The Biden administration has rightly talked a lot about pandemic preparedness. And to its credit, the latest White House budget proposes new funding to stop future disease threats. In the introduction to the global affairs budget, the State Department celebrates how this money will help make the world better prepared.
But there’s a catch. A hundred pages later, alongside increased funding for future pandemics, you’ll see it actually suggests cutting funding from three of the biggest, longstanding pandemics we’re already facing. U.S. programs for global tuberculosis, malaria, and HIV/AIDS all get scaled back, including by nearly 10% for TB.
This is a false choice, and a wrong one. All the evidence shows we don’t need to choose between stopping the current pandemics and preparing for the next one. The same systems can do both, if they have the funding.
Covid made PCR testing a household term for many of us. But it was nothing new to my colleagues around the world focused on tuberculosis, a global disease that’s fueled by poverty. When Covid arrived, TB health workers were already experts in PCR testing, masking, ventilation, contact tracing, and infection control. They were, after all, leading the fight against an airborne, respiratory pandemic. USAID, which is responsible for U.S. government support for TB globally, even points this out in its new strategy, explaining how TB programs quickly became the backbone of the Covid response in many countries.
In Bangladesh, doctors used TB testing machines to screen for both TB and Covid starting in 2020. Someone with a cough could get tested for TB and Covid in the same place, by the same health worker, on the same machine — then get the result and start treatment within a few hours. Those machines were in clinics well before Covid arrived; USAID TB funding had paid for them, out of the budget that the White House is now trying to cut.
In South Africa, this same USAID TB budget supported a network of 15 local NGOs in community-led door-to-door screening for TB. After the onset of Covid, the network started screening for Covid, too. There are similar examples in dozens of countries.
Of course the problem is that TB systems were already far underfunded, even with existing USAID support. That meant the best chance at responding to the new pandemic was an already fragile system.
The Biden administration rolled out a bold new global TB strategy last fall, with a stronger focus on equity, accountability, and pandemic preparedness. The sad irony is it’s been sandwiched between proposals to cut the funding to deliver it. This is the second year in a row the White House has proposed TB cuts (and the year before that, during the very worst of Covid, the TB budget request was flat). In fact, over the past decade, Presidents Obama, Trump, and now Biden have all proposed rolling back funding for TB.
Fortunately there’s been a different pattern on Capitol Hill.
The White House budget proposal is more of a wish list than clear policy, and Congress has rejected the TB cuts every time, whether the chambers were controlled by Republicans or Democrats. Instead, they have steadily (albeit slowly) increased funding. In 2022, 120 members of Congress from both parties called for boosting funding to $1 billion annually, from about $400 million today. As I write this, another letter is circulating on Capitol Hill calling for the same.
New legislation, the End Tuberculosis Now Act, would also help reinvigorate USAID’s impact on TB and pandemic preparedness. The bill came within inches of passing in December. It had largely unopposed bipartisan support, and only didn’t make it into law because the clock ran out at year’s end. Senate leaders reintroduced this bill in January, and the House followed suit just last week.
To be clear, the new Biden budget isn’t all bad news. It honors the U.S. pledge to the Global Fund to Fight AIDS, Tuberculosis and Malaria — a transformational commitment to community-led work against pandemics. It boosts funding for CEPI, a partnership to develop new vaccines, and Gavi, a partnership to deliver the vaccines we already have.
The budget also puts hundreds of millions of dollars toward a new, and so far untested, Pandemic Fund. This new global fund sits at the World Bank, and has been championed by the Biden administration. It’s not yet clear if this fund will reject the false choice between current and future pandemics, and instead fund the systems needed for both.
The Pandemic Fund is soliciting proposals this spring, and will use a set of WHO guidelines called the Joint External Evaluation to help decide what to fund. New research out of the U.K. maps these JEE guidelines against the latest technical guidance on tuberculosis. The overlap is overwhelming. Of the JEE measures the Pandemic Fund is using to judge its first call for proposals, virtually all of them line up with key pieces of the fight against tuberculosis. This could be a huge win-win, or a huge missed opportunity.
As Atul Gawande, the head of global health for USAID, pointed out recently, success against future pandemics depends on this kind of primary health care. If you want to measure pandemic preparedness, TB programs are one of the best proxies we have. Malaria and HIV programs are high on the list, too.
Of course supporting TB programs and other primary care isn’t just about stopping the next pandemic. It saves lives right now. Before Covid, TB was the world’s deadliest infectious disease despite being preventable, treatable, and curable. This is disgraceful. TB is a pandemic that’s fueled by stigma and poverty and inequity (and for anyone questioning the “pandemic” classification for TB or malaria or HIV, I suggest this reading).
The latest data from the World Health Organization shows that TB has gotten worse by every measure: More people sick, fewer people getting treatment, and more people dying. TB will likely claim back its shameful spot as the top killer in 2023. So, yes, this is about effective, inclusive pandemic preparedness. But it’s also about the rights of everyone, everywhere to the health care they deserve right now.
Colin Puzo Smith is director of global policy at RESULTS, a grassroots advocacy organization focused on poverty.
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