The control of tuberculosis has become more elusive with the increased incidence of HIV, and the continued selection of multidrug-resistant organisms. The intracellular pathogenesis of, and host-response to Mycobacterium tuberculosis present challenges to both classical chemotherapeutic and vaccination approaches, with the organism able to replicate in an unrestricted manner in lung but not other tissues. Adequate control of this pathogen, that has evolved so successfully for its symbiotic exploitation of man, will require complex approaches including additional chemotherapeutics of more acceptable toxicity and efficacy, vaccination and commitment to public health measures. In this review, the worldwide scope of the disease is outlined, and its direct and indirect costs considered. The organism enjoys the protective advantages of a slow replication and of a specialized phagolysosomal intracellular niche, requiring a host-response capable of breaching these cellular barriers. The challenges of current vaccine approaches, including live vaccines, target antigen selection and the antigen delivery and adjuventation necessary to elicit adequate pulmonary responses are discussed. Our current understanding is inadequate to control TB and the rekindling of fundamental experimental approaches to the organism, and the host response it evokes, are essential to generate the preventative and therapeutic means necessary for its worldwide control.