Centers for Disease Control and Prevention
Global Health Programs: FY2001-FY2011
Tiaji Salaam-Blyther
Specialist in Global Health
April 7, 2010
Congressional Research Service
7-5700
www.crs.gov
R40239
CRS Report for Congress
P
repared for Members and Committees of Congress

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Centers for Disease Control and Prevention Global Health Programs: FY2001-FY2011

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 mostly 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.
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 FY2011, Congress appropriate $353 million to CDC for global health programs—an
estimated 5% increase over FY2010 enacted levels. From FY2001 to FY2010, Congress made
available more than $3 billion available to CDC for global health programs.
CDC also partners in programs for which it does not have specific appropriations, such as global
efforts to address tuberculosis (TB) and respond to pandemic influenza. In addition, the State
Department and the U.S. Agency for International Development (USAID) transfer funds to CDC
for its role as an implementing partner in U.S. coordinated initiatives, including PEPFAR, PMI,
and the Neglected Tropical Diseases (NTD) Initiative.
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 111thCongress.

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Contents
Introduction ................................................................................................................................ 1
CDC’s Global Health Programs................................................................................................... 1
Global HIV/AIDS ................................................................................................................. 2
President’s Emergency Plan for AIDS Relief (PEPFAR).................................................. 3
Global Immunization ............................................................................................................3
Polio ............................................................................................................................... 4
Measles........................................................................................................................... 5
Global Malaria...................................................................................................................... 6
President’s Malaria Initiative........................................................................................... 6
Global Disease Detection ...................................................................................................... 7
Other CDC Global Health Programs...................................................................................... 7
Non-earmarked Global Health Activities ............................................................................... 8
Global Tuberculosis ........................................................................................................ 8
Pandemic and Avian Influenza ........................................................................................ 9
Afghan Health Initiative................................................................................................ 12
Health Diplomacy ......................................................................................................... 13
CDC Global Health Spending: FY2001-FY2011 ....................................................................... 13
CDC Global Health Spending: FY2001-FY2003 ................................................................. 13
CDC Global Health Spending: FY2004-FY2008 ................................................................. 14
CDC Global Health Funding: FY2009-FY2011 ................................................................... 16
Priorities in the FY2011 Budget .................................................................................... 17
Related Policy Issues ................................................................................................................ 18
CDC Reorganization ........................................................................................................... 18
What Role Should CDC Play in U.S. Global Health Assistance? ......................................... 19
Global Health Initiative................................................................................................. 19

Tables
Table 1. U.S. Assistance for International H1N1 Responses, FY2009 ........................................ 12
Table 2. CDC Global Health Spending: FY2001-FY2003.......................................................... 14
Table 3. CDC Global Health Spending: FY2004-FY2008.......................................................... 15
Table 4. CDC Global Health Funding: FY2009-FY2011............................................................ 17
Table 5. CDC Global Health Spending: FY2001-FY2011 .......................................................... 21

Contacts
Author Contact Information ...................................................................................................... 23
Acknowledgments .................................................................................................................... 23

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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 FY2010, highlights FY2011 proposed and enacted funding levels, 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 to the Center for Global Health through five main budget lines: Global
HIV/AIDS, Global Malaria, Global Disease Detection, Global Immunization, and Other Global

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 111thCongress.
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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Health. CDC programs are implemented bilaterally and in cooperation with other U.S. agencies,
international organizations, foreign governments, foundations, and nonprofit organizations.4
CDC is engaged in a wider range of global-health activities than what Congress appropriates for
global health initiatives. The HHS Office of Global Health Affairs, for example, transfers funds to
the Center for Global Health in support of global health efforts. In addition, CDC receives
support from other U.S. government agencies and departments, such as the Office of the Global
AIDS Coordinator (OGAC) at the U.S. Department of State, for the implementation of PEPFAR
programs,5 and the U.S. Agency for International Development (USAID), for partnership in PMI
and the Neglected Tropical Diseases (NTD) Initiative, among other programs.6 The section below
describes global health activities that Congress funds the Center for Global Health 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. For background information on the NTD Initiative, see CRS Report R40740, U.S. Global Health
Assistance: Background, Priorities, and Issues for the 111thCongress, by Tiaji Salaam-Blyther and 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 on global HIV/AIDS programs increased 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. Increased spending on
global HIV/AIDS programs by CDC during this time period was caused primarily by transfers
provided to the Center for the implementation of PEPFAR.10 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. In FY2009, OGAC transferred about $1.3 billion to CDC for
implementation of PEPFAR programs and has not yet released how much it transferred to CDC
for FY2010.11
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).12 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 FY199113 to $153.7
million in FY2010. 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.14

(...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 E-mail from Elizabeth Crosby, Health Policy Analyst, March 26, 2010.
12 WHO Website, Vaccine-Preventable Diseases, http://www.who.int/immunization_monitoring/diseases/en/.
13 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.
14 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.
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In partnership with WHO and UNICEF, CDC developed the Global Immunization Vision and
Strategy for 2006-2015 (GIVS),15 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
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.16 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 2008.17
The number of polio-endemic countries has decreased from 125 in 1988 to four in 2008:
Afghanistan, India, Nigeria and Pakistan.18 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).19 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.20 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

15 For more on the Global Immunization Vision and Strategy for 2006-2015, see http://www.who.int/vaccines-
documents/DocsPDF05/GIVS_Final_EN.pdf.
16 Information about polio was summarized by CRS from WHO Website on polio at http://www.who.int/mediacentre/
factsheets/fs114/en/index.html.
17 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.
18 For a history of polio eradication efforts, see http://www.polioeradication.org/history.asp.
19 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.
20 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.
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Eradication Initiative—WHO, UNICEF, and Rotary International—and houses the global
reference laboratory for polio.21
Measles
Measles is another highly contagious virus that mostly affects children younger than five years of
age.22 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 5).23 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.24
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.25 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. At the end of 2008, CDC’s global measles campaign contributed to the
decline in measles-related deaths from an estimated 733,000 deaths to about 164,000 in 2008.26

21 For more information on the Global Polio Eradication Initiative, see http://www.polioeradication.org/.
22 Information about measles was summarized by CRS from WHO, Measles, Fact Sheet, December 2008,
http://www.who.int/mediacentre/factsheets/fs286/en/index.html.
23 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.
24 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.
25 WHO, Measles, Fact Sheet, December 2008, http://www.who.int/mediacentre/factsheets/fs286/en/index.html.
26 FY2011 CBJ for CDC, p. 247.
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Global Malaria
Through its malaria programs, CDC conducts research and engages in prevention and control
efforts.27 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, and 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.28 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;
• 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. In FY2009, USAID
transferred $15 million to CDC, of which some $13 million was for PMI and nearly $2 million
for malaria efforts in the Mekong region.

27 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.
28 For more on outcomes of CDC’s malaria interventions, see CDC, FY2009 CBJ, p.333, http://www.cdc.gov/fmo/
topic/Budget%20Information/appropriations_budget_form_pdf/FY09_CDC_CJ_Final.pdf.
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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.”29 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 seven 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 China, Egypt, Guatemala, India, Kazakhstan, Kenya, and Thailand—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.30 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 2008.31 In FY2009, CDC provided emergency technical assistance in
over 70 humanitarian assistance missions.
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).32 While these two programs received
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.33 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

29 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.
30 For more information on GOARN, see http://www.who.int/csr/outbreaknetwork/en/.
31 For more information on GDD outcomes see CDC, FY2009 CBJ, 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.
32 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.
33 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.
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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.34
Non-earmarked Global Health Activities
CDC’s activities related to improving global health outcomes expand beyond those funded
through the Center for Global Health. CDC also leverages other resources to respond to global
requests for technical assistance related to disease outbreak response; prevention and control of
injuries and chronic diseases; emergency assistance and disaster response; environmental health;
reproductive health; and safe water, hygiene, and sanitation.35 Specifically, CDC supports global
TB and pandemic flu programs, which are a key priority for the Administration and Congress. In
addition, in FY2011 the Administration proposes that other programs previously funded through
other sources be transferred to the Center for Global Health, such as the Afghan Health Initiative
and the Health Diplomacy Initiative. The section below highlights those activities.
Global Tuberculosis
CDC collaborates with U.S. and multilateral partners to provide technical support in the global
effort to eliminate tuberculosis (TB). 36 Bilateral partners include the National Institutes of Health
(NIH) and USAID; multilateral partners include the Global Fund and WHO. Key activities in
CDC’s bilateral TB interventions include
• operations research;37
• improvement of TB screening and diagnostics;

34 For information on outcomes of SMDP, see CDC, FY2009 CBJ, p. 338, http://www.cdc.gov/fmo/topic/
Budget%20Information/appropriations_budget_form_pdf/FY09_CDC_CJ_Final.pdf.
35 For more information on other global health efforts, see http://www.cdc.gov/globalhealth/.
36 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.
37 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.
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• 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 MDR-TB and extensively drug resistant TB (XDR-TB).38 Multilateral partnerships also
include joint efforts with WHO to conduct surveillance of drug-resistant TB.
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;
• 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.39 The United States is the largest
single donor to global avian and pandemic preparedness efforts.40 The funds have been used to

38 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/.
39 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.
40 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.
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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;41
• $67 million for stockpiles of non-pharmaceutical supplies, including over 1.6
million PPE kits, approximately 250 laboratory specimen collection kits and
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

41 For more information about GAINS, see http://www.gains.org/.
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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.42 CDC creates
or develops reagents that are used to detect subtypes of influenza that are sent to national
influenza centers around the world.43 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
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.”44 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.45 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

42 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/.
43 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.
44 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.
45 PAHO, press release, “PAHO Recognizes Important US Contribution of Antivirals for Latin America and
Caribbean,” July 3, 2009
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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) also provides support.
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.
In response to President Obama’s request for supplemental funding for U.S. domestic and
international pandemic preparedness and response activities,46 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).
Officials from CDC’s Budget Office indicate that CDC spent $50.9 million on global pandemic
flu preparedness efforts in FY2009 (Table 4).47
Afghan Health Initiative
According to the United Nations Children’s Fund (UNICEF), Afghanistan has the highest child
mortality rate in the world.48 In 2008, an average of 65 children younger than five years died for
every 1,000 born worldwide. In sub-Saharan Africa, the child mortality rate reached 144; in
Afghanistan, it was 257. Similarly, in 2004, of every 1,000 children born in Afghanistan, 60 died
within their first month. In contrast, the average global neonatal rate was 28 and 38 for sub-
Saharan Africa. Statistics for maternal health in Afghanistan are equally abysmal. In 2005,
UNICEF estimated that 18 of every 1,000 Afghan mothers died from pregnancy-related causes,
and that over an Afghan mother’s lifetime, one of every eight is likely to die from pregnancy-
related causes. Meanwhile, in that same year, the average global maternal mortality rate was 4.0
and 8.2 for sub-Saharan Africa. Similarly, one of every 92 women worldwide is likely to die from
pregnancy-related causes, and one of every 22 in sub-Saharan Africa.

46 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.
47 E-mail from Elizabeth Crosby, Program Analyst, CDC Atlanta, January 2010.
48 Statistics taken from UNICEF, State of the World’s Children, Special Edition, Statistical Tables, November 2009,
http://www.unicef.org/rightsite/sowc/pdfs/statistics/SOWC_Spec_Ed_CRC_Statistical_Tables_EN_111809.pdf.
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The Afghan Health Initiative aims to improve the skills of health workers in Afghanistan and
improve health outcomes in the country. The FY2011 budget request includes a proposal to
transfer the daily management of the Afghan Health Initiative from the HHS Office of Global
Health Affairs to the Center for Global Health. Specifically, HHS sought to reduce by 20% the
number of maternal and neonatal (the first month of life) deaths in targeted Afghan hospitals by
the end of 2008. The FY2011 CBJ reported mixed results in key measures taken to reach this
goal.
Health Diplomacy
CDC’s health diplomacy activities aim to bolster ongoing efforts to control, eradicate, and
eliminate diseases worldwide. In particular, the objective is to strengthen the public health
capacity of partner organizations and governments globally and improve international responses
to natural and manmade disasters. For example, CDC proposes for FY2011 that it conduct
trainings in Latin American countries on adopting evidence-based approaches to health, including
chronic diseases, and that it support national field epidemiology training programs in the region.
CDC Global Health Spending: FY2001-FY2011
From FY2001 to FY2010, Congress provided CDC more than $3 billion for global health
activities—increasing funding for global health activities by about 50% in that time period. 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 $900 million to CDC for global health
work (Table 2). During this time period, spending by CDC on global health increased by more
than 50%. About half of that growth was targeted at HIV/AIDS interventions and about 40% at
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.
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Table 2. CDC Global Health Spending: FY2001-FY2003
(current U.S. $ millions, actual)
% Change:
% of Total
FY2001-
FY2001-
Global
Program FY2001
FY2002
FY2003
FY2003
FY2003
Health
Global HIV/AIDS
104.5
168.7
182.6
455.8
74.7%
51.6%
PMTCT/Global AIDS Trust Fund
n/s
25.0
39.7
64.7 n/a n/a
Global Immunization
106.6 133.7 147.8 388.1
38.6%
44.0%
Polio 91.2
102.3
105.7
299.2
15.9%
33.9
Other Global/Measles
15.4
31.4
42.1
88.9
173.4%
10.1
Global Malaria
13.0
13.0
12.6
38.6
-3.1%
4.4%
Global Disease Detection (GDD)
n/a n/a n/a n/a
n/a
n/a
Other Global Health
n/a
n/a
n/a
n/a
n/a
n/a
Total Global Health
224.1
315.4
342.9
882.5
53.1%
100.0%
Global Tuberculosis
0.8
1.0
1.1
2.9
37.5%

Source: Appropriations legislation and correspondence with Anstice Brand, CDC Washington, and Julie Racine-Parshall,
CDC Atlanta.
Note: n/a means not applicable.
CDC Global Health Spending: FY2004-FY2008
From FY2004 to FY2008, Congress made available about $1.7 billion to CDC for global health
work and global health spending by CDC increased by about 6% (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 52% 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 46% of
CDC’s global health budget (excluding PMTCT efforts) and funding for GDD amounted to about
comprised an estimated 8% 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
PEPFAR, spending on programs to combat the virus internationally accounted for about 82% of
CDC’s global health spending from FY2004 through FY2008, while the transfers alone
comprised about 69% 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.
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In FY2006, USAID began to transfer funds to CDC for its work as an implementing partner of
PMI. When transfers for PEPFAR and PMI are included, CDC spent about $6.6 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 ($1.5 billion) by nearly $2 billion.
Table 3. CDC Global Health Spending: FY2004-FY2008
(Current U.S. $ millions, actual)
% of
Global
FY2004-
Change:
Health:
FY2008
FY2004-
FY2004-
Program
FY2004 FY2005 FY2006 FY2007 FY2008 (Total)
FY2008
FY2008
Global
HIV/AIDS

266.9 123.8 122.6 121.0 118.9 753.2a -4.8% 40.5%
PMTCTa
142.0 State State State State 142.0 n/a n/a
Global
Immunization 137.9 144.3 144.3 142.3 139.9 708.7 1.5% 47.0%
Poliob
96.8 101.2 101.1 99.8 98.0 496.9 1.2% 32.9%
Other Global/Measlesb 41.0 43.2 43.2 42.6 41.8 211.8 2.0% 14.0%
Global
Malaria

9.2 9.1 9.0 8.9 8.7 44.9
-5.4% 3.0%
Global Disease
Detection
11.6 21.4 32.4 32.0 31.4 128.8
170.7% 8.5%
Other
Global
Health 2.4 3.4 3.4 3.3 3.5 16.0
45.8% 1.1%
Total Global
Health
428.0 302.0 311.7 307.5 302.4 1,509.6 5.73% 100.0%
Total Global Health
w/out PMTCT
286.0 302.0 311.7 307.5 302.4 1,651.6 16.2%
n/a
Transfers for
HIV/AIDS
184.5 436.3 603.1 916.9
1,262.7 3,403.6 584.2%
n/a

Transfers for Malaria
n/a
n/a
2.8
9.6
12.6
25.0
350.0%
n/a
Total w/Transfers,
including PMTCT
612.5 738.3 914.8
1,224.4
1,565.1 4,913.2 155.5%
n/a
Global Tuberculosisc 2.0 2.3 2.2 1.9 2.0 10.4 0.0% n/a
Pandemic/Avian
Influenzac
0.0 15.0 132.0 22.0 67.8 236.8
353.3% n/a
Sources: Appropriations legislation and correspondence with Anstice Brand and Rebecca Miller, CDC
Washington Office.
Notes: n/a means not applicable.
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. Although PMTCT funds are included in the totals, they are not included in the calculations for changes in
fiscal years and proportions of global health budget as they are not a sustained part of CDC’s global health
budget.
b. The figures for polio, and “other global/measles” are italicized to indicate that they are included in the
Global Immunization total.
c. Congress does not appropriate funds for global TB efforts and global pandemic/avian influenza activities to
the Center for Global Health. As such, those figures are not included in the global health totals. They are
included in this chart, however, because they are an important part of CDC’s global health work.
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CDC Global Health Funding: FY2009-FY2011
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.49 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.50 In
announcing the initiative, the President stated,
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.
Publically available documents do not indicate to what extent CDC will contribute to GHI.
In FY2010, Congress made available $336.2 million for CDC’s global health programs. The
Administration requests that Congress provide about $350 million for CDC’s global health
programs in FY2011, some 5% more than FY2010 enacted levels (Table 4).51 The bulk of the
increase is attributed to the “other global health category,” which is more than double the FY2010
enacted level. The President also requested a $49,000 increase for the Global Disease Detection
(GDD) program. This is not evident in the table below, however, due to rounding. Although
FY2011 requested levels are lower than FY2010 enacted levels for all other categories, CDC
officials indicate that this reduction reflects decreased spending on travel and contract
investments rather than programming expenses.52 Suggested spending on travel and contracting
services through global health programs declined by about $4.5 million from FY2010 enacted
levels.53

49 The White House, 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.
50 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/.
51 For background on CDC’s global health programs, see CRS Report R40239, Centers for Disease Control and
Prevention Global Health Programs: FY2001-FY2010, by Tiaji Salaam-Blyther.
52 E-mail from Elizabeth Crosby, Health Policy Analyst, CDC, March 5, 2010.
53 See the FY2011 CBJ for CDC, p.18.
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Table 4. CDC Global Health Funding: FY2009-FY2011
(current $ U.S. millions and %)
Change
Change
FY2009
FY2010
FY2010
FY2009-
FY2011
FY2010-
Program
Estimate
Request
Estimate
FY2010
Request
FY2011
Global AIDS Program
118.9
119.0
119.0
0.0%
118.1
-0.8%
Global Immunizations
143.3
153.5
153.7
7.3%
152.8
-0.6%
Polio 101.5
101.6
101.8
0.3%
101.6
-0.2%
Other/Measles 41.8
51.9
51.9
24.2%
51.2
-1.3%
Global
Malaria
9.4 9.4 9.4 0.0% 9.2 -2.1%
Global Disease Detection
33.7
33.8
37.8
12.2%
37.8
0.0%
Other Global Health
13.8
13.8
16.3
18.1%
35.1
115.3%
Afghanistan Health Initiative
5.8
5.8
5.8
0.0
5.8
0.0%
Health Diplomacy Initiative
4.5
4.5
2.0
-55.6%
2.0
0.0%
Total CDC Global
Health 319.1
329.5
336.2
5.4%
353.0
5.0%
Global Tuberculosis
1.6
n/s
n/s
n/s
n/s
n/s
Global Pandemic/Avian Flu
50.9
n/s
49.9
-2.0%
n/s
n/s
Source: Congressional Budget Justifications, appropriations legislation, and CDC officials.
Notes: n/s means not specified. Transfers for the Afghanistan Health and Health Diplomacy programs will not
occur until FY2011; the FY2009 and FY2010 budgets are adjusted for comparability purposes.
Priorities in the FY2011 Budget
In the FY2011 Congressional Budget Justification (CBJ) for CDC, the Administration highlighted
key priorities for CDC’s global health programs including the goal of eradicating polio in the
remaining four polio-endemic countries through a partnership with the Organization of the
Islamic Conference (OIC).54 Other areas of emphasis include increasing efforts to address and
contain infectious disease. Key proposals include the following:
Other Global Health
The FY2011 budget includes $35.1 million for global health programs funded through the “other
global health” line, some $19 million more than FY2010 enacted levels. According to the CBJ,
the additional funds will be used to develop at least three new Field Epidemiology and
Laboratory Training Programs (FELTP) and expand capacity at four existing programs. The
Administration also proposes spending the additional resources on programs related to improving
global water, sanitation, and hygiene ($10 million); and maternal, newborn, and child health ($2
million).

54 See the White House, “Remarks by the President on a New Beginning,” press release, June 4, 2009,
http://www.whitehouse.gov/the-press-office/remarks-president-cairo-university-6-04-09, and United Nations
Children’s Fund, “United States and Organization of the Islamic Conference Join Forces Against Polio,” press release,
December 3, 2009, http://www.unicef.org/immunization/index_51990.html.
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The HHS Office of Global Health Affairs (OGHA) also proposes transferring $5.8 million for
implementation of the Afghanistan Health Initiative, which aims to improve the capacity of
clinicians, particularly in the areas of logistics and health management. In addition, OGHA
suggests transferring $2.0 million for the Health Diplomacy Initiative, which uses U.S.
government and private sector resources to deliver direct patient care and train local health
workers. This effort is being initiated in Central America.
Global Disease Detection and Humanitarian Health
The Administration proposes spending $37.8 million on GDD. Though not evident due to
rounding, the FY2011 budget request is $49,000 higher than FY2010 enacted levels. The
additional funds will be used to increase oversight activities in Atlanta.55 In addition, the FY2011
budget includes $6.3 million for global health efforts targeted at populations affected by
humanitarian emergencies. These activities are funded through the International Emergency and
Refugee Health Branch (IERHB). As part of ongoing reorganization efforts, IERHB will become
part of the Center for Global Health.
Related Policy Issues
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.
CDC Reorganization
Dr. Julie Gerberding, over her seven-year term as the Director of CDC, conducted a
comprehensive restructuring of CDC through the Futures Initiative.56 One of the key changes that
she made was to create coordinating centers that would “help CDC’s scientists collaborate and
innovate across organizational boundaries, improve efficiency so that more money can be
redirected to science and programs in our divisions, and improve the internal services that support
and develop CDC staff.”57 There was considerable debate, however, about this change.
Arguments centered on whether the restructuring was politically motivated and effective.
Dr. Frieden has already begun to reorganize CDC. Although complete details about the
reorganization are not yet available, some information has been made publically available. For
example, Dr. Frieden has eliminated the coordinating centers that Dr. Gerberding established.58

55 E-mail from Elizabeth Crosby, Health Policy Analyst, March 26, 2010.
56 See the CDC webpage on the Futures Initiative at http://www.cdc.gov/futures/ and CRS Report RL34098, Public
Health Service (PHS) Agencies: Background and Funding, coordinated by Pamela W. Smith.
57 CDC, “Letter from Dr. Gerberding,” press release, April 21, 2005, http://www.cdc.gov/futures/g_letter_04-21-
05.htm.
58 See HHS, “Statement of Organization, Functions, and Delegations of Authority,” 74 Federal Register 68630-68631,
December 28, 2009.
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This decision was reportedly made following recommendations by an internal panel, which
concluded, among other things, that CDC would function more efficiently if it had fewer
bureaucratic levels.59 The inclusion of key programs, such as the Afghanistan Health Initiative, in
the FY2011 CBJ seem to indicate that activities funded through the Center for Global Health
(formerly the Coordinating Office for Global Health under Dr. Gerberding) might be expanded. It
remains to be seen what role, if any, the Center for Global Health will play in the implementation
and coordination of other global health activities managed under other centers, such as safe water
and sanitation programs overseen by the National Center for Environmental Health/Agency for
Toxic Substances and Disease Registry.
What Role Should CDC Play in U.S. Global Health Assistance?
The Administration’s emphasis on disease detection in the FY2011 global health budget request
reflects CDC’s goal of “protecting people worldwide from infectious, occupational,
environmental, and terrorist threats.”60 The FY2011 proposal includes a $49,000 increase on
activities that would strengthen the capacity of foreign health ministries to “to identify and
mitigate emerging public health threats”61 through the Global Disease Detection program.
Nonetheless, some health experts would like more resources to be allotted to enhancing and
expanding CDC’s work in disease detection and surveillance. Despite the emergence and re-
emergence of diseases such as severe acute respiratory syndrome (SARS), pandemic and avian
flu, and MDR-TB 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” but
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.
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.
Global Health Initiative
On May 5, 2009, President Obama announced his new Global Health Initiative (GHI), a six-year,
$63 billion from FY2009 to FY2014 to better coordinate the U.S. government’s approach to
global health programs.62 For example, the GHI looks to accelerate the integration of services

59 Robert Koenig, “New Chief Orders CDC to Cut Management Layers,” Science, August 7, 2009,
http://news.sciencemag.org/scienceinsider/2009/08/new-chief-order.html. Also see, Sheila Poole, “Science, efficiency
to drive CDC changes ,” Atlanta Journal-Constitution, January 1, 2010, http://www.ajc.com/health/science-efficiency-
to-drive-264238.html.
60 For more on CDC’s health protection goals, see http://www.cdc.gov/osi/goals/index.html, and CDC, State of CDC,
2008, http://www.cdc.gov/about/stateofcdc/pdf/SOCDC2008.pdf.
61 HHS, FY2011 CBJ for CDC, p. 242.
62 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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related to family planning, maternal health, and HIV/AIDS.63 In announcing the initiative, the
President stated,
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.
The Administration has indicated that it intends to apply the integrated approach of GHI to all
global health programs. However, key documents published by the Administration on the Global
Health Initiative focus primarily on global health programs implemented through USAID and the
Department of State.64 Little is known about the role other agencies, including CDC, might play
in its implementation. CDC’s FY2011 Congressional Budget Resolution indicates that CDC,
along with other HHS agencies, will play a key role in GHI, but no further information is
provided.


63 Hillary Rodham Clinton, U.S. Department of State Secretary, “Remarks on the 15th Anniversary of the International
Conference on Population and Development,” January 9, 2010, http://www.state.gov/secretary/rm/2010/01/135001.htm
64 For more information on the GHI, see http://www.pepfar.gov/ghi/.
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Table 5. CDC Global Health Spending: FY2001-FY2011
(current U.S. $ millions and %)
Change FY2001-
Change
Change
FY2001 FY2002 FY2003 FY2004 FY2005 FY2006 FY2007 FY2008
FY2009
FY2010
FY2009-
FY2010
FY2001-
FY2011 FY2010-
Program
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Actual
Estimate Estimate FY2010
Total
FY2010 Request FY2011
Global AIDS
Program
104.5 168.7 182.6 266.9 123.8 122.6 121.0 118.9 118.9 119.0 0.1% 1,446.9 13.9% 118.1 -0.8%
PMTCT/Global
AIDS Funda
n/s

25.0
39.7
142.0
State
State
State
State State State n/a n/a n/a n/a n/a
Immunizations 106.6 133.7 147.8 137.9 144.3 144.3 142.3 139.9 143.3 153.7 7.3% 1,393.8 44.2% 152.8 -0.6%
Poliob
91.2 102.3 105.7 96.8 101.2 101.1 99.8 98.0 101.5 101.8 0.3% 999.4 11.6% 101.6 -0.2%
Other
Global/Measlesb
15.4 31.4 42.1 41.0 43.2 43.2 42.6 41.8 41.8 51.9 24.2% 394.4
237.0% 51.2 -1.3%
Malaria
13.0 13.0 12.6 9.2 9.1 9.0 8.9 8.7 9.4 9.4 0.0%
102.3
-27.7% 9.2
-2.1%
Global Disease
Detection
0.0 0.0 0.0 11.6 21.4 32.4 32.0 31.4 33.7 37.8 12.2% 200.3 n/a 37.8 0.0%
Other Global
Health
0.0 0.0 0.0 2.4 3.4 3.4 3.3 3.5 13.8 16.3
18.1% 46.1 n/a 35.1
115.3%
Afghanistan
Health Initiativec
n/a n/a n/a n/a n/a n/a n/a n/a 5.8 5.8 0.0% 11.6 n/a 5.8 0.0%
Health
Diplomacy
Initiativec
n/a n/a n/a n/a n/a n/a n/a n/a 4.5 2.0
-55.6% 6.5 n/a 2.0
0.0%
Total
224.1 315.4 343.0 428.0 302.0 311.7 307.5 302.4 308.9 328.4 5.4% 3,189.4 46.5% 353.0 5.0%
Tuberculosisd 0.0 1.0 1.1 2.0 2.3 2.2 1.9 2.0 1.6 TBD n/a n/a n/a n/a n/a
Pandemic/Avian
Flud
0.0 0.0 0.0 0.0
15.0
132.0
22.0
67.8 50.9 TBD n/a n/a n/a n/a n/a
Transfers for
PEPFAR

n/a n/a n/a
184.5
436,3
603.1
916.9
1,262.7 TBD TBD n/a n/a n/a n/a n/a
Transfers for
PMI

n/a n/a n/a n/a n/a 2.8 9.6
12.6 13.2 TBD n/a n/a n/a n/a n/a
Sources: Appropriations legislation and correspondence CDC officials.
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Notes: Although FY2011 requested levels are lower than FY2010 enacted levels for al other categories, CDC officials indicate that this reduction reflects decreased
spending on travel and contract investments rather than programming expenses.
PMTCT means Prevention of Mother-to-Child HIV Transmission; n/a means not applicable.
a. Global AIDS Fund refers to the appropriation that Congress provided for the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The Global Fund had not yet been
named. Congress began to direct funds to CDC for PMTCT activities in FY2003; 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.
b. Figures related to polio and “other global/measles” are italicized to indicate that they are included in the Global Immunization total.
c. Transfers for the Afghanistan and Health Diplomacy programs will not occur until FY2011; the FY2009 and FY2010 budgets have been adjusted for comparability
purposes.
d. 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. Spending on combating these diseases is included here, however, because the related interventions are critical parts of CDC’s
global health efforts.
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Centers for Disease Control and Prevention Global Health Programs: FY2001-FY2011


Author Contact Information

Tiaji Salaam-Blyther

Specialist in Global Health
tsalaam@crs.loc.gov, 7-7677


Acknowledgments
Craig Moscetti, Intern, contributed to the January 29, 2010, update to this report.

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