Centers for Disease Control and Prevention
Global Health Programs: FY2001-FY2010
Tiaji Salaam-Blyther
Specialist in Global Health
August 21, 2009
Congressional Research Service
7-5700
www.crs.gov
R40239
CRS Report for Congress
P
repared for Members and Committees of Congress
Centers for Disease Control and Prevention Global Health Programs: FY2001-FY2010
Summary
A number of U.S. agencies and departments implement U.S. government global health
interventions. Overall, U.S. global health assistance is not always coordinated. Exceptions to this
include U.S. international responses to key infectious diseases. For example, U.S. programs to
address HIV/AIDS through the President’s Emergency Plan for AIDS Relief (PEPFAR), malaria
through the President’s Malaria Initiative (PMI), and avian and pandemic influenza through the
Avian Flu Task Force. Although several U.S. agencies and departments implement global health
programs, this report focuses on funding for global health programs conducted by the U.S.
Centers for Disease Control and Prevention (CDC), a key recipient of U.S. global health funding.
Congress appropriates funds to CDC for its global health efforts through five main budget lines:
Global HIV/AIDS, Global Immunization, Global Disease Detection, Malaria, and Other Global
Health. Although Congress provides funds for some of CDC’s global health efforts through the
above-mentioned budget lines, CDC does not, in practice, treat its domestic and global programs
separately. Instead, the same experts are used in domestic and global responses to health issues.
As such, CDC often leverages its own resources in response to global requests for technical
assistance in a number of areas that also have domestic components, such as outbreak response;
the prevention and control of injuries and chronic diseases; emergency assistance and disaster
response; environmental health; reproductive health; and safe water, hygiene, and sanitation.
From FY2001 to FY2009, Congress provided about $3.3 billion to CDC for global health
programs. In addition, CDC received transfers from the Office of the Global AIDS Coordinator
(OGAC) as an implementing partner of PEPFAR, and transfers from the U.S. Agency for
International Development (USAID) for PMI. Including these transfers, CDC’s spending on
global health activities from FY2004 to FY2008 totaled $5.2 billion, of which 78% was targeted
at HIV/AIDS programs. Data on FY2009 transfers have not yet been provided to CRS.
President Barack Obama has indicated early in his Administration that global health is a priority
and that his Administration would continue to focus global health efforts on addressing
HIV/AIDS. When releasing his FY2010 budget request, President Obama indicated that his
Administration would increase investments in global health programs and, through his Global
Health Initiative, improve the coordination of all global health programs. The President requested
that in FY2010, Congress approve $9.1 billion for all global health programs, including $479.8
million to CDC for global health programs—an estimated 3.4% increase over FY2009 enacted
levels for CDC global health activities. In the House (H.Rept. 111-220) and Senate
Appropriations Committee (S.Rept. 111-66) reports accompanying the FY2010 Labor, HHS,
Education Appropriations (H.R. 3293), funds for CDC’s global health activities exceed the
President’s request by some $4 million and $14 million, respectively.
There is a growing consensus that U.S. global health assistance needs to become more efficient
and effective. There is some debate, however, on the best strategies. This report explains the role
CDC plays in U.S. global health assistance, highlights how much the agency has spent on global
health efforts from FY2001 to FY2010, and discusses how funding to each of its programs has
changed during this period. For more information on U.S. funding for other global health efforts,
including those implemented by USAID, the Department of Defense (DOD), and the Global Fund
to Fight AIDS, Tuberculosis, and Malaria (Global Fund) and debates about making U.S. global
health assistance more efficient, see CRS Report R40740, U.S. Global Health Assistance:
Background, Priorities, and Issues for the 111th Congress.
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Centers for Disease Control and Prevention Global Health Programs: FY2001-FY2010
Contents
Introduction ................................................................................................................................ 1
CDC’s Global Health Programs................................................................................................... 1
Global HIV/AIDS ................................................................................................................. 2
President’s Emergency Plan for AIDS Relief (PEPFAR).................................................. 3
Global Malaria...................................................................................................................... 3
President’s Malaria Initiative........................................................................................... 4
Global Tuberculosis .............................................................................................................. 4
Global Disease Detection ...................................................................................................... 5
Pandemic and Avian Influenza .............................................................................................. 5
Global Immunization ............................................................................................................9
Polio ............................................................................................................................. 10
Measles......................................................................................................................... 11
Other CDC Global Health Programs.................................................................................... 11
CDC Global Health Spending: FY2001-FY2009 ....................................................................... 12
CDC Global Health Spending: FY2001-FY2003 ................................................................. 12
CDC Global Health Spending: FY2004-FY2008 ................................................................. 13
Apportionment of CDC Global Health Funding: FY2004-FY2008 ................................ 15
CDC Global Health Funding: FY2009-FY2010......................................................................... 15
Related Policy Issues ................................................................................................................ 17
What Role Should CDC Play in U.S. Global Health Assistance? ......................................... 17
Coordination of Global Health Programs............................................................................. 18
Workforce Levels................................................................................................................ 19
Figures
Figure 1. CDC Global Health Funding: FY2001-FY2009 .......................................................... 20
Tables
Table 1. U.S. Assistance for International H1N1 Responses, FY2009 .......................................... 8
Table 2. CDC Global Health Spending: FY2001-FY2003.......................................................... 13
Table 3. CDC Global Health Spending: FY2004-FY2008.......................................................... 14
Table 4. Apportionment of CDC Global Health Funding: FY2004-FY2008 ............................... 15
Table 5. CDC Global Health Funding: FY2009-FY2010............................................................ 16
Table 6. CDC Global Health Spending: FY2001-FY2010.......................................................... 21
Contacts
Author Contact Information ...................................................................................................... 22
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Centers for Disease Control and Prevention Global Health Programs: FY2001-FY2010
Introduction
Several U.S. agencies and departments implement global health interventions. With the
exceptions of initiatives to fight HIV/AIDS through the President’s Emergency Plan for AIDS
Relief (PEPFAR), malaria through the President’s Malaria Initiative (PMI), and pandemic flu
through the Avian Flu Task Force, the funding and implementation of U.S. global health
initiatives are not always coordinated among agencies and departments. There is a growing
consensus that U.S. foreign assistance needs to become more efficient and effective. There is
some debate, however, on the best strategies. As Congress considers how best to improve foreign
assistance, some Members are attempting to identify the scope and breadth of U.S. global health
assistance.1 This report highlights the global health efforts that the Centers for Disease Control
and Prevention (CDC) undertakes, outlines how much CDC has spent on such efforts from
FY2001 to FY2009, highlights FY2010 budget proposals from the Administration, House, and
Senate Appropriations Committee, and discusses some issues the 111th Congress and the
incoming director face.
Since 1958, CDC has been engaged in global health efforts. At first, CDC’s global health
engagement focused primarily on malaria control. CDC’s global health mandate has grown
considerably since then. In 1962, CDC played a key role in the international effort that led to
smallpox eradication and in 1967 expanded its surveillance efforts overseas to include other
diseases, when the Foreign Quarantine Service was transferred to CDC from the U.S. Treasury
Department.2 As CDC’s mission expanded, so have the authorities under which it operates.3
Today, CDC is a partner in a number of global disease control and prevention efforts, including
those related to HIV/AIDS, influenza, polio, measles, and tuberculosis (TB). In addition to its
work in controlling the spread of infectious diseases, CDC’s global health efforts aim to address
other global health challenges, such as chronic disease, injury prevention, child and maternal
health, and environmental health concerns.
CDC’s Global Health Programs
Congress provides funds to CDC for global health efforts through Labor, Health and Human
Services (HHS), and Education appropriations. The bulk of funds for CDC’s global health
programs are provided through five main budget lines: Global HIV/AIDS, Global Malaria, Global
Disease Detection, Global Immunization, and Other Global Health. In practice, CDC does not
1 For more information on debates about making U.S. global health assistance more efficient and U.S. funding for other
global health efforts, including those implemented by USAID, the Department of Defense (DOD), and the Global Fund
to Fight AIDS, Tuberculosis, and Malaria (Global Fund), see CRS Report R40740, U.S. Global Health Assistance:
Background, Priorities, and Issues for the 111th Congress.
2 In 1962, CDC established a smallpox surveillance unit, and a year later developed an innovative vaccination
technique that the World Health Organization (WHO) later adopted in its smallpox eradication efforts. In 1977,
smallpox was eradicated; the United States had invested $32 million on this effort. For more information, see CDC,
“Historical Perspectives History of CDC,” MMWR, vol. 45, no. 25 (June 28, 1996), pp. 526-530, http://www.cdc.gov/
mmwr/preview/mmwrhtml/00042732.htm. For more information on the Federal Quarantine Service, see CDC Website,
History of Quarantine at http://www.cdc.gov/ncidod/dq/history.htm.
3 CDC’s global health work is authorized under a number of acts, including the Public Health Service Act; Foreign
Assistance Act; Federal Employee International Organization Service Act; International Health Research Act;
Agriculture Trade Development and Assistance Act; Economy Act; Foreign Employees Compensation Program;
International Competition Requirement Exception; and relevant appropriations.
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treat its domestic and global programs separately. Instead, it uses the same experts to address
domestic and global health issues. As such, CDC is engaged in a wider range of activities than
what Congress appropriates for global health initiatives.
CDC programs are implemented bilaterally and in cooperation with other U.S. agencies,
international organizations, foreign governments, foundations, and nonprofit organizations.4 In
addition to the funds Congress provides to CDC for global health programs, the Office of the
Global AIDS Coordinator (OGAC) at the U.S. Department of State transfers funds to CDC as an
implementing partner of PEPFAR, which is implemented by a number of agencies and
departments.5 U.S. Agency for International Development (USAID) also transfers funds to CDC
as an implementing partner of PMI.6 The section below describes global health activities that
Congress funds CDC to implement.
Global HIV/AIDS
CDC launched its Global AIDS Program (GAP) in 2000 under the LIFE Initiative.7 GAP supports
HIV/AIDS interventions in 41 countries and offers technical assistance in an additional 29
others.8 To combat HIV/AIDS, CDC sends clinicians, epidemiologists, and other health experts to
assist foreign governments, health institutions, and other entities that work on a range of
HIV/AIDS-related activities. The key objectives of GAP are to help resource-constrained
countries prevent HIV infection; improve treatment, care, and support for people living with HIV;
and build health care capacity and infrastructure. Specific activities within the projects include:
• developing and implementing integrated evidence-based prevention, care, and
treatment programs;
• building sustainable public health capacity in laboratory services and systems;
• evaluating the scope and quality of global HIV/AIDS programs;
• strengthening in-country capacity to design and implement HIV/AIDS
surveillance systems and surveys; and
• supporting host government capacity to monitor and evaluate the process,
outcome, and impact of HIV prevention, care, and treatment programs.9
4 For more information on CDC’s partnerships, see http://www.cdc.gov/cogh/partnerships.htm.
5 First authorized in 2003 through the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act (P.L. 108-
25), PEPFAR is a coordinated approach to combating HIV/AIDS globally. In 2008, Congress extended authorization of
PEPFAR through the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Reauthorization Act (P.L. 110-293). For background information on PEPFAR, see
http://www.pepfar.gov/ and CRS Report RL34569, PEPFAR Reauthorization: Key Policy Debates and Changes to
U.S. International HIV/AIDS, Tuberculosis, and Malaria Programs and Funding, by Kellie Moss.
6 For background information on PMI, see http://www.pmi.gov/ and CRS Report R40494, The President’s Malaria
Initiative and Other U.S. Global Efforts to Combat Malaria: Background, Issues for Congress, and Resources, by
Kellie Moss.
7 For background information on the LIFE initiative and PEPFAR, see CRS Report RL33771, Trends in U.S. Global
AIDS Spending: FY2000-FY2008, by Tiaji Salaam-Blyther.
8 For more information on GAP see http://www.cdc.gov/globalaids/about/. For more information on outcomes of GAP,
see CDC, FY2009 Congressional Justification, pp. 317-322, http://www.cdc.gov/fmo/topic/Budget%20Information/
appropriations_budget_form_pdf/FY09_CDC_CJ_Final.pdf.
9 These bullets were summarized by CRS from E-mail correspondence with Anstice Brand, Program Analyst, CDC
(continued...)
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President’s Emergency Plan for AIDS Relief (PEPFAR)
CDC’s spending and engagement on addressing HIV/AIDS expanded significantly after the
launching of PEPFAR. From FY2004 through FY2008, appropriations to GAP changed little and
amounted to $753.2 million, representing about 40% of CDC’s global health spending. As an
implementing partner of PEPFAR, CDC also receives funds from the Office of the Global AIDS
Coordinator (OGAC) to combat HIV/AIDS globally.10 These transferred funds account for the
majority of CDC spending on international HIV/AIDS efforts. From FY2004 to FY2008, OGAC
transferred some $3.4 billion to CDC for global HIV/AIDS activities. When OGAC transfers are
added, from FY2004 to FY2008, HIV/AIDS spending accounted for nearly 80% of all spending
by CDC on global health. OGAC has not yet released how much it will transfer to each PEPFAR
implementing agency or department in FY2009.
Global Malaria
Through its malaria programs, CDC conducts research and engages in prevention and control
efforts.11 CDC staff provide technical assistance that helps several malaria endemic countries
strengthen their malaria control activities. Their work includes policy development, program
guidance and support, scientific research, and monitoring and evaluation. CDC malaria programs
are implemented bilaterally, in partnership with other multilateral organizations, and as part of the
coordinated U.S. strategy—PMI. CDC combats malaria bilaterally with foreign Ministries of
Health, through international initiatives such as Roll Back Malaria (RBM), and with multilateral
partners, such as the World Health Organization (WHO), the United Nations Children’s Fund
(UNICEF), the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) and the
World Bank. Through its multilateral partnerships, CDC has staff posted at the Global Fund;
UNICEF; the World Bank.
CDC’s global malaria efforts focus on utilizing data and applying research to develop evidence-
based strategies for malaria prevention and control; and monitoring and evaluating existing
malaria projects.12 Specific activities include:
• designing technical and programmatic strategies, which include training,
supervision, laboratory, communications, monitoring and evaluation, and
surveillance systems;
• developing plans to estimate the impact of malaria control and prevention efforts;
• evaluating impact of long-lasting insecticide-treated nets (LLINs) and monitoring
the spread of insecticide resistance;
(...continued)
Washington Office, February 2, 2009.
10 For background information on transfers made to CDC as an implementing partner of PEPFAR, see CRS Report
RL33771, Trends in U.S. Global AIDS Spending: FY2000-FY2008, by Tiaji Salaam-Blyther.
11 Information about CDC’s global malaria activities was summarized by CRS from CDC’s international malaria
Website at http://www.cdc.gov/malaria/cdcactivities/index.htm.
12 For more on outcomes of CDC’s malaria interventions, see CDC, FY2009 Congressional Budget Justification, p.333,
http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY09_CDC_CJ_Final.pdf.
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• improving surveillance with the use of hand-held computers equipped with
global positioning systems to conduct household surveys in remote villages; and
• evaluating the performance of health workers.
President’s Malaria Initiative
In addition to appropriations CDC receives for global malaria efforts, USAID transfers funds to
CDC as an implementing partner of the President’s Malaria Initiative. In June 2005, President
Bush proposed the initiative and asserted that with $1.2 billion spent between FY2006 and
FY2010, PMI would seek to halve malaria deaths in 15 target countries. PMI is led by USAID
and jointly implemented by CDC and USAID. From FY2006 through FY2008, USAID
transferred an estimated $25 million to CDC for global malaria programs. USAID has not yet
released how much it will transfer to CDC for global malaria programs in FY2009.
Global Tuberculosis
CDC collaborates with U.S. and multilateral partners to provide technical support in the global
effort to eliminate tuberculosis (TB). 13 Bilateral partners include the National Institutes of Health
(NIH) and USAID; multilateral partners include the Global Fund and WHO. Key activties in
CDC’s bilateral TB interventions include:
• operations research;14
• improvement of TB screening and diagnostics;
• surveillance of TB/HIV prevalence and multi-drug resistant TB (MDR-TB)
prevalence;
• laboratory strengthening; and
• infection control.
CDC also provides technical assistance to multilateral efforts to contain TB, including the
Directly Observed Therapy Short Course (DOTS) program and the Green Light Committee
Initiative, which helps countries access high-quality second-line anti-TB drugs for those infected
with multi-drug resistant TB (MDR-TB).15 Multilateral partnerships also include joint efforts with
WHO to conduct surveillance of drug resistant TB. From 2000 through 2004, CDC and WHO
(with support from USAID) conducted research to determine the extent of TB-drug resistance.16
Just two months after releasing its findings, in May 2006, South African officials invited CDC
and WHO officials to investigate an outbreak of extremely drug-resistant (XDR-TB), which
caused several deaths in Kwazulu-Natal, South Africa. Many health experts were alarmed by the
13 For background information on CDC’s efforts to address tuberculosis globally and on TB drug resistance, see CRS
Report RL34246, Tuberculosis: International Efforts and Issues for Congress, by Tiaji Salaam-Blyther.
14 CDC defines operations research as the application of scientific methods and models to improve decision-making,
resource allocation, and processes to predict and improve program performance.
15 For more information on DOTS, see http://www.who.int/tb/dots/en/ and for more information on the Green Light
Committee Initiative, see http://www.who.int/tb/challenges/mdr/greenlightcommittee/en/.
16 CDC, “Emergence of Mycobacterium tuberculosis with Extensive Resistance to Second-Line Drugs Worldwide,
2000-2004,” MMWR, vol. 55, no. 11 (March 24, 2006), pp. 301-305, http://www.cdc.gov/mmwr/preview/mmwrhtml/
mm5511a2.htm.
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high mortality rates that occurred in May 2006. The team observed 544 patients and diagnosed
221 (41%) with multi drug-resistant (MDR-TB), 53 of which were determined to have XDR-TB.
Only one of the 53 patients with XDR-TB survived. The mortality rate for the MDR-TB patients
was higher than 70% and about 98% for XDR-TB patients. CDC continues to support efforts to
improve surveillance of disease-resistant tuberculosis, including efforts by WHO to bolster XDR-
TB surveillance in southern Africa.
Global Disease Detection
Established in 2004, CDC’s Global Disease Detection (GDD) efforts aim to “protect the health of
Americans and the global community by developing and strengthening public health capacity to
rapidly detect and respond to emerging infectious diseases and bioterrorist threats.”17 The GDD
program draws upon existing international expertise across CDC programs to strengthen and
support public health surveillance, training, and laboratory methods; build in-country capacity;
and enhance rapid response capacity for emerging infectious diseases.
CDC has established six GDD centers, which serve as regional resources to bolster laboratory
capacity and epidemiology programs of the host countries and neighboring ones. Through the
centers—which are in Thailand, Kenya, Guatemala, China, Egypt and Kazakhstan—CDC focuses
on five key activities: (1) outbreak response, (2) surveillance, (3) pathogen discovery, (4) training,
and (5) networking. During health emergencies—such as the emergence of pandemic flu in
2009—CDC can use the centers for bilateral response or as part of the Global Outbreak Alert and
Response Network (GOARN), which is coordinated by WHO.18 Examples of GDD activities
include CDC responses to severe acute respiratory syndrome (SARS) outbreaks in 2003; the
Asian tsunami in 2004; ongoing avian influenza outbreaks, which began in 2004; and cholera
outbreaks in Zimbabwe in 2008.19
Pandemic and Avian Influenza
CDC works in over 35 high-risk countries around the world to prevent the spread of avian influenza to
humans and to help countries prepare and respond to any pandemic influenza that might arise,
including the 2009 H1N1 pandemic flu (discussed below). CDC influenza work is implemented
bilaterally and in cooperation with WHO, CDC’s GDD centers, Department of Defense (DOD)
international field stations and other groups. In this capacity, CDC helps governments and WHO
respond to and control avian influenza outbreaks, and to develop rapid response teams in high-risk
countries. Additional related activities include:
• helping foreign governments detect novel influenza viruses by building
laboratory capacity;
17 Information about GDD was summarized by CRS from CDC, Global Disease Detection, Policy Paper, June 2008,
http://www.cdc.gov/cogh/pdf/GDD_At_a_Glance_2008.pdf.
18 For more information on GOARN, see http://www.who.int/csr/outbreaknetwork/en/.
19 For more information on GDD outcomes see CDC, FY2009 Congressional Budget Justification, pp. 329-330,
http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY09_CDC_CJ_Final.pdf.
For more on CDC’s response to cholera outbreaks in Zimbabwe, see CDC, “CDC Responds to Cholera Outbreak in
Zimbabwe,” CDC Global Health E-Brief, Fourth Quarter 2008, p. 6, http://www.cdc.gov/washington/
EGlobalHealthEditions/pdf/4thQuarter2008GlobalHealthE-Brief.pdf.
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• strengthening epidemiology and avian influenza surveillance;
• enhancing laboratory safety;
• developing and training rapid response teams; and
• supporting the establishment of influenza treatment and vaccine stockpiles.
In FY2005, Congress provided emergency supplemental funds for U.S. efforts related to global
pandemic influenza preparedness and response. In each appropriation year since, Congress has
funded U.S. efforts to train health workers in foreign countries to prepare for and respond to a
pandemic that might occur from any influenza virus, including H5N1 avian flu and H1N1. The
U.S. Department of State announced in October 2008 that since FY2005, the United States has
pledged about $949 million for global avian and pandemic influenza efforts, accounting for
30.9% of overall international donor pledges of $3.07 billion.20 The United States is the largest
single donor to global avian and pandemic preparedness efforts.21 The funds have been used to
support international efforts in more than 100 nations and jurisdictions. The assistance focused on
three areas: preparedness and communication, surveillance and detection, and response and
containment. The $949 million was provided for the following efforts:
• $319 million for bilateral activities;
• $196 million for support to international organizations, including WHO, the U.N.
Food and Agriculture Organization (FAO), the U.N. Development Program
(UNDP), the International Federation of the Red Cross and Red Crescent
Societies (IFRC), the U.N. System Influenza Coordinator (UNSIC), the World
Organization for Animal Health (OIE), and the U.N. Children’s Fund (UNICEF);
• $123 million for regional programs, including disease detection sites;
• $83 million for a global worldwide contingency, available to address the evolving
nature of the threat;
• $77 million for international technical and humanitarian assistance and
international coordination;
• $71 million for international influenza research (including vaccines and modeling
of influenza outbreaks) and wild bird surveillance, including the U.S. launch of
the Global Avian Influenza Network for Surveillance (GAINS) for wild birds,
with a collection of tens of thousands of samples for H5N1 analysis;22
• $67 million for stockpiles of non-pharmaceutical supplies, including over 1.6
million PPE kits, approximately 250 laboratory specimen collection kits and
20 Correspondence with Jeffrey Lutz, Avian Influenza Action Group, U.S. Department of State, April 28, 2009 and U.S.
Department of State press release, “U.S. International Avian and Pandemic Influenza Assistance Approaches $950
Million,” October 25, 2008, http://2001-2009.state.gov/r/pa/prs/ps/2008/oct/111241.htm. Also see, State Department,
Avian and Pandemic Influenza, October 2008. For information on domestic spending on pandemic preparedness, see
CRS Report RS22576, Pandemic Influenza: Appropriations for Public Health Preparedness and Response, by Sarah
A. Lister. For information on domestic spending on H1N1, see CRS Report R40554, The 2009 Influenza Pandemic:
An Overview, by Sarah A. Lister and C. Stephen Redhead.
21 U.N. System Influenza Coordinator and World Bank, Responses to Avian Influenza and State of Pandemic
Readiness, Fourth Global Progress Report, October 2008, p. 83, http://un-influenza.org/files/081006-Synopsis2008.pdf.
22 For more information about GAINS, see http://www.gains.org/.
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15,000 decontamination kits for use in surveillance, outbreak investigation and
emergency response and containment efforts; and
• $13 million for global communications and outreach.
The cumulative pledge of $949 million consists of the following contributions, by agency:
• USAID: $542 million.
• HHS, including CDC, the National Institutes of Health (NIH), and the Food and
Drug Administration (FDA): $353 million.
• U.S. Department of Agriculture (USDA): $37 million.
• Department of Defense (DOD): $10 million.
• Department of State (DOS): $7 million.
In April 2009, an influenza virus that had never circulated among humans before began to spread
around the world. The virus is called Influenza A/HIN1; it is mostly treatable, and less than 1% of
those who have contracted the virus have died. By June 2009, WHO declared that the virus had
spread so pervasively that it had become a pandemic. The characterization was based on the reach
of the virus, not its virulence. As of August 12, 2009, WHO has confirmed 177,457 human H1N1
cases, including 1,462 deaths. About 87% of those fatalities occurred in the Americas, though the
WHO European region reported the highest number of cases—more than 32,000. WHO and HHS
maintain that the laboratory-confirmed cases are far lower than the actual number of cases, given
that countries are no longer required to test and report individual cases. Many countries use
laboratory tests to confirm H1N1 only in patients who are severely ill or have other high-risk
health conditions.
CDC has been engaged in international H1N1 pandemic responses since the virus was identified.
As one of four WHO collaborating centers around the world, the CDC influenza laboratory in
Atlanta routinely receives viral samples from many countries, including Mexico.23 CDC creates
or develops reagents that are used to detect subtypes of influenza that are sent to national
influenza centers around the world.24 Once the subtype of influenza is identified, CDC generates
testing kits that are sent to public health laboratories worldwide at no cost. At the onset of the
outbreak, CDC sent experts out to the field to help strengthen laboratory capacity and train health
experts to control the spread of a virus.
CDC has deployed 16 staff to Mexico and one health expert to Guatemala, including experts in
influenza epidemiology, laboratory, health communications, and emergency operations, including
distribution of supplies and medications, information technology, and veterinary sciences. These
teams work under the auspices of the WHO/Pan American Health Organization Global Outbreak
Alert and Response Network and a trilateral team of Mexican, Canadian, and American experts.
The teams aim to better understand the clinical illness severity and transmission patterns of H1N1
and improve laboratory capacity in Mexico. CDC’s Emergency Operations Center also
23 The other collaborating centers are in Britain, Japan, and Australia. For more information on WHO Collaborating
Centers, see http://www.who.int/csr/disease/influenza/collabcentres/en/.
24 Taken from CDC, “Press Briefing: CDC Media Availability on Human Swine Influenza Cases,” press release, April
27, 2009, http://www.cdc.gov/media/transcripts/2009/t090427.htm.
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coordinates and collaborates with the European Centre for Disease Prevention and Control
(ECDC) and the China CDC.
HHS Secretary Kathleen Sebelius announced on April 30, 2009, that the department “began
moving 400,000 treatment courses—valued at $10 million—to Mexico, which represent less than
1% of the total American stockpile.”25 In July 2009, Secretary Sebelius announced at a high-level
meeting held in Cancun, Mexico, with Mexican President Felipe Calderon, WHO Director-
General Margaret Chan, Pan American Health Organization (PAHO) Director Mirta Roses, and
other health ministers from throughout the Americas to discuss strategies to combat influenza that
the United States would donate an additional 420,000 courses of Tamiflu to countries in Latin
America and the Caribbean.26 In total, the Administration aims to distribute 2 million courses in
Latin America and the Caribbean.
As of May 18, 2009, the United States has provided more than $16 million to assist countries in
Latin America and the Caribbean respond to the H1N1 pandemic (Table 1). These funds are used
for H1N1 responses specifically, and build on influenza pandemic preparedness efforts that began
in earnest after the 2003 severe acute respiratory syndrome (SARS) outbreak and were expanded
at the peak of H5N1 outbreaks. U.S. international responses to the H1N1 pandemic are conducted
mostly by CDC and USAID, though the Department of Defense (DOD) has also provided
support. Foreign assistance efforts largely focus on commodity delivery and disease detection and
surveillance.
Table 1. U.S. Assistance for International H1N1 Responses, FY2009
(U.S. $ thousands)
Agency/Implementing Partner
Activity
Location
Amount
HHS/Government of Mexico
Health Mexico
10,000.0
USAID/Government of Mexico
Emergency Relief Supplies
Mexico
875.0
USAID/Pan American Health Organization (PAHO) Emergency Relief Supplies
Panama
262.0
USAID/PAHO Health
Central
America
2,500.0
USAID/World Health Organization
Health
Central America
2,500.0
USAID Administrative
Support
Mexico
100.0
USAID Total
6,237.0
DOD/Ministries of Health
Emergency Relief Supplies
Central America
234.7
Total U.S. Assistance
16,471.7
Source: USAID, Global—Influenza A/H1N1, Fact Sheet # 3, May 18, 2009.
25 HHS, “Secretary Sebelius Takes Two Key Actions On Strategic National Stockpile ,” press release, April 30, 2009,
http://www.hhs.gov/news/press/2009pres/04/20090430a.html. For information about the value of the 400,000 treatment
courses, see USAID, Global—Influenza A/H1N1, Fact Sheet # 3, May 18, 2009, p. 2, http://www.usaid.gov/our_work/
humanitarian_assistance/disaster_assistance/countries/pandemic_influenza/template/fs_sr/
pandemic_influenza_fs03_05-18-2009.pdf.
26 PAHO, press release, “PAHO Recognizes Important US Contribution of Antivirals for Latin America and
Caribbean,” July 3, 2009
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In response to President Obama’s request for supplemental funding for U.S. domestic and
international pandemic preparedness and response activities,27 Congress made available $50
million for USAID pandemic preparedness activities and $200 million to CDC for domestic and
international H1N1 activities through the FY2009 Supplemental Appropriations (P.L. 111-32).
The conference report did not specify, however, how much of the $200 million CDC should
spend on international efforts.
Global Immunization
According to the latest estimates, which were based on data collected in 2002, 1.4 million
children under age five die annually from vaccine- preventable diseases (VPDs).28 CDC has
increasingly supported efforts to prevent the transmission of vaccine-preventable diseases,
particularly polio and measles. CDC global immunization activities primarily focus on children
younger than age five, who are at the highest risk of contracting polio, measles, and other VPDs.
Appropriations in support of these efforts have grown from $3.1 million in FY199129 to $143.3
million in FY2009. Nearly all of the funds that Congress provides CDC for global immunizations
are earmarked for polio and measles interventions. CDC leverages funds from other sources to
prevent other VPDs and respond to global requests for technical assistance on immunization-
related epidemiologic and laboratory science.
CDC implements immunization programs bilaterally and through international partnerships with
groups such as WHO, UNICEF, PAHO, the World Bank, the American Red Cross, and Rotary
International. CDC staff are seconded to these organizations and offer technical and operational
support in improving global usage of immunizations. In addition, CDC officials serve on the
Global Alliance for Vaccines and Immunization (GAVI Alliance) and act as implementing
partners in a number of initiatives, including GAVI’s Hib and Accelerated Vaccine Introduction
Initiatives and the Meningitis Vaccine Project, all of which seek to accelerate introduction of new
or underutilized vaccines in developing countries that can reduce child mortality.30
In partnership with WHO and UNICEF, CDC developed the Global Immunization Vision and
Strategy for 2006-2015 (GIVS),31 which among other goals, outlines how the international
community will collaborate to reduce vaccine-preventable deaths and sickness by at least two-
thirds from 2000 levels. The strategy aims to sustain the gains made over the past decades in
27 The White House, “Letter from the President to the Speaker of the House ,” press release, April 30, 2009,
http://www.whitehouse.gov/the_press_office/Letter-from-the-President-to-the-Speaker-of-the-House-of-
Representatives/. Also see CRS Report R40531, FY2009 Spring Supplemental Appropriations for Overseas
Contingency Operations, coordinated by Stephen Daggett and Susan B. Epstein.
28 WHO Website, Vaccine-Preventable Diseases, http://www.who.int/immunization_monitoring/diseases/en/.
29 CRS summarized information about CDC’s global immunization efforts from CDC, Global Immunization Strategic
Framework: 2006-2010, http://www.cdc.gov/vaccines/programs/global/downloads/gisf-2006-2010.pdf. For more
information on outcomes of CDC immunization efforts, see CDC, FY2009 Congressional Justification, p. 327,
http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY09_CDC_CJ_Final.pdf.
30 For more on GAVI, see http://www.gavialliance.org/; the Hib Initiative, see http://www.hibaction.org/; and the
Accelerated Vaccine Introduction Initiative, see http://www.gavialliance.org/resources/
6___Accelerated_Vaccine_Introduction.pdf; and the Meningitis Vaccine Project, see http://www.who.int/vaccines/en/
olddocs/meningACproject.shtml.
31 For more on the Global Immunization Vision and Strategy for 2006-2015, see http://www.who.int/vaccines-
documents/DocsPDF05/GIVS_Final_EN.pdf.
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eradicating polio and eliminating measles (see below) by helping to ensure universal application
of routine immunizations and using those efforts to strengthen health systems.
Polio
Polio is a highly contagious virus that mostly affects children under five years of age.32 There is
no cure for polio; it can only be prevented through immunization. Less than 1% of those who
contract polio (one in 200) become irreversibly paralyzed. Between 5% and 10% of those who
become paralyzed die of respiratory failure—when the lungs become paralyzed. As a result of
global eradication efforts, polio cases have declined by more than 99% from an estimated
350,000 cases in 1998 to 1,648 cases reported in 2008.33
The number of polio-endemic countries has decreased from 125 in 1988 to four in 2008:
Afghanistan, India, Nigeria and Pakistan.34 Polio was nearly eradicated but resurged in 2003,
when some northern states in Nigeria suspended inoculations citing safety concerns. This action
led to a national epidemic and many global outbreaks. Between 2003 and 2007, the wild
poliovirus originating in Nigeria reached 20 countries and an Indian strain reached six additional
countries. By May 2007, most of the resulting outbreaks were arrested. However, six of the 26
countries that reported polio reinfection had not yet stopped transmission (Angola, Bangladesh,
Democratic Republic of the Congo, Ethiopia, Myanmar, Somalia); four additional countries that
border endemic areas continued to experience sporadic importations (Cameroon, Chad, Nepal,
Niger).35 Polio threatens not only countries bordering endemic countries, but all countries until its
transmission has been stopped globally.
CDC provides technical expertise and support to national governments and international
organizations in support of the global effort to eradicate polio.36 Its laboratory support is an
important component of such efforts. Over more than 20 years, CDC has helped countries build
laboratory capacity in polio, resulting in a global polio network that now involves 145
laboratories around the world, which processed almost 180,000 lab specimens in 2008. In its
multilateral efforts, CDC works closely with the other founding partners of the Global Polio
Eradication Initiative—WHO, UNICEF, and Rotary International—and houses the global
reference laboratory for polio.37
32 Information about polio was summarized by CRS from WHO Website on polio at http://www.who.int/mediacentre/
factsheets/fs114/en/index.html.
33 Estimated polio cases for 2008 were taken from Global Polio Eradication Initiative, Wild Poliovirus Weekly Update,
February 3, 2009, http://www.polioeradication.org/casecount.asp.
34 For a history of polio eradication efforts, see http://www.polioeradication.org/history.asp.
35 Dr. Margaret Chan, WHO Director General , The Case for Completing Polio Eradication, WHO, May 10, 2007, p.
1, http://www.polioeradication.org/content/general/TheCase_FINAL.pdf.
36 Information on CDC’s polio programs was summarized by CRS from U.S. Congress, Senate Committee on
Appropriations, Subcommittee on Labor, Health and Human Services, Education, and Related Agencies, Global
Health, Prepared Statement by Michael Leavitt, Secretary of the U.S. Department of Health and Human Services, 110th
Cong., 1st sess., May 2, 2007, S. Hrg. 110–443, pp. 9 and 10.
37 For more information on the Global Polio Eradication Initiative, see http://www.polioeradication.org/.
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Measles
Measles is another highly contagious virus that mostly affects children younger than five years of
age.38 In 2007, measles killed about 197,000 people worldwide, most of whom were children.
Healthy people usually recover from measles or suffer moderately from the disease. Measles
severely affects those who are poorly nourished, particularly those suffering from Vitamin A
deficiency or immune suppressing diseases, such as HIV/AIDS. Those who survive severe
measles infection may become blind or suffer from encephalitis (an inflammation of the brain),
diarrhea and related dehydration, ear infections, or respiratory infections such as pneumonia.
Among populations with high levels of malnutrition and a lack of adequate health care, up to 10%
of measles cases result in death.
From FY2001 through FY2009, CDC spent more than $342 million on global measles control
activities in 42 sub-Saharan African countries and 6 Asia ones (Table 6).39 With the funds, CDC
has purchased over 200 million measles vaccine doses and provided technical support to
ministries of health in those countries. Key technical support activities include:
• planning, monitoring, and evaluating large-scale measles vaccination campaigns;
• conducting epidemiological investigations and laboratory surveillance of measles
outbreaks; and
• conducting operations research.40
Along with WHO, UNICEF, the United Nations Foundation, and the American Red Cross, CDC
is a partner in the Measles Initiative, which has facilitated the precipitous decline in measles-
related deaths from 2000 to 2007. During this period, about 576 million children who live in high
risk countries were vaccinated against the disease.41 As a result, measles-related deaths decreased
globally by 74% during that time. The greatest improvements in measles death rates occurred in
the Middle East and sub-Saharan Africa, where measles deaths declined by about 90%. Although
measles was eliminated from the United States in 2000, travelers can carry the disease and cause
sporadic cases annually.
Other CDC Global Health Programs
Congress funds CDC’s efforts to build public health capacity among country leaders, particularly
health ministries, through the budget line entitled “Other Global Health.” Two key components of
these efforts are the Field Epidemiology (and Laboratory) Training Program (FE(L)TP) and the
Sustainable Management Development Program (SMDP).42 While these two programs received
38 Information about measles was summarized by CRS from WHO, Measles, Fact Sheet, December 2008,
http://www.who.int/mediacentre/factsheets/fs286/en/index.html.
39 Senate Committee on Appropriations, Subcommittee on Labor, Health and Human Services, Education, and Related
Agencies, Hearing on the FY2008 Budget of HHS, Hearing on H.R. 3043/S. 1710, 110th Cong., 1st sess., March 19,
2007, S. Hrg. 110–400, p. 650.
40 CDC defines operations research as the application of scientific methods and models to improve decision-making,
resource allocation, and processes to predict and improve program performance.
41 WHO, Measles, Fact Sheet, December 2008, http://www.who.int/mediacentre/factsheets/fs286/en/index.html.
42 The Field Epidemiology Training Program (FETP) and the Field Epidemiology and Laboratory Training Program
(FETLP) are two different programs. FE(L)TP refers to both.
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direct Congressional appropriations, they are also supported by funds from other sources,
including USAID, DOD, and the private sector.
FE(L)TP, established in 1980, is a full-time, two-year postgraduate applied public health training
program for public health leaders to help strengthen health systems, train health professionals,
build capacity to assess disease surveillance, and improve health interventions.43 The program is
modeled after CDC’s Epidemic Intelligence Service and is adapted to meet local needs.
Participants spend about 25% of their time in the classroom and 75% in field placements,
providing public health services to host countries’ health ministries. CDC develops the FE(L)TP
in conjunction with local health leaders to ensure sustainability and ultimately hand-off the
trainings to local officials (typically after four to six years). From 1980 to 2008, CDC has
consulted with and supported 30 FE(L)TPs and similar programs in 40 countries. CDC is
currently supporting FETP programs in 13 countries, FE(L)TP operations in 23 countries, and is
developing 10 new programs.
The Sustainable Management Development Program, established in 1992, also aims to strengthen
public health systems by bolstering leadership and management capacity of health workers.
SMDP participants take part in a six-week Management for International Public Health (MIPH)
course that trains managers from developing countries in the basic management skills of
planning, priority setting, problem solving, budgeting, and supervision. The program also works
with its partners to analyze the quality of organizational leadership, assess management skills,
and identify performance gaps in health systems. CDC helps the health leadership to create an
action plan for capacity development that includes a budget, a timeline, and measurable
outcomes. After concluding the program, CDC provides post-course technical assistance to
support the development of sustainable management development programs and post-training
incentives to stimulate lifelong learning. These incentives include website access, regional
networking among alumni, conferences, fellowships, and career development opportunities.44
CDC Global Health Spending: FY2001-FY2009
From FY2001 to FY2009, Congress provided CDC about $2.3 billion for global health
activities—increasing funding for global health activities by 108.1% (see Figure 1). Since
PEPFAR was launched in 2004, the United States has apportioned the bulk of its global health
spending on the plan. In light of the dominant role that PEPFAR has played in shaping U.S.
global health assistance, analysis about funding for CDC’s global health programs in this section
is organized to reflect changes that occurred before and after PEPFAR authorization.
CDC Global Health Spending: FY2001-FY2003
From FY001 to FY2003, Congress made available nearly $1 billion to CDC for global health
work (Table 2). During this time period, spending by CDC on global health increased by more
than 300%. About 56% of that growth was targeted at HIV/AIDS interventions and about 40% at
43 This section on “Other Global Health Programs” was summarized by CRS from E-mail correspondence with Anstice
Brand, Program Analyst, CDC Washington Office, February 2, 2009 and CDC, http://www.cdc.gov/smdp/about.htm.
44 For information on outcomes of SMDP, see CDC, FY2009 Congressional Budget Justification, p. 338,
http://www.cdc.gov/fmo/topic/Budget%20Information/appropriations_budget_form_pdf/FY09_CDC_CJ_Final.pdf.
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immunizations. At that time, there was vigorous debate about whether HIV/AIDS treatments
could be safely and effectively used in low-resource settings, particularly in sub-Saharan Africa.
In FY2002, Congress began to fund the International Mother and Child HIV Prevention Initiative,
which included the provision of HIV/AIDS medication that prevented mother-to-child HIV/AIDS
transmission (PMTCT). During this period, GDD had not yet been created and Congress had not
yet funded interventions against the reemergent H5N1 bird flu or the FE(L)TP programs. Global
efforts to detect infectious diseases and strengthen health systems were underway, however.
Table 2. CDC Global Health Spending: FY2001-FY2003
(current U.S. $ millions, actual)
Program FY2001
FY2002
FY2003
FY2001-
% Change:
% of Total
FY2003
FY2001-FY2003
Global Health
Global HIV/AIDS
104.5
168.7
266.9
540.1
155.4%
55.9%
PMTCT
n/s
25.0
182.6
207.6 730.4%
—
Global
Malaria
13.0 13.0 9.2 35.2 170.8%
3.6%
Global Tuberculosis
0.0
1.0
1.1
2.1
110.0%
0.2%
Global Disease Detection (GDD)
n/a n/a n/a n/a
n/a
n/a
Pandemic/Avian Flu
n/a n/a n/a n/a
n/a
n/a
Global Immunization
106.6 133.7 147.8 388.1
264.1%
40.2%
Polio 91.2
102.3
105.7
299.2
228.1%
—
Other Global/Measles
15.4
31.4
42.1
88.9
477.3%
—
Other Global Health
n/a
n/a
n/a
n/a
n/a
n/a
Total Global Health
224.1
316.4
425.0
965.5
330.8%
100.0%
Source: Appropriations legislation and correspondence with Anstice Brand, CDC Washington, and Julie Racine-Parshall, CDC Atlanta.
CDC Global Health Spending: FY2004-FY2008
From FY2004 to FY2008, Congress made available almost $2 billion to CDC for global health
work and global health spending by CDC increased by about 16% (excluding funds provided for
PMTCT efforts). During that time period, Congress became increasingly concerned about the
spread of infectious diseases, such as SARS and H5N1 avian flu, and began funding GDD.
Congress also appropriated funds for pandemic/avian flu preparedness and response efforts
through Labor, HHS, and Education appropriations acts, though legislation did not specify how
much CDC should spend on global efforts.
With mounting concerns about the global spread of infectious diseases, provisions for HIV/AIDS
comprised a smaller proportion of CDC’s global health budget. While Congress apportioned
about 56% of CDC’s global health appropriations on HIV/AIDS efforts from FY2001 to FY2003;
from FY2004 to FY2008, spending on HIV/AIDS interventions amounted to about 16% of
CDC’s global health budget (excluding PMTCT efforts) and funding for GDD and
pandemic/avian influenza interventions comprised nearly 20% of CDC’s global health budget
(Table 3).
Although funds for HIV/AIDS efforts comprised a smaller portion of CDC’s global health budget
through direct appropriations, due to transfers provided to CDC from OGAC for its role in
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PEPFAR, spending on programs to combat the virus internationally accounted for about 78% of
CDC’s global health spending from FY2004 through FY2008 (Table 4), while the transfers alone
comprised about 64% of CDC’s total global health budget during that five-year period. Transfers
from OGAC also included funds for CDC to continue ongoing PMTCT activities. In FY2004,
when PEPFAR was launched, Congress provided its last appropriation to CDC for PMTCT
activities and directed the funds at OGAC to coordinate.
In addition to those transfers, USAID began to transfer funds to CDC in FY2006 for its work
conducted as an implementing partner of PMI. When transfers for PEPFAR and PMI are
included, CDC spent about $5.3 billion on global health activities from FY2004 through FY2008.
Transfers for HIV/AIDS and malaria programs from FY2004 through FY2008 ($3.4 billion)
exceeded congressional appropriations for all CDC global health activities ($1.9 billion) by about
$1.5 billion.
Table 3. CDC Global Health Spending: FY2004-FY2008
(Current U.S. $ millions, actual)
FY2004-
%Change: % of Global
Program
FY2004 FY2005 FY2006 FY2007 FY2008 FY2008
FY2004-
Health:
(Total)
FY2008
FY2004-
FY2008
Global
HIV/AIDS
266.9 123.8 122.6 121.0 118.9 753.2 -55.5%
39.7%
PMTCTa
142.0 State State State State 142.0
n/a
—
Global HIV/AIDS w/out PMTCT
124.9
123.8
122.6
121.0
118.9
611.2
-4.8%
16.2%
Global
Malaria
9.2 9.1 9.0 8.9 8.7 44.9 -5.4% 2.4%
Global Tuberculosisb
2.0 2.3 2.2 1.9 2.0 10.4 0.0% 0.5%
Global Disease Detection
11.6
21.4
32.4
32.0
31.4
128.8
170.7%
6.8%
Pandemic/Avian Influenzab
0.0 15.0 132.0 22.0 67.8 236.8 353.3% 12.5%
Global
Immunization
137.9 144.4 144.3 142.3 139.9 708.8
1.5%
37.3%
Polioc 96.8
101.2
101.1
99.8
98.0
496.9
1.2%
—
Other Global/Measlesc
41.0 43.2 43.2 42.6 41.8
211.9 2.0%
—
Other Global Health
2.4
3.4
3.4
3.3
3.5
16.0
45.8%
0.8%
Total Global Health
430.0
319.4
445.9
331.4
372.2 1,898.9
-13.4%
100.0%
Total Global Health w/out PMTCT
320.5 319.4 445.9 331.4 372.2
1,789.6 16.2%
Transfers for HIV/AIDS
184.5 441.0 576.9 917.2
1,262.6
3,382.2 584.3%
63.7%
Transfers for Malaria
n/a
n/a
2.8
9.6
12.6
25.0
350.0%
0.5%
Total with Transfers, including
PMTCT
614.5 760.4 1,025.6 1,258.2 1,647.6 5,306.3
168.1%
Sources: Appropriations legislation and correspondence with Anstice Brand and Rebecca Miller, CDC Washington Office.
Notes: Spending levels on HIV/AIDS programs after FY2004 is lower because Congress began to include funds for the
International Mother and Child HIV Prevention in appropriations to the Global HIV/AIDS Initiative (GHAI).
a. Funds for PMTCT are italicized to indicate they are part of the Global HIV/AIDS total.
b. Congress does not appropriate funds to CDC for global TB efforts and global pandemic/avian influenza activities. CDC allots a
portion of its TB and pandemic/avian Influenza appropriations to global interventions. The figures for PMTCT, polio, and “other
global/measles” are italicized to indicate that they are included in the Global Immunization total.
c. Funds for Polio and Other Global/Measles are italicized to indicate that they are part of the Global Immunization total.
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Apportionment of CDC Global Health Funding: FY2004-FY2008
The greatest proportion of CDC’s total global health spending from FY2004 through FY2008 was
targeted at HIV/AIDS and immunization interventions and accounted for 40% and 37% of total
spending, respectively (Table 3). After transfers for international HIV/AIDS and malaria
activities are included, however, CDC spent almost 80% of its global health budget on HIV/AIDS
programs and 13% on immunization efforts (Table 4).
Table 4. Apportionment of CDC Global Health Funding: FY2004-FY2008
(% without transfers [WOT] and with transfers [WT])
FY2004-
FY2004
FY2005
FY2006
FY2007
FY2008
FY2008 Total
Program
WOT WT WOT WT WOT WT WOT WT WOT WT WOT WT
Global HIV/AIDS
62.1
73.5
38.8
74.3
27.5
68.2
36.5
82.5
31.9
83.9
39.7
77.9
Global Malaria
2.1
1.5
2.8
1.2
2.0
1.2
2.7
1.5
2.3
1.3
2.4
1.3
Global TB
0.5
0.3
0.7
0.3
0.5
0.2
0.6
0.2
0.5
0.1
0.5
0.2
Global Disease
Detection
2.7 1.9 6.7
2.8
7.3 3.2 9.7
2.5 8.4 1.9 6.8 2.4
Pandemic/Avian
Influenza
n/a n/a
4.7
2.0
29.6 12.9 6.6 1.7 18.2 4.1 12.5 4.5
Global
Immunization
32.1 22.4 45.2 19.0 32.4
14.1 42.9 11.3 37.6 8.5 37.3 13.4
Other Global
Health
0.6 0.4 1.1
0.4
0.8 0.3 1.0
0.3 0.9 0.2 0.8 0.3
Source: Calculated by CRS from appropriations legislation and correspondence with Anstice Brand and Rebecca Miller, CDC
Washington.
Notes: The first figure in each fiscal year column reflects the % of total CDC spending on each health category without transfers
from OGAC and USAID for HIV/AIDS and malaria interventions. The second figure in each fiscal year column represents the % of
total CDC spending on each health category including these transfers.
CDC Global Health Funding: FY2009-FY2010
Global health has emerged as a key foreign policy goal early in the Obama Administration. When
releasing his FY2010 budget request, President Obama indicated that his Administration would
increase investments in global health programs.45 On May 5, 2009, President Obama announced
his new Global Health Initiative, a six-year plan to spend $63 billion using an integrated approach
to fight the spread of infectious diseases while addressing other global health challenges.46 In
announcing the initiative, the President stated,
45 Office of Management and Budget, A New Era of Responsibility: Renewing America’s Promise, FY2010 Budget,
February 26, 2009, p. 32, http://www.whitehouse.gov/omb/assets/fy2010_new_era/
A_New_Era_of_Responsibility2.pdf.
46 The White House, “Statement by the President on Global Health Initiative,” press release, May 5, 2009,
http://www.whitehouse.gov/the_press_office/Statement-by-the-President-on-Global-Health-Initiative/.
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In the 21st century, disease flows freely across borders and oceans, and, in recent days, the
2009 H1N1 virus has reminded us of the urgent need for action. We cannot wall ourselves
off from the world and hope for the best, nor ignore the public health challenges beyond our
borders. An outbreak in Indonesia can reach Indiana within days, and public health crises
abroad can cause widespread suffering, conflict, and economic contraction. We cannot
simply confront individual preventable illnesses in isolation. The world is interconnected,
and that demands an integrated approach to global health.
President Obama’s first budget proposal did not include significant increases for CDC’s global
health activities. In his budget request, he proposed that CDC’s global health programs be funded
mostly at the same level and that Congress increase slightly provisions for immunization
activities (Table 5). In addition, CDC anticipates that the Director might apportion a slightly
higher level of funding for pandemic and avian flu activities. The House reported out $323.2
million for CDC’s global health programs, some $4 million more than the Administrated
requested, and the Senate Appropriations committee reported out $332.8 million, some $14
million higher than requested levels.
Table 5. CDC Global Health Funding: FY2009-FY2010
(current $ U.S. millions and %)
% Change from FY2009
Program
FY2009
FY2010
FY2010
FY2010
Estimate
Request
Estimate to FY2010
House
Senate
Request
Global AIDS Program
118.9
119.0
0.1%
119.0
119.0
Global Malaria
9.4
9.4
0.0%
9.4
9.4
Global Tuberculosis
1.6
1.6
0.0%
n/s
n/s
Global Disease Detection
33.7
33.8
0.3%
37.8
37.0
Global Pandemic/Avian Flu
156.0
159.0
1.9%
n/s
n/s
Global Immunizations
143.4
153.5
7.1%
153.5
153.9
Polio 101.5
101.6
0.1%
101.6
102.0
Other/Measles 41.8
51.9 24.2%
51.9
51.9
Other Global Health
3.5
3.5
0.0%
3.5
13.5
Total CDC Global Health
466.4
479.8
2.9%
323.2
332.8
Source: FY2010 budget request figures compiled by CRS from CDC’s FY2010 justification and Anstice Brand, CDC
Washington Office, FY2010 House figures compiled by CRS from the House and Senate reports (H.Rept. 111-220 and
S.Rept. 111-66, respectively) accompanying FY2010 House, Labor, and Education Appropriations (H.R. 3293).
In light of the 2009 pandemic flu, the House and Senate Appropriations Committee both provided
higher funding levels to enhance existing GDD centers and expand their numbers. The Senate
Appropriations Committee also boosted funding in the “other global health” category to enable
CDC to address the burgeoning chronic health problem in developing countries and to bolster the
human health workforce capacity in those areas. The committee expressed particular concern
about the rising numbers of deaths related to tobacco use, injuries, and violence in developing
countries. According to the Senate Appropriations Committee report, “70% of tobacco-related
deaths are expected to occur in the developing world by 2030.” The Committee also indicated
that the additional funds in the “other global health” category should be used to expand and
enhance FE(L)TP programs.
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Related Policy Issues
There has been some concern among global health experts that U.S. global health programs,
including those that CDC implements, do not address global health issues in a comprehensive
manner. Critics of this process point to significant investments in diseases such as HIV/AIDS,
while investments in other challenges remain relatively low. One observer contended that funding
for CDC’s global health programs disproportionately favors HIV/AIDS programs and does not
sufficiently support other health assistance that CDC does well, particularly programs related to
training health workers and strengthening health systems.47 There is also growing congressional
awareness of and interest in improving global health systems and integrating other health
challenges.
On May 15, 2009, President Obama appointed Dr. Tom Frieden to be the new Director of CDC.
Some health experts indicate that the recent appointment of Dr. Tom Frieden signals the Obama
Administration’s intention to raise the stature of CDC, expand its workforce, and address some of
the world’s most neglected health challenges, particularly those that CDC is most adept at
confronting. The section below discusses some issues the 111th Congress, the Obama
Administration and the incoming CDC Director might face.
What Role Should CDC Play in U.S. Global Health Assistance?
Mounting debate has focused on what role CDC should play in implementing U.S. global health
assistance. Some of the issues raised about CDC and global health have focused on the lack of
sustained resources and support for long-term global health efforts, particularly given the increase
in global health issues that CDC addresses, including responses to global disease outbreaks, rising
chronic disease prevalence in developing countries, and development of public health capacities
abroad. During the previous administrations, one critic contends, the agency mostly focused on
addressing disease outbreaks as they occurred, such as avian flu, rather than boosting support for
disease surveillance, which could be used to identify, prevent, and respond to any outbreak. 48
Many global health experts also accused former CDC Director Julie Gerberding of placing
political concerns above scientific ones when developing CDC’s budget, further eroding the
stature of the organization. These practice, some contended, reduced CDC’s credibility as a non-
biased scientific institution.
Several health experts advocate for the incoming director to restore CDC’s scientific credibility
by using evidence-based research to address both emergent and long-term health problems—such
as the growing disease burden of chronic disease—and make U.S. global health assistance more
effective. In the 2008 World Health Report, WHO asserted that comprehensive data on chronic
diseases and their determinants is “patchy and often lacks systematic focus.” 49 The capacity to
contextualize the impact of this growing health challenge, WHO maintains, is threatened by
deficient levels of data collection in most developing countries on basic health statistics, such as
those related to population health, births, and deaths. Some observers expect that Dr. Frieden
47 See Ruth Levine, Incoming CDC Director Needs a Global Perspective, Center for Global Development, Global
Health Policy Blog, January 12, 2009, http://blogs.cgdev.org/globalhealth/2009/01/incoming_cdc_directo.php.
48 Geoffrey Crowley, “A New Manifesto for CDC,” The Lancet, volume 373, June 6, 2009, p.1919.
49 WHO, World Health Report, 2008, p.73.
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might make the growing chronic disease problem in developing countries a priority, particularly
since he has tackled health issues during his tenure as Health Commissioner of New York City
that were not politically popular but had significant impacts on health outcomes, such as those
related to smoking cessation, healthy diets, and XDR-TB.50
Some health experts contend that more resources should be provided to enhance and expand
CDC’s work in disease detection and surveillance. The Government Accountability Office (GAO)
asserted that CDC is the “single largest contributor of expertise and resources” to WHO’s
Collaborating Centers, which among other things, provide developing countries with support and
access to highly specialized laboratory services.51 Despite the emergence and re-emergence of
diseases such as severe acute respiratory syndrome (SARS), pandemic and avian flu, multi- and
extremely-drug resistant tuberculosis (MDR- and XDR-TB) over the past decade, funding for
GDD has consistently ranked third among the five global health areas—exceeding malaria and
“other global health” and receiving less than HIV/AIDS and immunizations. Those expressing
concern about GDD funding levels assert that higher funding levels for GDD would enable CDC
to expand its global efforts to strengthen laboratory capacity, improve disease surveillance,
prevent the spread of diseases, and identify and contain disease outbreaks before they become
pandemics.
In the 111th Congress, both the House and Senate have demonstrated support for expanding
resources to GDD. The House passed a FY2010 Labor, HHS, and Education Appropriations bill
(H.R. 3293), which boosted funding for GDD by 12.2% over FY2009 levels. The Senate
Appropriations Committee reported out support for GDD 9.8% above FY2009 levels. Despite the
proposed increases, GDD remains the third highest funded global health category.
Some observers would like to see CDC’s significant experience in monitoring and evaluating
health programs more widely applied to U.S. global health programs. CDC’s expertise in this area
could be used to evaluate U.S. global health programs, as well as to identify data gaps.
Evaluations could be used to determine the most efficient use of U.S. global health funds,
particularly as it relates to identifying which health interventions would have the greatest impact
on overall health outcomes, both within regions and within countries.
Coordination of Global Health Programs
Although there is strong support in Congress for global health assistance, there are growing
concerns that insufficient coordination and integration of U.S. global health programs limit the
effectiveness and efficiency of these programs. On November 12, 2008, former U.S. Global AIDS
Coordinator Mark Dybul asserted that the United States could reach between 20% and 40% more
people with the same amount of funding by improving efficiency and minimizing duplication.52
50 See Gardiner Harris and Anemona Hartocollis, “New York City Official is Obama Pick for CDC,” New York Times,
May 15, 2009; Rachel Nugent, “Bring on the Chutzpah at CDC!” Center for Global Development, May 18, 2009,
http://blogs.cgdev.org/globalhealth/2009/05/bring-on-the-chutzpah-at-cdc.php; and Geoffrey Crowley, “A New
Manifesto for CDC,” The Lancet, volume 373, June 6, 2009, p.1919.
51 U.S. General Accounting Office, Challenges in Improving Infectious Disease Surveillance Systems, GAO-01-722,
August 2001, p.35, http://www.gao.gov/new.items/d01722.pdf.
52 Ambassador Mark Dybul, “How Will Congress and the Next Administration Sustain Progress on HIV/AIDS, TB,
and Malaria in the Face of the Global Financial Crisis?,” Question and Answer Period at CSIS Event, November 12,
2008, http://www.csis.org/component/option,com_csis_events/task,view/id,1847/.
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Some global health experts advocate for Congress to increase provisions for life-saving
interventions that target more than one disease. Supporters of this idea assert that it is more
efficient and less expensive to deliver multiple child health interventions during a single
campaign than to respond to diseases separately. Dr. Stephen Blount testified that CDC needed
“to seek more ways to promote integration across global programs.”53 Dr. Blount cited examples
of what could be done, such as distributing insecticide-treated bednets within immunization
campaigns or including information about making water clean and safe into PEPFAR basic care
packages. Dr. Blount also warned that Congress needed to significantly increase resources to
combat the increasing burden of non-communicable diseases (i.e., heart disease, diabetes, high
blood pressure, and cancer) in developing countries.
In their FY2010 Foreign Operations Appropriations bills, the House and Senate Appropriations
Committees emphasized the importance of improving the integration, coordination, monitoring,
and evaluation of U.S. global health programs. They also underscored the importance of
improving overall health systems. As passed by the House, the FY2010 House Foreign
Operations Appropriations directs the Secretary of State to issue a report to the Appropriations
Committees no later than 180 days after enactment that describes and examines all ongoing
global health programs by country that are funded through Foreign Operations and other
appropriations; discusses the impact, outcomes, and effectiveness of the programs; provides
specific information about complementary work by other private and public donors; and
recommends changes to such programs to improve results and enhance effectiveness. The Senate
committee report calls for instituting a more integrated and sustainable approach to fighting
disease, improving basic healthcare, and strengthening health systems. It also endorses the
President’s Global Health Initiative and describes it as an opportunity to create a comprehensive
and sustainable global health strategy that identifies specific initiatives, quantitative goals, and
appropriate funding levels for global health. Though CDC is not funded directly through foreign
operations appropriations, some of the programs that it implements—such as those related to
HIV/AIDS, malaria, and avian/pandemic flu—could be affected by these directives, should they
be enacted.
Workforce Levels
Although Congress has boosted appropriations to CDC for global health programs over the past
decade, GAO contends that CDC’s ability to fulfill its mission and address its expanded scope of
work is threatened by staff shortages. GAO cited a number of reasons for staff shortages,
including low staff morale; changing workforce demographics, exacerbated by impending losses of
essential personnel due to retirement; the limited supply of skilled public health professionals;
deficient diversity of its workforce; inability to adjust its workforce to expanding scope of work and
responsibilities; logistical difficulties involved in acquiring and retaining a skilled workforce; and
difficulties in managing a workforce with a large and growing number of contractors.54 Critics also
maintained that the reorganization of CDC during the Bush Administration, which one critic
53 U.S. Congress, Senate Committee on Appropriations, Subcommittee on Labor, Health and Human Services,
Education, and Related Agencies, Hearing on Global Health, 110th Cong., 1st sess., May 2, 2007, S. Hrg. 110-443
(Washington: GPO, 2007), p. 29.
54 GAO, Centers for Disease Control and Prevention Human Capital Planning Has Improved, but Strategic View of
Contractor Workforce Is Needed, GAO-08-582, May 2008, p. 1, http://www.gao.gov/new.items/d08582.pdf.
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Centers for Disease Control and Prevention Global Health Programs: FY2001-FY2010
asserted consolidated the power of the CDC Director, also contributed to staff shortages and
lower staff morale.55
In 2007, the House Oversight and Government Reform Committee expressed its concern about
staff levels and how they affected CDC’s work abroad. 56 To demonstrate the impact of staff
shortages on CDC’s work, the committee cited an internal memo that was leaked to the Atlanta
Journal Constitution. In the memo, Dr. Stephen Blount, Director of the CDC Office of Global
Health, reportedly indicated that “[s]ome positions have been delayed for so many months that
our partners doubt our commitment and credibility.”57 The committee noted constraints posed by
statutory time limits for CDC experts detailed to international organizations; criticized the process
by which CDC scientists are assigned to international organizations, including WHO; and
expressed concern that a “political office review[s] each assignment [abroad].” The committee
contended that this process unnecessarily extended the process.
Figure 1. CDC Global Health Funding: FY2001-FY2009
(Current U.S. $ millions)
300
250
200
150
100
50
0
l
ual
ate
ctual
ctual
ctual
ctual
ct
tual
ctual
tua
Ac
Ac
-50
A
A
A
A
A
A
stim
E
2001
2002
2003
2004
2005
2006
2007
2008
9
Y
Y
Y
Y
F
F
F
FY
FY
FY
F
FY
200
FY
GAP
Malaria
TB
GDD
Pandemic/Avian Flu
Other Global Health
Immunizations
Source: Calculated by CRS from appropriations legislation and correspondence with Anstice Brand and Rebecca Miller, CDC
Washington Office.
Note: This chart does not reflect a decline in support for HIV/AIDS activities. In FY2004, Congress began to fund PMTCT
activities through OGAC, though CDC continues to implement related efforts.
55 Gardiner Harris and Anemona Hartocollis, “New York City Official is Obama Pick for CDC,” New York Times, May
15, 2009.
56 Letter from Congressman Henry Waxman, Chair of the House Oversight and Government Reform Committee, to
Michael Leavitt, HHS Secretary, May 4, 2007, see http://oversight.house.gov/documents/20070504174220.pdf.
57 Ibid., p. 2.
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Table 6. CDC Global Health Spending: FY2001-FY2010
(current U.S. $ millions)
FY2001-
%Change
%Change
Program
FY2001 FY2002 FY2003 FY2004 FY2005 FY2006 FY2007 FY2008 FY2009
FY2010
FY2010 FY2010
Actual Actual
Actual Actual Actual Actual Actual
Actual Estimate FY2009
FY2001-
FY2009-
Total
FY2009
Request
FY2010
House
Senate
GAP
104.5 168.7 266.9 266.9 123.8 122.6 121.0 118.9 118.9 1,412.2
13.8% 119.0
0.1% 119.0 119.0
PMTCT
n/s
25.0
182.6
142.0
State
State
State
State
State
349.6
n/a
State
State
State
State
Malaria
13.0 13.0 9.2 9.2 9.1 9.0 8.9 8.7 9.4 89.5 -27.7% 9.4 0.0% 9.4 9.4
TB
0.0 1.0 1.1 2.0 2.3 2.2 1.9 2.0 1.6 14.1 100.0% 1.6 0.0% n/s n/s
GDD
0.0
0.0 0.0 11.6 21.4 32.4 32.0 31.4 33.7 162.5 100.0% 33.8 0.3% 37.8 37.0
Pandemic/Avian Flu
0.0
0.0
0.0
0.0
15.0
132.0
22.0
67.8
156.0
392.8
100.0%
159.0
1.9%
n/s
n/s
Immunizations
106.6 133.7 147.8 137.9 144.4 144.3 142.3 139.9 143.3 1240.2
34.4% 153.5
7.1% 153.5 153.9
Polio
91.2 102.3 105.7 96.8
101.2 101.1 99.8 98.0 101.5 897.6 11.3% 101.6 0.1% 101.6 102.0
Other
Global/Measles 15.4 31.4 42.1 41.0 43.2 43.2 42.6 41.8 41.8 342.5 171.4% 51.9 24.2% 51.9 51.9
Other Global Health
0.0
0.0
0.0
2.4
3.4
3.4
3.3
3.5
3.5
19.5
100.0%
3.5
0.0%
3.5
13.5
Total
224.1 316.4 425.0 430.0 319.4 445.9 331.4 372.2 466.4 3,330.8 108.1% 479.8
2.9% 323.2 332.8
Source: Appropriations legislation; and correspondence with Anstice Brand, CDC Washington Office, and Julie Racine-Parshall, CDC Atlanta Office.
Notes: Congress began to fund PMTCT activities in FY2002; the “n/s” in the FY2001 column indicates that Congress did not specify funds for that activity. After FY2004, Congress
funded PMTCT activities through the State Department, which oversees al global HIV/AIDS funds, though CDC continues to implement PMTCT programs. “State” reflects this
change.
Congress does not appropriate funds to CDC for global TB and pandemic/avian influenza activities. CDC al ots a portion of its TB and pandemic/avian Influenza appropriations to global
programs. Figures for TB and pandemic/avian flu in the FY2010 Request column reflects how much CDC estimates it will spend on those diseases in FY2010, not formal requests.
The “n/s” in the FY2010 House and Senate columns reflects the absence of language in House and Senate reports—H. Rept. 111-220 and S.Rept. 111-66, respectively—
accompanying FY2010 Labor, HHS, and Education Appropriations (H.R. 3293) to indicate funding for global interventions against either disease globally, though CDC is likely to
apportion funds to combat both.
Spending on combating these diseases is included here, however, because the related interventions are critical parts of CDC’s global health efforts. The conference report (H.Rept. 111-
151) accompanying the FY2009 Supplemental Appropriations Act (P.L. 111-32) made available $200 million to CDC for domestic and global pandemic influenza preparedness and
response activities. Those funds are not included here, however, because language did not indicate how much of those funds should be used for global activities.
Figures related to polio and “other global/measles” are italicized to indicate that they are included in the Global Immunization total.
Acronyms: GAP—Global AIDS Program; PMTCT—Prevention of Mother-to-Child HIV Transmission; TB—Tuberculosis; GDD—Global Disease Detection
CRS-21
Centers for Disease Control and Prevention Global Health Programs: FY2001-FY2010
Author Contact Information
Tiaji Salaam-Blyther
Specialist in Global Health
tsalaam@crs.loc.gov, 7-7677
Congressional Research Service
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