Three people have died of tuberculosis (TB) in Marion, Ala., since 2011. With a population of a little over 3,500, it is “an outbreak that is worse than in many developing countries,” said Eric Goosby, special envoy on tuberculosis for the United Nations. 

But when Alabama’s health department started to investigate the cases, it faced unprecedented resistance from patients.

"These people would just not tell us who they had been around," said Pam Barrett, TB controller for the Alabama Department of Public Health. "We tried several different approaches and got nothing but ‘I don’t want nobody knowing my business.'"

Wanting to entice people to get tested, Barrett and her team held a health fair with free food and drinks. All that followed, however, was disappointment -- and even some violence. 

“Turnout was horrible," she said. "We got glass beer bottles thrown at us. Most of the people who did come just ate pizza and left."

The case in this rural Alabama town may seem extreme, but it holds important lessons. There are pockets of the country that are vulnerable to outbreaks of once-eradicated diseases. Homeless shelters and prisons are particularly at risk. Even worse, tuberculosis is one of the easiest diseases to transmit to other people -- a fact that health-care decisionmakers seem to have lost sight of, said Donna Hope Wegener, executive director of the National Tuberculosis Controllers Association.

“It’s not like HIV, where you need intimate contact with someone to come down with it," she said. "You just need to be with them in a confined space with poor air flow. And it’s not uncommon for people living with the disease to be misdiagnosed for years.” 

Tuberculosis was largely erased after World War II, in part thanks to creation of a vaccine. But in recent years, rates among immigrants, black people and the homeless have become troubling. Because TB is considered to be a mostly eradicated disease and the vaccine's effectiveness is variable, it isn't widely used in the U.S. today. That's a mistake, according to Wegener, who said there needs to be more resources put into improving the vaccine and immunizing the most vulnerable populations.

In Marion, health officials exhausted traditional approaches to combat the outbreak and got nowhere. As it continued to spread, they decided to do something no other jurisdiction has done: pay people to get tested.

Anyone who came in for a blood test got $20, then $20 more for coming back to get their results. Another $20 was awarded for x-ray follow-ups, with $100 for finishing medication treatment, if deemed necessary. The project was funded by a grant from the Centers for Disease Control and Prevention.

During the pay-for-testing period, more than 2,000 people came in. Of these, 151 tested positive for the germ and three active cases were caught. The latent TB infection found in 151 people is asymptomatic and not infectious, but it does make them more likely to get infected if they're exposed to someone with an active case of the disease.

About 13 million people in the U.S. are living with a latent TB infection, according to a 2015 National Health and Nutrition Examination Survey. But we don’t know who those people are or where they are, according to Wegener, who cautions that "without more access to resources, we’re only going to see more instances like what happened in Marion.”

Last month, Alabama stopped paying people to get tested for TB, but the public health department still offers free testing to anyone who makes an appointment. The priority has shifted to making sure people with active and latent TB are maintaining their medication regimes. But that's no easy task when you have an understaffed department. 

“We’re going to have to be creative in our staffing for awhile," said Karen Landers, Alabama's assistant state health officer, noting that her team had to pull employees from other programs to help out in Marion.

 "TB is a disease we know how to prevent and how to treat," she said. "But yet it’s still here.”

*This story has been updated.