Back to the future in a U-shaped curve?

Controllers forced to cut programs, positions

As state TB control programs got the bad news last month about funding cutbacks, there was plenty of predictable grumbling about "the U-shaped curve of concern."

"We’ve definitely taken a hit," says David Ashkin, MD, medical advisor to Florida’s TB control program. "We were going to start trials on the new preventive therapy regimen [of rifampin and pyrazinamide]. Instead, we’re having to cut positions and cut programs."

In Texas, the mood was equally somber. "It’s not a great story to tell," says Charles Wallace, state TB controller. "The biggest impact from the cuts is that we’ll have to scrap our whole community-based infrastructure; the whole thing is about to be erased." Wallace is referring to a painstakingly-assembled network of partnerships with community-based organizations that serve minorities and ethnic groups at high risk for TB. Those groups comprise people of color; ethnic minorities including Bosnians, Russians, and Ethiopians; and a large Mexican community.

"These are people who often don’t speak the language yet and who need help linking up with a health department," he says. "A few weeks ago, we had to sit down with all these organizations and tell them that the funding is no longer there."

Officials at the National Tuberculosis Controllers’ Association (NTCA) say they are trying to limit the depth of funding cuts. "We’ve tried to get across the concept of a floor, and the idea that there’s a certain amount of funding you need to have to do surveillance and response even though the number of cases may be very small," says Bruce Davidson, MD, head of the NTCA. "Likewise, there need to be ceilings so that even if programs are very capable, there will be still be enough funding for other programs to carry out their high-priority activities."

Davidson also voices two other concerns. First, he says, programs that have done a good job reducing their caseloads shouldn’t be punished by having money withdrawn. Second, programs that have been active in all categories, including case and contact work as well as preventive programs, shouldn’t be penalized for their extra efforts.

"There’s always been a floor," replies Patty Simone, MD, chief of the field services branch for the division of TB elimination at the Centers for Disease Control and Prevention. As for a ceiling, "We’re certainly not going to give all the money to just one or two programs," she says. "We’re trying to be fair, to base our decisions on need and not to penalize programs that have done a good job."

Several factors make the CDC’s job tough, she adds. Even though TB controllers have asked for a simple formula — so many dollars per active case, for example — to ensure a fair distribution when funds are recompeted in fiscal year 2000, reality doesn’t lend itself to a simple formula, Simone says.

Some states, for example, get additional support from city, county, or state governments. What’s worse? she asks: penalizing programs that have worked hard to secure additional sources of local funding or penalizing those that haven’t?

Congress may enact cutbacks

The carryover problem, too, dates back to which programs asked for and received the biggest increases when caseloads first began to increase. Nearly half of all TB control programs have had some leftover funds every year since 1993, Simone says. The carryover has had the effect of benefiting practically all programs, but in the end, it may prove a Faustian bargain that provokes Congress to enact big cutbacks.

"I don’t know what the other programs were doing, but we were certainly spending all our funds," says Ashkin. "You’d think right now, as cases are going down, we’d be shifting gears toward prevention. But now that disease is going down, the money is going down, too. We’re close to many advances — new diagnostics, a new vaccine, now this new preventive therapy — and instead, we’re on that slippery slope of the U-shaped curve of concern."

When it comes time to recompete the awards for fiscal year 2000, Simone says she’s hoping to make a point with Congress by representing the funding needs according to a new scheme.

"Instead of asking for the moon, or asking simply for level funding, we need to explain [that] there always needs to be these two pots of money," she says. "The first is a stable amount that we’ll always need for case activities. The second is for elimination, and [it] will need to be expanded as we move toward that goal."

Maybe Congress will understand. If so, it may be possible, program advocates hope, to avoid repeating history.