The savings from shuttering USAID aren’t worth the global costs

I recently returned from Ethiopia, where I help to lead a program that has trained essentially all of the pulmonary physicians in that country. During my visit, I spoke at the annual scientific meeting of the Ethiopian Thoracic Society. I have attended that meeting many times; every year there is also a presentation from the leader of the USAID-supported Ethiopian national tuberculosis control program.

Just recently, in fact, USAID announced a major new initiative to control and prevent tuberculosis (including drug-resistant tuberculosis) in Ethiopia, which is classified by the World Health Organization as a high-burden country for tuberculosis.

This year, there was no representative from USAID at the meeting to discuss the tuberculosis situation in Ethiopia or plans to combat the disease. My colleagues in Ethiopia who had organized the meeting told me that their emails and phone calls to their USAID colleagues had gone unanswered.

This of course occurred in the wake of the recent decision in Washington to shutter the agency. Despite assurances that support of vital programs in areas such as AIDS, malaria and tuberculosis would continue, this does not appear to be the case.

Ethiopia is a very poor country and the largest recipient of USAID funds in sub-Saharan Africa, at roughly $1 billion annually, a mere 0.015 percent of the annual U.S. budget. A great deal of that money goes to food aid, but significant funds support efforts in disease control and public health. The consequences of withdrawing support for activities such as the national tuberculosis program could be devastating.

In recent years Ethiopia, with USAID support, has made significant strides in adopting modern tuberculosis diagnostics and in providing new and more effective regimens to patients with drug-resistant tuberculosis. What will happen without continued support of that program? Patients will go longer before their tuberculosis is diagnosed. Their lungs will be more extensively damaged, so that even after cure of their tuberculosis they will be left with life-long pulmonary impairment. Potentially most worrisome of all, rates of drug-resistant tuberculosis will likely rise.

Several years ago, I worked on a project to try to understand the epidemiology of drug-resistant tuberculosis in Kazakhstan, a country with an astoundingly high rate of that particular form of the disease. In fact, the highest rates of drug-resistant tuberculosis are today mostly found in Russia and the countries of the former Soviet Union.

I had a conversation with the physician who was then head of the national tuberculosis control program in Kazakhstan, and I asked him what the genesis of the problem was. He explained to me that at the time the Soviet Union collapsed, there was no money available for the public health authorities to purchase enough antibiotics to allow effective treatment of tuberculosis patients who had fallen ill and to sustain a functioning national tuberculosis program. Prescribing and administration of drugs became erratic and incomplete, which is a recipe for generating drug-resistance.

This was all true. Thousands of patients died from drug-resistant forms of tuberculosis, a disease that is usually quite curable. Thirty-five years later, the problem is still severe in those countries. Although better and more effective drugs and regimens are now available to treat drug-resistant tuberculosis, those drugs are more expensive than older drugs, and they require careful administration and monitoring.

Withdrawal of USAID support will severely threaten tuberculosis control efforts in Ethiopia and in many other countries around the world. Tuberculosis remains largely a disease of countries with limited resources, and aid from the U.S. has been critical making progress in many of those countries. Funds from USAID support the introduction of advanced diagnostic techniques and the purchase of adequate quantities of the safest, most effective drugs to treat all forms of the disease. And of course, as with all infectious diseases, the microorganisms that cause tuberculosis don’t know anything about national boundaries.

Tuberculosis is an ancient disease that over centuries has claimed the lives of millions of people. The modern era of treatment began only in the middle of the 20th century, and now we are able to cure the vast, vast majority of patients with drugs that should be available to everyone, everywhere. Hermann Biggs, a pioneering physician in public health in New York in the early part of the 20th century, famously said, “Public health is purchasable. Within natural limitations a community can determine its own death-rate.”

Withdrawing support for the diagnosis and treatment of malaria, HIV infection and tuberculosis will have predictable consequences. The amount of money that is saved by closing USAID will likely have very little impact in the U.S., but in the countries where that money was to have been spent, the consequences will be enormous and deadly.

Neil Schluger, M.D., Dean School of Medicine, New York Medical College.

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