By Erica Lessem
The road from Moscow has led us back to New York, home of the United Nations (UN) and TAG headquarters. New York is also home to one of the largest tuberculosis (TB) burdens in the U.S.[1] Incidence in New York City rose in 2017, and multidrug-resistant TB (MDR-TB), which is costly and difficult to diagnose and treat, is also on the rise.[2] Despite growing needs, funding for the TB response in New York City has dropped steadily over the past ten years, and fell precipitously in 2017 when New York State issued a surprise cut to its main TB budget line. As we look to other countries to commit to improving the global TB response and financing for TB research and development (R&D) at the UN High Level Meeting (HLM) in September, it’s also time to direct our gaze locally.
Global is National is Local
Chronic underfunding for TB research and programs has allowed the disease to persist with little decline in incidence globally, and even to surpass HIV as the leading infectious cause of death worldwide. Incidence in the U.S. is one of the lowest of any countries in the world, the U.S. has been a global leader in funding TB R&D, and the U.S. TB response in the U.S. is well-resourced relative to that of many other countries. But stagnant domestic TB funding makes rhetoric about U.S. commitment to ending TB within its own borders ring hollow. Indeed, the U.S.’s national TB program at the Centers for Disease Control and Prevention (CDC) has been called the Department of TB Elimination (DTBE) for decades. A National Action Plan for Combatting MDR-TB was launched in 2015.[3] Yet DTBE funding has been stuck at just $142 million annually for the past several years (out of an estimated need of $260 million per year), with inflation limiting the reach of those dollars each year. In turn, incidence is not budging and drug-resistant TB is increasing.
Such funding limitations mean programs must do more with less, which is especially problematic at a time when recent innovations mean we could actually be ending TB in the U.S. with the right resources. For example, addressing TB infection is an essential component of eliminating TB. DTBE research under the Tuberculosis Trials Consortium led to the development of a shorter regimen for treating TB infection, and complementary work with the DTBE’s TB Epidemiological Studies Consortium has identified diagnostic and programmatic approaches that make addressing TB infection on a large scale much more feasible. But a proposed comprehensive TB prevention concept that employs all available tools and targets those at highest risk cannot launch due to the lack of funding.
These troubling national trends are magnified at the local level, where state and city funding is also stagnant or on the decline. New York City had 56% less funding per case in 2017 than it did in 2007, after adjusting for inflation, thanks to a 65% decline in CDC funding, a 38% reduction in City funding, and a 27% drop in New York State funding. The resulting $18.9 million funding gap after adjusting for inflation has led to the closure of six of the city’s chest clinics, a reduction in clinic hours that makes it much harder for patients to seek care at convenient times, and the elimination of almost half of its TB workforce (plus additional part-time and temporary staff reductions). People who may have this life-threatening, communicable disease are having to wait weeks to even get an appointment.
History Repeats Itself
That TB rates haven’t risen further despite this consistent assault on the City’s TB response budget is a testament to the dedication and efficiency of the Department of Health and Mental Hygiene (DOHMH) Bureau of TB Control. But it is only a matter of time before the effect of this trifecta of financial battering from city, state, and federal levels hits hard. What’s worse, we will know we had it coming: similarly short-sighted cuts in the late 1980s that dismantled the public health response to TB contributed to a massive outbreak of drug-resistant TB in New York City that cost over $1 billion to control.[4]
Today’s precarious funding for the TB response in New York City is also remarkably similar to that of three decades ago in its perpetuation of discrimination and injustice. Foreign-born New Yorkers comprise 85% of TB patients in New York City. The majority have lived in the U.S. for over five years before falling ill, meaning that with the right resources, there would be ample time to intervene and prevent TB. But we are leaving them behind, echoing ethnic and class injustice from when the epidemic largely affected African Americans. As Karen Brudney, MD, who worked for the DOHMH at the time of the earlier MDR- TB outbreak describes, “In New York City in the late 1980s there was no tuberculosis program. It had been completely decimated. It had been de-funded. Why? Talk about double standards. Who got TB in NY back in the 1980s? Poor people, African Americans. Absolutely nobody white or middle class.”[5]
Regrettably, we’ve come full circle.New York prides itself on being a safe haven for immigrants. Yet if it does not have adequate resources to provide timely, culturally competent TB care and treatment, how safe can it really be?
Making Good on a Promise
The promise of ending TB in the U.S. will remain elusive until we dedicate adequate resources to do so. The HLM can galvanize the political will and resources required to eliminate TB as a public health threat not just abroad but in our own country, state, and home town. The federal government, New York State, and New York City must commit to adequate funding to restore critical services to reverse the increase in TB cases, particularly MDR-TB, and accelerate the decline of TB. New York can be a pioneer in the fight to end TB and set an example to its guests in September.
References
- U.S. Centers for Disease Control and Prevention. 2016 Reported Tuberculosis in the United States. Atlanta: 2016. https://www.cdc.gov/tb/statistics/ reports/2016/pdfs/2016_Surveillance_FullReport.pdf
- New York City Department of Health and Mental Hygiene. Bureau of Tuberculosis Control Annual Summary 2017. 2018 March. http://www1.nyc.gov/assets/doh/downloads/pdf/tb/tb2017.pdf
- The White House. National Action Plan for Combatting Multidrug-Resistant TB. Washington: 2015 December. https://obamawhitehouse.archives.gov/ sites/default/files/microsites/ostp/national_action_plan_for_tuberculosis_20151204_final.pdf
- Frieden TR, Fujiwara PI, Washko RM, Hamburg MA. Tuberculosis in New York City—turning the tide. N Engl J Med. 1995 Jul 27;333(4):229-233.
- Brudney K. Remarks from Panel on MDR-TB. 2016 Symposium Stop Double Standards: From Prevention through Cure to ZERO TB. Treatment Action Group. Liverpool: 2016 October. https://www.treatmentactiongroup.org/tb/advocacy/zero-symposium-2016