Tuberculosis Doesn’t Respect Borders—US Aid Cuts Could Fuel a Global Health Crisis

In 1900, one in every nine Americans who died succumbed to tuberculosis (TB). However, a remarkable breakthrough occurred with the discovery of a combination of antibiotics. Within a few years, US deaths from TB plummeted to less than one in 18 deaths, and by 2019, it accounted for merely one in every 320 fatalities. Globally, the incidence is higher, with TB responsible for approximately 2 percent of all deaths, totaling about 1.25 million lives each year.

Despite possessing the tools to cure TB, effectively implementing treatment remains a significant challenge, particularly in resource-constrained settings. The standard treatment demands a strict six-month regimen of multiple antibiotics. This can be arduous to complete in areas with limited healthcare access, unreliable drug supplies, or where patients must travel long distances for care.

A major obstacle is that most patients begin to feel better after only two months, often leading them to prematurely discontinue treatment. Unfortunately, TB bacteria are resilient; cutting the regimen short allows surviving bacteria to develop resistance. This transforms a previously curable infection into multidrug-resistant TB (MDR-TB), a much more dangerous and expensive disease to treat.

Resistant TB poses a severe threat to both patients and healthcare systems. Unlike regular TB, which responds to inexpensive first-line antibiotics, MDR-TB necessitates a far more costly regimen of second-line drugs. Until recently, treatment for MDR-TB also lasted up to two years, involving injections that were less effective and notoriously toxic, with side effects including hearing loss, kidney damage, and debilitating nausea.

Thankfully, recent innovations in TB drugs, such as bedaquiline, have vastly improved treatment outcomes for the majority of cases. While extremely rare, resistance to these newer drugs does exist. Such resistance can regrettably force patients back onto the arduous and toxic injectable treatments.

Governments commonly prioritize specific areas in global health. Driven partly by altruistic motivations, successive US administrations have consistently made TB a priority. The United States contributes approximately 50 percent of international donor funding for TB. These funds have been exceptionally well spent, with global TB programs saving an estimated 79 million lives since 2000.

Beyond altruism, there is a strong self-interested rationale for these investments. TB is highly infectious; a higher global burden inevitably means more cases will reach the United States. Furthermore, MDR-TB spreads just like regular TB, meaning each new case creates the potential for a wider epidemic of drug-resistant disease. Left unchecked, MDR-TB threatens to reverse decades of progress in global health, potentially reverting TB to an untreatable scourge.

It is reasonable for a new US administration to review all official development aid (ODA) commitments upon taking office. I am confident that any thorough assessment will underscore the immense value America derives from its investments in combating TB. However, the current 90-day freeze on most aid while this assessment proceeds is creating significant challenges for medication access.

Although waivers have been issued for TB treatment and other illnesses like HIV, their implementation faces difficulties. This is partly due to USAID staff being removed from office, leaving insufficient personnel to process these critical waivers. If this impedes access to treatment, the development of further drug resistance is all but assured.

Reducing access to vital treatments against drug-resistant TB will likely pose immense risks for everyone, including Americans. The potential consequences are severe:

• Firstly, resistance to these life-saving drugs will increase. Patients currently taking new second-line drugs, such as bedaquiline, might find their treatment curtailed, significantly raising their chances of acquiring bedaquiline-resistant TB. If it becomes harder to procure drugs through safe channels, there will likely be an increase in people resorting to substandard treatments. These often contain just enough of the drug to engender resistance but not enough to effectively treat the infection. Other individuals might discontinue treatments early due to escalating costs or unreliable supply chains.
• Secondly, there had been no new TB treatment for over 50 years until 2016, and it is not widely expected that new drugs will readily follow. The hope that research and development would increase if resistance rates tick up becomes much less likely if there is no viable market for purchasing new treatments. Eventually, this resistance will inevitably reach high-income countries, yet it will likely take years for new treatments to materialize, resulting in far more suffering.

These developments unfold against a troubling backdrop of accelerating TB rates within the United States. For every year between 1953 and 2020, TB rates in America steadily declined. However, this trend reversed in 2021, when TB rates began to rise, a worrying pattern that continued through 2022 and 2023, the most recent year for which data is available. There has been a 35 percent increase in cases between 2020 and 2023, and the total number of deaths from TB has reached its highest level since 2006. This is a concerning and worsening trend.

Compounding these statistics, one of the largest TB outbreaks in US history is currently unfolding in Kansas, having begun in 2024, and is therefore not yet captured in the aforementioned data. If the failure to treat TB outside of America persists, TB rates within the US will continue to climb. Worryingly, MDR-TB rates are likely to increase at an especially rapid pace.

It is crucial to contextualize these risks. The Center for Global Development (CGD) recently conducted research into the cost of treating various types of drug resistance. We estimated a cost of $148,000 per patient to treat drug-resistant TB in America. Across 11 different indications in 204 countries, TB treatment in America proved to be at least twice as expensive as any other type of drug resistance and nearly double the cost of treating any resistance, including TB, in any other country. Thankfully, for Americans, only about 1.4% of TB cases in the US are currently multi-drug resistant. However, if MDR-TB rates rise globally, those costs will escalate rapidly.

I am not aware of any detailed epidemiological modeling on how much TB might increase in the US if global action plans falter. However, it is possible to cost speculative outcomes. Currently in the US, 8.5 percent of TB cases are resistant to the first-line treatment Isoniazid. Within this group, 1.4 percent of TB cases are identified as MDR-TB. If all existing Isoniazid-resistant TB cases were to become MDR-TB cases, the annual cost of treating MDR-TB would increase by over $100 million.

Furthermore, if TB rates were to rise at twice the current rate, exceeding 30 percent a year, the cost of treating TB would soar to almost a billion USD annually by the end of the current administration. This scenario would also mean more than two and a half times as many Americans would die from TB during the current Trump administration than under the Biden administration. It is entirely possible that the actual impact could be far worse than these projections.

Globally, the rate of TB is nearly fifty times higher than in the US, and the MDR-TB rate is over 100 times greater. While it is unlikely that American rates will immediately reach this global average, should they ever do so, the cost of treating TB would increase to over $11 billion annually.

These figures do not even account for the approximately 33,000 Americans who would die every year from this terrible disease. They also exclude the immense macroeconomic impact, which typically tends to be about ten times greater than the direct health impact.

It is invariably cheaper to prevent a disaster than to bear the cost of picking up the pieces later. The current pause in foreign aid threatens to reverse critical progress against TB at a time when the world cannot afford another global health crisis. If funding is not swiftly restored in a manner that ensures treatments reach those who desperately need them, then MDR-TB will inevitably rise, and more lives will be tragically lost. The initial impact will be felt most acutely in high TB burden countries, but the repercussions will ultimately come back to haunt Americans, unleashing a preventable disaster.

Data note: Costs of treating TB were derived from the model behind Laurence et al. (2025) and McDonnell et al. (2024) dollar figures from CGD’s original work, and were inflated from 2022 to 2025 USD. US TB numbers are sourced from the US Centers for Disease Control and Prevention (CDC) and global TB numbers from the World Health Organization. Fatality rates for TB were taken as an average of the last five years with published CDC data. Portuguese numbers of 17.1 percent were used, instead of US numbers, as the fatality rate for MDR-TB, due to data limitations. This was deemed appropriate given that the fatality rate for all TB was 6.9 percent in both countries.

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