Sub-Saharan Africa could face a devastating resurgence of childhood tuberculosis (TB) in the next decade as a result of sharp cuts in United States global health funding a new study has warned.

The collapse of US bilateral health aid could lead to an additional 2.5 million pediatric TB cases and 340,000 pediatric TB deaths in Low- and Middle-Income Countries between 2025 and 2034, compared to pre-2025 funding levels, according to the study published in The Lancet Child & Adolescent Health, in October 20.

Until early this year, the US has been the world’s biggest supporter in the fight against TB, helping save more than 75 million lives through USAid and other programmes.

It was also the largest donor to the Global Fund and the US President’s Emergency Plan for AIDS Relief (Pepfar), which helped reverse Africa’s HIV-driven TB epidemics. But under President Donald Trump’s new regime, the US has sharply cut global health aid, dismantling USAid’s health division, suspending Pepfar, and quitting the World Health Organisation (WHO), raising fears of reversing decades of progress.

If the Global Fund also loses US support, and other donors halve their contributions, the toll would more than triple, triggering a surge of nearly nine million new child TB cases and 1.5 million deaths worldwide by 2034.

H. Chan School of Public Health (Harvard Chan School) and Boston University School of Public Health (BUSPH) provides the first comprehensive estimates of how children in low- and middle-income countries will be affected by the loss of US aid.

Its projections suggest that, even under conservative assumptions, Africa’s two decades of progress in TB control could be undone in just a few years.“If the recent and proposed cuts to US bilateral health aid continue, these losses would reverse decades of hard-won progress,” said Dr Leonardo Martinez, assistant professor of epidemiology at Boston University School of Public Health and the study’s senior author.

Until 2025, the US was the largest single contributor to TB control efforts globally, mainly through the USAid and its support for the Global Fund.

These programmesare credited with helping to prevent more than 75 million TB deaths worldwide, particularly in high-burden African countries like Angola, DR Congo, Ethiopia, Kenya, Mozambique, Nigeria, South Africa, Tanzania, and Zambia.

Following sweeping budget cuts and the dismantling of USAid’s global health division earlier this year, major TB and HIV prevention programmes have stalled or closed in several African countries.

Funding reductions under Pepfar have further disrupted joint TB-HIV interventions, leaving vulnerable children without diagnosis or treatment.“We have made slow and steady progress with TB, but it is still the number one infectious disease killer in the world,” said Dr Nicolas Menzies of Harvard T.

H. Chan School of Public Health, the study’s lead author.“If we take our foot off the pedal, we could soon see more children dying of TB than we have for many decades.”Sub-Saharan Africa carries over a quarter of the world’s TB burden, with children under 15 particularly at risk due to malnutrition, fragile health systems, and the high overlap with HIV infection.

The region relies heavily on US and multilateral funding for TB testing, drug procurement, and workforce support.

Using data from 130 countries, the Harvard–Boston team modeled TB incidence and mortality under different funding scenarios, incorporating variables such as vaccination coverage, HIV prevalence, and access to care.

The results show the steepest surges in Africa’s high-burden nations, where external funding often accounts for more than half of national TB budgets. In countries like Mozambique, Zambia, and Malawi, the researchers warn that losing donor support could collapse childhood TB treatment capacity almost overnight, erasing community-level gains made over the last two decades.“Children are often invisible in TB control efforts, yet they suffer the worst outcomes when systems fail,” Dr Martinez said. “Without funding, we are condemning another generation to preventable deaths.”TB, though curable and preventable, remains among the top 10 causes of death globally. While adult TB dominates public discourse, pediatric TB deaths have long been undercounted, largely because diagnosis in children is complex and under-reported.

The study also underscores the interconnectedness of TB and HIV epidemics. People living with HIV are 20 times more likely to develop TB, and children born to HIV-positive mothers face greater exposure risks. Consequently, cuts to HIV programmes, especially Pepfar, intensify the TB threat, particularly where both diseases are managed under integrated care models.

Cuts to TB treatment services are likely to trigger a surge in infections and disease spread at the population level, caution the researchers.

Although diagnosing TB in children remains challenging, recent investments have significantly improved detection and reporting rates across many countries, gains now at risk of being reversed by current and future funding cuts.

Researchers estimate that up to 90 percent of projected child TB deaths could still be prevented if funding is restored within a year. However, if cuts persist, Africa’s already strained health systems may struggle to recover.“Once health workers are laid off and diagnostic supply chains broken, restarting these systems becomes far more expensive than maintaining them,” said Dr Menzies.“The global community should act now before these losses become irreversible.” The findings arrive at a moment when international cooperation on health is weakening.

Experts warn that the US retreat from global health aid signals a dangerous precedent, one that undermines global solidarity just as developing countries grapple with overlapping crises including climate change, emerging pandemics, and conflict-driven displacement.

Still, they stress that international solidarity remains irreplaceable in controlling cross-border diseases. “TB is not a disease that respects geography or politics,” Dr Martinez noted. “If we allow progress to unravel in Africa, it will have global consequences.”The study concludes that safeguarding global health financing must be viewed not as charity, but as a shared investment in global stability. With child TB rates having declined slowly but steadily before 2025, any major disruption now risks triggering a rebound worse than the pre-2000 epidemic.“The tragedy is that these deaths are entirely preventable,” Dr Menzies said. “We know what works. What’s missing is the political will to keep investing in the systems that save lives.”

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