In testimony supporting the president’s budget request this week, USAID Administrator Rajiv Shah asserted that the funding proposed for his agency would allow it to “continue to make cost-effective interventions that save lives” and prevent the spread of infectious diseases.

But in the tightened spending environment that lawmakers and Shah cited repeatedly, a cut that is anything but cost-effective went unnoted in his remarks. Although the challenges to USAID’s work in such an environment are many, few cuts could be more expensive in the long run than reductions in spending to confront the spread of drug-resistant tuberculosis.


As it stands, the president’s budget acknowledges our country’s interest in preparing for future global health threats with the inclusion of $45 million for the new Global Health Security Initiative. That initiative will work with 30 countries to improve and develop responses to disease outbreaks, including drug-resistant infections. Committing that funding shows recognition that improving health capacities globally is not only the right thing to do, it is essential to protecting health at home.  At the same time, however, the president’s budget proposal, with stunning short-sightedness, calls for a $45 million cut for USAID’s TB program which provides support for TB programs, which address a threat we face now, in 30 of the world’s most burdened countries. The spending on the Global Health Security Initiative does not compensate for the cut in TB spending. If anything reducing funding for TB efforts will add to the challenges the new initiative will confront. And while the President’s continued commitment to the Global Fund to Fight AIDS, Tuberculosis and Malaria is commendable, those resources are similarly shortchanged when bilateral aid is not adequately funded.

Questioned by Rep. Barbara Lee (D-Calif.) on the impact of a nearly 20 percent reduction in spending to address tuberculosis, Shah’s answers could mislead legislators into imagining, as Shah intimated, that resources from the President’s Emergency Plan For AIDS Relief, from the Global Fund, and from middle-income countries could fill the gap. USAID controls the largest share of U.S. global TB resources, a share that makes up about 50 percent more than those directed by PEPFAR, which faces its own challenges, having been once again slated for flat-lined funding. Re-directing funding needed by PEPFAR or the Global Fund to TB efforts that have been supplied by USAID is a zero sum game. Citing the role that middle income countries must play in controlling their own tuberculosis epidemics ignores the truth that the impact of tuberculosis funding cuts will by far be greatest in low-income countries where efforts must be strengthened now to contain tuberculosis.

Finally, the president’s proposal also flat-lines domestic tuberculosis funding, including for the TB trials consortium and its quest for new medicines to treat drug the disease, domestically and globally. While these programs have yielded gains in the last decade, the legacy of previous decades of inattention to effective TB control has led to the continued spread of drug-resistant TB. It is likely that the continued global increase and spread of drug resistant strains of the disease, many of which are not treatable with available anti-TB drugs could reverse the hard-earned gains that have been made in combating TB in the past few decades.

We continue to confront the impact of past neglect. TB remains a global public health emergency. Although tuberculosis is preventable and treatable, it is easily transmitted by the air we breathe wherever it occurs and  it is anticipated that globally more than 8 million people will get sick with TB in the next year, and 1.4 million people will die of the disease. In the United States, 9,588 new TB cases were reported last year, with foreign-born individuals disproportionately affected, and that disproportion continues to increase. An approach to global health that does not address the threat that TB continues to pose globally will come with a price that we will continue to pay for years to come.

Fortunately, Congress rejected a similarly myopic approach to global health spending in the president’s last budget proposal. That was encouraging, and a hopeful sign of enlightenment not evidenced in the president’s global health budget request, or Shah’s response to it, for the coming year.

Friedland is a professor of Medicine and Epidemiology and Public Health at Yale School of Medicine and a member of the scientific advisory committee for the Infectious Diseases Society of Amnerica's Center for Global Health Policy.