U.S. must fight harder against TB


In 2011, tuberculosis killed 1.4 million people worldwide, almost as many as died from HIV/AIDS. And death isn’t the only damage TB does.

In many countries, women with the disease are stigmatized and abandoned. Families of poor victims find themselves thrust further into poverty. And infants and children who get TB — often from their parents — go undiagnosed. TB remains the most common cause of death among people with HIV, and in developing countries skyrocketing rates of smoking and diabetes — also risk factors for TB — are driving the epidemic.

Because about a third of all sufferers worldwide lack access to high-quality treatment, the disease easily spreads and becomes drug-resistant.

This is a problem for developed countries, too. In March, a Nepalese man with extensively drug-resistant TB flew to Brazil and then traveled by plane, car, boat and on foot before crossing Mexico into Texas. More than 60 percent of TB cases in the United States occur among the foreign-born, which means that to control TB within its borders, the U.S. must help control it overseas.

And yet the U.S. Agency for International Development has proposed to cut $45 million from TB spending for 2014 — 20 percent of that program’s budget.

During a congressional hearing last month, Rajiv Shah, the head of USAID, responded to concerns about the proposed TB budget cuts by saying, “We are expanding our efforts in HIV- related TB.” In fact, there are no plans to extend funding for HIV-related TB in 2014.

Furthermore, a $223 million cut has been proposed for Pepfar (the President’s Emergency Plan for AIDS Relief), which supports HIV-related TB programs. Although this reduction is counterbalanced by a $350 million increase in U.S. spending on the Global Fund to Fight AIDS, Tuberculosis and Malaria, only 17 percent of that agency’s budget has been used against TB.

USAID’s proposed budget cut will severely hamper the agency’s efforts to contain the global spread of drug-resistant TB, and to expand access to better drugs. In some parts of the world, more than a third of TB cases are multidrug-resistant. In India and South Africa, doctors are seeing strains that don’t respond to any known medicines. In the absence of technical assistance from USAID, well-intentioned efforts to treat such strains may simply lead to greater drug-resistance.

While USAID’s TB budget is being slashed, public-health spending on tuberculosis in the U.S. is also being cut. On top of belt tightening from sequestration, the administration of Barack Obama has been pillaging money from the Department of Health and Human Services’ Prevention and Public Health Fund, which goes to efforts such as immunizations, health screenings and smoking prevention. Last year, some of this money was used to prevent a scheduled cut in Medicare payments to doctors. This year, some will go toward educating and helping to enroll people in new health-insurance plans available under the Affordable Care Act.

Almost all TB specialists in the U.S. work in public clinics and hospitals. Many patients, being either uninsured or underinsured, have nowhere else to go for their treatment. Even after the Affordable Care Act is fully in place, public TB clinics will remain important safety nets for undocumented immigrants and legal immigrants who don’t yet qualify for public services. It’s safe to assume that cuts in public health funding will have the same effect we saw in the early 1990s after earlier reductions: Many patients will be inadequately treated, allowing greater transmission of TB and the emergence of multidrug-resistant strains.

What’s more, the Centers for Disease Control and Prevention — led by Tom Frieden, who once was New York’s TB czar — is planning to cut funding for its Tuberculosis Trials Consortium by 30 percent. The consortium has been looking for shorter, less-toxic drug combinations to treat tuberculosis and for better regimens against multidrug-resistant TB — an effort that has begun to pay off. Last year, the Food and Drug Administration approved bedaquiline, the first new TB drug in 40 years, which may reduce the duration of TB treatment (currently six months to two years, depending on drug resistance). Additional drugs in the consortium’s pipeline now may not make it to the end.

Access to old medicines and diagnostic tools is in jeopardy, too. The U.S. faces shortages of isoniazid and rifampin, two first-line TB drugs, as well as the second-line drugs streptomycin, cycloserine, ethionamide, rifabutin, amikacin, capreomycin and kanamycin. And there is a nationwide shortage of tuberculin, which has been used since the 1930s in a skin test to see if someone has been infected.

TB control is no easier today than it was 20 years ago. Our world is more interconnected, and multidrug-resistant TB is more common. Instead of cutting funding for national and international programs — almost certainly leading to unnecessary deaths — the Obama administration should be moving in the opposite direction. By strengthening the public health system to deliver essential TB services in the U.S. and abroad and expanding the number of TB drugs, we should be working to prevent all deaths from tuberculosis.

Celine Gounder is a primary care doctor and a specialist in infectious diseases and public health. She previously served as assistant commissioner for New York City’s Bureau of Tuberculosis Control.

© 2013, Bloomberg News

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