US budget negotiations threaten global health spending

EDITOR’S NOTE: This article is part of a GlobalPost Special Report titled “The Seven Million,” about the many challenges faced worldwide in an effort to reduce child mortality. The project is supported through a partnership with the Henry J. Kaiser Family Foundation as part of its U.S. Global Health Policy program. In the coming months, GlobalPost will examine this issue around the world. In this first of a continuing series of articles, Global Health Correspondent Sam Loewenberg and Global Health Reporting Fellow Marissa Miley reported from Washington, DC and Cambridge, Mass.

WASHINGTON – Many in Congress compare the budget process to balancing one’s checkbook at home. Now, as Congress braces for an historic struggle over the Obama administration’s proposed budget for fiscal year 2014, one of the biggest potential impacts of sought-after cuts will not be at home, but abroad, as millions of the world’s poorest people, especially children, could feel the pain of America’s belt-tightening.

The unfolding prelude to the budget fight, illustrated by a trove of correspondence to Congress reviewed by GlobalPost, illustrates the power that well organized lobbying has on influencing public policy. While the administration has pledged to focus its global health resources on the estimated seven million children who die every year, mostly from preventable causes, those efforts could be undercut by lawmakers eager to reduce government spending.

In testimony scheduled for Wednesday and Thursday, U.S. Agency for International Development (USAID) Administrator Rajiv Shah will make the case for the Obama administration’s global health budget. In its spending proposal, the administration has largely protected existing programs and has even increased budgets in some areas, including in maternal and child health, malaria, and vaccines, as well as funding for multilateral health programs.

The austerity budget put out by the Republican-controlled House of Representatives could significantly impact some of these programs that affect children, according to aid groups. The House plan, sponsored by Budget Committee Chairman Paul Ryan (R-Wisc.), would cut the base international affairs budget by 5.6 percent from levels already reduced from sequestration, according to the US Global Leadership Coalition, a foreign aid advocacy organization. Overall, the organization estimates this allocation is 25 percent less than what the base international affairs budget was four years ago.

“Given our debt crisis, the bar for justifying foreign aid is higher than ever. Wasteful spending on ineffective and unsustainable programs will not be tolerated,” said House Foreign Affairs Committee Chairman Ed Royce (R-Calif.), in an opening salvo on the committee’s website in anticipation of Thursday’s testimony by Shah.

Newly appointed Secretary of State John Kerry, in testimony before Congress last week, defended strong foreign assistance funding, declaring, “development is not charity. It’s an investment in a strong America and a free world.”

Even if the administration succeeds in preserving the current level of funding, public health experts warn that the global health budget is far too low to meet current needs. Of the 75 countries that account for nearly all of the world’s preventable child deaths, less than one-third are on track to meet the Millennium Development Goal on child mortality, according to the aid monitoring group Countdown to 2015. Thirteen countries have made little or no progress.

Prioritizing Health

A review of the correspondence to Congress obtained by GlobalPost provides insight into the behind the scenes battles that will determine how the United States will continue to support global health. Some of the letters are from members of Congress themselves, as they try to convince their colleagues to maintain or reform current programs. Tellingly, the letter with by far the most signatures — more than 100 — is for maintaining funding for the global HIV/AIDS program, known as PEPFAR (the President’s Emergency Plan for AIDS Relief). The program, which was started under the George W. Bush administration, has long had broad bipartisan support in Congress. In contrast with nearly every other disease that affects people in developing countries, HIV/AIDS has also had a profound impact on the US population, and thus resonates with voter-conscious lawmakers.

HIV/AIDS receives about two-thirds of the total US global health budget. The rest is divided between all other diseases, nutrition, and integrated health programs. It is these funds that are most at risk of getting cut in the ongoing budget negotiations. HIV/AIDS, despite its massive funding, is not one of the biggest causes of child mortality. Instead, the top causes are neo-natal deaths (largely due to lack of access to health care), malaria, pneumonia, and diarrhea. The problem, say child health advocates, is not that HIV/AIDS get too much, but that everything else gets too little.

While the Obama budget keeps funding for popular disease programs like AIDS (with relatively small cuts) and malaria (with a marginal increase), it proposes a 19 percent cut in the budget for tuberculosis (TB), a less well known, but still devastating disease that kills 1.4 million people per year. About 15 percent of TB cases are estimated to affect children. A letter from a bipartisan group of members of Congress to the House appropriations committee asked for funds to be reinstated, noting that one-in-four AIDS deaths are associated with TB co-infection. The members, echoing a broad consensus of public health experts, argue that insufficient funding can both undermine the gains made by PEPFAR as more people suffer TB, and that insufficient treatment programs have resulted in more than 300,000 cases per year of potentially devastating multidrug-resistant strains of the airborne disease.

"The lobby for tuberculosis is far weaker than HIV and, remarkably, malaria,"  said Roger Bate of the American Enterprise Institute, who himself has been one of the prime advocates for increasing support to the US malaria program. TB, he says, "is a real threat, it's expanding, and it deserves more money — and yet the budget is cut."

Advocacy groups recognize that the Obama administration has prioritized select global health efforts in its 2014 budget, such as international health initiatives like the Global Fund, which provides funding for HIV/AIDS, TB, and malaria, in line with USAID’s overall goal to maximize aid effectiveness, particularly in a tight fiscal climate. But they share concerns that potentially deeper cuts to the overall international affairs budget will compromise existing progress.

Rep. Gerry Connolly (D-VA) dismisses the claim that cutting foreign aid for health is good for cost savings: “It’s always their applause line. Of course you are talking than less than one percent  of the foreign budget – I mean it doesn’t balance anything.  And it’s cheap at the price, if you think about it as a powerful, diplomatic tool that allows us to do all kind of things without having to put troops on the ground,” said Connolly, himself a former congressional staffer who helped write the foreign aid legislation. “We lack a national consensus about what we should do. And that flows from our long time ambivalence about our role in the world.”

Food Fight

By far, the most controversial budget fight in global health is the Obama administration’s attempt at significantly reforming the way the US gives international food aid. The current system, which numerous reports have found to be highly wasteful, has the support of powerful vested interests in the shipping and agricultural industries, according to a review of advocacy documents.

This is not the first attempt at such reforms. The Bush administration tried to make a similar change, and was met with strident opposition from US agricultural and shipping interests, which have always successfully shot down past proposals, and had mobilized to oppose the current reform attempt even before it was officially announced.

Hunger is an underlying cause of child mortality in more than one-third of all child deaths, according to the WHO. While there have been strides made at a global level, in sub-Saharan Africa there has been barely been any progress on chronic childhood malnutrition, which only dropped from 43 percent in 1990 to 41 percent in 2010, according to the United Nations Development Programme.

The US is by far the world’s largest food donor, spending about $1.5 billion sending food to hungry people around the world. The changes, which would allow relief organizations to purchase more food locally rather than waiting it for it be shipped from the US, would save up to 50 percent of costs, reach 2 to 4 million more people, and save months of transport time, according to administration estimates. Advocates of reform point out that the US is the only major food donor in the world that still uses this system, and that other countries simply give cash to aid agencies, which can be used for local purchase of food.

Some foreign aid advocates argue that the Obama administration’s reform does not go far enough: in the eyes of these advocates, the proposal, which ensures that shipping of US food is at least 55 percent of the food aid budget, and thus does not maximize flexibility in providing aid.

Under the current system, developed in the 1950s as a way to offload surplus US harvests, America purchases grain, oil, and other products on domestic exchanges. The US then transports it on US flagged ships to hunger-afflicted regions. According to reports by the Government Accountability Office, this wastes around 50 percent of US spending on food aid, which goes to domestic agricultural and shipping industries. Many large aid groups have long advocated for a reform of this system, including CARE, Oxfam America, Partners in Health and ONE. 

At the same time, other aid groups have a vested interest in the current process, particularly the part of the system known as “monetization.” Under this system, American aid groups that receive the food may sell off some of it in the afflicted region, in order to fund other development programs for which they don’t receive direct funding. Members of an advocacy group for organizations that want to maintain the current system, the Alliance for Global Food Security, include religious aid organizations like World Vision, the United Methodist Committee on Relief, and the Adventist Development & Relief Agency, International. 

A 2011 GAO analysis found that this complicated process wastes about one-third of funds and can disrupt food local markets. 

American agricultural and shipping companies that are proponents of the current system argue that the fact that the food aid program also supports American industry has helped ensure that Congress continues to fund it. If it were just another budget item, it could face cuts.

In a March 21 letter to congressional leaders, written more than two weeks before the administration had released its proposal to reform the program, dozens of trade associations representing corn, wheat, beef, oil, and other agricultural interests, a gaggle of domestic shipping companies, and various faith-based aid groups, wrote: “Growing, manufacturing, bagging, shipping, and transporting nutritious U.S. food creates jobs and economic activity here at home, provides support for our U.S. Merchant Marine, essential to our national defense sealift capability, and sustains a robust domestic constituency for these programs not easily replicated in alternative foreign aid programs.”

Their rhetoric appears to have been picked up by sympathetic members of Congress, who penned their own letter two weeks later: “The Food for Peace program has supported key American interests both domestically, by supporting American agriculture and our merchant marine, and internationally by providing food aid to impoverished countries in desperate need. Changes to this program will threaten all of the missions it has supported, including particularly the domestic sealift capacity on which our military depends.”

The letter was co-authored by Rep. Elijah Cummings (D-Md.) with Duncan Hunter (R-Calif.). Cummings received $51,000 in campaign donations from the shipping industry and $4,250 from agriculture industry in the 2012 election cycle, while Hunter received $31,500 from agricultural and $22,250 from shipping companies, according to an analysis for GlobalPost by the Center for Responsive Politics, a watchdog group.

The Impact of Negelect

Meanwhile, other less glamorous diseases are either fighting to maintain their funding or have scant attention. Malaria, which kills about 500,000 children a year, still struggles to get strong support, despite a highly praised US government program that has shown large gains in prevention and treatment. With budget pressures looming, many supporters were fearful of large cuts and galvanized support from the business community and philanthropies, which so far has paid off. But the current budget pressures mean that badly needed expansions into two countries, Nigeria and Democratic Republic of Congo, which account for more than 40 percent of all malaria deaths, probably will not happen soon. Even worse, if further cuts were to come it would reverse the current gains as people who have lost resistance were again exposed, said Dr Mickey Chopra, chief of health at UNICEF. Children would die, he said. “Epidemiologically and medically it would be a disaster.”

The current budget battles affect not only existing programs, but trust in the US as a reliable, long-term partner, said Greg Adams, Director of Aid Effectiveness at Oxfam. A successful global health strategy relies upon close working relationships with governments. The constant fluxuations from congressional budget wars undermines the US’ ability to operate, he says.

“You’re not just cutting off medications, you’re damaging trust, damaging relationships and throwing progress backwards because people can’t depend on the US as a reliable partner. … That has a really powerful impact in getting people to engage with us,” said Adams.

One of the leading causes of death for children also receives the least attention: diarrhea. Mundane, and preventable, as it is, it still causes 11 percent of all deaths in children, according to Dr. Chopra.            

 Diarrhea, said Dr. Chopra, “is a condition which no one should die of. No child should die of it because we have very cost effective ways of treating it.” 

Additional reporting for this article by Marissa Miley.

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