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Still, TB’s higher profile could help, say experts
The 2002 federal budget that President George W. Bush submitted to Congress in April would eliminate line-item funding for TB and would hold TB funding to flat levels, policy experts say. Eliminating line-item funding potentially sets the stage for a return to block grants, a funding mechanism opposed virtually across the board by U.S. TB experts.
In the budget Bush submitted, TB funding at the Centers for Disease Control and Prevention (CDC) in Atlanta is shown bundled together with money for sexually transmitted diseases and for HIV.
Lobbyists and policy experts at the American Lung Association (ALA) say they’ve seen other signals that the new administration would like to return to block grants. "In the theme document" — the blueprint for the proposed budget which the president released in February — "there was language suggesting they want to move back to block granting," says Gary Ewert, a media spokesman for the Washington, DC-based ALA.
At the CDC, Ken Castro, MD, head of the Division for the Elimination of TB, was terse in his reaction to the budget news. "The proposed budget represents an effort to simplify administration of divisions at the CDC," he says. "It will be very important to keep track of resources appropriated for TB by Congress."
A start, not an ending
Still, the proposed budget is no more than a wish list, Hill-watchers say. Increased funding for TB "has never appeared in the President’s budget before; that’s something we’ve always gotten during the appropriations process," notes Ted Miller, press secretary to Congressman Sherrod Brown (D-OH), who recently introduced two bills that would substantially increase funding for TB at home and abroad. "There are going to be changes in that budget."
Ewert agrees: "Spending levels for health care overall [in the proposed budget] are below what’s needed to get a bill out of Congress," he says. "I think [Congress] will add something — but whether it’ll be something at the margin or something significant, I don’t know."
In the Bush proposal, the "bundle" composed of TB, HIV, and sexually transmitted diseases (STDs) would get only a modest funding increase of $24 million, of which little or even none seems intended for TB, says Ewert. "The text implies that $20 million of the $24 million increase would go to domestic and international HIV prevention," he says. That would leave just $4 million for the STD and TB divisions at the CDC to scrap over — unless the $4 million is intended as money to run the HIV programs. At many points, including that one, the Bush budget language simply isn’t clear enough to see what’s meant, say several ALA lobbyists.
Will block grants push TB rates higher?
Block-granting, also known as non-categorical funding, gives states much more discretion in how they use federal money.
"We’ve got solid evidence from the past that when there is block granting, funding for TB goes down, and TB goes up," says Ewert. Lee Reichman, MD, MPH, director of the National TB Center at the New Jersey Medical School in Newark, emphatically agrees. "I thought we’d learned our lesson," Reichman says. "If this [goes through,] we could all be in business a lot longer than we’d intended."
Clearly, the Bush proposals signal that a tough fight lies ahead, says Ewert. "For the last eight years, we had the Clinton administration," he says. "The endgame strategy there was that Republicans would send in a budget well below what was needed. Then the President and the [Democratic] leadership would hammer out some compromises, and we’d see huge increases at the end. Now we’ve got a new set of rules."
Certainly, it’s time for TB advocates to roll up their sleeves and get to work, adds Miller. "There is some urgency for people who feel these programs are important to let their Congresspeople know about it," he says.
The budget news cast a pall over earlier, much more positive developments.
On World TB Day in March, Brown introduced the two long-awaited bills, which were crafted chiefly by the Washington, DC-based National Coalition to Eliminate Tuberculosis and the ALA. Acting as co-sponsors for the two bills are Democrat Henry Waxman of California and Republicans Connie Morella of Maryland and Greg Ganske of Iowa.
The strong bipartisan support the bills have garnered should certainly help TB’s shot at leveraging more funding, say Miller and Ewert. "The fact that we’ve got people on both sides of the aisle supporting this bill certainly helps," Ewert says.
Policy-makers taking notice of TB
It also helps that policy-makers and the public are far more aware of TB-related issues now than they were four years ago, TB experts add. "I’ve been visiting Washington, DC, for years talking about TB, and this [year] is the first time that people went out of their way to meet and talk with us," Reichman says. "It wasn’t just courtesy visits with junior staff. These were Congresspeople and senior staff."
Originally conceived as an omnibus-style package that would incorporate both international and domestic proposals, the TB bill was later split into two pieces in hopes of increasing chances for passage by preventing it from having to work its way through multiple committees. The international bill will be referred to the Foreign Affairs Committee; the domestic bill, to the Energy and Commerce Committee. Brown, a long-time supporter of TB control and other health-related issues, is the ranking Democrat on the Commerce Committee’s Health Subcommittee.
The domestic bill, dubbed the Comprehensive Tuberculosis Elimination Act of 2001, seeks $240 million for the National Institutes of Health (NIH), a sum that would double the amount of money currently targeted for TB-related research at the NIH.
Bush’s proposed budget allots an additional $2.8 billion overall for NIH research. In order for part of that increase to be earmarked for TB, the amount named in Brown’s bill would first have to be authorized; then specific dollar amounts would have to be approved in a separate appropriations bill.
Brown’s domestic bill also seeks authorization to appropriate an additional $400 million for TB at the CDC. The current TB budget at the CDC is $126.5 million. The increase Brown’s bill names is intended to implement recommendations contained in an Institute of Medicine report on how to eliminate TB in the United States by means including the targeting of high-risk populations and by giving the CDC an expanded role in training and educational outreach to medical professionals and others who serve high-risk populations.
The Stop TB Now Act — the international bill Brown introduced at the same time as the domestic bill — seeks to authorize $200 million for TB control activities of the U.S. Agency for International Development (USAID). This year, $60 million was appropriated for TB at USAID; just four years ago, the amount stood at zero.
TB experts at WHO say that if appropriated, the increase for USAID would help catalyze the huge multinational commitment needed to trim TB deaths worldwide by half. TB experts at WHO say that would take a billion dollars a year for 10 years. "If the U.S. [does its part,] we can assemble that $1 billion internationally in a NATO-like plan that we can lead and put together," Brown says.
Global TB Drug Facility to get a slice of the pie
Most of the $200 million the Stop TB Now Act requests for USAID would go toward expanding TB control programs. The rest would be channeled to the Global TB Drug Facility, a newly created multinational organization housed at WHO and intended to provide a reliable supply of high-quality TB drugs to developing countries.
Canada has already pledged $11 million to the global drug facility. WHO officials say the drug facility — which is a "virtual" facility, not a true warehouse for drugs — needs $250 million in pledges from the United States between 2001 and 2005 to meet global treatment targets.
The increased U.S. commitment to fighting TB in low-income settings has already helped rally international support for fighting TB, says Brown. When he was visiting the recent Chicago conference of the International Union Against TB and Lung Disease, Brown says he listened to one international TB expert after another talk about that impact. "They say now that the U.S. is involved, it’s bringing on other countries around the world to be part of this whole effort," he says.