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

For every nine Americans who died in 1900, one of them died from tuberculosis (TB). But then miraculously a cure was found, through a combination of antibiotics, and within a few years US deaths had fallen to less than one in 18 deaths, and in 2019 it accounted for just 1 in every 320. Globally, the number is a little higher, with TB accounting for roughly 2 percent of all deaths, approximately 1.25 million deaths every year.

Yet while we have the tools to cure TB, using them effectively remains a challenge (it still kills around 7% of Americans who contract it), especially in resource-constrained settings. The standard treatment requires a strict six-month regimen of multiple antibiotics, which can be difficult to complete in places where healthcare access is limited, drug supplies are unreliable, or patients must travel long distances for care. The biggest obstacle is that most people start feeling better after just two months, often leading them to stop treatment prematurely. But TB bacteria are stubborn—cutting the regimen short allows surviving bacteria to develop resistance, turning what was once a curable infection into multidrug-resistant TB (MDR-TB), a far more dangerous and expensive disease to treat.

Resistant TB can be a nightmare for both patients and healthcare systems. Unlike regular TB, which can be treated with inexpensive first-line antibiotics, MDR-TB requires a far more expensive regimen of second-line drugs. Until a few years ago, it also required up to two years of treatment, including injections that are less effective, and far more toxic with side effects including hearing loss, kidney damage, and debilitating nausea. Thankfully, recent innovations in TB drugs, such as bedaquiline, have made treatment far better for the vast majority of cases. Whilst very rare, resistance to these new drugs exists, and lead to patients being put on the horrid injections.

It is common for different governments to prioritise different areas in global health. Partly for altruistic reasons, successive US governments have made TB a priority, contributing about 50 percent of international donor funding. These funds have been very well spent; across the world TB programmes since 2000 have saved an estimated 79 million lives.

As well as the pragmatic reason to respond, there is a strong self-interested case for making these investments, too. TB is infectious: the higher the global burden, the more cases will reach the United States. Further to this, MDR-TB spreads just like regular TB, meaning every 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, turning TB into an untreatable scourge, once again.

It's reasonable that the new administration in the US would like to review all official development aid (ODA) commitments upon taking office, and I am confident that any well-run assessment will highlight the value America gets from its investments in stopping TB. However, the 90-day freeze on most aid while this assessment is carried out causes real challenges for accessing medication. Even though waivers have been written for TB treatment and other illnesses like HIV, there are difficulties enacting them, in part because USAID staff have been removed from office and there aren’t the staff in place to implement these waivers. If this impedes access to treatment, resistance is all but assured.

Reducing access to vital treatments against drug-resistant TB will likely pose huge risks for everyone, including Americans. Firstly, resistance to these drugs will increase. People currently taking new second-line drugs, like bedaquiline, might have their treatment curtailed, greatly increasing their chance of acquiring bedaquiline-resistant TB. If it becomes harder to purchase the drugs through safe routes, there is also likely to be an increase in people taking substandard treatments which often include enough of the drug to engender resistance but not enough treat the infection. Other people might stop treatments early due to the cost or unreliability of supply chains. Secondly, there hadn’t been a new TB treatment in more than 50 years up until 2016. It’s not widely expected that new drugs will follow on from these. The hope that R&D would increase if resistance ticks up becomes much less likely if there isn’t a market for purchasing new treatments. Eventually this resistance will reach high-income countries, but it will likely take years for treatments to materialise, meaning far more people will suffer.

This is all happening against a backdrop of accelerating TB rates in the US. Every year between 1953 and 2020, rates of TB fell in America. But that changed in 2021, when TB rates started to rise, a trend which continued in 2022 and 2023 (the last year we have data for). There was a 35 percent increase in cases between 2020 and 2023, and total number of deaths from TB are at their highest level since 2006. This is a worrying trend and it’s getting worse. One of the largest TB outbreaks in US history is happening right now in Kansas, this began in 2024 and is not captured in the data above.

If a failure to treat TB outside of America continues, then TB rates will increase in the US, and MDR-TB rates will likely rise particularly fast. It's worth putting the risks into perspective. CGD recently undertook research into the cost of treating different types of drug resistance. We estimated a cost of $148,000 per patient to treat drug resistant TB in America. In total, we looked at 11 different indications in 204 countries; TB is at least twice as expensive as any other type of drug resistance in America, and almost twice 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 multi-drug resistant. But if MDR-TB rates rise across the world, those costs will increase fast.

I’m not aware of any detailed epidemiological modelling on how much TB might increase in the US if global action plans falter. But it’s possible to cost speculative outcomes (see Table 1). At the moment in the US, 8.5 percent of TB cases are resistant to the first line treatment Isoniazid, and within this group, 1.4 percent of TB cases are MDR-TB. If all of the Isoniazid-resistant TB cases became MDR-TB cases, the cost of treating MDR-TB would increase by over $100 million a year. If, on top of this, TB rates rise at twice the current rate to over 30 percent a year, then the cost of treating TB would rise to almost a billion USD a year by the end of the administration, and more than two and a half times as many Americans will die from TB during the current Trump administration than under Biden. It’s possible that the impact could be far worse than this. Globally, the rate of TB is almost fifty times higher than in the US, and the MDR-TB rate is over 100 times greater. Whilst it is unlikely that American rates will rise to this average in the short term, if they do reach this level it would see the cost of treating TB increase to over $11 billion.

Table 1. Cost of TB treatment in the US in four years under speculative scenarios, in million USD

That is to say nothing of the approximately 33,000 Americans who’d die every year from this horrid disease. It also doesn’t include the macro-economic impact, which tends to be about ten times greater than the health impact.

It's always cheaper to prevent a disaster than to pay to pick up the pieces later. The pause in foreign aid threatens to turn back the clock on TB progress at a moment when the world cannot afford another global health crisis. If funding is not restored quickly, in a way that sees treatments reach the people who need them, then MDR-TB will rise and more lives will be lost. The initial impact will be felt in high TB burden countries, but the repercussions will ultimately come back to haunt Americans, and a preventable disaster will unfold.

Data note: Costs of treating TB were derived from 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 World Health Organization. Fatality rates for TB was 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 seen as appropriate given that the fatality rate for all TB was 6.9 percent in both countries.