recent years, new ideas, technologies, and political commitments have reinvigorated the fight against this age-old disease that kills more people each year than HIV and malaria combined. But with key indicators just beginning to recover after moving in the wrong direction during the COVID-19 pandemic, hard-earned gains are at stake. In this rejuvenated yet challenging context, we critically review an idea and practice at the heart of the TB response—directly observed therapy or DOT. First, we explore DOT’s controversial method and history as a component of the World Health Organization’s recommended TB strategy. Second, we outline a rights-based disease response and examine DOT through the lens of human rights and related principles. Third, we review the evidence for DOT’s effectiveness. Fourth, we highlight DOT’s most salient and enduring problems. Finally, we propose two essential principles for the way forward to protect and promote the rights of people affected by TB.
