Even as the world is racing to contain the deadly Ebola epidemic in the Democratic Republic of Congo, the Trump administration is moving ahead with a plan that could decimate support for programs that detect and snuff out exactly such outbreaks.
The new plan, proposed by the State Department, aims to overhaul the Centers for Disease Control and Prevention’s work on a landmark global H.I.V. program that also helps countries manage surveillance for emerging diseases, strengthen laboratory networks and support childhood immunizations.
If the plan goes into effect on Oct. 1 as scheduled, it would effectively shut the agency out of overseeing many global health programs and shift control over the bulk of funds and decisions to the State Department.
The changes may sideline the country’s premier experts on global health and could lead to the closure of about a third of its 60 country offices within the next three years, according to some officials with knowledge of the programs.
“This is the end of autonomy and independence and long-term capacity at the C.D.C. for work in global health,” said Dr. Atul Gawande, a former head of global health at the U.S. Agency for International Development and a professor at Harvard Medical School.
The proposal is intended to diminish the agency’s authority in the President’s Emergency Plan for AIDS Relief, known as PEPFAR, a program credited with saving 26 million lives since it was created by the administration of President George W. Bush in 2003. Before 2025, U.S.A.I.D. managed more than half of PEPFAR’s budget, and the C.D.C. handled much of the rest.
The changes may jeopardize the health of the more than 12 million people on H.I.V. treatment supported by C.D.C. funds, said Dr. Michele Montandon, who led the agency’s team on mother-to-child transmission of H.I.V. until she was laid off in August.
“This will completely destabilize H.I.V. work abroad,” she said. “We’ve seen service disruptions, deaths and babies born with H.I.V. after shuttering U.S.A.I.D., and we can expect more to come if C.D.C. is also shut out of this work.”
The State Department said the plan would have no adverse effect on the C.D.C. or the work it does abroad.
“The State Department and Health and Human Services are working together to preserve the C.D.C.’s critical capabilities while modernizing how foreign assistance is delivered,” Tommy Pigott, a State Department spokesman, said in a statement. (The C.D.C. is a division of the Department of Health and Human Services.)
“The facts are straightforward: The State Department expects C.D.C. overseas funding to increase — not decrease — under the America First Global Health Strategy, and no C.D.C. offices are being closed because of State Department decisions,” he said.
Andrew Nixon, a spokesman for the Health and Human Services Department, said: “What is underway is a modernization of a fragmented system that for years tolerated duplication, overlapping investments and poor coordination across agencies.”
In a typical year under the current system, the State Department would hand the C.D.C. a budget of about $2 billion. The agency then would work with countries to set their health priorities and allocate the funds to ministries and partner organizations to support them.
The new plan replaces the health agency’s budget for the work with a “fee-for-service” menu that requires countries to choose and pay for assistance from C.D.C. staff in specific areas — wastewater and environmental surveillance, for example.
“Global health response should be based on need and the threat level, not whether a government signed up for a tiered service package in advance,” Dr. Montandon said.
In interviews, more than a dozen current and former employees of the C.D.C. and the State Department said they expected countries would, for financial or political reasons, pay for only a minimum of services, forgoing spending in areas that have less immediate impact but that are nonetheless important. (Many spoke on condition of anonymity because of fear of retaliation from the administration.)
They predicted that the new transactional model would further destabilize relationships with foreign governments, unravel public health programs and make Americans more vulnerable to infectious disease threats.
“It’s contrary to the U.S. interest to not maintain a large, substantial C.D.C. program in these countries,” said John Blandford, who worked at the State Department and led the C.D.C. division that includes the program from 2013 to 2016. Dr. Blandford then oversaw C.D.C. country offices, first in Vietnam and then in South Africa, till he retired from the agency last year.
He added that the State Department “does not have the expertise or the capacity to actually know what they should be doing in these programs.”
Over the decades, the agency’s work through PEPFAR extended well beyond H.I.V. to support the people and infrastructure required for other public health activities, often with little additional overhead. Together, the funds helped to maintain about 1,500 overseas employees, 1,700 labs and a program that trains local disease detectives for outbreak response.
For example, PEPFAR helped build up skills in diagnostics, contact tracing and data analysis that helped countries combat Covid. More recently, South African researchers were able to quickly decode the genetic sequence of the hantavirus that caused an outbreak. The C.D.C.’s country office in Congo is actively engaged in the current Ebola response.
C.D.C. officials in the program have worked closely with health ministries, building trust and relationships that become crucial during emergencies, Dr. Blandford said. “I really do worry that those relationships are not being respected in terms of what the payoff is when you move to a menu approach and basically treat C.D.C. as just a contractor to be utilized.”
Some C.D.C. scientists posted overseas also said they found what they called the State Department’s “rent-an-epidemiologist” proposal to be demeaning of their work. Neither they, nor their leaders in Atlanta, were consulted before the plan was presented to them on May 6.
In a call that day with staff of the C.D.C. division that oversees global H.I.V. work, Hank Tomlinson, the division’s director, said he had seen the document outlining the changes for the first time on Friday, May 1, five days earlier. “We didn’t have input into them beforehand,” he said, adding that over the weekend, he and others were able to get a few “serious issues” addressed. (The New York Times obtained a recording of the call.)
The Trump administration’s dismantling of U.S.A.I.D. last year has led to sharp decreases in the numbers of people newly tested, diagnosed and treated for H.I.V., and of people taking preventive drugs. The number of children who began treatment has fallen by 15 percent, according to a report this month from the Clinton Health Access Initiative.
In Haiti, the abrupt halt in aid forced some clinics to close, stranding patients who needed access to H.I.V. treatment. The C.D.C. contributes $112 million, about 80 percent, to Haiti’s H.I.V. budget, and a drop in those funds is likely to imperil even more clinics, said Dr. Alain Casséus, who leads infectious disease work at Zanmi Lasante, the largest health care provider in Haiti after the government.
Political instability makes it impossible for some people to travel and seek care in clinics that might still be open, he said, adding, “In areas where that’s not possible, we will see probably deaths piling up.”
This year, the administration delayed the transfer of PEPFAR funds to the C.D.C. by months, holding back money already appropriated by Congress for the work and eventually disbursing only $1.3 billion. Now, the new plan will “basically destroy PEPFAR,” said Dr. Thomas Frieden, who led the C.D.C. under President Barack Obama.
The administration is moving away from disease-specific programs like PEPFAR entirely, instead structuring foreign aid as bilateral agreements with governments, often with strings attached.
The new agreements do not set goals of eradicating polio, or driving down the H.I.V. and tuberculosis pandemics or maintaining goals in child mortality, Dr. Gawande said. “Instead, they’re just individual transactional deals with no larger goal or purpose in mind.”
The new model for C.D.C. services is also transactional, with oddly specific numbers. For example, the seventh item of 34 on the menu, “integrated country surveillance for emerging and zoonotic infectious diseases,” costs $105,372 each year for the lowest tier of support — which a small country like Eswatini might choose — $150,190 for the second and $418,898 for the highest tier, meant for large countries such as Congo with complex systems.
Any country that receives aid from the United States must pay for minimal administrative support. And any country that receives more than $125 million in aid must buy a minimum package of some services, including population health surveys, the training program for disease detectives and some disease surveillance — but not the integrated surveillance for emerging diseases. Only nine of the countries that have signed agreements with the United States meet that criterion.
But even they may skip support for polio eradication, vaccination during public health emergencies and other items on the menu. “They’re going to be hard-pressed to make choices when they can think about other things they can spend the money on,” Dr. Blandford said.
