Last-minute funding to ease programs’ pain

Cuts will be restored to most programs

That soft sound you hear may be the collective sigh of relief going up in TB control programs across the nation. By now the good news should be out: Of the extra $8.6 million awarded by Congress at the last moment, a little more than $7 million soon will flow to programs, which have seen federal budgets cuts ranging from 4% to 30%.

Paul Poppe, deputy director of the Division of TB Elimination at the Centers for Dis ease Control and Prevention in Atlanta, says that should translate to great news for most, if not all, of the 26 programs that found themselves strapped for cash and facing cutbacks in January.

"I don’t want to raise a false expectation that we’ll be able to bring all 26 programs back up to level funding," says Poppe. "But I suspect the 26 will become a much smaller group of perhaps a half dozen."

The new money should start flowing soon, Poppe says, because distribution will be based not on new applications, but on the same information the programs already have supplied to the CDC. The extra money will be allotted on the same basis and according to the same new rules as dictated in this year’s federal allocation, adds Poppe.

Phone conversations between CDC and program representatives about new money were expected to have started the first week in March, and money should begin arriving shortly thereafter, Poppe adds.

The new money won’t arrive a second too soon, say harried TB controllers across the nation. In the Southeast, where nine programs originally were told they’d have to make do with less this year, the cries of distress have been especially acute.

"We’ve been hanging on by our fingernails for years, and [with the last round of cuts] we’ve basically been gutted," says Nancy Dunlap, MD, medical director for Alabama’s state program. Federal funding cuts over the past two years have amounted to 25%, she says; on top of that, the state legislature decided to take away even more money. The effect has been to put Dunlap’s program into the critical care unit, she says.

"We have no people in the northern half of the state at all," she says. "We had four cases of meningitis last year, and one child died. The other day we had someone come in with Potts’ disease — you know they’d had TB for a long time. This year, our numbers are going down because no one’s reporting cases. It’s appalling. It’s lack of people."

In Mississippi, the picture earlier this year looked just as gloomy. Mike Holcombe, the state’s program manager, has pinched pennies by wiping out his entire travel budget. Worse, he adds, he’s had to eliminate contractual personnel who provide directly observed therapy. Last month found him grimly contemplating cuts of regular staffing positions as well.

"We’re already seeing a smaller number of people placed on preventive therapy," he says. "If this keeps up, we’ll see an increase in cases at some point in time."

State TB program suffering

In North Carolina, federal funding cuts have left the state lab’s BACTEC program in tatters, says Steve Martin, MPH, the state’s TB program director. "Now we can’t buy the new equipment we need or purchase supplies," he says. "With stuff like BACTEC, you’re either committed to the system or you’re not. It seems like someone [at the CDC] just made an arbitrary decision. If they never intended for us to get into BACTEC, why did they fund it to begin with?"

The chorus of complaints also reflects South ern states’ fears that the CDC’s new emphasis on foreign-born cases can’t be good for states where the morbidity is still concentrated among native-born Americans, many of them poor African-Americans.

"TB in the Southeast tends to be endemic," says Dunlap. "Thirty-six percent of native-born Americans with TB live in this part of the country — an enormous amount. With endemic TB, you have to have an ongoing commitment to have people in place. It’s not as if you can target a specific community and go in."

Southern states take a bigger hit

What’s more, southern TB controllers argue, with their states’ bigger areas and lower population density to cover, decreased funding hits them harder than it does the more densely populated Northeast. "In big cities, it’s possible for programs [taking funding cuts] to become more efficient," she points out. "But [here in the South], an outreach worker can only drive so far in one day. Already some of our people are driving three hours one way to get to their patients."

Programs outside the South that lack large proportions of foreign-born patients echo the same complaints. "There’s an awful lot of attention paid to foreign-born TB," says Bill Paul, MD, head of the Chicago TB control program. "But that’s not what we’ve got here." The demographics of TB in Chicago, in fact, more closely resemble the picture in Atlanta than in New York City or Los Angeles, he adds.

The same might be said for many other programs, he says. Take away New York state, California, and Texas, and you get a truer picture of the national TB problem. "I think the CDC is playing up foreign-born partly because of the global epidemic, which is certainly the biggest public health disaster of our time," Paul says. "But that doesn’t change the fact that what we have here are mostly U.S.-born, poor, inner-city people with TB — not foreign-born TB."

Paul and other TB controllers who looked at cutbacks earlier this year say they yearn for a funding formula that will account better for their programs’ needs — a rate that reflects simple morbidity, perhaps. Back at the CDC, however, Poppe says there simply is no easy answer. "When you have less funding to work with, there will always be winners and losers. There’s no way around it," he says. As for perfect formulas, he adds, they don’t exist.

"We can’t consider just morbidity, because then budgets would fluctuate with the numbers every year," he says. "And we have to take other factors into account: the number of foreign-born patients, case rates by population, the number of B1s and B2s that are followed, the number of suspect cases that are evaluated, and a whole host of other factors."

One thing is clear, says Paula Fujiwara, MD, TB controller for New York City, which lost a whopping $8.2 million in federal funds this year: "We can plan for cutbacks, and we become more efficient, but only up to a point. But if decreased funding continues, at some point we will no longer be able to deliver the kinds of services and results people expect."

In fiscal year 2001, at least, more cutbacks shouldn’t be a problem, says Poppe, because President Clinton has requested level funding for TB programs, which should, if Congress cooperates, result in a sum that will include this year’s last-minute appropriation of $8.6 million, for a total budget of $128 million next year.

"But let’s not fool ourselves. That’s not enough for effective TB control," Poppe adds. "We need to educate the legislators in every state to know that more funding is needed for TB control."

Adds Fujiwara: "If the country really wants to move to TB elimination, people need to realize it’s going to cost more, not less. Simply thinking that there’s this simple equation — that because there’s fewer cases, we can make do with less money — is all wrong."