USAID Freeze Potentially Risks Millions of Lives Affected by Tuberculosis

Budget cuts to US foreign aid threaten to upend essential aid programs—like tuberculosis (TB) care programs and other critical health services—potentially devastating USAID-dependent countries and resulting in the loss of millions of lives, according to a study in PLOS Global Public Health. ¹

The cuts to US foreign aid began on January 20, 2025, just 2 days after President Donald J. Trump was sworn into office and signed an executive order to freeze foreign aid, claiming that it no longer “aligned with American interests.”² Federal lawsuits filed by non-government organizations and global health advocates have been under review by the US Supreme Court for the majority of 2025.

However, just recently, the Trump administration's appeal to SCOTUS asking to freeze the $4 billion dollars approved by the US Court of Appeals—that must be spent by the end of the month—was granted, some of which would aid USAID-dependent countries dependent on the National Tuberculosis Program (NTP).³ In the past 2 decades, the US government has provided about $200 to $250 million annually in bilateral funding for the TB response. The program has saved more than 79 million lives and prevented nearly 3.65 million deaths in 2024 alone.^4-5 Researchers of the PLOS Global Public Health study predicted countries highly dependent on US government funding could expect an estimated addition of nearly 4.4 million cases of TB and almost 900,000 additional deaths.¹

USAID freeze can potentially increase the number of tuberculosis cases in countries dependent on US government funding. | Image Credit: @pathdoc-AdobeStock.jpeg

“The recent funding cuts are expected to catalyze the integration of health programs and the end of the siloed approach to health care programs that still characterizes healthcare service delivery in many parts of the world,” the study authors wrote.

Risk Assignment of US Foreign Aid-Dependent Countries

The study model assessed 26 high-burden countries (HBC), all of which are major recipients of US international aid, using publicly available reported data from the WHO. Data was obtained from 2021-2023, which researchers noted was a relatively stable period for funding contributions. These data were only available for 15 of the 26 countries. For those that did not have available data for 2021 or 2022, only 2023 data was used. Additionally, these 26 countries accounted for nearly 80% of the global TB burden. The countries were categorized based on their dependency on the US government. The categories were as follows:

• Low dependency: 0% to 22% of a country's NTP expenditures are funded by the US government. Eight of the 26 countries fell into this category. These HBCs have diversified funding and minimal reliance on US government funding, making them less susceptible to TB service disruptions.
• Moderate Dependency: 23% to 37% of a country's NTP expenditures are funded by the US government. Ten out of the 26 countries fell in this category and face moderate risk in US government funding cuts that could potentially cause budget strains and affect service and delivery and supply chains.
• High Dependency: More than 37% of a country's NTP expenditures are funded by the US government. Eight of the 26 countries fell into this category, making them extremely vulnerable to program disruptions and shortages of diagnostic tools, medications, and healthcare personnel.

The model used to identify the impact of funding cuts to the TB program focused on incidence of cases and mortality and the country’s ability to recover from said cuts. The cases were framed into three categories, all of which exemplify a USAID freeze and funding cut disrupting TB services for 90 days. The categories are as follows: 1) Minimum Impact Scenario (S1), in which the funding gap is subsequently met, and services are recovered to baseline in the next three months; 2) Moderate Impact Scenario (S2), in which the funding gap is subsequently met, but it takes 1 year for TB services to recover to baseline; and 3) Worst Possible Scenario (S3), in which the funding gap is not met and TB services do not recover from the level they reached during the freeze.

Projected Impact of USAID Funding Cuts

Across the 26 HBCs and the segregated scenarios S1-S3, researchers estimated 634,700 (95% CI, 447,700-806,600), about 1.6 million (95% CI, 1,210,400-2,060,000), and about 10.6 million (95% CI, 7,848,800-13,190,000) additional TB cases, respectively, from 2025 to 2030. TB deaths are projected to increase by 99,900 (95% CI, 65,200-130,000), 268,600 (95% CI, 185,800-337,900), and about 2.2 million (95% CI, 1,570,800-2,807,300) across these scenarios during the same period.

When adjusted for sensitivity, under which only 50% of NTP expenditures funded by the US government would influence disruptions in TB care, in the worst-case scenario (S3), the estimated additional cases are about 4.4 million (95% CI, 3,224,000-5,418,000) and additional deaths are 884,000 (95% CI, 618,900-1,106,100).

“Given the key role of the US as a key funder for TB research, withdrawal of USG support threatens the development of such critical new tools, further delaying progress and—without adequate mitigation—making End TB targets unattainable,” the study authors explained. “Hard-to-reach, high-risk, and vulnerable populations, previously connected to national TB programs through civil society organizations (CSOs), now face complete isolation as US-funded initiatives shut down.”

The study is limited by its simplified assumptions that may not fully capture real-world complexity. These estimates assume proportional impacts from US funding counts and use WHO data that may not reflect future contributions or varying country-level health system capacities, political stability, or donor support. Furthermore, the effects on drug-resistant TB were not modeled separately, as predictions may not reflect individual countries' unique situations.

“This scenario is extreme but now credible: with additional high-income countries also cutting back on international aid, new options are needed for mitigating the shortfall in USG funding,” the study authors concluded.

References

1. Mandal S, Nair S, Sahu S, Ditiu L, Pretorius C. A deadly equation: The global toll of US TB funding cuts. PLOS Glob Public Health. Published online September 10, 2025. doi:10.1371/journal.pgph.0004899

2. Reevaluating and realigning United States foreign aid. The White House. March 14, 2025. Accessed September 11, 2025. https://www.whitehouse.gov/presidential-actions/2025/01/reevaluating-and-realigning-united-states-foreign-aid/

3. Fritze J. Supreme Court temporarily allows Trump to pause billions in foreign aid. CNN politics. CNN. September 9, 2025. Accessed September 11, 2025. https://www.cnn.com/2025/09/09/politics/supreme-court-temporarily-allows-trump-to-pause-billions-in-foreign-aid

4. Fritze J. Trump urges Supreme Court to revisit fight over billions in foreign aid. CNN politics. CNN. September 8, 2025. Accessed September 11, 2025. https://www.cnn.com/2025/09/08/politics/supreme-court-trump-foreign-aid

5. Funding cuts impact access to TB services, endangering millions of lives. World Health Organization. Accessed September 11, 2025. https://www.who.int/news/item/05-03-2025-funding-cuts-to-tuberculosis-programmes-endanger-millions-of-lives

6. Bonavitacola J. Cuts to PEPFAR spell detrimental HIV outcomes in South Africa. AJMC. February 12, 2025. Accessed September 11, 2025. https://www.ajmc.com/view/cuts-to-pepfar-spell-detrimental-hiv-outcomes-in-south-africa