About two weeks ago, an internal memo leaked from the US Centers for Disease Control and Prevention (CDC). It informed personnel that the center was anticipating a loss of approximately 80% of its funding for international outbreak prevention work. Yesterday, the Washington Post reported in more detail  that starting in September 2019, the CDC will narrow its focus and eliminate many of its foreign country programs.

This move would have a profoundly detrimental effect on the ability of the American government to stop outbreaks like ebola before they come to the United States.

What CDC does overseas

The CDC works overseas in two different ways. It funds programming that it is implemented by international NGOs and companies that support disease surveillance and preparedness, and it works government-to-government with health agencies and departments that fight infectious disease.

Both these functions are important. The programming that CDC supports around the world does things like improve the capacity of national laboratories to diagnoses illnesses like HIV, TB, Hepatitis, and Zika. It helps countries build better national disease surveillance systems so that they can catch outbreaks early and stop them before they turn epidemic. And it builds health information systems, so data can be shared across regions within countries, and then internationally. These kinds of information systems let us track diseases as they evolve and help to predict and avoid pandemics like Ebola. Another donor could conceivably take on funding and overseeing those programs, but the CDC brings a unique set of technical skills into overseeing epidemiology programs. They are not the only institution in the world who could do that–but they are the best at it. At the moment, however, no other donors are stepping up.

The government-to-government relationships are equally important. CDC’s role as the lead US government institution on epidemiology gives it unique status and credibility overseas. Their US role means that foreign counterparts recognize them as colleagues and treat them accordingly. When a deputy minister of health for maternal and child health care discovers a sudden outbreak of HIV transmitted in hospitals, for example, she calls her CDC representative in country for help. When Haiti was threatened by cholera after Hurricane Matthew, CDC stepped up to help. Every time CDC investigates an HIV outbreak in Northern Kentucky, it adds to its international credibility. That’s not a role another donor can easily assume.

Why this happened

US government entities like the CDC get their money in two different ways. One is from annual budget allocations. Annual budget allocations are meant to be reliable and fund core government activities. They may increase or decrease from year to year, but they are meant to provide stable operational funding every single year. Supplemental budget allocations are different. They have a specific time frame – usually 2-5 years – and they are intended to provide support for specific, time-sensitive activities.

In 2013, CDC received about $600 million in the form of five years of supplemental funding from Congress. It was intended to address the Ebola pandemic in West Africa and to address the systemic global disease-tracking problems that the Ebola pandemic exposed. Using this funding, CDC established programs in countries like China, Pakistan, Haiti, Rwanda and Congo to prevent disease outbreaks of their own.

In the years since Ebola, that support has become more important, not less. The same surveillance and tracking systems that fought Ebola now respond to disease like Zikayellow fever, and influenza. The supplemental funding did help stop Ebola. But it turns out the Ebola pandemic wasn’t a freak one-time event. It was a symptom of a global disease surveillance system that needed more than five years of support. Yet the five years of supplemental funding run out in October 2019.

What will be cut because of this?

From October 2019, CDC will support overseas programs in only ten countries: Guatemala, India, Jordan, Kenya, Liberia, Nigeria, Senegal, Thailand, Uganda, and Vietnam. By contract, in October 2017, CDC was operational in 124 countries. That’s a massive decrease, and for an organizational focused on global disease surveillance in means a tremendous loss of information sources. The Ministry of Health can’t call on CDC if there’s no CDC in country – which means that 1) disease outbreaks may get worse and 2) CDC loses its access to frontline information on global disease.

What will the impact look like?

CDC’s operational interventions were key to ending the West Africa Ebola outbreak. It was their data visualization on possible pandemic growth that mobilized donors and national governments, and they followed that with financial support to keep Ebola programs running. CDC personnel did everything from data entry into national computer systems to assisting in laboratory diagnostics. As a consequence, they had real time access to Ebola data from West Africa. The pandemic was brought to an end.

Only four cases of Ebola were diagnosed in the United States, largely because effective screening at airports kept Ebola patients from traveling and spreading the virus. “CDC worked with ministries of health and airport authorities in all 3 heavily affected countries, as well as in other affected countries, to establish screening of travelers leaving the country by air to prevent sick or exposed persons from boarding planes,” the CDC reported. “By mid-2015, more than 200,000 travelers leaving Guinea, Liberia, and Sierra Leone had been screened.” Without active CDC programs, that kind of thing isn’t going to happen. Screening will still take place at US airports, but that’s a lot of infection spread along the way.

Overall, the impact of CDC’s loss of operational capacity will be two-pronged. First, this loss of financial and technical support will mean that disease outbreaks overseas will take longer to stop. Labs won’t detect them as fast, and once detected, information won’t be shared as fast. That will give outbreaks more time to turn into epidemics, and epidemics more time to turn into pandemics – like Ebola did.

Secondly, this loss of global disease surveillance capacity means that more dangerous infectious diseases will make it to the United States. This will happen because the overseas outbreaks will be worse, because the US won’t have the frontline disease intelligence it used to be able to access from other governments, and because CDC programs like airport screening won’t be in place when they’re needed.

This 80% to CDC”s foreign operations cut may save some money in the short term, but it comes at the expense of enhanced security and possibly the health of Americans in the homeland.

Discussion

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