“The machinery that we use to get TB treatment to people has just ground to a halt”

This is a quote from an interview with John Green, author of Everything is Tuberculosis. Green is a best-selling author who, in a Damascus moment, recognised some of the cultural undertones of this ancient disease. While researching his book, he also came to realise how appallingly TB’s been neglected.

He is also now explicit about the consequences of the current funding disaster (which are already profound), further warning that “they will become even more profound, unfortunately".

So what’s been happening for him to make this statement?

Two perfect storms on top of an existing persistent depressive weather system is what’s happened.

First of all, while all 192 member states committed in 2018 to help fund global TB control sufficiently to meet the targets they themselves had just set, what these states have collectively been providing up till now has amounted to less than a quarter of what they’d promised. (That was the 'existing persistent depression').

Then, two of the biggest international funders (the EU and the UK) decided to reduce their foreign aid budgets, switching these funds to satisfy political domestic demands to increase their ‘Defence Spending’. Doubtless, this satisfied many of their voters who were pushing for such changes, but we can reasonably rephrase what this switch actually amounts to in respect of human lives as follows: these governments have chosen to transfer money that was being used to preserve lives in lower-income countries in order to support a super-profitable global industry in higher income ones that explicitly designs and manufactures expensive tools that are mainly designed instead to do end lives.

And then to the Trump presidency (the second storm) which – apparently oblivious to the human cost of doing so – peremptorily and without any appropriate or due consideration terminated USAID, including issuing immediate ‘stop working’ notices as if they would have no effect on anyone but be of some sort of significant benefit to the U.S.A.

The facts behind these political decisions

On average globally, 80% of funding for national TB programmes comes from countries’ own domestic funds. In other words, overall these national TB programmes have never been as heavily subsidised by international aid as might be believed.

Logically, this would imply that the actions of the EU, the UK and the U.S. should only ever have a maximum 20% impact on the TB programmes and this hasn't been the case - but let's not forget that these programmes were being massively underfunded by everyone anyway, so every penny counted!. Allowing for economic discrepancies between countries, however, a more realistic picture emerges as follows: amongst all 'high-TB-burden' countries (i.e. TB endemic countries), domestic investment in TB programs was actually averaging out at 46% (so around half of these programmes’ budgets were being subsidised by that foreign aid). In high-TB-burden countries which are also defined economically as being of ‘low and middle income’ (LMICs), however, domestic investment in TB programmes is significantly lower, averaging out at around 27% (so three-quarters of their TB spend comes in as international aid) – but these countries were all already dangerously underfunded despite those international commitments to fund their programmes at a rate that is four times higher than has been being provided.

What this means is that these funding cuts are going to be most serious for the poor in these poorest countries – for the most vulnerable in other words. With this in mind, if any policy makers cared to consider their decisions, they should have expected that they would have the most appalling consequences in the poorer quarters of the world.

And this rapid, uncoordinated, and unstable withdrawal of foreign aid is indeed, right now, destabilising almost every national TB programme in TB endemic countries, with experts predicting a probable 310,000 extra deaths from tuberculosis by the end of this year. One analysis has further predicted two-and-a-quarter million extra TB deaths in the next five years (by the year when all those 192 UN member states committed to ‘ending' TB) - that is if things don't change. A live counter has even been launched online that shows this, that continuously tallies the reckoned number of extra lives lost since 24th January to the present. As of today, the extra deaths already stand at 24,540. But if you check on the link just above, an updated figure should appear which will be growing ever higher than this.

This is an unravelling catastrophe, in other words

The Stop TB Partnership’s Rapid Assessment

The Stop TB Partnership (of which Moxafrica is a member) recently conducted a rapid assessment on the impact on TB response in 12 high TB burden countries. We don’t know how these countries were selected, and only one is African (a region we will discuss in more detail shortly), but here are some headlines:

• Bangladesh: Activities at regional reference labs have been affected due to the suspension of USAID-supported microbiologists. Active Case Finding (ACF) supported by USAID projects (ACTB, TB-DNS) has been interrupted, affecting pediatric TB detection [pediatric TB is especially dangerous], diabetic clinics in large hospitals [diabetic patients are especially vulnerable to TB], and the field operations for 26 portable X-ray systems have been suspended. MDR patient management at hospitals has also been affected due to the suspension of dedicated medical doctors.

• Cambodia: Treatment support for half of the country has been impacted. Active Case Finding in half of the country has also halted, resulting in 100,000 people missing TB screening, with 300 DR-TB cases, and 10,000 DS-TB cases potentially going undetected.

• Ethiopia: 5,000 health staff are now unfunded by USAID and so have stopped working, severely affecting TB screening and detection.

• Pakistan: All screening and ACF activities in 27 districts have been suspended.

• Ukraine: TB treatment is affected due to drug supply issues (and Ukraine already havs perilous rates of MDR-TB).

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The Partnership’s summary is this: “The suspension of US Government funding has caused widespread disruptions across multiple aspects of TB response in high-burden countries.”

Stop TB’s TB Disruption Survey 

(as of 04/06/25 - constantly updated), identifying the numbers of reported disruptions in each country

Another Rapid Assessment – by The Union

In April, The International Union Against Tuberculosis and Lung Disease (The Union) published its own rapid assessment and reported that 65% of National TB Programmes (NTPs) in Africa (11 out of 17 respondents) had disclosed that the US Government funding stoppage had already negatively affected TB care and prevention. These effects included:

• Disruption in financial support for TB case detection and consequently reduced capacity for active case finding and diagnostic expansion

• Decreased availability of essential TB diagnostic tools, affecting laboratory operations and delaying patient diagnosis

• Layoffs of key TB service personnel, especially contract-based workers funded through external support

• Reduced financial resources for patient outreach and adherence monitoring, thus impacting treatment success rates

The survey responses were from Benin, Burkina Faso, Djibouti, Eswatini, Ethiopia, Guinea, Guinea-Bissau, Kenya, Madagascar, Namibia, Niger, Nigeria, Sierra Leone, Somalia, South Africa, Togo, Zimbabwe. Despite USAID funding termination, all these countries indicated that at this time they could at least still procure TB medications and diagnostic consumables (though we will shortly see that this may have been an optimistic statement based on Moxafrica’s own research).

The Union also established that:

• Patient access to diagnosis and treatment had already been affected in four of these countries

• Six countries had experienced disruptions in monitoring, evaluation, reporting and supervision

• In 11 countries, refresher training for existing staff, and all courses for new staff have been suspended

• Eleven countries noted that implementing partners, including international non-governmental organisations have reduced their operational scope, resulting in downsized TB programmes.

  
  

The WHO’s contribution

The month previously, the WHO had made its own statement (the WHO, of course, being directly targeted elsewhere by the Trump administration, and having to cut its own services as a consequence):

“Drug supply chains are breaking down due to staff suspensions, lack of funds and data failures, jeopardizing access to TB treatment and prevention services. Laboratory services are severely disrupted, with sample transportation, procurement delays and shortages of essential consumables halting diagnostic efforts.

“Data and surveillance systems are collapsing, undermining routine reporting and drug resistance monitoring. Community engagement efforts – including active case finding, screening and contact tracing – are deteriorating, reducing early TB detection and increasing transmission risks.

“Without immediate intervention, these systemic failures will cripple TB prevention and treatment efforts … and endanger millions of lives."

Moxafrica’s own analysis

Since we first heard a month ago from Goma in the Democratic Republic of Congo that there have been no TB drugs available for TB for the past four months, we have been actively trying to establish our own version of the realities on the ground.

We have heard that the supply of pediatric TB drugs and the four-drug-formulations for the first intensive phase of TB drug treatment has become problematic in Uganda, for instance, probably because of cutbacks in procurement resources. We have further heard of problems in Kenya, and also of some very disturbing cut-backs in South Africa (which include evidence of drug stock-outs), but other sources have been reluctant to reply, probably for political reasons.

Our general analysis is this. In the first two years of the COVID pandemic National TB programmes in high-burden countries were significantly disrupted as precious human resources were (mistakenly) switched from TB to COVID-19. This resulted in collateral increases in TB incident rates (more new cases each year) and extra mortalities, neither of which the world of TB has yet recovered from. There is absolutely no reason to believe that these current disruptions won’t be similar or worse.

Furthermore, it's been said that poor treatment of TB is worse than no treatment at all (this is because poor treatment management inevitably provokes more drug-resistance in the pathogen). Well, currently it looks like we are facing both – both poor treatment and no treatment at all, so there will inevitably be more TB circulating in vulnerable communities, more of it will be becoming drug-resistant, and there will inevitably be many more avoidable deaths - all caused by political expediencies in wealthy countries.

Meanwhile, we know that moxa was used before the TB drugs were discovered at the height of Japan’s TB epidemic in the 1930s with documentary evidence of effect. We also know that it can help improve recoveries alongside TB drugs because data from our own published research substantiate this. We have to acknowledge, however,  that we have no evidence that it might promote recovery tendencies in MDR-TB cases when there are no available drugs (though we are almost certain it will do, and the only reason that we have to acknowledge absence of evidence is because we have never been given access to MDR cases in such challenging circumstances, despite the majority of MDR-TB cases falling into this category for the last thirty years).

With the tiny resources we have at our disposal (which is very limited), and given all of the above, we are now committing the charity to helping anyone anywhere who might have been victimised by these recent cuts in funding. Dr Tedros, Director General of the WHO, has asked that everyone responds to this crisis “with a sense of urgency, initiating a response commensurate to the disruption”, and we will do our best to comply with his request.

Just get in touch, and let’s explore what is possible: info@moxafrica.org.

Finally

At the end of the Union’s report Dr Kobto Ghislain Koura, its Director of TB, said: “This crisis is a reminder that Africa cannot rely indefinitely on external aid to fight TB. It is time for governments to strengthen domestic funding and focus resources on evidence-based strategies that deliver the greatest impact.”  Of course in many ways he’s right, and we fully agree that national governments are often just as responsible for their respective funding shortfalls to their TB programmes as the donor nations - in fact we are on record as stating that politicians everywhere (as part of their social contract) need to do much more to protect their citizens who are most vulnerable to TB – but strengthening domestic funding is not simple. It's also easy to argue that money is tight everywhere, even in richer countries, and this is not that simple either.

In a follow-up blog, with the help of some analysis courtesy of the Treatment Action Group and Partners in Health, we will explore not just some of the myths that persist around these issues, but also the very existing structural violence that underlies the Trump administration’s inhumane policies, as well as how the business (because that what it is, a big profitable business) of foreign aid is so malevolently and deliberately misrepresented to the voting populations in higher-income donor countries in the Global North.